Free tissue transfer in treatment of the recalcitrant chronic venous ulcer.
We propose that a long-term cure for the recalcitrant chronic venous ulcer must involve a dual surgical approach including (1) wide excision of the ulcer and surrounding liposclerotic tissue bed, and (2) replacement by a free flap containing multiple, competent microvenous valves with a normal microcirculation. Advantages of free flaps over skin grafting include improvement of the underlying pathophysiology; increase in blood supply to the area; ability to cover exposed bone, joint, or tendon; and a lower incidence of recurrence. During the past 8 years, 20 consecutive muscle free flaps were performed in 18 patients for 19 recalcitrant venous ulcers (two "sequential" flaps to the ipsilateral leg in 1 patient and a repeat flap after initial failure in 1 patient). Twelve males and 6 females ranged in age from 17 to 76 years (mean, 44 years). Nontraumatic, nonosteomyelitic venous ulcers had been present for an average of 3.5 years (range, 1-10 years) and failed an average of 2.4 skin grafts (range, 0-6 grafts). Defects ranged from 100 to 600 cm2 (mean, 238 cm2). Donor tissues included rectus abdominis (N = 13), latissimus dorsi (N = 5), gracilis (N = 1), and serratus (N = 1) muscles. Recipient vessels included posterior tibial (N = 12), anterior tibial (N = 6), and peroneal (N = 2). In all instances except one, only one vein, usually one of the venae comitantes, was anastomosed in end-to-end fashion. Successful free tissue transfer was accomplished in 18 of 20 flaps (90%). Complications included infection with partial flap and/or skin graft loss (three flaps), and partial skin graft loss (two flaps). There were no recurrences within the flaps; however, breakdown occurred at the junction between the flap and residual adjacent liposclerotic skin in 1 patient. Follow-up average 32.7 months (range, 8-65 months); 3 patients were lost to follow-up. Free muscle transfer can provide a long-term cure for the recalcitrant venous ulcer by replacing the diseased tissue bed with healthy tissue containing multiple, competent microvenous valves and a normal microcirculation. This can be accomplished in one reconstructive procedure with excellent long-term results.
Weinzweig
N
N
Division of Plastic Surgery, University of Illinois at Chicago 60612-7316, USA.
Schuler
J
J
D000293:Adolescent; D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007866:Leg / Q000098:blood supply; D008297:Male; D008833:Microcirculation / Q000502:physiology; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D012086:Reoperation; D013524:Surgical Flaps / Q000379:methods* / Q000502:physiology; D017211:Treatment Failure; D014647:Varicose Ulcer / Q000503:physiopathology / Q000601:surgery*; D014680:Veins / Q000601:surgery; D014945:Wound Healing / Q000502:physiology