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30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
Fig. 30.19 Lateral calcaneal artery ap after incision
prior to dissection
437
Fig. 30.18 First dorsal metatarsal artery ap: ap elevation at the level of the dorsalis pedis artery
Anatomy
The lateral calcaneal artery skin ap is a proximally based neurovascular skin ap that includes
the lateral calcaneal artery, lesser saphenous
vein, and sural nerve. The LCA is a branch of
the peroneal artery. It arises at the level of the
lateral malleolus between the Achilles and peroneal tendons. It travels distally into the foot giving rise to several smaller branches and
terminating at the base of the fth metatarsal
(Fig.30.21) [22].
Surgical Technique
The procedure is performed in the lateral decubitus or prone position. This can be done under
regional or general anesthesia, with or without
tourniquet control. The patency of the artery is
assessed preoperatively with handheld doppler
or angiography. After proper wound bed preparation, the ap can be designed. The base of the
ap extends from the lateral border of the
Achilles to the posterior border of the lateral
Fig. 30.20 The proper plane for elevation is best found
through the posterior incision at the periosteal level
malleolus. The base can start just proximal to
the malleolus (Fig. 30.19). For posterior
defects, the ap extends distally towards the
plantar heel for a distance of approximately
8cm. The distal posterior incision can be made
down to the periosteum to identify the proper
plane (Fig.30.20). Once the ap is released distally, the dissection can proceed proximally.
Care is taken along the anterior border where
branches of the calcaneal artery and the sural
nerve are continuing into the foot. The ap is
elevated making sure to retain the LCA in the
ap which runs deep to the subcutaneous tissue
(Figs. 30.21 and 30.22). It is dissected proximally until an adequate arc of rotation is
achieved to reach the defect in a tension-free
manner (Figs.30.23 and 30.24). The donor site
typically requires skin grafting.
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D. Z. Martin and G. Del-Corral
Fig. 30.21 In well-vascularized feet the ap can be
extended by curving the ap design onto the foot and preserving the LCA and sural nerve as it curves distal to the
lateral malleolus
Fig. 30.22 The ap is then elevated distal to proximal
Fig. 30.24 Posterior rotation of the ap
Medial Plantar Artery
The medial plantar artery ap was rst described
by Shanahan etal. in 1979, as a rotational skin
ap isolated on the medial plantar artery for coverage of plantar defect. The medial plantar ap is
a fasciocutaneous ap (Mathes-Nahai Type B)
that overlays the instep area between the rst
metatarsophalangeal joint (MTPJ) and the calcaneus (midline of heel). The midline and the
navicular tuberosity are lateral and medial limits,
respectively.
This ap is composed of glabrous skin that is
ideally suited for reconstruction of weightbearing portions of the foot, such as the heel. The
ap can also be harvested as a neurotized ap of
protective sensation of the heal or as a free ap
for distant defects. Free ap reconstruction using
the medial plantar artery has been described for
sensate for nger pulp reconstruction [23, 24].
Anatomy
The skin ap is supplied by the medial plantar
artery, a branch of the posterior tibial artery,
which is one of the two terminal branches of the
tibial–peroneal trunk. The medial plantar artery
is the smaller of the two terminal branches of the
posterior tibial artery, the other being the lateral
plantar artery. The medial plantar nerve travels
with the pedicle and it is a terminal branch of the
posterior tibial nerve. The ap (12×6cm maximum) can be islanded and pedicled on these ves-
Fig. 30.23 Anterior rotation of the ap
sels to cover defects on the heel. Another variation
30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
439
is the distally based medial plantar artery ap
which is supplied by retrograde blood ow
through the medial plantar artery [25].
Surgical Technique
The procedure is performed under general or spinal anesthesia. A doppler ultrasound is used to
map the perforator over the medial plantar artery
and the posterior tibial artery behind the malleolus. A straight line connecting this point and the
plantar aspect of the rst metatarsal space denotes
the midaxis of the ap (Fig.30.25). This line is
divided into three equal parts. The perforator usually emerges in between the middle and distal
third and the ap is centered over the perforator.
The distal border should be kept 2cm behind the
metatarsal heads in order to avoid the weightbearing area [26].
