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Foot Reconstruction Treatment & Management

  • Author: Fabio Santanelli di Pompeo, MD, PhD; Chief Editor: Jorge I de la Torre, MD, FACS  more...
 
Updated: Apr 23, 2015
 

Surgical Therapy

The following table summarizes the most common surgical options according to dimensions, extension, and localization of the defect.[14, 15, 16]

Table 3. Surgical Options for Foot Reconstruction (Open Table in a new window)

Dimension Extension Localization Type of Flap
< 3 cm2 Soft tissue Weightbearing areas Local flap
< 3 cm2 Soft tissue Nonweightbearing areas Skin grafts
>3 cm2 Soft tissue Weightbearing areas Free flap (free fasciocutaneous, musculocutaneous flaps, muscle free flap plus skin graft)
>3 cm2 Soft tissue and bone loss Weightbearing areas Free osteocutaneous flap
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Local Flaps

Sole

See the list below:

  • Medial plantar flap (instep flap [2] )
    • Sensitive cutaneous flap harvested from nonweightbearing (NWB) area of the sole
      Medial plantar flap, instep flap (O'Brien and Shan Medial plantar flap, instep flap (O'Brien and Shanahan, 1979).
    • Maximum dimensions - 10 X 7 cm
    • Pedicle - Medial plantar artery either proximal or distally based
    • Arc of rotation - Defect of calcaneum, medial malleolar area, distal weightbearing (WB) areas on the heads of metatarsus
  • Transposition, rotation, and V-Y skin flaps [1]
    • Sensitive fasciocutaneous or cutaneous flaps to cover WB areas
    • Defects less than 3 cm2, with random vascularization
  • Flexor brevis digitorum
    • Muscular flap localized under the plantar aponeurosis, indicated to cover small bone exposure (A sensitive myocutaneous flap also can be harvested.)
    • Pedicle - Lateral plantar artery
    • Arc of rotation - Defect of calcaneum and of medial malleolar area
  • Abductor brevis hallucis
    • Muscular flap along the medial border of the foot
    • Pedicle - Branches from the medial plantar artery
    • Arc of rotation - Medial area of the calcaneum
  • Abductor brevis minimi dita
    • Muscular flap along the lateral border of the foot, larger than the abductor brevis hallucis
    • Pedicle - Branches from the lateral plantar artery
    • Arc of rotation - Lateral area of the calcaneum
  • Flexor brevis hallucis
    • Muscular flap that can be harvested alone or with the abductor brevis hallucis from the medial forefoot margin
    • Pedicle - Medial plantar artery and first web space artery
    • Arc of rotation - Dorsum of the foot, distal forefoot sole on the medial side
  • Island flaps from the toes
    • Sensitive fasciocutaneous flaps from the plantar side of the toes
    • Difficult dissection
    • Pedicle - Digitalis artery
    • Arc of rotation - Distal WB areas on the heads of metatarsus

A study by Struckmann et al indicated that both free and pedicled flaps are equally suitable for the reconstruction of plantar tissue defects. The study, in which 12 free flaps and nine pedicled flaps were used, found that the two flap types yielded essentially the same functional results.[17]

Dorsum

See the list below:

  • Dorsalis pedis flap [4]
    • Sensitive fasciocutaneous flap or a myocutaneous flap (including the extensor brevis digitorum muscle) that can be harvested from the dorsum of the foot
      Dorsalis pedis flap, described by McCraw and Furlo Dorsalis pedis flap, described by McCraw and Furlow (1975).
    • Pedicle - Dorsalis pedis artery, which is the terminal branch of the anterior tibialis artery
    • Arc of rotation - Medial or lateral dorsal area, malleolar areas
  • First web space (Gilbert and Morrison, 1975)
    • Fasciocutaneous sensitive flap harvested from the first web space
    • Very small dimensions
    • Pedicle - First web space artery, which is the terminal branch of the dorsalis pedis artery
    • Arc of rotation - Distal dorsum

Medial side

See the list below:

  • Medialis pedis flap [5]
    • Fasciocutaneous flap harvested on the anterior medial axis of the foot
      Medialis pedis flap described by Masquelet (1990). Medialis pedis flap described by Masquelet (1990).
    • Pedicle - Myocutaneous perforator branches from the medial plantar artery
    • Arc of rotation - Medial malleolar area, Achilles tendon

Lateral side

See the list below:

