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Crystal et al. Plast Aesthet Res 2019;6:1 I http://dx.doi.org/10.20517/2347-9264.2018.69 Page 7 of 10

Table 2. Advantages and limitations of local and free flaps for extremity reconstruction
Local flaps Free flaps
Advantages Reduced procedure time and less technically demanding [23] Superior diversity for donor and recipient site combinations
Donor tissue is similar in characteristic to that of the Covering large, tridimensional soft tissue defects
recipient site [23]
Pedicle provides a reliable, durable, and native blood supply Greater capacity for harvesting as composite or chimeric grafts
Can be performed under local anesthesia or conscious sedation Preferred option in distal lower extremity reconstruction [31]
Limitations Range of transfer is limited by pedicle length Requires infrastructure and equipment to support microvascular surgery
Extremity trauma may impact nearby tissue and preclude or Higher risk of complication due to reliance on non-native
limit local rearrangements microvascular anastomosis
Less utile in composite tissue defects Greater need for post-operative monitoring

musculocutaneous flap supplied by perforators of the descending branch of the lateral circumflex femoral
artery. Its reliable dissection pattern affords a long pedicle, large tissue paddle, and minimal donor site
morbidity, all of which are ideal for upper or lower limb reconstruction [24,38,39] . Thinning to 2-4 mm has safely
been reported [39,40] . Further advantages of the ALT include an ability for innervation via the lateral femoral
cutaneous nerve, offering improved recipient-site sensation, and options to co-harvest with the fascia lata
for tendon reconstruction [38,39] . Moreover, in severe extremity trauma with noted recipient vessel damage,
multidisciplinary teams of plastic and vascular surgeons can facilitate free flap techniques with concurrent
[41]
arterial reconstructions, vascular bypass, or arteriovenous-loop formation .

Current debate regarding the efficacy and outcomes of fasciocutaneous vs. muscle flaps for traumatic
reconstruction is controversial. Conventional belief has assigned superiority to muscle flaps, particularly
[42]
in large, tridimensional extremity defects with exposed bone and high risk of infection . Recently,
[43]
Stranix et al. reported a 40-year retrospective series in which fasciocutaneous flaps had statistically
significant increased take-back rates but superior salvage rates compared to muscle flaps, owed largely to
the cutaneous clinical monitoring of fasciocutaneous flaps. A retrospective series on traumatic upper and
lower limb reconstruction in wounded warriors demonstrated no statistically significant differences in
overall complication rate or days to ambulation among patients treated with muscle or fasciocutaneous
[44]
flaps, but found that muscle flaps had statistically significant increased rates of flap failure . However, a
recent multicenter analysis reported comparable limb salvage rates of 90% and 88%-94% when muscle or
[45]
fasciocutaneous flaps, respectively, were employed for lower extremity trauma reconstruction .

There is considerable discussion regarding the appropriate timing of extremity reconstruction following
trauma. Historically, advocates have suggested soft tissue coverage of extremity defects within 24-72 h of
[46]
the initial trauma . A more contemporary systematic review of upper extremity reconstruction found
no statistically significant association between reconstruction timing and flap complications including
[22]
infection, bony nonunion, and flap loss . However, lending support for the original works of Marko
[46]
Godina , an in-press systematic review of lower extremity reconstruction concluded that rates of flap loss
[47]
and infection were lower in those who received soft tissue reconstruction within 72 h . In our experience
with the Boston bombings, flap reconstruction was performed in the acute to subacute time period. This is
not always feasible, and experience from the 2015 Earthquake in Haiti demonstrated that negative pressure
wound therapy was an invaluable adjunct to temporize and protect wounds until reconstructive specialists
[48]
arrived and offered definitive tissue closure in the subacute period .
In conclusion, we must acknowledge that the heterogenous nature of extremity wounds following MCIs
remains a unique challenge for reconstructive surgeons. With the lack of high quality randomized
prospective trials; clinical expertise, available resources, and patient presentation will continue to guide
reconstructive decision making.