The free flap man: An heroic 50-year odyssey via multiple flaps.

Most lower extremity challenges can be solved by a solitary free flap. Yet if multiple wounds exist in a single extremity, or if bilateral extremities are involved, then multiple free flaps by necessity may be required to preserve ambulatory capabilities. Even rarer is their need in a sequential fashion. Thus is the uniqueness of this steelworker who at the young age of 23 sustained bilateral foot and ankle molten steel immersion injuries, initially salvaged by skin grafts virtually directly on bone. Over the next 50 years there were repeated episodes of graft instability that required five different free flaps to provide stable soft tissue coverage. Amputation was avoided, allowing minimal interruption at work as a bus driver until retirement. This patient's long journey was only possible due to the virtue of persistence, proving the value of that trait inherent within the true microvascular surgeon. It should be no wonder that appropriately this is the "free flap man."

Are "Free Flaps" "Free" Flaps?

BACKGROUND: Even standard microvascular tissue transfers are time consuming, require great skill and intensity, and can be stressful. Not surprisingly, work-related relative value units are considered by many microsurgeons to be suboptimal. Some might even say that "free flaps" indeed really are "free" flaps. METHODS: A retrospective review of related finances was undertaken for all free flaps performed in a single surgeon private practice during the latest possible year (2014) that included a complete 5-year follow-up to insure receipt of all expected reimbursements from accounts receivable. There were 61 free flaps available; but arbitrarily 12 free flaps were excluded since postmastectomy breast reconstruction always received mandatory insurance payment, as were additional two cases done pro bono as part of an international educational service. This left 47 free flaps to permit determination of gross payments, if any. RESULTS: Compensation summated for three distinct time intervals for all free flaps was preoperative: $10,855.92 (mean: $230.98/flap); intraoperative: $117,015.46 (mean: $2,489.69/flap); and postoperative: $45,296.28 (mean: $963.75/flap). Range of gross payment for the free flap portion only was 529.65 to $4,503.71. Total overall revenue received was $173,167.66 (mean: $3,684.42/flap). CONCLUSION: A true benefit cost-analysis even if microsurgery specific expenses could be estimated would be inaccurate, so that mean net income for each free flap could not be determined. Albeit a minimal gross payment was obtained for some free flap procedures, in no instance was there zero reimbursement. Based on that fact, there were no truly "free" free flaps in this private practice experience, which should encourage the younger surgeon to realize that economic viability is possible so that their enthusiasm for reconstructive microsurgery can be sustained.

Smartphone Thermography for Lower Extremity Local Flap Perforator Mapping.

BACKGROUND: The versatile application of local perforator flaps for coverage throughout the lower extremity has already been well proven. Often a "free-style" approach has been used to design these flaps, as conventional imaging devices for perforator identification may be too expensive or unavailable. The recent adaptation of Smartphone thermal digital imaging may now prove to be a cheaper and more readily available means for identifying the requisite perforators that will sustain these local flaps. METHODS: Over the past year, a prospective study was undertaken of all patients having a local perforator flap for coverage of a lower extremity defect. Twenty-eight local perforator flaps involving all subtypes were utilized in 25 patients. Smartphone thermography was used in all patients preoperatively to identify preferable perforator or vascular network "hot spots" that allowed appropriate flap design. Intraoperative and postoperative monitoring was similarly done for all flaps to determine outcomes. RESULTS: All local perforator flaps were based on perforators identified using smartphone thermography. All flaps (23 or 82.1%) that the thermal digital image predicted 100% viability totally survived. Five flaps were predicted to have marginal viability, but two nevertheless survived completely while the others required only minor readjustments. Peninsular and keystone variety perforator flaps were those most commonly used.Thermography always facilitated making the correct decision as to whether a proximal- or distal-based peninsular flap would be superior. Subfascial elevation of cool spots in keystone flaps were found to be least likely to interfere with flap perfusion. CONCLUSION: Smartphone thermography is an inexpensive and expeditious means for identification of "hot spots" that is always used by us to ensure perfusion to lower extremity perforator local flaps. This is a complementary technique for their safer design, harvest, and subsequent monitoring in conjunction with more complex screening tools as indicated.

