Page 35 - Read Online

Page 2 of 9 Kovar et al. Plast Aesthet Res 2019;6:10 I http://dx.doi.org/10.20517/2347-9264.2019.09

Conclusion: As per the principal, a tension-free closure is paramount to preventing tissue complications including direct
compression of a microvascular pedicle. However, with ongoing tissue edema skin grafting should be considered as a
reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional
complications and comparable post-operative outcomes.

Keywords: Free flap, limb salvage, skin graft, microsurgery

INTRODUCTION
Extremity reconstruction after trauma, oncologic resection, and diabetic complications often requires free
tissue transfer to provide soft tissue coverage of bone, vessel, and nerve. The circumferential shape of the
arm and leg, joint surfaces, motion, tendon glide and potential for weight bearing in addition to the relative
lack of elasticity of injured soft tissue, provides unique challenges for a tension free closure. Appropriate
flap design requires attentive preoperative planning toward the dimension and thickness of a given defect
while taking into consideration the anastomotic location, pedicle lie, vector, tension, motion, tendon
glide and potential for weight bearing. Even with optimal planning, excess tension placed over a vascular
pedicle can lead to flap demise. Tissue edema, ruddiness and tension can impact the survival of free flaps
if pressure is applied over anastomoses. Additional factors such as intraoperative thrombosis, pre-existing
vascular disease, or other perioperative patient risk factors can lead to proximal exposure of the pedicle or
[1-3]
vein grafts .
Tissue edema, especially secondary to renal disease, can be exacerbated in extremity surgery, secondary
to the inflammation of the injury itself, restricted motion, lymphatic disruption or radiation therapy, and
[4-7]
tourniquet use . Unfortunately, these factors can predate the surgery, and in fact represent a contribution
to the primary disease state and extremity wound.

With ongoing tissue edema, primary closure after vascular exposure can become increasingly difficult, even
to the point of potentially compressing the vascular pedicle or anastomosis. In these cases, the surgeon
could choose to mobilize the flap proximally to prevent vascular exposure, but this may leave a portion of
the recipient site uncovered. Alternatively, the flap can be left in place as intended to cover the recipient site,
and instead, the vascular pedicle is covered with a full or split thickness skin graft. The latter option may
prevent desiccation, but it is unclear if skin grafting the anastomosis, vein grafts and pedicle may provoke
microvascular collapse.

This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the
pedicle, in comparison with a matched cohort that achieved primary closure. The authors hypothesized
that skin grafting provides a tension-free closure when primary closure is unable to be performed and can
safely salvage a free-flap reconstruction without an increase in flap related or patient morbidity.

METHODS
All extremity free flaps performed at a single, Level 1 trauma center were entered into a prospectively
maintained registry including patient demographic information, clinical history, radiographic imaging,
procedural data, operative reports, postoperative care and long-term complications across 118 unique
variables. A REDCap database was utilized as a secure web-based application for data maintenance. A
trained member of the research team uploads data once monthly. Follow up clinic visits and photography
are specifically analyzed to identify limb salvage, flap failure, wound recurrence, patient ambulation, use of
assistive devices, patient disposition and rates of amputation. The database is maintained via institutional
review board approval. Operative reports were queried specifically wherein description of skin grafts placed