Jose Maria Serra, Augustin Ballesteros, Vincente Paloma, and Felipe Mesa
SIMULTANEOUS RECONSTRUCTION OF BOTH FEET WITH A VASCULARIZED LATISSIMUS
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DORSI FREE FLAP ABSTRACT Simultaneous reconstruction of both feet with a single vascularized latissimus dorsi free flap is reported. The authors describe the repair of extensive dorsal and plantar defects, as well as of heel lesions secondary to osteitis of the calcanei. The latissimus dorsi free flap serves well in combining the classic cross-leg procedure with microsurgical techniques.
It is generally agreed that reconstruction of extensive defects in the distal third of the leg, particularly in the foot, presents major surgical problems.1 The following report describes the use of a vascularized latissimus dorsi free flap for repairing defects in both legs, in both dorsal and plantar regions. With a need to repair both feet, with the impossibility of carrying out classic cross-leg procedures on both extremities at once, and with the relative ineffectiveness of other solutions, the authors combined the classic cross-leg procedure with microsurgical techniques. Only one vascular pedicle is utilized, but defects on both feet can be repaired.
CASE REPORTS CASE 1. In February 1987, a 59-year-old man suffered severe trauma in both feet when they were crushed by a truck. He had exposure of the left anterior tibial tendon, the tibiofibuloastragal joint, and the posterior neurovascular bundle in the left foot. In the
right foot, he suffered loss of skin, with exposure of muscle bellies and tendons on the dorsum of the foot (Fig. 1A). Seven months later, a vascularized free flap of the right latissimus dorsi was placed and covered with skin grafts taken from the thigh. The flap extended over the medial malleolar area of the left foot and the dorsal malleolar area of the right: thus, the dorsal areas of both feet were repaired at the same time (Fig. IB). The thoracodorsal artery in the flap was anastomosed to the anterior tibial artery of the left foot, and the venae comitantes were also anastomosed. After two months, the flap was divided in the middle and skin grafts were utilized. After a two-year follow-up, the patient's condition is satisfactory (Fig. ID). CASE 2. A 30-year-old woman had a meningococcal infection in August 1987 which caused disseminated intravascular obstruction and venous thrombosis in both feet, as well as necrosis of the plantar and calcaneal areas, resulting in osteitis of both calcanei (Fig. 2A). She spent one month in the intensive care unit, and three months on dialysis because of renal insufficiency, a consequence of the same infection.
Department of Plastic, Reconstructive and Aesthetic Surgery, University Clinic of Navarre, School of Medicine, Pamplona, Spain Reprint requests-. Dr. lose Maria Serra Renom, Dept. of Plastic, Reconstructive and Aesthetic Surgery, University Clinic of Navarre, Avda. Pio XII, s/n, Pamplona 31080, Spain Accepted for publication May 30, 1990 Copyright © 1990 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
353
OCTOBER 1990
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 6, NUMBER 4
Figure I. Case I. A, A 59-year-old man with wide traumatic lesions in left leg and right foot. B, Free flap after operative procedure. C, Two months later, the flap was divided in the middle and skin grafts were placed. D, Result two years postoperatively
354
Over an eight-month period, she also underwent several unsuccessful courses of treatment on the plastic surgery service of another hospital. On presentation in our hospital, arteriographic studies were carried out on her right leg, which showed sufficient flow for a flap to be attempted. A free flap of the left latissimus dorsi was used to join the heels and soles of both feet. After antibiotic treatment and debridement of the whole area (Fig. 2B), the thoracodorsal artery of the flap was anastomosed to the posterior tibial artery of the right foot, and the thoracodorsal vein to the external saphenous and dorsal veins of the same foot (Fig. 2C). The flap was covered by a skin graft taken from the left thigh (Fig. 2D). After two months, the flap was divided in the
middle, allowing both legs to move independently. The open areas were covered with a meshed skin graft taken from the posterior right thigh. Following one year of surgical procedures, the patient is now undergoing rehabilitation with an exercise regimen, and can walk by herself (Fig. 2E).
