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Post-traumatic defects of the distal third of the leg often require skipping a few steps of the well-established reconstructive ladder, due to the limited local reliable reconstructive options. In rare cases, the reconstructive plan and flap choice may encounter challenges when the patient has psychiatric illness affecting compliance with postoperative care. We describe a case of a patient with severe intellectual disability and an open fracture of the distal lower limb. After fracture management and debridement of devitalized tissues, the resultant soft tissue defect was covered with a free gracilis flap. On postoperative day 7, the patient ripped out the newly transplanted flap. The flap was too traumatized for salvage, so a contralateral free gracilis muscle flap was used. The patient showed good aesthetic and functional outcomes at a 1-year follow-up. When planning the postoperative management of patients with psychiatric illness, less complex and more robust procedures may be preferred over a long and complex surgical reconstruction requiring good compliance with postoperative care. The medical team should be aware of the risk of postoperative collapse, focus on the prevention of pain, and be wary of drug interactions. Whenever necessary, free tissue transfer should be performed despite potential compliance issues. [ABSTRACT FROM AUTHOR]

We then elaborated a stepwise approach, combining lymphatic surgery principles and plastic surgery flap techniques, that lead to an effective treatment algorithm where surgical options were wound-tailored to guarantee the best functional outcomes. Literature outcomes of surgical treatment (specifically lymphatic ligation ± muscle flaps) were compared with conservative therapy. [2] Importantly, authors screened the literature in the aim to match patient's conditions and preoperative risk factors to the leak treatment, defining a clear treatment algorithm. [Extracted from the article]