The Great Saphenous Vein—An Underrated Recipient Vein in Free Flap Plasty for Lower Extremity Reconstruction: A Retrospective Monocenter Study

Abstract

Background Reconstruction of large soft tissue defects of the lower extremity often requires the use of free flaps. The main limiting factor and potential for complications lie in the selection of proper donor and recipient vessels for microvascular anastomosis. While the superficial veins of the lower leg are easier to dissect, they are thought to be more vulnerable to trauma and lead to a higher complication rate when using them instead of the deep accompanying veins as recipient vessels. No clear evidence exists that proves this concept.

Methods We retrospectively studied the outcomes of 97 patients who underwent free flap plasty to reconstruct predominantly traumatic defects of the lower extremity at our institute. The most used flap was the gracilis muscle flap. We divided the population into three groups based on the recipient veins that were used for microvascular anastomosis and compared their outcomes. The primary outcome was the major complication rate.

Results Overall flap survivability was 93.81%. The complication rates were not higher when using the great saphenous vein as a recipient vessel when comparing to utilizing the deep concomitant veins alone or the great saphenous vein in combination to the concomitant veins.

Conclusions In free flap surgery of the lower extremity, the selection of the recipient veins should not be restricted to the deep accompanying veins of the main vessels. The superficial veins, especially the great saphenous vein, offer an underrated option when performing free flap reconstruction.

Keywords

microsurgery - free tissue flaps - reconstructive surgical procedures - lower extremity

Authors' Contributions

A.M.: conception and design of the work, data collection, data analysis and interpretation, drafting the article, critical revision of the article, final approval of the version to be published; L.K.: critical revision of the article; L.K.: data collection; U.M.R.: critical revision of the article, final approval of the version to be published; A.B.: conception and design of the work, critical revision of the article, final approval of the version to be published.

Ethical Approval

Ethical approval for this study was obtained from the institutional review board (HCRI ID 2020–0135).

Patient Consent

Written informed consent was obtained from all the patients.

Publikationsverlauf

Eingereicht: 31. Mai 2021

Angenommen: 16. Juli 2022

Artikel online veröffentlicht:
23. September 2022

• References

• 1 Gorman PW, Barnes CL, Fischer TJ, McAndrew MP, Moore MM. Soft-tissue reconstruction in severe lower extremity trauma. A review. Clin Orthop Relat Res 1989; (243) 57-64
• 2 Engel H, Lin CH, Wei FC. Role of microsurgery in lower extremity reconstruction. Plast Reconstr Surg 2011; 127 (Suppl. 01) 228S-238S
• 3 Tomaino M, Bowen V. Reconstructive surgery for lower limb salvage. Can J Surg 1995; 38 (03) 221-228
• 4 Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004; 114 (06) 1457-1466
• 5 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
• 6 Kim SY, Lee KT, Mun GH. Postoperative venous insufficiency in microsurgical lower extremity reconstruction and deep vein thrombosis potential as assessed by a caprini risk assessment model. Plast Reconstr Surg 2015; 136 (05) 1094-1102
• 7 Muramatsu K, Shigetomi M, Ihara K, Kawai S, Doi K. Vascular complication in free tissue transfer to the leg. Microsurgery 2001; 21 (08) 362-365
• 8 Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 1999; 103 (07) 1937-1948
• 9 Lorenzo AR, Lin CH, Lin CH. et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2011; 64 (05) 649-655
• 10 Yazar S, Lin CH. Selection of recipient vessel in traumatic lower extremity. J Reconstr Microsurg 2012; 28 (03) 199-204
• 11 Badash I, Burtt K, Leland H. et al. Effects of perioperative venous thromboembolism on outcomes in soft tissue reconstruction of traumatic lower extremity injuries. Ann Plast Surg 2019; 82 (5S, Suppl 4): S345-S349
• 12 Janhofer DE, Lakhiani C, Kim PJ. et al. The utility of preoperative arteriography for free flap planning in patients with chronic lower extremity wounds. Plast Reconstr Surg 2019; 143 (02) 604-613
• 13 Acland RD. Refinements in lower extremity free flap surgery. Clin Plast Surg 1990; 17 (04) 733-744
• 14 Stranix JT, Borab ZM, Rifkin WJ. et al. Proximal versus distal recipient vessels in lower extremity reconstruction: a retrospective series and systematic review. J Reconstr Microsurg 2018; 34 (05) 334-340
• 15 Heidekrueger PI, Ehrl D, Heine-Geldern A, Ninkovic M, Broer PN. One versus two venous anastomoses in microvascular lower extremity reconstruction using gracilis muscle or anterolateral thigh flaps. Injury 2016; 47 (12) 2828-2832
• 16 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Int J Surg 2014; 12 (12) 1495-1499
• 17 World Medical Association. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. Bull World Health Organ 2013; 12 (12) 1495-1499 PubMed
• 18 Lee ZH, Abdou SA, Ramly EP. et al. Larger free flap size is associated with increased complications in lower extremity trauma reconstruction. Microsurgery 2020; 40 (04) 473-478