Research Article| Volume 50, SUPPLEMENT 5, S32-S39, December 2019

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Selecting a free flap for soft tissue coverage in lower extremity reconstruction

Published:October 21, 2019DOI:



      Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps.


      Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided.


      The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.


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        • Byrd H.S.
        • Spicer T.E.
        • Cierney 3rd., G.
        Management of open tibial fractures.
        Plast Reconstr Surg. 1985; 76: 719-730
        • Godina M.
        Early microsurgical reconstruction of complex trauma of the extremities.
        Plast Reconstr Surg. 1986; 78: 285-292
        • Kim S.W.
        • Youn S.
        • Kim J.D.
        • Kim J.T.
        • Hwang K.T.
        • Kim Y.H.
        Reconstruction of extensive lower limb defects with thoracodorsal axis chimeric flaps.
        Plast Reconstr Surg. 2013; 132: 470-479
        • Pu L.L.
        • Medalie D.A.
        • Rosenblum W.J.
        • Lawrence S.J.
        • Vasconez H.C.
        Free tissue transfer to a difficult wound of the lower extremity.
        Ann Plast Surg. 2004; 53: 222-228
        • Bajantri B.
        • Bharathi R.R.
        • Sabapathy S.R.
        Wound coverage considerations for defects of the lower third of the leg.
        Indian J Plast Surg. 2012; 45: 283-290
        • Shaw W.W.
        Microvascular free flaps. the first decade.
        Clin Plast Surg. 1983; 10: 3-20
        • Wong C.H.
        • Ong Y.S.
        • Wei F.C.
        The anterolateral thigh - Vastus lateralis conjoint flap for complex defects of the lower limb.
        J Plast Reconstr Aesthet Surg. 2012; 65: 235-239
        • Ozkan O.
        • Coskunfirat O.K.
        • Ozgentas H.E.
        The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities.
        Ann Plast Surg. 2004; 53: 455-461
        • Orseck M.J.
        • Smith C.R.
        • Kirby S.
        • Trujillo M.
        Early ambulation after microsurgical reconstruction of the lower extremity.
        Ann Plast Surg. 2018; 80: S362-S364
        • Hwang J.H.
        • Kim E.S.
        • Kim K.S.
        • Kim D.Y.
        • Lee S.Y.
        Latissimus dorsi muscle and its short perforator-based skin compound free flap.
        Ann Plast Surg. 2007; 58: 381-387
        • Germann G.
        • Bickert B.
        • Steinau H.U.
        • Wagner H.
        • Sauerbier M.
        Versatility and reliability of combined flaps of the subscapular system.
        Plast Reconstr Surg. 1999; 103: 1386-1399
        • Redett R.J.
        • Robertson B.C.
        • Chang B.
        • Girotto J.
        • Vaughan T.
        Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction.
        Plast Reconstr Surg. 2000; 106: 1507-1513
        • Chang E.I.
        • Ibrahim A.
        • Papazian N.
        • et al.
        Perforator mapping and optimizing design of the lateral arm flap: anatomy revisited and clinical experience.
        Plast Reconstr Surg. 2016; 138: 300e-306e
        • Heller L.
        • Levin L.S.
        Lower extremity microsurgical reconstruction.
        Plast Reconstr Surg. 2001; 108 (quiz 1042): 1029-1041
        • Foley W.D.
        • Stonely T.
        CT angiography of the lower extremities.
        Radiologic clinics of North America. 2010; 48 (ix): 367-396
        • Kang M.J.
        • Chung C.H.
        • Chang Y.J.
        • Kim K.H.
        Reconstruction of the lower extremity using free flaps.
        Arch Plast Surg. 2013; 40: 575-583
        • Tansini I.
        Nuovo processo per l'amputazione della mammaella per cancere.
        Riforma Med. 1896; 12: 3-5
        • Watson J.S.
        • Craig R.D.
        • Orton C.I.
        The free latissimus dorsi myocutaneous flap.
        Plast Reconstr Surg. 1979; 64: 299-305
        • Mackinnon S.E.
        • Dellon A.L.
        Technical considerations of the latissimus dorsi muscle flap: a segmentally innervated muscle transfer for facial reanimation.
        Microsurgery. 1988; 9: 36-45
        • Leckenby J.
        • Butler D.
        • Grobbelaar A.
        The axillary approach to raising the latissimus dorsi free flap for facial re-animation: a descriptive surgical technique.
        Arch Plast Surg. 2015; 42: 73-77
      1. McGraw JB, Papp C. The fleur de lis autogenous latissimus breast reconstruction, C. Hartrampf (Ed.), Breast reconstruction with living tissue, Raven Press, New York (1991)

