Soft Tissue Reconstruction in the Extremities: Principles, Techniques, and Outcomes

Che-Hsiung Lee; Shih-Heng Chen

doi:10.1055/s-0045-1809975

Seminars in Plastic Surgery, Inhaltsverzeichnis

Semin Plast Surg 2025; 39(03): 140-148
DOI: 10.1055/s-0045-1809975

Review Article

Soft Tissue Reconstruction in the Extremities: Principles, Techniques, and Outcomes

Authors

Che-Hsiung Lee

¹Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan

²Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Shih-Heng Chen

¹Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan

²Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Abstract

Soft tissue reconstruction in the extremities is complicated by the fact that injuries often involve composite defects of skin, muscle, tendon, nerve, and bone. In both the upper and lower limbs, achieving reliable soft tissue coverage, restoring function, and reducing complications are critical goals. The upper extremity requires precision and fine manipulation, whereas the lower limb should be reconstructed to support weight-bearing and mobility. Free flaps have become a routine part of the surgical armamentarium, offering flexible solutions tailored to different needs. Donor sites in the lower extremities are favored due to the availability of high-quality tissue, minimal visible scarring, and the possibility of a two-team approach. Careful planning not only improves wound healing but also accelerates rehabilitation and reduces the need for revision surgeries, underscoring the importance of flap choice, anatomical knowledge, and surgical skill.

Keywords

soft tissue coverage - extremity reconstruction - free flaps - functional restoration

