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Fig. 42.5 (a) The patient suffered from right chest empy- ema due to tuberculosis. The tuberculosis had been eradi­cated after medication leaving a large cavity in the right chest. Many attempts of de-cortication had been per­formed trying to expand the lung but all failed. Due to the multiple incisions on the right chest wall, there was no sufcient muscle for insertion into the cavity. There was persistent pus discharge every day and he had to go to the
hospital for dressing change every day. He could not go to work for almost 30 years. (b) Reconstruction was per­formed with the left latissumus dorsi and distal half of the serratus anterior muscle, which was transferred as a free ap for the obliteration of the empyema space. (c) The wound healed completely and he returned to normal life after surgery
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Fig. 42.6 (a) The female patient sustained severe lymph- edema with prominent swelling of the right lower limb and repetitive infection. On examination, the skin and subcutaneous tissue had advanced brosis as hard as a
42.3 Discussion onOther Issues
Plastic surgeons frequently encounter lower extremity wounds in their daily clinical practice. Lower extremity reconstruction has unique dif­culties due to the anatomical and functional char­acteristics of the lower extremity. Acute complex wounds that are very difcult to reconstruct may occur after extensive trauma and cancer excision in the lower extremity. Furthermore, there may be complex non-healing lower extremity ulcers, including venous stasis, diabetic, and arterial ischemic ulcers [4, 15]. Vasculitis, pyoderma gangrenosum, sickle cell disease, calciphylaxis, and autoimmune diseases are the other causes of ulcers in the lower extremities [15, 16].
rock. (b) Modied Charles’ procedure was performed, and the lymph node ap was transferred to the right foot afterward. The patient had no more infection or ulcer and could go to work with normal social life
Additionally, ulcers related to osteomyelitis are prevalent in the lower extremity. These wounds usually have developed after trauma and are char­acterized by extensive brosis and ischemia [17]. Effective treatment for osteomyelitis and cover­age of the ulcer remains one of the challenges in reconstructive surgery.
Before the reconstruction of the chronic ulcer of the lower extremity, the patient must be physi­ologically stable, and adverse conditions such as venous hypertension, arterial insufciency, and diabetes of the patient, which cause the ulcer, must be taken under control [18]. In addition, wound colonization and infection should ade­quately be controlled with serial debridements and an appropriate antibiotic regimen before per-
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forming reconstructive surgery. Different recon­structive options are available for different anatomical regions in lower extremity reconstruction. The following discussion is focused on three common chronic wounds: (1) venous ulcers, (2) diabetic ulcers, and (3) pressures.
42.3.1 Venous Ulcers
Venous ulcers are the most common cause of ulceration and account for 70–80% of all ulcers in the lower extremity [19, 20]. The rst step in the management of venous ulcers is bed rest with leg elevation, compression therapy, debridement, and local wound care [21, 22]. In case of infec­tion, antibiotics can be used, and other medica­tions such as pentoxifylline, which have been proven to accelerate healing, can also be used. In addition to conventional wound care, cellular and tissue-based products are also helpful for wound care [23]. However, none of these conservative methods correct the underlying pathophysiology. Current surgical treatments include skin grafting, ablation of the saphenous vein, interruption of the perforating veins with subfascial endoscopic surgery, treatment of iliac vein obstruction with stenting, and removal of incompetent supercial veins with phlebectomy, stripping, sclerotherapy, or laser therapy [24, 25]. Invasive surgeries are being replaced by less invasive percutaneous pro­cedures, such as radiofrequency therapy, endo­vascular laser ablation, and ultrasound-guided foam sclerotherapy [25]. Despite conservative treatments, skin grafts, and advanced surgical attempts to improve venous hemodynamics, the recurrence rate in venous ulcers reaches 70% at 6months [26]. Even if surgical interventions cor­rect venous pathophysiology, they cannot pro­vide an improvement on the irreversibly scarred and lipodermatosclerotic extremity. At this point, complete removal of the venous ulcer and all sur­rounding lipodermatosclerotic tissue and recon­struction with distant healthy tissues may effectively prevent recurrences.
Dunn et al. used fasciocutaneous free aps
(scapular, anterolateral thigh, posterior calf) on
six patients to reconstruct recalcitrant venous ulcers in 1994. All the patients had undergone previous surgical interventions such as skin grafts, subfacial ligation, and local aps, but venous ulcers recurred. They pathologically proved no sign of lipodermatosclerosis with skin biopsies taken from the aps 7 years after the operations [27]. In 1997, Weinzweig and Schuler published their series of reconstructions using 20 muscle aps in 18 patients with non-traumatic non-osteomyelitic venous ulcers for an average of 3.5years [28]. Flap’s success rate was 90%. They mostly used the rectus abdominis muscle ap; they preferred the latissimus dorsi muscle ap for large defects, the rectus abdominis mus­cle ap or “split” latissimus dorsi muscle ap for medium-sized defects, and the gracilis and ser­ratus muscle aps for small defects. They con­cluded that with free muscle transfer, the diseased recipient bed could be covered with healthy tis­sue containing competent micro-venous valves with normal circulation to provide a long-term cure. They also stated that free ap surgery is much more cost-effective than conventional treatments, which have high recurrence rates. However, a study argued that free muscle aps provide temporary palliation, not a permanent solution in treating chronic venous ulcers [29]. In this study, with a mean follow-up of 5.4years, 14 free aps (8 latissimus muscle aps, 3 serratus muscle aps, 1 deltoid ap, 1 scapular fascia ap, and 1 serratus fascia ap) were used for the treat­ment of chronic venous ulcers, and all patients developed new ulcers within an average of
17.2months. Another clinical article supporting that free tissue transfers can provide rapid heal­ing and long-term relief from severe venous ulcers by improving venous hemodynamics and resolving the tissue-related components of chronic ulceration was published in 2000 [30]. Besides free ap transfers, a regional ap was proposed to reconstruct chronic venous ulcers. After the excision of the ulcer and its surrounding lipodermatosclerotic skin, the coverage of the defect and ligation of perforating veins can be performed in a one-stage operation by distally based sural ap without the need for microsurgi­cal techniques [31].