DISCUSSION In extensive defects of both feet, with both plantar and dorsal involvement, repair by means of local flaps is not feasible, nor is the use of such flaps as the classic cross-leg. For sizeable defects that affect both extremi-
SIMULTANEOUS RECONSTRUCTION OF BOTH FEET/SERRA, BALLESTEROS, PALOMA, MESA
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B
Figure 2. Case 2. A, A 30-year-old woman with necrosis of the plantar and calcaneal areas, resulting in osteitis of both calcanei secondary to a meningococcal infection. B, The area after debridement. C, Site of microvascular anastomoses. D, The muscle flap covered by a meshed skin graft. E, Result at one-year follow-up.
ties at the same time, we require a free flap that is capable of covering large areas.2 The latissimus dorsi muscle has been traditionally used for coverage in various parts of the body,3"5 and it is an excellent choice for repair of extensive dual extremity defects when local donor areas do not provide sufficient cutaneous coverage,6 as in the cases reported. In one of our cases, the dorsal area was recon-
structed; in the other, the flap was used for posterior and plantar area repair. The procedure is useful for reconstructing extensive defects that could not be treated by other alternatives. A further advantage of repairing two feet in this manner is that only one latissimus muscle is used, thereby insuring a better functional and cosmetic result.7 There have been reports of bilateral latissimus
355
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 6, NUMBER 4
356
REFERENCES 1. Me Craw IB: Selection of alternative local flaps in the leg and foot. Clin Plast Surg 6:227, 1979 2. Serafin D, Voci VE: Reconstruction of the lower extremity: Microsurgical composite tissue transplantion. Clin Plast Surg 10:55, 1983 3. Serra ]M, Vila R: Colgajo dorsal ancho. In Microcirugia Repamdora. Barcelona: Salvat Editores, S.A., 1985 4. Serafin D, Sabatier RE, Morris RL, Georgiade N: Reconstruction of the lower extremity with vascularized composite tissue: Improved tissue survival and specific indications. Plast Reconstr Surg 66:230, 1980 5. Maxwell GP, Manson PN, Hoopes IE: Experience with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg 64:1, 1979 6. Maruyama Y, Onishi K, lwahira Y, Motegi, M: Free compound rib-latissimus dorsi osteomusculocutaneous flap in reconstruction of the leg. | Reconstr Microsurg 3:13, 1986 7. Serra JM, SamayoaV, Valiente E, Kloehn G: Neurotizationof the remaining latissimus dorsi muscle following muscle flap transplant. 1 Reconstr Microsurg 4:415, 1988 8. Zhong-lia Y: The use of bilateral latissimus dorsi myocutaneous flaps to cover large soft tissue defects in the lower limbs of children. | Reconstr Microsurg 4:83, 1988 9. Gordon L, Buncke HI, Alpert BS: Free latissimus dorsi muscle flap with split thickness skin graft cover: A report of 16 cases. Plast Reconstr Surg 70:173, 1982 10. Godina M: Preferential use of end-to-side arterial anastomoses in free flap transfers. Plast Reconstr Surg 64:673, 1979
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use for repairing large soft-tissue defects of the extremities.8 However, the use of both muscles produces serious secondary consequences. Our procedure has the advantage of performing microsurgical anastomoses on only one vascular pedicle in one leg, and using a single latissimus dorsi flap for simultaneous repair of defects in both legs. The use of a muscle flap with splitthickness skin-graft coverage also has advantages over the myocutaneous flap, in that swelling is reduced at the recipient site and there is improved concealment of the defect at the donor site.9 In the two reported cases, the pedicle of the crossleg muscle flap was not separated until two months postoperatively, because both patients had severe infections which were being treated with antibiotics. Although previous authors have described other successful flaps, such as the groin flap, in the reconstruction of both feet,10 we prefer the latissimus dorsi cross-leg flap. We believe this flap produces a perceptible improvement in vascularization over other alternatives, and thus aids in ameliorating the infections associated with reconstruction of the plantar and dorsal areas of the foot.
