Foot Reconstruction Treatment & Management

Updated: Sep 20, 2019
  • Author: Fabio Santanelli di Pompeo, MD, PhD; Chief Editor: Jorge I de la Torre, MD, FACS  more...
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Surgical Therapy

The following table summarizes the most common surgical options according to dimensions, extension, and localization of the defect. [25, 26, 27]

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




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

Pedicled perforator or propeller flap, and/or free flap (free fasciocutaneous, musculocutaneous flaps, muscle free flap plus skin graft)

>3 cm2

Soft tissue and bone loss

Weightbearing areas

Free osteocutaneous flap


Local Pedicled or Perforator Flaps


See the list below:

  • Medial plantar flap (instep flap [3] )

    • 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 [2]

    • 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. [28]

A literature review by Crowe et al found that among reports on reconstruction of the plantar surface of the foot, 53% involved locoregional flaps, with 32%, 10%, and 5% involving free tissue transfer, skin grafting, and multiple methods, respectively. Locoregional flaps consisted most commonly of reverse sural artery flaps, while free flaps most often utilized the latissimus dorsi muscle. The study also found that isolated heel defects were the most frequent plantar foot reconstruction targets and that, regardless of primary neurotization, the majority of locoregional and free flaps demonstrated protective sensation. [29]


See the list below:

  • Dorsalis pedis flap [5]

    • 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 [6]

    • 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 [4]

    • 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 [30]

    • 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/propeller flap from the peroneal artery.

    • Fasciocutaneous flap along the axis between the peroneus longus and brevis muscles

    • Pedicle - Septocutaneous branches from the peroneal artery

    • Arc of rotation - Lateral malleolar area, calcaneum, and proximal area of the dorsum

      Perforator flap from the peroneal artery. Perforator flap from the peroneal artery.
  • Perforator/propeller flap from the posterior tibial artery

    • Fasciocutaneous flap along the axis between soleus and flexor longus digitorum muscles

    • Pedicle - Septocutaneous branches from the posterior tibialis artery

  • Reverse dermis or fascia flap of the lower leg [31]

    • 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


See the list below:

  • Thoracodorsal artery perforator flap (TDAP) [32]

    • 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 [33]

    • 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 [34]

    • Advantages - Consistent reliable blood supply and good texture

    • Disadvantages - Small dimensions if direct closure of the donor area is required, small diameter of the vessels, donor-site morbidity, thin skin

    • Pedicle - Superficial peroneal perforators, inferior superficial peroneal artery perforators


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 [9]

    • 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 [35]

    • Harvested in the same area as the scapular flap

    • Shares similar advantages and disadvantages

    • Pedicle - Descendant branch of the circumflex artery of the scapula


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 [11]

    • 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 [8]

    • 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


See the list below:

  • Latissimus dorsi [7]

    • 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


See the list below:

  • Iliac crest [23]

    • 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 [22]

    • 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

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.

  • For propeller perforator flaps from either the peroneal or tibial row, begin the dissection at the level of the identified perforator, taking care not to injury it; after its dissection, outline and harvest the flap.


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.

  • Propeller flaps may suffer from early edema or venous congestion due to pedicle twist. In some cases, venous distal supercharging may be indicated



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.



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.)


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. [36]

A study by Heidekrueger et al reported that in microsurgical reconstruction of the plantar foot, functional outcomes from the use of anterolateral thigh (ALT) flaps and gracilis flaps were similar overall. However, the ALT flaps were associated with significantly less recipient- and donor-site pain, superior sensation recovery, and less scarring, although the rate of secondary surgeries was significantly greater among the ALT patients in comparison with those who received gracilis flaps (39% vs 19%, respectively). [37]

A study by Sato et al suggested that the use of free flaps in the reconstruction of extensive tissue defects from diabetic foot ulcers may increase patients’ chances of achieving independent ambulation. The investigators found that of 23 patients who underwent free flap reconstruction for diabetic foot ulcers (using free rectus abdominis, latissimus dorsi, or anterolateral thigh flaps), 16 experienced successful surgery, with 12 of these individuals attaining independent ambulation. [38]

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. (Perforator or propeller flaps are elegant alternatives, although they are more technically demanding.) 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.