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Bolletta et al. Plast Aesthet Res 2019;6:22 I http://dx.doi.org/10.20517/2347-9264.2019.22 Page 5 of 14

Cutaneous and fasciocutaneous flaps
Compared to muscle flaps, fasciocutaneous flaps allow supple and thin coverage with ideal surfacing,
without needing skin grafting. They are also better re-elevated in case of secondary surgeries [17,56,57] .
Due to the many different perforator flaps described, it is often possible to choose a flap with suitable
characteristics without needing to change the patient’s position, and often allowing a two-team approach
in order to reduce operative time. If the deep fascial layer is not needed for reconstructive purposes,
cutaneous flaps can be elevated above it, including suprafascial components nourished by the perforator
vessel. Preserving the deep fascia reduces donor site morbidity and chances of muscle herniation. It also
allows harvesting thinner and more pliable flaps, which can be designed in order to better match the
characteristics of the defect. Sensory nerves can be included for reinnervation and superficial veins to
[67]
increase the venous outflow . The flap can be thinned during or immediately after harvesting, hence
[68]
maximizing aesthetic results with a reduced need for surgical revisions . Obviously, the perforator
dissection of these flaps is technically demanding and it may result in small caliber vessels anastomosis,
requiring high surgical skills and knowledge of vascular anatomy [69,70] . The characteristics of these flaps
have increased their use as first option in difficult upper limb reconstructions, where it is extremely
important to achieve optimal coverage and early rehabilitation.

[51]
Wang et al. in 2017 reviewed the evidence for application of different important perforator flaps in upper
extremity reconstruction, such as the anterolateral thigh (ALT), superficial circumflex iliac perforator
(SCIP), deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps.
The ALT resulted in being the most versatile flap, due to the possibility of harvesting it thicker or thinner,
therefore functional both in larger defects of the proximal arm and distally, where a thin and supple flap is
needed. The SCIP flap finds its indication in the hand and wrist area [Figure 1] whereas the DIEP and SIEA
flaps are better suited for the proximal arm. Many authors have reported the use of free fasciocutaneous
flaps in the lower extremity, even in complicated cases with open fractures, chronic osteomyelitis, diabetic
complications and limb salvage [56,57,71-75] . The ALT is the flap of choice in many cases, especially in open
traumatic wounds, with fractures of the tibia, ankle and foot [57,58,72] . It can be utilized with a portion of the
[5]
[76]
fascia lata to reconstruct tendons as well (i.e., the Achilles) . Abdelfattah et al. evaluated free perforator
flaps, other than ALT, for the reconstruction of lower limb defects, including superficial circumflex iliac
perforator (SCIP), gluteal artery perforator (GAP), thoracodorsal artery perforator (TDAP), deep inferior
epigastric perforator (DIEP), posterior interosseous artery perforator (PIAP), upper medial thigh perforator,
and medial sural artery perforator (MSAP) flaps in their 563 cases experience. They propose an algorithm
[5]
for flap selection based on the characteristics of each flap . Other than the already described ALT, SCIP
and DIEP flaps, GAP flaps appeared to be indicated in moderate size defects located in the posterior body
surface but, as a drawback, they have a short pedicle and may require supermicrosurgical technique [77,78] .
TDAP flap on the other hand have a long pedicle and can be utilized as a composite flap by harvesting it
with scapular bone [79,80] . PIAP and MSAP flaps provide excellent single-stage coverage for small defects in
the lower leg and foot . This study suggests the reliability of free perforator flap reconstruction for lower
[81]
extremity defects. Their series of 552 patients had a high success rate (96.2%), even though they treated a
large number of diabetic limb salvage cases. Previous works reported achieving similar rates of success in
using perforator flaps in complicated lower extremity reconstructions [17,56,57,74,75] .

WEIGHT-BEARING ISSUE IN THE LOWER LIMB
In lower limb reconstruction weight-bearing areas may be involved, where the epidermal-dermal layer
is thicker and attached, through fibrous connective tissue, to the plantar aponeurosis. Fat lobules are
[82]
located within these fibrous septa. This structure provides shock-absorbing function and prevents shear .
In order to reconstruct this area like-with-like, the medial plantar flap was introduced. It was initially
described as a cross-leg flap but it has been used since, both as pedicled, for ipsilateral defects, and as a