Microvascular reconstruction of pediatric lower extremity trauma using free tissue transfer

  • L. C. Boyd
  • G. A. Bond
  • A. Hamidian Jahromi
  • S. D. Kozusko
  • Zinon Kokkalis
  • P. KonofaosEmail author
Expert's Opinion • LOWER LIMB - PAEDIATRIC


While free tissue transfer has long been established as a reliable microsurgical technique in the adult population, its application in pediatric reconstruction is a relatively recent phenomenon. Despite initial concerns regarding minute vessel diameters, increased propensity for vasospasm, and limited tissue availability, pediatric free tissue transfer is now a widely used technique that has demonstrated an acceptable level of donor and recipient site morbidity in children. Five flaps commonly used in the reconstruction of lower extremity trauma are discussed in this paper: the latissimus dorsi, rectus abdominis, anterolateral thigh, gracilis, and the subscapular and parascapular flaps. The indications, blood supply, advantages, and disadvantages of each are detailed. Incredible progress has been made in the application of microsurgical techniques to the pediatric population over the last several decades. With a healthy understanding of the anatomy and functionality of the donor site, the reconstructive surgeon can repair a variety of complex injuries with an acceptable morbidity and mortality rate.


Pediatrics Free flap Trauma Lower extremity Microsurgery 


Compliance with ethical standards

Conflict of interest

All of the authors declare that they have no conflict of interest.


