Thirty-four free tissue transfers for reconstruction of various tissue defects to the lower extremities were performed in thirty-two children over a nineteen-year period (1980-1999). Patient ages ranged from three to nineteen years (mean 10.8 years). Four donor sites were used: gracilis muscle, latissimus dorsi muscle, iliac crest osteocutaneous, and vascularized fibula.

Fourteen patients had tissue defects related to trauma: nine received a gracilis flap; five received a latissimus dorsi flap. Five patients had tissue defects related to tumor resection: three patients with a Ewing’s sarcoma resection defect received free fibulae; one patient with an osteogenic sarcoma resection defect received a gracilis flap and another received an iliac crest osteocutaneous flap. Fifteen patients had congenital anomaly related tissue defects: five with equinovarus foot deformity related defects received gracilis flaps; ten with congenital tibial pseudoarthrosis received free fibulae.

Vascular outcome was assessed based on the achievement of flap perfusion and post-surgical vascular revisions. Complete flap survival was achieved in thirty-two cases (85.3%), partial flap loss in three cases (8.82%), and a complete flap loss in two cases (5.9%). Early revision surgery for the five partial or failed flaps consisted of debridement and split thickness skin graft or flap removal. No patients required vascular takebacks or experienced vascular spasm. There were no systemic problems associated with the long and complex surgeries.

Functional outcome was assessed based on ambulation, surgical revisions for functional problems, post-surgical morbidities, and whether the flap served its intended purpose. Ambulation was achieved in 97.1% of cases. Functional surgical revisions were required in 32.4% of cases and included scar revisions, flap debulking, bone grafts, and pin insertion. The most prevalent morbidity was persistent leg length discrepancy (35.3% of cases). Only one successful flap was unable to meet its intended purpose, as a tibial pseudoarthrosis persisted despite initial excision.

Our results show that free tissue transfer is safe and dependable for tissue defects of the lower extremity in children. From our experience, free flaps used for the repair of defects from congenital tibial pseudoarthrosis have a high vascular success but also require an extensive rehabilitation course with only moderate functional success. There was no significant difference between flap surgeries performed immediately, intermediately or late after trauma. These procedures have a wide range of indications and despite the need for revisionary surgery and an extensive rehabilitation course, functional and vascular success can be achieved.