European Journal of Plastic Surgery (2023) 46:597–607

https://doi.org/10.1007/s00238-023-02052-6

ORIGINAL PAPER

Cross‑leg free flaps and cross‑leg vascular cable bridge flaps for lower
limb salvage: experience before and after COVID‑19
Pedro Ciudad1,2 · Joseph M. Escandón3 · Oscar J. Manrique3 · Lilyan Llanca1 · César Reynaga1 · Horacio F. Mayer4

Received: 21 October 2022 / Accepted: 23 January 2023 / Published online: 17 March 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
Background Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive
departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps
(CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our
protocols for standard of care adapted to the COVID-19.
Methods We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb
salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and
surgical outcomes.
Results Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs
(54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had
combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The
average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus
62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the
CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002).
Conclusions In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient
vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve
resource allocation in the setting of severely ill patients during COVID-19.
Level of evidence: Level III, Therapeutic.

Keywords Soft tissue injuries · Free tissue flaps · Leg injuries · Lower extremity · Limb salvage · Reconstructive surgical
procedures · Surgical flaps

Introduction

Current evidence on validated scoring systems that assist

surgeons to determine whether limb salvage should or should
* Pedro Ciudad not be attempted for complex wounds of lower extremities
[email protected] is still inconsistent and reproducibility is limited [1–3].
1
Some studies have even shown equivalent results comparing
Department of Plastic, Reconstructive and Burn Surgery,
Arzobispo Loayza National Hospital, Lima, Peru amputation versus lower limb reconstruction in severely
2
compromised limbs [4, 5]. Patients undergoing amputations
Institute of Plastic, Reconstructive and Aesthetic Surgery,
Ciruesthetic, Clinic, Lima, Peru often present depression, posttraumatic stress disorder, or
3
phantom pain [6], and can represent an increased economic
Division of Plastic and Reconstructive Surgery, University
of Rochester Medical Center, Rochester, NY, USA burden when compared to patients undergoing limb salvage
4
[7]. In order to avoid amputation, it is important to evaluate
Department of Plastic Surgery, Hospital Italiano de Buenos
Aires, University of Buenos Aires Medical School, Hospital
all reconstructive alternatives and approaches to improve
Italiano de Buenos Aires University Institute (IUHIBA), surgical results and enhance patient-reported outcomes
Buenos Aires, Argentina according to proper patient selection [8].

13
Vol.:(0123456789)
598 European Journal of Plastic Surgery (2023) 46:597–607

Ideal surgical outcomes following free tissue transfer Patients and methods
depend in great part on the quality of recipient vessels. For
lower limb reconstruction, free flaps cannot be transferred Study protocol
if there are extensive traumatic injuries with axial vessel
damage, severe peripheral arterial disease, vascular throm- This study was conducted in accordance with the World
bosis, or patients with suboptimal baseline characteristics Medical Association Declaration of Helsinki. After institu-
[9]. Additionally, relative contraindications for microvascu- tional review board approval, a retrospective review of data
lar reconstruction include previous radiotherapy, electrical was conducted including all consecutive patients undergoing
injury, and single-vessel runoff. In these circumstances, the reconstruction with free flap for lower limb salvage from
risk of free flap loss or necrosis increases, and cross-leg January 2018 to June 2022. We included patients undergoing
free flaps (CLFF) or cross-leg vascular cable bridge flaps CLFFs and CLVCBFs for lower limb salvage. We excluded
(CLVCBF) may offer an appropriate reconstructive alterna- patients who underwent pedicled cross-leg flaps, reconstruc-
tive [9]. tions with flow-through flaps perfused from the ipsilateral
The coronavirus disease 19 (COVID-19) pandemic has limb, and patients with incomplete data.
generated massive pressure on healthcare systems around
the globe [10]. During this period, medical centers have Variables
increased the total inpatient capacity, redeployed medical
staff from their usual roles, and created COVID-19 wards in Our demographic and baseline characteristics included the
response to the increased demand for healthcare. Further- number of patients; age; sex (male/female); smoking status;
more, microsurgical units providing complex reconstruc- past medical history of diabetes, peripheral vascular disease,
tive services added further pressure to centers managing the congestive heart failure, hypertension, chronic kidney
large influx of critically ill patients with COVID-19, generat- disease, or liver dysfunction; preoperative American Society
ing an increased competition for radiologic services, access of Anesthesiologists (ASA) physical status; and etiology of
to operating rooms, use of available ventilators, and vacant the defect or indication for reconstruction.
inpatient rooms [10]. Also, as non-urgent surgeries were Surgical variables included the type of anesthesia,
postponed, including the cases of lower limb microvascular duration of surgery, location of defects, number of flaps,
reconstruction, increased risk of pain, complication rates, type of flap, type of magnification for anastomosis
and mortality alongside limited recovery, function, and qual- (microscope versus magnification loupes), recipient
ity of life have been hypothesized to result from delaying vessels of contralateral limb, and type of donor site closure
surgical management [11]. (primary/skin graft-assisted closure). We extracted data for
Reconstruction of lower limb defects can be problematic postoperative outcomes as follows: length of the stay in the
due to the lack of local soft tissue for transposition. Preserv- intensive care unit (ICU), time for excision of the pedicle,
ing the morphology and biomechanics adds complexity to donor site complications, and recipient site complications.
the procedures and management [12]. Previous reports have
evidenced the disruptive effect of COVID-19 in microsurgi- Surgical management
cal and reconstructive departments [13]. Most studies on this
subject have evidenced the necessity to diverge from standard All patients were thoroughly assessed during physical
clinical practices towards new protocols and different surgical examination and using computed tomography angiograms
management methods to provide more comprehensive care to evaluate the current status of vascular structures of the
for patients that require lower limb reconstruction [13]. lower extremity and to detect potential recipient vessels
In response to COVID-19, we promoted alternative anes- [8]. The surgical technique has been reported in previous
thesia modalities favoring neuraxial techniques to decrease studies [8, 14]. Briefly, CLFFs were used for extensive
post-anesthesia care unit (PACU) admissions, reduce the use injuries comprising the leg when a pedicled cross-leg flap
of ventilators, and ease the transition of patients to the floor; was deemed inappropriate, while CLVCBFs were used if
we favored the use of loupe magnification to expedite the coverage of larger areas and increased reach was required.
initiation and finalization of cases in a resource-constrained For CLVCBFs, a vascular bridge was designed with radial
setting, and we implemented several workhorse flaps to opti- forearm free flaps as a flow-through free flap [8, 15]. The
mize postoperative care in a pandemic setting. Herein, we latissimus dorsi (LD) [16], medial sural artery perforator
reported our experience with CLFF and CLVCBF for lower (MSAP) [17], profunda artery perforator (PAP) [18], fibula
limb salvage, technical consideration to decrease morbidity, osteocutaneous [15], or anterolateral thigh (ALT) free flap
and some structural modifications to our protocols for the were anastomosed to the distal segment of the flow-through
standard of care adapted to COVID-19. cable bridge RFAFF for CLVCBF (Fig. 1) [8, 14]. For