In Pursuit of the "Perforator" in the Perforator Skin Flap.

Another congress of the World Society for Reconstructive Microsurgery (WSRM) this past year in Bologna was magnificent not just for the presentation of so many keynote lectures by the giants of our field nor the novel and innovative ideas shown by those who will someday follow in those footsteps, but by making all of us realize how many capable microsurgeons there are now practically everywhere in this world, doing incredibly important surgical management of challenges that previously were unmet and resulted in sheer devastation for so many of our patients. How much we are the same in our goals, aspirations, and abilities could not be overlooked, but it is amazing how much we also want to learn more together-each relying on the other. To do so, we must not forget our origins as we appropriately plan for the future. All this we philosophized in our WSRM panel on lower extremity reconstruction, while emphasizing on the surface the perforator flap that at the least today has caught everyone's attention. In this overview to follow, we once again tell two stories, starting with the beginnings of the concept of flaps in showing how the nomenclature has evolved over time according to our various surgical manipulations. Often overlooked, though, is a parallel timeline by the anatomists who have better elucidated the circulation to these flaps, where it will become obvious that often long ago the existence of perforators was recognized by them long before known by the surgeons. At least today, these two paths have at least temporarily intersected. Our pursuit of the "perforator" in the perforator skin flap has come full circle, following the course of the history of the flap itself-a pursuit of excellence.

Attributes of Perforator Flaps for Prophylatic Soft Tissue Augmentation Prior to Definitive Total Knee Arthroplasty.

BACKGROUND: As our population ages, the demand for total knee arthroplasty (TKA) will dramatically increase to ensure an independent lifestyle with unimpeded and pain-free ambulation. Complications will be inevitable, especially in that patient with preexisting soft tissue deficits or extensive scarring in the knee region. Under these circumstances, prophylactic soft tissue augmentation should be strongly considered and be extremely beneficial. METHODS: A retrospective review of all TKA procedures at our institutions over the past two decades revealed seven patients who specifically had soft tissue augmentation prior to their definitive TKA. Each had a single perforator flap used to achieve this. In no cases was a muscle flap used for this purpose. Excluded were all patients who had a flap of any kind for coverage of an exposed prosthesis or to accomplish wound healing after the TKA. RESULTS: Seven perforator flaps were utilized in seven patients for soft tissue replacement prior to the ultimate TKA. For smaller defects in three patients, a local island medial sural artery perforator flap was used. For larger defects in four patients, an anterolateral thigh perforator free flap was necessary. All flaps were successful. The only complication was an implant infection after one anterolateral thigh free flap that required a revision arthroplasty that eventually allowed salvage. Unrestricted ambulation was possible in all patients except for one who had a preexisting contralateral below-knee amputation. CONCLUSION: As the number of TKA procedures in the near future increases, prevention of the absolute number of complications becomes even more important. An awareness that any knee region suboptimal soft tissue base can lead to wound breakdown and then periprosthetic infection should alert all involved that prevention of this sequela can be best achieved by prior soft tissue augmentation. Preferably, this may be possible by capturing the assets of local and free perforator flaps.

Synchronous Closure of A Large Medial Perforator-Based Superficial Circumflex Iliac Artery Perforator Free Flap Donor Site Using an Ipsilateral Lateral Perforator-Based Superficial Circumflex Iliac Artery Perforator Propeller Flap.

A superior advantage of the superficial circumflex iliac artery perforator flap is that any donor site residue can easily be hidden by clothing. Usually designed as narrow or moderate-sized flaps based on medial perforators of the superficial branch, this readily allows primary donor site closure. However, for larger flaps, tension-free closure requires that the thigh remain flexed or even a skin graft used. Another alternative would be to use an adequate lateral perforator of the deep branch, if available, as the vascular hub of a propeller flap that extended into the adjacent flank, that could then be rotated into the medial groin to facilitate simultaneous direct closure of both flap donor sites.

The S&T Lecture: An Introduction to the 9th Congress of WSRM.