  • Lateral calcaneal flap [3]
    • Cutaneous sensitive flap below the lateral malleolar area along the lateral side of the foot
      Lateral calcaneal artery skin flap, described by G Lateral calcaneal artery skin flap, described by Grabb and Argenta (1981).
    • Pedicle - Lateral calcaneal artery, which is the terminal branch of the peroneal artery; reinnervation is provided by branches from the sural nerve
    • Arc of rotation - Achilles tendon and lateral malleolar area

Lower one third of the leg

See the list below:

  • Sural flap [18]
    • Sensitive fasciocutaneous flap harvested from the posterior area of the leg
      Sural flap; perforator flap from peroneal artery; Sural flap; perforator flap from peroneal artery; described by Donski and Fogdestam, 1983.
    • Pedicle - Sural artery, branch of the peroneal artery
    • Arc of rotation - Achilles tendon and lateral malleolar area
  • Perforator flap from posterior tibialis artery
    • Fasciocutaneous flap along the axis between soleus and flexor longus digitorum muscles
      Perforator flap from the peroneal artery. Perforator flap from the peroneal artery.
    • Pedicle - Septocutaneous branches from the posterior tibialis artery
    • Arc of rotation - Medial malleolar area, calcaneum, proximal area of the dorsum
  • Reverse dermis or fascia flap of the lower leg [19]
    • Dermal or fascia flap harvested from the posterior area of the leg to be skin grafted
    • Pedicle - Random
    • Arc of rotation - Calcaneum, Achilles tendon
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Free Flaps for the Foot

Perforator

See the list below:

  • Thoracodorsal artery perforator flap (TDAP) [20]
    • Reliable skin flap, thick skin flap more similar to the skin of the foot
    • Advantages - No donor-site morbidity, long vascular pedicle (>18 cm)
    • Disadvantages - Small diameter of the vessels
    • Pedicle - Perforator of the thoracodorsal artery
  • Anterolateral thigh perforator flap [21]
    • Reliable skin flap
    • Advantages - No donor-site morbidity, large pliable skin flap and sufficient bulk
    • Disadvantages - Small diameter of the vessels
    • Pedicle - Perforator from the descending branch of the lateral femoral circumflex artery
  • Anterolateral leg perforator flaps [22]
    • Advantages - Consistent reliable blood supply and good texture
    • Disadvantages - Small dimensions if direct closure of the donor area is required, small diameter of the vessls, donor-site morbidity, thin skin
    • Pedicle - Superficial peroneal perforators, inferior superficial peroneal artery perforators

Cutaneous

See the list below:

  • Groin flap (Daniel and Taylor, 1973)
    • First flap that was used to reconstruct a defect of the calcaneum
    • Iliac crest region as a donor area allows large flap harvest (30 X 15 cm) with direct closure
    • Disadvantages - Difficult dissection in overweight patients and small diameter vessels
    • Pedicle - Superficial iliac circumflex artery
  • Scapular [8]
    • Can be harvested from the infraspinosa fossa of the scapula
    • Advantages - Easy dissection, long pedicle, large diameter of vessels, direct closure of donor area, possibility of composite flaps combining other muscle flaps
    • Disadvantages - Thickness of the flap and difficult reinnervation
    • Pedicle - Circumflex artery of the scapula
  • Parascapular [23]
    • Harvested in the same area as the scapular flap
    • Shares similar advantages and disadvantages
    • Pedicle - Descendant branch of the circumflex artery of the scapula

Fasciocutaneous

See the list below:

  • Radial (Chang, 1978)
    • Most versatile and used free flap for foot reconstruction that now often is harvested as a pure cutaneous flap
    • Advantages - Easy dissection, long pedicle with large diameter vessels, reinnervation through cutaneous antibrachial nerves, and possibility to combine bone
    • Disadvantages - Mainly due to donor area morbidity that must be closed with a graft
    • Pedicle - Radial artery
  • Lateral arm [10]
    • Thin and small flap that can be harvested from the anterior-lateral area of the lower one third of the arm
    • Advantages - Easy dissection and reinnervation
    • Disadvantages - Small dimensions if direct closure of the donor area is required and small diameter of the vessels
    • Pedicle - Septocutaneous branches from the brachialis profunda artery
  • Dorsalis pedis [7]
    • Previously described as a local flap; also can be harvested as a free flap, but its small dimensions and its pedicle, which is one of the main arteries of the foot, make it a second choice flap
    • Pedicle - Dorsalis pedis artery

