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a
b
J. M. Felder and J. P. Hong
c
d
e
Fig. 32.23 Massive wounds and the choice of fasciocutaneous versus muscle aps for coverage of infected tendons. An undiagnosed diabetic man presented with a
necrotizing infection due to mucormycosis. (a, b) Radical
debridement resulted in circumferential wounds with
extensively exposed tibia and tendons. (c) The wound was
reconstructed with “stacked” ALT aps and skin grafting.
The rst ap was anastomosed end-to-side to the anterior
tibial artery, and the second ap end-to-end to a owthrough vessel of the rst ap. There was initially satisfactory contour. The patient developed an abscess beneath
the aps several weeks out from surgery, due to persistent
mucor infection and potentially due to nonadherence of
the fasciocutaneous ap to the underlying infected tendons. A muscle ap might have had better adherence to
the tendons for eradication of infection. (d, e) The patient
was lost to follow-up and returned several months later
with healed but very swollen aps. These photos are after
1 week of compression therapy. Early and sustained postoperative compression therapy might have prevented the
edema seen here, especially in the context of a circumferential wound with loss of the supercial venous drainage
system. A muscle ap would likely have been less prone
to develop edema and would have been a better option
a
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b
d
c
e
Fig. 32.24 Coverage of massive wounds and the choice
between fasciocutaneous and muscle aps for large wounds
with infected tendons. (a, b) A 64-year-old diabetic man presented with a severe, circumferential venous stasis ulcer with
exposure and infection of multiple tendons. (c, d) Following
radical debridement with preservation of longitudinal structures, the wound was covered with a latissimus dorsi muscle
ap anastomosed end-to-side to the posterior tibial vessels.
(e) By 8weeks post-op, the ap and skin graft had excellent
contour. There was no occurrence of infection beneath the
ap, which had good adherence to the infected tendons. There
was no notable edema despite the known presence of venous
stasis disease. This contrasts favorably to the outcome with
fasciocutaneous ap for a similar situation in Fig.32.23
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J. M. Felder and J. P. Hong
Recipient Vessel Selection
Recipient vessels in the ankle and foot include
the anterior tibial, posterior tibial, and peroneal
vascular systems. Detailed knowledge of the
anatomy of each is critical to successful operative planning, particularly in the presence of vascular disease where anatomy is abnormal.
Readers are referred to the excellent article by
Attinger on angiosomes of the foot and ankle for
a detailed review of vascular anatomy and its
assessment [4].
Selection is straightforward in diabetics with
minimal or no vascular disease, such as very
young patients. However, in the more common
scenario of concomitant peripheral vascular disease, recipient vessel selection is often the most
challenging and critical facet of reconstructive
planning.
Recipient vessels of the foot and ankle can be
broken down into “major” and “minor” vessels,
which anatomically roughly correspond to “proximal” and “distal.” Major systems include the
tibial vessels at the ankle, and the peroneal vessels in the leg behind the bula (the peroneal vessels are infrequently used). Minor systems
include perforators of major vessels, distal
branches of the major systems, such as the rst
dorsal metatarsal artery (FDMA) (Fig. 32.25),
medial and lateral plantar systems, digital vessels
(Figs.32.6 and 32.7), intrinsic muscle pedicles,
peroneal vessels at the ankle (Fig. 32.15), and
intact collateral vessels in the setting of PVD.It
is strongly recommended to obtain formal angiography for recipient vessel planning in all cases
[21]. In addition to anatomical information, angiography gives information on the consequences
of potential vessel sacrice—for instance, even if
a palpable pulse of the dorsalis pedis is present,
end-to-end anastomosis to this vessel may be
devastating to a foot with an occult occlusion of
the posterior tibial artery, where the plantar pedal
circulation is dependent on retrograde ow from
the dorsal system. Formal angiography sufces
for vessel selection if one of the major systems is
to be used. However, for the minor vessels, angiography alone may not give the spatial information needed to accurately locate suitable
recipients, particularly in the setting of
PVD.Duplex ultrasound has lately become a frequently employed and useful technique for
assessment of minor vessels as recipients for e.g.,
“supermicrosurgery” using aps such as the
SCIP that have small caliber and short pedicles.
