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31 Free Tissue Transfer in Diabetic Limb Salvage: Lessons Learned and Best Practices for Functional…
Approximately one month later, the patient
was re-admitted for debridement, lengthpreserving transmetatarsal amputation (which
was especially important given the patient’s contralateral BKA), tendon Achilles lengthening
(TAL), and microsurgical free ap. We proceeded
with our management algorithm as outlined in
Fig.31.1 prior to FTT:
• Multiple debridements were performed and
cultures were obtained in order to achieve a
clean wound bed prior to FTT.Cultures grew
Candida albicans but this was ultimately
attributed to secondary colonization. Targeted
antimicrobial therapy was administered lead-
ing up to FTT.
• As described above, vascular surgery was
consulted and arteriogram was performed dur-
ing the patient’s initial hospitalization.
Arteriogram revealed multiple areas of ste-
nosis and occlusion of the anterior tibial
artery, which was treated with endovascular
revascularization. The posterior tibial artery
was also noted to have an occlusion without
Fig. 31.5 Right foot after length-preserving transmetatarsal amputation and anterior tibial donor site
preparation
distal reconstitution.
• Vascular surgery was also consulted for
venous studies. Venous duplex was performed
twelve days prior to FTT and ndings were
signicant for (1) no evidence of reux, (2) no
visualized perforators, and (3) no visualization
of the small saphenous vein from the junction
to the proximal calf.
• Hypercoagulability studies revealed that the
patient was weakly positive for lupus antico-
agulant and also had low protein S levels.
These ndings did not necessitate further
workup with hematology or specialized intra-
operative management.
• Endocrinology was consulted for optimiza-
Fig. 31.6 Harvested vastus lateralis free ap
tion of blood glucose levels. At the time of the
patient’s initial admission, the patient’s hemo-
globin A1c was 8.8% and he had glucometer
readings as high as 294mg/dL the day before
FTT.The patient was a non-smoker.
The descending branch of the lateral circumex
femoral artery was anastomosed to the recipient
anterior tibial artery in an end-to-side fashion,
followed by two venous anastomoses which
were performed in an end-to-end fashion using
After TMA and percutaneous TAL were performed (Fig.31.5), a vastus lateralis free ap
was harvested from the right thigh (Fig. 31.6).
a venous coupler. The patient was noted to have
extensive calcications in the recipient and
donor site arteries; therefore, the arterial anasto-
457
458
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P. K. Dekker et al.
mosis was performed in an inside-to-outside
fashion. After ap inset, a split-thickness skin
graft (STSG) was harvested, meshed, and
afxed to the ap with staples (Fig.31.7). The
patient was discharged 17 days after FTT. At
ten-month postoperative follow-up, the patient’s
ap donor and recipient sites were well healed
and the patient was full weight-bearing with a
custom molded orthosis (CMO)/ankle-foot
orthosis (AFO) on the right lower extremity and
a prosthetic device on the left lower extremity
(Fig.31.8).
Fig. 31.7 Medial (a)
and dorsal (b) views of
the ap immediately
after microvascular
anastomosis and skin
grafting
Case 31.2 Supercial Circumex Iliac Artery
Perforator Free Flap
A 62-year-old female with a past medical history signicant for right hallux rigidis presented
approximately three weeks after undergoing
right metatarsophalangeal joint fusion with 5/10
pain around the surgical site. The patient
reported that she had completed a full 10-day
course of antibiotics postoperatively. The patient
was afebrile (36.6). Examination of the surgical
site revealed intact sutures and erythema and
skin sloughing around the incision. Incisional
Fig. 31.8 Final
postoperative
appearance
31 Free Tissue Transfer in Diabetic Limb Salvage: Lessons Learned and Best Practices for Functional…
459
dehiscence probing to hardware was noted distally (Fig.31.9). There was no purulence. X-ray
of the foot showed generalized soft tissue swelling consistent with postoperative changes.
Intravenous antibiotics were initiated and the
patient was admitted for surgical management
of her wound.
Fig. 31.9 Right foot wound prior to free ap closure
• Vascular surgery was consulted in order to
evaluate blood ow to the distal extremity.
This exam was particularly in this patient,
who was a current smoker. Arteriogram
revealed three-vessel runoff to the patient’s
foot and venous duplex studies revealed (1)
no evidence of reux, (2) no evidence of deep
or supercial vein thrombosis, (3) no visualization of the distal small saphenous vein due
to dressings/drainage, and (4) no visualization
of perforators.
• The patient underwent multiple debride-
ments and cultures were obtained in order to
achieve a clean wound bed prior to proceeding
with FTT. Infectious disease was consulted
for management of targeted antimicrobial
therapy.
• Hypercoagulability studies were all negative with the exception of minimally elevated
anticardiolipin antibodies and minimally elevated protein C levels. No further hematology
workup was required.
Once it was determined that the patient was
ready for denitive closure, a SCIP ap was harvested from the patient’s left thigh (Fig.31.10).
