Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

7. Freeman BS. Plantar flaps used for sole, heel lesions, Texas J Med 1968; 64:64.
8. McFarlane RM. Hyperkeratosis and ulceration of the heel in the nonparaplegic patient. Plast Reconstr
Surg 1962;29:674.

Chapter 533
Fasciocutaneous Cone Flap
W. CALDERÓN
P. ANDRADES
P. LENIZ
J. L. PIÑEROS
S. LLANOS
R. ROA
O. IRIBARREN
M. STEINER
D. CALDERÓN
The fasciocutaneous cone flap is a reliable and versatile option consisting of the combination of a rotation flap
and a V-Y flap. The final shape of the repair is a cone, and the flap can be used to cover defects in various parts
of the body (1, 2, 3, 4, 5, 6, 7, 8, 9).
INDICATIONS
The fasciocutaneous cone flap was initially designed to cover exposed bone in an open, lower-extremity
fracture (Fig. 533.1). When osteomyelitis is present, a muscle flap is preferred; however, when no evidence
of infection is found, this fasciocutaneous flap is indicated.
FIGURE 533.1 A: Open wound with bone exposed. B: A rotation flap is rotated to cover the defect. C: A
cone fasciocutaneous flap is elevated superiorly to close the defect created by the rotation flap.
ANATOMY
The rotation and V-Y flaps are random-pattern fasciocutaneous flaps, with their blood supply coming from the
deep arteries. Sensation to the flap is preserved.

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FIGURE 533.2 A: Triangular flap elevated on fascial bed and advanced to fill the defect created by the rotation.
B: AV-to-Y closure. C: Late postoperative photograph.
FLAP DESIGN AND DIMENSIONS
The flap is elevated like a rotation flap, with a 1:1 width-to-length ratio. The donor site is covered with a V-Y
fasciocutaneous flap, which has a 3:1 height-to-base ratio. The result is a cone-shaped flap (Fig. 533.2).
OPERATIVE TECHNIQUE
The primary defect is first covered by a rotation fasciocutaneous flap. A V-Y advancement fasciocutaneous flap
is then designed to close the donor site. It is important to free the fascia all around the V-Y flap, to achieve the
best advancement (Figs. 533.3 and 533.4).
FIGURE 533.3 A: A traumatic defect at the ankle. B: This is closed with a rotation flap and a sliding cone flap.
CLINICAL RESULTS
Between June 2002 and March 2007, we operated on 100 patients with this technique. All were men, and
patient ages ranged from 20 to 52 years. Initially, we began with open fractures of the distal lower extremity
(tibia), and, because of good results, we subsequently treated other parts of the
body with the same procedure (elbow, plantar region, big toe, arm, calvaria, and ankle). The cutaneous
defects ranged from 0.5 to 3.5 cm2. We experienced one necrosis of a V-Y flap and one necrosis of a
rotation flap; both were repaired with split-thickness skin grafts.

FIGURE 533.4 A healed defect with a rotation flap and a cone flap on the sole of the foot.
SUMMARY
This cone-shaped flap, versatile for use at different physical locations, is especially practical when local
physical characteristics are to be preserved.
References
1. Calderón W, Andrades P, Leniz P, et al. The cone flap: a new and versatile fasciocutaneous flap. Plast
Reconstr Surg 2004;114:6.
2. Calderón W, Chang N, Mathes SJ. Comparison of the effects of bacterial inoculation in musculocutaneous
and fasciocutaneous flaps. Plast Reconstr Surg 1986;77:785.
3. Fix RJ, Vasconez LO. Fasciocutaneous flaps in reconstruction of the lower extremity. Clin Plast Surg
1991;18:571
4. Hallock GG. Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds. J Trauma
1989;29:1240.
5. Hallock GG. Distal lower leg random fasciocutaneous flaps. Plast Reconstr Surg 1990;86:304.
6. Healy C, Tiernan E, Lamberty BG, Campbell RC. Rotation fasciocutaneous flap repair of lower limb
defects. Plast Reconstr Surg 1995;95:243.
7. Masquelet A, Gilbert A. Flaps in limb reconstruction. London: Martin Dunitz, 1995.
8. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg
1981;34:215.
9. Tolhurst DE, Haesecker B, Zeeman RJ. The development of the fasciocutaneous flap and its clinical
applications. Plast Reconstr Surg 1983; 71:597.