The ultrasound generally should be performed by
the surgeon him/herself, who must be an experienced operator of the equipment.
In general, for any critical defect, major vessels are a preferred solution due to their reliability, anatomic consistency, and long-term patency.
“Traditional” workhorse type aps require large
caliber vessels for anastomosis. Major vessels
should never be used when in-line ow to the
vessel is absent or cannot be reestablished by vascular surgery. The downside of using major vessels comes into play in the distal foot, where
intervening tissue between the major vessels at
the ankle and the distal defect becomes a problem
with respect to pedicle placement. This may
require sacrice of intervening skin (making the
wound worse in the case of ap failure), or
unconventional treatment of the pedicle, such as
skin grafting the pedicle itself (Fig. 32.11). As
well, closure over the anastomosis to major vessels often produces compression of the veins,
which creates other considerations for ap inset.
Minor vessels are generally useful when
attempting to minimize the morbidity of reconstruction with the “supermicrosurgical” approach.
Minor vessels are an excellent option in the setting of normal vascular anatomy, or mild to moderate PVD.Minor vessels, for those experienced
with supermicrosurgery, are best used for forefoot/toe defects, dorsal foot defects, ankle
defects, or salvage of partial foot amputations.
Minor vessel anastomosis is generally with endto- end technique. The most common example is
use of the SCIP ap with anastomosis to distal
vessels (Figs. 32.10 and 32.25). This approach
has benets in that small vessels are present
within or immediately adjacent to the wound, and
their preparation requires minimal or no dissection of the foot outside of the wound (Figs.32.5,
32.6, 32.7 and 32.8). This minimizes surgical
trauma to the foot. It also potentially shortens
operative time, as both ap pedicle dissection are
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a
b
c
d
f
e
Fig. 32.25 Use of the rst dorsal metatarsal artery
(FDMA) system as recipient vessels. These vessels are
ideal recipients for reconstruction of open TMA defects.
(a, b) A diabetic man underwent guillotine TMA for necrotizing infection. The green Acland clamp is on the
FDMA. (c) A SCIP ap was used for reconstruction, with
end-to-end anastomosis to the rst dorsal metatarsal
artery and subcutaneous vein. (d) The ap was monitored
using the “scratch test” to look for bright red bleeding. At
1 week post-op, the ap is viable. However, one can see
that nursing staff mistakenly made repeated scratches.
Only one scratch is necessary, and it can be encouraged to
bleed repeatedly with mechanical agitation. (e, f)
Demonstrating healed ap at 8weeks post-op. The wrinkled skin is due to the use of compression wrapping,
which facilitates rapid healing
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J. M. Felder and J. P. Hong
more rapid (using aps with short pedicles), and
recipient vessel preparation is rapid, as only a
short length of small vessels needs to be isolated.
In contradistinction to major vessels, minor vessels can be used when in-line ow is absent; e.g.,
when supplied via collaterals, so long as there is
strong pulsatile outow from the vessel. The
downside of using minor vessels is their anatomic
inconsistency in the setting of PVD, and the anatomical limits imposed by nding appropriate
vessels near enough to the wound when using
aps with very short pedicles. It is essentially
mandatory to use preoperative duplex ultrasound
to conrm the presence and exact location of
usable vessels when taking this approach, as traditional pencil Doppler examination with surgical exploration can be very misleading [22]. The
anatomy of blood supply to minor vessels in the
setting of PVD may be markedly distorted, with
abnormal collateral channels taking unpredictable courses.
