Local flaps for reconstruction of lower extremity defects: updated literature review
DOI:
https://doi.org/10.24054/cbs.v4i1.4293Keywords:
Surgical Flaps, Perforator Flap, Myocutaneous Flap, Lower Extremity, Plastic SurgeryAbstract
Free flaps are the gold standard for the reconstruction of lower extremity defects; however, the use of local perforator-based flaps has increased due to their lower complexity, reduced surgical times, and lower cost. This review analyzes their applications, benefits, complications, and limitations. A literature review was conducted through a search in PubMed, Scopus, and SciELO databases, using the specified MeSH terms. Articles meeting the established inclusion and exclusion criteria were selected. Multiple local flaps used in the reconstruction of lower extremity defects were identified, including the gastrocnemius flap, soleus flap, reverse-flow sural flap, propeller flap, and keystone flap, each with specific indications according to the location and extent of the defect. Recent innovations include the use of perforator-based flaps and surgical planning assisted by ultrasound or angiography. In resource-limited settings, options such as the propeller flap and reverse-flow sural flap stand out for their versatility, lower technical complexity, and reduced operative time compared with free flaps. Local flaps remain a valid, safe, versatile, and cost-effective option for soft tissue coverage in the lower extremities, particularly valuable in resource-limited settings. Further studies are needed to optimize their selection and standardize protocols.
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Jakubietz, R. G., Meffert, R. H., Jakubietz, M. G., Seyfried, F., & Schmidt, K. (2020). Lokale Lappenplastiken als letzter Versuch vor der Unterschenkelamputation: eine Übersicht [Local flaps as a last attempt to avoid lower extremity amputation: an overview]. Der Unfallchirurg, 123(12), 961–968. https://doi.org/10.1007/s00113-020-00814-6
Ota, M., Motomiya, M., Watanabe, N., Shimoda, K., & Iwasaki, N. (2024). Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study. BMC musculoskeletal disorders, 25(1), 297. https://doi.org/10.1186/s12891-024-07433-x
Ellabban, M. A., Awad, A. I., & Hallock, G. G. (2020). Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction. Seminars in plastic surgery, 34(3), 200–206. https://doi.org/10.1055/s-0040-1715154
Hifny, M. A., Tohamy, A. M. A., Rabie, O., & Ali, A. A. A. (2020). Propeller perforator flaps for coverage of soft tissue defects in the middle and distal lower extremities. Annales de chirurgie plastique et esthetique, 65(1), 54–60. https://doi.org/10.1016/j.anplas.2019.04.002
Blough, J. T., & Saint-Cyr, M. H. (2021). Propeller Flaps in Lower Extremity Reconstruction. Clinics in plastic surgery, 48(2), 173–181. https://doi.org/10.1016/j.cps.2021.01.002
Emam, A., Machhada, A., Tilston, T., Colavitti, G., Katsanos, D., Chapman, T., Wright, T., & Khan, U. (2021). Free tissue versus local tissue: A comparison of outcomes when managing open tibial diaphyseal fractures. Injury, 52(6), 1625–1628. https://doi.org/10.1016/j.injury.2021.02.013
Jakubietz, R. G., Schmidt, K., Holzapfel, B. M., Meffert, R. H., & Jakubietz, M. G. (2020). Pedicled perforator flaps for mid-tibial soft tissue reconstruction in medically compromised patients. JPRAS open, 24, 47–55. https://doi.org/10.1016/j.jpra.2020.02.002