OCTOBER 1990
SIMULTANEOUS RECONSTRUCTION OF BOTH FEET WITH A VASCULARIZED LATISSIMUS
Downloaded by: NYU. Copyrighted material.
DORSI FREE FLAP ABSTRACT Simultaneous reconstruction of both feet with a single vascularized latissimus dorsi free flap is reported. The authors describe the repair of extensive dorsal and plantar defects, as well as of heel lesions secondary to osteitis of the calcanei. The latissimus dorsi free flap serves well in combining the classic cross-leg procedure with microsurgical techniques.
It is generally agreed that reconstruction of extensive defects in the distal third of the leg, particularly in the foot, presents major surgical problems.1 The following report describes the use of a vascularized latissimus dorsi free flap for repairing defects in both legs, in both dorsal and plantar regions. With a need to repair both feet, with the impossibility of carrying out classic cross-leg procedures on both extremities at once, and with the relative ineffectiveness of other solutions, the authors combined the classic cross-leg procedure with microsurgical techniques. Only one vascular pedicle is utilized, but defects on both feet can be repaired.
CASE REPORTS CASE 1. In February 1987, a 59-year-old man suffered severe trauma in both feet when they were crushed by a truck. He had exposure of the left anterior tibial tendon, the tibiofibuloastragal joint, and the posterior neurovascular bundle in the left foot. In the
right foot, he suffered loss of skin, with exposure of muscle bellies and tendons on the dorsum of the foot (Fig. 1A). Seven months later, a vascularized free flap of the right latissimus dorsi was placed and covered with skin grafts taken from the thigh. The flap extended over the medial malleolar area of the left foot and the dorsal malleolar area of the right: thus, the dorsal areas of both feet were repaired at the same time (Fig. IB). The thoracodorsal artery in the flap was anastomosed to the anterior tibial artery of the left foot, and the venae comitantes were also anastomosed. After two months, the flap was divided in the middle and skin grafts were utilized. After a two-year follow-up, the patient's condition is satisfactory (Fig. ID). CASE 2. A 30-year-old woman had a meningococcal infection in August 1987 which caused disseminated intravascular obstruction and venous thrombosis in both feet, as well as necrosis of the plantar and calcaneal areas, resulting in osteitis of both calcanei (Fig. 2A). She spent one month in the intensive care unit, and three months on dialysis because of renal insufficiency, a consequence of the same infection.
Department of Plastic, Reconstructive and Aesthetic Surgery, University Clinic of Navarre, School of Medicine, Pamplona, Spain Reprint requests-. Dr. lose Maria Serra Renom, Dept. of Plastic, Reconstructive and Aesthetic Surgery, University Clinic of Navarre, Avda. Pio XII, s/n, Pamplona 31080, Spain Accepted for publication May 30, 1990 Copyright © 1990 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
353
OCTOBER 1990
Downloaded by: NYU. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 6, NUMBER 4
Figure I. Case I. A, A 59-year-old man with wide traumatic lesions in left leg and right foot. B, Free flap after operative procedure. C, Two months later, the flap was divided in the middle and skin grafts were placed. D, Result two years postoperatively
354
Over an eight-month period, she also underwent several unsuccessful courses of treatment on the plastic surgery service of another hospital. On presentation in our hospital, arteriographic studies were carried out on her right leg, which showed sufficient flow for a flap to be attempted. A free flap of the left latissimus dorsi was used to join the heels and soles of both feet. After antibiotic treatment and debridement of the whole area (Fig. 2B), the thoracodorsal artery of the flap was anastomosed to the posterior tibial artery of the right foot, and the thoracodorsal vein to the external saphenous and dorsal veins of the same foot (Fig. 2C). The flap was covered by a skin graft taken from the left thigh (Fig. 2D). After two months, the flap was divided in the
middle, allowing both legs to move independently. The open areas were covered with a meshed skin graft taken from the posterior right thigh. Following one year of surgical procedures, the patient is now undergoing rehabilitation with an exercise regimen, and can walk by herself (Fig. 2E).