In the setting of signicant PVD, we consider
the use of major vessels the safest option. Salvage
in these cases is a difcult prospect, and vessels
with the most reliable and robust ow should be
used, to add substantial tissue and vascularity to
the foot and to simplify the already challenging
variable of recipient vessel selection. Optimization
of major vessels should always be performed by
vascular surgery prior to the ap. Pulsatile vessels
are ideal, but anastomosis to severely atherosclerotic vessels is a common scenario and does not
affect success rates provided that in-line ow is
present and technique is meticulous. We always
employ end-to-side anastomotic technique when
utilizing major recipient vessels, as all diabetics
can be expected to have progression of peripheral
vascular disease over time; maintaining multivessel inow is therefore critical. When major
vessels are not available adjacent to the wound,
such as in the case of a dorsolateral foot defect in
a single-vessel leg fed by the posterior tibial
artery, then vein grafting to the intact major system may be necessary and is preferable to the use
of minor collateral vessels for substantial defects.
Alternatively, when possible, a distal vascular
bypass can be performed by vascular surgery and
anastomosis can be to either the bypass vessel or
the distal reconstitution of, e.g., the posterior tibial artery that the bypass targets (Fig. 32.26).
Muscle aps provide the lowest outow resistance, and so should be used preferentially when
using highly diseased major recipient vessels that
required signicant angioplasty or bypass to serve
as targets. Skin aps with limited vascular beds
create resistance to outow, which may contribute
to thrombosis of vessels that are already tenuous
and have been freshly injured by angioplasty or
bypass anastomosis.
With all of the above in mind, the second step
of our algorithm should be considered as
follows:
Review angiography or other vascular imaging (e.g., ultrasound) and commit to a choice of
recipient vessels, using the best-available
vessels.
• If there is no signicant PVD and high-quality
vessels are available adjacent to the wound,
these should be chosen preferentially, regard-
less of their size.
The supermicrosurgery approach with
small adjacent recipient vessels and thin
skin aps with short pedicles minimizes
operative length and morbidity.
• If severe PVD is present or no suitable small
vessels are adjacent to the wound, major
recipient vessels should be chosen regardless
of their distance from the wound.
Flaps with long pedicles or vein grafting
may be necessary.
• Critical or “high stakes” defects may shift the
decision in favor of major recipient vessels
and highly reliable workhorse aps.
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a
b
c
d
e
f
g
Fig. 32.26 Flaps may be used in conjunction with a distal vascular bypass when no other options for salvage are
available. In this case, muscle aps should be used to provide additional outow for the bypass and assist with
maintaining patency. (a, b) A diabetic man with severe
PVD and long-segment chronic total occlusions of the
anterior tibial, posterior tibial, and peroneal arteries
underwent guillotine TMA for a gangrenous forefoot
wound. The remaining foot was poorly vascularized and
the plantar ap was insufcient for closure of the TMA.
(c) A popliteal to posterior tibial artery bypass was performed to restore ow to the foot. (d) The distal bypass
vessel was then the only available recipient option for a
free ap. (e) Flap anastomosis is performed end-to-side to
h
i
the distal bypass vessel. Access to the forefoot from the
medial ankle is via a trough along the glabrous junction.
The implantable doppler is placed on the recipient vein,
proximal to the venous anastomosis (proximal to coupler
in picture). (f) The serratus muscle ap was chosen
because it has a long pedicle for reach from the ankle to
the forefoot and because the muscle provides a large outow bed (with low resistance) for the bypass. (g) Closure
over the 3 anastomoses was not possible at the conclusion
of the case, and so the anastomoses were covered temporarily with a biologic matrix (Integra Bilayer matrix), and
then later with a full thickness skin graft. (h, i) Stable
result at 3months
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J. M. Felder and J. P. Hong
Flap Selection
A wide variety of aps are applicable to diabetic
foot reconstruction, and their selection and application is limited only by the surgeon’s imagination and the constraints imposed by vascular
disease.
