European ]r~&l ,Ill J ..... ,of PI ~li ~l-lJr~ © Springer-Verlag 1997 Eur J Plast Surg (1997) 20:284 Single-stage revascularization and free flap coverage in the treatment of ischemic lower limb lesions Eur J Plast Surg (1996) 19:245-252 Doctors Van Landyt and associates must be congratulat- following their revascularization with far less morbidity. ed on their series of twenty consecutive patients with Case I may have been able to undergo split thickness lower extremity tissue loss and peripheral vascular dis- skin grafting following extensor tendon excision if the ease. Those of us that have cared for these difficult pa- interossesous muscles and metatarsal periosteum are tients truly understand how much work is involved in well vascularized. We have found that extensor tendon each case; preoperatively, intraoperatively and postoper- excision rarely causes adverse sequelae in these patients atively. Though it is well established that combined pe- who have hyperextension at the metatarsophalangel joints as a result of their diabetic peripheral neuropathy. ripheral vascular surgery and microvascular free tissue Case II may have been closed with a fillet of the medial transfer, whether performed concurrently or in a staged manner, can lead to successful limb salvage, this manu- forefoot structures so that a flap could be constructed to script does offer some new technical "pearls" which close a proximal transmetatarsal amputation. Patients might be employed by those of us involved with these who are left with only two rays following debridement challenging clinical problems. will often have a biomechanically unstable foot destined to reulcerate. In such cases, transmetatarsal amputation The authors demonstrate a close working relationship is a better choice. The patient in Case III may have been with their vascular surgical colleagues. As such, the dis- tal anastomosis of the distal bypass graft is performed a candidate for skin grafting, if after revascularization end-to-side rather than the more "traditional" end-to-end and excision of the extensor tendons the underlying tis- sue appears able to support a thin split thickness skin method. This leaves the distal end of the vein graft free graft (similar to case I). Case IV photos shows necrosis for the microvascular transfer. I particularly like this con- of the distal forefoot. Judging from the pre and postoper- cept as it provides the microsurgeon with a bit more free- dom with flap inset and positioning as well as allowing ative pictures a more proximal transmetatarsal amputa- the reconstructive surgeon to avoid the use of vein grafts tion would have avoided the need for free tissue transfer. In my personal series of 56 patients undergoing distal from the bypass graft to the flap pedicle. This technique revascularization and free tissue transfer for limb sal- is well suited for the "single-stage" approach but could vage, the only absolute indication for performing simul- be adapted to the sequential approach as the end of the taneous procedures is when coverage of the distal bypass distal bypass graft may be "banked" for later use. graft is required. A relative indication has been poor out- Even in the expert hands of these authors, however, flow in the foot as the flap will provide additional runoff significant complications occurred: 2 perioperative and may improve the patency rate of distal bypass grafts deaths (10%), cardiogenic pulmonary edema (10%), in these circumstances. My experience with the latter, transient ischemic attacks (10%), and renal fafilure re- however, has been poor as these patients often exhibit quiting dialysis (5%). I note these not to discourage un- prolonged delays in flap incorporation into the "native" dertaking such complex reconstructions but to under- foot tissues and, in two patients, led to eventual limb score the importance of meticulous patient selection for amputation in spite of a viable free flap. these procedures. We must never perform a free tissue Once again, I want to commend the authors on their transfer for limb salvage in this patient group if simpler excellent work but caution the readers to be extremely techniques would accomplish limb salvage. The recon- selective in applying free tissue transfer techniques when structive surgeon must fully understand all "local" flap simpler methods may be utilized. options as well as the techniques of forefoot and midfoot amputations that permit bipedal ambulation without in- L.B. Colen, MD creasing the energy expenditure of ambulation. Though 6161 Kempsville Road there is a limited amount of information one can glean Suite #300 from photographs, the patients cited in their manuscript Norfolk, VA 23502 may have been candidates for simpler reconstructions USA
European Journal of Plastic Surgery – Springer Journals
Published: Sep 1, 1997
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