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Referenzen

References
1 Wink JD, Gandhi RA, Ashley B, Levin LS. Flap reconstruction of the hand. Plast Reconstr Surg 2020; 145 (01) 172e-183e
2 Wu RT, Lin C-H, Hsu C-C, Wei F-C. Evolution of free flap reconstruction in the upper extremity: perspective from a tertiary plastic and reconstructive institution. J Hand Surg Eur Vol 2024; 49 (01) 8-16
3 Harrison BL, Lakhiani C, Lee MR, Saint-Cyr M. Timing of traumatic upper extremity free flap reconstruction: a systematic review and progress report. Plast Reconstr Surg 2013; 132 (03) 591-596
4 Benanti E, De Santis G, Leti Acciaro A, Colzani G, Baccarani A, Starnoni M. Soft tissue coverage of the upper limb: A flap reconstruction overview. Ann Med Surg (Lond) 2020; 60: 338-343
5 Chim H, Ng ZY, Carlsen BT, Mohan AT, Saint-Cyr M. Soft tissue coverage of the upper extremity: an overview. Hand Clin 2014; 30 (04) 459-473 , vi
6 Farrelly E, Tarapore R, Lindsey S, Wieland MD. Management of the mangled extremity. Surg Clin North Am 2024; 104 (02) 385-404
7 Ng ZY, Salgado CJ, Moran SL, Chim H. Soft tissue coverage of the mangled upper extremity. Semin Plast Surg 2015; 29: 48-54 . Thieme Medical Publishers.
8 Neumeister M, Hegge T, Amalfi A, Sauerbier M. The reconstruction of the mutilated hand. Semin Plast Surg 2010; 24: 077102 . Thieme Medical Publishers.
9 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
10 Kolbenschlag J, Klinkenberg M, Hellmich S, Germann G, Megerle K. Impact of timing of admission and microvascular reconstruction on free flap success rates in traumatic upper extremity defects. J Reconstr Microsurg 2015; 31 (06) 414-419
11 Alphonsus CK. Principles in the management of a mangled hand. Indian J Plast Surg 2011; 44 (02) 219-226
12 Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg 1987; 80 (01) 1-14
13 Yazar S, Lin C-H, Wei F-C. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004; 114 (06) 1457-1466
14 Cholok D, Saberski E, Lowenberg DW. Approach to complex lower extremity reconstruction. Semin Plast Surg 2022; 36: 233-242 . Thieme Medical Publishers, Inc.
15 Jeyaratnam S, Sebastin SJ, Das De S. Revisiting the reconstructive ladder for soft tissue reconstruction in the lower extremity. Ann Transl Med 2024; 12 (01) 7
16 Khan M, Hayat W, Khan N, Ullah H, Ali Q, Khan R. Soft tissue reconstruction of thumb: Classification of defects and standardization of treatment. Pol Przegl Chir 2022;95(04):0
17 Chen H-C, Buchman MT, Wei F-C. Free flaps for soft tissue coverage in the hand and fingers. Hand Clin 1999; 15 (04) 541-554
18 Muneuchi G, Suzuki S, Ito O, Kawazoe T. Free anterolateral thigh fasciocutaneous flap with a fat/fascia extension for reconstruction of tendon gliding surface in severe bursitis of the dorsal hand. Ann Plast Surg 2002; 49 (03) 312-316
19 Mih AD. Pedicle flaps for coverage of the wrist and hand. Hand Clin 1997; 13 (02) 217-229
20 Hsu C-C, Loh CYY, Wei F-C. The anterolateral thigh perforator flap: its expanding role in lower extremity reconstruction. Clin Plast Surg 2021; 48 (02) 235-248
21 Lin C-H, Zhu Z-S, Lin C-H, Hsu C-C, Yeh J-T, Lin Y-T. Primary free functioning muscle transfer for fingers with accompanying tendon transfer for thumb provide one-stage upper extremity composite reconstruction in acute open wound. J Trauma Acute Care Surg 2012; 72 (03) 737-743
22 Velazquez C, Whitaker L, Pestana IA. Degloving soft tissue injuries of the extremity: characterization, categorization, outcomes, and management. Plast Reconstr Surg Glob Open 2020; 8 (11) e3277
23 Hsu W-M, Wei F-C, Lin C-H, Chen H-C, Chuang C-C, Chen H-T. The salvage of a degloved hand skin flap by arteriovenous shunting. Plast Reconstr Surg 1996; 98 (01) 146-150
24 Lo S, Lin Y-T, Lin C-H, Wei FC. A new classification to aid the selection of revascularization techniques in major degloving injuries of the upper limb. Injury 2013; 44 (03) 331-335
25 Rodríguez-Lorenzo A, Lin C-H, Lin C-H, Ching W-C, Lin Y-T. Replantation of a degloved hand with added arteriovenous anastomoses: report of two cases. J Hand Surg Am 2009; 34 (10) 1864-1867
26 Lin C-H, Lin Y-T, Sassu P, Lin C-H, Wei F-C. Functional assessment of the reconstructed fingertips after free toe pulp transfer. Plast Reconstr Surg 2007; 120 (05) 1315-1321
27 Huang R-W, Chi M-C, Hsieh Y-H. et al. Comparing innervated and non-innervated glabrous skin flaps for volar digital defects: Insights from patient-reported outcomes. Plast Reconstr Surg 2021; 10: 1097
28 Lin Y-T, Henry SL, Lin C-H. et al. The shunt-restricted arterialized venous flap for hand/digit reconstruction: enhanced perfusion, decreased congestion, and improved reliability. J Trauma 2010; 69 (02) 399-404
29 Lin Y-T, Hsu C-C, Lin C-H, Loh CYY, Lin C-H. The position of ‘shunt restriction’ along an arterialized vein affects venous congestion and flap perfusion of an arterialized venous flap. J Plast Reconstr Aesthet Surg 2016; 69 (10) 1389-1396
30 Roberts JM, Carr LW, Haley CT, Hauck RM, Michelotti BF. Venous flaps for revascularization and soft-tissue coverage in traumatic hand injuries: a systematic review of the literature. J Reconstr Microsurg 2020; 36 (02) 104-109
