Lower Limb Reconstruction

What is lower limb reconstruction?

Lower limb reconstruction is performed with the aim of limb salvage and preservation of function. Plastic surgeons work closely with general surgeons and orthopaedic surgeons, who are often referring surgeons for conditions that may threaten limb loss. Common conditions that may lead to a referral for lower limb reconstruction are trauma – open fractures or degloving injuries involving the lower limb; cancer and infection – necrotizing fasciitis or diabetic infections of the foot and lower limb.

"Surgeons who have the necessary training, expertise, and experience in reconstructive surgery are fit to perform cosmetic surgeries with excellent outcomes. Those surgeons who are only trained in aesthetic procedures will have much more difficulty doing the same. The more tools and training in plastic surgery the surgeons have, the more qualified they are! "

The lower limb can be broadly divided into 2 main areas: above the knee and below the knee. The below-knee area can be further subdivided into 3 broad areas: upper 1/3, middle 1/3, and lower 1/3.

Above-knee defects, in the area from the hip to the knee, often have abundant soft tissue; hence, most of the soft tissue defects in this area are amenable to reconstruction with direct closure or local and pedicle flaps.

The upper third of the leg, including the knee, can be reconstructed with either pedicle flaps from the thigh or the calf area. Some common conditions requiring treatment in this area include infections after a total knee reconstruction and open injuries or fractures of the knee. The gastrocnemius or hemisoleus flap (muscles from the calf) can be used to reconstruct distal knee defects and defects in the upper third of the leg, whilst the anterolateral thigh flap (from the thigh) can be used in the reconstruction of proximal knee defects.

The middle third of the leg injuries often present as open fractures of the tibia bone, and reconstruction can be performed with the adjacent gastrocnemius or hemisoleus muscle flaps. In severe cases of open tibia fractures with extensive collateral muscle damage, a free tissue transfer may be necessary.

The distal third of the leg includes the ankle and the foot. The main distinction in this area is the absence of soft tissue around the ankle joint and the foot for local or pedicle flaps. Traditionally, injuries or infections affecting this area often require free tissue transfer for reconstruction. However, with advances in reconstruction, selected conditions may still be amenable to reconstruction using pedicled flaps.

Patients with diabetic foot ulcers deserve a special mention here, as this is becoming an increasingly common reason for lower limb amputation. Early medical attention can allow early intervention to improve diabetes control, improve blood supply to the foot, and treat the infection to prevent further tissue loss. In the past, reconstruction and limb salvage for diabetic patients were unpopular due to the high failure rates. With improved understanding of flap physiology, we can now provide reconstruction and limb salvage for patients with diabetes.

What are the steps of a lower limb reconstruction?

Depending on the severity of the lower-limb injuries, your reconstruction may involve primary skin closure, skin grafting, vacuum-assisted delayed closure devices, local flaps, and free tissue transfer. Speak to Dr Ricardo early to discuss options for limb salvage and reconstruction.

Step 1 – Anaesthesia

Medications are administered to help you remain comfortable during the surgical procedure. The choices include intravenous sedation and general anaesthesia. Dr Ricardo will recommend the best choice for you.

Step 2 – Preparation for surgery

The success of lower limb salvage starts with an early referral to a plastic surgeon. Imaging studies may be required to assess the extent of the injury and also to ascertain the vascular supply to the limb. Detailed planning of the reconstructive options will be made and discussed with both the patient and Dr Ricardo. Once the plans are finalized, the patient is prepared for surgery. Most of these operations will require general anaesthesia, and a review by the anaesthesia team will be done before the operation.

Step 3 – Surgical procedure

Depending on the severity of the injury, the reconstruction may range from simple skin closure to more complex free tissue transfer. Occasionally, local tissue, such as calf skin or muscle, can be used to rotate in and cover the defect. However, if there is significant tissue loss with critical structures, such as bones or nerves exposed, free tissue transfer from a distant site, e.g., the thigh to the foot, will be required to reconstruct the missing tissue components and salvage the limb.

What should I expect during my lower limb reconstruction recovery?

In the immediate postoperative period, patients are usually observed in a high-dependency ward by nurses specialized in the care of flaps. Patients are usually kept fast for the first 24 hours, and thereafter, if the flap is stable, they are allowed feeds. Tubes and drains are usually removed after a few days. Patients are mobilized early, if possible, under the physiotherapist's supervision. Whilst they are unable to weight-bear on the affected limb, they are often started on wheelchair mobilization and crutches. Once the flap is stable, the patients can be discharged and followed up in the outpatient clinic. Depending on the severity of the injury, patients may take weeks to months for rehabilitation as they begin their road to recovery.

Limb reconstruction and limb salvage can be life-changing for patients, enabling them to regain or maintain the ability to ambulate. However, the road to recovery can be long and it may take some time before they are rehabilitated to full recovery.