The operation proceeds by making an incision
along the medial border of the ap. Elevation of
the ap now proceeds in the subfacial level and
below the plantar aponeurosis. The neurovascular
bundle now lies in between the exor digitorum
brevis (FDB) muscle laterally and abductor hallucis (AbH) muscle medially. Each muscle is
retracted in the opposite direction to expose the
pedicle and the medial plantar nerve. Sometimes,
it is recommended to add a portion of the adductor hallucis and exor digitorum brevis muscles
along with the ap.
The pedicle can now be identied distally and
divided to allow for proximal dissection. The dissection should remain in the subfacial level and
continue to the level of the calcaneal tuberosity.
The remaining of the lateral incisions can now be
made after pedicle elevation and the ap is com-
pletely elevated (Fig.30.26). The abductor hallucis muscle can be divided in order to increase
the arc rotation of the ap (Fig.30.27). Venous
insufciency can result as the venae comitantes
are quite small. To lessen this possibility, a supercial vein (if encountered) can be harvested and
preserved with the ap [27]. The main trunk of
the medial plantar nerve should be preserved to
avoid sensory loss over the distal foot (Fig.30.28).
Donor site closure proceeds with the use of a full
Fig. 30.26 Medial plantar ap: ap dissection
Fig. 30.27 Medial plantar artery ap pedicle dissection
(red arrow). Medial plantar nerve dissected with ap for
ap neurotization (black arrow)
Fig. 30.25 Medial plantar artery ap: skin markings (red
line)
Fig. 30.28 Supercial dissection of the medial and lateral plantar nerves (arrows)
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thickness skin graft or partial thickness graft. The
patient remains non-weight-bearing for 14days
until the graft is completely healed [28].
Reverse Sural Artery Flap
The reverse sural artery ap is presented as an
alternative ap for small to medium size defects
when free ap procedures hold a higher risk. The
reverse sural artery ap was rst described by
Masqualet in 1992 [29]. It was rst depicted as a
random ap based on the supercial ow of the
sural artery. Traditionally, it has been used for
sensate reconstruction of lateral malleolar and
heal defects [30]. The distally based supercial
sural artery ap is one of these neurocutaneous
aps, and its circulation depends on anastomosis
of peri-sural vasculature with distal perforators of
the peroneal artery near the lateral malleolus.
Anatomy
The proximally based sural artery ap is a fasciocutaneous, Mathes-Nahai type I ap (one
dominant pedicle). The anatomic structures
composing the ap are the sural artery, supercial and deep fascia, sural nerve, and saphenous
vein. Both the sural artery and short saphenous
vein originate from the popliteal artery and vein,
respectively. The supercial sural artery arises
from the popliteal artery in 65% of the cases,
from the medial sural artery in 20%, and from
the lateral sural artery in 8.3% [31]. In most
cases, the artery descends into the lateral malleolus, and in less than 30% of the cases it fades
distally into the distal third of the leg. It has a
constant distal anastomosis with septocutaneous
perforators from the peroneal artery and posterior tibial artery (5cm above the lateral malleolus), which will supply a reverse-ow ap
(Fig.30.29). It is important to avoid raising the
ap too far distally, as this could potentially
affect the arterial and venous structures needed
to preserve retrograde ow.
Surgical Technique
The procedure is performed under general or
spinal anesthesia. Prone or lateral decubitus
D. Z. Martin and G. Del-Corral
Fig. 30.29 Reverse sural artery supercial anastomosis
through septocutaneous perforators from the peroneal
artery
position with proper padding can be used for
ap elevation. A vein nder can be used to mark
the supercial saphenous vein network. The
ap markings are as follows. A straight line is
drawn connecting a point 1.5 cm posterior to
the lateral malleolus and the cleft formed by the
gastrocnemius muscle. This is the longitudinal
30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
441
Fig. 30.30 Reverse sural artery ap: ap markings. The
pivot point is marked 5cm from the lateral malleolus. The
vascular axis of the ap is between the midpoint of the
malleolus and the lateral edge of the Achilles tendon
axis of the sural nerve and the vascular pedicle.
The end of the distal dissection is marked with
a transverse line 5cm above the lateral malleolus. This is the pivot point of the ap, proximal
to the most distal perforators from the peroneal
artery. A doppler can be used to mark the course
of the peroneal artery perforators at the lateral
malleolus.
