In this episode of Plastics in Practice, we break down one of the most enduring debates in reconstructive microsurgery: Muscle vs. Fasciocutaneous (FC) flaps for lower limb trauma. For decades, residents were taught that muscle was mandatory for open fractures and osteomyelitis due to its superior vascularity and dead-space obliteration. But does the modern evidence support this?

We analyze landmark papers including the massive retrospective review by Yazar et al. and the controlled osteomyelitis study by Salgado et al., which suggest clinical equivalence between the two tissue types. We also dive into the biological nuances reviewed by Chan et al., highlighting why muscle might still hold the edge in specific scenarios—and how chimeric flaps offer a "best of both worlds" solution.

Key Takeaways for Residents:

• Debridement is King: The single most critical factor for success is not the tissue type, but the adequacy of the debridement.

• Clinical Equivalence: For distal third and ankle defects, FC flaps show statistically equivalent rates of flap survival, infection, and union compared to muscle flaps.

• The Practical Edge: FC flaps offer superior aesthetics, less donor morbidity, and are easier to re-elevate for secondary orthopedic procedures (hardware removal/bone grafting).

• Biological Nuance: Muscle tissue retains biological superiority (osteogenic potential and antimicrobial properties) for deep, complex, 3D dead spaces.

• The Chimeric Solution: Consider chimeric flaps (e.g., ALT + Vastus Lateralis) to combine biological dead-space filling with cutaneous coverage.

Citations:

1. Yazar S, Lin CH, Lin YT, et al. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle open tibial fractures. Plast Reconstr Surg. 2006;117(7):2468-2475. doi:10.1097/01.prs.0000224304.56885.c2

2. Salgado CJ, Mardini S, Jamali AA, et al. Muscle versus nonmuscle flaps in the reconstruction of chronic osteomyelitis defects. Plast Reconstr Surg. 2006;118(6):1401-1411. doi:10.1097/01.prs.0000239579.37760.92

3. Chan JK, Harry L, Williams G, Nanchahal J. Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps. Plast Reconstr Surg. 2012;130(2):284e-295e. doi:10.1097/PRS.0b013e3182589e63

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Disclaimer: This content is for educational purposes only and is not medical advice.

Foot and ankle reconstruction is a battlefield of function and form. Every subunit has its own demands — the dorsum needs thin, pliable coverage; the heel demands durable, glabrous-like skin. In this landmark PRS 2010 paper, Hollenbeck et al. applied the subunit principle to 165 free flaps, giving surgeons a blueprint for tailored, long-term reconstruction success.

Summary:This episode breaks down the seven distinct subunits of the foot and ankle, each with unique reconstructive goals. We discuss the data behind flap outcomes, limb salvage (89% at 5 years), and complication rates, including the common pitfalls like flap debulking and late ulceration — especially in the heel subunit.
We’ll explore how subunit-based flap planning improves durability, shoe-fit, and overall limb function — plus, how specific flaps like the radial forearm, ALT, and latissimus dorsi perform across zones.

Key Takeaways:

• 7 subunits = 7 reconstructive goals.

• Heel (Subunit 5) = highest instability risk.

• Mean ambulation: 3.1 months.

• Limb salvage: 89% at 5 years.

• Subunit mapping improves both form and function.

  
  

Citation:

Hollenbeck ST, Woo S, Komatsu I, et al. Longitudinal Outcomes and Application of the Subunit Principle to 165 Foot and Ankle Free Tissue Transfers. Plast Reconstr Surg. 2010;125(3):924–934. DOI: 10.1097/PRS.0b013e3181cc9630

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Orbital floor fractures are among the most common midfacial injuries—and understanding when and how to operate is key for every resident. In this episode, we break down the anatomy, evaluation, and evidence-based management of orbital blowout fractures, based on Gart & Gosain’s Plastic and Reconstructive Surgery 2014 review.

We cover:

• Mechanisms — buckling vs. hydraulic theory, and why both matter.