Muscular

See the list below:

  • Latissimus dorsi [6]
    • Can be harvested as a pure muscle flap or as a myocutaneous flap; together with the radial flap, often is used for the foot
    • Advantages - Large dimension, easy dissection, long pedicle, and large diameter of the vessels
    • Main disadvantages - Thickness of the flap, which decreases in at least 6 months time, and sacrifice of major muscle
    • Pedicle - Thoracodorsal artery
  • Gracilis (Tamai, 1971)
    • Muscular or myocutaneous flap (only a small skin paddle) that can be harvested from the medial side of the thigh
    • Easy dissection, vessel diameter of approximately 2 mm, and length of approximately 6 cm
    • Donor area can be closed directly without functional defect; rarely used for the foot
    • Pedicle - Medial circumflex of femoris artery
  • Anterior serratus
    • Muscular flap that is harvested in the lateral side of the truncus
    • Advantages - No sacrifices of significant muscle such as latissimus dorsi, possibility to combine with other flaps, direct closure of the donor area, and long pedicle
    • Main disadvantage - Difficult dissection
    • Pedicle - Branch from thoracodorsal artery

Osteocutaneous

See the list below:

  • Iliac crest [12]
    • Already described as a cutaneous flap; also can be harvested with the bone; includes a double pedicle and a difficult dissection
    • Usually suggested for calcaneum loss or whenever a large amount of bone is required
    • Donor area always closed directly but usually painful in the postoperative period
    • Pedicle - For the bone, profundus iliac circumflex artery; for the skin paddle, superficial iliac circumflex artery
  • Fibula [11]
    • Long and hard bone of the leg that can be harvested for almost all of its length, except for the last 5 cm, without functional impairment
    • More suitable for metatarsal bone loss
    • Dissection not easy for the septocutaneous branches that support the skin paddle
    • Soleus muscle also can be included in the flap
    • Pedicle - Peroneal artery
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Preoperative Details

Evaluation of foot injuries mainly must consider the following:

  • Amount of tissue loss (dimension and extension of the defect)
  • Localization (WB or NWB areas)
  • Neurovascular damage

Consider etiology of the defect, age of the patient, concomitant diseases, concomitant leg fracture, and working activity.

A meticulous planning of the defect to be reconstructed can be accomplished with a pattern.

In free flaps, the choice of the recipient vessels depends on the vascular condition of the foot and leg.

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Intraoperative Details

See the list below:

  • In patients with limited defects, position the patient supine or prone according to the location of the defect.
  • For major surgical treatment, position the patient according to both the location of the defect and the type of reconstruction to allow simultaneous flap harvest and preparation of the recipient area.
  • Extend the debridement of the defect to vital tissues.
  • Check the actual size of the loss after the debridement.
  • With free flaps, verify the condition of the recipient vessels under magnification.
  • The harvest of the flap can be performed under tourniquet with osteocutaneous flaps such as the fibula.
  • Raise the flap and transfer it to fill the gap.
  • Use drains whenever necessary.
  • Close the donor area according to the surgeon's preference.
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Postoperative Details

See the list below:

  • Position the patient, possibly on an air or water mattress, with both legs slightly elevated.
  • Monitor the viability of the flap in the early postoperative period according to the reconstructive procedure.
  • For free flaps, monitor every 2 hours in the first 2 days and 4 times per day until 2 weeks postoperatively with the aid of a Doppler probe to check the patency of the microanastomosis and to survey the skin or muscle island.
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Follow-up

See the list below:

  • Observe contour and stability of the reconstruction after 2 weeks and 1, 3, 6, and 12 months postoperatively.
  • In patients with defects of the sole, load and walking ability generally are recovered in 1 month.
  • In patients who underwent primary bone reconstruction, load and walking ability are delayed until bone union is achieved, as evaluated with serial radiographs or bone scans.
  • Custom-made shoes can be recommended for 3-6 months.
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Complications

See the list below:

  • Complications may be divided into general and specific, and specific complications can be related to the recipient or to the donor area.
  • Generic complications are those related to each surgical procedure (eg, reaction to anesthetics, hematoma, seroma, infection).
  • Specific complications include partial loss of the flap (eg, de-epithelialization of the flap, occasional minor breakdowns of the flap, malunion).
  • In free flap transfers, complications may be divided into 2 groups: complications of the donor area and complications of the recipient area.
  • Donor area complications include hematoma, seroma, skin graft loss, and wound dehiscence. Recipient area complications include partial or total loss of the flap.
  • Early complications mainly are related to vascular problems such as venous or arterious thrombosis and may require a re-exploration of the anastomosis.
  • Late complications are infections and pressure sores due to early recovery under the 100% load. (Click here to complete a Medscape CE activity about pressure ulcers.)
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Outcome and Prognosis