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Chapter 534
Bipedicle Skin Flap to The Heel
N. I. ELSAHY
EDITORIAL COMMENT
Random flaps, especially in the vascularly compromised patient, are less secure than when the flaps are
fashioned over a known arterial blood supply.
When there is deep tissue loss over the posterior heel, coverage should be accomplished by a flap. Local
random pattern skin flaps are poorly vascularized and must be delayed before transposition. To improve the
blood supply to a random pattern skin flap and to eliminate the need for delay, a local bipedicle skin flap may be
used (1).
INDICATIONS
This bipedicle skin flap has been used to repair ulcers of the non-weight-bearing areas of the heel caused
by pressure from a tight cast, immobilization in bed, direct trauma, and excision of a tumor or congenital
sinus.
FIGURE 534.1 A: Pressure ulcer in the posterior heel. The ulcer was deep to the bone, with destruction of
the overlying periosteum. B: Incision in the lateral aspect of the foot, with V backcut made superiorly and
inverted V backcut inferiorly to facilitate mobilization of the flap. C: Healed flap and donor site.
The vertical bipedicle flap has the following advantages:
1. It involves a simple one-stage operation.
2. It eliminates skin-graft complications over the defect, such as graft loss, hyperkeratosis, an unstable graft,
and a painful scar.
3. It covers the defect with a thick layer of skin and subcutaneous tissue with good sensation, helping to
prevent recurrence of the ulcer.
4. The donor area is placed well on the side of the foot, where a skin graft will “take” more easily and
remain stable.

FLAP DESIGN AND DIMENSIONS
This bipedicle skin flap to the heel is an advancement flap. Its length is twice that of the defect and usually varies
from 4 to 6 cm. The width of the flap should be at least half the length, that is, about 2 to 3 cm. The lateral
incision should parallel the vertical long axis of the ulcer (see Fig. 534.1). Two bipedicle flaps, one on each side
of the defect, may be used if the defect is too large to be closed with only one flap.
OPERATIVE TECHNIQUE
A backcut extension of the upper end of the lateral incision as a small V and of the lower end as an inverted V
facilitates mobilization of the flap (Fig. 534.1B). The flap is then undermined, advanced, and sutured in place.
The donor area is covered with a split-thickness skin graft.
CLINICAL RESULTS
This flap is not without complications. Skin necrosis at the suture line may occur, especially if the defect is
large and the patient is diabetic or has peripheral vascular disease. There is no functional deficit from using
this flap.
SUMMARY
A random pattern bipedicle skin flap can be used to cover heel defects.
Reference
1. Elsahy NI. The use of the bipedicle flap for the repair of ulcers in the non-weight-bearing areas of the heel.
Acta Chir Plast 1978;20:34.

Chapter 535
V-Y Advancement Flaps to The Heel and Ankle
Y. MARUYAMA
Y. IWAHIRA
EDITORIAL COMMENT
This presents a most helpful maneuver for the coverage of defects in the heel, with similar type of skin. It
has the advantage of providing coverage “of the same kind” and avoids the problems of friction and
insensitivity.
The V-Y advancement subcutaneous pedicle flap is useful for reconstruction of relatively small defects,
especially in the lower leg. This flap, because of the attached local pedicle, provides comparatively safer
applications than other flaps, even in the heel and ankle areas (1, 2, 3).
INDICATIONS
A difficult part of reconstructing ankle and heel defects is coverage of the exposed calcaneal tendon and
bony prominence. Because of the location of such defects and the constant wearing of shoes, even small
skin defects often present problems of healing. Past experiences with cross-leg flaps have provided less
than satisfactory solutions, because of the prolonged immobility required and the resultant defect in the
contralateral donor leg. There is also a problem with a satisfactory blood supply in these areas, using a
conventional local flap.
The V-Y advancement flap has the advantages of short operating time in one stage; it does not require
division of the pedicle, and color and texture matches are excellent. The remaining tissue can be effectively
used, and skin grafting is not required at the donor site. Moreover, this local triangular flap, including fascia,
with closure in a V-Y fashion, encourages a safe blood supply in the ankle region (1). For more reliable
results, we limit this procedure to patients under 60 years of age without systemic vascular disease. The
flap has also been reported for use in the facial region (4, 5).
FLAP DESIGN AND DIMENSIONS
The triangular flap is designed to be 1.5 to 2 times as long as the diameter of the defect in the plane of
advancement, and with its base equal to the perpendicular diameter of the defect (Fig. 535.1A). To facilitate a
more distant advancement, the thickness of the layer of undermining between the distal and proximal portions of
the flap is varied, taking every precaution to preserve the underlying subcutaneous structures. For flap survival
and mobility, a ratio of 1:2 can be recommended. In our experience, flaps have been easily moved between 1.0
and 3.5 cm.
OPERATIVE TECHNIQUE
The incision is made, following a triangular design (Fig. 535.1A). We undermine the distal end of the flap in the
subcutaneous layer as little as necessary. The opposite end of the flap, consisting of a component with
subcutaneous and fascial tissues, is deeply undermined under the fascia (Fig. 535.1B). Freeing is continued,

