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Othman et al. Plast Aesthet Res 2022;9:29 https://dx.doi.org/10.20517/2347-9264.2021.135 Page 3 of 10

serves a role in successful soft-tissue coverage through increased tissue vascularization as well as providing
recipient sites in the case where a free flap may be necessary.

Simultaneously, orthopedic surgeons will address bony defects. In order to optimize the wound bed and
soft-tissue efficiency, collaboration at this stage is crucial; the goals for soft-tissue coverage in concordance
with orthopedic planning will ensure an appropriate pathway in the initial stages, particularly in the
complex patient. Regardless, this phase begins with bony restoration. Oftentimes, the defects will necessitate
hardware for bony restoration by orthopedic surgeons. Unfortunately, even with proper collaboration,
communication, and pre-operative planning, this may require additional debridement or discontinuity of
native soft-tissue in order to ensure bony correction [8,11,13,14] . This is highlighted in the setting of prolonged
orthopedic rehabilitation, as further soft-tissue coverage may be required. Regardless, the expected phases of
recovery can be planned for with early onset collaboration and planning.

When collaboration is ensured, the plastic surgeon must optimize the wound bed and surrounding soft-
tissue regardless of the repair strategy. Early debridement is essential for success, as multiple studies have
indicated that warding off potential infection, or minimizing already-seeded harmful microbes, increases
[15]
the rate of salvage of bone and soft-tissue, as well as overall limb preservation . The authors advocate for
meticulous debridement as needed (i.e., save tissue that can be saved), as this helps facilitate definitive
reconstruction by minimizing the ultimate area of the final defects. It goes without saying that this can be
the difference between a local flap and more invasive procedures such as the recruitment of a free flap or
staged local reconstruction. Anecdotally, we find that this collaboration and open communication with
[8]
expert colleagues in other disciplines facilitate these goals .
TISSUE TEMPORIZATION
Once the initial repair and debridement have commenced, the authors aim for immediate reconstruction.
However, oftentimes, the setting of extensive trauma will not allow for immediate reconstruction. This can
be for several reasons - the complicated trauma patient may require several urgent interventions prior to
lower extremity intervention, i.e., life over limb. Secondly, extensive defects may present to centers lacking
the microsurgical expertise necessary to address the extent of soft-tissue coverage [4,5,14] . Finally, orthopedic
and vascular intervention may require staged approaches that complicate the ability to achieve definitive
[17]
coverage . The late Dr. Godina , a pioneer across plastic surgery and in the realm of limb salvage and
[16]
lower extremity trauma, advocated for early soft-tissue coverage within three days of presentation in his
landmark article published in 1986. Though this long held up as an important tenant of limb salvage,
subsequent advances in wound care, microbial management, and soft-tissue temporization have made it
possible to achieve strong outcomes in a delayed fashion.

In recent years, several studies from high-volume trauma institutions, including our own, have advocated
for anywhere between 7-90 days in achieving strong outcomes [18,19] . Central to this principle has been the
advent of the wound vacuum and NPWT. In brief, NPWT facilitates increased blood flow and infection
mitigation within the wound bed, helping to provide some of the advantages of soft-tissue coverage
Subsequently, this may allow for “ladder stepdown”, where initial careful debridement and subsequent
granulation can minimize defect size to allow for local tissue options that were previously untenable [18,20] .
The early application of NPWT has been shown to increase reconstructive success; however, this
necessitates several important caveats - early debridement and clearance of gross infection and necrotic
tissue are crucial to maximizing NPWT success . Further, the use of NPWT over exposed bone, tendon,
[21]
nerves, or blood vessels must be met with careful consideration, and is most often times not indicated. This
is especially true in the setting of osteomyelitis. In these situations, wounds can be temporized through a