13
European Journal of Plastic Surgery (2023) 46:597–607 599

Fig. 1  Cross-leg vascular cable

bridge flaps. Defect in right
lateral leg (upper left), radial
forearm free flap anastomosed
to contralateral posterior tibial
vessels as a vascular bridge
(upper right), free latissimus
dorsi flap inset into right lower
extremity defect and anas-
tomosed to contralateral leg
pedicle of radial forearm free
flap (lower left), and division of
pedicle 1–2 months after sur-
gery and rotation of the radial
forearm flap (lower right)

CLFFs, the aforementioned free flaps were directly anasto- lower limb reconstruction with LD flaps. Flap checks
mosed to the contralateral leg (Fig. 2) [8, 14]. were performed with handheld Doppler every hour the
When combined spinal-epidural anesthesia was imple- first 2 days after surgery, every 4 h on postoperative day
mented, ALT flaps, PAP flaps, or MSAP flaps were used. three, and every 6 h during postoperative day four through
General anesthesia was preferred in patients who had seven.

Fig. 2  Free cross-leg flap. Free

latissimus dorsi flap shaped
and inset to cover a right lower
extremity defect. Anastomosis
is based on contralateral poste-
rior tibial vessels

13
600 European Journal of Plastic Surgery (2023) 46:597–607

After 5 to 6 weeks, ischemic preconditioning was using the chi-square test. The outcomes of cable bridge
implemented to stress the flap and promote angiogenesis. vascular RFAFFs were also reported and included in the
During the week prior to division, pedicles of flaps were analysis in patient who had CLVCBFs.
clamped every day for several minutes. Once optimal
revascularization was determined, the vascular bridge or
the pedicle of the cross-leg flap was divided and used as a Results
rotation flap to cover any exposed area. External fixation
at the time of reconstruction was necessary to stabilize Twenty-four patients were included, eleven (45.8%)
the legs and avoid the avulsion of the pedicle of the CLFF underwent reconstruction with CLFF while 13 had
or vascular bridge with an orthopedic external fixator or CLVCBFs (54.2%). Nineteen patients (79.2%) were males
a custom-made orthopedic plaster cast. To preserve the and five were females (20.8%) (p = 0.833). The average
muscle mass and enhance venous return, physical therapy age of patients was 37.2 years (range, 27–50 years). Five
using static contracture was started as soon as possible patients were active smokers at the time of reconstruction
with the patient still in the room bed. (20.8%), three had past medical history of diabetes
(12.5%), and five had hypertension (20.8%). The most
common indication for reconstruction was trauma (50%)
Statistical analysis followed by burns (16.6%), osteomyelitis (16.6%), and
diabetic ulcers (16.6%) (Table 1).
R statistical software, version 4.0.0 (R Core Team, Fifteen patients (62.5%) underwent lower limb
2020), was used for statistical analysis [19]. The Mann- reconstruction under general anesthesia while nine (37.5%)
Whitney test or t-test was used to analyze continuous had combined spinal-epidural anesthesia (Table 2). The
data. Categorical variables of paired data were compared overall surgical time (10.5 h versus 8.2 h, p <.001) and

