Download PDF
J Reconstr Microsurg 2020; 36(02): 116-126
DOI: 10.1055/s-0039-1697920
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Reconstruction of Lower Extremity Defects Using the Serratus Anterior Free Flap: A Systematic Review and Retrospective Case Series

Aneesh Karir
1   Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
,
Michael J. Stein
2   Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada
,
Sarah Shiga
2   Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada
,
Jing Zhang
2   Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada
› Author Affiliations Funding None.
Further Information

Publication History

23 March 2019

20 August 2019

Publication Date:
25 September 2019 (online)

Also available at
    Permissions and Reprints

Abstract

Background Free tissue transfer is the most common modality for distal third lower extremity reconstruction, yet complication rates remain high. The serratus anterior muscle free flap, which can be harvested alone or as a chimeric flap, is a robust and reliable option that remains the primary modality for distal third lower extremity defects at our institution. The objective of this study was to perform a systematic review of lower extremity reconstruction with the serratus anterior free flap and provide a retrospective review of cases at our institution.

Methods A systematic review of the literature was conducted using PubMed, Embase, and Cochrane Library (PROSPERO CRD42018110692). Articles reporting reconstruction of lower extremity and foot defects using serratus anterior free flaps in adults were included. A retrospective cohort study of serratus anterior free flaps was then performed from 2012 to 2018 at our institution.

Results Thirty-seven articles meeting inclusion criteria provided data on 198 flaps: 125 (63%) serratus-only flaps and 73 (37%) chimeric flaps based on the subscapular axis. Among the serratus-only flaps, defects were primarily due to chronic wounds (51%) or acute infections (33%). Flap survival rate was 97%, and the major and minor complication rates were 5 and 9%, respectively. Of the 10 cases included in the case series, flap survival rate was 100%, there were no major complications, and the minor complication rate was 44%. The average time to flap healing was 95 days and average lower extremity functional scale score was 58/80 among five patients.

Conclusion Serratus anterior muscle free flaps are a versatile and reliable option for distal third lower extremity reconstruction.