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until the flap moves into the defect with minimum tension (Fig. 535.1C). The pedicle, including the fascia, should
be as broad and deep as possible, especially if undermining is close to the original wound. Blunt dissection is
recommended. The flap is sutured with subcuticular 5-0 Vicryl at the advancing edge and at the V-Y junction
(Fig. 535.1C).
CLINICAL RESULTS
Most of our cases healed without complications. The donor sites were all closed primarily (Fig. 535.1D).
Superficial distal skin necrosis at the distal margin may occur; however, reepithelialization occurs within 2
weeks postoperatively. There has been no functional deficit, and the flaps have endured against constant
friction for a long time.
SUMMARY
A V-Y advancement pedicle flap, including fascia, is used for reconstruction of soft-tissue defects in the heel
and ankle region.

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FIGURE 535.1 A: A 7-year-old boy with a defect at the posterior heel. The V-Y flap is designed adjacent to
the defect. B: Elevation of the flap, varying the thickness of undermining as little as possible to resurface
the defect. C: Transposition of the flap. D: Appearance 1 year postoperatively. (From Maruyama Y, et al,
ref. 1, with permission.)
References
1. Maruyama Y, Iwahira Y, Ebihara H. V-Y advancement flap in the reconstruction of skin defects of the
posterior heel and ankle. Plast Reconstr Surg 1990;65:786.
2. Iwahira Y, Maruyama Y. The design of a plantar flap with respect to plantar fissures. Jpn J Plast Surg
1992;35:293.

3. Colen LB, Replogle SL, Mathes Si. The V-Y plantar flap for reconstruction of the forefoot. Plast Reconstr
Surg 1988;81:220.
4. Zook EG, Van Beek AL, Russell RC. V-Y advancement flap for facial defects. Plast Reconstr Surg
1980;65:786.
5. Argamaso RV. V-Y-S plasty for closure of a round defect. Plast Reconstr Surg 1974;53:99.

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Chapter 536
Deepithelialized “Turnover” Skin Flap of The Lower Leg and Foot
R. L. THATTE
N. LAUD
EDITORIAL COMMENT
Anatomic knowledge of the septocutaneous vessels that are segmental branches from the three main
arteries supplying the leg is the basis for these turnover flaps. The segmental septocutaneous vessels that
arise at intervals from each of the three vessels into the leg, the last one approximately 10 cm above the
medial malleolus, course through the intermuscular septum, perforate the fascia, and arborize on top of the
fascia to supply the overlying skin and connect with vessels above and below. If only one of the
septocutaneous vessels is maintained intact, then an independent territory can be outlined that can either
be made into a proximally or distally based, flap or a “turnover” flap, as demonstrated in this chapter.
One-stage skin-flap coverage from local tissues is an ideal solution for complicated wounds in any part of the
body. The one-stage random-pattern and axial-pattern deepithelialized “turnover” flaps of the lower leg and foot
fulfill this expectation (1, 2, 3, 4).
INDICATIONS
The turnover flap is a simple, quick, one-stage procedure and is particularly suitable for longitudinal defects
on the lower leg, where the application of other local flaps is limited. Defects that need skin-flap coverage
may have partly scarred skin on their periphery. The base of a turnover flap can be placed in such a
scarred area as long as the area has intact tendons or muscles underneath it. When the flap turns over, it
covers its own base. If the base area is scarred, the flap cover improves its quality; however, the flap should
not be used if the base is undermined.
The turnover flap is especially useful when there is still a defect adjacent to a previously transferred flap. In
actual practice, rotation or transposition of the existing flap skin to the adjacent area is a difficult maneuver,
because any transferred skin flap is surrounded on all sides by scarring. This problem can be overcome by
a deepithelialized turnover flap out of the existing flap skin (see Fig. 536.1).
The procedure reduces the risk of partial or major failures in the transfer of skin flaps of large dimensions
around the whole circumference of the lower extremity (see Fig. 536.2). There also appears to be a strong
possibility that the fascia in the lower leg can be transposed or turned over to cover defects with exposed
bone. When it comes to sacrificing tissue, the fascia might be a more appropriate choice than muscle (5).
ANATOMY
The principal blood supply to skin comes from the perforator vessels (6) (Fig. 536.2). A random-pattern flap
survives mainly on the blood supply from these perforator vessels, the circulation in skin being carried forward by
the intradermal anastomoses. The deepithelialized surface of the flap is the more vascular of its two surfaces
because of exposed rich intradermal anastomoses. When the flap turns over, this

