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SECTION
IV
Special Topics
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261
19
Treatment of
Recalcitrant Venous
Ulcers with Free Tissue
Transfer for
Limb Salvage
Stephen J. Kovach and L. Scott Levin
INTRODUCTION
Venous ulcers of the lower extremity are a common problem in clinical
practice and are estimated to affect 4% of the population over the age of
65.
1
This represents a signifi cant number of patients who must be dealt with
clinically. The majority of patients will be treated conservatively, but
patients with large areas of ulceration or those who have ulcers that are
resistant to conservative means represent a challenging clinical problem.
For many patients, recurrent and recalcitrant venous ulceration may be a
limb-threatening condition.
The underlying pathophysiologic state that results in venous ulceration
is that of chronic venous hypertension.
2
Initial treatment of the patient with
chronic venous ulceration is aimed at correction of this chronic hyperten-
sion through nonsurgical and surgical means. This treatment is accom-
plished through well-recognized techniques, including compression
garments, venous stripping, and subfascial endoscopic perforator surgery
(SEPS). All patients will have had some attempts at skin graft coverage of
their ulcers prior to consideration of free tissue transfer, and some may
have had attempted local fl ap coverage. Patients become candidates for
free fl ap coverage of recalcitrant venous ulcers only after exhausting these
more conservative means for healing their ulcers and achieving durable
soft tissue coverage.
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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262 Treatment of Recalcitrant Venous Ulcers
Chronic venous ulcers typically have poor wound beds for the imbibition
and vascular ingrowth needed to support skin grafting. The dermal micro-
circulation has been shown to have pathologic changes that are not condu-
cive to the healing of skin grafts.
3
Also, simple skin grafting of ulcers is
usually doomed to failure because nothing has been done to alter the
underlying pathology of venous hypertension and subsequent fi brosis of
the surrounding tissues. This surrounding lipodermatosclerosis (LDS) is
fi brotic tissue with a tenuous blood supply that must be considered as
pathologic and prone to ulceration and poor wound healing.
4
Any surgical
intervention to achieve coverage of existing ulcers or prevent the formation
of new ones must take the area of LDS into consideration (Figures 19-1A
and 19-1B).
Local fl aps are limited in the distal third of the leg where the majority
of venous ulceration occurs. The local tissue available is typically involved
in the disease process and is sclerotic, which limits its mobility and utility.
Vascularized tissue is needed to cover the ulcer that is independent of the
wound bed or local area for its vascular supply. Free tissue transfer with
its own independent arterial supply and venous outfl ow is a means to
achieve this. However, the patient referred for free tissue transfer univer-
sally has had multiple prior surgeries and attempted skin grafting without
lasting resolution of the chronic wounds and has come to the option of free
tissue transfer as a “last resort.”
Free tissue transfer has been proven a valuable means of achieving soft
tissue coverage for wounds of the lower extremity.
5
Successful free tissue
transfer rates are on the order of 96%
6
but may be somewhat less in the
lower extremity, particularly after trauma. If one looks at failure rates of
free fl aps, venous thrombosis is the leading etiology, both clinically and
experimentally.
7
Underlying venous pathology in the extremity is therefore
obviously concerning, but free tissue transfer to the lower extremity in the
setting of chronic venous disease for coverage of recalcitrant ulcerations
has been reported to be successful ranging from 77% to 100% of the
time
8–16
(see Table 19-1). The literature that comprises free tissue transfer
for chronic, nonhealing venous wounds is spartan, with few surgeons having
extensive experience. The surgical technique of free tissue transfer for
coverage of venous ulcers began as limited case reports
8,13,16
and now has
been borne out to be a clinically effective means in smaller case series in
properly selected patients.
9–12,15
PATIENT EVALUATION AND SELECTION
The crucial fi rst step in evaluating the patient with the recalcitrant
venous ulcer as a candidate for free tissue transfer is to make sure that
venous insuffi ciency is the true underlying etiology. Venous disease is the
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Treatment of Recalcitrant Venous Ulcers 263
FIGURE 19-1 A. Typical-appearing venous ulcer on medial aspect of lower third of
extremity. Note the surrounding area of LDS that must be considered as part of the patho-
logic process of venous ulceration. B. Appearance of the venous ulcer following excision of
ulcer surrounding area of LDS and coverage with a fasciocutaneous (radial forearm) free
fl ap.
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264 Treatment of Recalcitrant Venous Ulcers
most common cause of lower extremity ulcers, but multiple other patholo-
gies must be ruled out prior to undertaking free tissue transfer. One must
be sure that the patient does not have arterial insuffi ciency, infectious
ulceration, diabetic ulcer, underlying vasculitis, or clotting diathesis.
17
As
outlined in previous chapters in this text, patients should receive a com-
plete evaluation of the patency of their superfi cial and deep venous systems
with noninvasive duplex scanning to confi rm the underlying pathophysiol-
ogy of venous hypertension. The underlying venous hypertension must be
addressed, and most patients have undergone a regimen of elevation, unna
boots, and local wound care without success.
18,19
These regimens may aid
in alleviating the symptomology of their underlying disease, but they do
nothing to correct the pathophysiology. Many patients have additionally
undergone intervention to correct their venous hypertension through other
means such as stripping or SEPS. Once venous insuffi ciency has been
confi rmed as the underlying pathology, and the patient has failed conserva-
tive and lesser surgical attempts at closure, one can then proceed to discuss
the surgical option of free tissue transfer.
