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Page 4 of 14 Bolletta et al. Plast Aesthet Res 2019;6:22 I http://dx.doi.org/10.20517/2347-9264.2019.22
[44]
and 1% and 5% of total necrosis) [46,47] . Bekara et al. in 2016 presented a comparison between free flaps
and pedicled propeller flaps in the distal third of the lower extremity by performing a systematic review
with meta-analysis of all published data. In order to analyze the data, they included under “coverage
failure” both partial and total flap necrosis needing a second reconstructive procedure. They did not find
a statistical significance in the difference of coverage failure between the two groups, even though it was
rather more frequent in the free flaps group. On the other hand, partial necrosis affected more the propeller
flaps group, but not undermining their overall success rates. By showing that complication rates were
comparable in the two groups, they suggested that the flap of choice may be decided depending on defect
size, using pedicled-propeller flaps for smaller defects and free flaps for larger ones.

Free flaps
Despite all the stated above on pedicled perforator flaps, it is true that free flaps present many advantages
which makes them an irreplaceable tool in extremity reconstruction. Pedicled flaps are inevitably limited
[48]
by restricted tissue accessibility and characteristics . On the other hand, free flaps can be chosen and
[1]
custom designed according to the defect . Characteristics of an ideal free flap are similarity with defect
area and tissue reliability to allow secondary surgeries. Donor-site morbidity should be minimal. A long
pedicle is always an advantage because it allows safer microanastomosis, further away from the wounded
area [49,50] . In upper extremity reconstruction, it is advisable to perform end-to-side anastomosis in order to
[51]
spare main vascular axis and avoid reducing hand perfusion . Muscular, fasciocutaneous and cutaneous
flaps can all be used in extremity reconstruction.

Muscle flaps
For many years muscle flaps have been the first choice for the lower limb reconstruction and are still a
reliable option in many cases. Muscular flaps were preferred because of their usually long pedicle, relatively
easy harvest, capability of obliterating dead space in large defects and better conforming to the irregular
[52]
surface of the wound or plates used for bone fixation . Due to their capacity of improving blood supply,
their use have also been indicated when dealing with wounds with high infection risk [53,54] . Even in the
upper extremity they have been used for large defects, in particular in the proximal arm, where they
are still bulky at the beginning, but, thanks to progressive atrophy and revisions it is possible to obtain
acceptable results [10,55] . However, muscle flaps have downsides such as sacrificing a functioning muscle
and requiring coverage, often with skin grafts. This affects the aesthetic appearance of the reconstruction.
Moreover, muscle flaps may limit tendon gliding and their elevation for secondary surgeries (i.e., tenolysis)
[51]
is harder . Most commonly used muscle flaps are, according to many authors, latissimus dorsi, serratus
anterior, rectus abdominis and gracilis [56-58] . The latissimus dorsi presents many advantages and it is a
considered a “workhorse” flap. It is the largest muscle available and is a very good option for covering
large areas, including exposed tendons, nerves and bone. Its dissection is quite easy and its pedicle has
reasonable length and caliber, making it a reliable flap [52,59] . It may be necessary, depending on the defect, to
change the position of the patient for flap harvesting and this can be time and effort consuming. The same
disadvantage has to be considered for serratus anterior muscle flap, together with the difficulties in sparing
the long thoracic nerve during pedicle dissection, in order to avoid winged scapula [60-63] . The serratus
anterior flap can be raised as a small muscle flap with a long pedicle, and it is usually indicated in smaller
defects without close recipient vessels. Portion of a rib can be raised with the flap if a bone component is
needed for reconstruction. The rectus abdominis muscle flap is a bulky flap suitable for obliterating space
in deep, moderate-size wounds. Donor site morbidity is its major concern, with abdominal bulge and
hernia formation [11,64-66] . Free muscle flaps are also used for functioning muscle transfer in upper and lower
extremity. The latissimus dorsi flap can be used by harvesting the thoracodorsal nerve, which is responsible
for its motor function, but, in many cases gracilis flap is preferred. The gracilis muscle has similar
characteristics to the muscles of the forearm and a tendinous portion suitable for digits tendon attachment.
For these reasons, gracilis flap is a very useful flap in finger function restoration with very little donor site
morbidity .
[1]