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Page 2 of 11 Diamond et al. Plast Aesthet Res 2019;6:20 I http://dx.doi.org/10.20517/2347-9264.2019.26

Conclusion: Primarily thinned perforator flaps performed well in the setting of lower extremity limb salvage, critical limb
ischemia, osteomyelitis, and the Charcot foot - expanding their role in the armamentarium for lower extremity care.

Keywords: Perforator flap, diabetic foot, limb salvage

INTRODUCTION
Free microvascular tissue transfer in combination with aggressive debridement, targeted antimicrobial
therapy, optimization of distal perfusion and boney stabilization remains a powerful tool to heal lower
extremity wounds with osteomyelitis - restoring functional ambulation [1-3] . Godina along with Mathes
described the role of muscle-flap coverage for high-energy wounds with infected bone almost 40 years ago.
[1-7]
[4]
They achieved an 89% infection clearance rate . Numerous authors have demonstrated similar results .
Lower extremity salvage in the setting of high-energy trauma, critical limb ischemia and the diabetic
foot often includes management of denuded and dysvascular bone with variable degrees of osteomyelitis
ranging from superficial contamination, to deeper medullary involvement, from localized to diffuse
[8,9]
infections described by the four-tiered Cierny-Mader classification . Traditionally muscle-bearing flaps
were used to create a local tissue environment conducive to healing and fill-in tissue dead-space. Muscle
has been thought of as more effective than fasciocutaneous flaps in overcoming bacterial colonization and
infection due to improved oxygen delivery and restoration of wound bed perfusion [2,3,6,10] . However this has
been refuted over the past decade by a number of authors [3,5,7,11] .

[12]
Over time, a deeper understanding of perforasome anatomy , microsurgical technical refinements [13-16] ,
perioperative protocols and improved instrumentation has empowered reconstructive surgeons to reliably
[17]
utilize skin-only and fasciocutaneous flaps for coverage of lower extremity defects . Nonetheless,
challenges remain as traditional perforator-based flap thickness can interfere with post-operative function,
particularly in the lower extremity, wherein bulky, thick, flaps can interfere with footwear, contour across
joints, irregular weight bearing surface and can lead to flap breakdown [2,13,14] . Technical refinements in
anterolateral thigh (ALT) harvest offer reliable methods to achieve thinner flaps, minimizing debulking
procedures, improving contour and decreasing donor morbidity.

Recent reports consistently demonstrate that elevation of the ALT flap in different planes allow for the
possibility of safe, consistent, and definitive distal extremity reconstruction in a single stage [15,18,19] . However,
limited data exists for successful limb salvage with use of thin fasciocutaneous flaps in the setting of
osteomyelitis, limb ischemia and the Charcot foot. Our goal is to describe the routine use of the primarily
thinned ALT flap in varying thicknesses for lower limb salvage surgery, and to assess outcomes in patients
at high risk for failure.

METHODS
Patient data
All lower extremity free flaps performed at a single, Level 1 medical center were entered into a
prospectively maintained registry including patient demographic information, clinical history, radiographic
imaging, procedural data, operative reports, postoperative care and long-term complications across 116
unique variables. A REDCap database was utilized as a secure web-based application for data maintenance.
A trained member of the research team uploads data once monthly. Follow up radiographic reports and
clinic visits are specifically analyzed to identify limb salvage failure, nonunion, malunion, osteomyelitis,
flap failure, wound recurrence, patient ambulation, use of assistive devices, patient disposition and rates of
amputation. The database is maintained via institutional review board approval.