Lower limb salvage by microvascular free-tissue transfer in patients with homozygous sickle cell disease

Chronic, excruciatingly painful ulcerations of the lower extremities in patients with homozygous sickle cell anemia (HbSS) present a frustrating clinical problem for the reconstructive surgeon. Despite adequate wound care and skin grafting, there is a dismally high incidence of recurrence. Furthermore, there is a paucity of reliable locoregional fasciocutaneous, muscle, and myocutaneous flaps in the ankle region. Free-tissue transfer has become the procedure of choice for reconstruction of the lower third of the leg. However, in sickle cell anemia, does the obligate period of flap ischemia inherent in free-tissue transfer inevitably doom a flap to failure? We present our multidisciplinary experience over 55 months with five free flaps in four homozygous sickle cell anemia patients 21 to 38 years old who had chronic nonhealing leg ulcerations. Special perioperative measures included exchange transfusion to lower hemoglobin S to below 30 percent, maintaining the hematocrit at 31 to 35 percent, intraoperative flap washout and perfusion with warm heparinized saline-dextran solution, administration of dextran and aspirin intraoperatively and postoperatively, prophylactic topical and systemic anti-Pseudomonas antibiotics, supplemental oxygen, and warm ambient room temperature. Flaps included the latissimus dorsi muscle (two patients), the temporoparietal fascia (one patient), and "split" omentum for bilateral lower limb salvage (one patient). Successful free-tissue transfer was accomplished in all patients. One patient suffered gradual partial occlusion of the microcirculation by sickled erythrocytes following a transient hypothermic, hypotensive episode. Sufficient flap tissue survived to permit skin grafting with an excellent result. Pseudomonas infection occurred in two patients (three flaps).(ABSTRACT TRUNCATED AT 250 WORDS)