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Page 2 of 14 Bolletta et al. Plast Aesthet Res 2019;6:22 I http://dx.doi.org/10.20517/2347-9264.2019.22

INTRODUCTION
Nowadays, the development of both trauma care and oncological treatments increased the number
of situations in which plastic surgeons are called to perform difficult limb salvage and complex,
tridimensional reconstructions. Fortunately, sophistication of microsurgical techniques and improvements
in the comprehension of the blood supply to tissues in different areas of the body allow the ongoing
[1]
evolution of reconstructive tissue transfer . This enables surgeons, not only to extend the indication for
limb preservation but also to obtain better results, in terms of both aesthetic and function recovery. Due
to their highly specific characteristics, the techniques and goals of reconstruction are different in the
upper and lower extremity. The upper limb represents the area responsible for fine movements essential in
everyday life, but it is also often exposed and involved in social relations. Therefore, both functional and
aesthetical reconstruction should be achieved. In the lower extremity, reaching a functional reconstruction
that allows the patient to walk properly without pain is the primary goal, even though, nowadays, reaching
[2-4]
an aesthetic reconstruction is always desirable, when possible . Today, many have come to agree that
a microsurgical approach is the standard of care in most cases of extremity reconstruction and limb
[5]
preservation . Many different flaps can be used in order to reconstruct bone defects, muscular function
and soft tissue coverage. Advances in microsurgery allows to overstep Levin’s reconstructive ladder with
[6-9]
specific and patient-customized reconstructive approaches .

Upper extremity
Defects of the upper extremity may involve different tissue types with specific functions (i.e., muscles or
tendons involved in hand and finger mobility) and large coverage area that allows secondary procedures, if
[10]
needed . It would be preferable to avoid flaps that need to sacrifice the radial or ulnar artery, in order not
to alter and diminish the vascular inflow and outflow from the already damaged limb, causing not only
sensory alteration and cold intolerance but also chronic edema and tissue ischemia [11-13] . If the function of
flexors or extensors of fingers or other joints (i.e., wrist or elbow) is damaged, a functioning muscle transfer
may be used [14,15] . Goal of upper limb reconstruction is to restore fine functions of the hand, together with
aesthetic coverage that allows prompt mobilization of the hand and joints in order to avoid stiffness from
prolonged immobilization.

Lower extremity
When planning a microsurgical reconstruction, it has to be taken into account that the lower limb
[16]
presents greater risks compared to other districts . These are represented by the status of the vascular
network in the lower extremity, which may be affected by many conditions such as peripheral vascular
disease or diabetes, and also by the fact that the area is responsible for weight bearing. The skin coverage
in most of the lower leg is thin and tight over muscles and sometimes directly over the bone [17,18] .
Sometimes circumferential coverage is needed and post-operative edema and scarring have to be taken
into consideration . Therefore, lower limb reconstruction is one of the most challenging, with a higher
[18]
incidence of free flap loss compared to microsurgical reconstructions performed in other districts [19-23] .
Patients in need of lower extremity reconstruction also include various number of traumatic injuries.
For this reason, it is extremely important, in evaluating the patient and developing the reconstructive
strategy, to assess the condition of vessels in the extremity . When Gustilo classification system was firstly
[20]
introduced, it already highlighted the fact that limb perfusion was essential in determining reconstructive
options. In fact, type IIIC describes devascularized limbs needing vascular repair as having the worst
prognosis [24,25] . Goal of lower limb reconstruction is to restore the fundamental functions, the possibility to
walk and wear shoes, together with proper coverage in order to avoid recurrent ulceration and acceptable
aesthetic result.