        • OM R.
        • RK D.
        Endoscopic plastic surgery.
        Springer, New York1996
        • Al Maksoud A.M.
        • Barsoum A.K.
        • Moneer M.
        Squamous cell carcinoma of the heel with free latissimus dorsi myocutaneous flap reconstruction: case report and technical note.
        J Surg Case Rep. 2016; 2016
        • Katsaros J.
        • Schusterman M.
        • Beppu M.
        • Banis Jr., J.C.
        • Acland R.D.
        The lateral upper arm flap: anatomy and clinical applications.
        Ann Plast Surg. 1984; 12: 489-500
        • Yousif N.J.
        • Warren R.
        • Matloub H.S.
        • Sanger J.R.
        The lateral arm fascial free flap: its anatomy and use in reconstruction.
        Plast Reconstr Surg. 1990; 86 (discussion 1146-1137): 1138-1145
        • Kuek L.B.
        • Chuan T.L.
        The extended lateral arm flap: a new modification.
        J Reconstr Microsurg. 1991; 7: 167-173
        • Brandt K.E.
        • Khouri R.K.
        The lateral arm/proximal forearm flap.
        Plast Reconstr Surg. 1993; 92: 1137-1143
        • Klinkenberg M.
        • Fischer S.
        • Kremer T.
        • Hernekamp F.
        • Lehnhardt M.
        • Daigeler A.
        Comparison of anterolateral thigh, lateral arm, and parascapular free flaps with regard to donor-site morbidity and aesthetic and functional outcomes.
        Plast Reconstr Surg. 2013; 131: 293-302
        • Wei F.
        • S M.
        Lateral arm flap.
        Flaps and reconstructive surgery. Elsevier, 2017: 511-524
        • Hamdi M.
        • Coessens B.C.
        Distally planned lateral arm flap.
        Microsurgery. 1996; 17: 375-379
        • Orticochea M.
        The musculo-cutaneous flap method: an immediate and heroic substitute for the method of delay.
        Br J Plast Surg. 1972; 25: 106-110
        • Harii K.
        • Ohmori K.
        • Sekiguchi J.
        The free musculocutaneous flap.
        Plast Reconstr Surg. 1976; 57: 294-303
        • Macchi V.
        • Vigato E.
        • Porzionato A.
        • et al.
        The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study.
        Clinical Anatomy (New York, NY). 2008; 21: 696-704
        • Addosooki A.I.
        • Doi K.
        • Hattori Y.
        Technique of harvesting the gracilis for free functioning muscle transplantation.
        Tech Hand Up Extrem Surg. 2006; 10: 245-251
        • Huemer G.M.
        • Larcher L.
        • Schoeller T.
        • Bauer T.
        The free gracilis muscle flap in achilles tendon coverage and reconstruction.
        Plast Reconstr Surg. 2012; 129: 910-919
        • Penaud A.
        • Besset M.
        • Quignon R.
        • et al.
        The free gracilis muscle flap in the foot and ankle reconstructive surgery.
        Ann Chir Plast Esthet. 2014; 59: 42-52
        • Papadopoulos O.
        • Konofaos P.
        • Georgiou P.
        • et al.
        Gracilis myocutaneous flap: evaluation of potential risk factors and long-term donor-site morbidity.
        Microsurgery. 2011; 31: 448-453
        • Chicarilli Z.N.
        • Ariyan S.
        • Cuono C.B.
        Free radial forearm flap versatility for the head and neck and lower extremity.
        J Reconstr Microsurg. 1986; 2: 221-228
        • Medina 3rd., M.A.
        • Salinas H.M.
        • Eberlin K.R.
        • et al.
        Modified free radial forearm fascia flap reconstruction of lower extremity and foot wounds: optimal contour and minimal donor-site morbidity.
        J Reconstr Microsurg. 2014; 30: 515-522
        • Ozkan O.
        • Ozkan O.
        • Bektas G.
        • Cinpolat A.
        Experiences with the flow-through radial forearm flap as a bridge in lower extremity reconstruction.
        Microsurgery. 2016; 36: 128-133
        • van Kampen R.J.
