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Page 6 of 10 Crystal et al. Plast Aesthet Res 2019;6:1 I http://dx.doi.org/10.20517/2347-9264.2018.69

can be performed with a pedicled radial forearm flap (RFF) or lateral arm flap (LAF). Supplied by a
long vascular pedicle from the anterograde radial artery or retrograde palmar arch, the adipofascial to
fasciocutaneous RFF is considerably resourceful. With traumatic elbow injuries often exposing bone,
tendon, or neurovasculature, the RFF and LAF can effectively resurface the thin yet tenacious native
[25]
tissue . Although the latissimus dorsi muscle flap (LDF) is a more sizeable regional alternative for elbow
[25]
reconstruction, Choudry et al. showed increased rates of flap failure when pedicled LDFs were compared
to pedicled RFFs or local fasciocutaneous flaps for elbow reconstruction. Moreover, RFFs and LAFs can be
harvested as composites, with radial or humeral bone grafts and/or tendon for complex defects. Sacrifice
of the radial artery in RFFs must be considered, however there appears to be minimal patient-reported
[26]
hand function impairment, independent of donor site closure strategy . In proximal arm and shoulder
trauma, local tissue advancements and scapular or parascapular flaps are readily applied. A trapezius
[9]
flap was utilized to reconstruct a shoulder defect following the Ankara bombings . As a pedicle supplied
[27]
by the dorsal scapular artery, this approach has minimal reported donor site morbidity . Based on the
thoracodorsal artery, the pedicled LDF provides a well vascularized muscle to fasciocutaneous flap employed
for proximal upper extremity and axillary soft tissue defects [28,29] . The use of functional, pedicled LDFs have
been described to restore upper arm strength and function following reconstruction with considerable
success [28,30] . This said, a systematic review assessing donor site morbidity highlighted several publications
which report symptomatic shoulder strength limitations following latissimus dorsi transfer, partly reduced
[29]
by muscle sparing and perforator based approaches .
With regard to lower extremity reconstruction, conventional practice suggests use of gastrocnemius
[31]
and soleus flaps for coverage of injuries at the proximal and middle thirds of the leg, respectively .
The complication rates of these local flaps are often cited as minimal; however, studies have identified
[32]
a quantifiable decrease in donor limb strength following reconstruction . Representative claims of
such nature are often challenging to quantify as the untrialed alternative is recipient limb amputation.
Subsequently, in our series, a soleus muscle flap was employed for tissue closure while another patient
[7]
required a gastrocnemius muscle flap for amputation site closure without complication . Additional local
flaps, such as the innervated sural flap and reverse hemisoleus flap, have been described for reconstruction
of the distal third of the leg and foot with good functional outcomes [23,33,34] . These distally oriented flaps are
potential alternatives to free flap tissue transfer in resource constrained locations. Still, they are technically
demanding local flaps - a victim of the November 2015 France terror attacks ultimately required secondary
[16]
amputation after failure of a pedicled sural flap utilized for posterior ankle reconstruction . A review by
[35]
Follmar et al. found that distally oriented sural flaps had complication rates of 50%-59%, with relatively
[33]
high rates of venous congestion. Sugg et al. retrospectively identified similar complication rates, but
prevented venous congestion by widening the flap pedicle. In contrast to the leg and foot, significant bulk
and musculature of the thigh affords exceptional flexibility for local tissue rearrangements if not direct
primary closure. Supported by the medial and lateral femoral circumflex arteries, the thigh provides reliable
vasculature for local flaps and is an ideal donor site for free flap transfer.

Unfortunately, local flaps become less utile as traumatic wounds become more complex, involve composite
[31]
defects, and occur more distally [Table 2]. In these situations, free flap transfer is preferred . The robust
anterolateral thigh flap (ALT) and previously described LDF and RFF serve as versatile approaches to upper
and lower extremity reconstruction. Used in the Boston Bombings and Ankara Terrorist Attacks, these
workhorse free flaps are dependable for large or distal defects seen after explosions or natural disasters. As
a testament to their utility, several series on extremity free flap reconstruction have reported flap failure
rates < 10% with few cases requiring secondary amputation [36,37] . Liberated from their pedicles, the LDF
and RFF combine previously described advantages and limited donor site morbidity with a freedom of
recipient site location and orientation. Notably, the ALT provides a tailored thickness fasciocutaneous or