DISCUSSION In extensive defects of both feet, with both plantar and dorsal involvement, repair by means of local flaps is not feasible, nor is the use of such flaps as the classic cross-leg. For sizeable defects that affect both extremi-
SIMULTANEOUS RECONSTRUCTION OF BOTH FEET/SERRA, BALLESTEROS, PALOMA, MESA
Downloaded by: NYU. Copyrighted material.
B
Figure 2. Case 2. A, A 30-year-old woman with necrosis of the plantar and calcaneal areas, resulting in osteitis of both calcanei secondary to a meningococcal infection. B, The area after debridement. C, Site of microvascular anastomoses. D, The muscle flap covered by a meshed skin graft. E, Result at one-year follow-up.
ties at the same time, we require a free flap that is capable of covering large areas.2 The latissimus dorsi muscle has been traditionally used for coverage in various parts of the body,3"5 and it is an excellent choice for repair of extensive dual extremity defects when local donor areas do not provide sufficient cutaneous coverage,6 as in the cases reported. In one of our cases, the dorsal area was recon-
structed; in the other, the flap was used for posterior and plantar area repair. The procedure is useful for reconstructing extensive defects that could not be treated by other alternatives. A further advantage of repairing two feet in this manner is that only one latissimus muscle is used, thereby insuring a better functional and cosmetic result.7 There have been reports of bilateral latissimus
355
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 6, NUMBER 4
356
REFERENCES 1. Me Craw IB: Selection of alternative local flaps in the leg and foot. Clin Plast Surg 6:227, 1979 2. Serafin D, Voci VE: Reconstruction of the lower extremity: Microsurgical composite tissue transplantion. Clin Plast Surg 10:55, 1983 3. Serra ]M, Vila R: Colgajo dorsal ancho. In Microcirugia Repamdora. Barcelona: Salvat Editores, S.A., 1985 4. Serafin D, Sabatier RE, Morris RL, Georgiade N: Reconstruction of the lower extremity with vascularized composite tissue: Improved tissue survival and specific indications. Plast Reconstr Surg 66:230, 1980 5. Maxwell GP, Manson PN, Hoopes IE: Experience with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg 64:1, 1979 6. Maruyama Y, Onishi K, lwahira Y, Motegi, M: Free compound rib-latissimus dorsi osteomusculocutaneous flap in reconstruction of the leg. | Reconstr Microsurg 3:13, 1986 7. Serra JM, SamayoaV, Valiente E, Kloehn G: Neurotizationof the remaining latissimus dorsi muscle following muscle flap transplant. 1 Reconstr Microsurg 4:415, 1988 8. Zhong-lia Y: The use of bilateral latissimus dorsi myocutaneous flaps to cover large soft tissue defects in the lower limbs of children. | Reconstr Microsurg 4:83, 1988 9. Gordon L, Buncke HI, Alpert BS: Free latissimus dorsi muscle flap with split thickness skin graft cover: A report of 16 cases. Plast Reconstr Surg 70:173, 1982 10. Godina M: Preferential use of end-to-side arterial anastomoses in free flap transfers. Plast Reconstr Surg 64:673, 1979
Downloaded by: NYU. Copyrighted material.
use for repairing large soft-tissue defects of the extremities.8 However, the use of both muscles produces serious secondary consequences. Our procedure has the advantage of performing microsurgical anastomoses on only one vascular pedicle in one leg, and using a single latissimus dorsi flap for simultaneous repair of defects in both legs. The use of a muscle flap with splitthickness skin-graft coverage also has advantages over the myocutaneous flap, in that swelling is reduced at the recipient site and there is improved concealment of the defect at the donor site.9 In the two reported cases, the pedicle of the crossleg muscle flap was not separated until two months postoperatively, because both patients had severe infections which were being treated with antibiotics. Although previous authors have described other successful flaps, such as the groin flap, in the reconstruction of both feet,10 we prefer the latissimus dorsi cross-leg flap. We believe this flap produces a perceptible improvement in vascularization over other alternatives, and thus aids in ameliorating the infections associated with reconstruction of the plantar and dorsal areas of the foot.
OCTOBER 1990
