Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Feb 25:44:222-232.
doi: 10.1016/j.jpra.2025.02.012. eCollection 2025 Jun.

Sequential Free Flaps in Lower Extremity Reconstruction

Dun-Wei Huang  1   2 , Floris V Raasveld  1   3   4 , Omar Moussa  1   5 , Krystle Tuaño  4 , Ian L Valerio  4 , Kyle R Eberlin  4
Affiliations

Sequential Free Flaps in Lower Extremity Reconstruction

Dun-Wei Huang et al. JPRAS Open. .

Abstract

Introduction: Sequential free flaps are often utilized for complex defects, particularly for recurrent head and neck tumors. However, their application in lower extremity (LE) reconstruction following trauma or oncology is less common. This study evaluated the indications, flap survival rates, and complications of sequential free flaps utilized in LE reconstruction.

Methods: Data from our multicenter database spanning from 2002 to 2020 were analyzed retrospectively through chart review. Adult patients who underwent sequential free flaps to the LE without complete initial flap loss were included. Outcome measures included ultimate flap viability and complications associated with sequential reconstructions.

Results: A total of 6 patients were identified: 2 patients (33%) required a second reconstruction following trauma, 1 patient (17%) following tumor recurrence, and 3 patients (50%) for chronic wounds related to infection. Most second free flaps survived (83%), with the exception of one in which the patient ultimately underwent a transfemoral amputation. Complications were observed in 3 patients (50%).

Conclusion: The main indication for second free flap reconstruction in the LE is the failure of durable wound closure with the first reconstruction, despite the absence of flap loss. In these complex scenarios, it is often prudent to utilize preoperative vascular imaging and to use distinct recipient vessels from those used in the first flap. Overall, sequential free flaps can be used in complex cases of limb salvage; however, they are associated with a substantial risk of complications.

Level of evidence: Therapeutic-IV.

Keywords: Complications; Lower extremity; Revision surgery; Sequential free flap.

PubMed Disclaimer

Figures

Figure 1:
Figure 1
Flowchart of the patient inclusion and exclusion process. The figure was created with Biorender.com.
Figure 2:
Figure 2
Decision tree for the selection of the anastomosis method for the second free flap in sequential reconstruction. Abbreviations: ATA, anterior tibial artery; clamp test, intraoperative clamp trial; E-E, end-to-end; E-S, end-to-side; PTA, posterior tibial artery; PVR, pulse volume recording. The figure was created with Biorender.com.
See this image and copyright information in PMC

References

    1. Moratin J., Horn D., Heinemann M., et al. Multiple sequential free flap reconstructions of the head and neck: A single-center experience. PlastReconstrSurg. 2021;148(5):791e–799e. - PubMed
    1. Gupta A.K., McKenna W.G., Weber C.N. Local recurrence in head and neck cancer: relationship to radiation resistance and signal transduction. Clin Cancer Res. 2002;8(3):885–892. - PubMed
    1. Hanasono M.M., Corbitt C.A., Yu P., Skoracki R.J. Success of sequential free flaps in head and neck reconstruction. J PlastReconstrAesthetSurg. 2014;67(9):1186–1193. - PubMed
    1. Cooper J.S., Porter K., Mallin K., et al. National cancer database report on cancer of the head and neck: 10-year update. Head Neck. 2009;31(6):748–758. - PubMed
    1. Chiu W.K., Chou C.Y., Chen S.G., Chen C., Wang H.J., Yang T.F. Is sequential free flap safe in oral cancer reconstruction in the same patient? an outcome and complication analysis. Jpn J Clin Oncol. 2020;50(2):152–158. - PubMed

LinkOut - more resources