Keywords

lower extremity reconstruction - serratus free flap - free tissue transfer
 

  • References

  • 1 Wettstein R, Schürch R, Banic A, Erni D, Harder Y. Review of 197 consecutive free flap reconstructions in the lower extremity. J Plast Reconstr Aesthet Surg 2008; 61 (07) 772-776
    CrossrefPubMedGoogle Scholar
  • 2 Benacquista T, Kasabian AK, Karp NS. The fate of lower extremities with failed free flaps. Plast Reconstr Surg 1996; 98 (05) 834-840 , discussion 841–842
    CrossrefPubMedGoogle Scholar
  • 3 Culliford IV AT, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: a single institution's experience over 25 years. Ann Plast Surg 2007; 59 (01) 18-21 , discussion 21–22
    CrossrefPubMedGoogle Scholar
  • 4 Kim Y, Chung Y, Kwon T, Lee D, Cha J. Reconstruction of soft-tissue defects using serratus anterior adipofascial free flap. Plast Reconstr Surg 1999; 103 (03) 925-929
    CrossrefPubMedGoogle Scholar
  • 5 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
    CrossrefPubMedGoogle Scholar
  • 6 Takayanagi S, Tsukie T. Free serratus anterior muscle and myocutaneous flaps. Ann Plast Surg 1982; 8 (04) 277-283
    CrossrefPubMedGoogle Scholar
  • 7 Tsukada H, Osada H. Reconstruction of the hemidiaphragm and hemipericardium using combined reversed latissimus dorsi and serratus anterior muscle flaps. Surg Today 2006; 36 (03) 291-293
    CrossrefPubMedGoogle Scholar
  • 8 Pittet B, Mahajan AL, Alizadeh N, Schlaudraff KU, Fasel J, Montandon D. The free serratus anterior flap and its cutaneous component for reconstruction of the face: a series of 27 cases. Plast Reconstr Surg 2006; 117 (04) 1277-1288
    CrossrefPubMedGoogle Scholar
  • 9 Duteille F, Waast D, Perrot P, Cronier P, Hubert L, Pannier M. The serratus anterior free flap in limb reconstruction. About 30 cases [article in French]. Ann Chir Plast Esthet 2005; 50 (01) 71-75
    CrossrefPubMedGoogle Scholar
  • 10 Binkley JM, Stratford PW, Lott SA, Riddle DL. ; North American Orthopaedic Rehabilitation Research Network. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther 1999; 79 (04) 371-383
    PubMedGoogle Scholar
  • 11 Azouz SM, Castel NA, Vijayasekaran A, Rebecca AM, Lettieri SC. Lower-limb reconstruction with chimeric flaps: The quad flap. Microsurgery 2019; 39 (02) 182-187
    CrossrefPubMedGoogle Scholar
  • 12 Battiston B, Artiaco S, Piana R, Boux E, Tos P. Midfoot reconstruction with serratus anterior-rib osteomuscular free flap following oncological resection of synovial sarcoma. J Orthop Traumatol 2015; 16 (04) 347-350
    CrossrefPubMedGoogle Scholar
  • 13 Brenner P, Zwipp H, Rammelt S. Vascularized double barrel ribs combined with free serratus anterior muscle transfer for homologous restoration of the hindfoot after calcanectomy. J Trauma 2000; 49 (02) 331-335
    CrossrefPubMedGoogle Scholar
  • 14 Cronenwett JL, McDaniel MD, Zwolak RM. , et al. Limb salvage despite extensive tissue loss. Free tissue transfer combined with distal revascularization. Arch Surg 1989; 124 (05) 609-615
    PubMedGoogle Scholar
  • 15 de Fontaine S, Decker G, Goldschmidt D. Anomalous blood supply to the serratus anterior muscle flap. Br J Plast Surg 1994; 47 (07) 505-506
    CrossrefPubMedGoogle Scholar
  • 16 Duteille F, Thibault F, Perrot P, Renard B, Pannier M. Salvaging limbs in cases of severe purpura fulminans: advantages of free flaps. Plast Reconstr Surg 2006; 118 (03) 681-685 , discussion 686–687
    CrossrefPubMedGoogle Scholar
  • 17 Egozi D, Fodor L, Ullmann Y. Salvage of compromised free flaps in trauma cases with combined modalities. Microsurgery 2011; 31 (02) 109-115
    CrossrefPubMedGoogle Scholar
  • 18 Georgescu AV, Ivan O. Serratus anterior-rib free flap in limb bone reconstruction. Microsurgery 2003; 23 (03) 217-225
    CrossrefPubMedGoogle Scholar
  • 19 Goldschmidt D, Van Geertruyden J, de Fontaine S. Free-flap evolution after hyperthermic regional chemotherapy in the isolated limb for malignant melanoma. J Reconstr Microsurg 1998; 14 (06) 397-399
