Upper and Lower Limb Salvage with Omental Free Flaps: A Long-Term Functional Outcome Analysis

BACKGROUND: The omentum is one of the oldest, but often overlooked options for extremity reconstruction.  Due to the large amount of pliable tissue, long vascular pedicle, associated lymphoid tissue, and angiogenic properties, the omentum should be considered when reconstructing complex extremity defects.  We report the largest series of free omental transfers for reconstruction of complex extremity defects.

MATERIALS AND METHODS: A retrospective analysis of 27 omental free tissue transfers in 24 patients with complex upper and lower extremity defects between 1999 and 2013 was performed.  Indications, operative technique, and outcomes were evaluated.  Functional outcomes were analyzed using clinical examination, TESS scores/functional scales and patient satisfaction scores.

RESULTS: Patient age ranged from 12-71 years with 19 males and 5 females. Mean follow-up was 4.5 years.  Indications included defects due to crush-degloving injuries, IIIB/IIIC fractures, pitbull mauling, infection or debilitating scar contracture.  Eleven omental flaps were for upper and sixteen for lower extremity defects, with bilateral coverage using split omentum performed in three patients.  Mean defect size was 780 cm² and all patients achieved wound coverage.   Complications included total flap loss (1), partial flap loss (4) partial skin graft loss (4), and donor site infection (1). One patient chose to undergo revision amputation after one year due to poor function. Laparoscopic-assisted harvest was performed in three cases. The long-term clinical outcomes, TESS scores/functional scales and patient satisfaction are discussed.

CONSLUSION: The long vascular pedicle, the vascular anatomy within the omentum and large amount of pliable tissue allow the omentum to be aggressively contoured for complex defects and is especially valuable in bilateral or multi-site injuries. By maintaining its unique physiology, including ometal stromal cells and lymphoreticular bodies, the omentum may facilitate healing by reducing edema and fighting infection. The long-term clinical and functional outcomes are promising in limbs, which are often deemed unsalvageable.