Osseointegration (OI), targeted muscle reinnervation (TMR), and vascularized composite allotransplantation (VCA) are just a few ways by which our reconstructive ladder is evolving. It is important to recognize that amputation does not necessarily denote failure, but surgeons should strive to find ways to provide these patients with means for obtaining better satisfaction and quality of life postoperatively. TMR and OI have added options for mutilating lower extremity injuries that necessitate amputation. More recently, the senior author (Levin LS) described the “penthouse” floor of the reconstructive ladder being VCA. Despite the advances in VCA over the last 20 years, there are many challenges that face this discipline including indications for patient selection, minimizing immunosuppressive regimens, standardizing outcome measures, establishing reliable protocols for monitoring, and diagnosing and managing rejection. Herein, the authors review TMR, OI, and VCA as additional higher rungs of the reconstructive ladder.

Aim: Quadriceps strength and knee extension, the most important factors limiting the ability to rise from a chair, are crucial for walking at an appropriate speed, ascending and descending stairs, and performing activities such as running, dancing, and jumping. Resection of the anterior compartment of the thigh, including all four quadriceps muscles, for the treatment of a sarcoma is uncommon; however, when necessary, it is very debilitating and adversely affects a patient’s quality of life without functional reconstruction. Currently, there are a limited number of complex and difficult reconstructions to restore quadriceps function that have been described with variable outcomes. We describe a simple technique that employs a single gracilis functional muscle transfer to replace essential quadriceps function.

Methods: This is a case series describing the use of either a free or pedicled single gracilis muscle to restore quadriceps function following sarcoma resection.

Results: Four patients underwent an anterior compartment sarcoma resection that resulted in a large segmental defect and/or denervation of all four quadriceps muscles such that no quadriceps function would remain without reconstruction. All four patients underwent a functional reconstruction using a single gracilis. Three of the living patients achieved British Medical Research Counsel Grade 4 strength, can achieve full knee extension, are able to navigate stairs, and are able to ambulate without a brace. The fourth patient unfortunately was deceased in under three months following his tumor resection.

Conclusion: Despite its small size in comparison to the quadriceps muscles, with physiotherapy and training, the gracilis muscle demonstrates the capacity to hypertrophy and replace quadriceps function following limb salvage surgery.

Aim: The versatile application of perforator free flaps for coverage of any extremity has been well proven. Often, a “free-style”-like approach is used to design these flaps, as conventional imaging techniques for perforator identification may be too expensive or unavailable. As will be demonstrated, the recent application of a thermal imaging camera using a smartphone is a cheaper and therefore more universal means to better identify the requisite perforators upon which a free flap can be designed and then monitored.

Methods: Smartphone thermography can be used on any patient preoperatively to identify preferable perforators or vascular network “hot spots” within the desired donor site territory. Intraoperative management of the choice of perforators and subsequent flap dissection can be similarly facilitated. Intermittent postoperative monitoring based on changes of the thermal image color palette will provide a comparison that can be used to determine if perfusion across the microanastomosis is sustained.

Results: An overview of how to use a smartphone in concert with a thermal imaging camera is outlined. Dynamic infrared thermography represents a thermal stress necessary with a smartphone to better identify donor site “hot spots”.

Conclusion: Smartphone thermography is an inexpensive and expeditious means for identification of “hot spots” that correlate with perforators that would suffice to insure perfusion to a free perforator flap. However, since perforator caliber and course cannot be determined, this should be considered to be only a complementary adjunct for conventional methods. Nevertheless, its simplicity will overall improve the safer design, harvest, and subsequent monitoring of free flaps.

