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Evans et al. Plast Aesthet Res 2022;9:34 https://dx.doi.org/10.20517/2347-9264.2021.134 Page 7 of 14

Figure 2. Perforator flap for lower extremity reconstruction. (A) Pre-operative markings of an anterior lateral thigh (ALT) flap based on
three perforating vessels from the descending lateral femoral circumflex pedicle. (B) ALT fasciocutaneous flap with dissected
perforating vessels. (C) Large skin paddles can be successfully elevated based on perforators for the reconstruction of soft tissue
defects in the lower extremity. (D) ALT flap inset with preferential end-to-side anastomosis.

As a result of the perforasome theory, vascular mapping of perforators has developed numerous additional
options for free tissue transfer and local tissue rearrangements in the lower extremity [43,46,96,97] . Perforator-
based local flaps have gained favor in reconstructing small soft tissue defects of the lower extremity.
Numerous perforators exist within the lower limb for flap harvest, with a study by Morris et al. ,
[98]
demonstrating 93 perforators in 21 distinct territories for use. Increasing understanding of vascular
perforators in the lower extremity has allowed local perforator flaps, such as the propeller and keystone flap,
to not only replace like with like, but also reconstruct soft tissue defects that would previously require free
tissue transfer [99,100] [Figure 3].

Advances in microsurgery have placed a greater emphasis on the importance of decreasing donor site
morbidity and reducing patient harm. In addition to utilizing perforasomes and fasciocutaneous flaps,
peripheral nerve blocks, epidurals and local anesthesia have proven to be effective alternatives to general
anesthesia for select patients [101-103] . Reconstruction of the lower extremity often necessitates multiple surgical
procedures and long operative times for patients. Successful free tissue transfer and local flaps under nerve
block may provide reconstructive options for patients who would otherwise be unable to tolerate general
anesthesia. Additionally, without the need for endotracheal intubation, and airway protection, utilization of
nerve blocks may allow for patients to maintain adequate nutrition, which is often interrupted with serial
debridement and reconstructive efforts in traumatic injuries [Figure 4].