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Othman et al. Plast Aesthet Res 2022;9:29 https://dx.doi.org/10.20517/2347-9264.2021.135 Page 5 of 10

cases requiring secondary skin grafting to the donor site, though this is much less common in the lower
[30]
extremity reconstruction . One popular flap design is the propeller flap, allowing for distal or proximal
coverage at significant lengths when rotated 180°. However, the authors prefer to avoid this flap where
possible, as we have not seen high success rates as others have reported in the literature, likely due to the
tenuous nature of the flap design mixed with the inflammatory milieu presenting in acute trauma settings .
[31]
Named local flaps, particularly myofascial and myocutaneous based flaps, are well described in the literature
based on the area of defects. The gastrocnemius has long been a workhorse in lower extremity
reconstruction of the proximal third of the leg, owning to its wide reach, muscular bulk, and reliable
anatomy, most commonly whence harvesting the medial head based on the medial sural artery. The soleus
flap is traditionally taught as a useful tool for middle-leg trauma and dead space defects requiring the filling.
Recently, it has also been described as useful for some distal defects, increasing its flexibility [32,33] . The soleus
has multiple dominant vascular pedicles dependent upon location, from proximal to distal being peroneal
and PT, which also for this versatility and ability to harvest for various defects.

One named fasciocutaneous flap that introduces flexibility for both proximal and distal defects is the medial
[34]
sural artery perforator flap . As mentioned, this can be particularly advantageous when smaller 3-
dimensional defects are present that do not warrant free flap reconstruction. Additionally, for proximal
defects, perhaps reaching the knee, the anterolateral thigh (ALT) flap has been described successfully as a
“reverse ALT”, though its usage for this purpose requires retrograde based perforation and is often not the
first choice for this purpose [35-37] . Additionally, in the traumatic setting, the zone of injury can be extended to
the distal blood supply, compromising the perforators on which the flap is based upon.

Unfortunately, for defects of the distal third, the traditional teaching is that these are often limited in the
local tissue options available. Recent years have demonstrated this to be more of an archaic dogma, though
it can be argued that wide range adoption of local options is still in its infancy given the difficulty and
limited soft-tissue available to this area, especially when factoring in tissue loss that can accompany
traumatic defects. However, when tissue is available, beyond the above-discussed options, some authors
have detailed success utilizing several named perforator flaps based upon the peroneal artery, medial sural,
and lateral sural arteries [34,38] .

Free tissue transfer
When dermal matrices and local tissue options are not feasible, it is then the authors will pivot to free tissue
transfer. This can be for several indications, including, but not limited to, extensive tissue loss, inadequate
wound beds, wounds requiring multiple future re-operation, and exposure of critical structures. When
selecting a recipient site, factors that must be taken into consideration include the anatomic location of
defect and the status of vascular perfusion. It has been suggested that vascular injury may serve as a
surrogate for severity of defect, and injury to the posterior tibial artery, in particular, may be associated with
worsened limb-salvage and flap-based outcomes, including flap failure [19,39] . The posterior tibial artery is the
most commonly selected recipient target for free flap reconstruction. Further, anastomosis outside the zone
of injury or at a disease-free site is paramount to successful free tissue transfer in the lower extremity .
[40]
The traditional teaching for free tissue transfer centers upon the debate between muscle-based and fascia-
based free flaps. The initial school of thought was that muscle flaps may be better for filling dead space,
particularly in infection-prone areas, and thus they were traditionally the preferred choice for most lower
extremity trauma requiring free tissue reconstruction. However, recent research, including our own, has
demonstrated that the clinical scenario should guide flap selection, and that each flap type has its preferred