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Plast Aesthet Res 2022;9:49. 10.20517/2347-9264.2022.63 © The Author(s) 2022.
Open Access Letter to Editor

Reply to “Soleus muscle flap for reconstruction of lower extremity trauma. Workhorse or glue factory?”

1Major Trauma Centre, University Hospital of Wales, Cardiff CF144XW, UK.

2Welsh Centre for Burns and Plastic Surgery, Swansea SA66NL, UK.

3Swansea University Medical School, Swansea University, Swansea SA28PY, UK.

Correspondence to: Dr. Ahmed Emam, Major Trauma Centre, University Hospital of Wales, Cardiff CF144XW, UK. E-mail:

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    Academic Editors: Matthew Iorio, Marten Basta | Copy Editor: Peng-Juan Wen | Production Editor: Peng-Juan Wen

    © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (, which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

    Dear Editor,

    We read with interest your recently published article entitled “Soleus muscle flap for reconstruction of lower extremity trauma. Workhorse or glue factory?” by Kondra K, Jimenez C, Stanton E, Roohani I, Becerra J, Carey J. published in Plast Aesthet Res 2022;9:36. We would like to congratulate the authors for their contribution to this field and provide some additional insights from our own clinical practice in a major national trauma centre in the UK.

    In their retrospective review of 187 local leg flaps, the authors indicated that the soleus muscle flap can be used as a workhorse for open lower limb fractures, including Gustilo-Anderson classification 3B and 3C injuries, which are by definition high energy. However, what the authors fail to highlight is that in high-energy open lower limb fractures, the zone of injury is extensive and often associated with severe damage to the local musculature of the lower limb, including the soleus muscle itself, thereby precluding its use for reliable reconstruction[1,2]. This may explain their observed high levels of osteomyelitis/hardware infection. Rather than being limited by the reconstructive ladder, the recognized gold standard for lower limb reconstruction is to tailor it to the patient, defect, and injury characteristics to ensure the best clinical outcomes. Consideration of free flaps, which bring in healthy, well-vascularized tissue to enable fracture healing and prevent infection, is key in these situations[3].

    Additionally, the use of the soleus muscle flap for reconstruction has functional implications and is recognized to affect the weight bearing status of patients and their long-term ambulation[4]. In their clinical series, the authors noted that only 35.3% of patients were able to ambulate independently after 7.5 months, which does not compare favourably with published reports of ambulation following free flap with a mean of 9.8 days and 13.4 days depending on the fracture treatment and prolonged rehabilitation[5]. Therefore, we feel that this is another additional benefit of using free tissue transfer for lower limb reconstruction.

    Kind Regards,
    Ahmed Emam
    Consultant Plastic Surgery
    Major Trauma Centre, University Hospital of Wales


    Authors’ contributions

    Contributed to the analysis of the previously published paper, review of related literature and produced the final letter: EL-Shishtawy K, Jessop Z, Marsden N, Emam A

    Availability of data and materials

    Not applicable.

    Financial support and sponsorship


    Conflicts of interest

    All authors declared that there are no conflicts of interest.

    Ethical approval and consent to participate

    Not applicable.

    Consent for publication

    Not applicable.


    © The Author(s) 2022.


    • 1. Elniel AR, Giannoudis PV. Open fractures of the lower extremity: current management and clinical outcomes. EFORT Open Rev 2018;3:316-25.

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    • 2. Ali AM, Noyes D, Cogswell LK. Management of open fractures of the lower limb. Br J Hosp Med (Lond) 2013;74:577-80.

    • 3. Kang MJ, Chung CH, Chang YJ, Kim KH. Reconstruction of the lower extremity using free flaps. Arch Plast Surg 2013;40:575-83.

      DOIPubMed PMC
    • 4. Kramers-de Quervain IA, Läuffer JM, Käch K, Trentz O, Stüssi E. Functional donor-site morbidity during level and uphill gait after a gastrocnemius or soleus muscle-flap procedure. J Bone Joint Surg Am 2001;83:239-46.

    • 5. Jokuszies A, Neubert N, Herold C, Vogt PM. Early start of the dangling procedure in lower extremity free flap reconstruction does not affect the clinical outcome. J Reconstr Microsurg 2013;29:27-32.


    Cite This Article

    EL-Shishtawy K, Jessop Z, Marsden N, Emam A. Reply to “Soleus muscle flap for reconstruction of lower extremity trauma. Workhorse or glue factory?”. Plast Aesthet Res 2022;9:49.




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