The right thigh was not used as a donor site due
to the presence of intertrigo on this side. The
supercial circumex iliac artery perforator was
anastomosed to a side branch of the dorsalis
Fig. 31.10 Harvested
supercial circumex
iliac artery perforator
(SCIP) free ap
460
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P. K. Dekker et al.
pedis artery in an end-to-end fashion, followed
by two venous anastomoses: the supercial circumex iliac vein was anastomosed to a deep
vein of the anterior tibial artery and a supercial
saphenous vein tributary was anastomosed to the
saphenous vein. Both venous anastomoses were
performed in an end-to-end fashion using a
venous coupler. A small piece of bilaminar
wound matrix was used for coverage at the proximal end of the ap-skin interface in order to minimize tension on the pedicle (Fig. 31.11). Five
months after free ap reconstruction the patient
underwent ap debulking with liposuction as
Fig. 31.11 Dorsal (a)
and dorsolateral (b)
views of the patient’s
right foot after free ap
inset with bilaminar
wound matrix to limit
pedicle compression
well as a minor revision procedure to remove a
portion of the ap that was growing pubic hair
(Fig.31.12). At six-month postoperative follow up, the patient was healing well (Fig.31.13).
In general, thigh-based aps can be relied on
as the workhorse aps for lower extremity reconstruction. At our institution, the most commonly
utilized aps are the ipsilateral ALT ap or VL
ap, both of which are based on the descending
branch of the lateral femoral circumex artery
[25]. Both of these aps offer the benets of
upper body and core strength preservation, low
donor site morbidity, and long pedicles that are
Fig. 31.12 Dorsal (a)
and dorsolateral (b)
views of free ap after
debulking procedure
a b
31 Free Tissue Transfer in Diabetic Limb Salvage: Lessons Learned and Best Practices for Functional…
Fig. 31.13 Flap
appearance at six-month
follow-up
461
large in diameter [25, 51–53]. The ALT ap can
be taken with or without underlying muscle,
making it a good choice for defects requiring less
bulk, while the VL is a useful option for defects
requiring a thicker paddle. The SCIP and MSAP
aps are two other options that can be useful for
reconstruction of defects that require thin paddles
for coverage. Limitations of the SCIP ap include
a short, small caliber pedicle while limitations of
the MSAP ap include tedious muscle dissection
and susceptibility to vein damage given the large
caliber of tributaries [54, 55]. The gracilis ap is
another thigh-based option but is often not used
because of short pedicle length.
Vessel Anastomosis
Microvascular anastomosis can be particularly
challenging in the diabetic patient population,
as these patients often have comorbid peripheral
vascular disease, atherosclerosis, and or diffuse
calcications which can cause recipient and
donor vessels to become stiff, brotic, and fragile [25, 56]. These vessels are susceptible to
traumatic injury and intimal damage during
microsurgical anastomosis, increasing susceptibility to thrombosis and other surgical complications [25, 57, 58]. These patients also often
have limited vascular supply to the lower
extremity; therefore, the optimal anastomosis
technique is one that allows for preservation of
distal blood ow [25, 59]. End-to-end anastomosis is therefore not ideal in these patients as it
requires a major recipient artery to be sacriced
in order to perfuse the ap. End-to-side anastomosis not only preserves distal blood ow to the
limb but it also reduces the risk of recipient vessel vasospasm and allows the surgeon to compensate for vessel mismatch [60–62]. We prefer
to use a longitudinal slit arteriotomy, as opposed
to excising the vessel wall with scissors, as the
former minimizes intimal trauma and allows for
even further control of vessel size mismatch
[61, 63]. Utilization of longitudinal slit arteriotomy with end-to-side anastomosis in highly
comorbid patients undergoing free tissue transfer for lower extremity reconstruction at our
institution has yielded excellent long-term limb
salvage (83.5%) and ap success (93%) rates
[63]. We generally gently palpate an area with-
out calcium to make our incision. Two large
Acland clamps are used to prop the vessel up.
The donor vessel is cut at a 60-degree angle. A
toe stitch is performed and tied down. The heel
stitch is left untied with a micro clip on it to
allow for visualization of each bite. The more
difcult side is sutured rst in a running interrupted fashion. Then the heel stitch is tied down.
In patients who have diffusely calcied donor
and recipient vessels, use of an end-to- side
interpositional saphenous vein graft eliminates
outside-to-inside suturing which can dislodge
calcic plaques and increase the risk of anastomotic failure [25, 58, 63]. For severe calcications, a cardiac needle on 7-0 Prolene can be
used to perform the microsurgical anastomosis.
Inside-to-outside suturing with a saphenous
vein interposition graft tacks fragile intima up
and minimizes disruption [25, 58, 63].
462
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P. K. Dekker et al.
