CLINICAL ARTICLE Microsurgical reconstruction of extensive lower extremity defects with the conjoined parascapular and latissimus dorsi free flap Amir K. Bigdeli MD | Benjamin Thomas MD | Florian Falkner MD | Christian A. Radu MD | Emre Gazyakan MD | Ulrich Kneser MD Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany Correspondence Amir K. Bigdeli, MD, Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann- Strasse 13, 67071 Ludwigshafen, Germany. Email: amir.bigdeli@bgu-ludwigshafen.de Abstract Background: Extensive lower extremity soft-tissue defects pose a reconstructive challenge. We present our experience with the conjoined parascapular and latissimus dorsi (CPLD) free flap. Methods: From October 2008 to October 2017, 69 patients (14 female, 55 male) with a mean age of 50 years (range: 16–79 years) underwent reconstruction of lower extremity defects with the CPLD free flap. Mean defect size was 24 × 36 cm (range: 14 × 20 to 45 × 80 cm). Results: Mean latissimus dorsi (LD) flap size was 19 × 28 cm (range: 14 × 20 to 28 × 42 cm) and mean parascapular (PSC) flap size was 8 × 25 cm (range: 5 × 12 to 11 × 33 cm). Six patients (9%) experienced a total of eight microvascular complica- tions: arterial thrombosis (n = 1), venous thrombosis (n = 6), combined arterial and venous thrombosis (n = 1). The re-exploration rate was 13%. Major complications of the donor-site were seen in 9 patients (13%), of the flap in 13 patients (19%), and of both in 6 patients (9%). Fifteen patients experienced partial flap necrosis (22%). Three CPLD and one PSC flap were lost (5%). PSC flap length was a significant predictor of distal flap necrosis (χ 2 (1) = 13.2, p = .004, OR = 1.343, 95% CI [1.098–1.642]). PSC flap width was a significant predictor of donor-site revisions (χ 2 (1) = 15.9, p = .010, OR = 4.745, 95% CI [1.584–14.213]). Arterio-venous loops (AVLs) tended to increase the risk of microvascular thrombosis (χ 2 (1) = 3.7, p = .08, OR = 4.1, 95% CI [0.9–18.7]). Conclusions: The CPLD free flap is an extremely large and highly reliable flap, all- owing one-stage reconstruction of extensive lower extremity defects. It may over- come the need for multiple flaps in selected cases. 1 | INTRODUCTION Free flap surgery has evolved to a routine procedure for reconstruc- tion of complex soft-tissue defects of the lower extremity. Neverthe- less, complex, extensive, and unusually large, as well as separate, defects continue to pose a significant challenge. Microvascular recon- struction with multiple flaps is possible, but time-consuming and challenging, regardless of whether performed simultaneously or in stages. Combined free flaps represent a promising alternative to multi- ple individual flaps, allowing for one-stage reconstructions of such defects (Hallock, 2008a). In this context, the subscapular system offers the greatest variety of independent flaps including cutaneous, muscular, and bone components, all linked together by a common source vessel (Hallock, 1997). Hallock has introduced a simplified Received: 10 February 2020 Revised: 27 June 2020 Accepted: 28 July 2020 DOI: 10.1002/micr.30640 Microsurgery. 2020;1–10. wileyonlinelibrary.com/journal/micr © 2020 Wiley Periodicals LLC 1