surface advantageously faces the defect. In contrast, the raw undersurface of a conventional skin flap has a thin
layer of fat covering it.
FLAP DESIGN AND DIMENSIONS
Figure 536.2 shows a complicated wound overlying the tibia and the blood supply of an area of skin on the
medial side of the wound. A flap raised from this area with an adequate base-to-length ratio (base unit = x, flap
units = 3x) should survive (Fig. 536.2A), even if the surface of the flap, as well as its base, is deepithelialized.
This is so because the technique of taking a medium-thickness skin graft leaves the intradermal anastomoses
intact.
A deepithelialized turnover dorsalis pedis flap for a lateral malleolar defect has been recently reported (6, 7), its
advantage being that a dissection in front of the ankle is not needed to convert the flap into an island to facilitate
its transposition. The deepithelialized turnover dorsalis pedis flap is also quite likely to be useful for defects in the
lowest anterior surface of the leg. The dimensions of such a flap are about equal to the anterior half of the
circumference of the lower leg (see Fig. 536.3).
OPERATIVE TECHNIQUE
Figure 536.2B shows the flap turned over on itself and covering the defect on the tibia. In the drawing (as well as
in clinical practice), the area where the flap turns over on itself is a gentle curve, allowing unhindered circulation.
The turned-over surface of the flap needs skin-graft cover. The defect left by flap transfer is covered by a split-
thickness skin graft removed at the time of deepithelialization (Figs. 536.1 and 536.4, 536.5, 536.6).
CLINICAL RESULTS
In the 3 years of my experience, I have lost only one turnover flap of a total of 32 in the lower leg and foot.
The failure was due to a faulty plan, according to which the base of the flap was undermined from the side
of the chronic posttraumatic ulcer over which the flap turned over.
Seven out of a total of over 60 deepithelialized flaps executed in the upper and lower (2, 5, 7, 8, 9)
extremities in the last 3 years have by now presented with discharging sinuses on their periphery. Of these,
one sinus was confirmed to be due to osteomyelitis. In another patient, the discharge was occasional and
minimal, and no active treatment was undertaken. In the remaining five patients, buried epithelium was
responsible for the chronic discharge. The lesions were treated by placing a sinus probe in the discharging
tract and excising the epithelial cyst and the tract by an incision placed over the probe. The wound was
closed primarily and healed primarily in all five patients.
SUMMARY
Notwithstanding the preceding complications, the deepithelialized turnover flap is valuable for defects in the
lower leg and foot. Its application for salvage where losses have occurred in skin flaps during transfer is
equally valuable. The procedure is quick and safe and can be executed in one stage.

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FIGURE 536.1 A,B: Instead of achieving flap cover over the whole area at one time, a flap of approximately
250 cm2 was first transferred on the posterior side of the leg from the opposite thigh in two stages (cross-
thigh flap). (Continued)
FIGURE 536.1 (Continued) C,D: This flap in its lower four fifths was then divided into two equal parts, each
part to be turned over after deepithelialization, for a defect in front of the ankle. E: The base for the two
turnover flaps was a long strip of about 2-cm width at its own periphery. The base of the turnover flap on
one side is shown by cross-hatching. F,G: The flaps were turned over and sutured in the midline anteriorly.
The turned-over flaps, as well as the defect left by the maneuver, were covered by a split-thickness skin
graft. The final result, was a healed and stable area. Note that the bulk of the original flap has been shared,

P.1457
leading to a more pleasing appearance. Elastic support with bandages is not needed.
FIGURE 536.2 A: Cross section of the leg showing a wound over the tibia and the blood supply to intact
skin on the medial side of this wound. A deepithelialized flap is raised from the skin medial to the wound
over the tibia. B: The flap turned over.
FIGURE 536.3 Hypothetical use of a deepithelialized dorsalis pedis flap for defects on the anterior
circumference of the lower leg.

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FIGURE 536.4 A: An 18-year-old man was admitted to the hospital with a posttraumatic ulcer measuring
approximately 2 cm in transverse diameter over the Achilles tendon. The ulcer had failed to heal following
two attempts at split-thickness skin grafting, and skin flap cover was considered essential. B: An area
approximately 4 cm in diameter was marked on the medial side of the ulcer. This was deepithelialized, and
the skin was removed as shown. The line on the deepithelialized site shows the 1-cm2 area that is left intact
as the base of the flap. C: The flap was turned over and sutured over the ulcer. The defect left by the flap
transfer was covered by skin removed at the time of deepithelialization. The turned-over flap then was
covered with a split-thickness skin graft from another location. D: A healed, stable area 6 months
postoperatively.