Just what is the S&T lecture? In the beginning it appeared to be a dubious distinction, another task thrust upon me but different in that I had absolutely no idea what was wanted or would be appropriate. At the least, it seemed reasonable to recite a simple introductory story for what would be an extraordinary conclave. First, an appreciation was due to our dedicated leaders of World Society of Reconstructive Microsurgery (WSRM), who this year (2017) have put together the most extravagant meeting ever, intended to include not just the glamorous but the entire scope of rudimentary reconstructive microsurgery. We know we must acquire all this knowledge to succeed today and tomorrow, but also need not to overlook the struggles and sacrifices our predecessors had to overcome. Too often the past is forgotten, only to then inefficiently be repeated. Today then, this will be a short story, a story of our past that must never be cast aside. The WSRM here today is a great international forum where we can then mingle with all of our colleagues to help dictate the present, but also define the future role of all specialities here where the ultimate goal is to help those most in need. This S&T lecture will just be a history story, subject to your interpretation. Enjoy!

Free versus Pedicled Perforator Flaps for Lower Extremity Reconstruction: A Multicenter Comparison of Institutional Practices and Outcomes.

BACKGROUND: Of all body regions, lower extremity wounds have been and remain the greatest challenge. Perforator free flaps have been accepted as a reasonable option to solve this dilemma but require the complexity of microsurgery. As a consequence, the possibility that pedicled perforator flaps could supplant even perforator free flaps has recently gained intense enthusiasm. METHODS: A retrospective investigation was undertaken to compare the validity for the use of perforator flaps of all types at three dissimilar institutions, that is, a university, a regional center, and a community hospital. All flaps performed in the 5-year period, 2011 to 2015, were included to allow at least 1-year follow-up before data analysis. A total of 433 free perforator flaps and 52 pedicled perforator flaps had been performed specifically for the lower extremity. RESULTS: Patient demographics, wound etiology, and comorbidities were similar for all institutions. Free flaps were more commonly needed after trauma and for chronic ulcers. Pedicled flaps were more likely an option after tumor excision. Large defects or those involving the foot were better served by free flaps. Overall success for free perforator flaps was 90.1% and for pedicled perforator flaps was 92.3%, with no significant difference noted (p = 0.606) between institutions. Peripheral vascular disease was the only significant comorbidity risk factor for both free and pedicled flap failure. CONCLUSION: Perforator flaps in general have become a reasonable solution for soft tissue defects of the lower extremity. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap could potentially be successful. Pedicled perforator flaps, if adequate healthy soft tissues remain adjacent to the defect, forecast a continuance of the evolution in seeking simplicity yet reliability by the best flap possible for soft tissue closure of the lower limb wound.

The Chimera Flap: A Quarter Century Odyssey.

Incredibly complicated multidimensional defects have always strained the ingenuity of the reconstructive surgeon. Secondary perhaps to vascularized composite allotransplantation as a solution to this dilemma, the compound flap has been developed to be a more useful and available alternative. Their greatest versatility has been proven by its subtype, the chimera flap. The chimera flap itself consists of multiple flaps, the latter possibly composed of bone, skin, muscle, and so on, where each part has an independent vascular supply, and each part is independent of any physical interconnection whatsoever with the other components, except where joined ultimately only to a common vascular pedicle. An appellation for this concept was first introduced a quarter century ago in this very journal, a time frame now the impetus for a recapitulation of its origin and subsequent history that proves that it has eventually withstood the test of time and has been successfully assimilated into the reconstructive repertoire.

The role of free flaps for salvage of the exposed total ankle arthroplasty.

Total ankle arthroplasty in the right circumstances cannot only relieve discomfort; but, unlike an ankle arthrodesis, can restore enhanced ambulatory capabilities. Subsequent wound healing issues have the potential to ultimately lead to implant removal, a disaster that can be avoided by as early intervention as possible that will provide sustainable wound closure. Over the past 5 years, 5 patients have presented in a delayed fashion with wound breakdown following total ankle arthroplasty that required a free flap for successful prosthesis salvage. The mean wound size was 78.0 cm2 (range 14-200 cm2 ). Two gracilis and 2 latissimus dorsi muscle free flaps were chosen as a malleable means not just to cover but to fill these usually large 3-dimensional wounds. A single radial forearm perforator free flap was selected in one case for a superficial wound that required a long vascular pedicle to reach outside the zone of injury. The postoperative course for all was uneventful, with a minimum follow-up of 4 months. Function preservation following total ankle arthroplasty wound breakdown even after an untimely delay in referral can still be maintained using microsurgical tissue transfers. © 2014 Wiley Periodicals, Inc. Microsurgery 37:34-37, 2017.

