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29 Skin Grafting
427
Fig. 29.7 (a) Healing
of the donor site on
postoperative day 22, (b)
healing of the left lower
extremity ulcer by
STSG, and (c) healing
of the right lower
extremity ulcer by STSG
a
c
Two months following STSG application, the
patient began experiencing breakdown of her left
lower extremity skin graft with the formation of a
3.5 × 1.5cm ulcer. Graft breakdown was believed
to be secondary to reduced ambulation, weight
gain, and worsening lymphedema. Her right lower
extremity STSG, however, remained intact. One
year after the rst STSG, the ulcerative wound
bed that developed from the patient’s left lower
extremity graft enlarged to 11 × 6cm. The patient
underwent debridement of the left lateral leg compartment and peroneal tendon, followed by the
application of a second STSG to the wound bed 4
days later. The same protocol, including donor
site, graft thickness, and mesh ratio, was used for
the repeat STSG.Within 1 week, there was 100%
graft take on the patient’s left leg. Despite proper
postoperative care including leg elevation and the
use of lymphedema pumps, the patient developed
two ulcers in the graft within 4 months of repeat
STSG application. The ulcers had a brogranular
base and produced green drainage. Wound bed
cultures grew Pseudomonas aeruginosa and at
most recent follow-up (approximately 2 years
after initial presentation) the patient is undergoing
ongoing therapy with several topical and oral antibiotics. Despite the complex features of this
patient’s wound etiology, this case demonstrates
the ability of STSG to serve as a reliable source of
wound coverage, even in instances when repeat
grafting is required.Disclosure StatementThere
b
are no nancial disclosures, commercial associations, or any other conditions posing a conict of
interest to report for any of the above authors.
References
1. Ratner D.Skin grafting. From here to there. Dermatol
Clin. 1998;16(1):75–90. https://doi.org/10.1016/
s0733- 8635(05)70488- 5.
2. Blok CS, Vink L, Boer EM, Montfrans CV,
Hoogenband HM, Mooij MC, et al. Autologous
skin substitute for hard-to-heal ulcers: retrospective
analysis on safety, applicability, and efcacy in an
outpatient and hospitalized setting. Wound Repair
Regen. 2013;21(5):667–76. https://doi.org/10.1111/
wrr.12082.
3. Rose JF, Giovinco N, Mills JL, Naja B, Pappalardo J,
Armstrong DG.Split-thickness skin grafting the highrisk diabetic foot. J Vasc Surg. 2014;59(6):1657–63.
https://doi.org/10.1016/j.jvs.2013.12.046.
4. Ramanujam CL, Zgonis T. Stepwise surgical
approach to diabetic partial foot amputations with
autogenous split thickness skin grafting. Diabet Foot
Ankle. 2016;7(1):27751. https://doi.org/10.3402/dfa.
v7.27751.
5. Mccartan B, Dinh T. The use of split-thickness
skin grafts on diabetic foot ulcerations: a literature
review. Plast Surg Int. 2012;2012:1–6. https://doi.
org/10.1155/2012/715273.
6. Iwuagwu FC, Wilson D, Bailie F. The use of skin
grafts in postburn contracture release: a 10-year
review. Plast Reconstr Surg. 1999;103(4):1198–204.
https://doi.org/10.1097/00006534- 199904040- 00015.
7. Thornton JF, Gosman AA. Skin grafts and skin substitutes and principles of aps. In: Selected readings
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A. Sayyed et al.
in plastic surgery, vol. 10. 1st ed. Dallas, TX: Selected
Readings in Plastic Surgery; 2004. p.1–6.
8. Braza ME, Fahrenkopf MP. Split-thickness skin
grafts. In: StatPearls. Treasure Island, FL: StatPearls
Publishing; 2020. https://www.ncbi.nlm.nih.gov/
books/NBK551561/. Accessed 31 Jul 2020.