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Harii K, Yamada A, Ishihara K, Miki Y, Itoh M. A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomoses. Plast Reconstr Surg 1982; 70 (05) 620-629
    CrossrefPubMedGoogle Scholar
  • 21 Kim SW, Youn S, Kim JD, Kim JT, Hwang KT, Kim YH. Reconstruction of extensive lower limb defects with thoracodorsal axis chimeric flaps. Plast Reconstr Surg 2013; 132 (02) 470-479
    CrossrefPubMedGoogle Scholar
  • 22 Kim SW, Kwon YH, Kim JT, Kim YH. Foot reconstruction using a serratus anterior muscle flap from the same donor site after failure of a thoracodorsal artery perforator flap. Microsurgery 2014; 34 (02) 153-156
    CrossrefPubMedGoogle Scholar
  • 23 Kim SW, Jeon SB, Hwang KT, Kim YH. Coverage of amputation stumps using a latissimus dorsi flap with a serratus anterior muscle flap: acomparative study. Ann Plast Surg 2016; 76 (01) 88-93
    CrossrefPubMedGoogle Scholar
  • 24 Kim SW, Youn DG, Kim JT, Kim YH. A thoracodorsal artery perforator chimeric free flap for prevention of microvascular pedicle compression in lower extremity reconstruction. Microsurgery 2018; 38 (01) 46-50
    CrossrefPubMedGoogle Scholar
  • 25 Kurokawa M, Muneuchi G, Hamagami H, Fujita H. Reconstruction of four metatarsal bone and soft-tissue defects using a serratus anterior muscle rib osteomyocutaneous free flap. Plast Reconstr Surg 1998; 101 (06) 1616-1619
    CrossrefPubMedGoogle Scholar
  • 26 Leong M, Granick MS. Microvascular tissue transfer in a pregnant patient. J Reconstr Microsurg 1998; 14 (06) 411-415
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Lin CH, Wei FC, Levin LS. , et al. Free composite serratus anterior and rib flaps for tibial composite bone and soft-tissue defect. Plast Reconstr Surg 1997; 99 (06) 1656-1665
    CrossrefPubMedGoogle Scholar
  • 28 Mastroianni M, Leto Barone AA, Shanmugarajah K. , et al. Lower extremity soft tissue defect reconstruction with the serratus anterior flap. Microsurgery 2014; 34 (03) 183-187
    CrossrefPubMedGoogle Scholar
  • 29 Moscona RA, Ullmann Y, Hirshowitz B. Free composite serratus anterior muscle--rib flap for reconstruction of severely damaged foot. Ann Plast Surg 1988; 20 (02) 167-172
    CrossrefPubMedGoogle Scholar
  • 30 Rausky J, Binder JP, Mazouz-Dorval S, Hamou C, Revol M. Perforator-based chimaeric thoracodorsal flap forfoot reconstruction. J Plast Reconstr Aesthet Surg 2013; 66 (12) 1798-1800
    CrossrefPubMedGoogle Scholar
  • 31 Sano K, Hallock GG, Ozeki S. , et al. Devastating massive knee defect reconstruction using the cornucopian chimera flap from the subscapular axis: two case reports. J Reconstr Microsurg 2006; 22 (01) 25-32
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Sia WT, Xu GG, Puhaindran ME, Tan BK, Cheng MH, Chew WY. Reconstruction of extensive soft-tissue defects with concomitant bone defects in the lower extremity with the latissimus dorsi-serratus anterior-rib free flap. J Reconstr Microsurg 2015; 31 (06) 407-413
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Spiro SA, Oppenheim W, Boss WK, Schneider AI, Hutter AM. Reconstruction of the lower extremity after grade III distal tibial injuries using combined microsurgical free tissue transfer and bone transport by distraction osteosynthesis. Ann Plast Surg 1993; 30 (02) 97-104
    CrossrefPubMedGoogle Scholar
  • 34 Sung IH, Jang DW, Kim SW, Kim YH, Kim SW. Reconstruction of diabetic lower leg and foot soft tissue defects using thoracodorsal artery perforator chimeric flaps. Microsurgery 2018; 38 (06) 674-681
    CrossrefPubMedGoogle Scholar
  • 35 Takayanagi S, Ohtsuka M, Tsukie T. Use of the latissimus dorsi and the serratus anterior muscles as a combined flap. Ann Plast Surg 1988; 20 (04) 333-339
    CrossrefPubMedGoogle Scholar
  • 36 Thomas WO, Harris CN, Moline S, Harper LL, Parker JA. Versatility of the microvascular serratus anterior muscle vascularized rib flap (SARIB) for multifaceted requirement reconstructions. Ann Plast Surg 1998; 40 (01) 23-27
    CrossrefPubMedGoogle Scholar