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42.3.2 Diabetic Ulcers
Diabetic ulcers are the second, and ischemic or arterial ulcers (non-diabetic) are the third com­mon cause of chronic wounds on the lower extremities [32]. Up to 25% of patients with leg ulcers have peripheral arterial disease [33]. The primary cause of diabetic ulcers is diabetic neu­ropathy; the other reason is ischemia due to peripheral arterial disease, frequently caused by the combination of neuropathy and ischemia [34]. The lifetime risk of a person with diabetes devel­oping a foot ulcer could be as high as 25%, and diabetic foot ulcers are the single most signicant risk factor for nontraumatic foot amputations in persons with diabetes [35, 36]. Due to the high incidence of foot ulcers, amputations remain a source of morbidity and mortality in persons with diabetes. Amputations are 15 times more com­mon in persons with diabetes than those without the disease; limb amputations due to diabetes are associated with an increased risk of additional amputations and have a 57% 5-year mortality rate [37]. Considering these dramatic data, reconstruc­tion of the extremity and preventing amputations should be the most crucial goals in treating patients with diabetic or ischemic ulcers.
Amputation rates in diabetic patients have been considerably reduced by combined revascu­larization and free tissue transfers, hence offering patients a better quality of life and increasing the 5-year survival rates [38, 39]. However, in the past, there were hesitations for free aps in dia­betics and patients with atherosclerosis, while free tissue transfers were frequently used to reconstruct traumatic lower extremity defects. Restoring adequate blood ow to the lower extremity is sufcient for secondary healing or successful treatment with skin grafts in many ischemic ulcers. However, for complex defects with exposed bone or tendons, skin grafts or local aps are often insufcient for reconstruction. In these cases, free tissue transfer is the only option to save the extremity [40]. It has been shown that many comorbidities, including diabetes, are not contraindications to free ap surgery [41–43]. Free aps have been widely used for salvage of
ischemic extremities that otherwise would not be salvageable [44–46].
In 1985, Briggs etal. performed free muscle (rectus abdominis) and free fasciocutaneous aps (radial forearm ap and scapular ap) recon­struction 2–3weeks after revascularization with bypass in four patients with ischemic ulcers, three of whom were diabetic [47]. They used arterial bypass vein graft as the recipient vessel in their series, showing that the graft is a suitable alternative as a recipient vessel in extremities where the native vessels cannot be used. They suggested that distal revascularization and micro­vascular free tissue transfer can be used for extremity salvage in selected patients, especially for wounds with exposed tendons and bone. In 1987, Colen published the series in which he used ten free aps (gracilis muscle, serratus ante­rior, and scapular free aps) for wound recon­struction in seven patients with diabetes and severe peripheral vascular disease [48]. Revascularization was performed with bypass surgery in 7 of 10 extremities, and denitive ap surgery was performed 5–7days after revascular­ization. In patients with osteomyelitis, muscle aps were used for their effectiveness, and sen­sate aps were used when the weight-bearing area was required to be covered. He pointed out that because of two misconceptions (diabetic patients, even with a normal pedal pulse, have “small-vessel disease,” and there is endothelial proliferation in the small vessels of diabetic patients), free ap surgery is avoided; however, studies have revealed that these are not true. He stated that salvage of the extremity by a free tis­sue transfer is invaluable, especially in patients whose contralateral leg had been amputated before.
Today, many free ap options, including mus­cle aps, fasciocutaneous aps, and perforator aps, such as anterolateral thigh (ALT) ap [39,
49–51], supercial circumex iliac artery perfo-
rator (SCIP) ap [39, 52], profunda artery perfo­rator (PAP) ap [53], gluteal artery perforator (GAP) ap [54, 55], medial sural artery perfora­tor (MSAP) ap [56], and thoracodorsal artery perforator (TDAP) ap [57, 58] are used with a
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success rate of 85–92% in the reconstruction of diabetic ischemic ulcers [59].
Diabetic ulcers may often be complicated by the presence of osteomyelitis, and they may be more complicated by ischemia of the involved limb secondary to peripheral vascular disease [60]. Treatment of osteomyelitis, which is still challenging for plastic surgeons, includes aggres­sive debridement, appropriate antibiotic therapy, and coverage of the soft tissue defect with well­vascularized tissue [60, 61]. For years, skin grafts, local muscle aps, and cross-leg aps have been used for soft tissue coverage following debridement [62–64]. However, none of these reconstruction methods have been as effective as reconstructions with free aps, which provide coverage of the infected bone with well­vascularized tissue [65, 66].
