Soft-tissue reconstruction of the distal lower leg and foot: are free flaps the only choice? Review of 215 cases.

Free flaps are the first choice procedure to manage soft-tissue defect of the lower limb for many authors, but loco-regional pedicled flaps are an alternative since they were described in the 1980s. We analysed the changes in our practice to reconstruct soft-tissue defects of the distal third of the leg. A retrospective chart review identified 215 cases of distal leg soft-tissue defect treated in the department during 15 years. The mean age was 43, and the sex ratio was 2.4. The aetiology, the size, the septic status and location of each wound were noted. The surgical procedures used and the complications have been analysed. The size and location of the wounds were comparable over the 15 years considered. Microsurgical tissue transfers were predominant in the 1980s and decreased in the 1990s, whereas the pedicled flap had an opposite evolution. In our experience, pedicled flaps are related to a non-significant lower rate of complication (18%) than free flaps (27%). Moreover, complications of local and regional flaps are less severe. Our practice has changed to make pedicled flaps our first choice to cover soft-tissue defects of the lower limb. However, we still use free flaps as a first choice for wide or composite defects, when pedicled flaps are not feasible or for cosmetic considerations to avoid additional scarring of the leg.