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Background: This retrospective case series compares the outcomes and postoperative oxygen levels in patients who underwent free flap versus primary closure/local flap reconstruction for ischemic diabetic foot wounds to determine the influence of free flap on the surrounding ischemic tissues. The authors hypothesized that the free flap would benefit the surrounding ischemic tissue as a nutrient flap by increasing the tissue oxygen content., Methods: The patients were divided into two groups: group 1 underwent free flap reconstruction, and group 2 underwent partial foot amputation with primary closure/local flap. Patient demographics, endovascular intervention, surgical outcome, postreconstruction intervention, and prereconstruction and postreconstruction transcutaneous oximetry were analyzed., Results: Among 54 patients, 36 were in group 1 and 18 were in group 2. There were no differences in patient demographics between the two groups. All patients had successful angioplasty. Statistical significance was noted in postreconstruction intervention in which group 2 required 2.8 ± 2.9 débridements (versus 1.2 ± 2.5 for group 1) and seven of 18 below-knee amputations (versus three of 36 for group 1) (p < 0.05). Transcutaneous partial pressure of oxygen levels were significantly higher in group 1 at 6 months after reconstruction (61.6 ± 7.5 versus 32.6 ± 5.8 mmHg) (p < 0.01)., Conclusion: This study shows that the role of the free flap in ischemic diabetic limb may expand beyond that of providing coverage over the vital structures, and it supports the use of the free flap as a nutrient to increase oxygen content in the ischemic diabetic foot., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background:  Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs., Methods:  Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type., Results:  Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9-20 days). Patients were followed-up for a median of 344 days (range: 142-594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type., Conclusion:  TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: A superficial circumflex iliac artery perforator flap has several advantages, such as reduced thickness, minimal donor-site morbidity, and inconspicuous scar. However, the application of a superficial circumflex iliac artery perforator flap is restricted because of its limited pedicle length. The aim of this article was to outline the technical modifications of superficial circumflex iliac artery perforator flap elevation to obtain long pedicles., Methods: This is a prospective study of 31 consecutive patients who required a long pedicled superficial circumflex iliac artery perforator flap between September of 2016 and December of 2019 at the authors' center. According to a preoperatively marked pathway of the superficial branch of the superficial circumflex iliac artery, the superficial circumflex iliac artery perforator flap was designed. During the elevation, the design was modified according to the perforator location in the free-style technique. The characteristics of the patients and the flaps, including pedicle length, were recorded. The revision rate, complication rate, and need for a secondary procedure were analyzed., Results: The mean follow-up period was 563 days (range, 92 to 1383 days). The mean length of the pedicle obtained was 6.9 cm (range, 6 to 8 cm) from the point where the pedicle merges into the flap. Long pedicles were anastomosed to the main source vessel or branch without tension. No major complications were reported., Conclusions: Overcoming the short pedicle length of a superficial circumflex iliac artery perforator flap by designing the flap laterally and performing an intraflap dissection is a reliable option when a longer pedicle is required, irrespective of the specific anatomy of the superficial circumflex iliac artery., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Successful reconstruction of diabetic ulcers using free flap surgery can prevent further amputation and promote limb salvage to maintain normal gait of the patient and increase the quality of life after surgery. To minimize the postoperative complication and days of stay in hospital, surgeons should thoroughly investigate the risk factors and underlying conditions, including the general condition and local factors., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  Overall success rate after diabetic foot reconstruction using free flap has been acceptable, but certain parts of the foot like the heel remains more challenging., Patients and Methods:  This retrospective study reviewed 37 patients reconstructed with free flaps for diabetic foot ulcer on the heel region from 2008 to 2017. Flap outcome in addition to various risk factors were analyzed; arterial status on heel, the American Society of Anesthesiologists (ASA) physical status, smoking, hypertension, hypercholesterolemia, chronic