Table 1  Baseline demographic Variables Cross-leg free flap Free cable bridge flap p-value
characteristics
Number of patients (No.) 11 (45.8%) 13 (54.2%)
Sex 0.833
Male (%) 8 (72.7%) 11 (84.6%)
Female (%) 3 (27.3%) 2 (15.4%)
Age (years) 39.09 (range, 29–50) 35.61 (range, 27–44) 0.214
Smoking (%) 3 (27.3%) 2 (15.4%) 0.833
Comorbidities
Diabetes (%) 1 (9.1%) 2 (15.4%) 0.877
Peripheral vascular disease (%) 0 (0%) 0 (0%) -
Congestive heart failure (%) 0 (0%) 0 (0%) -
Hypertension (%) 2 (18.2%) 3 (23.1%) 0.834
Chronic kidney disease (%) 0 (0%) 0 (0%) -
Liver disease (%) 0 (0%) 0 (0%) -
ASA 0.556
Class I (%) 10 (90.9%) 10 (76.9%)
Class II (%) 1 (9.1%) 2 (15.4%)
Class III (%) 0 (0%) 1 (7.7%)
Etiology of the defect 0.182
Trauma (%) 3 (27.3%) 9 (69.2%)
Burn (%) 2 (18.2%) 2 (15.4%)
AVM excision (%) 0 (0%) 0 (0%)
Diabetic ulcer (%) 3 (27.3%) 1 (7.7%)
Osteomyelitis (%) 3 (27.3%) 1 (7.7%)
Osteoradionecrosis (%) 0 (0%) 0 (0%)

ASA American Society of Anesthesiologists Physical Status Classification System, AVM arteriovenous mal-
formation, BMI body mass index

13
European Journal of Plastic Surgery (2023) 46:597–607 601

Table 2  Surgical outcomes Variables Cross-leg free flap Free cable bridge flap P-value

Number of patients (No.) 11 (100%) 13 (100%)

Type of anesthesia < .001
General anesthesia (%) 2 (18.2%) 13 (100%)
Epidural (%) 0 (0%) 0 (0%)
Combined spinal-epidural (%) 9 (81.8%) 0 (0 %)
Duration of the surgery (hours) 8.2 10.5 < .001
Defect size of defects (­ cm2) 370 510 < .001
Location of defects 0.757
Knee (%) 0 (0%) 0 (0%)
Upper third of the leg (%) 1 (9.1%) 3 (23.1%)
Middle third of the leg (%) 4 (36.4%) 4 (30.8%)
Lower third of the leg (%) 3 (27.3%) 4 (30.8%)
Foot and ankle (%) 3 (27.3%) 2 (15.4%)
Total number of flaps 11 (100%) 26 (100%)
Flap for reconstruction 0.431 Ω
Anterolateral thigh free flap (%) 6 (54.5%) 4 (30.8%)
Latissimus dorsi free flap (%) 2 (18.2%) 5 (38.5%)
Free fibula osteocutaneous flap (%) 0 (0%) 2 (15.4%)
MSAP flap/PAP flap (%) 3 (27.3%) 2 (15.4%)
Radial forearm free flap† N/A 13 (50%)
Anastomosis 0.851
Microscope (%) 8 (72.7%) 9 (69.2%)
Loupes (%) 3 (27.3%) 4 (30.8%)
Recipient vessels 0.503
Posterior tibial A. and V. (%) 9 (81.8%) 11 (84.6%)
Medial sural A. and greater saphenous V. (%) 1 (9.1%) 0 (0%)
Dorsalis pedis A. and V. (%) 1 (9.1%) 2 (15.4%)
Donor site closure 0.016
Primary closure (%) 9 (81.8%) 10 (38.5%)
Skin graft (%) 2 (18.2%) 16 (61.5%)

†Cable bridge flap

A artery, MSAP medial sural artery perforator flap, PAP profunda artery perforator, V vein
ΩExcluded the Radial Forearm Free Flaps from analysis

average size of defects (510 ­cm2 versus 370 ­cm2, p < .001) under general anesthesia (11.1%) and three under com-
were significantly higher in the CLVCBF group when bined spinal-epidural anesthesia (16.6%). Thirteen
compared to the CLFF group. Overall, thirty-seven free CLVCBF cases were performed under general anesthesia
flaps were transferred for reconstruction of lower limbs (72.2%). During COVID-19 pandemic, six CLFF cases
(100%). Of the total number of CLFFs (n = 11), six were performed under combined spinal-epidural anes-
ALT flaps (54.5%), two LD free flaps (18.2%), and three thesia (100%). The proportion of cases performed with
PAP flaps (27.3%) were used for reconstruction (Figs. 3 microscope magnification (70.8%, n = 17) or loupe mag-
and 4). Of the total number of patients who underwent nification (29.2%, n = 7) for the micro-anastomosis were
reconstruction with CLVCBFs, four patients had ALT comparable between groups (p = 0.851). A higher propor-
flaps (30.8%), five patients had LD flaps (38.5%), two tion of reconstructions during COVID-19 were performed
had MSAP or PAP flaps (15.4%), and two had free fibula with loupe magnification.
osteocutaneous flaps (15.4%, p = 0.431). Thirteen RFAFFs The recipient vessels were the contralateral poste-
were used as a vascular bridge (Fig. 5). rior tibial artery and vein in 20 reconstructions (83.3%),
Eighteen cases were performed before the COVID-19 medial sural artery and greater saphenous vein in one
pandemic (Table 3). Two CLFF cases were performed patient (4.2%), and dorsalis pedis artery and vein in three

13
602 European Journal of Plastic Surgery (2023) 46:597–607

Fig. 3  Cross-leg anterolateral

thigh free flap inset to cover left
distal lower extremity defect.
The recipient vessels were the
contralateral posterior tibial
vessels

