Use of Skin Substitute to Facilitate Tension-Free Closure Over the Vascular Pedicle and Free Flap in Lower Extremity Reconstruction

Introduction: Free tissue transfer to the lower extremity are often challenging cases, as the lack of local tissue laxity and convex surface of the lower extremity can lead to pedicle compression after inset. Methods exist to lessen this risk of compression, including additional free tissue transfer, local tissue rearrangement, and skin grafting. We hypothesize that one cause of venous thrombosis and flap failure is excessive pressure over the flap and vascular pedicle. Veins could collapse from postoperative swelling after primary closure, causing impaired blood flow dynamics and elevating the risk of flap loss if not recognized. This study describes the use of skin substitutes to facilitate a tension-free closure over the vascular pedicle and around the flap. Methods: An IRB-approved retrospective review was conducted of patients undergoing lower limb reconstruction with free tissue transfer and skin substitute. Between June 2024 and December 2025, eighteen patients were included. Patient demographics, comorbidities, reconstruction characteristics, and surgical outcomes were recorded. Postoperative complications were monitored for at least 30 days. Results: One patient returned to the operating room within 24 hours after reconstruction secondary to venous thrombosis, and another returned within 24 hours due to an arterial bleeder. Both patients progressed without any further complications. There were two instances of partial flap loss, and there were no cases of total flap loss. Conclusions: Here, we demonstrate the use of skin substitute for pedicle coverage. This method allows additional coverage of the pedicle with minimal compression.