The ap is then outlined and centered over
the pedicle. A tear drop conguration can be
used to assist in later closure of the proximal
defect (Fig.30.30). An incision is made in the
proximal border of the ap directly where the
sural nerve and vessels can be identied at the
midaxis of the ap. The dissection now proceeds from proximal to distal in the subfacial
Fig. 30.31 Subfacial ap elevation. Medial sural vessels
(blue arrow)
level (Fig. 30.31). Muscular perforators from
the gastrocnemius are visualized and ligated.
The incision in a lazy S fashion is then carried
distally. The underlying pedicle is elevated with
a width of approximately 2–3cm, including the
deep fascia [32]. The adipofascial cuff that
remains around the pedicle should not be vio-
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Fig. 30.32 Adipo-facial sleeve with preservation of the
sural nerve, artery, and short saphenous vein
lated and the vascular structures should not be
skeletonized (Fig. 30.32). The tourniquet is
deated, and the circulation in the ap is
checked. The ap is then transposed distally and
sutured to the receptor site. Our preference is to
connect the defect and donor incisions and avoid
a subcutaneous tunnel. The tear drop shape of
the ap allows for easy inset and direct visualization of the pedicle [33]. Donor site closure
proceeds in primary fashion if the defect is less
than 4cm. When closure is not possible, a skin
graft is preferably used. Venous supercharging
has also been found to be benecial, as described
by Herlin etal [34]. This is indicated especially
for medial malleolus defects where it is easy to
perform an anastomosis using the great saphenous axis, unlike the heel or Achilles’ region
which has a dearth of supercial veins. Highrisk patients, such as the elderly, smokers, those
with peripheral artery disease, diabetics, and
those with signs of venous congestion, should
undergo ap delaying in two stages to avoid
postoperative vascular complications.
D. Z. Martin and G. Del-Corral
Fig. 30.33 Flap design based upon a rst metatarsal
head wound
Fillet Flap ofToe
The llet ap of the toe is a versatile ap, easy to
raise, and adheres to the “spare parts” principle
of plastic surgery. It can be used to close distal
dorsal, plantar, and forefoot wounds, as well as
provide durable coverage for adjacent toes especially at the metatarsal phalangeal joint. It
requires intact forefoot perfusion to be successful
[35].
Anatomy
The llet ap of toe is based upon the dual perfusion of the medial and lateral digital arteries.
Depending on the perfusion of the foot it can be
based upon one or both arteries. Typically, there
are associated wounds involving the toe that dictate the design of the ap.
Surgical Technique
This procedure can be performed under local or
regional anesthesia. Incision placement is based
upon the intended destination of the ap. For
dorsal foot wounds, the incision is placed dorsally and for plantar wounds, the incision is
placed plantarly. The incision extends distally to
the nail fold (Fig.30.33). The nail fold, germinal, and sterile matrixes are excluded from the
ap and left adherent to the distal phalanx.
Depending on the length of ap needed, the incision can be carried medially and laterally around
the nail and connected distally at the hyponych-
30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
443
Fig. 30.34 Flap elevated with preservation of both digital arteries
Fig. 30.35 Degloved toe, discarded
ium. The incision is made full thickness to the
periosteum and the toe bones are then degloved
back to the metatarsal joint. Depending on the
intended use, the ap can be elevated with double or single pedicles. The ap can be elevated
with [36] or without tourniquet control. The tendons can either be included with the ap or proximally transected. Once the ap has been
elevated and the phalanges degloved, the toe can
be disarticulated with a scalpel (Figs.30.34 and
30.35). The ap edges can be inspected for
bleeding. Flap inset can then be performed typically with permanent suture (Fig. 30.36). The
ap can be tailored during inset. Care should be
taken to not skeletonize or disrupt the pedicle
during this dissection. Flap dimensions of
4–5.5cm have been described in literature [36].
Local wound care is usually sufcient to manage
Fig. 30.36 Transposition of ap for coverage. Flap is
trimmed and inset
minor ap tip necrosis. The ap design is variable based upon the location of the wound and
condition of the toe.
