Sequential free tissue transfers for simultaneous upper and lower limb salvage.

Background: The Iraq and Afghanistan Wars have presented military reconstructive surgeons with a high volume of challenging extremity injuries. In recent years, a number of upper and lower extremity injuries requiring multiple tissue transfers for multiple limb salvages in the same casualty have been encountered. Our group will discuss the microsurgical challenges, algorithms, and success and complication rates for this cohort of war injured patients. Methods: All consecutive limb salvage cases requiring free flaps from 2003 to 2012 were reviewed. Cases involving simultaneous free tissue transfers were identified. Data collected included success rates and complications with comparisons made between the single and multiple free-flap limb salvage cohorts. Results: Seventy-four free flap limb salvage cases were performed over the 10-year period. Of these cases, four patients received two free flaps to separate upper and lower extremity injuries for limb salvage within a single operative setting. The complication rate was 63%, which was significantly higher than those cases in which a single microvascular anastomosis was performed (26%, p 5 0.046). However, the higher complication rate did not increase the flap or limb salvage failure rates (p 5 0.892 and 0.626). Conclusions: The last decade of war trauma has provided a high volume of extremity injuries requiring limb salvage procedures including casualties who underwent single and multiple free flap coverage procedures. Although multiple flap limb salvage procedures have a higher complication rate, they can be performed within the same patient without concern for increased failure rate in carefully selected and appropriately managed patients. V C 2013 Wiley Periodicals, Inc. Microsurgery 33:447-453, 2013. The devastating nature of combat blast injuries frequently results in multiple extremity trauma with extreme soft tissue losses combined with open orthopedic fractures. These challenges necessitate challenging coverage solutions that often require multiple components of the reconstructive ladder and=or elevator. Delayed primary closure, dermal substitutes, and skin grafting often coupled with adjacent tissue transfers, rotational, and=or free flaps have roles in successful definitive closure for war-related combat and blast wounds. 1‐3 Free flaps have been critical in certain combat extremity injuries from the recent conflicts. These flaps permit harvest from areas protected by body armor, allowing for viable tissue sources that can also be transferred from outside the extensive zones of direct blast injury. The massive size and extent of traumatic wounds in this population typically require large free flaps, or even multiple free flaps, for successful extremity coverage and salvage. Through these efforts, limbs otherwise destined for amputation have been salvaged. Furthermore, in those cases where amputation was necessary, residual amputation length preservation through free tissue transfer has been achieved, permitting our amputees to use more functional or optimal prosthetic devices. The particular flaps utilized for extremity salvage