Flap Inset
After the microsurgical anastomosis and removal
of all vessel clips, a Cook-Swartz implantable
Doppler probe can be placed on the vein in order
to allow for continuous monitoring of anastomotic patency. In the lower extremity, limited
domain can cause venous compression during
inset. Therefore, it is critical to use the implantable doppler to monitor the vein during inset. A
ViOptix Tissue Oximeter can also be placed on
skin-based aps after closure to monitor postoperative ap perfusion. We have found that supplementation of clinical observation with these
additional monitoring tools allows for more
timely and accurate identication of possible ap
compromise.
Postoperative Optimization
Flap Monitoring
The most common causes for ap re-exploration
include pedicle (particularly venous) thrombosis
and hematoma formation [4]. Not surprisingly,
shorter time to re-exploration is associated with
increased rates of ap salvage [4]. For this reason, postoperative ap monitoring is an essential
component of ap success. The vast majority of
ap complications necessitating urgent reexploration will arise within the rst 48h after
surgery; therefore, inpatient monitoring is typically recommended for 3–4days postoperatively
[4, 64]. Hourly ap checks are recommended for
the rst 24h after surgery and then can be spaced
to every four hours for the next 48h [47, 65]. In
addition to utilization of objective ap monitoring tools such as the Cook doppler and ViOptix,
several visual and tactile cues obtained via physical exam are worrisome for ap compromise and
warrant prompt investigation: changes in ap
skin color, capillary rell, and tissue turgor; scant
or brisk dermal bleeding; or a ap that is cool to
the touch [47].
While the vast majority of reconstructive surgeons agree that a dangle protocol should be
part of any postoperative plan following free tis-
sue transfer, there is considerable variability
with respect to the timing of initiation and frequency of such protocols. A recent systematic
review found that the vast majority of studied
protocols included 48h of bedrest after surgery
followed by initiation of a dangle protocol on
postoperative day three [66]. Patients were typically allowed to start weight-bearing at the conclusion of the dangling protocol barring any
concomitant orthopedic injuries that would preclude this [66]. The importance of patient counseling and education bears repeating at this
stage, as failure to comply with weight-bearing
and ambulation progression can lead to ap
failure.
Conclusion
Preparing for free tissue transfer reconstruction
requires coordinated care among various medical
and surgical specialties. Free tissue transfer is a
highly reliable reconstructive option for patients
with diabetes, but optimization of blood sugar
and other underlying comorbidities prior to surgery is essential to ap success. Thigh-based
aps can be used for the vast majority of lower
extremity defects and end-to-side anastomosis
allows for preservation of distal vascular supply.
In the postoperative period, frequent ap checks
and adherence to weight-bearing and ambulation
protocols are key to ap success.
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Advanced Plastic Surgical
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Reconstruction Options
intheLower Extremity
JohnM.Felder andJoonPioHong
32
Introduction
For microsurgeons, diabetic foot reconstruction
represents an opportunity to provide substantial
quality of life and mortality benets to an often
neglected patient population. However, free tissue transfer in diabetics is among the most challenging for a variety of reasons, with a higher risk
of failure than in many types of microsurgery.
The multifactorial nature of the disease and the
inevitable presence of multiple signicant medical comorbidities mandate that reconstruction be
approached in the context of a multidisciplinary
team. Even with a team approach, questions as
basic as indications for salvage may be difcult
to answer, and much of the literature surrounding
microsurgical reconstruction focuses on ap success rates rather than the more complex questions
of proper patient selection and meaningful outcomes. Presenting scenarios vary widely in
regard to wound types, underlying bony and vascular abnormalities, functional abilities and
demands of the patient, complicating medical
diseases, social resources, and availability of
J. M. Felder
Division of Plastic Surgery, Department of Surgery,
Washington University in St. Louis School of
Medicine, St. Louis, MO, USA
J. P. Hong (*)
Department of Plastic Surgery, Asan Medical Center,
University of Ulsan, Seoul, South Korea
e-mail: joonphong@amc.seoul.kr
infrastructure to support complex reconstructive
efforts.
This chapter is geared toward the surgeon who
already has a strong grasp of these complex
issues. Advanced reconstructive techniques provide microsurgeons additional tools to tackle
challenging and complex cases, as well as tools
to reduce the morbidity of reconstruction. A
broad palette of options allows the surgeon to be
exible and create elegant solutions that are best
suited to the unique circumstance of the patient.
Examples of advanced techniques include
“supermicrosurgery” (anastomosis involving
vessels <0.8mm in luminal diameter), perforator
to perforator anastomoses, superthin aps, owthrough aps, and other techniques. Advanced
reconstruction requires the surgeon to be able to
shift perspectives away from classic dogma when
needed to choose the actual best option for the
given scenario. Unfamiliar principles such as
working with small vessels near the zone of
injury may actually provide the simplest, quickest, and least morbid reconstruction to the patient
without jeopardizing outcomes. However, judicious use of both old and new principles will be
required to obtain consistently excellent outcomes across the spectrum of problems encountered in this challenging eld.
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_32
467
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