renal failure patient, hemoglobin A1c level, C-reactive protein, and osteomyelitis., Results:  Overall flap survival was 73% and resulted in limb salvage and functional ambulation. Total flap loss was 27% and the majority ended up with high-level amputation. Among the risk factors evaluated, the arterial status of the heel and ASA status significantly increased the odds for failure. When both arterial branches to the heel were impaired, the odds of failure were 80 times higher to fail ( p < 0.05)., Conclusion:  The vascularity of the surrounding tissue of the defect plays a critical role in overall success of diabetic heel reconstruction. Aggressive debridement using the angiosome concept is necessary to assure surrounding tissue has a good circulation. Despite the high chance of failure, success will lead to limb salvage and to reasonable functional ambulation whereas failure to salvage the heel will lead to higher level amputation. This warrants microsurgeons to make an effort to perform reconstruction to the heel defect after obtaining maximal vascularity after angioplasty., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Microsurgical lower extremity reconstruction remains a challenge. The use of perforator flaps in lower extremity reconstruction is expanding. The authors present an algorithm to guide in the selection of the ideal free perforator flap that can be tailored to each lower extremity defect., Methods: The authors conducted a retrospective review of lower extremity reconstruction using free perforator flaps over a 7-year period. Demographics, comorbidities, defect characteristics, operative details, complications, and secondary procedures were documented. Pairwise comparisons of flap types were performed to differentiate flaps on the basis of flap size, thickness, and pedicle length., Results: A total of 563 free perforator flaps were performed. The most common causes were trauma (36.5 percent) and diabetes (24.4 percent). Nine flaps were used, with the most common being superficial circumflex iliac perforator (51.2 percent) and anterolateral thigh (33.2 percent). Size differed significantly between flap types (p < 0.05), with the exception of thoracodorsal artery perforator versus gluteal artery perforator flaps (p = 0.26). The thinnest flaps were posterior interosseous artery perforator (3.7 ± 0.5 mm) and superficial circumflex iliac perforator (5.4 ± 0.8 mm). The thickest flaps were deep inferior epigastric perforator (11.1 ± 3.9 mm) and anterolateral thigh (9.0 ± 1.5 mm). The shortest pedicles were in posterior interosseous artery perforator (3.3 ± 0.3 cm) and superficial circumflex iliac perforator flaps (5.2 ± 0.8 cm). The longest pedicles were in deep inferior epigastric perforator (11.7 ± 1.4 cm), thoracodorsal artery perforator (9.3 ± 1.4 cm), and anterolateral thigh flaps (9.2 ± 0.8 cm)., Conclusions: Free perforator flaps are reliable in lower extremity reconstruction. The authors believe their algorithm for flap selection helps to optimize form and function, decrease operative time, and minimize donor-site morbidity and secondary procedures., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The benefits of total transmetatarsal amputation over higher level amputation are well known. However, there are no studies evaluating the effects of first ray- or first two ray-sparing transmetatarsal amputation with flap coverage. The authors evaluated this approach with regard to functional outcome and to identify long-term complications., Methods: Retrospective data of 59 patients were evaluated according to their surgical method. Complete transmetatarsal amputation with free flap reconstruction was designated as the transmetatarsal amputation group with 27 patients and first ray- or first two ray-preserving transmetatarsal amputation with free flap reconstruction was designated as the ray group, with 32 patients. Demographics, flap outcomes, additional procedures after initial healing, and functional outcomes were measured and evaluated., Results: There was no statistically significant difference in demographic distribution and flap outcomes in either group, except for poor blood glucose control in the ray group. Additional procedures after initial healing showed no statistical difference, but the tendency of minor procedures was higher in the ray group. The maximum achieved ambulatory function was significantly better in the ray group, with an ambulatory function score of 4.4 compared with 3.7 in the transmetatarsal amputation group (p = 0.012)., Conclusions: The preservation of the first ray or first two rays with free flap reconstruction may functionally benefit the patients despite the higher tendency toward minor procedures after initial healing. Furthermore, the progressive deformity of the preserved first and second toes will inevitably occur, requiring patients to undergo further surgery. Further studies are warranted to evaluate this approach., Clinical Question/level of Evidence: Therapeutic, III.