9. Sanniec K, Nguyen T, Asten SV, Fontaine JL,
Lavery LA. Split-thickness skin grafts to the
foot and ankle of diabetic patients. J Am Podiatr
Med Assoc. 2017;107(5):365–8. https://doi.
org/10.7547/15- 200.
10. Walters ET, Pandya M, Rajpal N, Abboud MM,
Elmarsa T, Steinberg JS, etal. Long term outcomes
of split-thickness skin grafting to the plantar foot. J
Foot Ankle Surg. 2020;59(3):498–501. https://doi.
org/10.1053/j.jfas.2019.09.027.
11. Naz I, Walters ET, Janhofer DE, Penzler MM, Tefera
EA, Evans KK, Steinberg JS, Attinger CE, Akbari
CM, Kim PJ. Outcomes of Split-thickness skin
grafting for foot and ankle wounds in patients with
peripheral arterial disease. Wounds. 2019;31(11):
272–8.
12. Turissini JD, Elmarsa T, Evans KK, Kim PJ.Major
risk factors contributing to Split thickness skin graft
failure. Georgetown Med Rev. 2019;3:1.
13. Bian Y, Sun C, Zhang X, Li Y, Li W, Lv X, et al.
Wound-healing improvement by resurfacing splitthickness skin donor sites with thin split-thickness
grafting. Burns. 2016;42(1):123–30. https://doi.
org/10.1016/j.burns.2015.07.008.
14. Bradow BP, Hallock GG, Wilcock SP. Immediate
Regrafting of the Split thickness skin graft donor
site assists healing. Plast Reconstr Surg Glob
Open. 2017;5(5):e1339. https://doi.org/10.1097/
gox.0000000000001339.
15. Anderson JJ, Wallin KJ, Spencer L. Split thickness
skin grafts for the treatment of non-healing foot and
leg ulcers in patients with diabetes: a retrospective
review. Diabet Foot Ankle. 2012;3(1):10204. https://
doi.org/10.3402/dfa.v3i0.10204.
16. Prohaska J, Cook C. Skin grafting. In: StatPearls.
Treasure Island, FL: StatPearls Publishing; 2020.
https://www.ncbi.nlm.nih.gov/books/NBK532874/.
Accessed 11 Sep 2020.
Local Flaps forReconstruction
andLimb Salvage oftheFoot
andAnkle
DavidZ.Martin andGabrielDel-Corral
30
Introduction toLocal Flap
Reconstruction oftheFoot
Despite the challenges posed by the diabetic foot,
local ap reconstruction of the lower extremity
can be performed with success rates greater than
90% in the appropriately selected patient. The
success matches that of free ap reconstruction
with lower overall reoperation rate [1].
In order for local ap reconstruction to succeed, the surgeon must adhere to the basic principles of reconstructive surgery. The foot is an
unforgiving anatomic location. Ensuring a wellvascularized wound with respect to the angiosomes and performing serial debridements prior
to reconstruction are crucial to success. Similarly,
a respect for the underlying bony pathology or
tendon imbalance will impact long-term success.
Finally, ap selection will be impacted by vascular status, tissues requiring coverage, and location of wound. The value of good postoperative
care cannot be overstated. Designing a postoperative protocol that patients can reasonably follow
and involving them in the care plan is vital.
Ensuring a well-vascularized limb as early as
possible during limb salvage can increase the
D. Z. Martin (*) · G. Del-Corral
Department of Plastic and Reconstructive Surgery,
Georgetown University Medical Center,
Washington, DC, USA
e-mail: David.z.martin@medstar.net;
Gabriel.A.DelCorral@medstar.net
chances of a good outcome. The surgeon must
think beyond the ankle-brachial index as an indicator of adequate perfusion. Waveform analysis
and determining whether the ow is antero or retrograde into each of the six angiosomes inform
the surgeon about the vascularity of the wound
and the availability of local reconstructive
options. When the ow is inadequate, the surgeon
must partner with the vascular interventionalist to
ensure adequate perfusion. The six angiosomes
of the foot include the calcaneal, medial, and
plantar branches of the posterior tibial artery, the
anterior perforating and calcaneal branches of the
peroneal artery, and the dorsal pedis artery originating from the anterior tibial artery [2].