The robust blood supply of the muscle ap allows the delivery of good antibiotics to the wound, increases oxygen tension, and increases phagocytic activity to ght the infection [17, 67,
68]. Furthermore, muscle aps promote bone
healing in the early phases of wound healing [69] and obliterate dead spaces very well. Because of these properties, free muscle aps have been used in treating chronic osteomyelitis and have been preferred over fasciocutaneous aps. In 2005, Hong etal. used the ALT ap effectively in the treatment of chronic osteomyelitis [70]. Zweifel­Schlatte et al. published a series of 14 patients treated with free fasciocutaneous aps in 2006 [71]. Hong et al. showed that perforator aps (ALT ap, SCIP ap, TDAP ap, upper medial thigh (UMG) ap, and superior gluteal artery perforator (SGAP) ap) could be used effectively in the treatment of chronic osteomyelitis in their extensive series including 120 patients [72]. A meta-analysis revealed that fasciocutaneous aps can be used in treating osteomyelitis as effec­tively as muscle aps and that adequate debride­ment, appropriate antibiotic selection, as well as sufcient duration of treatment are much more critical than ap selection [73].
There are many pedicled locoregional ap options that can be safely used in soft tissue reconstruction of diabetic and ischemic ulcers
and do not require salvage with free tissue transfers. For the proximal third of the leg, gas­trocnemius muscle ap with skin graft remains the rst option [74]. Proximally based soleus ap and bipedicled tibialis anterior ap are the other alternatives for this region. For the middle third defects of the leg, the gastrocnemius muscle and soleus muscle aps provide reliable pedicled aps [75, 76]. The other regional muscle ap options for the reconstruction of middle third defects of the leg are exor digitorum longus ap, extensor digitorum longus ap, extensor digitorum hallucis ap, exor hallucis longus ap, and tibialis anterior ap [76–78]. It was pro­posed that free ap reconstruction is the rst and only reliable option for the reconstruction of defects located in the distal third of the leg, as there is not enough soft tissue coverage to be used as a ap and local muscle aps are often unreliable in this region [18, 65]. However, today there are other reliable options in many cases since fasciocutaneous aps, perforator aps and propeller perforator aps are included in the reconstructive options, and their reliability has been proven [79, 80].
Free aps are the most appropriate recon­struction method for large defects or composite tissue loss in the lower extremity. However, due to their signicant advantages, pedicled perfora­tor (propeller) aps have been widely used to reconstruct small- or medium-sized lower extremity defects [81, 82]. These advantages include preservation of the source vessels, pres­ervation of the underlying muscles, minimal donor site morbidity, and a more effortless surgi­cal technique that does not require microvascu­lar anastomosis, and they are less morbid for unhealthy patients [83–85]. The posterior tibial artery perforator (PTAP) ap, anterior tibial artery perforator (ATAP) ap, peroneal artery perforator (PAP) ap, medial sural artery perfo­rator (MSAP) ap, lateral sural artery perforator (LSAP) ap, lateral superior genicular artery perforator (SGAP) ap, dorsal metatarsal artery perforator (DMtAP) ap, and dorsalis pedis adi­pofascial perforator ap (DPAP) are the pedicled perforator aps that have been used in lower
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extremity reconstruction [86, 87]. The most commonly used aps are PTAP aps (58%) and PAP aps (25.7%) [88]. The most commonly used aps for the reconstruction of the distal third of the leg are PTAP, PAP, and ATAP aps. For the reconstruction of the proximal and mid­dle leg, besides PTAP, PAP, and ATAP aps, MSAP ap can also be a ap choice [89].
The use of perforator aps in lower extremity reconstructions is increasing. However, there is a tendency to return to free aps due to high com­plication rates (especially at the distal third of the leg) [88]. In the analysis of 15 studies, including 186 cases, the overall complication rate was found to be 25.8%, the most common ones are partial ap loss (11.3%) and venous congestion (8.1%), but the failure rate was found to be 1.1% [86]. In another study that included 21 studies and 310 propeller aps, the total ap necrosis rate was 5.5%, with a partial necrosis rate of
11.6% [90]. In a meta-analysis of 40 articles and 428 cases, ap complications were found in
25.2%, including partial necrosis (10.2%) and complete necrosis (3.5%); the signicant risk factors for complications were age older than 60 years, diabetes, and arteriopathy [88]. The same group showed that partial necrosis is sig­nicantly higher for pedicled propeller aps; however, the overall complication rate of perfora­tor propeller aps is comparable with free aps with similar coverage success [87].
42.3.3 Pressure Sores
Pressure ulcers are the most common chronic wound independent of location [32]. Pressure sores are caused by unrelieved pressure on the soft tissue over a bony prominence. It develops in patients with a sensory decit or motor decit, or both, for extrinsic factors (shear, pressure, fric­tion, and moisture) and intrinsic factors (isch­emia, sepsis, decreased autonomic control, malnutrition, etc.). Pressure ulcer development is destructive for the patient, healthcare provider, and community [91]. The most common sites of pressure ulcers are the sacrum (36.9%) and heel
(30.3%). Ischium, trochanter, malleolus, elbow, knee, scapula, and occiput are the other sites for pressure ulcers [92]. Stages I and II pressure sores can be managed conservatively, and stages III and IV ulcers frequently require surgical inter­vention [93]. Previously, muscle aps were the mainstay in reconstruction. Since 1980, fasciocu­taneous aps have taken their place in the treat­ment of pressure ulcers [94]. The functional loss when a muscle ap is used for reconstruction in ambulatory patients must be considered. Fasciocutaneous aps protect the muscle and function and allow the muscle to be used for reconstruction if needed in the future [95].
