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Page 8 of 14 Bolletta et al. Plast Aesthet Res 2019;6:22 I http://dx.doi.org/10.20517/2347-9264.2019.22

expanding targeted muscle reinnervation applications in prosthesis control [106] . Older studies reported
complex Gustilo type IIIC injuries result in very high amputation rates, together with high and unjustified
costs for the healthcare system and the patients [107-109] . Recent studies, though, evaluated the impact of
salvaged limbs both on patients’ quality of life and costs for the healthcare system, suggesting it to be
beneficial in both instances [110,111] . Moreover, in these complicated cases, the introduction of devices such
as the topical negative pressure therapy, has allowed surgeons to improve the local general conditions in
terms of reduction of bacterial load and creation of a wound bed more suitable for a reconstructive attempt.
Despite this, the management of these complex injuries is still debated. It has been demonstrated by several
[23]
[20]
studies that vascular injury increases the severity of trauma . Stranix et al. , compared Gustilo IIIB
injuries with increasing arterial injury, finding that limbs with a single vessel uninjured had higher flap
[20]
[112]
failure risk . A recent work by Ricci et al. though, compared the reconstructive outcomes of patients
with Gustilo type IIIC injuries after emergent revascularization in order to determine whether there was
an optimal treatment algorithm. According to their results, the rates of complications in these patients
were comparable with the routinely reconstructed type IIIB injuries, therefore worth considering for limb
salvage.

Both in upper and lower extremity, if the vascular defect is located within the soft-tissue defect, a flow-
through flap can be considered as a reconstructive option. It may allow reconstruction of both vascular
[113]
continuity and coverage with a single procedure . Different studies have shown that free flow-through
flaps can be useful for emergency treatment of complex limb injuries with high success rate [113,114] . Even
though bringing a vascularized tissue to the injured leg or arm can already be beneficial for the overall
blood supply of the region, a flap with flow-through anastomosis will certainly increase the perfusion of
the distal limb. This also present other advantages such as increasing direct venous return and reducing
[114]
[115]
edema formation, therefore improving the salvage rates . Fujiki et al. analyzed whether flow-through
anastomosis affects the failure rate of free flaps, compared with traditional end-to-end and end-to-side
anastomosis techniques. According to their clinical findings, in the leg, flow-through anastomosis for both
the artery and vein had an excellent success rate. Moreover, flow-through venous anastomosis tended to
reduce failure rates compared with conventional techniques.

Sometimes in devascularized limb salvage, local tissue is not available and direct free flap reconstruction
[116]
can’t be performed due to the lack of adequate recipient vessels . Since World War II, a valuable option
in these cases have been represented by cross-leg flaps, giving the possibility of transferring contralateral
healthy tissue to the injured lower limb [117,118] . The use of this technique has continued over time, with
different cross-leg flaps reported, and satisfying outcomes [119-121] . Advances in microsurgical techniques have
enhanced direct reconstruction but, some of the new concepts, such as free flaps and flow-through flaps,
can be applied also to cross-leg flaps. Cross-leg free flaps can therefore be performed as a free flap firstly
anastomosed to contralateral recipient vessels and then, secondarily, autonomized on the affected limb
random blood supply. These reconstructive approach, in our experience, can be utilized in the distal third
[122]
of leg, in case of large size defects with the absence of usable recipient vessels . When the extent of the
injury requires further reach and a longer flap, a flow-through free flap can be used as a carrier for a second
free flap. The free cross-leg bridge flap is anastomosed to contralateral recipient vessels granting a sufficient
blood supply to the second free flap in order to reach and provide coverage for the entire defect. In our
experience, the radial forearm free flap is best suited a vascular bridge flap. The skin paddle can be incised
in a “bone” shape, with wider extremities to cover the anastomosis sites. The choice of the second free flap
depends on defect size and characteristics. LD or vertical rectus abdominis myocutaneous flaps can be
used for wide defects, moreover LD flap can be raised with portion of 1 or 2 ribs, for bony reconstruction.
Initially the free flaps were raised in two stages, allowing assessment of the radial forearm flap survival
before second flap harvest. In our latest experience, we feel confident that the procedure can be performed
in a single stage. In the second surgery, an external fixator is used in order to avoid damages to the flap