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Page 4 of 11 Zhang et al. Plast Aesthet Res 2019;6:30 I http://dx.doi.org/10.20517/2347-9264.2019.040

TIMING OF RECONSTRUCTION
Historically, surgeons have advocated for prompt soft-tissue coverage of lower-extremity defects following
trauma [16,17] . In his landmark study in 1986, Godina demonstrated improved rates of flap loss, infection,
[16]
and length of hospital stay with soft-tissue coverage provided within the first 72-h of injury . Three days
remains the benchmark goal for acute reconstruction. Indeed, despite a trend towards a more permissive
timeline of soft-tissue coverage, recent analyses corroborate improved free-flap failure rates and reduced
rates of infection with immediate reconstruction within the 72-h window, although these statistical
analyses remain dependent on Godina’s index cohort of over 500 patients, to date the most prolific of
[18]
studies analyzed . Obviously, surgeons strive for prompt bony stabilization and soft-tissue coverage as
soon as logistically possible; however, clinical reality and the presence of concomitant injury to vital organ
systems often preclude definitive reconstruction in the acute setting. Facilitated by advances in wound care,
this critical window has since been liberalized in the setting of recent studies demonstrating noninferior
outcomes with reconstruction in the subacute and chronic phases of injury following serial debridement
without compromise of flap survival rates or patient function [17,19-25] . This trend has accelerated over the
previous decade: the mean timing of definitive reconstruction has progressed from 6 to 12.5 days in the
[26]
decade from 2002 to 2011 . This trend also reflects the prioritization of adequate wound debridement to
[20]
ensure adequate preparation of the recipient wound bed. As demonstrated by Karanas et al. , definitive
soft-tissue coverage should allow for serial debridement to minimize the risk of catastrophic deep-space,
or bony infection, even if this process delays reconstruction outside of the acute window. Data from
the armed combat literature also underlie the importance of ensuring a clean and adequately debrided
wound bed . Pollak et al. found that time to initial operative debridement was not an independent risk
[27]
[27]
factor for the risk of infection following high-energy low-extremity trauma; however, prompt admission
to definitive trauma treatment center was protective, suggesting prompt global patient management and
wound care is essential to favorable reconstructive outcomes.

Perhaps more than any other therapeutic advancement, the widespread use of negative pressure wound
therapy (NPWT) has proven essential for the temporization of definitive reconstruction [22,24,28] . Multiple
hypotheses exist as to why the physiologic advantages of NPWT have facilitated the optimization of wound
care including providing ideal wound healing environment via minimization of edema, reducing surface
area of the wound, and providing reduced capillary afterload translating to increased perfusion of nascent
granulation tissue [29,30] . Indeed, the physiological benefits attributed to NPWT are felt to oppose the effects
of tissue fibrosis, inflammation, and edema thought to potentially threaten microvascular anastomoses
driving the emphasis of early reconstruction. The use of NPWT has extended the critical time to definitive
soft-tissue coverage to as far out as weeks to months from the initial injury, with numerous studies
documenting comparable rates of flap loss, infection, and hospital stay following soft tissue coverage. In
fact, certain cohorts report improved outcomes approaching significance of chronically reconstructed
wounds compared with more acute reconstruction, lending further credence to temporization of
[24]
[22]
reconstruction outside of the acute window . As initially observed by Steiert et al. , increasingly
permissive time to definitive coverage appears concordant with the increasing complexity of the wounds
being reconstructed, which helps to better understand the deviation from the 72-h orthodoxy. To be clear,
when feasible, recent data still corroborate improved outcomes with earlier reconstruction. The work of
[23]
Liu et al. demonstrated that, while delay to definitive reconstruction past seven days conferred increased
risk for osteomyelitis and potential flap complications, NPWT was protective against reoperation and
venous thrombosis in those populations unable to undergo acute reconstruction. Taken together, prompt
reconstruction should remain the operative goal, but timing should involve nuanced considerations of the
[31]
patient and injury, as excellent outcomes remain feasible long after the previously espoused 72-h window .
Unfortunately, operative considerations are not the only determinants of timing to reconstruction; the
[32]
work of Shammas et al. identified a number of sociodemographic risk factors, including older age,
nonwhite race, and geographic region for delays to soft tissue coverage. Acute reconstruction should not