Cushing and Phillips have listed the ap options that can be used to reconstruct common pressure ulcers [93]. Gluteus muscle ap or myo­cutaneous ap may be designed as advancement, rotation, or island ap. Split gluteus muscle ap (based on superior or inferior gluteal artery), V-to-Y rectus femoris ap, other hamstring advancement aps, and gracilis ap are options for muscle ap for the reconstruction of ischial pressure ulcers. In the reconstruction of ischial pressure ulcers, fasciocutaneous aps such as tensor fasciae latae and gluteal thigh ap can also be used. Gluteal aps (fasciocutaneous, muscle only, musculocutaneous, split, or perforator) are the mainstay of reconstruction for sacral pressure ulcers. The other alternatives are transverse and vertical lumbosacral aps. The rst choice for the reconstruction of trochanteric pressure sore is the tensor fascia lata perforator ap. The other reli­able options are vastus lateralis, rectus femoris, and gluteal thigh aps.
At the time of admission, 30–70% of patients have more than one pressure sore [96, 97], and recurrence rates reach up to 56% after wound closure [98, 99]. There are numerous options for local and regional aps for the treatment of pri­mary pressure sores in the pelvic region. Closing the recurrent pressure sores may usually be pos­sible by using these options or even by reusing previous aps. However, in some cases, all the regional aps may have been used; reconstruc­tion with free aps may be considered in such recalcitrant cases. Chen etal. successfully used a
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lleted lower leg myocutaneous free ap to reconstruct three large pressure sores in a patient and showed that free aps could be used for pres­sure ulcer reconstruction in rare indications [100]. After this rst case, the same group used the latissimus muscle free ap for pressure ulcer reconstruction [101]. For pressure ulcer recon­struction, fasciocutaneous free aps such as lat­eral thigh ap, medial plantar ap, parascapular ap [102], latissimus dorsi muscle-splitting free ap [103], and free perforator aps such as ALT and TDAP [104] were also used.
42.4 Conclusion
Chronic wounds are serious health issues for patients that cause morbidity and sometimes even mortality; however, with appropriate wound care following the basic principles of wound healing, it is possible to close most chronic wounds with­out requiring surgical interventions. Nevertheless, there may be ulcers complicated for various rea­sons, and closure of these complex wounds is possible with surgery. For the closure of compli­cated wounds, there are always advanced recon­struction options available in plastic surgery, including complex free tissue transfers with microsurgery and super microsurgery. In com­plex defects and ulcers, a combination of general surgery, chest surgery, orthopedic surgery, vascu­lar surgery, and medical treatment may be neces­sary in addition to various technologies such as vacuum-assisted wound closure systems, hyper­baric oxygen therapy, tissue expanders, vascular cable aps and lymphatic cable ap, endovascu­lar surgery, etc.
References
1. Teller P, White TK.The physiology of wound heal­ing: injury through maturation. Surg Clin North Am. 2009;89(3):599–610. https://doi.org/10.1016/j.
suc.2009.03.006.
2. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconstr Surg. 2016;138(3 Suppl):9S–17S. https://doi.org/10.1097/
PRS.0000000000002773.
3. Childs DR, Murthy AS. Overview of wound healing and management. Surg Clin North Am. 2017;97(1):189–207. https://doi.org/10.1016/j.
suc.2016.08.013.
4. Jones CM, Rothermel AT, Mackay DR. Evidence­based medicine: wound management. Plast Reconstr Surg. 2017;140(1):201e–16e. https://doi.
org/10.1097/PRS.0000000000003486.
5. Mustoe TA, O’Shaughnessy K, Kloeters O.Chronic wound pathogenesis and current treatment strat­egies: a unifying hypothesis. Plast Reconstr Surg. 2006;117(7 Suppl):35S–41S. https://doi.
org/10.1097/01.prs.0000225431.63010.1b.
6. Zhao R, Liang H, Clarke E, Jackson C, Xue M. Inammation in chronic wounds. Int J Mol Sci. 2016;17(12):2085. https://doi.org/10.3390/
ijms17122085.
7. Broughton G II, Janis JE, Attinger CE.Wound heal­ing: an overview. Plast Reconstr Surg. 2006;117(7 Suppl):1e-S–32e-S. https://doi.org/10.1097/01.
prs.0000222562.60260.f9.
8. Teot L, Ohura N. Challenges and manage­ment in wound care. Plast Reconstr Surg. 2021;147(1S-1):9S–15S. https://doi.org/10.1097/
PRS.0000000000007628.
9. Buchanan PJ, Kung TA, Cederna PS. Evidence­based medicine: wound closure. Plast Reconstr Surg. 2014;134(6):1391–404. https://doi.org/10.1097/
PRS.0000000000000720.
10. Mathes SJ, Nahai F.Clinical applications for mus­cle and musculocutaneous aps. St. Louis: Mosby;
1982. p.3.