The salvage of mangled lower-extremities after severe injury remains a daunting operative dilemma, but one that continues to evolve with advances in microsurgical and orthopedic techniques. Specifically, trends in clinical practice including the decision to salvage and timing of soft-tissue coverage are changing in concordance with improvements in wound care, flap selection for soft-tissue provision, and preoperative imaging. Due to these improvements, more complex wounds are increasingly eligible for reconstruction. It remains unclear, however, whether success in limb salvage confers improved functional patient outcomes. We present a review of the literature tracing recent advances in the salvage of mangled extremities following traumatic injury, with a focus on practice trends regarding timing of reconstruction, operative approaches, and preoperative imaging.

Lower extremity reconstruction is challenging for a variety of reasons. New techniques for soft tissue coverage continue to evolve. While free flaps are always an option, free flaps require significant microsurgical expertise, a proficient staff, advanced equipment, and a patient with a somewhat healthy baseline. However, as microsurgery has evolved, so has the identification of new anatomy and new techniques - namely, perforator based pedicled flaps. These flaps have expanded options for lower extremity reconstruction, and continue to advance the field of microsurgery. The purpose of this article is to review the evolution of perforator based pedicled flaps in the lower extremity, review the anatomy, and offer examples of design and indications.

The management of extremity soft tissue sarcoma is constantly evolving, and, in recent decades, limb salvage has been the main goal. More commonly, this is being achieved with a combination of neo-adjuvant radiotherapy, followed by wide excision and soft tissue reconstruction in the form of vascularised soft tissue transfer. Although limb salvage is now readily achievable, the resultant functional disabilities following excision of major musculotendinous and neurovascular structures can be life changing. In recent years, there has been a move towards functional limb reconstruction in the form of free functioning muscle transfer. This paper reviews the advances in functional limb reconstruction in the setting of preoperative radiation and reports our experience in this challenging reconstructive field.

Perforator-pedicled propeller flaps, which base their blood supply on isolated perforators, have been gaining popularity among plastic surgeons over the past two decades. They have proven to be of great value in the reconstruction of soft tissue defects in different areas of the body but are, thanks to their maximal mobility, mostly used in the reconstruction of extremities. In this article, we focus on perforator-pedicled propeller flaps in lower limb reconstruction, where they can be implemented in the coverage of primary as well as secondary soft tissue defects. Firstly, a brief literature review on evolution of propeller flap use in lower extremity is provided. Moreover, we present our surgical technique including the use of indocyanine green real-time angiography for reliable flap transfer. In addition, we report 3 cases of patients in whom we used a local propeller flap for the closure of skin defects in different parts of the leg.

In the recent decades, microsurgical reconstruction has evolved from simple survival of the affected extremity to the improvement of functional and aesthetic outcome. This review retraces the main contributions to the advances of microsurgery for reconstruction of upper and lower extremities and limb preservation. In the upper extremity, it is important to restore fine motility, together with allowing prompt mobilization. In the lower limb, care must be taken in the reconstruction of weight-bearing areas and the aim must be proper ambulation and shoe wearing. Local perforator flaps can be considered for medium size defects. They provide thin coverage and can be performed in short operating time. Their use, though, is often limited by tissue availability. Free flaps allow to overcome this problem and, thanks to the recent development in the study of perforator vessels, the microsurgeon can choose the flap with the most appropriate characteristics. Chimeric flaps can accomplish simultaneous reconstruction of different tissue components and large bone defects often require vascularized bone reconstruction. When dealing with limb preservation it is very important to consider residual functionality. Functioning muscle transfer and targeted muscle re-innervation can be performed in these cases. A useful reconstructive tool in severely damaged limbs with limited blood supply is the use of cross-leg free flaps. In conclusion, extremity reconstruction and limb preservation are reaching new heights thanks, not only to the work of plastic surgeons, but also to the new developments in other fields of study such as oncology, traumatology, radiology and medical engineering.

Aim: There are limited reports in the United States demonstrating outcomes of primarily thinned fasciocutaneous flaps in the setting of critical limb ischemia, Charcot collapse and osteomyelitis. We hope to determine patient and flap related outcomes in advanced lower extremity disease.