A retrospective study by Cho et al indicated that diabetes, chronic ulceration, an elevated platelet count, and an abnormal angiogram increase the risk of reconstruction failure in patients undergoing foot and ankle free tissue transfer. The study involved 231 free flap procedures (in 225 patients) for foot and ankle reconstruction, with the investigators identifying chronic ulceration and an elevated preoperative platelet count as independent risk factors for postoperative foot ischemia (ie, ischemia-related tissue necrosis not occurring at the reconstruction site), and diabetes and an abnormal preoperative angiogram as predictors of flap failure.[24]

Other considerations

The treatment of foot ulcers is often difficult, with a relatively high incidence of recurrence, especially in older patients with vascular or dysmetabolic diseases.

Always consider the general condition of the patient in advance to plan the most correct treatment of the local defect. The prognosis is strictly dependent on the age of the patient and the etiology of the defect.

From a surgical point of view, flaps usually give a better result than grafts, with a low rate of breakdowns or recurrence. However, grafts can be remarkably durable on weightbearing (WB) areas and may be the first choice in certain situations.

Even if grafts are advisable in some patients, local flaps provide the most similar tissue and must be the first choice when the defect is not less than 3 cm wide.

The advent of microsurgery and the use of free flaps have changed the approach for the treatment of large defects.

Fasciocutaneous flaps for pure soft tissue loss are versatile and usually offer a suitable paddle of tissue to reconstruct either WB or nonweightbearing (NWB) areas. Surgical recovery is fast, and the patient can wear normal shoes early on.

Muscular or myocutaneous flaps must be necessary in large avulsions with bone infection. Surgical recovery with these flaps can be slightly longer, especially because of their thickness, which prohibits the use of normal shoes.

Myocutaneous flaps, particularly bulky in the beginning, usually reduce their thickness in 6 months because of the process of atrophy of the denervated muscle.

Finally, osteocutaneous flaps truly represent the option to avoid amputation, restoring not only the loss of tissue but especially the function of the foot in the gait.

The future of this field will be influenced by new technologies and cellular cultures, with the possibility of reproducing any type of tissue in the laboratory.

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Contributor Information and Disclosures
Author

Fabio Santanelli di Pompeo, MD, PhD Associate Professor of Plastic Surgery, Sapienza University of Rome School of Medicine and Psychology; Chief of Plastic Surgery Unit, Sant'Andrea Hospital, Rome

Fabio Santanelli di Pompeo, MD, PhD is a member of the following medical societies: American Society of Plastic Surgeons, International Confederation for Plastic and Reconstructive and Aesthetic Surgery, European Association of Plastic Surgeons, Societa Italiana di Microchirurgia, Swedish Associations of Plastic Surgeons, Osservatorio Nazionale Identit? di Genere

Disclosure: Nothing to disclose.

Coauthor(s)

Francesca Romana Grippaudo, MD, PhD Assistant Professor, Department of Plastic Surgery, S Andrea Hospital, Faculty of Medicine and Psycology, Sapienza University of Rome, Italy

Francesca Romana Grippaudo, MD, PhD is a member of the following medical societies: International Confederation for Plastic and Reconstructive and Aesthetic Surgery, Italian Society of Plastic Reconstructive Surgery and Aesthetics

Disclosure: Nothing to disclose.

Stefania Tenna, MD 

Disclosure: Nothing to disclose.

Guido Paolini, MD, PhD 

Disclosure: Nothing to disclose.

Emanuele Cigna, MD, PhD Consultant Plastic Surgeon, Department of Surgery, Unit of Plastic Reconstructive and Hand Surgery, University of Rome La Sapienza, Italy

Emanuele Cigna, MD, PhD is a member of the following medical societies: World Society for Reconstructive Microsurgery, Italian Society of Plastic Reconstructive Surgery and Aesthetics

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Additional Contributors

Christian E Paletta, MD, FACS Clinical Professor of Surgery and Instructor of Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth; Clinical Professor of Surgery and Instructor in Surgery, Rwanda Human Resources for Health, Rwanda Ministry of Health and Clinton Health Access Initiative

Christian E Paletta, MD, FACS is a member of the following medical societies: American Society of Plastic Surgeons, Plastic Surgery Research Council, American Council of Academic Plastic Surgeons, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

B Sekhar Chandrasekhar, MD Associate Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Southern California

B Sekhar Chandrasekhar, MD is a member of the following medical societies: American Association of Plastic Surgeons, American College of Surgeons, American Society for Reconstructive Microsurgery, and California Medical Association

Disclosure: Nothing to disclose.