Prior to ap repair, the foot must be free of all
devitalized tissue and infection. Debridement is
fundamental and multiple debridements are typically required. Instituting a practice of debriding
to negative post-debridement qualitative culture
has been shown to improve success inlocal ap
reconstruction of the foot at 90days [3].
Bone pathology and tendon imbalance should
be assessed as part of the reconstructive plan.
Osteomyelitis is managed surgically with postdebridement cultures and pathologic margins
directing decisions regarding length of antibiotic
therapy. Major Charcot reconstructions or tendon
rebalancing may be delayed until after successful
wound reconstruction. However, planning for the
management of these pathologies is important at
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_30
429
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D. Z. Martin and G. Del-Corral
the time of closure to improve the chances of
long-term functional limb restoration.
Once the wound has been adequately prepared, the vascular status optimized, and structural pathology assessed, ap repair can
proceed.
Flap selection is based upon the location and
size of the wound, the involved structures (bone,
tendon, nerve, or artery), and whether the tissue
will be weight-bearing.
Local ap reconstruction is generally reserved
for smaller defects. However, it can be combined
with skin substitutes and autografting to achieve
broader wound coverage if the vital structures
can be covered with the local ap. Wound closure
alone is not sufcient in functional limb restoration. Consideration must be given to the durability of the reconstruction over time.
Local foot aps can be skin only, axial or perforator based, or include intrinsic muscles. It is
often necessary to skin graft the donor site.
Keeping the donor site on a non-weight-bearing
surface will improve the durability of the repair.
Intrinsic muscles are good choices when available to cover bone. The choice is typically based
upon the location of the wound. Commonly used
intrinsic muscles of the foot include: Abductor
digiti minimi (for lateral ankle and calcaneal coverage), abductor hallucis brevis (for medial midfoot, heel, and ankle coverage), extensor
digitorum brevis (for anterior ankle coverage),
and exor digitorum brevis (for plantar heel coverage) [4].
When muscle is not needed or available, pedicled skin aps can be useful. These include aps
based upon the following: rst dorsal metatarsal
artery, lateral calcaneal artery, medial plantar
artery, and the reverse sural artery.
Finally, llet toe aps, random aps, and tissue expansion can be utilized to round out the
choices for local ap reconstruction of the foot.
lateral foot. It is a type II Mathes-Nahai ap and
it is a straightforward elevation. The donor site is
typically closed primarily. The muscle itself can
be grafted or small defects left to heal
secondarily.
Anatomy
The ADM muscle originates from the calcaneal
tuberosity. It travels along the plantar lateral
aspect of the foot to the base of the fth metatarsal and then on to the lateral base of the fth toe
proximal phalanx. The dominant pedicle is a
branch off the lateral plantar artery proximally. It
is used as a proximally based ap.
Surgical Technique
Flap elevation is typically performed under
regional anesthesia without tourniquet control.
Loupe magnication and a handheld doppler
can facilitate identication of minor and major
pedicles. Surgical approach begins with a plantar lateral incision along the course of the muscle (Fig. 30.1). Existing wounds may be
incorporated into the incision plan. The subcutaneous fat pad is easily separated from the
muscle fascia on its supercial aspect. The tendon is released distally at the base of the fth
toe and dissection proceeds proximally. Suture
tagging of the tendon can aid dissection. The
muscle is separated from the exor digitorum
minimi brevis medially. The muscle easily separates from the metatarsal dorsally. Ligation of
minor pedicles can be done with bipolar cautery
or ligation clips. The pedicles are identied
along the medial border of the muscle.