AlMugaren, F. M., Pak, C. J., Suh, H. P., & Hong, J. P. (2020). Best Local Flaps for Lower Extremity Reconstruction. Plastic and reconstructive surgery. Global open, 8(4), e2774. https://doi.org/10.1097/GOX.0000000000002774
Jones, C. M., Roberts, J. M., Sirlin, E. A., Cavanaugh, G. A., Anagnostakos, J. P., Hauck, R. M., & Spence Reid, J. (2021). Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures. Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 74(11), 2933–2940. https://doi.org/10.1016/j.bjps.2021.03.105
Kondra, K., Roohani, I., Swerdlow, M., Brown, M., O'Brien, D., Pekcan, A., Stanton, E., & Carey, J. (2022). Outcomes of Local versus Free Flaps for Lower Extremity Trauma. The American surgeon, 88(10), 2544–2550. https://doi.org/10.1177/00031348221103651
Kondra, K., Roohani, I., & Carey, J. N. (2023). Outcomes of Local Versus Free Flaps for Reconstruction of the Proximal One-Third of the Leg. Annals of plastic surgery, 90(5S Suppl 3), S268–S273. https://doi.org/10.1097/SAP.0000000000003465
Azoury, S. C., Kovach, S. J., & Levin, L. S. (2022). Reconstruction Options for Lower Extremity Traumatic Wounds. The Journal of the American Academy of Orthopaedic Surgeons, 30(16), 735–746. https://doi.org/10.5435/JAAOS-D-21-01081
Bulla, A., Delgove, A., De Luca, L., Pelissier, P., & Casoli, V. (2020). The esthetic outcome of lower limb reconstruction. Annales de chirurgie plastique et esthetique, 65(5-6), 655–666. https://doi.org/10.1016/j.anplas.2020.07.007
Posso C, Wolff G, Cardona E. Colgajos en hélice de las arterias perforantes para la reconstrucción de los defectos de cubrimiento en la extremidad inferior: experiencia de la IPS Universitaria, Medellín, Colombia. Rev Colomb Cir. 2017;32:290–6. https://doi.org/10.30944/20117582.37
LaValley, M. N., Dugue, D., Diaddigo, S. E., Kuonqui, K. G., Tyler, W. K., & Bogue, J. T. (2024). A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews, 8(3), e23.00290. https://doi.org/10.5435/JAAOSGlobal-D-23-00290
Lancaster, P., Kocialkowski, C., Pearce, O., Khan, U., Riddick, A., & Kelly, M. (2022). Open lower limb fractures in the elderly. Injury, 53(6), 2268–2273. https://doi.org/10.1016/j.injury.2022.03.029
Vathulya, M., Dhingra, M., Nongdamba, H., Chattopadhyay, D., Kapoor, A., Dhingra, V. K., Mago, V., & Kandwal, P. (2021). Evaluation of pedicled flaps for type IIIB open fractures of the tibia at a tertiary care center. Archives of plastic surgery, 48(4), 417–426. https://doi.org/10.5999/aps.2020.02089
Azi, M. L., Ramalho, A., Sá, C., Sadgursky, D., Viveiros, A., Alencar, D. F., & Belangero, W. D. (2023). Ankle function after reconstruction of post-traumatic soft tissue defects with soleus and/or gastrocnemius local muscle flaps. Injury, 54 Suppl 6, 110744. https://doi.org/10.1016/j.injury.2023.04.031
Matuszewski, P. E., & Ulrich, G. L. (2023). How to get the most out of your gastrocnemius and soleus flaps. OTA international : the open access journal of orthopaedic trauma, 6(4 Suppl), e255. https://doi.org/10.1097/OI9.0000000000000255
Pu L. L. Q. (2021). Locoregional Flaps in Lower Extremity Reconstruction. Clinics in plastic surgery, 48(2), 157–171. https://doi.org/10.1016/j.cps.2021.01.001
Fisal, A. A., Abdel-Hamid Romeih, M., Younes, L. M., El-Rosasy, M., Rodriguez, P., Liette, M. D., & Masadeh, S. (2020). Distally Based Medial Hemisoleus Muscle Flap for Wound Coverage in the Distal Third of the Leg. Clinics in podiatric medicine and surgery, 37(4), 631–647. https://doi.org/10.1016/j.cpm.2020.05.002