References
  1. McCraw JB. Selection of alternative local flaps in the leg and foot. Clin Plast Surg. 1979 Apr. 6(2):227-46. [Medline].

  2. Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg. 1979 Sep. 64(3):295-8. [Medline].

  3. Grabb WC, Argenta LC. The lateral calcaneal artery skin flap (the lateral calcaneal artery, lesser saphenous vein, and sural nerve skin flap). Plast Reconstr Surg. 1981 Nov. 68(5):723-30. [Medline].

  4. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap. A clinical study. Plast Reconstr Surg. 1975 Feb. 55(2):177-85. [Medline].

  5. Masquelet AC, Romana MC. The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg. 1990 May. 85(5):765-72. [Medline].

  6. Baudet J, Guimberteau JC, Nascimento E. Successful clinical transfer of two free thoraco-dorsal axillary flaps. Plast Reconstr Surg. 1976 Dec. 58(6):680-8. [Medline].

  7. Robinson DW. Microsurgical transfer of the dorsalis pedis neurovascular island flap. Br J Plast Surg. 1976 Jul. 29(3):209-13. [Medline].

  8. Dos Santos F. L’artere scapulaire posterieure. Paris; 1980.

  9. Acland RD, Schusterman M, Godina M, et al. The saphenous neurovascular free flap. Plast Reconstr Surg. 1981 Jun. 67(6):763-74. [Medline].

  10. Song R, Song Y, Yu Y. The upper arm free flap. Symposium on one stage reconstruction. Song R, ed. Clinics in Plastic Surgery. New York: WB Saunders; 1982. Vol 9: 27-36.

  11. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg. 1975 May. 55(5):533-44. [Medline].

  12. Taylor GI. The current status of free vascularized bone grafts. Clin Plast Surg. 1983 Jan. 10(1):185-209. [Medline].

  13. Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin Plast Surg. 1986 Oct. 13(4):663-80. [Medline].

  14. Sarzaeem MM, Lemraski MM, Safdari F. Chronic Achilles tendon rupture reconstruction using a free semitendinosus tendon graft transfer. Knee Surg Sports Traumatol Arthrosc. 2011 Oct 29. [Medline].

  15. Ahmed SK, Fung BK, Ip WY, Chow SP. Lateral tibial condyle reconstruction by pedicled vascularized fibular head graft: long-term result. Strategies Trauma Limb Reconstr. 2011 May 17. [Medline].

  16. Gomez MM, Casal D. Reconstruction of Large Defect of Foot with Extensive Bone Loss Exclusively Using a Latissimus Dorsi Muscle Free Flap: A Potential New Indication for This Flap. J Foot Ankle Surg. 2011 Sep 23. [Medline].

  17. Struckmann V, Hirche C, Struckmann F, et al. Free and pedicled flaps for reconstruction of the weightbearing sole of the foot: a comparative analysis of functional results. J Foot Ankle Surg. 2014 Nov-Dec. 53(6):727-34. [Medline].

  18. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region: a preliminary report. Scand J Plast Surg. 1983. 17:191.

  19. Pakiam AI. The reversed dermis flap. Br J Plast Surg. 1978 Apr. 31(2):131-5. [Medline].

  20. Jeon BJ, Lee KT, Lim SY, et al. Plantar reconstruction with free thoracodorsal artery perforator flaps. J Plast Reconstr Aesthet Surg. 2013 Mar. 66(3):406-13. [Medline].

  21. Hong JP, Kim EK. Sole reconstruction using anterolateral thigh perforator free flaps. Plast Reconstr Surg. 2007 Jan. 119(1):186-93. [Medline].

  22. Yang X, Zhang G, Liu Y, Yang J, Ding M, Tang M. Vascular anatomy and clinical application of anterolateral leg perforator flaps. Plast Reconstr Surg. 2013 Apr. 131(4):534e-43e. [Medline].