Abductor Digiti Minimi Muscle Flap
The adductor digiti minimi (quinti) [ADM] muscle provides a small but reliable ap for reconstruction of the proximal to mid-plantar and
Fig. 30.1 Incision is planned along the lateral glabrous
junction. Fifth metatarsal base is outlined
30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
431
Fig. 30.2 ADM proximally transposed
Fig. 30.3 ADM extended by releasing attachments to
metatarsal base while preserving vascular pedicle
Dissection proceeds proximally as needed for
length depending on the location of the wound
(Figs.30.2, 30.3 and 30.4). The major pedicle is
identied as a branch of the lateral plantar artery
at approximately the level of the proximal
cuboid [5] (Fig.30.3). Care is taken at inset to
prevent kinking of the pedicle. Doppler and
physical assessment can assure safe transposition. The muscle can be inset with absorbable
suture. Immediate skin grafting can be performed if needed.
Abductor Hallucis Muscle Flap
The abductor hallucis (ABH) muscle is usually
used as a proximally based ap to cover defects
at the medial aspect of the foot. It is classied as
Fig. 30.4 ADM proximally transposed after release from
metatarsal base
a Mathes-Nahai type II, supplied by one major
proximal pedicle and minor distal pedicles. The
ap is primarily useful for reconstructions of the
calcaneus, medial malleolus, and medial midfoot. The muscle belly of the ap can be harvested with minimal morbidity and the scar is
hidden in a non-weight-bearing area. The small
muscle belly is ideal for closure of defects less
than or equal to 3–6cm. Structural stability and
resistance to infection are the main advantages of
muscle aps in comparison to fasciocutaneous
aps when used for reconstruction of the sole of
the foot [6].
Anatomy
The abductor hallucis muscle ap receives its
blood supply from both the dorsal and ventral
plantar system. The three main vessels are: the
medial plantar artery, the deep branch of the
medial plantar artery, and the supercial branches
of medial plantar artery (Figs. 30.5, 30.6, 30.7
and 30.8). The lateral plantar artery is preserved
during ap harvest, conserving the blood supply
to the sole of the foot [7].
Surgical Technique
The procedure is started with the patient under
general or spinal anesthesia. Tourniquet control
can be used, but it is not necessary. A ventral incision is made along the medial aspect of the foot
towards the axis of the rst metatarsal. The plantar fascia is incised from the medial and lateral
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D. Z. Martin and G. Del-Corral
Fig. 30.5 Abductor hallucis muscle: elevation with perforator from the medial plantar artery
Fig. 30.6 Abductor hallucis muscle ap and calcaneal
defect
Fig. 30.7 Flap inset and closure
border of the abductor hallucis. The insertion of
the abductor hallucis is identied at the calcaneal
tubercle. The muscle belly is dissected off the
base of the proximal phalanx of the hallux.
Supra-muscular dissection between the Abductor
Hallucis muscle and the Flexor Hallucis Brevis
tendon allows for complete exposure of the ap.
Muscular branches from the medial plantar artery
should be carefully preserved. The ap is then
rotated proximally and inset into the calcaneal
defect (Fig.30.6). To prevent compression of the
pedicle, the calcaneal attachments/plantar fascia
can be released. If a greater arc of rotation is
needed, the ap can be raised as an island ap
allowing better rotation and more tissue bulk [8,
9].
The donor site can be covered with xenograft,
and negative wound pressure therapy. A split
thickness skin graft can be used 3 weeks later.
The patient should remain on weight-bearing
restrictions for 4 weeks until there is full incorporation of the graft (Fig.30.7).
30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
Fig. 30.9 A lazy S incision can be designed along the
axis of a line from the lateral malleolus to the rst web
space
inserts into the extensor longus tendons of toes
2–4 and into the proximal phalanx of the hallux
via the extensor hallucis brevis muscle. The lateral tarsal artery is the dominant pedicle entering
proximally under the muscle belly [11] as a direct
branch from the dorsalis pedis (DP) artery. It is a
Mathes-Nahai type II vascular supply [12].
