Again, the patient refused to consider a leg amputation. He agreed to the high risk of failure of a second-attempt free flap, and this time his right LD muscle was used to reach the anterior tibial vessels as the second recipient site above the ankle. This flap totally survived uneventfully, although the patient, now 6 months after the use of the second flap, later has a very bulky foot even with the relatively thin muscle flap. He does ambulate on the sole of this foot and refuses any further procedures.
Of the 13 second-attempt free flaps used for salvage of flaps that had totally failed, 7 (54%) were completely successful. Three patients required yet a third free flap that finally survived, and by definition, this was a delayed procedure. Two of these were muscle free flaps (Table 1). The timing of early interventions was evenly distributed between flap subgroups, but usually a second perforator free flap was used if there was any delay (Table 3). The consensus for an early second flap at the initial operation or re-exploration was to take advantage of the same exposed recipient vessels because of easy accessibility.
Free flap failures are uncommon but not rare. Perfection may be an elusive goal, but a good outcome usually will still require some form of vascularized tissue coverage. Preservation of life or limb, therefore, justifies a second attempt that many have shown to be highly successful.7–10 Perforator flaps offer a wide range of potential donor sites to serve not only as the primary selection for a given defect but also as a reasonable backup option.15,16 However, as with any choice of a secondary flap, a careful analysis of the patient’s condition must first be undertaken to confirm whether or not such an alternative is an appropriate option.6
Despite the current publicity for perforator flaps, muscle flaps are not yet passe.18 Although not a panacea, muscle flaps have a limited but not negligible value as seen in this experience. Muscle flaps can be rapidly harvested in emergent situations where speed is of the essence as the anatomy is rarely anomalous, and even the experienced surgeon knows that perforator flap harvest requires a careful, delicate microdissection.19 Often, the first-chosen perforator flap had the ideal contour for the given defect, and unfortunately, especially in the Western Hemisphere, other choices would just be too bulky. Sometimes the deep inferior epigastric artery perforator flap has been chosen only for the secondary gain of body recontouring, with also a donor scar easily hidden, while not respecting totally recipient-site requirements.20 A relatively thin muscle flap would then be the next best choice perhaps even from the beginning. A muscle-only flap always permits direct closure of the donor site, leaving a linear scar as opposed to the poor aesthetic residue if the perforator flap donor site must be skin grafted. The risk of vein grafts can sometimes be avoided by using a long muscle flap instead to reach the recipient site. Finally, if one believes in the “true” perforator flap concept,21 after raising a perforator flap on a musculocutaneous perforator, the underlying muscle should remain relatively unharmed and can itself still be used secondarily as a local or free muscle flap that will further restrict secondary donor-site morbidity!22
Most undesirable sequelae after any free flap failure may best be avoided by a second free flap attempt.7–10 This does not mean that if a perforator free flap fails then a second perforator free flap must be done, although that might still best satisfy the demands of the given defect.15,16 Another choice to consider is a muscle flap that, depending on the defect location, can even be a local muscle transposition. Remember that every muscle has a function and that specific contribution will be lost if it must be used as an adynamic transfer. Muscles also atrophy over time, and contour will be altered. Muscles usually need to be skin grafted, which will always lead to an inferior aesthetic result when compared with a properly chosen perforator flap. Nevertheless, a role still exists for muscle flaps under the proper circumstances as reiterated here, and this option should not be forgotten.
The author acknowledges David C. Rice, BS, Physician Extender, Sacred Heart Hospital, Allentown, who assisted with the operative procedures.
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