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Azadgoli et al. Plast Aesthet Res 2018;5:3 I http://dx.doi.org/10.20517/2347-9264.2017.32 Page 7 of 12

harvested bone flap is the free fibula flap, which can be used in three major reconstructive ways: traditional
vascularized fibula flap, vascularized fibula flap combined with an allograft, and vascularized double-
[33]
barreled fibula .
The traditional vascularized fibula flap as a bony replacement is indicated in areas that endure lighter
loads or when reinforcement of weak areas is needed. The free fibula flap with an allograft, which was
[34]
first described by Capanna et al. in 1993, involves the insertion of the vascularized fibular graft into
the intramedullary canal of an allograft, which is then used to fill the bony defect. This flap provides
strength and stability early on, making it ideal for anatomical locations where high forces are applied.
For areas that must withstand intermediate stress loads, the free double-barreled fibula flap is typically
chosen. This flap allows for twice the volume of the fibula to be substituted with the same number of
[33]
microvascular anastomoses . It is generally indicated for femur and proximal tibia reconstruction as well
as reconstruction of the tibia of younger patients who are physically active [35,36] . Additionally for radiation-
induced long-bone fractures, the vascularized fibula can also be osteotomized longitudinally and used as an
[37]
onlay graft . The fibula can also be harvested as a combined osteocutaneous flap for composite defects of
the lower extremity [6,10] .

An additional osteomuscular flap that has been reported to have good outcomes for coverage after distal
[38]
[24]
tibial osteosarcoma resection is the fibula-flexor hallucis longus osteomuscular flap . Saito et al. also
describe adequate aesthetic and functional outcomes with the use of a free composite graft of latissimus
dorsi and scapular bone as well as a free osteocutaneous scapular-parascapular flap. Finally, in cases of
allograft bone reconstruction of the lower extremities, soft tissue flap coverage using latissimis dorsi and
[39]
rectus abdominis flaps has been shown to maximize limb salvage .
Nerve reconstruction
Radical sarcoma resection often leads not only to extensive soft tissue defects, but also suboptimal degrees
of functionality secondary to damage to surrounding nerves. Functional outcomes following conventional
[40]
limb-sparing procedures reported in the literature have been close to 75% .

Reinnervated muscle transfer, which has been extremely valuable in a number of reconstructive procedures,
[41]
may also become necessary in patients with sarcoma resection. Doi et al. describe a patient with synovial
sarcoma of the anterior compartment of the lower leg who received a gracilis flap to cover the defect. The
motor nerve of the gracilis was sutured to the motor branch of the tibialis anterior muscle from the peroneal
nerve, resulting in gradual increase in power and range of toe and ankle extension postoperatively. In a
[42]
second series by Doi et al. , reinnervated latissimus dorsi transfer was used to improve or supplement knee
flexion or extension by connecting to the sciatic or femoral nerve at the time of reconstruction.

Vascular reconstruction
While arterial reconstruction is always indicated after limb-sparing surgery to prevent ischemia, the need for
venous reconstruction is not as well-established, as venous ligation compromise the limb. Studies showing
[43]
high occlusion rates have led to debates regarding the benefits of venous revascularization . Additionally,
there have been reports of symptoms of severe venous insufficiency such as edema, claudication, and
[44]
hyperpigmentation after reconstruction .

A large series of lower limb soft tissue sarcoma resection with arterial and venous reconstruction was
[44]
conducted by Nishinari et al. in 25 patients. Graft occlusion rates were found to be significantly greater
in patients who received synthetic grafts vs. those who received saphenous vein grafts (P = 0.02), which is
[14]
consistent with the results of other studies . However occlusion rates were not different between arterial
[44]
and venous reconstruction and there was no association between prior radiotherapy and graft occlusion .
[45]
Wortman et al. reported one-year patency rates of venous bypass grafts to be 65%, with high numbers of