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FIGURE 536.5 A: A 9-year-old boy was admitted to the hospital with a dense adherent scar 9 cm vertically
and 5 cm transversely in front of the ankle. There was a history of an avulsion-crush type of injury. B: X-ray
showing fracture of the tibia and loss of the lower portion of the tibia. Skinflap cover was considered
essential prior to treatment of bony defect near the ankle. C: An area 9 cm vertically and 8 cm transversely
was marked for deepithelialization on the lateral side of the leg and foot. D: A deepithelialized flap from this
area being turned over. Flap size is 9 × 6.5 cm. E: Flap well settled 6 months postoperatively.
FIGURE 536.6 A: A small area in the distal part of a cross-leg flap had become necrotic, producing an ulcer
that measured 5 × 2.5 cm. An area 5 × 5 cm was marked out to the medial side of the ulcer over the dorsum
of the foot, and the whole of this area was deepithelialized. B: The crosshatched area (1 cm wide) shown in
part A also was deepithelialized but was left attached to its bed as the base of the flap. C: The turnover flap
was sutured over the ulcer, and all the raw surfaces were covered by a split-thickness skin graft. D: The
graft “took” completely, and the area remained soundly healed when reviewed 3 months later. (From
Thatter et al., ref. 7, with permission.)

References
1. Pakiam AI. The reverse dermis flap. Br J Plast Surg 1978;31:131.
2. Thatte RL. Random-pattern deepithelialized “turnover” flaps to replace skin loss in the upper third of the
leg. Br J Plast Surg 1981;34:312.
3. Mahler D, Yanai E. The deepithelialized hinged flap. Ann Plast Surg 1981;7:298.
4. Thatte RL. One-stage random-pattern deepithelialized “turnover” flap in the leg. Br J Plast Surg
1982;35:287.
5. Daniel RK, Williams HB. The free transfer of skin flaps by microvascular anastomosis: an experimental
study and reappraisal. Plast Reconstr Surg 1973;52:16.
6. Thatte RL, Patil D, Talwar P. Deepithelialized “turnover” axial-pattern flaps in the lower extremity. Br J
Plast Surg 1983;36:327.
7. Thatte RL, Dhami LD, Patil UA. Deepithelialized turnover flaps for “salvage” operations. Br J Plast Surg
1983;36:178.

Chapter 537
Reversed Dermis Flap
A. I. PAKIAM
The reversed dermis graft has been used for coverage of small areas of devitalized tissue after debridement (1).
The reversed dermis flap is a logical extension of the concept of the reversed dermis graft.
INDICATIONS
There are advantages in deepithelializing a flap and applying it dermis side down. While still kept alive by its
pedicle, the numerous cut vessels of the dermal surface have a much greater potential for making sufficient
anastomoses, particularly on poor beds, than the relatively avascular fatty undersurface of the conventional
flap. Its use not only increases the number of possible flaps for repair of a given defect but simplifies flap
repair in many instances. The reversed dermis flap is especially good for foot and ankle defects with
exposed bone (2). It also has been used for reconstruction in many other areas of the body (2, 3, 4, 5, 6, 7,
8, 9, 10, 11, 12).
ANATOMY
A study of the blood supply of the skin demonstrates that the vessels at the subdermal level branch repeatedly
as they approach the skin surface and, therefore, become smaller and more numerous. This difference is evident
when one compares a skin graft taken at a more superficial level with one taken at a deeper level. The
superficial graft site shows multiple, punctate, smaller bleeding vessels, whereas the thicker graft site
demonstrates larger, fewer vessels. The former situation exposes more vessels for a vascular linkup of tissue
transplants and aids in the “bridging” phenomenon, where small avascular areas may be covered successfully.
FLAP DESIGN AND DIMENSIONS
Two main types of flaps can be recognized: the direct bridge pedicle flap, used between adjacent digits or limbs
or as distant flaps, and local turnover flaps, where the pedicle could remain intact by deepithelializing the skin
bridge itself.
The established differences between axial and random flaps apply to reversed flaps. Whenever possible, an
axially based flap should be used. Similarly, a local flap is preferable to a distant flap.
On the extremities, it would seem logical to use proximally or distally based turnover flaps. In larger defects, one
may be faced with a near circumferential operated area with an attendant increased incidence of peripheral
lymphedema with side flaps.
OPERATIVE TECHNIQUE
Because of a more rapid “take” of the flap, division is earlier than for conventional flaps. Because the flap usually
involves just one stage, the procedure is less involved than either distant or free flaps.
The bases of flaps that are turned over 180 degrees are easily kinked, with disastrous results. Occasionally,
epithelial cysts occur that may require excision (Fig. 537.1).
SUMMARY