11. Mathes SJ, Nahai F.Reconstructive surgery: prin­ciples, anatomy & technique. St. Louis: Quality Medical Publishing; 1997.
12. Zenn MR, Jones G. Surgical decision-making: options, principles, and techniques. In: Zenn MR, Jones G, editors. Reconstructive surgery anatomy, technique, and clinical applications. St. Louis: Quality Medical Publishing; 2012. p.7–34.
13. Gottlieb LJ, Krieger LM. From the reconstruc­tive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93(7):1503–4. https://doi.
org/10.1097/00006534- 199406000- 00027.
14. Erba P, Ogawa R, Vyas R, Orgill DP.The reconstruc­tive matrix: a new paradigm in reconstructive plastic surgery. Plast Reconstr Surg. 2010;126(2):492–8.
https://doi.org/10.1097/PRS.0b013e3181de232b.
15. Hafner A, Sprecher E.Ulcers. In: Dermatology. 4th ed. Amsterdam: Elsevier; 2018. p.1826–1846e1.
16. Shanmugam VK, Angra D, Rahimi H, McNish S.Vasculitic and autoimmune wounds. J Vasc Surg Venous Lymphat Disord. 2017;5(2):280–92. https://
doi.org/10.1016/j.jvsv.2016.09.006.
17. Mathes SJ, Alpert BS, Chang N. Use of the muscle ap in chronic osteomyelitis: experi­mental and clinical correlation. Plast Reconstr Surg. 1982;69(5):815–29. https://doi.
org/10.1097/00006534- 198205000- 00018.
42 Advanced Reconstruction inWound Care
https://t.me/medicina_free
495
18. Reddy V, Stevenson TR.MOC-PS(SM) CME article: lower extremity reconstruction. Plast Reconstr Surg. 2008;121(4 Suppl):1–7. https://doi.org/10.1097/01.
prs.0000305928.98611.87.
19. Tatsioni A, Balk E, O’Donnell T, Lau J. Usual care in the management of chronic wounds: a review of the recent literature. J Am Coll Surg. 2007;205(4):617–624e57. https://doi.org/10.1016/j.
jamcollsurg.2007.05.032.
20. Caprini JA, Partsch H, Simman R.Venous ulcers. J Am Coll Clin Wound Spec. 2012;4(3):54–60.
https://doi.org/10.1016/j.jccw.2013.11.001.
21. Chaitidis N, Kokkinidis DG, Papadopoulou Z, Kyriazopoulou M, Schizas D, Bakoyiannis C.Treatment of chronic venous disorder: a compre­hensive review. Dermatol Ther. 2022;35(2):e15238.
https://doi.org/10.1111/dth.15238.
22. Lurie F, Bittar S, Kasper G.Optimal compression therapy and wound care for venous ulcers. Surg Clin North Am. 2018;98(2):349–60. https://doi.
org/10.1016/j.suc.2017.11.006.
23. Falanga V, Sabolinski M. A bilayered living skin construct (APLIGRAF) accelerates complete closure of hard-to-heal venous ulcers. Wound Repair Regen. 1999;7(4):201–7. https://doi.
org/10.1046/j.1524- 475x.1999.00201.x.
24. Verma H, Tripathi RK.Algorithm-based approach to management of venous leg ulceration. Semin Vasc Surg. 2015;28(1):54–60. https://doi.org/10.1053/j.
semvascsurg.2015.07.002.
25. Alavi A, Sibbald RG, Phillips TJ, etal. What’s new: management of venous leg ulcers: treating venous leg ulcers. J Am Acad Dermatol. 2016;74(4):643–
64. ; quiz 665–6. https://doi.org/10.1016/j.
jaad.2015.03.059.
26. O’Donnell TF Jr, Passman MA, Marston WA, etal. Management of venous leg ulcers: clinical prac­tice guidelines of the Society for Vascular Surgery (R) and the American Venous Forum. J Vasc Surg. 2014;60(2 Suppl):3S–59S. https://doi.org/10.1016/j.
jvs.2014.04.049.
27. Dunn RM, Fudem GM, Walton RL, Anderson FA Jr, Malhotra R. Free ap valvular transplan­tation for refractory venous ulceration. J Vasc Surg. 1994;19(3):525–31. https://doi.org/10.1016/
s0741- 5214(94)70081- 8.
28. Weinzweig N, Schuler J. Free tissue transfer in treatment of the recalcitrant chronic venous ulcer. Ann Plast Surg. 1997;38(6):611–9. https://doi.
org/10.1097/00000637- 199706000- 00008.
29. Steffe TJ, Caffee HH.Long-term results following free tissue transfer for venous stasis ulcers. Ann Plast Surg. 1998;41(2):131–7; discussion 138–9. https://
doi.org/10.1097/00000637- 199808000- 00004.
30. Kumins NH, Weinzweig N, Schuler JJ.Free tissue transfer provides durable treatment for large non­healing venous ulcers. J Vasc Surg. 2000;32(5):848–
54. https://doi.org/10.1067/mva.2000.110344.
31. Top H, Benlier E, Aygit AC, Kiyak M. Distally based sural ap in treatment of chronic venous ulcers. Ann Plast Surg. 2005;55(2):160–5; dis­cussion 166–8. https://doi.org/10.1097/01.
sap.0000168887.25946.54.