433
Fig. 30.8 Latex injection. Abductor hallucis muscle with
muscular perforator from the medial plantar artery
Extensor Digitorum Brevis
MuscleFlap
The extensor digitorum brevis [EDB] muscle ap
provides muscle coverage for anterior and lateral
ankle defects. Its donor site can be closed primarily. Its harvest, however, results in incisions
within the dorsalis pedis [DP] angiosome which
can result in wound healing complications. To
extend the EDB distal ligation of the DP artery is
required. Care should be taken with this ap to
ensure adequate collateral circulation from the
lateral plantar artery [4]. Its size makes it more
appealing than other intrinsic muscle aps for
larger (5×7cm) defects around the ankle and calcaneus [10].
Anatomy
The Extensor Brevis (EB) muscle originates from
the tendocalcaneal ligament of the lateral foot. It
Surgical Technique
The operation is performed with the patient in the
supine position under general or regional anesthesia. The EB muscle belly can be identied by
having patients extend their toes preoperatively.
A curvilinear incision is made along a line from
the lateral malleolus to the rst dorsal webspace
(Fig.30.9). The lateral tarsal branch of the DP is
identied distal to the retinaculum along with the
motor branch of the deep peroneal nerve.
Dissection is performed between the extensor
hallucis longus and extensor digitorum longus
[EDL] (Fig.30.10). Creating a plane, dissection
proceeds from medial to lateral elevating the
EDL from the EB.Incising the extensor retinaculum facilitates this elevation. Once the plane is
developed, the EB tendon are divided distally and
the ap is elevated distally to proximally. The
lesser vascular pedicles are ligated, preserving
the lateral tarsal artery and deep peroneal nerve
(Fig. 30.11). The arc of rotation can then be
extended by ligating the DP distal to the pedicle
(Fig.30.12) [12]. The donor site is closed primarily. The ED muscle belly can be grafted.
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D. Z. Martin and G. Del-Corral
Fig. 30.12 If more length is needed the DP artery is
ligated distal to the pedicle and the arc of rotation is
increased. Muscle is shown over the lateral malleolus
Fig. 30.10 A plane is developed between the EHL and
EDL. Dissecting medially to laterally the EDL is dissected off the EB muscle
Fig. 30.11 The EB tendons are released distally and the
ap is elevated, ligating the distal pedicles and preserving
the lateral tarsal artery
Fig. 30.13 Calcaneal wound with osteomyelitis.
(Courtesy Paul J Carroll, DPM)
Although typically used as a proximally based
ap, there are reports in the literature of using retrograde ow through the DP artery to provide
muscle coverage to the forefoot [13].
Flexor Digitorum Brevis Muscle Flap
The exor digitorum brevis [FDB] is a proximally based muscle ap. It is typically used to
cover calcaneal defects. It is a Mathes-Nahai type
II ap. Because it is a muscle ap, it is well suited
for the management of osteomyelitis (Fig.30.13).
Although the donor site is closed primarily, skin
grafting is typically used to cover the muscle
after inset.
30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
435
Fig. 30.14 Flap elevation through plantar midline with
transposition. (Courtesy Paul J Carroll, DPM)
Anatomy
The exor digitorum muscle originates from the
medial process of the calcaneus and inserts into
the middle phalanges of toe two, three, four, and
ve via tendons. The plantar fascia lies immediately supercial to it and the muscle is bordered
medially by the abductor hallucis and laterally by
the abductor digiti minimi. The lateral plantar
artery is dominant. The artery enters within the
proximal one third of the muscle [14].
Surgical Technique
Flap elevation is typically performed under
regional anesthesia without tourniquet control.
Loupe magnication and a handheld doppler can
facilitate identication of minor and major pedicles. A midplantar incision is made with dissection performed to the plantar fascia (Fig.30.14).
The fascia is longitudinally incised and elevated
medially and laterally exposing the muscle belly
of the exor digitorum brevis. The fascia can be
included in the ap if additional bulk is needed.
