title: Striving for Normalcy after Lower Extremity Reconstruction with Free Tissue: The Role of Secondary Esthetic Refinements.
abstract: BACKGROUND
  Many patients with successful lower extremity salvage have postoperative functional and esthetic concerns. Such concerns range from contour irregularity preventing proper shoe-fitting to esthetic concerns involving color, contour, and texture match. The purpose of this study is to determine the overall incidence as well as factors associated with an increased likelihood of undergoing secondary, esthetic refinements of lower extremity free flaps and to review current revision techniques.
  
  
  METHODS
  All patients undergoing lower extremity soft tissue coverage for limb salvage procedures between January 2007 and June 2013 at a single institution were included in the analysis. Patients who underwent secondary refinements for lower extremity free flaps were compared with patients not undergoing secondary procedures.
  
  
  RESULTS
  During the study period, 152 patients underwent reconstruction and were eligible for inclusion. Of these, 32 (21.1%) patients underwent secondary, esthetic revisions. Few differences in patient or case characteristics were noted, although revision patients trended toward being younger, having lower body mass index, with defects secondary to acute trauma located below the ankle. The most common revision was complex soft tissue rearrangement or surgical flap debulking/direct excision (87.5% of patients), followed by scar revision (12.5%), suction-assisted lipectomy (3.1%), laser scar revision (3.1%), and tissue expansion with local tissue rearrangement (3.1%).
  
  
  CONCLUSIONS
  A significant portion of patients desire secondary revisions following the initial procedure. This is especially true of younger patients with below ankle reconstruction. In many patients, an esthetic consideration should not be of secondary concern, but should be part of the ultimate reconstructive algorithm for lower extremity limb salvage.
authors.affiliation: Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Jonas A
authors.initials: JA
authors.lastname: Nelson
authors.affiliation: Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: John P
authors.initials: JP
authors.lastname: Fischer
authors.affiliation: Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Nicholas T
authors.initials: NT
authors.lastname: Haddock
authors.affiliation: Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Duncan
authors.initials: D
authors.lastname: Mackay
authors.affiliation: Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Wink
authors.affiliation: Division of Plastic Surgery, Temple University Hospital, Philadelphia, Pennsylvania.
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Newman
authors.affiliation: Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: L Scott
authors.initials: LS
authors.lastname: Levin
authors.affiliation: Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Kovach
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D004954:Esthetics / Q000523:psychology; D005260:Female; D058752:Free Tissue Flaps / Q000098:blood supply; D006801:Humans; D007869:Leg Injuries / Q000503:physiopathology / Q000523:psychology / Q000601:surgery*; D023821:Limb Salvage / Q000379:methods* / Q000523:psychology; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000523:psychology; D012086:Reoperation / Q000523:psychology* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D015626:Tissue Expansion / Q000379:methods; D016896:Treatment Outcome