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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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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Major upper extremity amputation is one of the most devastating injuries a patient can face. Unlike lower extremity amputations where prosthetics may restore function, the upper limb remains uniquely challenging. That’s why every effort should be made to replant the amputated extremity. But replantation is only the beginning — secondary reconstructive surgery is often required to optimize function.

In this episode, we review the landmark study on secondary reconstructive surgery after major upper extremity replantation. With a survival rate of 89% in 45 patients, the average number of secondary procedures was three per patient. These procedures varied predictably based on the level of injury:

• Upper arm → Most often required soft-tissue coverage and tendon transfers.

• Proximal forearm/elbow → Free functioning muscle transfers (FFMT) were most common to restore flexion/extension.

• Distal forearm/wrist → Tenolysis dominated, followed by tendon transfers and arthrodesis.

Timing also mattered: soft-tissue coverage occurred early (within weeks), while tenolysis and tendon transfers typically occurred 1–2 years post-replant. The treatment algorithm highlights how zone of injury and level of amputation guide predictable reconstructive needs.

Key Takeaways:

1. Average 3 secondary procedures per successful replant.

2. Procedure type depends on level of amputation.

3. Soft-tissue coverage is early; tendon work often delayed.

4. FFMT is crucial for proximal-level functional restoration.

5. Functional recovery is challenging but achievable with staged strategy.

   
   

📚 References:
Fufa D, Lin CH, Lin YT, Hsu CC, Chuang CC, Lin CH. Secondary Reconstructive Surgery Following Major Upper Extremity Replantation. Plast Reconstr Surg. 2014;134(4):713–720. doi:10.1097/PRS.0000000000000538

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Hand trauma with vascular compromise demands fast and accurate decision-making. In this episode of Plastics in Practice, we review two pivotal studies shaping how we triage and manage these patients: the use of pulse oximetry for objective assessment of vascular injuries and the role of IV heparin following digital replantation.

Traditional bedside exam—capillary refill, Doppler signals, pinprick—remains subjective and operator-dependent. Tarabadkar et al. (PRS, 2015) demonstrated that pulse oximetry provides reliable, objective data:

• Digits with ≥95% SpO₂ had no ischemic injury.

• Digits ≤84% SpO₂ all required operative repair .

  This tool can reduce unnecessary transfers and streamline triage.

On the anticoagulation side, Nishijima et al. (PRS, 2019) conducted a randomized trial on unfractionated heparin after digital replantation. Their findings:

• No overall survival benefit with routine heparin.

• Higher risk of congestion/complications in the heparin group.

• Subgroup benefit for patients ≥50 years old, with significantly higher success when given heparin .

Key Takeaways:

1. Pulse ox is quick, widely available, and should be part of every vascular hand trauma triage.

2. Cutoffs: ≥95% → safe; ≤84% → surgical intervention needed.

3. Routine IV heparin post-replantation is unnecessary.

4. Consider targeted use of heparin in older patients or high-risk vascular repairs.

5. Evidence-based triage + anticoagulation = better outcomes, less morbidity.

References:

• Tarabadkar N, Iorio ML, Gundle K, Friedrich JB. Plast Reconstr Surg. 2015;136(6):1227-33. doi:10.1097/PRS.0000000000001777

• Nishijima A, Yamamoto N, Gosho M, et al. Plast Reconstr Surg. 2019;143(6):1224e-1232e. doi:10.1097/PRS.0000000000005665