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The reversed dermis flap can be used to cover exposed ankle and foot defects. The possibilities of this flap
are protean, and it is anticipated that more uses for this flap will be found in the future.
FIGURE 537.1 A: Chronic painful ulcer of the medial malleolus with exposed bone. The hatched area is
deepithelialized. B: After debridement, the defect was covered by a proximally based reversed dermis flap
with a deepithelialized skin bridge in one stage. C: Both the flap and the donor site are covered with a
medium-thickness split-thickness skin graft. D: The result at 3 weeks. The small area of overgraft failure on
the donor site will heal spontaneously. Pain has been relieved.
References
1. Hynes W. The skin dermis graft as an alternative to the direct or tubed flap. Br J Plast Surg 1954;7:97.
2. Pakiam AI. The reversed dermis flap. Br J Plast Surg 1978;31:131.
3. Braithwaite F. Closure of a tracheooesophageal fistula. Br J Plast Surg 1961;14:138.

4. Hasman L. Uzaver defektu bronchopleurokutannimi pistelemi dekortikovanym lalokem. Acta Chir Orthop
Traumatol (Czech) 1967;34:6.
5. Clodius L, Smahel J. The reverse dermal-fat flap: an alternative cross leg flap. Plast Reconstr Surg
1973;52:85.
6. Maurice DG, Sharma DP. Repair of pharyngocutaneous fistula. Br J Plast Surg 1975;28:268.
7. Harashima T, Wadoa M, Inai T, Kakegawa T. A turnover deepithelialized deltopectoral flap to close
fistulae following antethoracic oesophageal reconstruction. Br J Plast Surg 1979;32:278.
8. Leonard AG. Reconstruction of the chest wall using a deepithelialized “turn over” deltopectoral flap. Br J
Plast Surg 1980;33:187.
9. Mahler D, Yanoi E. The deepithelialized hinged flap. Ann Plast Surg 1981;7:298.
10. Morris A McG. Rapid skin cover in hand injuries using the reverse dermis flap. Br J Plast Surg
1981;34:194.
11. Thatte RL. Random-pattern deepithelialized “turn over” flaps to replace skin loss in the upper third of the
leg. Br J Plast Surg 1981;34:312.
12. Tomono T, Hirose T, Matsuo K, Matsui, T. A denuded “turn over” deltopectoral flap combined with a
latissimus dorsi myocutaneous flap in the repair of extensive radionecrosis of the chest wall. Br J Plast Surg
1982;35:63.

Chapter 538
Filleted Toe Flap
A. J. J. EMMETT
Neurovascular island flaps, particularly those of toe skin, offer readily available skin that can be turned onto the
weight-bearing metatarsal head area (1, 2, 3). A patient whose ability to walk is limited by a chronically painful
area on the sole is often happy to exchange the toe for a painless foot (3).
INDICATIONS
Repairs of the sole of the foot are complicated by the specialized requirements of the skin and
subcutaneous tissue in that area. The firm adhesion of skin to plantar fascia limits skin mobility and makes it
a firm gripping pad for heavy traction. The lobulated fat cells between the skin and plantar fascia give the
skin in this area a resilience unlike most other skins. The rugose nature of the skin provides an ideal nonslip
surface.
Sensation is the all-important factor, and over the long term, a flap must have adequate sensation for
survival. It is well known that a flap transferred from the groin or abdomen to the sole of the foot is initially
firm but later becomes floppy. Local flaps on the sole of the foot can be transferred from non-weight-bearing
areas and a graft placed in the donor site. With dissection, these flaps tend to lose sensation to a degree,
and they are limited in size. I have used this method in a number of patients to repair the chronic scarred
painful area on the sole of the foot subsequent to repeated surgery or injury (see Fig. 538.3).
FLAP DESIGN AND DIMENSIONS
Generally, all the soft tissue of the toe is used in the flap, discarding the skeleton. Alternatively, one-half the toe
skin on one neurovascular bundle could be used, grafting the resulting defect on the toe.
The neurovascular pattern of the foot (Figs. 538.1 and 538.2A) allows a toe flap to be hinged as far back as the
plantar arch, although dissection deep to the toe flexors is involved. The big toe has been used as a
neurovascular island for a heel defect (2), and the second and third toes have been used for heel repair (1). For
replacement of a defect in the metatarsal head area, the toe may be hinged at the level of the transverse plantar
ligament.
OPERATIVE TECHNIQUE
The toe is opened dorsally (Fig. 538.2A), and the soft tissues are dissected from the skeleton, identifying the
neurovascular bundles (Fig. 538.2B). The toe skeleton then can be removed with or without the metatarsal head,
depending on the foot and its requirements. The neurovascular bundles are identified and mobilized, dividing the
transverse ligament. The toe skin is freed, and excess skin at the base of the toe may be resected (Fig. 538.2C).
The toe then is free to hinge into the defect (Fig. 538.3).
CLINICAL RESULTS
The lost toe presents a minor cosmetic disability, but it is well accepted after adequate discussion with the
patient (see Fig. 538.3E). The flap has good circulation, and no vascular problems have been encountered.
Healing and long-term survival of the flap are excellent.