The muscle is exposed distally until the tendons
are identied. The tendons are divided and the
ap is dissected distally to proximally. The ap is
dissected off the quadratus plantae which lies
deep to the ap. Care is taken to preserve the perforators from the medial and lateral plantar arteries. The muscle is rotated into position
(Fig.30.15). The donor site is closed with permanent monolament suture and muscle can then be
grafted (Fig. 30.16). Disoriginating the muscle
Fig. 30.15 Flap inset. (Courtesy Paul J Carroll, DPM)
Fig. 30.16 Primary closure of donor site with integra
grafting of muscle. (Courtesy Paul J Carroll, DPM)
and elevating the lateral plantar artery are techniques that can extend the reach of this ap [15].
If the lateral plantar artery is included in the ap,
care must be taken to ensure the dorsalis pedis
pulse is preserved.
First Dorsal Metatarsal Artery Flap
The rst dorsal metatarsal artery (FDMA) ap
has been useful in the reconstruction of the
defects on the dorsomedial side of the distal foot.
The initial report of the FDMA ap was published by McCraw and Furlow in 1975 [16].
Ishikawa later described the distally based
FDMA ap that was used to reconstruct the
defects of the great toe, as well as the rst ray
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D. Z. Martin and G. Del-Corral
defects [17]. The vascular branching pattern
allows for multiple variations of the ap including adipofascial and fasciocutaneous in reverse,
propeller-type, and proximal transposition
options (Fig.30.17).
Anatomy
The rst dorsal metatarsal artery originates from
the dorsalis pedis or the deep plantar artery. The
course of the rst dorsal metatarsal artery (FDMA)
has three variations relating to its orientation with
respect to the rst dorsal interosseous muscle
belly. In 10% of cases it can course supercial to
the muscle. In the majority of cases, the artery
passes under the muscular arch formed by the
tibial head of the rst dorsal interosseous muscle
and runs adjacent to the rst metatarsal bone. The
tibial head can be easily divided and the artery can
be easily dissected in this space. No intramuscular
dissection is needed. Multiple cutaneous perforators can be identied between the heads of the
rst and second metatarsals. The FDMA distal
branch assumes a more supercial course after
piercing the metatarsal ligament and frequently
connects with the medial plantar artery [18].
Surgical Technique
The operation begins with doppler ultrasound for
identication of the rst dorsal metatarsal artery
and dorsalis pedis artery. A vein nder or a tourniquet without exsanguination can be used to
delineate the venous network. Dissections proceed by incising a skin island directly over the
audible perforator. The ap is then elevated in the
subfascial plane until identication of the distal
segment of the rst dorsal metatarsal artery.
The dissection now proceeds, proximally, until
identication of the proximal pedicle. Careful
transection of all fascial attachments surrounding
the pedicle follows to minimize the risk of venous
congestion and ap failure. If a larger arc of rotation is needed, resection of the EHB muscle can
be performed to allow for a tension- free ap inset
[19]. The ap can be rotated up to 180°, making
this ap useful to cover defects of the dorsum of
the toe or webspace or defects exposing tendons
on the distal dorsum of the foot [20] (Fig.30.18).
The donor site can be closed primarily or with
the assistance of a skin graft or skin substitute.
Immobilization of the foot is recommended for 1
week with a posterior splint for support.
After this period, the patient can be transitioned into a walking boot until the incision is
completely healed. Custom inserts and shoe gear
can be useful in maintaining an even distribution
of weight across the foot and decrease pressure
over the ap site.
Lateral Calcaneal Artery Skin Flap
The lateral calcaneal artery (LCA) skin ap is a
durable and reliable method of reconstructing the
posterior heel and calcaneus of small and medium
sized defects. Alternative methods of reconstruction in this area include free tissue transfer or
skin grafting depending on the patient and wound
Fig. 30.17 First dorsal metatarsal artery ap: latex injection ap outline
conditions. This ap was described in detail in
1981 by William Grabb and Louis Argenta [21].
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