A review of every ap is beyond the scope of
this chapter, and multiple examples are provided
in the included case presentations. However,
pearls and pitfalls relating to ap selection are
presented below. Flaps are considered as “workhorse” and “supermicrosurgical.” Workhorse
aps are all muscle aps, and skin aps such as
the anterolateral thigh (ALT), TDAP, or radial
forearm that are based on larger vascular systems; generally with 2mm or greater caliber vessels. Supermicrosurgical aps are those with
vessel calibers of 1mm or less and include aps
such as the SCIP or PIA.
We typically begin the process of ap selection by rst committing to a choice of recipient
vessels and then choosing a ap based on its pedicle. This is because recipient vessels are often
not normal or even absent in diabetics with PVD
and so the particular anatomy of remaining vessels is a constraining factor in planning the reconstruction. A ap with an appropriate pedicle
length to allow a straight/unkinked lie of the
pedicle and appropriate vessel size for anastomosis to the intended recipient vessels should be
chosen. The particular ap (there are usually
multiple possibilities depending on the reconstructive requirements of the wound) is then chosen based on the combination of its pedicle
characteristics and tissue characteristics. In the
era of supermicrosurgery, the mantra of “bigger
vessels and longer pedicle length are better” is
therefore no longer always true. A ap with a
short pedicle and smaller vessels may very well
be the most advantageous if appropriate recipient
vessels are available next to or within the wound,
whereas a longer pedicle with larger diameter
vessels is favorable for distant recipient vessels
and severe PVD.
In some perforator aps, such as the ALT
and TDAP, pedicle length can sometimes be
adjusted by choosing more proximal or more
distal perforators to supply the skin island, to
achieve either a shorter or longer pedicle length.
The surgeon should also not be afraid to shorten
the pedicle of a ap if doing so allows a better
inset. It is better to have a smaller vessel caliber
with an unkinked pedicle inset, then to have a
longer pedicle with redundancy. Smaller vessel
caliber does not affect ap success rate in our
experience.
After choosing a ap with the appropriate
pedicle, other characteristics of the ap can be
considered to match the wound requirements
and vascular situation. Among the workhorse
aps, it is important to realize that atherosclerosis differentially affects certain ap pedicles.
Generally, aps harvested from the lower
extremity are the rst to be affected, and the
ALT pedicle is the most prone to atherosclerosis
among workhorse aps (the same applies to the
vastus lateralis muscle ap). The ap can be
used despite the presence of atherosclerosis in
the pedicle, but considerable anastomotic technical difculty may be encountered if both the
ap and the recipient vessel are atherosclerotic.
In this situation, some authors advocate the use
of an interposition vein graft at the anastomosis
[23]. Among lower extremity workhorse aps,
the gracilis pedicle, based on the medial femoral
circumex, tends to be relatively spared from
vascular disease. The gracilis is a highly useful
ap in the foot, being highly reliable in its perfusion, having good caliber vessels for anastomosis to either major or minor recipients, and
also a short enough pedicle length to allow
direct coverage of the anastomosis with the
muscle ap itself (Fig.32.5). The sural arteries
also tend to be spared in diabetic PVD, which
makes the medial sural artery perforator
(MSAP) ap a tempting choice. However, the
use of this ap must be considered carefully, as
its donor site is the basis for the posterior ap of
the below knee amputation (BKA) which is a
very realistic eventual prospect for many in this
patient population. Additionally, closure of the
donor site of this ap creates compression or
tightness of the leg, which may be problematic
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for venous drainage of the ap. For these reasons, we do not employ the MSAP in diabetic
foot reconstruction.
The chest vessels are typically the last to be
affected by atherosclerosis and for this reason
the latissimus, serratus, and other derivatives of
the thoracodorsal system are particularly useful
in the setting of PVD. This system offers the
ability to cover large areas and use chimeric
components including muscle, skin, and bone.
