In summary, the use of simultaneous multiple microvascular transplants in both the acute and elective setting is now possible for complex reconstructions. It requires four to nine surgeons, two to three scrub nurses, and the equipment and instruments to supply multiple teams operating simultaneously. Untold combinations of tissue transplants are now available to solve these complex reconstructive problems. Combining multiple microvascular transplants into a single operation can reduce patient morbidity, cost, and anesthetic time, and hopefully earlier restoration of function and less permanent disability can be achieved.12

Clinical Cases

CASE 1

A 22-year-old hospital orderly developed pneumococcal sepsis leading to hypotension, vasculitis, and subsequent gangrene of all four extremities. He was referred for reconstruction 6 weeks following his initial illness.

FIG. 28-01. Initial preoperative status, with bilateral dry gangrene of multiple toes and the left heel.

FIG. 28-02. Following debridement, vascularized bone was exposed at both metatarsal areas and the left calcaneus. Reconstruction was performed with simultaneous transplantation of a left latissimus dorsi flap to the left foot and a right gracilis flap to the right foot to complete coverage in a single procedure.

FIG. 28-03. The latissimus flap was split longitudinally to allow 160-degree rotation of a muscle slip to cover the metatarsal heads. The flap was revascularized through the posterior tibial system. The motor nerves of each flap were anastomosed to the left sural and right deep peroneal nerves, respectively.

FIG. 28-04. Five-year follow-up. The patient is ambulatory without gait deficits, and there has been no soft tissue breakdown of the skin-grafted muscle. Protective deep pressure sensation is present over both flaps and the patient takes meticulous care of his feet.

CASE 2

A 27-year-old plastic surgery resident suffered a severe crushing injury to his dominant right hand in a building collapse during an earthquake. The initial nonreplantable injury was closed with a pedicled groin flap.

FIG. 28-05. Preoperative view. The dorsal coverage provided by the original groin flap is supple without breakdown. No metacarpal joints remain except in the thumb.

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