Fig. 4  Cross-leg latissimus

dorsi free flap inset to cover
right lower extremity defect.
The recipient vessels were the
contralateral posterior tibial
vessels

patients (12.5%). No difference was found between groups pedicle division of fasciocutaneous flaps in the CLFF
regarding the recipient vessels (p = 0.503). Following group when compared to CLVCBFs (45 days versus 59
flap transfer for reconstruction with CLFFs, primary days, p = 0.002). The average time for pedicle division of
closure of the donor site was possible in nine patients osteo-fasciocutaneous flaps was 68 days.
(81.8%) and split-thickness skin grafts (STSGs) were Donor site morbidity in patients who underwent CLFFs
required in 2 patients (18.2%). Following flap transfer included partial STSG loss in one patient (50%) and partial
for reconstruction with CLVCBFs, 16 donor sites required skin necrosis in one patient (9.1%). Donor site morbidity
STSG (61.5%) for closure while 10 (38.5%) were closed in patients who had CLVCBFs included partial STSG loss
primarily (p = 0.016) (Table 2). in four patients (14.3%), partial skin necrosis in one patient
(3.8%), and donor site infection in one patient (3.8%). No
Postoperative outcomes significant difference was found between groups for donor
site morbidity (Table 4).
ICU admission was reported in two patients (18.2%) who Two total flap loss (7.7%) and three partial flap loss
underwent reconstruction with CLFFs and 12 (92.3%) (11.5%) were reported following reconstruction with
with CLVCBFs (p <.001). None of the patients who had CLVCBFs. Also, three anastomosis revisions were
combined spinal-epidural anesthesia was admitted to the required due to venous thrombosis (11.5%) and four
ICU (100%). The average time for pedicle transection patients reported prolonged pain of the recipient site
of muscle CLFFs and muscle CLVCBFs was compara- (15.4%). None of the patients who underwent reconstruc-
ble between groups (60 days versus 62 days, p = 0.864). tion with CLFFs experienced total flap loss (0%), but two
A significantly shorter average time was evidenced for experienced partial flap loss (18.2%). Two patient required

13
European Journal of Plastic Surgery (2023) 46:597–607 603

Fig. 5  A Intraoperative findings

of reconstruction of lower and
middle third of the leg with
fibula osteocutaneous free flap
using radial forearm free flap
as cross-leg vascular cable
bridge flap. B Immediate and
late postoperative photos after
reconstruction with cross-leg
vascular cable bridge flap

Table 3  Type of procedure and Period Type of reconstruction Magnification Total

type of anesthesia over different
periods of time CLFF GA CLFF S-E CLVCBF GA CLVCBF S-E Microscope Loupes

Total 2 (8.3%) 9 (37.5%) 13 (54.2%) 0 (0%) 17 (70.8%) 7 (29.2%) 24 (100%)

2018–2019 2 (11.1%) 3 (16.6%) 13 (72.3%) 0 (0%) 16 (88.9%) 2 (11.1%) 18 (75%)
2020–2022 0 (0%) 6 (100%) 0 (0%) 0 (0%) 1 (16.6%) 5 (83.4%) 6 (25%)

CLFF cross-leg free flap, CLVCBF cross-leg vascular cable bridge flap, GA general anesthesia, S-E spinal-
epidural

revision of the anastomosis due to venous congestion in Discussion

one case (9.1%) and arterial obstruction in another case
(9.1%). One patient experienced recipient site infection Due to the high contamination rate and active transmis-
(9.1%), and two presented prolonged recipient site pain sibility of the coronavirus, countries around the globe
(18.2%). The rates of recipient site complications were have experienced several global health challenges since
comparable between groups. the beginning of the COVID-19 pandemic [20]. The

13
604 European Journal of Plastic Surgery (2023) 46:597–607

Table 4  Postoperative outcomes Variables Cross-leg free flap Free cable bridge flap P-value

Number of patients (No.) 11 (100%) 13 (100%)

Number of flaps (No.) 11 (100%) 26 (100%)
Admission to ICU (%) 2 (18.2%) 12 (92.3%) < .001
Time for pedicle division (days)
Muscle flaps (days) 60 62 0.864
Fasciocutaneous flap (days) 45 59 0.002
Osteo-fasciocutaneous (days) N/A 68 -
Donor site complications (%)
Partial skin graft loss (%) 1 (50%) 4 (14.3%) 0.743
Partial skin necrosis (%) 1 (9.1%) 1 (3.8%) 0.519
Infection (%) 0 (0%) 1 (3.8%) 0.510
Recipient site complications (%)
Total flap loss (%) 0 (0%) 2 (7.7%) 0.344
Partial flap loss (%) 2 (18.2%) 3 (11.5%) 0.589
Revision of anastomosis (%) 2 (18.2%) 3 (11.5%) 0.589
- Arterial thrombosis (%) 1 (9.1%) 0 (0%) 0.119
- Venous thrombosis (%) 1 (9.1%) 3 (11.5%) 0.827
Surgical site infection (%) 1 (9.1%) 0 (0%) 0.119
- Superficial incisional (%) 1 (9.1%) 0 (0%) 0.119
- Deep incisional (%) 0 (0%) 0 (0%) -
Hematoma (%) 0 (0%) 0 (0%) -
Deep venous thrombosis (%) 0 (0%) 0 (0%) -
Prolonged pain (%) 2 (18.2%) 4 (15.4%) 0.833