• Clinical findings — diplopia, enophthalmos, oculocardiac reflex.

• Timing of repair — urgent (<48 hrs) indications vs. delayed (within 2 weeks).

• Surgical approaches — transconjunctival vs. subtarsal vs. subciliary.

• Implant materials — bone grafts, porous polyethylene, titanium mesh, and resorbables.

• Pediatric nuances — trapdoor fractures, oculocardiac reflex, and growth considerations.

🔑 Key Takeaways:

1. Early repair (<48 hrs) improves outcomes in entrapment and oculocardiac reflex.

2. Enophthalmos >2 mm or >50% floor involvement = strong indication for repair.

3. Transconjunctival approach offers lowest visible scarring; avoid subciliary ectropion.

4. In children, consider resorbable materials to avoid growth restriction.

📚 Reference:
Gart MS, Gosain AK. Orbital Floor Fractures. Plast Reconstr Surg. 2014;134(6):1345–1355. DOI: 10.1097/PRS.0000000000000719

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Mandible fractures are the most common indication for surgical repair of facial fractures, and their management continues to evolve with modern plating systems and imaging.

In this episode of Plastics in Practice, we break down the key anatomy, causes, diagnostic pearls, and surgical strategies you need to know for the boards and the operating room.

We start with the anatomy of the mandible — from condyle to symphysis — and review the opposing muscle forces that make fracture management so challenging . Then we dive into epidemiology: in the U.S., interpersonal violence dominates, while motor vehicle collisions are more common worldwide .

From there, we walk through preoperative evaluation and imaging, emphasizing the role of CT over panoramic radiographs for detecting posterior fractures. We also cover timing of repair, antibiotic prophylaxis, and surgical principles: restoring occlusion, rigid vs. functional fixation, and key approaches to angle, symphysis, bilateral, condylar, comminuted, and edentulous fractures.

• Mandible fractures occur most often in men 25–34, usually from assaults or MVCs.

• CT is the gold standard for imaging.

• Early repair is ideal, but delays >72h don’t significantly raise infection risk.

• Antibiotics are recommended, but evidence for type/duration remains weak.

• Surgical principle: restore occlusion + stable fixation, tailored to fracture site.

  
  

📚 References:Morrow BT, Samson TD, Schubert W, Mackay DR. Evidence-Based Medicine: Mandible Fractures. Plast Reconstr Surg. 2014;134(6):1381–1390. doi:10.1097/PRS.0000000000000717

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Frontal sinus fractures are among the most challenging maxillofacial injuries — rare but high-stakes, with potential for meningitis, brain abscess, and lifelong sinus complications if mismanaged. In this episode of Plastics in Practice, we break down the stepwise algorithm for diagnosis and management of frontal sinus trauma.

We’ll walk through the embryology and anatomy that make these fractures unique, the critical role of the frontonasal duct, and how to decide between preservation, obliteration, or cranialization. You’ll learn the management principles for anterior vs posterior wall fractures, when to use a galeal frontalis flap, and how to recognize and prevent long-term complications such as mucopyocele formation.

Key Takeaways:

• Diagnosis: Forehead lacerations and glabellar hematomas are red flags; always evaluate with CT scans.

• Anterior wall fractures: Non-displaced can be observed; displaced require reduction and fixation.

• Posterior wall fractures: CSF leak, duct injury, or dural tear dictate sinus obliteration or cranialization.

• Frontonasal duct injury: Always mandates obliteration with grafts or flap coverage.

• Complications: Chronic infection, meningitis, contour deformities — long-term follow-up is essential.

References:

Yavuzer R, Sari A, Kelly CP, Tuncer S, Latifoglu O, Celebi MC, Jackson IT. Management of Frontal Sinus Fractures. Plast Reconstr Surg. 2005;115(6):79e–93e. doi:10.1097/01.PRS.0000161988.06847.6A

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Zygoma fractures are among the most common midfacial injuries, directly impacting both function and aesthetics. For plastic surgery residents, mastering the anatomy, evaluation, and surgical management of these fractures is essential.

