Muscle, Skin, & Bones – Principles of Lower Extremity Reconstruction

by Jacqueline Israel, MD

Lower extremity salvage after traumatic injury requires a team approach, with the motivated patient positioned at the team’s center [1]. I recently observed this while rotating on Orthopedic Trauma, during which we are taught principles of fracture care and soft tissue coverage that are essential to facilitating optimal recovery. The Lower Extremity collection in the PRS Resident Reader consists of 5 articles that emphasize these principles and review the multidisciplinary nature of lower extremity reconstruction.

The first article in the collection, “Perineal and Lower Extremity Reconstruction” by Hollenbeck at al, is a well-organized CME review of reconstructive options for the perineum and leg. A unique aspect of this paper is that it reviews soft tissue reconstruction of the foot and ankle, and divides this region into subunits to facilitate a better understanding of reconstructive options depending on the functional demands, skin characteristics, and aesthetic considerations of each subunit.IsraelFeet1

Figure 1. Image from Hollenbeck et al, demonstrating the six subunits of the foot and ankle [2].

In the second article, “Evidence-Based Medicine: Lower Extremity Acute Trauma,” Dr. Geoffrey Hallock reviews reconstructive options and perioperative considerations in the context of levels of evidence. Hallock emphasizes the need for a clean wound prior to reconstruction: “Three words aptly summarize what is needed – debridement, debridement, and then more debridement” [2]. A strength of this article is its supplemental digital content, with videos that review flap considerations based on location and size.


Figure 2. Image from Hallock et al, illustrating how one can divide the lower leg into “thirds” when considering reconstructive options [3].

The third paper, “Angiosomes of the Foot and Ankle and Clinical Implications for Limb Salvage: Reconstruction, Incisions, and Revascularization” by Attinger et al, is an anatomic paper that reviews the arterial supply of the ankle and foot. The authors performed 50 cadaver dissections and used colored methyl methacrylate to characterize 6 angiosomes of this region. A particularly useful aspect of this article is the section entitled, “Using the principles of angiosomes to make safe incisions in normal and vascularly compromised patients.” Trainees will also find it helpful to review Doppler probe techniques to characterize flow in distal vessels.


Figure 3. One of the images of the cadaver studies in Attinger at al [4].

The MOS-PS(SM) CME article, “Lower Extremity Reconstruction” by Reddy and Stevenson, outlines preoperative planning, goals for limb salvage, and postoperative complications in a systematic, organized way that is beneficial to any resident or plastic surgeon seeking a detailed yet efficient review. This paper also includes a helpful table of common CPT codes.


Figure 4. from Reddy and Stevenson [5].

Finally, the fifth paper in this collection, “The Role of Microsurgery in Lower Extremity Reconstruction” describes microsurgical techniques when pedicled flaps are not feasible for adequate reconstruction. Soft tissue coverage, bony reconstruction of large long-bone defects (e.g. contralateral free fibula flap, see Figure 5), muscle transfer to restore function, and reconstruction of the foot to restore weight-bearing surfaces are all discussed [6]. Engel and his colleagues invite the reader to consider future trends in lower extremity reconstruction, namely the development of standardized outcomes tools, the use of new technology to design more advanced prostheses, and the growing role of vascularized composite allotransplantation in the setting of extremity injury [6].


Figure 5. Free fibula osteoseptocutaneous flap from Engel et al [6].

In summary, the following principles are recurring themes emphasized in this collection:

  1. The choice to pursue extremity salvage versus amputation should be individualized.
  2. Exposed bone, blood vessels, and nerves require stable soft tissue coverage.
  3. Adequate blood supply is essential for healing and successful reconstruction.
  4. Prior to reconstruction, wounds should be debrided and free of infection, and fractures should be addressed.
  5. The lower leg can be divided into thirds when considering options for local and free tissue coverage.

The Lower Extremity collection is an excellent, comprehensive resource for residents and students. To further expand this collection, one could consider including resources that describe the technical aspects of commonly used flaps, such as the gastrocnemius muscle flap [7].


Most articles cited in this blog can be found in one convenient location The Resident Reader: Reconstruction- Lower Extremity collection.

  1. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-92.
  2. Hollenbeck ST, Toranto JD, Taylor BJ, et al. Perineal and Lower Extremity Reconstruction. Plast Reconstr Surg November 2011;128(5):551e-562e
  3. Hallock GG. Evidence-Based Medicine: Lower Extremity Acute Trauma. Plast Reconstr Surg December 2013;132(6):1733-41.
  4. Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the Foot and Ankle and Clinical Implications for Limb Salvage: Reconstruction, Incisions, and Revascularization. Plast Reconstr Surg June 2006; 117(7S):261S-91S.
  5. Reddy V, Stevenson TR. MOC-PS CME Article: Lower Extremity Reconstruction. Plast Reconstr Surg April 2008; 121(4):1-7.
  6. Engel H, Lin C, Wei F. Role of Microsurgery in Lower Extremity Reconstruction. Plast Reconstr Surg January 2011;127(1S):228S-36S.
  7. McCraw JB, Fishman JH, Sharzer LA. The Versatile Gastrocnemius Myocutaneous Flap. Plast Reconstr Surg 1978;62(1):15-23.

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