Lower Limb Reconstruction

What is lower limb reconstruction?

Lower limb reconstruction is done with the aims of limb salvage and preserving 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 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 sub-divided 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, there is often 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.

Upper third of the leg including the knee can be reconstructed with either pedicle flaps from the thigh or the calf area. Some of the common conditions needing treatment in this area include infections after a total knee reconstruction and open injuries or fractures to 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 fracture where there is a lot of collateral damage to the muscle, 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 to this area 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 treatment of the infection to prevent further tissue loss. In the past, reconstruction and limb salvage for diabetic patients used to be unpopular due to the high failure rates. With an improved understanding of flap physiology, we are now able to provide reconstruction and limb salvage for patients with diabetes.

What are the steps of a lower limb reconstruction?

Depending on the severity of the injuries to the lower limb, your reconstruction may involve primary closure of skin, skin grafting, use of vacuum-assisted devices for delayed closure, 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 for your comfort during the surgical procedure. Lower limb reconstruction surgery is usually performed under general anaesthesia due to its precise nature and often extended duration.

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 involve simple closure of skin to more complex options of free tissue transfer. Occasionally, local tissue such as skin from the calf 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. from the thigh to the foot, will need to be performed 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 will usually be observed in a high-dependency ward with nurses who are specialized to look after flaps. Patients are usually kept faster 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, and this will be done with supervision from the physiotherapist. 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 as they 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.