31 Akdeniz Doğan ZD, Çavuş Özkan M, Tuncer FB, Saçak B, Çelebiler Ö. A comparative clinical study of flap thickness: medial sural artery perforator flap versus anterolateral thigh flap. Ann Plast Surg 2018; 81 (04) 472-474
32 Kim HB, Min JC, Pak CJ, Hong JPJ, Suh HP. Maximizing the versatility of thin flap from the groin area as a workhorse flap: the selective use of superficial circumflex iliac artery perforator (SCIP) free flap and superficial inferior epigastric artery (SIEA) free flap with precise preoperative planning. J Reconstr Microsurg 2023; 39 (02) 148-155
33 Hsieh Y-H, Wei H-I, Hsu C-C, Lin C-H. Evolution and diversity of medial sural artery perforator flap for hand reconstruction. Hand Clin 2024; 40 (02) 209-220
34 Goh TLH, Park SW, Cho JY, Choi JW, Hong JP. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap–a review of 210 cases. Plast Reconstr Surg 2015; 135 (02) 592-601
35 Lin C-H, Wei F-C, Lin Y-T, Chen C-T. Composite palmaris longus-venous flap for simultaneous reconstruction of extensor tendon and dorsal surface defects of the hand–long-term functional result. J Trauma 2004; 56 (05) 1118-1122
36 Yeh HK, Fang F, Lin Y-T, Lin C-H, Lin C-H, Hsu C-C. The effect of systemic injury score on the decision making of mangled lower extremities. Injury 2016; 47 (10) 2127-2130
37 Kugach K, Apel PJ. Soft tissue coverage for foot and ankle trauma. Clin Podiatr Med Surg 2024; 41 (03) 593-606
38 Wong JK, Deek N, Hsu C-C, Chen H-Y, Lin C-H, Lin C-H. Versatility and “flap efficiency” of pedicled perforator flaps in lower extremity reconstruction. J Plast Reconstr Aesthet Surg 2017; 70 (01) 67-77
39 Hsiao J-C, Zelenski NA, Tseng Y-J. et al. Evaluating resource utilization with free or pedicled perforator flaps in distal leg reconstruction. J Reconstr Microsurg 2023; 39 (06) 462-471
40 Lin C-H, Hsieh Y-H, Lin C-H. The medial sural artery perforator flap in lower extremity reconstruction. Clin Plast Surg 2021; 48 (02) 249-257
41 Lee C-H, Chang NT, Hsiao J-C. et al. Extended use of chimeric medial sural artery perforator flap for 3-dimensional defect reconstruction. Ann Plast Surg 2019; 82 (1S Suppl 1): S86-S94
42 Lu T-C, Lin C-H, Lin C-H, Lin Y-T, Chen R-F, Wei F-C. Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg 2011; 64 (03) 386-393
43 Kuo Y-R, Yeh M-C, Shih H-S. et al. Versatility of the anterolateral thigh flap with vascularized fascia lata for reconstruction of complex soft-tissue defects: clinical experience and functional assessment of the donor site. Plast Reconstr Surg 2009; 124 (01) 171-180
44 Sakarya AH, Tsai K-Y, Hsu C-C. et al. Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions. J Plast Reconstr Aesthet Surg 2022; 75 (05) 1557-1566
45 Kuo Y-R, Seng-Feng J, Kuo FM, Liu Y-T, Lai P-W. Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases. Ann Plast Surg 2002; 48 (02) 161-166
46 Kuo Y-R, Jeng S-F, Kuo M-H. et al. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. Plast Reconstr Surg 2001; 107 (07) 1766-1771
47 Hung S-Y, Loh CYY, Chen H-C. Supercharging extra-large anterolateral thigh flaps for single-stage resurfacing of massive burn defects over upper extremity elbow joints. J Burn Care Res 2018; 39 (05) 831-834
48 Tsai J, Liao HT, Wang PF, Chen CT, Lin CH. Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement. Microsurgery 2013; 33 (05) 342-349
49 Wong C-H, Ong YS, Wei F-C. Revisiting vascular supply of the rectus femoris and its relevance in the harvest of the anterolateral thigh flap. Ann Plast Surg 2013; 71 (05) 586-590
50 Cheng M-H, Ulusal BG, Wei F-C. Reverse first dorsal metatarsal artery flap for reconstruction of traumatic defects of dorsal great toe. J Trauma 2006; 60 (05) 1138-1141
51 Lin CH, Zelken J, Hsu CC, Lin CH, Wei FC. The distally based, venous supercharged anterolateral thigh flap. Microsurgery 2016; 36 (01) 20-28
52 Yazar S, Lin C-H, Lin Y-T, Ulusal AE, Wei F-C. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006; 117 (07) 2468-2475 , discussion 2476–2477
53 Lin C-H, Lin Y-T, Yeh J-T, Chen C-T. Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect. Plast Reconstr Surg 2007; 119 (07) 2118-2126
54 Zelken JA, Lin C-H. An algorithm for forefoot reconstruction with the innervated free medial plantar flap. Ann Plast Surg 2016; 76 (02) 221-226
55 Jeng S-F, Shih H-S, Papadakis M. Plantar forefoot reconstruction: A proposal of a management algorithm based on a case series analysis: Plantar forefoot reconstruction. J Plast Reconstr Aesthet Surg 2022; 75 (01) 173-182
56 Koster ITS, Borgdorff MP, Jamaludin FS, de Jong T, Botman M, Driessen C. Strategies following free flap failure in lower extremity trauma: a systematic review. JPRAS Open 2023; 36: 94-104
57 Geeroms M, Lu Y-J, Hsu C-C, Huang R-W, Lin C-H, Lin C-H. Perfusion dynamics during secondary flap debulking with liposuction. J Reconstr Microsurg 2024; 40 (06) 423-434
58 Lin T-S, Jeng S-F, Chiang Y-C. Resurfacing with full-thickness skin graft after debulking procedure for bulky flap of the hand. J Trauma 2008; 65 (01) 123-126