2004 double free flaps

Burns 30 (2004) 729–738

Double free flaps harvested from one or two donor sites for one ortwo-staged burn reconstruction: models of sequential-link and

independent-link microanastomoses

Samir Mardini, Feng-Chou Tsai∗, Jui-yung YangDivision of Plastic Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei Medical University,

252 Wu Hsing Street, Taipei 110, Taiwan

Accepted 3 March 2004

Abstract

Extensive burn injuries and subsequent scarring result in functional and aesthetic impairments. The use of free flaps in burn reconstruc-tions provides superior outcomes especially when other, more conservative reconstructive methods fail and curtail efforts of relentlessrehabilitation. Multiple chronic scar-associated problems and extensive acute burn defects are conventionally resolved by multiple proce-dures. Thus, two or extensive scar regions are typically reconstructed using two free flaps (double free flaps) in two separate, proceduresutilizing two independent donor sites. This leads to a protracted course of repetitive operations, hospitalizations, and rehabilitation, causinga prolonged period of discomfort and disability. The definition of double free flaps is two independent free flaps with two sets of microanas-tomoses. This paper illustrates, via a case-series, that double free flaps could be performed in one procedure, with both flaps harvestedfrom either one or two donor sites. Two flaps are then utilized to resolve one large or two problem areas at the same time. Revascularizationof the flaps is achieved via either a sequential-link or independent-link microanastomoses. The advantages of harvesting double free flapsfrom one region and using them in one stage to reconstruct one or two defect area include: (1) providing a large area of soft, pliable skinfrom one region for re-surfacing burn injuries or resolving scar associated problems, (2) decreasing the treatment course and potentialdisability, (3) decreasing donor site morbidities, (4) increasing maneuverability and conformability of the flap, and (5) affording a betterfunctional and aesthetic outcome.© 2004 Elsevier Ltd and ISBI. All rights reserved.

Keywords:Free flaps; Burns; Microsurgery

1. Introduction

The primary advantage of using free flaps as tissue re-placement for burn reconstruction is the low recontracturerate. Conventional reconstructive methods such as split andfull thickness skin grafting often produce a recontracturethat requires other procedures to correct the primary defor-mity [1–7]. Donor sites for free tissue transfer are limitedand may pose a problem when deciding on potential donorsites. Ironically, these patients with limited donor sites oftenrequire more tissue as they have more than one contracturesite. The traditional principle of free tissue transfer, which re-solves one problem region at a time such as multiple-stagedreconstruction, prolongs patient hospitalization, proceduraltime, rehabilitation and period of disability. The surgeon is

∗ Corresponding author. Tel.:+886-2-27372181x1336.E-mail address:[email protected] (F.-C. Tsai).

also often faced with the dilemma of prioritizing sites ofcontracture release and donor sites of free flaps.

Double free flaps performed in one setting have the advan-tage of limiting the number of procedures. In addition, whentwo flaps are harvested from the same donor region, the pa-tient becomes less debilitated and overall recovery time maybe improved. Previous reports of double free flaps have fo-cused on their use in reconstructing composite defects pro-duced by trauma or head and neck cancer ablation[8–11].Long operative times and the potential for great donor sitemorbidity have precluded surgeons from performing theseextensive procedures. The purpose of this case-series is toclassify and evaluate the different types of double free flapsused in post-burn contracture release according to the num-ber of stages involved, number of donor sites required andnumber of contracture regions reconstructed. This paper willalso endeavor to demonstrate the optimal reconstructive way

0305-4179/$30.00 © 2004 Elsevier Ltd and ISBI. All rights reserved.doi:10.1016/j.burns.2004.03.009

730 S. Mardini et al. / Burns 30 (2004) 729–738

to utilize double free flaps harvested from one donor site asa one-stage procedure.

2. Patients and methods

Between March 2000 and January 2003, 11 patients weretreated with double free flaps. There were 8 males and 3 fe-males with a mean age of 39.6 years (range: 28–60). Theetiology of burn injuries included flame burns (7 patients),electrical burns (3 patients), and chemical burns (1 patient).Indications for free flaps in burn reconstruction were: (1)exposure of vital structures, (2) significant limitations in ac-tive or passive range of motion (ROM), and (3) the pres-ence of discomfort and disability. Double free flaps wereused in four patients for the reconstruction of acute burndefects and in seven patients to cover the defects createdfollowing the release of chronic burn contractures. Doublefree flaps were classified into three different types accordingto the operative times, duration of hospitalization, treatmentperiod, number of donor sites, number of reconstructive re-gions, associated morbidities and reconstructive outcome(Tables 1–3).

