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Page 6 of 12 Azadgoli et al. Plast Aesthet Res 2018;5:3 I http://dx.doi.org/10.20517/2347-9264.2017.32

epigastric artery perforator flap has also been used for these situations, this flap is often too bulky and
provides a less aesthetic option.

Below knee
In the distal leg, dead-space obliteration is generally not a concern and the use of bulky musculocutaneous
flaps, such as TRAM flaps, can result in significant contour deformities. As a solution, several authors
describe the ALT flap as a preferred method for distal lower extremity defects following sarcoma resection,
[9]
given the easy ability to reshape the flap [11,22] . In a series by Barner-Rasmussen et al. , 73 patients with
soft tissue tumors located predominantly in the distal leg received 75 free-flap procedures with a 95% flap
survival rate and a 97% limb salvage rate. A majority of the flaps used were latissimus dorsi flaps (72%) and
ALT flaps (12%). The rectus abdominis and latissimus dorsi flaps as well as free scapula flaps have been
[6]
described for this region by Cordeiro et al. with an overall success rate close to 90%. Other flaps commonly
[9]
used in the lower leg are the radial forearm flap, gracilis flap, tensor fascia lata flap, and fibula flap .
Ankle/foot
Several factors must be taken into account when reconstructing oncologic defects of the ankle and foot.
In addition to considering the need for adjuvant radiotherapy, the soft tissue of this area is very thin and
must provide a smooth surface for the tendons underneath. Traditional flaps used to cover defects of the
distal third of the foot have included the rectus abdominis, latissimus dorsi, gracilis, and rectus femoris
[24]
[23]
flaps . Free scapular and ALT flaps have also been used with adequate results . Muscle flaps provide
excellent coverage, and while they are initially quite bulky for this region, they flatten significantly with time
as they atrophy. Thus fasciocutaneous flaps have been described as a successful alternative with superior
contouring [25,26] .

Although the versatile ALT flap has also been used in the past, the amount of adipose deposit in this flap can
be addressed by primary thinning via a supra-fascial dissection or secondary procedure using mechanical
[27]
lipectomy. A third approach was described by Weichman et al. where they reported a series using an
adipofascial ALT flap with a split thickness skin graft to cover dorsal foot defects on three patients after
sarcoma resection. In addition to its superior contour, the fascial plexus of the adipofacial flap is stronger
[28]
than that of the thinned ALT, and the extra fascia can be used to reconstruct local tendons .

The fasciocutaneous radial forearm flap has also been reported to have good results in reconstruction of the
foot and ankle, providing normal contour and durable stability [29,30] . Unfortunately however, it can result in
[31]
significant donor-site morbidity and occasional bulkiness. Thus, Medina et al. proposed a using a radial
forearm fascial free flap for dorsal foot defects and reported its use in a patient with wound dehiscence
following sarcoma resection and radiation therapy, with no resulting complications or contour defects.
Another flap that can provide excellent results in the ankle if the size of the defect permits is the temporalis
[6]
fascia free flat .
In contrast to the dorsum of the foot, reconstruction of the weight-bearing sole of the foot requires strong
[32]
soft tissue that is resistant to pressure, weight, and stress. Struckmann et al. covered heel defects in 12
patients with a variety of free flaps including latissimus dorsi, gracilis, lateral arm, ALT, and parascapular
free flaps. They found that myofasciocutaneous flaps had the best functional results, followed by
adipocutaneous and muscle flaps with split-thickness skin grafts, while fasciocutaenous flaps had the lowest
outcomes. However there was no significant difference between specific flap type.

ADDITIONAL CONSIDERATIONS: COMPROMISED STRUCTURES
Bone involvement
For bone reconstruction, the flap is chosen based on specific patient needs including location of the lesion,
level of activity of the individual, need for adjuvant therapy, and growth potential. The most commonly