In this episode of Plastics in Practice, we break down the essentials of zygoma fractures. From the quadripod anatomy of the zygomaticomaxillary complex to the clinical signs of malar flattening, trismus, and infraorbital nerve paresthesia, we review how to approach diagnosis and treatment. We cover preoperative imaging and timing, operative approaches from transconjunctival to coronal, and fixation strategies tailored to fracture severity. Key complications, including enophthalmos, infraorbital nerve dysfunction, and lid malposition, are highlighted with strategies for prevention and management.

Takeaways:

• Anatomy: Zygoma as a quadripod with five fixation points .

• Evaluation: Pain, diplopia, malar flattening, sensory changes .

• Timing: Ideally within 1–2 weeks; earlier for children .

• Approaches: Gingivobuccal sulcus, transconjunctival, coronal .

• Complications: Retrobulbar hematoma, enophthalmos, nerve injury .

References:

Ellstrom CL, Evans GRD. Zygoma Fractures. Plast Reconstr Surg. 2013;132(6):1649–1657. doi:10.1097/PRS.0b013e3182a80819

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Middle and distal leg defects can be among the most challenging reconstructive problems in plastic surgery. But what if you could avoid microsurgery and still achieve reliable “like-with-like” coverage?

In this episode, we break down the principles, technique, and outcomes of perforator propeller flaps for lower extremity reconstruction. Drawing from the landmark PRS Global Open article by Mendieta et al. (2018), we discuss their series of 28 patients in Nicaragua and how local propeller flaps performed in small-to-medium defects of the mid and distal leg. These flaps preserve the major vascular axes, avoid the morbidity of muscle sacrifice, and eliminate the need for microsurgical anastomosis.

Key technical pearls include the two-centimeter pedicle dissection rule, use of handheld Doppler for flap planning, and ensuring tension-free inset. We’ll also cover complication rates (14% in this series, mostly partial necrosis), predictors of success, and when skin grafts for donor site closure may be necessary.

Takeaways:

• Preserve the main arteries and muscle—propeller flaps provide “like-with-like” coverage.

• Most are based on a single perforator (posterior tibial in 50% of cases).

• Up to 180° rotation is possible with careful dissection.

• Donor site can be closed primarily in most cases (85.7%).

• Complication rates are acceptable and comparable to free flaps.

References:Mendieta M, Cabrera R, Siu A, et al. Perforator Propeller Flaps for the Coverage of Middle and Distal Leg Soft-tissue Defects. Plast Reconstr Surg Glob Open. 2018;6:e1759. doi:10.1097/GOX.0000000000001759

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When faced with high-energy lower extremity trauma, the question of salvage versus amputation is one of the toughest decisions in reconstructive surgery. This episode breaks down the evidence and provides practical pearls for plastic surgery residents and trainees.

We walk through the landmark LEAP study and subsequent meta-analyses comparing functional outcomes between limb salvage and early amputation. We also review flap timing (Godina’s “within 72 hours” principle), the evolving role of negative pressure wound therapy, and flap selection strategies based on leg thirds. Importantly, we highlight cost-utility data and long-term functional results that shape how we counsel patients.

Key Takeaways:

• Injury severity scores should not be the sole factor in amputation decisions.

• Early flap coverage (<72 hrs) reduces infection risk, but negative pressure therapy can buy safe time.

• Limb salvage success rates approach 95% in modern free tissue transfer.

• Salvage and amputation yield similar long-term function, but salvage often carries higher complication and rehospitalization rates.

• Cost-utility analysis favors salvage for Gustilo IIIB/C fractures, especially in younger patients.

References:
Medina ND, Kovach SJ, Levin LS. An Evidence-Based Approach to Lower Extremity Acute Trauma. Plast Reconstr Surg. 2011;127(2):926-931. doi:10.1097/PRS.0b013e3182046a16

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