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The Vastus Lateralis Free Flap for lower extremity Gustilo grade III reconstruction
Alexander J. Kaminsky, MD MPH1, Vineet Mehan, MD1, Reza Miraliakbari, MD2.
1Inova Fairfax Hospital, Falls Church, VA, USA, 2VCU School of Medicine Inova Campus, Falls Church, VA, USA.

BACKGROUND: Orthopedic trauma patients with Gustilo grade III injuries to the distal third of lower extremity have historically presented the plastic surgeon with challenges to identify the optimal reconstructive management. While many modalities of treatment have been proposed, free tissue transfer remains as the only option in limb salvage for many patients. Presently there is no consensus on the ideal autologous tissue for transfer in large lower extremity defect reconstruction. We present our initial experience utilizing the Vastus Lateralis for lower extremity Gustilo grade III reconstruction.
METHODS: A retrospective case series was performed for two board certified plastic surgeons (RM & VM) between september 2008 and April 2012 at our institution. A total of 38 free tissue transfers were performed for lower extremity reconstruction, out of which 18 were Vastus lateralis flaps. Inclusion criteria were patients referred for lower extremity reconstruction who were candidates for free tissue transfer. Exclusion criteria were the referred patients who had other options available to them in limb reconstruction.
RESULTS:There were 16 males (88%) with an average age of 44.3 years (19 -69 yo). The average wound size was 12.5cm x 11.7cm (4-25cm x 6-25cm). Seven day flap viability was 18/18 (100%) and 30 day flap viability was 16/18 (88%). We encountered four complication (22%): a hematoma requiring drainage, distal flap loss requiring a reverse saphenous vein graft extension, and two complete flap losses. Of the two failed flaps, one was lost to heparin induced thrombocytopenia and the other to venous congestion complicated by MRSA infection.
CONCLUSIONS: The vastus lateralis free flap, in our experience, is the ideal free flap for any lower extremity reconstruction, specially in cases of large defects and salvage operations. We have tailored this muscle to match the shape and size of the defect, even able to tangentially thin it prior to insetting. The long pedicle has easily allowed us to stay out of the zone of injury. We have harvested this free flap as muscle, myocutaneous, or as chimeric vastus lateralis-ALT free flaps. In conclusion have found the vastus lateralis free flap to be extremely reliable and versatile.


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