ICU intensive care unit, LOSS length of stay

impact of this situation has been so meaningful, some prominent, that it has been shown to improve 5-year survival
reports have suggested the need to take a step down on rates and maintain functional outcomes [26].
the reconstructive ladder to provide optimal health care In some cases, a single recipient vessel or no recipient
management [20]. On the other hand, the implication of vessel can be identified during preoperative evaluation or
severe acute respiratory syndrome 2 (SARS-2) in the cur- intraoperative assessment [8]. These patients represent
rent microsurgical management of patients could be taken the most intricated reconstructions for microvascular free
as an opportunity to improve perioperative protocols for tissue transfer and a more complex approach is required [8].
microvascular reconstruction, especially in countries with Although previous reports have evidenced the feasibility
limited health care access and delayed vaccination [21, of using a single-vessel runoff as recipient vessel, the
22]. For instance, proof of this concept was evidenced risk of injuring the only vessel perfusing the lower limb
in this current report with the incorporation of different is exceedingly high for some surgeons to contemplate this
anesthesia protocols alongside the reduction of ventilators, alternative [27]. Certainly, if an end-to-side anastomosis is
minimization of the use of microscopes, and reduction of attempted in a single-vessel extremity, partial or complete
patient admission to ICU for postoperative flap monitoring flap loss and limb necrosis distal to the anastomosis site
during complex microvascular lower limb reconstruction. can occur as possible aftermath of the procedure [8, 28].
With contemporary developments and the introduction of Alternatively, a super-microvascular approach has been
cutting-edge technology, microvascular free tissue transfer suggested for these patients. With this technique, the
has become an optimal alternative for lower limb salvage, vascular quality of major vessels in the lower extremity is of
even in patients with substandard wound healing status, cal- less apprehension and there is no need for deep dissections
cified vessels, or peripheral vascular disease [23, 24]. Free of major vessels as anastomoses are performed with
flaps provide well-vascularized tissue for long-lasting cover- cutaneous perforators [29]. Nonetheless, this approach may
age of important structures (e.g., vessels, cartilage, nerves) not be possible in certain cases due to discrepancies in vessel
and enhance distal lower limb perfusion [25]. The effect of caliber or unsuitable dimensions of perforator flaps to fill or
healthy transplanted autologous tissue in limb salvage is so cover the whole extension of defects [24, 29].

13
European Journal of Plastic Surgery (2023) 46:597–607 605

In case no recipient vessel is available, long arteriovenous Despite their advantages, crossed-leg flaps remain a tech-
fistulas or vein grafts have been reported [30]. Likewise, ipsi- nically challenging operation and should be only considered
lateral pedicle flaps or propeller flaps can be also considered; when all limb salvage alternatives have failed or are not fea-
nonetheless, these flaps are fixed to their pedicle and usually sible. Careful consideration should be given to donor site
do not reach the distal segment of defects due to their limited morbidity and patient comorbidities prior to surgical inter-
length [12, 30] Similarly, comparable length restrictions have vention with this approach. Adequate postoperative manage-
been encountered using ipsilateral flow-through flaps. But ment, such as DVT prophylaxis, specialized beds, and in-bed
again, the additional requirement of the presence of at least physical therapy can reduce the possibility of complications.
one healthy main vessel perfusing the limb limits their use Furthermore, physical therapy is of paramount importance
in single-vessel runoff extremities [8, 31]. In some cases, the following the removal of the external fixator to re-establish
reverse ALT pedicled flap has been reported to be versatile for quick ambulation, prevent contraction or atrophy of the legs,
coverage of the leg’s proximal third [32]. However, even after and avoid other potential risks such as DVT. A dangling
supercharging, it may not fulfill the reconstructive requirements protocol is used to accustom the flaps to gravity and motion
for large defects, exposure of osteosynthesis material and bone, as soon as the patient starts walking.
or defects in the lower third of the leg [32–35]. Besides the fact that this is a complex procedure and
As shown in our series, CLFFs and CLVCBFs are resource- involves a careful preoperative assessment, requires
ful alternatives and should be considered in a surgeon’s arma- multiple anastomosis, has several steps, and an experienced
mentarium for distal lower extremity salvage in patients with microsurgeon is required, patient selection is another key
single-vessel runoff or with no recipient vessels [8]. This factor to achieving successful reproducible outcomes [8]. As
approach is advantageous as the recipient vessels are usually seen from our results, limb salvage with CLFs is best suited for
located outside the zone of injury with the additional benefit of highly motivated young patients, with optimal health baseline
avoiding further incisions and dissections in an already com- status, able to tolerate complex surgical interventions with
promised or affected limb [8]. Postoperative assessment with long intraoperative times, extended periods of inpatient care,
ICG-angiography to evaluate revascularization can decrease and patients who are compliant with prompt physiotherapeutic
the time for pedicle division, especially if there is past sur- regimens [8, 38]. Certainly, multiple long surgical procedures
gical history of oncologic ablative procedures and preopera- and limited mobility during the early postoperative period in
tive radiation of the recipient wound bed [8, 36]. With ICG- unfitted patients with several comorbidities increase the risk of
angiography, surgeons can objectively evaluate if the flap has complications and these subjects are not good candidates for
integrated and if division of the pedicle can be accomplished complex non-lifesaving interventions [8].
without complications secondary to lack of perfusion [8, 37]. Healthcare systems and institutions have acknowledged
In fact, the prolonged time for pedicle division in our series the imperative role of proper patient admission to the ICU
may be explained by the lack of fluorescein imaging to evalu- after the COVID-19 pandemic. Critical care management
ate the revascularization of flaps. should be reserved for seriously sick and de-compensated
For the selection of recipient vessels, the preoperative patients; otherwise, it unnecessarily increases healthcare-
assessment should guide the decision-making but we related costs [39, 40]. Contemporary reports have shown
prioritize the use of the posterior tibialis artery and vein of comparable outcomes in patients admitted to the ICU versus
the contralateral leg as seen from our series. In most cases, the floor immediately after free flap reconstruction of lower
we try to implement end-to-side anastomoses to the recipient limbs [41]. Likewise, despite the patients presented in our
vessels to avoid disrupting perfusion distal to the anastomosis series having complex procedures, with the incorporation
site in a healthy lower limb and to reduce the incidence of of combined spinal-epidural neuraxial anesthesia, we were
vasospasm. Once the flap is inset, another important aspect able to transfer patients directly to our plastic surgery floor
to decrease morbidity is to cover the pedicle, as exposure can unit. In this setting, and especially for patients who under-
lead to the dissection of any of these vessels. For instance, went CLVCBFs which had two free flaps, we were able to
in most of the cases, a precise dissection was carried out better monitor the postoperative status of free flaps and had
of local flaps surrounding the recipient vessels on the better control of the physiotherapeutic regimen [42]. None
contralateral leg. By elevating these flaps, local tissue of of the patients required mechanical ventilation or presented
the contralateral leg/foot can be maximized to cover the with postoperative hemodynamic compromise when using
anastomosis site and part of the flap’s pedicle. Likewise, this type of anesthesia, decreasing the rate of ICU admis-
if local tissue rearrangement of the contralateral leg is sion and increasing the availability of these resources for
deemed inappropriate to cove the pedicle, the design of the severely ill patients. In accordance with previous statements
skin paddle of the free flap was tailored so that a distal by Evans et al., most centers admit patients to ICU for fre-
fasciocutaneous segment was specifically used to be wrapped quent flap monitoring as opposed to medical necessity [41].
around the pedicle at the time of inset. In this reports with a multidisciplinary approach including