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SUMMARY
The filleted toe flap is an excellent way to provide durable, well-tolerated tissue to the sole of the foot.
FIGURE 538.1 The neurovascular anatomy of the foot, demonstrating that a flap can be filleted from the toe
and transferred as far back as the heel. (From Emmett, ref. 3, with permission.)
FIGURE 538.2 A: The design of the flap. B: The toe is skeletonized on its neurovascular bundles. C: The

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bony structures, with or without the metatarsal head, are removed and the flap is transferred. (From
Emmett, ref. 3, with permission.)
FIGURE 538.3 A: An avulsion injury of the foot with loss of skin and fat. B: After a split-thickness skin graft
had healed the wound and narrowed the defect, the patient was left with a painful area on walking. He
needed replacement of the missing fat pad and skin. C: An example of a filleted toe flap after elevation and
removal of the skeleton. (Continued)
FIGURE 538.3 (Continued) D: A filleted toe flap was then used, producing a stable area that was not
painful on walking. E: The donor site leaves a minor cosmetic deformity. (From Emmett, ref. 3, with
permission.)
References
1. Snyder GB, Edgerton MT. The principle of the island neurovascular flap in the management of ulcerated
anaesthetic weight-bearing areas of the lower extremity. Plast Reconstr Surg 1965;36:518.
2. Kaplan I. Neurovascular island flap in the treatment of trophic ulceration of the heel. Br J Plast Surg
1969;22:143.
3. Emmett AJJ. The filleted toe flap. Br J Plast Surg 1976;29:19.

(Trang không có chữ)

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Chapter 539
Reverse Anterior Tibial Artery Flap
Y. P. PENG
EDITORIAL COMMENT
This is a very sophisticated flap for resurfacing the ankle and foot but fraught with difficulties. The arterial
circulation is not reliable and must be checked before turning the flap down, either preoperatively with
radiology or intraoperatively with release of tourniquet. The author has not reported how many cases he
has abandoned. Venous congestion is an expected problem in this reverse flow flap.
The reverse anterior tibial artery flap is designed for foot and ankle resurfacing. Illustrated are the anatomy of the
malleolar-, tarsal-, and metatarsal-level anastomoses between the anterior and posterior tibial artery system that
perfuses the flap, the surgical technique, and measures to avoid complications.
INDICATIONS
Skin defects in the ankle and foot region have always been a difficult resurfacing problem (1, 2, 3, 4). Free
flaps are often indicated. The reverse anterior tibial artery flap was first designed for resurfacing the donor
site of the big toe wrap-around flap
(5, 6). A long and thin flap (3 × 8 cm) was used to reconstruct the plantar surface of the big toe. The
indications were subsequently extended for the reconstruction of larger defects on the dorsum of the foot
and ankle.
This anterior tibial artery flap can be used in antegrade fashion to resurface proximal defects around the
knee and proximal tibia. It can also be harvested as a free flap or as an osteocutaneous flap incorporating
part of the bony tibia.
ANATOMY
Anatomy of the Anterior Tibia-Dorsalis Pedis-First Dorsal Metatarsal Artery
The anterior tibial artery supplies the skin of the anterolateral aspect of the leg. Multiple fasciocutaneous
perforators traverse through the extensor and peroneal compartment to reach the skin in the proximal half of the
leg (7, 8, 9, 10). Proximally, the anterior tibial artery lies between the tibia and the tibialis anterior muscle (TA),
close to the deep peroneal nerve. Pedicled flaps based on these perforators will require tedious dissection, if
proximal dissection to the vascular pedicle is required.

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FIGURE 539.1 Top: Periosteal perforators of the anterior tibial artery supplying the flap, with tibialis anterior
muscle retracted laterally. Bottom: Cross section of leg illustrating relation of anterior tibial artery periosteal
perforator with interosseous membrane and lateral surface of tibia.
We observed periosteal perforators that reach the skin in the plane between the tibia and the tibialis anterior
muscle, lying on the periosteum of the bone (Fig. 539.1). On average, five to seven well-spaced periosteal
perforators are found along the length of the tibia. These perforators were first mentioned by Crock and Morrison
(10), and a periosteal flap based on these perforators was successfully used to cover a tibial nonunion defect in
1992.
The anterior tibial artery gains a more superficial position distally, to lie between the tendons of the extensor
hallucis longus (EHL) and the extensor digitorum longus (EDL) below the extensor retinaculum, before emerging
as the dorsalis pedis artery in the ankle. The accompanying deep peroneal nerve has already given off its
muscular innervations in its distal course. Thus raising the anterior tibial flap based on the distal periosteal
perforators requires less dissection and better preserves vascularity and innervation of the limb. Because they
are closely adherent to the periosteum of the tibia, segments of periosteum must be harvested to preserve these
perforators.