Table 1Two-staged reconstruction with double free flaps harvested from two different regions for the reconstruction of two separate defects

Case Etiology Defect Flap and anastomosis type(S or I)

Size(cm × cm)

Operationtime (h)

Total hospital stay (days) Complication

Acute burn1 Electric Foot MP (I) 9× 5.5 4 29 Nil

Hand ALT (I) 19 × 11 4.5 Nil

2 Electric Left wrist LD (I) 18× 5 4 100 NilRight wrist G (I) 25× 4.5 4.3 Nil

3 Flame Foot MP (I) 10× 5 4 46 NilHand ALT (I) 14 × 7.5 4.5 Nil

Chronic burn4 Flame Neck Left LD (I) 21× 7 3.4 7 Nil

Hand Right pre-expanded LD (I) 28× 15 3.5 8 (interval: 2.8 months) Nil

5 Flame Left axilla Left TFL (I) 20× 6 3.2 19 Marginal necrosisRight axilla Right pre-expanded TFL (I) 28× 9.5 3.9 7 (interval: 3.6 months) Nil

6 Flame Neck Right ALT (I) 25× 5 4.5 14 NilLeft hand Left ALT (I) 20× 5 4.8 7 (interval: 3.4 months) Nil

ALT: anterolateral thigh; LD: latissimus; G: gracilis; TFL: tensor fascia lata; MP: medialis pedis; S: sequential-link; I: independent-independentmicroanastomosis.

Table 2One-staged reconstruction using double free flaps harvested from two different regions for the reconstruction of two separate defects

Case Etiology Defect Flap andanastomosistype (S or I)

Size (cm× cm) Operation time (h) Total hospital stay (days) Complication

7 Chemical Axilla Right ALT (I) 28× 7 5.5 7 NilNeck Left MT (I) 24 × 7

8 Flame Axilla (right) Right ALT (I) 29× 7.5 7.5 7 NilAxilla (left) Left ALT (I) 28 × 7.5

3. Case report

3.1. Two-staged reconstruction with double free flapsharvested from two different regions for the reconstructionof two separate defects

3.1.1. Case 1: acute burnA 54-year-old male suffered from 40% total body surface

area (TBSA) electrical burn involving the four limbs, depthvarying from second to third degrees. The right index andmiddle fingers, the big and second toes were amputated dueto severe tissue damage. The right foot defect measured 9 cm× 5.5 cm with exposed bone and the right hand defect mea-sured 19 cm× 11 cm (Figs. 1A, B and 2A). Nine days later,in a 7 h operation, the foot defect was debrided and coveredwith a free medialis pedis flap (Fig. 1C–E). Eight days afterthe initial operation, in a 7.5 h operation, the hand defect wasreconstructed with a free anterolateral thigh (ALT) perfora-tor flap (Fig. 2B–D) Both flaps survived and the donor siteswere closed with skin grafts. The patient was discharged 29days following the initial presentation. A thinning procedureof the ALT flap was performed after 4 months. At 3 yearsfollow-up, the patient was doing well (Figs. 1F and 2E, F).

S. Mardini et al. / Burns 30 (2004) 729–738 731

Table 3One-staged reconstruction using double free flaps harvested from the same donor region for the reconstruction of one defect

Case Etiology Defect Flap andanastomosistype (S or I)

Size (cm× cm) Operation time (h) Total hospital stay (days) Complication

Acute burn9 Electric Scalp Right ALT (S) 18× 8 6.2 28 Nil

Right TFL (S) 18× 6

Chronic burn10 Flame Hand Right ALT (S) 18× 7 5.7 15 Marginal necrosis (ALT flap)

Right MT (S) 15× 5

11 Flame Neck Left ALT (I) 14× 7 6.2 21 Marginal necrosis (ALT flap)Left TFL (I) 14 × 7

MT: medial thigh.

