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Page 4 of 11 Gimenez et al. Plast Aesthet Res 2022;9:28 https://dx.doi.org/10.20517/2347-9264.2021.129

amputation is associated with a faster return to day-to-day activities, fewer surgeries, and decreased
immediate healthcare-related costs [30-36] . In contrast, limb salvage is associated with decreased rates of
psychological morbidity and is more cost-effective in the long term, given the significant expenses
associated with serial prosthetic replacement throughout an individual’s lifetime.

When opting for limb salvage, the timing of definitive reconstruction remains a controversial topic;
[37]
however, most centers agree that early definitive wound coverage, as proposed by Godina , is preferable.
With the addition of negative pressure wound therapy as an adjunct for managing lower extremity wounds,
numerous studies have demonstrated that definitive coverage can be performed past the initial 72 h period
with similar outcomes [38-42] . Specifically, in children, Rinker et al. noted that patients who underwent soft
[42]
tissue coverage within 7 days of injury exhibited decreased complication rates following surgery than those
[40]
whose defect was covered after one-week post-injury. In contrast, Lee et al. noted no difference in flap
failure or other complications in adults when wound coverage was performed in the acute, subacute, and
chronic periods. While adequate debridement, prevention of infection, and diligent wound care can extend
the timeline of reconstruction, definitive coverage should still be completed as early as possible to allow
patients to resume ambulation. Finally, the patient’s and family’s expectations, along with the various
reconstructive options and their expected outcomes and postoperative rehabilitation protocols, should be
discussed frankly prior to surgery.

SOFT TISSUE RECONSTRUCTIVE OPTIONS
The goals of lower extremity soft tissue reconstruction are to restore form and function by providing
durable coverage with minimal donor site morbidity. Generally, we minimize the use of non-surgical
wound care modalities in order to minimize the psychological morbidity associated with dressing changes.
Both locoregional and free tissue transfer are employed for reconstruction, with technical selection being
determined by the location and size of the defect as well as the availability of donor tissues. The leg,
particularly at its distal aspect, is challenging to reconstruct because of the limited tissue laxity, thin skin
envelope, and high prevalence of superficial vital structures in the region; as such, reconstructive surgeons
typically divide the leg into thirds to guide reconstructive efforts [Figure 2] .
[43]

Locoregional tissue transfer
Local and regional flaps are viable reconstructive options when used in patients with small- and middle-
sized defects with sufficient surrounding soft tissue. When employed under appropriate conditions,
locoregional flaps are associated with decreased hospital length-of-stay, shorter operations, and reduced
short-term healthcare-related costs compared to free tissue transfer [44,45] . Locoregional tissue transfer is
primarily employed to treat soft tissue defects in the upper and middle one-third of the leg, given the
paucity of tissue available in the distal one-third. In the upper one-third, permutations of the gastrocnemius
flap with overlying skin grafting allow the surgeon to reconstruct many defects with minimal impairment to
the patient’s ability to perform plantarflexion of the foot [46,47] . Similarly, the soleus flap is another muscle flap
that can be used in conjunction with skin grafting to repair defects of the middle one-third with minimal
functional morbidity [48,49] . While free tissue transfer is preferred for defects of the distal one-third, a distally-
based reverse sural artery flap along with several muscle flaps, such as the peroneus brevis and hemisoleus
muscle flaps, are alternatives to free tissue transfer for patients who are not candidates for microsurgical
reconstruction [50-52] .

Free tissue transfer
Free tissue transfer is the gold-standard reconstructive modality in medically-fit patients who require
[53]
reconstruction of large, composite defects not amenable to reconstruction with local or regional flaps .