Downsides of the latissimus ap are the potential
to create weakness of the shoulder girdle that
may be relevant in transfers (or crutch walking)
for temporarily or permanently nonambulatory
patients. This has not been proven, but is worth
considering. This can be avoided by using the
transverse partial latissimus ap [24], which sacrices some of the area of the ap but preserves
function and maintains the advantage of healthy
ap vessels. Specic pitfalls of the latissimus
and its derivatives are the need to consider pedicle coverage. The usable segment of the thoracodorsal pedicle extends well proximal to the
proximal border of the muscle, so that the muscle does not overlap the anastomosis. This is particularly relevant in the foot and ankle, as
opposed to the leg. There is little soft tissue laxity in the foot to close over an anastomosis, and
the length of the pedicle is such that the muscle
itself cannot be positioned over the anastomosis
without creating redundancy and a risk for kinking. Thus, when using the latissimus on the foot
or ankle, the surgeon should make preparations
for pedicle coverage. This can at times be done
by including a propeller-type island of skin in
the proximal muscle [25]; however, this is inadvisable in obese patients. Other options include
harvest of serratus muscle for pedicle coverage,
skin grafting of the pedicle, or use of a biologic
matrix for temporary pedicle coverage followed
by delayed skin grafting.
The SCIP ap is currently enjoying a surge
of popularity for diabetic foot reconstruction.
The ap can be harvested and completed very
quickly, which is an important consideration
for minimizing operative time in sick patients
[26, 27]. The minimal recipient vessel dissec-
tion minimizes surgical injury to the remaining
foot. The SCIP contours very well to convex
defects and provides rapid skin-to-skin healing
(Figs. 32.6, 32.8, 32.10, 32.25 and 32.27).
However, as previously discussed, the ap does
have some limitations, including: the necessity
of appropriate recipient vessels adjacent to or
within the wound, the thin nature of the skin
that may be less durable for weight bearing
surfaces, and its minimal ability to treat dead
space. The pedicle of the SCIP ap can also be
calcied in the setting of severe PVD such as
that seen in ESRD.In the setting of PVD, when
the ap is anastomosed to abnormal collateral
or other distal vessels, the viability of inow
from these vessels may be uncertain in the long
term, particularly if angioplasty is used to
achieve adequate inow prior to surgery. When
using the SCIP ap, it is important to include
the supercial circumex iliac vein (SCIV) or
supercial inferior epigastric vein (SIEV) as
the venous drainage for the ap, rather than
solely on the vena comitante of the ap.
Isolated use of the perforator vena comitante
has been associated with partial ap necrosis in
our experience, whereas use of the supercial
subcutaneous venous system provides consistent venous drainage. The SCIV is directly
subdermal in the lateral portion of the SCIP
ap, and then penetrates the Scarpa’s fascia
medially. Most of the ap drainage comes from
the lateral association of the vein with the skin.
To maintain a thin ap, it is necessary to keep
the vein with the ap laterally (where it is in
the subcutaneous layer) and then separately
dissect the vein from the medial portion of the
ap (where the vein changes to the subscarpal
layer). The posterior interosseous artery (PIA)
ap is an alternative to the SCIP ap. It is also
very thin, with an even shorter pedicle, which
may be desirable in certain scenarios
(Fig. 32.7). As compared to the SCIP, the
venous drainage is more straightforward, being
reliably drained by the perforator vena comitante. Donor site morbidity is minimal,
although esthetically less desirable than the
SCIP donor site.
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J. M. Felder and J. P. Hong
ab
Fig. 32.27 The SCIP ap is popular in diabetic foot
reconstruction because it is thin and contours well to convex defects. Its short pedicle with small-caliber vessels
allows use of minor recipient vessels near the wound. (a)
First ray amputation defect resulting from diabetic foot
Our general advice on use of the SCIP ap in
the diabetic foot is that it is an excellent option
for diabetics without severe PVD, in which only
skin coverage is required without signicant
need for dead space obliteration. In this setting,
it provides a rapid and simple solution with minimal reconstructive morbidity. Use of the SCIP
ap in patients with severe PVD should be
approached more carefully. In this setting, recip-
ient vessel mapping with ultrasound and ow
velocity measurements is critical, as normal
infection. (b) 10 weeks following reconstruction with
SCIP ap. The patient had a congenitally absent dorsalis
pedis, and the ap was anastomosed to a dorsal foot small
perforator artery and subcutaneous vein
small-vessel vascular anatomy is inherently
abnormal. Published literature from authors
experienced with SCIP reconstruction has identied concomitant PVD and history of prior
amputation as the only two signicant predictive
factors for ap failure [28]. Use of essentially
the terminal portion of a diseased vascular system for inow has the twin disadvantages of
unpredictable inow and skin healing to potentially diseased surrounding tissues. Many surgeons who use SCIP aps in the setting of PVD
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routinely utilize hyperbaric oxygen therapy
(HBOT) as an adjunct. In many health systems,
this is a difcult proposition with regard to logistics and insurance coverage.