        • Corten E.M.
        • Schellekens P.P.
        The split radial forearm flap for lower leg defects.
        Ann Plast Surg. 2014; 73: 535-539
        • Avery C.M.
        Review of the radial free flap: is it still evolving, or is it facing extinction? part one: soft-tissue radial flap.
        Br J Oral Maxillofac Surg. 2010; 48: 245-252
        • Song Y.G.
        • Chen G.Z.
        • Song Y.L.
        The free thigh flap: a new free flap concept based on the septocutaneous artery.
        Br J Plast Surg. 1984; 37: 149-159
        • Koshima I.
        • Fukuda H.
        • Utunomiya R.
        • Soeda S.
        The anterolateral thigh flap; variations in its vascular pedicle.
        Br J Plast Surg. 1989; 42: 260-262
        • Zhou G.
        • Qiao Q.
        • Chen G.Y.
        • Ling Y.C.
        • Swift R.
        Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations.
        Br J Plast Surg. 1991; 44: 91-96
        • Wei F.C.
        • Jain V.
        • Celik N.
        • Chen H.C.
        • Chuang D.C.
        • Lin C.H.
        Have we found an ideal soft-tissue flap? an experience with 672 anterolateral thigh flaps.
        Plast Reconstr Surg. 2002; 109 (discussion 2227-2230): 2219-2226
        • Seth A.K.
        • Iorio M.L.
        Super-Thin and suprafascial anterolateral thigh perforator flaps for extremity reconstruction.
        J Reconstr Microsurg. 2017; 33: 466-473
        • Fox P.
        • Endress R.
        • Sen S.
        • Chang J.
        Fascia-only anterolateral thigh flap for extremity reconstruction.
        Ann Plast Surg. 2014; 72: S9-13
        • Brody R.M.
        • Pandey N.C.
        • Bur A.M.
        • et al.
        Anterior lateral thigh osteomyocutaneous free flap reconstruction in the head and neck: the anterolateral thigh osteomyocutaneous femur bone flap.
        Head Neck. 2016; 38: 1788-1793
        • Colterjohn N.R.
        • Davis A.M.
        • O'Sullivan B.
        • Catton C.N.
        • Wunder J.S.
        • Bell R.S.
        Functional outcome in limb-salvage surgery for soft tissue tumours of the foot and ankle.
        Sarcoma. 1997; 1: 67-74
        • Nosrati N.
        • Chao A.H.
        • Chang D.W.
        • Yu P.
        Lower extremity reconstruction with the anterolateral thigh flap.
        J Reconstr Microsurg. 2012; 28: 227-234
        • Acar M.A.
        • Gulec A.
        • Aydin B.K.
        • Erkocak O.F.
        • Yilmaz G.
        • Senaran H.
        Reconstruction of foot and ankle defects with a free anterolateral thigh flap in pediatric patients.
        J Reconstr Microsurg. 2015; 31: 225-232
        • Hong J.P.
        • Shin H.W.
        • Kim J.J.
        • Wei F.C.
        • Chung Y.K.
        The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity.
        Plast Reconstr Surg. 2005; 115: 142-147
        • Pedersen J.
        • Song D.H.
        • Selber J.C.
        Robotic, intraperitoneal harvest of the rectus abdominis muscle.
        Plast Reconstr Surg. 2014; 134: 1057-1063
        • Pennington D.G.
        • Pelly A.D.
        The rectus abdominis myocutaneous free flap.
        Br J Plast Surg. 1980; 33: 277-282
        • Lee M.J.
        • Dumanian G.A.
        The oblique rectus abdominis musculocutaneous flap: revisited clinical applications.
        Plast Reconstr Surg. 2004; 114: 367-373
        • Reath D.B.
        • Taylor J.W.
        The segmental rectus abdominis free flap for ankle and foot reconstruction.
        Plast Reconstr Surg. 1991; 88 (discussion 829–830): 824-828
        • Buntic R.F.
        • Brooks D.
        Free partial medial rectus muscle flap for closure of complex extremity wounds.
        Plast Reconstr Surg. 2005; 116: 1434-1437
        • Sadove R.
        • Merrell J.C.
        The split rectus abdominis free muscle transfer.
