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Page 10 of 11 Diamond et al. Plast Aesthet Res 2019;6:20 I http://dx.doi.org/10.20517/2347-9264.2019.26

does not fully capture limb salvage rates particularly in individuals with osteomyelitis who can go on
to recur after one year and or those with critical limb ischemia whose disease is not reversed by flap
coverage. We also have not explored basic laboratory, animal research or clinical pathologic review facets of
fasciocutaneous flaps that promote wound healing. Thus we can comment very little the physiologic basis
of our findings. This certainly will be an avenue of further pursuit. Further, this nonrandomized single-site
study carries potential selection and treatment biases inherent in unique to the surgeon and institutions
practices. However, it is our hope that with further multi-institutional participation, presentation and
publication, particularly to our podiatry, vascular surgery and orthopedic colleagues that we can expand
our practice and move from small scale low-power studies to larger powered research - working toward
prospective trial. This will be particularly helpful in those patients requiring revascularization by either
open or endovascular means to delineate selection of patients fit for free tissue transfer and the timing of
such interventions.

The superthin, suprafascial and subfascial variations of the ALT flap, are reliable, safe and effective options
for lower limb salvage surgery in the setting of osteomyelitis, limb preservation and Charcot collapse.
Incorporating these flaps widens the reconstructive surgeon’s armamentarium to replace like tissue, avoid
a muscle-flap donor, improve contour, shoe gear and allow bony healing - translating to healthy weight
[27]
bearing limbs and restoring ambulation . Limb ischemia necessitating revascularization prior to flap
reconstruction remains a major risk factor for limb loss, particularly in the patient with concomitant
osteomyelitis.

DECLARATIONS
Authors’ contributions
Study design: Diamond S, Doval AF, Iorio ML
Manuscript preparation: Diamond S, Iorio ML
Data acquisition: Diamond S, Doval AF, Scott B
Data analysis: Scott B

Availability of data and materials
IRB approved retrospective study based on BIDMC hospital charted data.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
IRB approval prior to data acquisition and study design.

Consent for publication
An informed consent for publication has been taken from the patients.

Copyright
© The Author(s) 2019.

REFERENCES

1. Salgado CJ, Mardini S, Jamali AA, Ortiz J, Gonzales R, et al. Muscle versus nonmuscle flaps in the reconstruction of chronic osteomyelitis
defects. Plast Reconstr Surg 2006;118:1401-11.