  1. 1.
    Aboelatta YA, Aly HM (2013) Free tissue transfer and replantation in pediatric patients: technical feasibility and outcome in a series of 28 patients. J Hand Microsurg 5(2):74–80. Google Scholar
  2. 2.
    Devaraj VS, Kay SP, Batchelor AG, Yates A (1991) Microvascular surgery in children. Br J Plast Surg 44(4):276–280Google Scholar
  3. 3.
    Konttila E, Koljonen V, Kauhanen S, Kallio P, Tukiainen E (2010) Microvascular reconstruction in children-a report of 46 cases. J Trauma 68(3):548–552. Google Scholar
  4. 4.
    Malt RA, McKhann C (1964) Replantation of severed arms. JAMA 189:716–722Google Scholar
  5. 5.
    Harii K, Ohmori K (1975) Free groin flaps in children. Plast Reconstr Surg 55(5):588–592Google Scholar
  6. 6.
    Ohmori K, Harii K, Sekiguchi J, Torii S (1977) The youngest free groin flap yet? Br J Plast Surg 30(4):273–276Google Scholar
  7. 7.
    Irons GB, Verheyden CN, Peterson HA (1982) Experience with the ipsilateral thigh flap for closure of heel defects in children. Plast Reconstr Surg 70(5):561–568Google Scholar
  8. 8.
    Iwaya T, Harii K, Yamada A (1982) Microvascular free flaps for the treatment of avulsion injuries of the feet in children. J Trauma 22(1):15–19Google Scholar
  9. 9.
    Canales F, Lineaweaver WC, Furnas H, Whitney TM, Siko PP, Alpert BS, Buncke GM, Buncke HJ (1991) Microvascular tissue transfer in paediatric patients: analysis of 106 cases. Br J Plast Surg 44(6):423–427Google Scholar
  10. 10.
    Godina M (1986) Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 78(3):285–292Google Scholar
  11. 11.
    Qiu E, Kurlander DE, Ghaznavi AM (2018) Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg. Google Scholar
  12. 12.
    Rinker B, Valerio IL, Stewart DH, Pu LL, Vasconez HC (2005) Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10-year review. Plast Reconstr Surg 115(6):1618–1624Google Scholar
  13. 13.
    Lutz BS, Wei FC, Ng SH, Chen IH, Chen SH (1999) Routine donor leg angiography before vascularized free fibula transplantation is not necessary: a prospective study in 120 clinical cases. Plast Reconstr Surg 103(1):121–127Google Scholar
  14. 14.
    Klein S, Hage JJ, van der Horst CM, Lagerweij M (2003) Ankle-arm index versus angiography for the preassessment of the fibula free flap. Plast Reconstr Surg 111(2):735–743. Google Scholar
  15. 15.
    Young DM, Trabulsy PP, Anthony JP (1994) The need for preoperative leg angiography in fibula free flaps. J Reconstr Microsurg 10(5):283–287. (discussion 287–289) Google Scholar
  16. 16.
    Rosson GD, Singh NK (2005) Devascularizing complications of free fibula harvest: peronea arteria magna. J Reconstr Microsurg 21(8):533–538. Google Scholar
  17. 17.
    Korompilias A, Gkiatas I, Korompilia M, Kosmas D, Kostas-Agnantis I (2018) Reverse sural artery flap: a reliable alternative for foot and ankle soft tissue reconstruction. Eur J Orthop Surg Traumatol. Google Scholar
  18. 18.
    Yildirim S, Calikapan GT, Akoz T (2008) Reconstructive microsurgery in pediatric population-a series of 25 patients. Microsurgery 28(2):99–107. Google Scholar
  19. 19.
    Mathes SJ, Nahai F (1981) Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 67(2):177–187Google Scholar
  20. 20.
    Mackinnon SE, Dellon AL (1988) Technical considerations of the latissimus dorsi muscle flap: a segmentally innervated muscle transfer for facial reanimation. Microsurgery 9(1):36–45Google Scholar
  21. 21.
    Kang MJ, Chung CH, Chang YJ, Kim KH (2013) Reconstruction of the lower extremity using free flaps. Arch Plast Surg 40(5):575–583. Google Scholar
  22. 22.
    Leckenby J, Butler D, Grobbelaar A (2015) The axillary approach to raising the latissimus dorsi free flap for facial re-animation: a descriptive surgical technique. Arch Plast Surg 42(1):73–77. Google Scholar
  23. 23.
    Serletti JM, Schingo VA Jr, Deuber MA, Carras AJ, Herrera HR, Reale VF (1996) Free tissue transfer in pediatric patients. Ann Plast Surg 36(6):561–568Google Scholar
  24. 24.
    Fayanju OM, Garvey PB, Karuturi MS, Hunt KK, Bedrosian I (2018) Surgical procedures for advanced local and regional malignancies of the breast. In: Bland KI, Copeland III EM, Klimberg VS, and Gradishar WJ (eds) The breast: comprehensive management of benign and malignant diseases. Elsevier Inc., Philadelphia, pp 778–801Google Scholar
  25. 25.
    Odobescu A, Buncke G, Trumble T (2017) Soft-tissue coverage of the hand. In: Trumble T, Rayan G, Baratz M, Budoff J, Slutsky DJ (eds) Principles of hand surgery and therapy, 3rd edn. Elsevier Inc., Philadelphia, pp 571–595Google Scholar
  26. 26.
    Momeni A, Lanni M, Levin LS, Kovach SJ (2017) Microsurgical reconstruction of traumatic lower extremity defects in the pediatric population. Plast Reconstr Surg 139(4):998–1004. Google Scholar
