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Cross-leg flaps and reconstructive surgery in the 21st century.

In September 2013, Lu and colleagues published a series of cross-leg f laps in the Journal of the American College of Surgeons. The appearance of this article in such a prestigious journal demands attention. Does this article require reconsideration of this venerable procedure and a revision of modern strategies of lower extremity reconstruction, or is it a stunning anachronism that overlooks effective modern strategies and procedures? These questions have both clinical and academic dimensions. The article by Lu et al summarizes 56 patients with complex lower extremity injuries treated with cross-leg f lap procedures during an 8-year period. After initial treatment with debridement, dressings, and marginal skin grafts, these wounds were covered with cross-leg f laps. Each f lap was divided with an additional procedure in a mean of 13 days after the initial f lap inset. Two (3.3%) of the f laps failed. The authors conclude that ‘‘using a cross-leg f lap before resorting to a free f lap is more in accordance with treatment principles of plastic surgery.’’ Does this article justify a reconsideration of the role of cross-leg f laps in lower extremity reconstruction? For example, a recent 2-volume text on lower extremity reconstruction contains 3 brief mentions of cross-leg f laps among its 1400 pages. Is a major revision in order? We think not. Momeni et al have already raised cogent objections to the content and conclusions of this advocacy of cross-leg flaps, but their points bear repeating. Compared with either microsurgical flaps or other welldescribed single-stage reconstructions, the cross-leg flap subjects each patient to an additional lower extremity wound, longer hospitalization, prolonged immobilization, and an additional procedure for flap division. The cross-leg flap failure rate of 3.3% is comparable with or higher than failure rates cited in contemporary studies of microsurgical flaps. The deficiencies of the cross-leg flap are evident in comparison with a clinical series by Zhu et al. These surgeons treated 226 patients with complex foot and ankle wounds by performing 62 pedicled flaps and 164 microsurgical flaps. All procedures were done in a single stage. All the pedicled flaps survived. Eight (4.8%) of 164 free flaps were lost, but these 8 wounds were later closed with salvage procedures. If the 226 patients in this series were treated with cross-leg flaps as described by Lu et al, the patients would have been subjected to a total of 2938 additional days of hospitalization and immobilization and 218 additional procedures (taking into account 8 procedures used to salvage the failed microsurgical flaps in the single-stage series). Clearly, Zhu et al demonstrated that the wide range of currently practiced single-stage lower extremity flaps (including microsurgical and pedicled flaps) has conclusive advantages over cross-leg flaps. Such 2-stage procedures can occasionally be useful in extraordinary circumstances but cannot sustain the contention by Lu et al that cross-leg flaps ‘‘should have priority over the free flap.’’ Why does the readership of the Journal of the American College of Surgeons have access to the eccentric article by Lu et al and not the article by Zhu et al which shows a representative application of contemporary reconstructive techniques? The answer to this academic question is an extension of points raised by Dr Bruce Mast in a recent editorial. Dr Mast describes the threat of clinical marginalization of plastic surgery through trends toward cosmetic surgery and away from reconstructive surgery done in hospital settings. The appearance of the cross-leg f lap article in a major journal represents an academic marginalizaton. Clearly, the editorial review of the cross-leg f lap article could not have included reviewers competent in current reconstructive techniques and familiar with related current literature. In addition, major surgery journals are apparently not receiving or considering manuscripts describing current practices of reconstructive surgery. Plastic surgeons must become involved in the editorial processes of major journals to ensure that the achievements and advances of the specialty are credibly represented in the literature. Major journals themselves should maintain plastic surgery authorities in editorial review processes to avoid articles that describe the equivalents of traction reduction of hip fractures, elastic bandage management of mandible fractures, long-term truss treatment of hernias, and cholecystostomy and that advocate the use of such antique strategies as primary treatments of problems long since demonstrated to be more effectively managed by more advanced approaches. Plastic surgeons themselves should direct manuscripts to major journals. The topic of abdominal wall reconstruction generally receives equivalent sophisticated publications in general surgery and specialty journals. Current practices of extremity reconstruction, nerve reconstruction, and the many other developing dimensions of plastic surgery deserve broader exposure in the literature to create appropriate clinical and academic awareness of plastic surgery practice in the 21st century.