The SCIP can be used in cases of PVD and
is used by the authors. However, attention to
the details noted above is critical. Ultrasound
mapping of recipient vessels with flow velocity measurements, consideration for pre- and
postoperative use of HBOT, and enough experience with supermicrosurgery to allow flexibility in decision-making. The chosen minor
recipient vessel must have strong pulsatile
flow, not impaired flow, in order for the flap to
be successful; this is where ultrasound mapping with flow velocity becomes useful.
Additionally, the surgeon must respect the
angiosomes of the foot and ankle and realize
that in the setting of PVD, the wound may be a
declaration of failure of the entire angiosome.
Thus, the entire angiosome may need to be
resected to properly prepare the defect, such
that the defect edges will have sufficient perfusion to heal to the flap [28].
With regard to the longstanding question of
whether muscle or fasciocutaneous aps are
preferable, this remains subject to debate. We
suggest not viewing this question as binary—it
has subtleties that need to be considered.
However, it is the authors’ recommendation that
muscle aps still be frequently employed as an
option, even in the setting of “advanced reconstruction.” Diabetic foot reconstruction is complex, and efforts to improve outcomes should be
utilitarian. Simplifying ap factors can remove
one more element of difculty from the equation. Several other factors make muscle aps
very useful. Muscle is the best substrate for conforming to irregular contours and lling dead
space, which is often a concern in more grave
wounds (which frequently are those requiring
free tissue transfer). Muscle adheres more rapidly to the underlying tissue bed, reducing the
risk of seroma or abscess formation. Although
the efcacy of particular ap types for coverage
of osteomyelitis as a global issue probably has
more to do with adequate bony debridement and
host factors than with ap choice, it has been
our experience nonetheless that muscle is very
effective for adhering to bone and providing
rapid tissue healing, which seems to be helpful
in the setting of infection. When extensive tendon coverage is necessary, aps lined with fascia on their undersurface, such as the
fasciocutaneous ALT, are more prone than muscle to have delayed adherence to the underlying
tendons and allow uid collections to form. This
is because the undersurface of fascia is poorly
vascularized and because muscular fascia is, by
design, relatively inexible. Whereas this may
be desirable in areas where tendon excursion is
critical such as hand reconstruction, it represents a considerable risk in the diabetic foot
population where rapid resolution of wound and
infection is the paramount consideration
(Figs.32.22, 32.23 and 32.24). Muscle also has
the advantage of thin coverage after atrophy has
taken place, which allows return to normal footwear. Finally, muscle aps also have a largervolume vascular bed which equates to greater
outow and lower outow resistance. This is an
important consideration in situations where the
risk of arterial thrombosis is high (such as in the
case of severely calcied recipient vessels without normal intima or when vein grafts are used),
or in instances where the ap is critical to maintain the patency of a vascular bypass or angioplasty. A larger outow bed and lower outow
resistance may add to the durability of vascular
interventions such as angioplasty or bypass, as
compared to smaller skin aps or the native diseased microvasculature which have a high resistance to ow (Figs.32.26 and 32.28).
In contrast, fasciocutaneous aps of the foot
are more likely to require revisions for contour
issues [29], particularly in the setting of obesity,
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