        Ann Plast Surg. 1987; 18: 179-181
        • Momeni A.
        • Lanni M.
        • Levin L.S.
        • Kovach S.J.
        Microsurgical reconstruction of traumatic lower extremity defects in the pediatric population.
        Plast Reconstr Surg. 2017; 139: 998-1004
        • Korompilias A.V.
        • Lykissas M.G.
        • Vekris M.D.
        • Beris A.E.
        • Soucacos P.N.
        Microsurgery for lower extremity injuries.
        Injury. 2008; 39: S103-S108
        • Haykal S.
        • Roy M.
        • Patel A.
        Meta-analysis of timing for microsurgical free-flap reconstruction for lower limb injury: evaluation of the godina principles.
        J Reconstr Microsurg. 2018; 34: 277-292
        • Stranix J.T.
        • Anzai L.
        • Mirrer J.
        • et al.
        Dual venous outflow improves lower extremity trauma free flap reconstructions.
        J. Surg. Res. 2016; 202: 235-238
        • Stranix J.T.
        • Rifkin W.J.
        • Lee Z.H.
        • et al.
        Comparison of hand-sewn versus coupled venous anastomoses in traumatic lower extremity reconstruction.
        J Reconstr Microsurg. 2019; 35: 31-36
        • Park S.
        • Han S.H.
        • Lee T.J.
        Algorithm for recipient vessel selection in free tissue transfer to the lower extremity.
        Plast Reconstr Surg. 1999; 103: 1937-1948
        • Stranix J.T.
        • Borab Z.M.
        • Rifkin W.J.
        • et al.
        Proximal versus distal recipient vessels in lower extremity reconstruction: a retrospective series and systematic review.
        J Reconstr Microsurg. 2018; 34: 334-340
        • Zenn M.R.
        • Levin L.S.
        Microvascular reconstruction of the lower extremity.
        Semin Surg Oncol. 2000; 19: 272-281
        • McGhee J.T.
        • Cooper L.
        • Orkar K.
        • Harry L.
        • Cubison T.
        Systematic review: early versus late dangling after free flap reconstruction of the lower limb.
        J Plast Reconstr Aesthet Surg. 2017; 70: 1017-1027
        • Cao Z.M.
        • Du W.
        • Qing L.M.
        • Zhou Z.B.
        • Wu P.F.
        • Yu F.
        • Pan D.
        • Xiao Y.B.
        • Pang X.Y.
        • Liu R.
        • Tang J.Y.
        Reconstructive surgery for foot and ankle defects in pediatric patients: comparison between anterolateral thigh perforator flaps and deep inferior epigastric perforator flaps.
        Injury. Aug 2019; 50: 1489-1494
        • Noblet T.M.
        • Jackson P.C.
        • Foster P.
        • Taylor D.M.
        • Harwood P.J.
        • Wiper J.D.
        Managing soft tissues in severe lower limb trauma in an ageing population.
        Injury. 2018; 49 (Epub 2018 Mar 13. PubMed PMID:29588023): 1197-1202
        • Galal S.
        Minimally invasive plate osteosynthesis has equal safety to reamed intramedullary nails in treating gustilo-anderson type I, II and III-A open tibial shaft fractures.
        Injury. Apr 2018; 49 (Epub 2018 Mar 8. PubMed PMID:29530513): 866-870
        • Antonini A.
        • Rossello C.
        • Salomone C.
        • Riccio G.
        • Felli L.
        • Burastero G.
        The peroneus brevis flap in the treatment of bone infections of the lower limb.
        Injury. 2017; 48: S76-S79
        • Khadim M.F.
        • Emam A.
        • Wright T.C.
        • Chapman T.W.L.
        • Khan U.
        A comparison between the major trauma centre management of complex open lower limb fractures in children and the elderly.
        Injury. 2019; 50: 1376-1381
        • Demitri S.
        • Vicenti G.
        • Carrozzo M.
        • Bizzoca D.
        • De Franceschi D.
        • Moretti B.
        The masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: a case report.
        Injury. 2018; 49: S58-S62