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Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
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Reliability and Safety of Cross-Leg Free Latissmus Dorsi Muscle Flap in Reconstruction of Mutilating Leg Injuries Using End-to-Side Anastomosis

  • Ahmed Gaber Abdelmegeed (Department of Plastic and Reconstructive Surgery, Sohag University Hospital) ;
  • Mahmoud A. Hifny (Department of Plastic Surgery, Faculty of Medicine, South Valley University) ;
  • Tarek A. Abulezz (Department of Plastic and Reconstructive Surgery, Sohag University Hospital) ;
  • Samia Saied (Department of Plastic and Reconstructive Surgery, Sohag University Hospital) ;
  • Mohamed A. Ellabban (Plastic and Reconstructive Surgery Unit, Suez Canal University Hospitals and Medical School) ;
  • Mohamed Abdel-Al Abo-Saeda (Department of Plastic and Reconstructive Surgery, Sohag University Hospital) ;
  • Karam A. Allam (Department of Plastic and Reconstructive Surgery, Sohag University Hospital) ;
  • Mostafa Mamdoh Haredy (Department of Plastic and Reconstructive Surgery, Sohag University Hospital) ;
  • Ahmed S. Mazeed (Department of Plastic and Reconstructive Surgery, Sohag University Hospital)
  • Received : 2022.12.30
  • Accepted : 2023.07.04
  • Published : 2023.09.15
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Abstract

Background Free tissue transfer is considered the gold standard option for the reconstruction of distal leg defects. Free tissue transfer using recipient vessels in the contralateral leg (cross-leg bridge) is a potential option to supply the flap if there are no suitable recipient vessels in the injured leg. Most studies have described this technique using end-to-end anastomosis which sacrifices the main vessel in the uninjured leg. This study evaluated the use of a cross-leg free latissimus dorsi muscle flap for the reconstruction of defects in single-vessel legs, using end-to-side anastomosis to recipient vessels in the contralateral leg without sacrificing any vessel in the uninjured leg. Methods This is a retrospective study that included 22 consecutive patients with soft tissue defects over the lower leg. All the reconstructed legs had a single artery as documented by CT angiography. All patients underwent cross-leg free latissimus dorsi muscle flap using end-to-side anastomosis to the posterior tibial vessels of the contralateral leg. Results The age at surgery ranged from 12 to 31 years and the mean defect size was 86 cm2. Complete flap survival occurred in 20 cases (91%). One patient had total flap ischemia. Another patient had distal flap ischemia. Conclusion Cross-leg free latissimus dorsi muscle flap is a reliable and safe technique for the reconstruction and salvage of mutilating leg injuries, especially in cases of leg injuries with a single artery. As far as preservation of the donor limb circulation is concerned, end-to-side anastomosis is a reasonable option as it maintains the continuity of the donor leg vessels.

