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Evans et al. Plast Aesthet Res 2022;9:34 https://dx.doi.org/10.20517/2347-9264.2021.134 Page 3 of 14

In his thesis, reviewing 826 free flaps, Godina found that only 1% of patients developed an infection when
acutely debrided and reconstructed within 72 hours, with a flap failure rate of 0.75%. Conversely, when
reconstruction was delayed beyond 72 hours, the flap failure rate was noted to be 8%-12%, with an infection
[2]
rate of 9%-18% . While optimal timing in extremity reconstruction has evolved throughout the years,
Godina’s principle of early intervention survives as a principal tenet in extremity reconstruction.

Godina additionally emphasized the importance of preserving vascular patency to the distal extremity.
While adequate perfusion can be met with a single vessel runoff in the lower extremity, Godina encouraged
the use of end-to-side anastomoses in his reconstructions to ameliorate the risk of vascular
insufficiency [28,30] . Although complications rates are equivalent between end-to-end and end-to-side
anastomosis, Godina focused on preserving maximum perfusion when able [15,19] .

While the plastic surgeon’s toolbox and flap selection have expanded largely since Godina’s time, Godina
performed many of his free tissue transfers based on the subscapular axis . The patient was placed in the
[30]
lateral decubitus position, with posterior access utilized in dissecting out recipient vessels within the lower
extremity. Godina advocated for beginning dissection of recipient vessels outside the zone of injury and
dissecting distally to the first evidence of pathology. Although fallen out of favor for other modalities,
Godina believed that all anastomoses should be done proximal to the zone of injury, and that an arterial
autograft should be utilized to bridge gaps within the zone of injury [30-36] .

Godina’s flap selection was limited by his time. Soft tissue coverage was typically achieved with free muscle
flaps with skin grafting or, less frequently, myococutaneous flaps [3,37] . Moreover, muscle flaps were believed
to be a highway for antibiotic therapy to bathe contaminated wounds, making them preferential in the
reconstruction of traumatic injuries [12,16,17,38,39] . Today, fasciocutaneous and perforator flaps are exceptional
flap options for reconstruction of the lower extremity and demonstrate less donor site morbidity when
compared to muscle flaps [40-45] . Ultimately, as advancements in lower extremity reconstruction continue to
emerge, it is evident that the “Godina Method” remains at the foundation of reconstructive
microsurgery [46,47] .

BUILDING ON GODINA’S FOUNDATION–INNOVATIONS IN LOWER EXTREMITY
RECONSTRUCTION
While Godina advocated for early debridement and coverage of injuries within 72 hours, surgeons have
continued to investigate optimal timing for extremity reconstruction. Time to coverage has since been
refined, with multiple authors showing improved outcomes with early soft tissue coverage extending to 7-10
days [1,2,23,48,49] . Overall improvements in infection rates, bony union and flap success have demonstrated the
utility in delaying reconstruction to an urgent setting (7-10 days), emphasizing the importance of serial
debridement of non-viable tissue and preparing an adequate wound bed prior to functional limb salvage.

[4]
In 2000, Gopal et al. , introduced the “fix and flap” method in which lower extremity traumatic injuries
[50]
were treated via a combined orthopedic and plastic surgery approach . The authors suggested treating
lower extremity injuries in a single stagged procedure in which early radical debridement, skeletal
stabilization, and soft tissue coverage were performed. Results demonstrated favorable outcomes for
surgeries performed within 72 hours of injury and comparable data compared to stagged reconstruction.
Overall, timing in lower extremity reconstruction remains at the surgeon’s discretion. The literature appears
concerted that early debridement in the acute setting is critical to decreasing complication rates, and
reconstructive efforts should be ideally performed prior to 10-14 days [1,3-6,23,48,49,51] .