Refinements in lower extremity free flap surgery.

This chapter recommends numerous factors that are significant refinements in approach and execution of lower extremity free flaps. I encourage a clear conceptual separation between the two essential phases of successful reconstruction of problem wounds: wound preparation and flap transfer. I have found that antibiotic beads maintain the sterility of temporary bony dead space. Due emphasis should be given to preparation of the surgeon, patient, and wound, allowing a nonemergency approach to lower extremity free flap coverage. The surgeon needs to be familiar with a variety of flaps beyond the usual workhorse group. Also, attention should be paid to perioperative warmth and hydration, and vessels affected by posttraumatic vessel disease must be avoided. A positive attitude toward the use of vein grafts whenever necessary is important. I also favor careful planning of the exact size and shape of the flap and length of the vessels along with use of a widely spatulated technique of end-to-side anastomoses.