32. Kirsner RS, Vivas AC. Lower-extremity ulcers: diagnosis and management. Br J Dermatol. 2015;173(2):379–90. https://doi.org/10.1111/
bjd.13953.
33. Fonder MA, Lazarus GS, Cowan DA, Aronson­Cook B, Kohli AR, Mamelak AJ. Treating the chronic wound: a practical approach to the care of nonhealing wounds and wound care dressings. J Am Acad Dermatol. 2008;58(2):185–206. https://doi.
org/10.1016/j.jaad.2007.08.048.
34. Alavi A, Sibbald RG, Mayer D, etal. Diabetic foot ulcers: part I.Pathophysiology and prevention. J Am Acad Dermatol. 2014;70(1):1e1–18; quiz 19–20.
https://doi.org/10.1016/j.jaad.2013.06.055.
35. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J.The global burden of diabetic foot dis­ease. Lancet. 2005;366(9498):1719–24. https://doi.
org/10.1016/S0140- 6736(05)67698- 2.
36. Boulton AJ, Vileikyte L. The diabetic foot: the scope of the problem. J Fam Pract. 2000;49(11 Suppl):S3–8.
37. Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortal­ity and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13(1):16. https://doi.org/10.1186/
s13047- 020- 00383- 2.
38. Randon C, Vermassen F, Jacobs B, De Ryck F, Van Landuyt K, Taes Y. Outcome of arterial reconstruction and free-flap coverage in diabetic foot ulcers: long-term results. World J Surg. 2010;34(1):177–84. https://doi.org/10.1007/
s00268- 009- 0250- 9.
39. Oh TS, Lee HS, Hong JP.Diabetic foot reconstruc­tion using free aps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg. 2013;66(2):243–50.
https://doi.org/10.1016/j.bjps.2012.09.024.
40. Kolbenschlag J, Hellmich S, Germann G, Megerle K. Free tissue transfer in patients with severe peripheral arterial disease: functional outcome in reconstruction of chronic lower extremity defects. J Reconstr Microsurg. 2013;29(9):607–14. https://doi.
org/10.1055/s- 0033- 1354739.
41. Wettstein R, Schurch R, Banic A, Erni D, Harder Y. Review of 197 consecutive free ap reconstruc­tions in the lower extremity. J Plast Reconstr Aesthet Surg. 2008;61(7):772–6. https://doi.org/10.1016/j.
bjps.2007.11.037.
42. Herold C, Gohritz A, Meyer-Marcotty M, etal. Is there an association between comorbidities and the outcome of microvascular free tissue transfer? J Reconstr Microsurg. 2011;27(2):127–32. https://doi.
org/10.1055/s- 0030- 1268851.
496
https://t.me/medicina_free
H.-C. Chen and B. Kaya
43. Xiong L, Gazyakan E, Kremer T, etal. Free aps for reconstruction of soft tissue defects in lower extrem­ity: a meta-analysis on microsurgical outcome and safety. Microsurgery. 2016;36(6):511–24. https://
doi.org/10.1002/micr.30020.
44. Ozkan O, Coskunrat OK, Ozgentas HE.Reliability of free-ap coverage in diabetic foot ulcers. Microsurgery. 2005;25(2):107–12. https://doi.
org/10.1002/micr.20094.
45. Sato T, Yana Y, Ichioka S. Free ap reconstruction for diabetic foot limb salvage. J Plast Surg Hand Surg. 2017;51(6):399–404. https://doi.org/10.1080/
2000656X.2017.1285782.
46. Wukich DK, Raspovic KM. What role does func­tion play in deciding on limb salvage versus ampu­tation in patients with diabetes? Plast Reconstr Surg. 2016;138(3 Suppl):188S–95S. https://doi.
org/10.1097/PRS.0000000000002713.
47. Briggs SE, Banis JC Jr, Kaebnick H, Silverberg B, Acland RD.Distal revascularization and microvas­cular free tissue transfer: an alternative to amputa­tion in ischemic lesions of the lower extremity. J Vasc Surg. 1985;2(6):806–11. https://doi.org/10.1067/
mva.1985.avs0020806.
48. Colen LB. Limb salvage in the patient with severe peripheral vascular disease: the role of microsurgical free-tissue transfer. Plast Reconstr Surg. 1987;79(3):389–95. https://doi.
org/10.1097/00006534- 198703000- 00013.
49. Hong JP. Reconstruction of the diabetic foot using the anterolateral thigh perforator ap. Plast Reconstr Surg. 2006;117(5):1599–608. https://doi.
org/10.1097/01.prs.0000207057.16292.8f.
50. Seth AK, Iorio ML.Super-thin and suprafascial antero­lateral thigh perforator aps for extremity recon­struction. J Reconstr Microsurg. 2017;33(7):466–73.
https://doi.org/10.1055/s- 0037- 1601422.
51. Chou C, Kuo PJ, Chen YC, et al. Combination of vascular intervention surgery and free tissue trans­fer for critical diabetic limb salvage. Ann Plast Surg. 2016;77(Suppl 1):S16–21. https://doi.org/10.1097/
SAP.0000000000000812.