3.1.2. Case 5: chronic bilateral axillary contracturesA 37-year-old male worker suffered from bilateral ax-

illary contractures as a result of a previous flame burninjury. Split thickness skin grafting followed by 1 yearcourse of aggressive postoperative physical rehabilitationwere performed with minimal improvement. The left ax-illary contracture was excised and released. A free ten-sor fascia lata (TFL) cutaneous perforator flap measuring20 cm × 6 cm was harvested from the left thigh to coverthe defect; its vessels were anastomosed to the left tho-racodorsal artery and a concomitant vein (Fig. 3A). Tworectangular-shaped tissue expanders (500 and 350 cc) wereinserted into the right thigh, around the perforator vessels

Fig. 1. (A and B) Deep burn injuries over the right big toe and second toe with bone exposure. (C–F) A free medialis pedis flap from the left foot wasused to cover the exposure defect.

of the right TFL perforator flap at the same time. Totaloperative time was 3.2 h, and the patient was dischargedafter on postoperative day 19. The donor site was closedwith a skin graft due to wound dehiscence. After serialsaline injections over 3.6 months, the pre-expanded freeTFL perforator flap (measuring 28 cm× 9.5 cm) was usedto cover the defect after right axillary contracture releaseand the donor site was closed primarily. Operative timewas 3.9 h and total hospital stay was 7 days. Both flapshealed without complications. A de-fatting procedure of theright axilla flap was performed at 2 months postoperatively.At 6 months follow-up, excellent functional results wereseen.


Fig. 2. (A) The exposed second to fourth metacarpophalangeal joint with dorsal skin defect after debridement. (B–F) The defect was resurfaced with afree anterolateral thigh perforator flap.

3.2. One-staged reconstruction using double free flapsharvested from two different regions for the reconstructionof two separate defects

3.2.1. Case 7: chronic left neck and axillary contracturesA 30-year-old male worker presented with cervical and

axillary contractures following a chemical burn injury. De-spite a 6 months course of aggressive rehabilitation, mini-mal improvement was noted. A one-staged double free flapprocedure was performed. The contracture over the left neckwas excised and covered with a free medial thigh (MT) per-forator flap from the left thigh (24 cm× 7 cm); its vesselswere anastomosed to the left superior thyroid artery and abranch of internal jugular vein. A free ALT perforator flap(28 cm× 7 cm) from the right thigh was used to reconstructthe defect in the right axilla created following the contracturerelease. Both donor sites were closed primarily. The totaloperative time was 5.5 h, and total hospital stay was 7 days.There were no complications. No aggressive rehabilitation,splinting, or revision procedure was performed postopera-tively. At 7 months follow-up, good functional and aestheticresults were seen (Fig. 4).

3.3. One-staged reconstruction using double freeflaps harvested from the same donor region for thereconstruction of one defect

3.3.1. Case 9: chronic dorsal hand contractureA 40-year-old male suffered from a flame burn injury

which resulted in a contracture of the dorsal aspect of

the right hand. Despite 6 months of rehabilitation, no im-provement was noted in the range of motion (Fig. 5A).Contracture release followed by double free flap coveragewas performed. A special lazy-S design was made overthe left thigh and two flaps were harvested: medial andALT flaps (Fig. 5B). The MT perforator flap (15 cm×5 cm) (Fig. 5C) and ALT perforator flap (18 cm× 7 cm)were inset into the defect and the flap vessels were se-quentially linked and anastomosed to the superficial radialartery and cephalic vein over the snuff box (Fig. 5D). Thedonor site was closed primarily, and the total operativetime was 5.7 h. Despite some marginal necrosis of the ALTflap, which was debrided, both flaps healed without furtherincidents. At 11 months follow-up, the patient was satis-fied with the aesthetic and functional outcome (Fig. 5Eand F).

4. Results

All perforator flaps survived without re-exploration. Threeflaps had a small area of marginal necrosis that healed fol-lowing bedside debridement and a short course of dress-ing changes. Hospital stay, treatment and operative timesare shown inTable 4. No significant donor site morbid-ity was present. All patients got the maximal functionalimprovement within average 2 weeks of home rehabilita-tion. An improved passive and active range of motion wasachieved in all cases at an average follow-up time of 7months.


Fig. 3. (a) Left axilla: (above) preoperative limited range of motion; (below) postoperative photographs after reconstruction with a TFL perforator flap. (b)Right axilla: (A and B) contracture area; (C) tissue expander was inserted over the right thigh; (D) flap harvest with a tissue expander (TE); (E and F)postoperative photographs after 6 months follow-up.