The First Dorsal Metatarsal Artery Perforator Propeller Flap.

BACKGROUND: Distal foot and toe defects requiring a vascularized flap for coverage have very limited options, oftentimes justifying even a free flap. Perforator flaps in general and propeller flaps in particular have opened up an entirely new subset of local tissue transfer alternatives that can potentially avoid the difficulties that accompany microvascular tissue transfers. The first dorsal metatarsal artery (FDMA) perforator propeller flap represents another variation of this theme. METHODS: A standard FDMA flap from the dorsum of the foot was raised in reversed fashion based on the distal communicating branch or "perforator" from the plantar foot circulation in 2 patients with great toe defects. All distal skin tissue between this perforator and the defect was kept with the FDMA flap as an attached minor blade, to thereby create an FDMA propeller flap. RESULTS: Salvage of the great toe in both patients was achieved. The benefit of the minor blade of the propeller was to fill a portion of the donor site defect of the traditional FDMA major blade, to permit tension-free donor site closure of the dorsal foot without sequela. CONCLUSIONS: The distal-based FDMA flap can be useful as a local flap for coverage of distal foot and toe wounds, but direct donor site closure can be problematic as mirrored by its relative the dorsalis pedis flap. The FDMA perforator propeller flap variation can achieve the same reconstructive goals while simultaneously transferring vascularized tissue into the dorsal foot donor site to thereby minimize the tension if direct closure is possible or minimize the need for a skin graft in this notoriously difficult region.

Partial failure of a perforator free flap can be salvaged by a second perforator free flap.

INTRODUCTION: Perforator flaps as an innovative method for soft tissue transfer that maximizes function preservation, were originally introduced primarily as free flaps. Their reliability and versatility has been found to not differ from other sources of free flaps where total failure is an uncommon event. Partial failure should also be recognized as a possible dilemma that is perhaps more of a unique untoward sequela of perforator flaps. METHOD: A retrospective review of our flap experience over the past decade included 310 perforator free flaps. Partial perforator flap failure that required a second free flap for salvage was selected in 6 patients. RESULTS: All perforator free flaps in our experience that had some form of partial failure were anterolateral thigh [ALT] free flaps. Clinically initially unrecognizable but ultimately distal flap ischemia could be attributed to poor flap design, and was the cause of immediate partial flap necrosis in 2 cases. Delayed difficulties were complications not specific to perforator flaps. In all cases, a free flap was considered the best option, and a second perforator free flap proved to resolve all reconstructive objectives. CONCLUSIONS: The root cause of partial failure of a perforator free flap was found to be either iatrogenic or de novo in origin. The proper design requires an awareness of the correct topographic axis and an understanding of the perforasome concept to better insure adequate flap perfusion. If a free flap is still considered the best solution after a partial failure, the advantages and benefit of a second perforator free flap should not be overlooked.

Abdominoplasty as the patient impetus for selection of the deep inferior epigastric artery perforator free flap for knee coverage.

Extensive wounds about the knee can rarely be covered with local or even regional flaps. Free flaps often then become obligatory. Many factors will determine the surgeon's selection of the best donor site. Yet the patients' concerns with donor site morbidity cannot be overlooked. Most would agree that a large, but relatively thin flap would be optimal to preserve knee mobility. The deep inferior epigastric artery perforator (DIEAP) flap would therefore not usually be the donor site of choice from the surgeon's perspective. However, the opportunity to have a concomitant abdominoplasty that would improve body image or result in a scar readily hidden by clothing is an enticement for the patient not to be dismissed, under what normally are otherwise depressing circumstances. Over the past decade, three female patients have chosen the DIEAP free flap solely for the latter reasons, fully realizing that later flap revision would be needed to improve the function and appearance at the recipient site.