52. Myung Y, Yim S, Kim BK.A comparison of axial circumference between supercial circumex iliac artery perforator ap and other workhorse aps in dorsal foot reconstruction. J Plast Surg Hand Surg. 2017;51(6):381–6. https://doi.org/10.1080/20006
56X.2017.1279621.
53. Ciudad P, Kaciulyte J, Torto FL, etal. The profunda artery perforator free ap for lower extremity recon­struction. Microsurgery. 2022;42(1):13–21. https://
doi.org/10.1002/micr.30745.
54. Hong JP, Yim JH, Malzone G, Lee KJ, Dashti T, Suh HS.The thin gluteal artery perforator free ap to resurface the posterior aspect of the leg and foot. Plast Reconstr Surg. 2014;133(5):1184–91. https://
doi.org/10.1097/PRS.0000000000000127.
55. Orfaniotis G, Nicoli F, Maruccia M, Ciudad P, Chen HC. The thin gluteal artery perforator free ap to
resurface the posterior aspect of the leg and foot. Plast Reconstr Surg. 2015;135(4):793e–4e. https://
doi.org/10.1097/PRS.0000000000001093.
56. Lin CH, Hsieh YH, Lin CH.The medial sural artery perforator ap in lower extremity reconstruction. Clin Plast Surg. 2021;48(2):249–57. https://doi.
org/10.1016/j.cps.2021.01.003.
57. Kim SW, Sung IH, Kim YH. Reconstruction of severe atherosclerotic and obstructive diabetic feet using thoracodorsal artery perforator aps with long vascular pedicles. Microsurgery. 2018;38(3):287–
94. https://doi.org/10.1002/micr.30251.
58. Lim SY, Kim GH, Sung IH, etal. Lower extremity salvage with thoracodorsal artery perforator free ap in condition of symmetrical peripheral gangrene. Biomed Res Int. 2018;2018:6508607. https://doi.
org/10.1155/2018/6508607.
59. Kwon JG, Cho MJ, Pak CJ, Suh HP, Hong JP. A retrospective case series on free ap recon­struction for ischemic diabetic foot: the nutri­ent ap further explained. Plast Reconstr Surg. 2022;149(6):1452–61. https://doi.org/10.1097/
PRS.0000000000009132.
60. Rao N, Ziran BH, Lipsky BA. Treating osteo­myelitis: antibiotics and surgery. Plast Reconstr Surg. 2011;127(Suppl 1):177S–87S. https://doi.
org/10.1097/PRS.0b013e3182001f0f.
61. Tierny C, Casoli V, Chadefaux G, etal. Management of chronic osteomyelitis by an orthoplastic team: 7-year experience of a University Hospital. Plast Reconstr Surg. 2021;148(2):443–53. https://doi.
org/10.1097/PRS.0000000000008175.
62. Atiyeh BS. The cross-leg ap: a new perspective. Plast Reconstr Surg. 1994;94(1):223–4. https://doi.
org/10.1097/00006534- 199407000- 00049.
63. Ger R. Muscle transposition for treatment and prevention of chronic post-traumatic osteo­myelitis of the tibia. J Bone Joint Surg Am. 1977;59(6):784–91.
64. Ger R, Efron G.New operative approach in the treat­ment of chronic osteomyelitis of the tibial diaphy­sis. A preliminary report. Clin Orthop Relat Res. 1970;70:165–9.
65. Frykman GK, Leung VC. Free vascular­ized aps for lower extremity reconstruc­tion. Orthopedics. 1986;9(6):841–8. https://doi.
org/10.3928/0147- 7447- 19860601- 10.
66. Musharaeh R, Osmani O, Musharaeh U, Saghieh S, Atiyeh B. Efcacy of microsurgi­cal free-tissue transfer in chronic osteomyelitis of the leg and foot: review of 22 cases. J Reconstr Microsurg. 1999;15(4):239–44. https://doi.
org/10.1055/s- 2007- 1000097.
67. Russell RC, Graham DR, Feller AM, Zook EG, Mathur A. Experimental evaluation of the antibiotic carrying capacity of a mus­cle ap into a brotic cavity. Plast Reconstr Surg. 1988;81(2):162–70. https://doi.
org/10.1097/00006534- 198802000- 00003.
42 Advanced Reconstruction inWound Care
https://t.me/medicina_free
497
68. Gosain A, Chang N, Mathes S, Hunt TK, Vasconez L. A study of the relationship between blood ow and bacterial inoculation in musculocutaneous and fasciocutaneous aps. Plast Reconstr Surg. 1990;86(6):1152–62; discussion 1163.
69. Richards RR, McKee MD, Paitich CB, Anderson GI, Bertoia JT.A comparison of the effects of skin cov­erage and muscle ap coverage on the early strength of union at the site of osteotomy after devasculariza­tion of a segment of canine tibia. J Bone Joint Surg Am. 1991;73(9):1323–30.
70. Hong JP, Shin HW, Kim JJ, Wei FC, Chung YK.The use of anterolateral thigh perforator aps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg. 2005;115(1):142–7.
71. Zweifel-Schlatter M, Haug M, Schaefer DJ, Wolnger E, Ochsner P, Pierer G. Free fasciocu­taneous aps in the treatment of chronic osteo­myelitis of the tibia: a retrospective study. J Reconstr Microsurg. 2006;22(1):41–7. https://doi.
org/10.1055/s- 2006- 931906.