Keywords

References

  1. Scott LL, Baumeister S. Lower extremity. In: Wei FC, Mardini S, eds, Flaps and Reconstructive Surgery. Philadelphia PA: Saunders; 2009:62-70 
  2. Chen H, El-Gammal TA, Wei F, Chen H, Noordhoff MS, Tang Y. Cross-leg free flaps for difficult cases of leg defects: indications, pitfalls, and long-term results. J Trauma 1997;43(03):486-491  https://doi.org/10.1097/00005373-199709000-00016
  3. Yu L, Tan J, Cai L, et al. Repair of severe composite tissue defects in the lower leg using two different cross-leg free composite tissue flaps. Ann Plast Surg 2012;68(01):83-87  https://doi.org/10.1097/SAP.0b013e3181fe9351
  4. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work. Plast Reconstr Surg 1979;64(06):745-759  https://doi.org/10.1097/00006534-197912000-00001
  5. Ding SY. [Treatment of chronic osteomyelitis of leg with free latissimus dorsi musculocutaneous flap anastomosed to contralateral leg vessels]. Chung Hua Cheng Hsing Shao Shang Wai Ko Tsa Chih 1993;9(02):106-107, 159 
  6. Knobloch K, Herold C, Vogt PM. Freier Latissimus-dorsi-Transfer zur Rekonstruktion von Weichteildefekten der unteren Extremitat. Oper Orthop Traumatol 2012;24(02):122-130  https://doi.org/10.1007/s00064-011-0094-y
  7. Ozkan O, Cinpolat A, Bektas G, et al. Reconstruction of the lower extremity with cross-leg free flaps. J Reconstr Microsurg Open 2016;1(01):12-18  https://doi.org/10.1055/s-0036-1571278
  8. Sief K, Shaker A. Salvage of severely mutilated lower limb using cross-leg free latissimus dorsi flap. Egypt J Plast Reconstr Surg 2010;34(01):17-22 
  9. Yamada A, Harii K, Ueda K, Asato H, Tanaka H. Versatility of a cross-leg free rectus abdominis flap for leg reconstruction under difficult and unfavorable conditions. Plast Reconstr Surg 1995;95(07):1253-1257  https://doi.org/10.1097/00006534-199506000-00017
  10. Yu ZJ, Tang CH, Ho HG. Cross-bridge free skin flap transfer: case report. J Reconstr Microsurg 1985;1(04):309-311  https://doi.org/10.1055/s-2007-1007091
  11. Yu ZJ, Zeng BF, Huang YC, et al. Application of the cross-bridge microvascular anastomosis when no recipient vessels are available for anastomosis: 85 cases. Plast Reconstr Surg 2004;114(05):1099-1107  https://doi.org/10.1097/01.PRS.0000135331.08938.4A
  12. Townsend PL. Indications and long-term assessment of 10 cases of cross-leg free DCIA flaps. Ann Plast Surg 1987;19(03):225-233  https://doi.org/10.1097/00000637-198709000-00008
  13. Akyurek M, Safak T, Ozkan O, Kecik A. Technique to re-establish continuity of the recipient artery after end-to-end anastomoses in cross-leg free flap procedure. Ann Plast Surg 2002;49(04):430-433  https://doi.org/10.1097/00000637-200210000-00017
  14. Bali ZU, Karatan B, Tuluy Y, Kececi Y, Yoleri L. Preserving the blood flow of the recipient artery in cross-leg free flap procedure for lower extremity reconstruction. Int J Low Extrem Wounds 2020;19(03):255-261  https://doi.org/10.1177/1534734620913414
  15. Topalan M. A new and safer anastomosis technique in cross-leg free flap procedure using the dorsalis pedis arterial system. Plast Reconstr Surg 2000;105(02):710-713  https://doi.org/10.1097/00006534-200002000-00037
  16. Gencel E, Eser C, Kesiktas E, Tabakan I, Yavuz M. A cross flow-through pedicle free latissimus dorsi flap for high voltage electrical burns. Burns 2016;42(04):e55-e60  https://doi.org/10.1016/j.burns.2015.10.014
  17. Fischer JP, Wink JD, Nelson JA, et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013;29(06):407-416  https://doi.org/10.1055/s-0033-1343952
  18. Pu LL. A comprehensive approach to lower extremity free-tissue transfer. Plast Reconstr Surg Glob Open 2017;5(02):e1228 
  19. Broer PN, Moellhoff N, Mayer JM, Heidekrueger PI, Ninkovic M, Ehrl D. Comparison of outcomes of end-to-end versus end-to-side anastomoses in lower extremity free flap reconstructions. J Reconstr Microsurg 2020;36(06):432-437  https://doi.org/10.1055/s-0040-1702156
  20. Zhang GL, Chen KM, Zhang JH, Wang SY. Repair of a large soft tissue defect in the leg with cross-leg bridge free transfer of a latissimus dorsi myocutaneous flap: a case report. Chin J Traumatol 2012;15(06):373-375 
  21. Morris AM, Buchan AC. The place of the cross-leg flap in reconstructive surgery of the lower leg and foot: a review of 165 cases. Br J Plast Surg 1978;31(02):138-142  https://doi.org/10.1016/S0007-1226(78)90064-4
  22. Barclay TL, Sharpe DT, Chisholm EM. Cross-leg fasciocutaneous flaps. Plast Reconstr Surg 1983;72(06):843-847  https://doi.org/10.1097/00006534-198312000-00021
  23. Abdelmegeed AG, Abulezz TA, Abo-Saeda MA, Allam KA. Perforator-based pedicled cross-leg flaps in pediatric patients: a new idea to increase flap reach. Ann Plast Surg 2021;86(05):568-572  https://doi.org/10.1097/SAP.0000000000002523
  24. Hifny MA, Tohamy AMA, Rabie O, Ali AAA. Propeller perforator flaps for coverage of soft tissue defects in the middle and distal lower extremities. Ann Chir Plast Esthet 2020;65(01):54-60  https://doi.org/10.1016/j.anplas.2019.04.002
  25. Ricci JA, Abdou SA, Stranix JT, et al. Reconstruction of Gustilo type IIIC injuries of the lower extremity. Plast Reconstr Surg 2019;144(04):982-987  https://doi.org/10.1097/PRS.0000000000006063
  26. Arnez ZM, Papa G, Ramella V, Novati FC, Ahcan U, Stocco C. Limb and flap salvage in Gustilo IIIC injuries treated by vascular repair and emergency free flap transfer. J Reconstr Microsurg 2017;33(S 01):S03-S07  https://doi.org/10.1055/s-0037-1603737
  27. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma 1989;29(08):1086-1094  https://doi.org/10.1097/00005373-198908000-00005
  28. Cho EH, Garcia RM, Blau J, et al. Microvascular anastomoses using end-to-end versus end-to-side technique in lower extremity free tissue transfer. J Reconstr Microsurg 2016;32(02):114-120  https://doi.org/10.1055/s-0035-1563397
  29. Haddock N, Garfein ES, Reformat D, Hecht E, Levine J, Saadeh P. Perforator vessel recipient options in the lower extremity: an anatomically based approach to safer limb salvage. J Reconstr Microsurg 2010;26(07):461-469  https://doi.org/10.1055/s-0030-1254230
  30. Bayramicli M, Tetik C, Sonmez A, Gurunluoglu R, Baltaci F. Reliability of primary vein grafts in lower extremity free tissue transfers. Ann Plast Surg 2002;48(01):21-29  https://doi.org/10.1097/00000637-200201000-00003
  31. Luo S, Gao J, Luo J. A case report of cross-leg free latissimus dorsi myocutaneous flap transplantation. E J Plastic Surg 1999:22329-330 
  32. Buncke HJ, Alpert B, Shah KG. Microvascular grafting. Clin Plast Surg 1978;5(02):185-194  https://doi.org/10.1016/S0094-1298(20)32161-1
  33. Germann G, Steinau HU. The clinical reliability of vein grafts in free-flap transfer. J Reconstr Microsurg 1996;12(01):11-17  https://doi.org/10.1055/s-2007-1006446
  34. Bullocks J, Naik B, Lee E, Hollier L Jr. Flow-through flaps: a review of current knowledge and a novel classification system. Microsurgery 2006;26(06):439-449  https://doi.org/10.1002/micr.20268
  35. Zhou HX, He L, Yin D, et al. Modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure for complex lower extremity reconstruction. J Orthop Surg Res 2022;17(01):262