Methods: The authors conducted a retrospective review of fasciocutaneous free flaps of variable thickness for lower extremity salvage. Osteomyelitis and non-osteomyelitis patients were compared according to our primary outcome measures: functional ambulation, bone healing and complications to flap and patient. Subgroups with critical limb ischemia, Charcot collapse and diabetic foot were analyzed separately.

Results: Fifty-nine patients underwent free flap reconstruction: osteomyelitis (n = 20, 34%), Charcot collapse (n = 22, 37%), and/or critical limb ischemia (n = 12, 20%). All patients underwent anterolateral thigh flaps tailored for defect-specific thicknesses: 17 superthin, 25 suprafascial, 17 subfascial. There were no significant differences between groups in terms of partial and complete flap loss (P = 1.000 and P = 0.108). Ninety-one percent of patients were ambulatory at follow up. Eighty-five percent of individuals with osteomyelitis cleared their infection demonstrating radiographic bone healing. Two patients developed recalcitrant deep space infections ultimately requiring amputation. Subgroup analysis did not show any differences in flap related complications within the diabetic Charcot population. In multivariate regression, preoperative revascularization was independently associated with failure of limb salvage.

Conclusion: Primarily thinned perforator flaps performed well in the setting of lower extremity limb salvage, critical limb ischemia, osteomyelitis, and the Charcot foot - expanding their role in the armamentarium for lower extremity care.

Aim: The management of complex dorsal hand wounds with extensor tendon loss is controversial. Treatment has focused on soft tissue coverage, but there is limited evidence comparing immediate vs. staged tendon reconstruction. This review evaluates existing literature to determine the optimal management of composite hand defects.

Methods: A MEDLINE database review was performed including objective measurements such as number of operations, total active motion, grip strength, days to maximum range of motion (ROM), and return to work. Data extraction included demographics, surgical techniques, complications, and relative outcome. We compared primary and secondary staged reconstruction to correlate any significant differences in outcome and determine optimal timing and technique for extensor tendon reconstruction. We extracted information on flap types including regional and free tissue transfer with tendinous components vs. staged tendon grafts.

Results: Comparison of outcomes showed that patients with immediate reconstruction had fewer operations, faster return to maximum ROM, and greater chance of returning to work. The most successful single stage flaps include the radial forearm, suitable for reconstructing one to three tendons and the dorsalis pedis for three or four tendons; however, there were significantly more complications in immediate reconstruction particularly regarding donor site morbidity. Pedicled flaps had better total active motion. The two-stage approach resulted in acceptable functional outcomes without significant complications.

Conclusion: Immediate cutaneous tendinous flaps have clear advantages over staged approaches for reconstruction of composite dorsal hand wounds. Benefits include less operations, faster time to maximum ROM, and higher percent of patients returning to work; however, significantly more flap related complications were seen. Immediate pedicled radial forearm provided the best total active motion with least complications. When patient circumstances dictate, a fascial perforator free flap offers a suitable environment for staged tendon grafts with good functional outcomes reported albeit longer time to achieve them.

Aim: Composite tissue defects encompassing bone and/or isolated bony defects can pose a surgical challenge; however, their reconstruction is critical for successful functional limb salvage. These cases become increasingly problematic as secondary defects, following multiple nonvascularized grafting attempts resulting in complex bony nonunion. Herein, our experience utilizing fibula vascularized bone grafts (VBGs) for bone restoration will be presented to demonstrate their utility in a variety of reconstructions for limb salvage.

Methods: This is a case series describing a series of vascularized fibula grafts for extremity reconstruction performed by a single academic surgeon over multiple institutions in seven years.

Results: Twenty-seven (27) total VBGs met inclusion criteria and underwent reconstruction for traumatic (16), oncologic (6) and chronic degenerative (5) etiologies. Bony union was achieved in 26 of 27 cases.