72. Hong JPJ, Goh TLH, Choi DH, Kim JJ, Suh HS. The efcacy of perforator aps in the treat­ment of chronic osteomyelitis. Plast Reconstr Surg. 2017;140(1):179–88. https://doi.org/10.1097/
PRS.0000000000003460.
73. Kovar A, Colakoglu S, Iorio ML.Choosing between muscle and fasciocutaneous free ap reconstruction in the treatment of lower extremity osteomyelitis: available evidence for a function-specic approach. J Reconstr Microsurg. 2020;36(3):197–203. https://
doi.org/10.1055/s- 0039- 1698469.
74. Bibbo C. The gastrocnemius ap for lower extremity reconstruction. Clin Podiatr Med Surg. 2020;37(4):609–19. https://doi.org/10.1016/j.
cpm.2020.07.002.
75. Pu LL. Soft-tissue coverage of an extensive mid­tibial wound with the combined medial gastrocne­mius and medial hemisoleus muscle aps: the role of local muscle aps revisited. J Plast Reconstr Aesthet Surg. 2010;63(8):e605–10. https://doi.org/10.1016/j.
bjps.2010.05.003.
76. Guzman-Stein G, Fix RJ, Vasconez LO.Muscle ap coverage for the lower extremity. Clin Plast Surg. 1991;18(3):545–52.
77. Dumont CE, Neumann H, Lingenfelter EJ.Pedicled aps for lower extremity reconstruction in the elderly: a retrospective study of 16 cases. Ann Plast Surg. 2004;53(4):368–72. https://doi.org/10.1097/01.
sap.0000135138.45902.52.
78. Galumbeck M, Colen LB.Soft tissue reconstruction. Coverage of lower leg. Rotational ap. Orthop Clin North Am. 1993;24(3):473–80.
79. Pu LLQ. Locoregional aps in lower extremity reconstruction. Clin Plast Surg. 2021;48(2):157–71.
https://doi.org/10.1016/j.cps.2021.01.001.
80. Pinsolle V, Reau AF, Pelissier P, Martin D, Baudet J. Soft-tissue reconstruction of the distal lower leg and foot: are free aps the only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg.
2006;59(9):912–7; discussion 918. https://doi.
org/10.1016/j.bjps.2005.11.037.
81. Mohan AT, Sur YJ, Zhu L, etal. The concepts of pro­peller, perforator, keystone, and other local aps and their role in the evolution of reconstruction. Plast Reconstr Surg. 2016;138(4):710e–29e. https://doi.
org/10.1097/PRS.0000000000002610.
82. Ayestaray B, Ogawa R, Ono S, Hyakusoku H. Propeller aps: classication and clinical applications. Ann Chir Plast Esthet. 2011;56(2):90–
8. https://doi.org/10.1016/j.anplas.2010.11.004.
83. Geddes CR, Morris SF, Neligan PC. Perforator aps: evolution, classication, and applications. Ann Plast Surg. 2003;50(1):90–9. https://doi.
org/10.1097/00000637- 200301000- 00016.
84. Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator aps: clinical results and vascular anatomy. Plast Reconstr Surg. 2010;126(5):1589–603. https://doi.org/10.1097/
PRS.0b013e3181f02ee3.
85. Herlin C, Sinna R, Chaput B. Muscle versus fas­ciocutaneous free aps in heel reconstruction: systematic review and meta-analysis discussion. J Reconstr Microsurg. 2015;31(3):240–2. https://doi.
org/10.1055/s- 0034- 1395941.
86. Gir P, Cheng A, Oni G, Mojallal A, Saint-Cyr M. Pedicled-perforator (propeller) aps in lower extremity defects: a systematic review. J Reconstr Microsurg. 2012;28(9):595–601. https://doi.
org/10.1055/s- 0032- 1315786.
87. Bekara F, Herlin C, Somda S, de Runz A, Grolleau JL, Chaput B. Free versus perforator-pedicled propeller aps in lower extremity reconstruc­tion: what is the safest coverage? A meta-analysis. Microsurgery. 2018;38(1):109–19. https://doi.
org/10.1002/micr.30047.
88. Bekara F, Herlin C, Mojallal A, etal. A systematic review and meta-analysis of perforator-pedicled propeller aps in lower extremity defects: identica­tion of risk factors for complications. Plast Reconstr Surg. 2016;137(1):314–31. https://doi.org/10.1097/
PRS.0000000000001891.
89. Blough JT, Saint-Cyr MH. Propeller aps in lower extremity reconstruction. Clin Plast Surg. 2021;48(2):173–81. https://doi.org/10.1016/j.
cps.2021.01.002.
90. Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN.A review of propeller aps for distal lower extremity soft tissue reconstruction: is ap loss too high? Microsurgery. 2013;33(7):578–86.
https://doi.org/10.1002/micr.22134.
91. Rubayi S, Chandrasekhar BS.Trunk, abdomen, and pressure sore reconstruction. Plast Reconstr Surg. 2011;128(3):201e–15e. https://doi.org/10.1097/
PRS.0b013e31822214c1.
92. Amlung SR, Miller WL, Bosley LM. The 1999 National Pressure Ulcer Prevalence Survey: a benchmarking approach. Adv Skin Wound Care. 2001;14(6):297–301. https://doi.
org/10.1097/00129334- 200111000- 00012.
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