Fig. 4. Preoperative and postoperative photographs: (above) lateral cervical contracture; (below) axillary contracture. MT: medial thigh perforator flap. ALT:anterolateral thigh perforator flap.

Fig. 5. (A) Dorsal contracture of the right hand; (B) double free flaps (MT and ALT perforator flaps) were harvested via a midline incision over the leftthigh; (C) the MT perforator flap; (D) both flaps were positioned together to cover the contracture defect via a sequential-link microanastomosis; (E andF) postoperative photographs after 11 months follow-up.


Table 4Comparison between different methods

Two-staged, two donor site, two-regions One-staged, twodonor site,two-regions

One-staged, one donor site, one-region

Total treatment course(plus interval)

Acute: 58.3 days; chronic: 110days (interval: 3.1 months)

7 days Acute: 28 days; chronic: 18 days

Hospital stay Acute: 58.3 days; chronic: 20 days 7 days Acute: 28 days; chronic: 18 daysOperation time Acute: 4.2 h; chronic: 3.88 h 6.5 h Acute: 6.2 h; chronic: 5.95 h

5. Discussion

Although skin grafting is the most popular procedure usedaround the world for burn injuries due to its re-usability,stability and simplicity, its drawbacks, however, include thetendency to re-contract and discolor, not to mention donorsite scarring as an associated morbidity[12–14]. Free flapsoffer an option of reconstruction with good quality tissues forreplacement or coverage in burn injuries and associated scarcontractures. Local and pedicled flaps have limited valuedue to the lack of good quality tissue available in the sameregion of the defect and due to their inherent poor bloodsupply at the most critical part (the distal part of the flap).There appears to be an increasing inclination towards theusage of free flaps in reconstructive surgery as it provides abetter functional and cosmetic outcome concurrently. Micro-surgery is currently performed mainly in specialized centersof teaching institutions and tertiary referral establishmentsdue to the need for a specialized surgical team and postop-erative care. However, any surgeon who wants to providea quality reconstructive service should feel an obligation tobroaden their reconstruction options and techniques, in anattempt to overcome surgical limitations and offer their pa-tients the better treatment option[15].

Thin free perforator flaps provide good quality tissue thatis particularly suitable for burn reconstruction as the maincomponent required in a burn defect is skin[16–18]. Tsaiand coworkers advocated the use of free ALT perforator flaps

Fig. 6. Comparison of donor sites from two different flap harvests for the same size defect: (left) one large free flap with skin graft coverage at thedonor site; (right) double free flaps with primary closure of the donor site.

for the reconstruction of anterior cervical contractures afterfailure of other reconstructive methods; excellent neck mo-bility and aesthetic results were achieved[6]. Other choicesof free flaps have been proposed for re-surfacing contrac-tures, however, certain disadvantages have limited their use.For example, when free musculocutaneous flaps are used, amore significant donor site morbidity is noted and the flapis usually too bulky[1,2,7].

One single free flap resolves one specific problem region,thus theoretically, more free flaps can re-surface more prob-lem areas. Due to the limited donor sites available in burn pa-tients, the surgeon is often faced with the predicament of pri-oritizing the reconstructive efforts. When the most severelyaffected region is reconstructed first, often the other regionsare neglected or they may undergo worsening of the contrac-ture due to a shift in focus of the rehabilitation treatment.Even if treated within the same operation, the less severeregion may be treated with less optimal methods. Multiplereconstructive procedures can also result in a prolongationof the total recovery time and rehabilitation period. This canbear heavily on the patient dealing with undergoing such anextensive treatment protocol. In addition, the scarring asso-ciated with skin grafting may discourage patients who arealready dealing with large areas of scars in other regions.

