eMedicine Specialties > Plastic Surgery > Lower Extremity Reconstruction
Lower Extremity Reconstruction, Foot: Treatment
Updated: Jun 26, 2008
Treatment
Surgical Therapy
The following table summarizes the most common surgical options according to dimensions, extension, and localization of the defect.
Table 3. Surgical Options for Foot Reconstruction
Open table in new window
Table
| Dimension | Extension | Localization | Type of Flap |
| <3 cm 2 | Soft tissue | Weightbearing areas | Local flap |
| <3 cm 2 | Soft tissue | Nonweightbearing areas | Skin grafts |
| >3 cm 2 | Soft tissue | Weightbearing areas | Free flap (free fasciocutaneous, musculocutaneous flaps, muscle free flap plus skin graft) |
| >3 cm 2 | Soft tissue and bone loss | Weightbearing areas | Free osteocutaneous flap |
| Dimension | Extension | Localization | Type of Flap |
| <3 cm 2 | Soft tissue | Weightbearing areas | Local flap |
| <3 cm 2 | Soft tissue | Nonweightbearing areas | Skin grafts |
| >3 cm 2 | Soft tissue | Weightbearing areas | Free flap (free fasciocutaneous, musculocutaneous flaps, muscle free flap plus skin graft) |
| >3 cm 2 | Soft tissue and bone loss | Weightbearing areas | Free osteocutaneous flap |
Local Flaps
Sole
- Medial plantar flap (instep flap2 )
- Sensitive cutaneous flap harvested from nonweightbearing (NWB) area of the sole (see Image 8)
- 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 flaps1
- 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
Dorsum
- Dorsalis pedis flap4
- Sensitive fasciocutaneous flap or a myocutaneous flap (including the extensor brevis digitorum muscle) that can be harvested from the dorsum of the foot (see Image 9)
- 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
- Medialis pedis flap5
- Fasciocutaneous flap harvested on the anterior medial axis of the foot (see Image 10)
- Pedicle - Myocutaneous perforator branches from the medial plantar artery
- Arc of rotation - Medial malleolar area, Achilles tendon
Lateral side
- Lateral calcaneal flap3
- Cutaneous sensitive flap below the lateral malleolar area along the lateral side of the foot (see Image 11)
- 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
- Sural flap14
- Sensitive fasciocutaneous flap harvested from the posterior area of the leg (see Image 12)
- 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 (see Image 13)
- 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 leg15
- Dermal or fascia flap harvested from the posterior area of the leg to be skin grafted
- Pedicle - Random
- Arc of rotation - Calcaneum, Achilles tendon
Free Flaps for the Foot
Cutaneous
- 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
- Scapular8
- 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
- Parascapular16
- 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
- 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 arm10
- 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 pedis7
- 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
- Latissimus dorsi6
- 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
- Iliac crest12
- 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
- Fibula11
- 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
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.
Intraoperative Details
- 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.
Postoperative Details
- 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.
Follow-up
- 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.
Complications
- 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.)
More on Lower Extremity Reconstruction, Foot |
| Overview: Lower Extremity Reconstruction, Foot |
| Workup: Lower Extremity Reconstruction, Foot |
 Treatment: Lower Extremity Reconstruction, Foot |
| Follow-up: Lower Extremity Reconstruction, Foot |
| Multimedia: Lower Extremity Reconstruction, Foot |
| References |
| « Previous Page | Next Page » |
References
McCraw JB. Selection of alternative local flaps in the leg and foot. Clin Plast Surg. Apr 1979;6(2):227-46. [Medline].
Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg. Sep 1979;64(3):295-8. [Medline].
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. Nov 1981;68(5):723-30. [Medline].
McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap. A clinical study. Plast Reconstr Surg. Feb 1975;55(2):177-85. [Medline].
Masquelet AC, Romana MC. The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg. May 1990;85(5):765-72. [Medline].
Baudet J, Guimberteau JC, Nascimento E. Successful clinical transfer of two free thoraco-dorsal axillary flaps. Plast Reconstr Surg. Dec 1976;58(6):680-8. [Medline].
Robinson DW. Microsurgical transfer of the dorsalis pedis neurovascular island flap. Br J Plast Surg. Jul 1976;29(3):209-13. [Medline].
Dos Santos F. L'artere scapulaire posterieure. Paris; 1980.
Acland RD, Schusterman M, Godina M, et al. The saphenous neurovascular free flap. Plast Reconstr Surg. Jun 1981;67(6):763-74. [Medline].
Song R, Song Y, Yu Y. The upper arm free flap. Symposium on one stage reconstruction. In: Song R, ed. Clinics in Plastic Surgery. Vol 9. New York: WB Saunders; 1982:27-36.
Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg. May 1975;55(5):533-44. [Medline].
Taylor GI. The current status of free vascularized bone grafts. Clin Plast Surg. Jan 1983;10(1):185-209. [Medline].
Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin Plast Surg. Oct 1986;13(4):663-80. [Medline].
Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region: a preliminary report. Scand J Plast Surg. 1983;17:191.
Pakiam AI. The reversed dermis flap. Br J Plast Surg. Apr 1978;31(2):131-5. [Medline].
Nassif TM, Vidal L, Bovet JL, et al. The parascapular flap: a new cutaneous microsurgical free flap. Plast Reconstr Surg. Apr 1982;69(4):591-600. [Medline].
Chang Di Sheng. Radial artery fascial flap. Presented at: Annual Meeting of the American Society of Plastic Reconstructive Surgery. Honolulu, HI; October 1982.
Masuoka T, Nomura S, Yoshimura K, et al. Deep inferior epigastric perforator flap for foot reconstruction using an external pedicle. J Reconstr Microsurg. May 2005;21(4):231-4. [Medline].
Mathes SJ, Nahai F. Clinical application for muscle and musculocutaneous flaps. St Louis: Mosby; 1982.
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. Jul 1983;72(1):56-65. [Medline].
Nerlich AG, Zink A, Szeimies U, et al. Ancient Egyptian prosthesis of the big toe. Lancet. Dec 23-30 2000;356(9248):2176-9. [Medline].
O'Brien B McC, Morrison WA. Reconstructive Microsurgery. Churchill Livingstone; 1987.
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. Sep 1973;52(3):271-8. [Medline].
Organek AJ, Klebuc MJ, Zuker RM. Indications and outcomes of free tissue transfer to the lower extremity in children: review. J Reconstr Microsurg. Apr 2006;22(3):173-81. [Medline].
Strauch B, Vasconez LO, Hall-Finlay EJ. Grabb's Encyclopedia of Flaps. Vol 3. 2nd ed. Philadelphia: Lippincott-Raven; 1998.
Further Reading
Keywords
lower extremity reconstruction, foot surgery, foot pressure, foot reconstruction, foot surgery, weightbearing, foot defects, foot ulcers, padding properties, body weight, foot flap, saphenous nerve, sciatic nerve, ankle, sole, dorsum, toes, extensor brevis digitorum, extensor hallucis, metatarsal bones, anterior tibial pedicle, posterior tibial pedicle, peroneal pedicle, internal plantar nerve, posterior tibial nerve