  • 37 Trignano E, Fallico N, Nitto A, Chen HC. The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and rib free flap. Microsurgery 2013; 33 (03) 173-183
    CrossrefPubMedGoogle Scholar
  • 38 Turgut G, Kayalı MU, Köse O, Baş L. Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: a case report. Strateg Trauma Limb Reconstr 2010; 5 (03) 155-158
    CrossrefPubMedGoogle Scholar
  • 39 Ueng SW, Chuang DC, Cheng SL, Shih CH. Management of large infected tibial defects with radical debridement and staged double-rib composite free transfer. J Trauma 1996; 40 (03) 345-350
    CrossrefPubMedGoogle Scholar
  • 40 Weinzweig N, Schuler J. Free tissue transfer in treatment of the recalcitrant chronic venous ulcer. Ann Plast Surg 1997; 38 (06) 611-619
    CrossrefPubMedGoogle Scholar
  • 41 Whitney TM, Buncke HJ, Alpert BS, Buncke GM, Lineaweaver WC. The serratus anterior free-muscle flap: experience with 100 consecutive cases. Plast Reconstr Surg 1990; 86 (03) 481-490 , discussion 491
    CrossrefPubMedGoogle Scholar
  • 42 Wu WC, Chang YP, So YC, Ip WY, Lam CK, Lam JJ. The combined use of flaps based on the subscapular vascular system for limb reconstruction. Br J Plast Surg 1997; 50 (02) 73-80
    CrossrefPubMedGoogle Scholar
  • 43 Xu XY, Zhu Y, Liu JH. Treatment of calcaneal osteomyelitis with free serratus anterior muscle flap transfer. Foot Ankle Int 2009; 30 (11) 1088-1093
    CrossrefPubMedGoogle Scholar
  • 44 Xu XY, Zhu Y, Liu JH. Reconstruction of soft tissue defects of the lower limb using the free serratus anterior flap. Orthop Surg 2009; 1 (02) 113-120
    CrossrefPubMedGoogle Scholar
  • 45 Cho EH, Shammas RL, Carney MJ. , et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: amulticenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
    CrossrefPubMedGoogle Scholar
  • 46 Paro J, Chiou G, Sen SK. Comparing muscle and fasciocutaneous free flaps in lower extremity reconstruction--does it matter?. Ann Plast Surg 2016; 76 (Suppl. 03) S213-S215
    CrossrefPubMedGoogle Scholar
  • 47 Stranix JT, Lee ZH, Jacoby A. , et al. Forty years of lower extremity take-backs: flap type influences salvage outcomes. Plast Reconstr Surg 2018; 141 (05) 1282-1287
    CrossrefPubMedGoogle Scholar
  • 48 Lee ZH, Abdou SA, Daar DA. , et al. Comparing outcomes for fasciocutaneous versus muscle flaps in foot and ankle free flap reconstruction. J Reconstr Microsurg 2019
    PubMedGoogle Scholar
  • 49 Guzman-Stein G, Fix RJ, Vasconez LO. Muscle flap coverage for the lower extremity. Clin Plast Surg 1991; 18 (03) 545-552
    CrossrefPubMedGoogle Scholar
  • 50 Yaremchuk MJ. Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity. Clin Plast Surg 1986; 13 (04) 621-632
    CrossrefPubMedGoogle Scholar
  • 51 Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 1992; 89 (03) 478-487 , discussion 488–489
    CrossrefPubMedGoogle Scholar
  • 52 Philandrianos C, Moullot P, Gay AM. , et al. Soft tissue coverage in distal lower extremity open fractures: comparison of free anterolateral thigh and free latissimus dorsi flaps. J Reconstr Microsurg 2018; 34 (02) 121-129
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 Demirtas Y, Kelahmetoglu O, Cifci M, Tayfur V, Demir A, Guneren E. Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity. Microsurgery 2010; 30 (01) 24-31
    PubMedGoogle Scholar
  • 54 Nelson JA, Fischer JP, Haddock NT. , et al. Striving for normalcy after lower extremity reconstruction with free tissue: the role of secondary esthetic refinements. J Reconstr Microsurg 2016; 32 (02) 101-108
    Article in Thieme ConnectPubMedGoogle Scholar
  • 55 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
    CrossrefPubMedGoogle Scholar
  • 56 Kaminsky AJ, Li SS, Copeland-Halperin LR, Miraliakbari R. The vastus lateralis free flap for lower extremity Gustilo grade III reconstruction. Microsurgery 2017; 37 (03) 212-217
    CrossrefPubMedGoogle Scholar
  • 57 Franco MJ, Nicoson MC, Parikh RP, Tung TH. Lower extremity reconstruction with free gracilis flaps. J Reconstr Microsurg 2017; 33 (03) 218-224
    Article in Thieme ConnectPubMedGoogle Scholar