The definition of double free flaps is two independentfree flaps with two sets of microanastomoses. Double freeflaps have been used for reconstructing extensive compositedefects of the head and neck region[8–11]. Whereas ablative


Table 5Comparison of different kinds of staged procedures

Two-staged, two donor site, two-regions One-staged, two donor site, two-regions One-staged, one donor site, one-region

Total treatment course Long Short ShortHospital stay Long Short ShortOperation time Short Long ModerateDonor site morbidities ++ ++ +

Fig. 7. (a) Sequential-link and independent-link microanastomoses. (b) The layout of the sequential-link microanastomosis, note the ALT ‘connectorpedicle’ and its two ends. PC: the proximal connecting microanastomosis with recipient vessels; DC: the distal connecting microanastomosis with medialthigh pedicle.


surgery results in defects requiring thick, composite tissue,burn reconstruction requires thin, pliable skin only. Althoughdouble free flaps are more technique dependent and demandlonger operative times, burn scar reconstruction should focuson decreasing the number of stages, donor site morbiditiesand rehabilitation needs. More areas can be treated whileachieving excellent functional and aesthetic results in allregions (Table 5). That is, to perform a one-stage procedure,utilizing two free flaps, from one donor site to reconstruct abigger or greater number of problem regions, also allowingfor primary closure of the donor site (Fig. 6). This providesa more efficient result with less overall morbidities.

Microanastomoses for double free flaps are classifiedinto two types: sequential-link and independent-link[16](Fig. 7a). The sequential-link microanastomoses, so-called“flow-through” microanastomoses is analogous to that of athree-way intravenous connector, which diverts the bloodsupply evenly into two separate destinations. The pedicleof the first flap has two microanastomoses, the proximalconnection, which is linked to the recipient vessels, andthe distal connection, which is linked to the pedicle ofthe second flap (Fig. 7b). In all sequential-link anasto-moses, the first flap must have a ‘connector pedicle’, thatis, a pedicle with a perforator which is perpendicular tothe main supply vessel (T-shaped), thus enabling adequateblood flow to either continue into or drain from the secondanastomosis; the ALT flap, and forearm flap pedicles areexamples of a ‘connector pedicle’. This type of anastomo-sis is especially valuable in areas with limited numbers ofsuitable recipient vessels, such as the dorsum of the handor the scalp. The independent-link microanastomosis con-sists of two pedicles anastomosed separately to two setsof independent recipient vessels. The fear of flap failureassociated with sequential-link microanastomoses is a rea-sonable concern, however, excellent patency rates achievedwith free tissue transfer allow this method to be performed.Both sequential link and independent link models requirethe same number of anastomoses to be performed withless time spend on searching for a second set of recipientvessels.

Cutaneous perforator flaps from the thigh offer a consis-tent anatomy and an availability of multiple flaps that canbe harvested independently or in combination[19–29]. Thethigh is an ideal model for multiple flaps, as it provides,through one midline incision, ALT flaps, TFL flaps, MTflaps and posterior thigh (PT) flaps. Thus, the advantages ofthigh flaps in burn reconstruction include: (1) excellent flapconsistency to match the defect (thinness and pliability), (2)availability of multiple flaps that can be harvested togetheror separately, (3) easy concealment of the donor site scarwith clothing, and (4) minimal donor site morbidity. Doublefree flaps can be harvested from one thigh if the distance be-tween the two perforators of the flaps is optimal. MT, ALTand TFL perforator flaps are particularly suitable in this in-stance because they have independent cutaneous perforatorsadequately apart.

One-stage reconstruction with double free flaps elim-inates the intervening recovery and rehabilitation periodfound when two stage operations are performed. In our se-ries, the average period between the first and second stagewas 3.1 months in chronic contracture cases and 8 days foracute reconstructions. Although double free flaps requirelong operative times, with proper planning and a two teamapproach, this period is minimized. Patient recovery is moreoptimal and less overall energy is expended by the patienton rehabilitation and recovery.

In summary, the use of one-staged double free perforatorflaps for burn reconstruction harvested from one donor sitehas many advantages: (1) provision of a larger area with softpliable skin for re-surfacing burn injuries; (2) decreasingthe duration of total treatment course and period of disabil-ity, recovery, pain, and rehabilitation; (3) decreasing donorsite morbidities, especially in allowing for primary closureof these sites; (4) increasing maneuverability of the flap toconform to the defects and (5) providing a superior func-tional and aesthetic outcome than other methods of burn re-construction. The disadvantages are few, consisting of theneed for a longer operative time and the demand for bettermicrosurgical techniques.

Double free perforator flaps performed in one opera-tive procedure is a viable alternative for reconstruction ofacute burn defects and for defects created after chroniccontracture release. In one setting, from one donor site,large or two defects can be reconstructed with supple pli-able skin with minimal morbidity inflicted on the donorsite.

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