Random Skin Flaps
Local rotational and advancement aps have
been well described in the plastic surgery literature. There is a role for these aps in limb salvage
as well. Unlike other parts of the body where ap
length: width ratios can exceed 3:1 and 4:1, in the
foot, maintaining a 1:1 ratio is advised
(Figs. 30.37, 30.38, 30.39, 30.40, 30.41, 30.42,
30.43 and 30.44). These aps can be very sensi-
tive to tension and atraumatic tissue handling is
needed to decrease the risk of delayed wound
healing.
Tissue Expansion
Internal tissue expansion of the lower extremity
is known to carry a higher complication risk than
expansion of other areas of the body [37]. It is
generally not feasible in the foot and ankle. In
certain circumstances the technique of external
tissue expansion can be applied to achieve
delayed primary closure of a wound. The successful application of external tissue expansion
can result in full thickness coverage over tendon
and bone leaving an incisional scar more durable
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D. Z. Martin and G. Del-Corral
Fig. 30.37 V-Y advancement ap. (Courtesy John S.
Steinberg, DPM)
Fig. 30.38 V-Y advancement ap. After incising through
the skin, cut down through fascia. Avoid any undermining.
(Courtesy John S.Steinberg, DPM)
Fig. 30.39 V-Y advancement ap. Place sutures to minimize distal ap tension. Notice focal blanching at suture
locations. (Courtesy John S.Steinberg, DPM)
than a skin graft. Multiple techniques have been
described in literature including stapling rubber
bands in a crisscross pattern across a wound [38]
and commercially available products that apply a
constant 1.2 kg tension to skin anchors placed
around a wound [39]. Given the relatively inelastic nature of the tissues in the foot, particularly in
the presence of inammation and edema, the role
of tissue expansion in the authors’ limb salvage
practice is limited, but recurring. Generally,
wounds that can almost be primarily approximated are best suited for this technique. External
tissue expansion can be synergistically paired
with negative pressure wound therapy. Larger
defects with signicant gaps between the wound
edges are better served with alternative forms of
reconstruction when available.
30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
445
Fig. 30.40 V-Y advancement ap. Complete healing.
(Courtesy John S.Steinberg, DPM)
When using the constant tensioning device on
the foot, several principles should be followed. If
the skin edges are adherent to the wound bed,
they will need to be undermined to allow advancement of the expanded tissue. The skin needs to be
protected from the monolament band spanning
between the skin anchors. Without this, linear
areas of necrosis may occur along the course of
the band. The stapled anchors and tension band
can cause irritation and wounds themselves.
Fig. 30.41 Rotational ap. When possible avoid incisions over high pressure areas like the metatarsal heads.
(Courtesy John S.Steinberg, DPM)
Early removal (between 24 and 72h) is preferred
to limit additional wounding. When the device is
removed it may be necessary to revise skin edges
at the time of delayed primary repair. Despite
these limitations, external tissue expansion can
serve as a valuable instrument in the limb salvage
surgeon’s toolbox.
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D. Z. Martin and G. Del-Corral
Fig. 30.42 Rotational ap. After incising along the arc of
the ap, undermining is performed until the ap can freely
rotate into position. (Courtesy John S.Steinberg, DPM)
Fig. 30.44 Rotational ap. Complete healing. (Courtesy
John S.Steinberg, DPM)
Conclusion
Local ap reconstruction of the foot is an important
component of any limb salvage service. The procedures tend to be straightforward and mostly can be
done under ankle block anesthesia making it safer
for the patient with multiple medical comorbidities
than other more complex forms of reconstruction.
It is critical that the surgeon take a holistic approach
prior to entertaining any of these procedures.
Medical management, vascular assessment, and
wound bed preparation are prerequisites for any
planned ap procedure in the lower limb.
Acknowledgment The authors wish to thank Zachary
D.Martin BA (candidate) for his assistance in the cadaver
lab.
References
Fig. 30.43 Rotational ap. Inset of the ap is performed
taking care to make sure that the distal-most aspect of the
ap is not under tension. (Courtesy John S. Steinberg,
DPM)
1. Kozak GM, Hsu JY, Broach RB, Shakir S, Calvert C,
Stranix JT, Messa C, Levin LS, Serletti JM, Kovach
SJ, Fischer JP. Comparative effectiveness analysis
of complex lower extremity reconstruction: out-
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