  23. Nassif TM, Vidal L, Bovet JL, et al. The parascapular flap: a new cutaneous microsurgical free flap. Plast Reconstr Surg. 1982 Apr. 69(4):591-600. [Medline].

  24. Cho EH, Garcia RM, Pien I, et al. Vascular considerations in foot and ankle free tissue transfer: Analysis of 231 free flaps. Microsurgery. 2015 Mar 23. [Medline].

  25. Chang Di Sheng. Radial artery fascial flap. Honolulu, HI; October 1982. Presented at: Annual Meeting of the American Society of Plastic Reconstructive Surgery:

  26. Masuoka T, Nomura S, Yoshimura K, et al. Deep inferior epigastric perforator flap for foot reconstruction using an external pedicle. J Reconstr Microsurg. 2005 May. 21(4):231-4. [Medline].

  27. Mathes SJ, Nahai F. Clinical application for muscle and musculocutaneous flaps. St Louis: Mosby; 1982.

  28. Morrison WA, Crabb DM, O'Brien BM, et al. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg. 1983 Jul. 72(1):56-65. [Medline].

  29. Nerlich AG, Zink A, Szeimies U, et al. Ancient Egyptian prosthesis of the big toe. Lancet. 2000 Dec 23-30. 356(9248):2176-9. [Medline].

  30. O'Brien B McC, Morrison WA. Reconstructive Microsurgery. Churchill Livingstone; 1987.

  31. O'Brien BM, MacLeod AM, Hayhurst JW, et al. Successful transfer of a large island flap from the groin to the foot by microvascular anastomoses. Plast Reconstr Surg. 1973 Sep. 52(3):271-8. [Medline].

  32. Organek AJ, Klebuc MJ, Zuker RM. Indications and outcomes of free tissue transfer to the lower extremity in children: review. J Reconstr Microsurg. 2006 Apr. 22(3):173-81. [Medline].

  33. Strauch B, Vasconez LO, Hall-Finlay EJ. Grabb's Encyclopedia of Flaps. 2nd ed. Philadelphia: Lippincott-Raven; 1998. Vol 3:

 
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Different evolutions of the foot in primates.
View of the 2 arches of the foot.
Lateral and medial views of the vectors.
Xeroradiography shows the dispositions of the shafts and the 2 arches theory.
Radiograph illustrating the dispositions of the shafts in the ankle joint and the heel.
Computerized baropodometry of the foot. Views of the different pressure levels.
Nuclear magnetic resonance of the foot. This examination best shows bone, joints, and ligaments as well as the soft tissues. Nuclear magnetic resonance is important when making the diagnosis in ankle or heel diseases.
Medial plantar flap, instep flap (O'Brien and Shanahan, 1979).
Dorsalis pedis flap, described by McCraw and Furlow (1975).
Medialis pedis flap described by Masquelet (1990).
Lateral calcaneal artery skin flap, described by Grabb and Argenta (1981).
Sural flap; perforator flap from peroneal artery; described by Donski and Fogdestam, 1983.
Perforator flap from the peroneal artery.
Soleus muscle flap.
Dystrophic ulcer of the heel.
First web space flap based on pedidial artery.
Flap from the first web space (4 X 6 cm).
The flap is transferred to reconstruct the posterior heel defect; reconstruction of the donor area by split-thickness skin graft.
Long-term view of the donor area.
Crush injury of the forefoot, plantar view.
Crush injury of the forefoot, dorsal view.
Injury of the foot after debridement and reconstruction by means of free latissimus dorsi muscle transfer with mesh skin graft, revascularized end to end on the posterior tibial artery and vein.
Long-term result, plantar view, after repair of injury of the foot.
Long-term result, dorsal view, after repair of injury of the foot.
Avulsion of the foot sole, plantar view.
Avulsion of the foot sole, side view.
Planning of a large forearm flap.
Long-term result after reconstruction with free forearm transfer revascularized side to end on the posterior tibial artery and vein.
Side view after reconstruction of the sole with free forearm flap transfer, long-term result.
Table 3. Surgical Options for Foot Reconstruction
Dimension Extension Localization Type of Flap
< 3 cm2 Soft tissue Weightbearing areas Local flap
< 3 cm2 Soft tissue Nonweightbearing areas Skin grafts
>3 cm2 Soft tissue Weightbearing areas Free flap (free fasciocutaneous, musculocutaneous flaps, muscle free flap plus skin graft)
>3 cm2 Soft tissue and bone loss Weightbearing areas Free osteocutaneous flap
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