13
606 European Journal of Plastic Surgery (2023) 46:597–607

the nurses and physiotherapists, we were able to transfer Funding None of the authors received any funds or has any financial
patients directly to the floor using neuraxial anesthesia repli- interests to disclose for the research, authorship, and publication of
this article.
cating outcomes on flap survival from previous articles [41].
Finally, with the implementation of neuraxial anesthesia, Declarations
several authors have suggested that the peripheral
vasocontraction secondary to pain, hypovolemia, and Ethical approval All procedures performed in studies involving human
hypothermia is reduced [43]. In the context of microvascular participants were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Helsinki declaration
reconstructive surgery for lower limb salvage, the chemical and its later amendments or comparable ethical standards.
sympathectomy-like effect achieved with regional anesthesia
has been shown to improve the rate of arterial and venous Conflict of interest Horacio F. Mayer is the Editor-in-Chief of the
spasm, and improve flow velocity in the immediate European Journal of Plastic Surgery.
postoperative period, promoting flap survival [44–47]. These Pedro Ciudad, Joseph M. Escandón, Oscar J. Manrique, Lilyan Llanca,
variables might have played a role in the success rate of César Reynaga declare no conflict of interest.
some surgical cases presented in this series.

References
Limitations 1. Russell WL, Sailors DM, Whittle TB, Fisher DFJ, Burns
RP (1991) Limb salvage versus traumatic amputation. A
This current report is a single-center study implementing decision based on a seven-part predictive index. Ann Surg
213(5):471–473
a retrospective review of data. Therefore, temporal 2. McNamara MG, Heckman JD, Corley FG (1994) Severe open
associations are often difficult to assess, some variables fractures of the lower extremity: a retrospective evaluation
were not evaluated, causality cannot be determined, and of the Mangled Extremity Severity Score (MESS). J Orthop
there is an inherent risk of bias and possible inaccuracy of Trauma 8(2):81–87
3. Johansen K, Daines M, Howey T, Helfet D, Hansen STJ (1990)
data related to our methodology. Despite this is the largest Objective criteria accurately predict amputation following lower
report using CLVCBFs, the limited sample size may decrease extremity trauma. J Trauma 30(5):563–568
the significance of some associations. The assessment of 4. Bosse MJ, MacKenzie EJ, Kellam JF et al (2002) An analysis of
outcomes could be improved with standardized patient-based outcomes of reconstruction or amputation after leg-threatening
injuries. N Engl J Med 347(24):1924–1931
questionnaires for quality of life and limb function. 5. MacKenzie EJ, Bosse MJ, Pollak AN et al (2005) Long-term
persistence of disability following severe lower-limb trauma.
Results of a seven-year follow-up. J Bone Joint Surg Am
87(8):1801–1809
Conclusion 6. Bhuvaneswar CG, Epstein LA, Stern TA (2007) Reactions to
amputation: recognition and treatment. Prim Care Companion
In selected patients, CLFFs and CLVCBFs offer an optimal J Clin Psychiatry 9(4):303–308
7. MacKenzie EJ, Jones AS, Bosse MJ et al (2007) Health-care
alternative for lower limb salvage using recipient vessels costs associated with amputation or reconstruction of a limb-
out of the zone of injury from the contralateral limb. These threatening injury. J Bone Joint Surg Am 89(8):1685–1692
reconstructive methods avoid the requirements of amputation 8. Manrique OJ, Bishop SN, Ciudad P et al (2018) Lower extrem-
in patients with single-vessel runoff or severe peripheral ity limb salvage with cross leg pedicle flap, cross leg free flap,
and cross leg vascular cable bridge flap. J Reconstr Microsurg
vascular disease, where using the only patent vessel can 34(7):522–529
further increase the risk of amputation. Furthermore, the 9. Mahajan RK, Srinivasan K, Ghildiyal H et al (2019) Review
implementation of combined spinal-epidural anesthesia of cross-leg flaps in reconstruction of posttraumatic lower
can decrease the requirements of PACU admission and extremity wounds in a microsurgical unit. Indian J Plast Surg
52(1):117–124
ventilators to improve resource allocation. 10. Campbell E, Zahoor U, Payne A et al (2021) The COVID-19
Pandemic: the effect on open lower limb fractures in a Lon-
Acknowledgements Each author participated sufficiently in the work don major trauma centre - a plastic surgery perspective. Injury
to take public responsibility for the content. 52(3):402–406
11. Patel NG, Reissis D, Mair M et al (2021) Safety of major recon-
Authors’ contributions (i) conceptualization: Ciudad P; (ii) data curation: structive surgery during the peak of the COVID-19 pandemic in
Ciudad P; (iii) formal analysis: Ciudad P; (iv) funding acquisition: all the United Kingdom and Ireland - multicentre national cohort
authors; (v) investigation: Ciudad P; (vi) methodology: Ciudad P; (vii) study. J Plast Reconstr Aesthet Surg 74(6):1161–1172
project administration: all authors; (viii) resources: Ciudad P; (ix) 12. Gupta S, Gupta P, Khichar P, Mohammad A, Escandón JM,
software: Escandón JM; (x) supervision: Ciudad P, (xi) validation: all Kalra S (2022) Perforator propeller flaps for lower extremity
authors; (xii): visualization: all authors; (xiii) writing—original draft: all soft-tissue defect reconstruction: shortening the learning curve.
authors; (xiv) writing—review and editing: all authors. J Clin Orthop Trauma 27:101831

