Lower extremity reconstruction is one of the most challenging areas of plastic surgery, where surgeons must decide between limb salvage and primary amputation. This episode breaks down the principles from the PRS CME article by Reddy and Stevenson, giving residents and fellows a clear roadmap for evaluation, decision-making, and flap selection.

We start with preoperative assessment: patient comorbidities (diabetes, vascular disease, smoking), vascular status, and fracture stabilization. From there, we cover the spectrum of reconstructive options—secondary intention healing, skin grafting, local flaps, free flaps, and VAC therapy.

Key discussion includes:

• Limb salvage vs. amputation: Absolute vs. relative indications, scoring systems, and functional outcomes.

• Flap selection by anatomic thirds: Gastrocnemius and tibialis anterior for proximal third; soleus for middle third; reverse sural fasciocutaneous flap for distal third.

• Free tissue transfer pearls: When to use latissimus, rectus, gracilis, or osteocutaneous fibula flaps.

• Foot reconstruction: Weight-bearing vs. non-weight-bearing surfaces, plantar flaps, and toe fillet options.

• VAC therapy: Benefits, pitfalls, and when to use it.

• Complications: Hematoma, infection, flap failure, and osteomyelitis.

By the end, you’ll have a structured way to approach lower extremity wounds, anticipate complications, and make evidence-based decisions for limb salvage.

References:
Reddy V, Stevenson TR. Lower extremity reconstruction. Plast Reconstr Surg. 2008;121(4):1–7. doi:10.1097/01.prs.0000305928.98611.87

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