Patients who are referred as candidates for free tissue transfer have
exhausted the more traditional methods of surgical intervention after pro-
longed and lengthy periods of conservative management. Essentially, all
patients will have undergone multiple prior attempts at closure of their
wounds, typically represented as failed excision and skin grafting or as
failed regional fl aps. Because the majority of venous ulcers occur in the
distal one-third of the extremity, local options for rotational muscle or
fasciocutaneous fl aps are very limited and impractical in the majority of
TABLE 19 -1 Published Series of Free Tissue Transfer for Recalcitrant
Venous Ulcers*
Series Pts/Flaps Flap Type Flap Failure Recurrence: F/U
Allen (1989) 2/2 1 muscle 0% None: 8 Mos
1 fasciocutaneous None: 18 Mos
Swartz (1989) 7/7 Muscle 0% None: 4 Yrs
Ramirez (1992) 13/13 Muscle 23% None: 1–7 Yrs
Dunn (1994) 6/8 Fasciocutaneous 0% None: Mean 24 Mos
Weinzweig (1997) 1/1 Muscle 0% None
Weinzweig (1997) 18/20 Muscle 10% 1 separate site: 32 mos
Steffe (1998) 11/14 Muscle/fascial 14% 100%
Kumins (2000) 22/25 Muscle/omentum 4% 12% separate site
Isenberg (2001) 9/9 Fasciocutaneous 0% 33% separate site
* Separate site equates to ulcer recurrence outside the fl ap.
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Treatment of Recalcitrant Venous Ulcers 265
cases. For this reason, their limited arc of rotation, and the involvement of
the surrounding soft tissue with LDS, they are not that useful. Addition-
ally, in ulcers that have exposed tendons or other vital structures, skin
grafts or local fl aps are not able to achieve adequate soft tissue coverage.
The only surgical means for achieving soft tissue coverage after multiple
failed attempts is microsurgical free tissue transfer.
Ideal patients who will be candidates for free tissue transfer are those
without prohibitive underlying comorbidities that would allow them to
undergo a signifi cant surgical undertaking. Patients must have suitable
donor vessels for both arterial infl ow and venous outfl ow for the fl ap.
Additionally, the area of ulceration to be covered must be of a size that
will allow coverage with a free fl ap, and they must have a suitable source
of donor tissue. The microsurgical fl aps that are typically employed are the
latissimus dorsi, gracilis, and scapular fl ap (Figure 19-2). All these fl aps
have a fi nite area of coverage, and the largest area that can be covered with
a single fl ap is in the range of 200 cm
2
. The area that must be covered is
typically underestimated. The visible area of ulceration may only be the
“tip of the iceberg” because there is typically a large area of LDS surround-
ing the ulcer that must be considered part of the underlying pathologic
problem that needs to be debrided widely
1
(Figures 19-3 and 19-4). It has
been shown that there are multiple derangements within the venous micro-
circulation, as well as an increased number of leukocytes within the dermis
of patients with venous ulcers. The result of these derangements is infl am-
mation with fi brosis in the surrounding tissues and friable tissue prone to
FIGURE 19-2 Outline of a typical scapular fl ap area prior to harvest. The scapular fl ap
is a fasciocutaneous fl ap that has been successfully used as a free fl ap for coverage of recal-
citrant venous ulcers.
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266 Treatment of Recalcitrant Venous Ulcers
bleeding and ulceration with minor trauma.
20–25
For these reasons, the
lipodermosclerotic areas must be widely debrided; otherwise, one will face
the problem of recurrent ulceration.
Special mention should be made regarding the patient with arterial
insuffi ciency in the setting of concomitant venous ulceration. Free tissue
transfer for extremity salvage in the setting of arterial insuffi ciency has
been shown to be successful, and any patient with a combined ulcer should
undergo arterial revascularization with comcomitant or subsequent free
tissue transfer if needed to reconstruct soft tissue defi cits that would oth-
erwise dictate limb loss. Free tissue transfer in the setting of arterial insuf-
fi ciency has been shown to be safe and effective, albeit with a higher risk
of fl ap loss and complications.
26–29
FLAP SELECTION
The selection of the appropriate fl ap for microvascular free tissue trans-
fer is dependent on several variables. One must consider the size of the
FIGURE 19-3 Appearance of venous ulcer prior to debridement. All areas of LDS
must be debrided if at all possible. Debridement should include the underlying fascia, and
all ectatic veins that are encountered should be ligated.
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Treatment of Recalcitrant Venous Ulcers 267
recalcitrant ulcer and the surrounding area of LDS in order to appreciate
the dimensions of the eventual wound that will have to be covered. It is
crucial to take into account the area that will require coverage upon exci-
sion of the lipodermosclerotic area. Failure to do this will result in a fl ap
that will not adequately cover the defect. Flaps are classifi ed based on their
anatomic components contained within the fl ap (i.e., muscle, fascial, mus-
culocutaneous, fasciocutaneous).
30
Flaps used in coverage of venous ulcers
are typically of two types: fasciocutaneous or muscle. Both of these types
of fl aps have been shown to be effective in achieving durable coverage of
recalcitrant ulcers, and one does not necessarily have an advantage over
the other regarding effi cacy or recurrence (Figures 19-5A and 19-5B). Both
have been shown to possess competent venous valves that may help to
restore the appropriate hemodynamic balance.
31,32
Common donor sites for
fasciocutaneous fl aps include the radial forearm, scapular and parascapu-
lar region, and the antero-lateral thigh. Muscle fl aps typically will be graci-
lis or latissimus muscles. The donor site morbidity of the free fl ap must be
considered, as should the dimensions that are obtainable with each fl ap.
Ease of harvesting of the fl ap must be taken into account and the avoid-
ance, if possible, of having to reposition the patient to harvest the fl ap while
in the operating room.
FIGURE 19-4 Appearance of venous ulcer in Figure 19-3 after radical debridement.
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