Efficacy of a "provisional incision" for longitudinal flap division after free-flap surgery

Fix and flap surgery for severe open limb fractures is already a standard treatment. In cases where the fracture is complicated or accompanied by bone defects, secondary surgery is required for fracture sites covered with a myocutaneous flap after the soft tissue condition has stabilized. We applied the delayed procedure concept used for distant flaps and attempted to prevent postoperative myocutaneous flap necrosis by performing a provisional incision prior to the longitudinal incision of the flap. We report the course of five cases of the longitudinal division of the myocutaneous flap using "provisional incision" after free-flap surgery for severe open fracture and verify its usefulness. In this case series, five patients with severe open limb fractures treated from 2020 to 2021 who underwent longitudinal incision of the myocutaneous flap using provisional incision after free-flap surgery were included. The types of flaps used for soft tissue reconstruction in the acute phase, the reasons for the need for secondary surgery, the period from soft tissue reconstruction to additional surgery, and the healing status of soft tissue after secondary surgery were all investigated retrospectively. The types of flaps used for soft tissue reconstruction were latissimus dorsi myocutaneous flap in four cases and anterolateral thigh flap in one case. The breakdown of secondary surgery was osteosynthesis in one case, plate removal in one case, and bone cement removal and autologous bone grafting in three cases. The period from soft tissue reconstruction to secondary surgery ranged from 6 weeks to 4 months. In all cases, the wound healed without necrosis of the myocutaneous flap. For the treatment of severe open limb fractures, longitudinal division of the myocutaneous flap using "provisional incision" is a safer approach to the necessary secondary surgery and reduces the possibility of necrosis of the flap.