13
European Journal of Plastic Surgery (2023) 46:597–607 607

13. Zindrou D, Halle M, Jakobsson S (2022) The COVID-19 pandemic 32. Pan S-C, Yu J-C, Shieh S-J, Lee J-W, Huang B-M, Chiu H-Y
consequences on microsurgical reconstructions: a single center’s (2004) Distally based anterolateral thigh flap: an anatomic and
shift of indications. Plast Reconstr Surgery Glob Open 10(4):e4309 clinical study. Plast Reconstr Surg 114(7):1768–1775
14. Ciudad P, Vargas MI, Castillo-Soto A et al (2020) Manejo de 33. Komorowska-Timek E, Gurtner G, Lee GK (2010) Supercharged
heridas traumáticas de difícil cicatrización con colgajos micro- reverse pedicle anterolateral thigh flap in reconstruction of a mas-
vasculares. J Wound Care 29(LatAm sup 2):27–34 sive defect: a case report. Microsurgery 30(5):397–400
15. Ciudad P, Agko M, Date S et al (2018) The radial forearm free flap as 34. Swartz WM, Ramasastry SS, McGill JR, Noonan JD (1987) Dis-
a “vascular bridge” for secondary microsurgical head and neck recon- tally based vastus lateralis muscle flap for coverage of wounds
struction in a vessel-depleted neck. Microsurgery 38(6):651–658 about the knee. Plast Reconstr Surg 80(2):255–265
16. Ciudad P, Manrique OJ, Bustos SS et al (2020) The modified extended 35. Yildirim S, Avci G, Akan M, Misirlioğlu A, Aköz T (2003) Anter-
fleur-de-lis latissimus dorsi flap for various complex multi-directional olateral thigh flap in the treatment of postburn flexion contractures
large soft and bone tissue reconstruction. Cureus 12(2):e6974 of the knee. Plast Reconstr Surg 111(5):1630–1637
17. Baliarsing A, Date S, Ciudad P (2018) Medial sural artery as a 36. Mohammad A, Saha S, Escandón JM (2022) Hyperbaric oxygen
salvage recipient vessel for complex post traumatic microvas- therapy in management of diabetic foot ulcers: indocyanine green
cular lower limb reconstruction. Microsurgery 38(2):157–163 angiography may be used as a biomarker to analyze perfusion and
18. Ciudad P, Kaciulyte J, Lo TF et al (2022) The profunda artery per- predict response to treatment. Plast Reconstr Surg 149(2):346e–347e
forator free flap for lower extremity reconstruction. Microsurgery 37. Pestana IA, Coan B, Erdmann D, Marcus J, Levin LS, Zenn MR
42(1):13–21 (2009) Early experience with fluorescent angiography in free-tissue
19. R Core Development Team. R Core Team (2021). R: a language transfer reconstruction. Plast Reconstr Surg 123(4):1239–1244
and environment for statistical computing. (Version 4.0) 38. Jin W, Chang S, Zhang Z, Wu X, Wu B, Qi J, Wei Z (2022) Paral-
[Computer Software]. Retrieved from https://​cran.r-​proje​ct.​org/. lel cross-leg free flap with posterior tibial artery perforator pedicle
Published online 2021. https://​cran.r-​proje​ct.​org propeller cable bridge flap for the treatment of lower extremity
20. Rashid HU, Rashid M, Khan N, Ansari SS, Bibi N (2021) Taking wounds: A Case Series Report. J Invest Surg 35(7):1572–1578.
a step down on the reconstruction ladder for head and neck recon- https://​doi.​org/​10.​1080/​08941​939.​2022.​20581​27
struction during the COVID-19 pandemic. BMC Surg 21(1):120 39. Rapoport J, Teres D, Zhao Y, Lemeshow S (2003) Length of
21. Payton JI, Wong S, Lombana NF, Saint-Cyr MS, Altman AM, stay data as a guide to hospital economic performance for ICU
Brooke SM (2021) Microsurgery in the era of COVID-19. Proc patients. Med Care 41(3):386–397
(Bayl Univ Med Cent) 34(2):269–273 40. Kozak GM, Hsu JY, Broach RB et al (2020) Comparative effective-
22. Shachar T, Yaacobi DS, Cohen K, Olshinka A, Ad-El DD (2021) ness analysis of complex lower extremity reconstruction: outcomes
Reconstructive microsurgery in the COVID-19 environment. Plast and costs for biologically based, local tissue rearrangement, and free
Reconstr Surg Glob Open 9:e3691 flap reconstruction. Plast Reconstr Surg 145(3):608e–616e
23. Nigam M, Zolper EG, Sharif-Askary B, Abdou SA, Charipova K, 41. Deldar R, Abu El Hawa AA, Gupta N, Truong BN, Bovill JD, Fan KL,
