Microvascular free tissue transfer has revolutionized the treatment of lower-extremity wounds. However, amputation is still frequently recommended to patients with complex lower-extremity wounds and/or significant medical conditions because limb salvage after free tissue transfer in these patients remains uncertain. In the past 3 years, more than 75 free tissue transfers to lower extremities were performed at our institution. Among them, eighteen patients (13 males, 5 females, age 17-71 years) with complex wounds in their lower-extremities and/or significant medical conditions had free tissue transfers for limb salvage. Seven patients had extensive soft tissue defect (>1/2 length) of the legs or feet and 6 had composite tissue defect of the legs or feet requiring bony reconstruction. Two patients had both bony and extensive soft tissue defects. An additional 5 patients also had significant peripheral vascular problems due to various medical conditions. A total of nineteen free tissue transfers (16 free muscle flaps, 2 osteomyocutaneous flaps, and 1 adipofascial flap) were performed in 18 patients (One patient had bilateral transfers, see figures below). A saphenous vein loop or graft was used in 3 patients. Free tissue transfer was successful in 16 of 18 patients (89%). Flap loss occurred in 2 patients (One at 2-week post-op) and both were treated successfully with either a second free tissue transfer or pedicle flaps. Four (4/17, 24%) patients required reoperation for salvage of a free flap. A bone graft was done subsequently in 4 patients. Successful limb salvage has been achieved in all 18 patients (18/18, 100%) with a healed wound for up to 30 months. Thus, we believe that free tissue transfer for limb salvage in difficult patients is still a worthwhile procedure and should be attempted if possible. Meticulous pre-op preparation and intra-op execution combined with the use of innovative microsurgical techniques are the keys for success.

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