  27. 27.
    Pedersen J, Song DH, Selber JC (2014) Robotic, intraperitoneal harvest of the rectus abdominis muscle. Plast Reconstr Surg 134(5):1057–1063. Google Scholar
  28. 28.
    Sadove R, Merrell JC (1987) The split rectus abdominis free muscle transfer. Ann Plast Surg 18(2):179–181Google Scholar
  29. 29.
    Reath DB, Taylor JW (1991) The segmental rectus abdominis free flap for ankle and foot reconstruction. Plast Reconstr Surg 88(5):824–828 (discussion 829–830) Google Scholar
  30. 30.
    Suominen S, Asko-Seljavaara S, von Smitten K, Ahovuo J, Sainio P, Alaranta H (1996) Sequelae in the abdominal wall after pedicled or free TRAM flap surgery. Ann Plast Surg 36(6):629–636Google Scholar
  31. 31.
    Pennington DG, Pelly AD (1980) The rectus abdominis myocutaneous free flap. Br J Plast Surg 33(2):277–282Google Scholar
  32. 32.
    Neligan PC, Buck II DW (2014) Lower extremity reconstruction. In: Neligan P, Buck II WD (eds) Core procedures in plastic surgery, 1st edn. Elsevier Inc., Philadelphia, pp 166–184Google Scholar
  33. 33.
    Franco MJ, Nicoson MC, Parikh RP, Tung TH (2017) Lower extremity reconstruction with free gracilis flaps. J Reconstr Microsurg 33(3):218–224. Google Scholar
  34. 34.
    Deutinger M, Kuzbari R, Paternostro-Sluga T, Quittan M, Zauner-Dungl A, Worseg A, Todoroff B, Holle J (1995) Donor-site morbidity of the gracilis flap. Plast Reconstr Surg 95(7):1240–1244Google Scholar
  35. 35.
    Acar MA, Gulec A, Aydin BK, Erkocak OF, Yilmaz G, Senaran H (2015) Reconstruction of foot and ankle defects with a free anterolateral thigh flap in pediatric patients. J Reconstr Microsurg 31(3):225–232. Google Scholar
  36. 36.
    Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH (2002) Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 109(7):2219–2226 (discussion 2227–2230) Google Scholar
  37. 37.
    Mathes SJNF (1997) Reconstructive surgery: principles, anatomy, and technique. Churchill Livingstone, New YorkGoogle Scholar
  38. 38.
    Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K (1998) Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg 102(5):1517–1523Google Scholar
  39. 39.
    Zhou G, Qiao Q, Chen GY, Ling YC, Swift R (1991) Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg 44(2):91–96Google Scholar
  40. 40.
    Xu DC, Zhong SZ, Kong JM, Wang GY, Liu MZ, Luo LS, Gao JH (1988) Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg 82(2):305–310Google Scholar
  41. 41.
    Koshima I, Fukuda H, Utunomiya R, Soeda S (1989) The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg 42(3):260–262Google Scholar
  42. 42.
    Chen D, Jupiter JB, Lipton HA, Li SQ (1989) The parascapular flap for treatment of lower extremity disorders. Plast Reconstr Surg 84(1):108–116Google Scholar
  43. 43.
    Jobe MT (2017) Microsurgery. In: Azar FM, Canale ST, Beaty JH (eds) Campbell’s operative orthopaedics, 13th edn. Elsevier Inc., Philadelphia, pp 3225–3297Google Scholar
  44. 44.
    Angrigiani C, Pefaure J, MackFarlane M (2009) Scapular and parascapular flaps. In: Wei FC, Mardini S (eds) Flaps and reconstructive surgery. 1st edn., Elsevier Inc., Philadelphia, pp 271–285Google Scholar
  45. 45.
    Barwick WJ, Goodkind DJ, Serafin D (1982) The free scapular flap. Plast Reconstr Surg 69(5):779–787Google Scholar
  46. 46.
    Lickstein LH, Bentz ML (2003) Reconstruction of pediatric foot and ankle trauma. J Craniofac Surg 14(4):559–565Google Scholar
  47. 47.
    Duteille F, Lim A, Dautel G (2003) Free flap coverage of upper and lower limb tissue defects in children: a series of 22 patients. Ann Plast Surg 50(4):344–349. Google Scholar
  48. 48.
    Alkureishi LWT, Purnell CA, Park P, Bauer BS, Fine NA, Sisco M (2018) Long-term outcomes after pediatric free flap reconstruction. Ann Plast Surg 81(4):449–455. Google Scholar
  49. 49.
    Van Landuyt K, Hamdi M, Blondeel P, Tonnard P, Verpaele A, Monstrey S (2005) Free perforator flaps in children. Plast Reconstr Surg 116(1):159–169Google Scholar
  50. 50.
    Upton J, Guo L (2008) Pediatric free tissue transfer: a 29-year experience with 433 transfers. Plast Reconstr Surg 121(5):1725–1737. Google Scholar
  51. 51.
    Parry SW, Toth BA, Elliott LF (1988) Microvascular free-tissue transfer in children. Plast Reconstr Surg 81(6):838–840Google Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Plastic SurgeryUniversity of Tennessee Health Science Center (UTHSC)MemphisUSA
  2. 2.Department of SurgeryUniversity of Tennessee Health Science Center (UTHSC)MemphisUSA
  3. 3.Department of Orthopaedic SurgeryUniversity of PatrasPatraGreece

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