This paper reports long-term results of free-flap coverage of lower extremity wounds in patients with peripheral vascular disease. A total of 70 flaps were reviewed in 75 patients. Inclusion criteria included an unreconstructible soft-tissue defect and the requirement of an amputation had free-flap coverage not been chosen. Mean age was 60 years and mean hospital stay 32 days. Within the first 30 days, six flaps failed (8 percent). There were no flap failures after 30 days. Survival analysis showed 5-year flap survival to be 77 percent. The most common complication of successful flaps was marginal necrosis, occurring in 9% of patients and managed with flap advancement or secondary intention healing. Medical complications occurred in 11% of patients. The only factor found to be indicative of a poor outcome was the combination of diabetes and renal insufficiency. The authors’ stress their preferred approach, combining free-tissue transfer with bypass grafting at a single operative procedure, performed in approximately 60% of their cases. They report increased technical difficulty of a two-staged approach. Mean operative time for the simultaneous procedures was 6.5 hours.
While this analysis focuses on the lower extremity, there is pertinent information that can be gained for upper and lower extremity vascular insufficiency. In short, free-flap procedures are not necessarily contraindicated in the diabetic patient with peripheral vascular disease. When the latissimus dorsi is used in this patient population, consideration should be given to discard the distal margin of the muscle when possible. This was found to be a common source of marginal flap necrosis. Great caution should be used, however, in individuals with diabetes and renal failure. This combination of comorbidities is a poor predictor for flap survival and limb salvage. Lastly, in the ischemic extremity, a free-tissue muscle transfer may hypothetically provide a low-resistance tissue bed that will provide supplemental flow to the ischemic region and promote angiogenesis.
Plastic and Reconstructive Surgery