Conclusion: The decision-making process for bony reconstruction in these scenarios is difficult and multivariable. Fibula VBGs can provide a single-stage solution for autologous bony and soft tissue replacement of large or complex bone defects and can often be superior options compared with non-vascularized bone grafts or non-bone internal fixation techniques. Their osteogenic potential is unmatched by allogenic or synthetic substitutions. These benefits are evident in a variety of clinical settings such as pediatrics, oncology and trauma.

Aim: Free tissue transfer is essential for extremity reconstruction following traumatic injuries, oncologic resection, and diabetic complications. However, given the circumferential shape of the arm and leg, a small amount of ongoing edema can prevent a tension-free closure. Additionally, intraoperative thrombosis, vascular disease can lead to proximal exposure of the pedicle or vein grafts. This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle, in comparison with a matched cohort with a tension-free primary closure.

Methods: A retrospective review was completed of all patients that underwent free flap reconstruction of an extremity defect from January 2014 to December 2017 at a single academic institution. Flaps that utilized skin grafting for closure were compared to those closed primarily. Adjunct operative procedures, demographics, and complications were evaluated.

Results: A total of 71 patients fulfilled the inclusion criteria. The 11 flaps in 10 patients underwent skin grafting over the pedicle. The two cohorts were comparable in age, gender, BMI, and co-morbidities, excluding renal disease which was present in 40% (n = 4) of skin grafted group compared to 6.5% (n = 4) in the primary closure group. Flap area, operative time, and anastomosis technique were comparable between the two groups. There was no significant difference in the rates of post-operative complications including partial flap loss, complete flap loss, infection. Mean follow up time in the skin grafting group was 14.2 months and 20.2 months for the primary closure group.

Conclusion: As per the principal, a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle. However, with ongoing tissue edema skin grafting should be considered as a reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional complications and comparable post-operative outcomes.

Lower extremity injury and deformity can result from a number of etiologies. Regardless of the underlying cause, the decision to pursue amputation or reconstruction of a lower limb is challenging for both patients and practitioners. This decision is largely dependent on the patient’s premorbid health and function, functional goals and preferences, and characteristics and viability of the affected limb. The role of adaptive devices following surgery should never be underestimated. Advances in prostheses and orthoses have provided patients with a wider range of options to consider when deciding between limb reconstruction and amputation. The primary goals of any adaptive device are to improve function, prevent recurrence or ulceration of the defect, and allow for use of conventional footwear and/or clothing. When a lower extremity amputation is indicated, selection of the correct level is of critical importance in order to optimize healing potential and function. Each distinct level has certain inherent prosthetic and orthotic considerations. Likewise, the application of an adaptive device following reconstruction of the lower extremity also has demonstrable benefits and must be tailored to the specific defect and procedure performed. Knowledge of available prosthetic and orthotic options is of considerable importance for the reconstructive surgeon tasked with limb salvage or resurfacing an amputated extremity. This article reviews considerations of various types of lower extremity amputation and reconstruction, and provides a framework for the role of adaptive devices following surgery.

Aim: Mass casualty incidents (MCIs) are a devastating source of morbidity and mortality, testing the infrastructure of acute care management and challenging the ability to reconstruct limbs. Herein, we look to further a discussion on upper and lower limb reconstruction following MCIs.

Methods: Review of the literature, including our institute’s experience with the 2013 Boston Marathon Bombings, the 2015-2016 Terror Attacks in Ankara, and the 2010 earthquake in Haiti, pertaining to extremity reconstruction following MCIs.

Results: The three aforementioned case profiles highlight extremity wounds associated with MCIs and the subsequent reconstructive role of plastic surgeons. Surgical intervention or temporization of extremity wounds is a critical responsibility of plastic surgeons in this setting. Limb salvage is possible and often the preferred option following disasters.

Conclusion: Intentional or naturally occurring MCIs are a grim reality. Successful response to these events requires prompt mobilization of emergency medical staff and hospital activation. Plastic surgeons play a paramount role in multidisciplinary management of trauma with a particularly important involvement in limb reconstruction.