Ceccaroni, A., Cuomo, R., Pentangelo, P., Gentile, A., Marra, C., Rozen, W. M., Seth, I., Lim, B., & Alfano, C. (2024). Exploring Reverse Sural Flap Necrosis in Lupus-like Syndrome: Challenges and Strategies in Lower Limb Reconstruction-A Case Presentation. Medicina (Kaunas, Lithuania), 60(12), 2053. https://doi.org/10.3390/medicina60122053
Johnson, L., Liette, M. D., Green, C., Rodriguez, P., & Masadeh, S. (2020). The Reverse Sural Artery Flap: A Reliable and Versatile Flap for Wound Coverage of the Distal Lower Extremity and Hindfoot. Clinics in podiatric medicine and surgery, 37(4), 699–726. https://doi.org/10.1016/j.cpm.2020.05.004
Zang, M., Zhu, S., Chen, B., Li, S., Han, T., & Liu, Y. (2020). Perforator Propeller Flap "Relay" for Distal Lower Extremity Soft Tissue Reconstruction. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 59(5), 1128–1132. https://doi.org/10.1053/j.jfas.2020.05.012
Franchi, A., Fritsche, E., & Scaglioni, M. F. (2020). Sequential propeller flaps in the treatment of post-traumatic soft tissue defects of the lower limb - a case series. Injury, 51(12), 2922–2929. https://doi.org/10.1016/j.injury.2020.02.031
Pawlak, N., De La Cruz Ku, G., Chatterjee, A., Persing, S., & Homsy, C. (2024). The Keystone Perforator Island Flap: Review of Utility and Versatile Clinical Applications. Plastic and reconstructive surgery. Global open, 12(2), e5556. https://doi.org/10.1097/GOX.0000000000005556
Hallock G. G. (2020). The use of smartphone thermography to more safely unmask and preserve circulation to keystone advancement flaps in the lower extremity. Injury, 51 Suppl 4, S121–S125. https://doi.org/10.1016/j.injury.2020.05.029
Le Guern, A., Wiart, T., Modiano, P., & Lebas, D. (2021). The keystone flap and its simplified version for malignant skin tumor defects of the lower limbs: A review of 25 cases. Annales de dermatologie et de venereologie, 148(4), 241–245. https://doi.org/10.1016/j.annder.2021.04.006
Visconti G, Bianchi A, Hayashi A, Salgarello M. The Use of Ultrasound Technology in Planning Perforator Flaps and Lymphatic Surgery. In: Nikkhah, D., Rawlins, J., Pafitanis, G. editores. Core Techniques in Flap Reconstructive Microsurgery. Cham: Springer; 2023. p.47-53. https://doi.org/10.1007/978-3-031-07678-7_6
Binhimd, U., Alkaabi, S. A., Alsabri, G. A., Honart, J. F., Leymarie, N., & Kolb, F. (2022). Superficial temporal artery capillary perforator-based island flap for conchal bowl and external auditory canal reconstruction. Annales de chirurgie plastique et esthetique, 67(1), 42–48. https://doi.org/10.1016/j.anplas.2021.11.005
Thomas, B., Warszawski, J., Falkner, F., Nagel, S. S., Schmidt, V. J., Kneser, U., & Bigdeli, A. K. (2020). A comparative study of preoperative color-coded Duplex ultrasonography versus handheld audible Dopplers in ALT flap planning. Microsurgery, 40(5), 561–567. https://doi.org/10.1002/micr.30599
Aluja-Jaramillo F, Cifuentes S, López C. Angiotomografía en la evaluación de arterias perforantes para reconstrucción mediante colgajos: lo que el cirujano quiere saber y el radiólogo debe informar. Rev Argent Radiol. 2023;86:30-40. https://doi.org/10.24875/RAR.M22000003
Radhakrishnan, G. S., Anand, S., Salim, S., & Boopathi, K. (2022). Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects-Anatomical Study and Clinical Application. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 61(3), 497–502. https://doi.org/10.1053/j.jfas.2021.09.025
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