Perineal and Lower Extremity Reconstruction

Duke University, Durham, North Carolina, United States
Plastic and Reconstructive Surgery (Impact Factor: 2.99). 11/2011; 128(5):551e-563e. DOI: 10.1097/PRS.0b013e31822b6b87
Source: PubMed


After reading this article, the participant should be able to: 1. Perform a preoperative assessment of patients undergoing perineal and lower extremity reconstruction. 2. Describe the various tissue flaps used to perform these reconstructions and the advantages and disadvantages of each. 3. Provide appropriate postoperative care and interventions to maximize outcomes.
The lower extremity and perineum provide the foundation for upright posture and ambulation. These areas are made up of intricate contours with variable skin types and must withstand the functional demands of organ orifice support and weight-bearing forces. Successful reconstruction calls for careful preoperative planning and consideration of the site-specific demands.
The authors reviewed literature regarding the most current treatment strategies for lower extremity and perineal reconstruction.
Perineal reconstruction is typically related to genitourinary or digestive tract abnormalities, mainly malignancies. Local and regional flaps are the mainstay of therapy, depending on their availability and the need for adjuvant therapy. Postoperatively, pressure reduction and closed-suction drainage are of major consideration. The lower extremities are prone to trauma, and these wounds often involve underlying and exposed bony abnormalities, and this must be considered in operative planning. Significant defects may be reconstructed with local or regional flaps and free-tissue transfer. The location of the wound and extent of surrounding tissue compromise are of major concern when determining flap coverage. Postoperatively, transition to ambulation and weight-bearing status is paramount.
Reconstruction of the lower extremity and perineum requires recognition of the high functional demands of these areas. Local and regional flaps and free tissue transfer allow reconstruction of complex wounds in these areas. Selecting the correct flap and navigating the postoperative recovery to arrive at functional restoration remain a significant challenge.

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    ABSTRACT: Purpose: To evaluate risk factors that contribute to postoperative complications and flap loss in complex upper extremity reconstruction. Methods: Retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using a Chi Square and Fischer’s exact tests. Results: Two hundred eighty-two cases met inclusion criteria. Wounds underwent soft tissue reconstruction within 24 hours (25.9%), days 2-7 (12.2%), or after day 7 (61.9%). Forty-seven (16.7%) of injuries were located proximally. Over half of the cases had an open (25.9%) or closed (34.4%) fracture. Gustilo fracture grade was IIIA (0.1%), 3B (17.4%), or IIIC (7.8%). Superficial infection, deep infection, and osteomyelitis occurred in seventeen (6%), twenty-four (8.5%), and fifteen (5.3%) cases, respectively. Twelve cases (4.3%) experienced total, and five (1.8%) partial, flap loss. An interpositional vein graft was used in 41 (14.5%) and anastomotic revision was performed in 53 (18.8%). Mean follow-up was 37.5 ± 49.5 months. Timing of reconstruction did not significantly affect postoperative outcomes. Proximal location of injury was significantly associated with superficial (RR=6.5, p<0.01) and deep infection (RR=5.3, p<0.01), and osteomyelitis (RR=4.0, p<0.01), although not with flap failure (p=0.3). Presence of an open fracture was significantly associated with developing superficial (RR=3.1, p=0.013) and deep infection (RR=1.9, p<0.01), as well as osteomyelitis (RR=1.6, p<0.01). Having a closed fracture did not negatively influence postoperative outcomes. Gustilo IIIC fractures were associated with a higher risk of flap loss (RR=3.5, p=0.03). Use of an interpositional vein graft was 3.2 times more likely to result in flap loss (14.6% vs. 4.56%, p=0.01). Flaps requiring anastomotic revision had a 7.9 times higher risk of experiencing flap loss (20.75% vs. 0.26%, p<0.01). Conclusions: This study supports the safety using early free tissue transfer for reconstruction of the traumatized upper extremities. Injuries proximal to the elbow, and trauma resulting in open fracture, were associated with a significantly higher infection rate. Gustilo IIIC fractures, need for interpositional vein grafts, and anastomotic revision resulted in significantly higher risk of flap loss, whereas the presence of fracture, fracture fixation, injury location, and use of vein grafts were not predictors of flap failure.
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    Eplasty 02/2013; 13:ic31.
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    ABSTRACT: Purpose: Complex lower extremity wounds present a significant challenge to the reconstructive surgeon. We report a consecutive experience of free tissue transfers for lower extremity reconstruction with a focus on outcomes and flap selection. Methods: A retrospective review of all free tissue transfers for lower extremity reconstruction between 2006 and 2011 was performed. Minor complications were defined as nonoperative complications (infection, seroma, hematoma, wound breakdown, and partial loss). Major complication required a surgical intervention (total flap loss, thrombosis, nonunion, amputation, and hematoma). Results: A total of 119 free flaps were performed in 114 patients. Reconstructed defects were most commonly derived from acute traumatic (N = 40) or chronic traumatic (N = 34) wounds, oncologic (N = 14), or diabetic (N = 8). Flap loss occurred at a rate of 5.9% and the overall lower extremity salvage rate was 93%. Complications were significantly higher for free tissue transfers to the region of the distal tibia (p = 0.04). Major complications were significantly higher in patients with chronic obstructive pulmonary disease (p = 0.02) and in patients who experienced intraoperative technical difficulties (p = 0.014). Flap loss was significantly higher when the rectus abdominis flap was used (p = 0.02) and when a delayed venous thrombotic event occurred (p = 0.001). Conclusion: Patient comorbidities and defect location can be associated with higher rates of complications; flap selection and delayed venous thrombotic events appear to be associated with flap failure.Level of Evidence Prognostic/risk category, level III.
    Journal of Reconstructive Microsurgery 04/2013; 29(6). DOI:10.1055/s-0033-1343952 · 1.31 Impact Factor
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