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Zhang et al. Plast Aesthet Res 2019;6:30 I http://dx.doi.org/10.20517/2347-9264.2019.040 Page 5 of 11

be performed at the expense of patient and wound optimization, as definitive soft-tissue coverage in the
subacute, and chronic intervals have been demonstrated to be safe and effective.

Soft tissue coverage is similarly dependent on the integrity of bony fixation to provide adequate tension
across joints for preservation of locomotion, and to prevent collapse of soft-tissues. Fortunately, the science
and practice of orthopedic reduction and fixation has developed in parallel with microsurgical techniques.
Amongst the most challenging operative dilemmas from orthopedic injury is the management of resulting
segmental defects. Multiple surgical strategies exist and remain used in clinical practice to restore
bony length and adequate union following traumatic bone loss or defects resulting from debridement.
Techniques including distraction osteogenesis (Ilizarov Technique), autologous bone grafting, and
mesh implants have demonstrated adequate results regarding ultimate restoration of bone length and
stability [33-35] . More recently, the Masquelet technique has emerged as a novel and reliable strategy for the
[36]
purposes of restoration of bone defects . Initially described in results published in 2000, the strategy
utilizes staged operations to induce a periosteum surrogate, “Inflammatory Membrane”, around a cement
spacer, which is subsequently replaced with autologous bone graft [37,38] . Amongst multiple retrospective
studies, clinical success rates have been reported in up to 89%-93% of cases, despite bony defects greater
than 10 cm [39,40] . Despite the paucity of long-term functional outcomes, the technique has gained clinical
traction, and has been used increasingly in concert with advances in provision of soft-tissue coverage for
the purposes of lower extremity reconstruction.

OPERATIVE CONSIDERATIONS OF RECONSTRUCTION
Once the degree of injury has been appropriately assessed, the decision to proceed with reconstruction
has been made, and the stability of the wound bed has been assured, considerations regarding the
appropriate tissue to be transplanted must be made. General principles regarding the distribution of
injury and corresponding donor site of soft-tissue coverage remain applicable and continue to guide
surgical management. The tenets of the reconstructive ladder remain applicable when reconstructing
lower extremity injuries. Often, despite significant fractures, local muscle flap coverage and skin grafting
provide excellent results. However, given unique challenges posed at certain areas, namely around the
knee and proximal tibia, as well as the distal leg, ankle, and foot, surgeons are increasingly utilizing more
complex solutions, as espoused by the “reconstructive elevator” paradigm. As conceived and popularized
[41]
by Gottlieb and Krieger , the reconstructive elevator argues for skipping over simpler solutions in favor
of a reconstructive approach that more accurately approximates the functional and anatomic deficits of the
injury. For instance, given the paucity of tissue, and resulting exposure of bony and articulating surfaces,
free-flap reconstruction has become the default surgical option for injuries of the distal lower extremity.

While certain micro-surgical principles have remained unchallenged, recent data have led to the
liberalization of other reconstructive dogmas held by many practicing surgeons. The requirement of
a clean wound bed for recipient tissue remains an immutable tenet of reconstruction. The translation
of autologous tissue should only occur in a clean wound-bed free of necrotic or infected tissue, and
preferably over appropriately reduced bony framework. In contrast, discussion regarding the selection
of autologous tissue to be harvested as well as the selection of recipient vasculature continues to evolve.
Recently, a trend towards the use of perforator fasciocutaneous flaps has proportionately displaced the
[42]
use of bulkier myofasciocutaneous free-flaps . Improved understanding of perfasomes, and increasing
facility with perforator dissection have resulted in the wide-spread adoption of using fasciocutaneous
flaps for extremity reconstruction [42,43] . Despite concerns that the use of fasciocutaneous flaps preclude the
superior blood supply conferred by transferred muscle, these flaps are no more prone to ischemia and flap
failure. Similarly, fasciocutaneous flaps are resistant to shear and breakdown in weight bearing areas when
compared with muscle containing flaps . That being said, multiple “work-horse” flaps provide appropriate
[44]