Bekeny JC, Fan KL, Steinberg JS, Attinger CE,Evans KK (2022) Evans KK (2022) Intensive care unit versus floor admission following
Expanding criteria for limb salvage in comorbid patients with lower extremity free flap surgery: Is there a difference in outcomes?
nonhealing wounds: The MedStar Georgetown Protocol and lessons Microsurgery 42(7):696–702. https://​doi.​org/​10.​1002/​micr.​30935
learned after 200 lower extremity free flaps. Plast Reconstr Surg 42. Fereydooni A, O’Meara T, Popescu WM, Dardik A, Ochoa Chaar
150(1):197–209 CI (2020) Use of neuraxial anesthesia for hybrid lower extremity
24. Escandón JM, Ciudad P, Poore SO, Mayer HF, Saha S, Morrison revascularization is associated with reduced perioperative morbid-
CS, Langstein HN, Manrique OJ (2022) Experimental models and ity. J Vasc Surg 71(4):1296–1304.e7
Practical Simulators for Supermicrosurgery: an Updated System- 43. Macdonald DJ (1985) Anaesthesia for microvascular surgery. a
atic Review and Meta-analysis. Plast Reconst Surg. https://​doi.​ physiological approach. Br J Anaesth 57(9):904–912
org/​10.​1097/​PRS.​00000​00000​010084 44. Hahnenkamp K, Theilmeier G, Van Aken HK, Hoenemann CW
25. DeFazio MV, Han KD, Akbari CM, Evans KK (2015) Free tissue (2002) The effects of local anesthetics on perioperative coagulation,
transfer after targeted endovascular reperfusion for complex lower inflammation, and microcirculation. Anesth Analg 94(6):1441–1447
extremity reconstruction: setting the stage for success in the presence 45. Kurt E, Ozturk S, Isik S, Zor F (2005) Continuous brachial plexus
of mutlivessel disease. Ann Vasc Surg 29(6):1316.e7–1316.e15 blockade for digital replantations and toe-to-hand transfers. Ann
26. Oh TS, Lee HS, Hong JP (2013) Diabetic foot reconstruction Plast Surg 54(1):24–27
using free flaps increases 5-year-survival rate. J Plast Reconstr 46. Laskowski IA, Muhs B, Rockman CR et al (2007) Regional
Aesthetic Surg 66(2):243–250 nerve block allows for optimization of planning in the creation of
27. Ducic I, Rao SS, Attinger CE (2009) Outcomes of microvascular arteriovenous access for hemodialysis by improving superficial
reconstruction of single-vessel lower extremities: limb salvage venous dilatation. Ann Vasc Surg 21(6):730–733
versus amputation. J Reconstr Microsurg 25(8):475–478 47. Hingorani AP, Ascher E, Gupta P et al (2006) Regional anesthesia:
28. Haddock N, Garfein ES, Reformat D, Hecht E, Levine J, Saadeh P preferred technique for venodilatation in the creation of upper
(2010) Perforator vessel recipient options in the lower extremity: extremity arteriovenous fistulae. Vascular 14(1):23–26
an anatomically based approach to safer limb salvage. J Reconstr
Microsurg 26(7):461–469 Publisher’s note Springer Nature remains neutral with regard to
29. Escandón JM, Ciudad P, Mayer HF et al (2022) Free flap transfer jurisdictional claims in published maps and institutional affiliations.
with supermicrosurgical technique for soft tissue reconstruction:
a systematic review and meta-analysis. Microsurgery Published Presentation: This article has not been presented in a national or
online. https://​doi.​org/​10.​1002/​micr.​30894 international meeting.
30. Lin C-H, Mardini S, Lin Y-T, Yeh J-T, Wei F-C, Chen H-C (2004)
Sixty-five clinical cases of free tissue transfer using long arterio- Springer Nature or its licensor (e.g. a society or other partner) holds
venous fistulas or vein grafts. J Trauma 56(5):1107–1117 exclusive rights to this article under a publishing agreement with the
31. Bullocks J, Naik B, Lee E, Hollier LJ (2006) Flow-through flaps: author(s) or other rightsholder(s); author self-archiving of the accepted
a review of current knowledge and a novel classification system. manuscript version of this article is solely governed by the terms of
Microsurgery 26(6):439–449 such publishing agreement and applicable law.

13