FIGURE 539.2 Reverse anterior tibial flap anatomy. Schematic diagram illustrating the three levels of ankle
anastomoses of anterior and posterior tibial systems supplying the flap.
The reverse-flow anterior tibial artery flap can be harvested and is vascularized by the anastomotic plexus
between the anterior tibial and posterior tibial arterial system around the ankle and in the foot. The deep plantar
artery, a branch of the dorsalis pedis artery, communicates with the deep plantar arch, a continuation of the
lateral plantar artery, at the base of the first metatarsal. This forms the most-distal and most-significant
anastomosis (level 1, metatarsal anastomosis). Arising 4 cm proximal to the deep plantar artery are the medial
and lateral tarsal branches of the dorsalis pedis artery (level 2, tarsal anastomosis). The medial and lateral
malleolar branches originate a further 2 cm proximally (level 3, malleolar anastomosis). The tarsal branches are
covered by the muscle of the extensor hallucis brevis muscle, which can be used as a landmark (Fig. 539.2).
FLAP DESIGN AND DIMENSIONS
Preoperatively, the patient should be assessed to determine the presence of both anterior and posterior tibial
artery systems. A clinically palpable posterior tibial and dorsalis pedis pulse is a reliable and simple way. In
electing to use this technique to resurface a dorsal foot wound after trauma, an angiogram of the foot can be
done preoperatively to ascertain the integrity of the deep plantar artery, which forms a direct communication of
the two systems.
The anterior tibial artery is outlined by joining the midpoint between the tibial tuberosity and fibular head
proximally and the midpoint between the medial and lateral malleolus distally. To resurface a dorsal foot or toe
defect, the flap is designed centered on the lower third of the artery, where the artery is superficial, with the pivot
point clearly marked. Longer flaps allow more perforators to be harvested and facilitate primary closure of the
donor site, if the flap is less than 3 cm wide. The cutaneous vascular territory of the anterior tibial artery has
been demonstrated to reach 2 cm medial to the anterior border of the tibia (10). It will be prudent to restrict the
medial margin to the anterior border of the tibia, to minimize the exposure of the bone.
For the reverse-flow flap to be successful, it is of vital importance that the design of the flap take into
consideration the following points. First, the deep plantar artery should be preserved, as this forms the most
distal level of anastomosis. Second, the pivot point of the reverse anterior tibial flap must be determined before
the procedure. It is a good measure to add another 1 cm of pedicle length for tension-free transposition, with the
ankle adopting its natural posture of slight plantar flexion. To resurface the most distal and plantar aspect of the
big toe, the malleolar and tarsal anastomoses can be sacrificed to increase pedicle length. Third, after islanding
the flap, it is prudent to clamp temporarily the anastomosis intended for ligation, as well as the proximal anterior
tibial artery, and to release the tourniquet to check for flap vascularity. If the flap cannot be adequately supplied
in this situation, it can be converted to a free anterior tibial artery flap, or the flap can be replaced, and an
alternative flap can be raised.
OPERATIVE TECHNIQUE
The flap is harvested from the fibular side, carrying out a subfascial dissection to the interval between the tibialis
anterior muscle and the tibia. Retracting the tibialis anterior muscle laterally will expose the periosteal perforators
(Fig. 539.1, top). These originate from the posteromedial surface of the anterior tibial artery and must be freed
from their attachments to the interosseous membrane (Fig. 539.1, bottom). As the periosteal perforators are
closely adherent to the tibia, it is safe to harvest the underlying segment of periosteum together with the
perforators, to prevent damage. The muscular branches of the anterior tibial artery are ligated. The dissection is
carried out distally, to expose the first branches of the ankle anastomotic network, the medial and lateral
malleolar arteries.
The island flap is then passed under the distal tendons of the TA and EHL to avoid tenting of the artery that runs

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below these tendons. Access to cover the distal foot and ankle structures is thus accomplished (Fig. 539.3).
CLINICAL RESULTS
Thirty-three foot and ankle reconstructions with the described technique were performed. The size of the
flaps ranged from 6 cm2 to 45 cm2. The number of perforators per flap ranged from one to four. Primary
closure of the anterior tibial flap donor site was achieved with smaller flaps. The remaining cases required
full-thickness skin-graft coverage of the anterior compartment muscles. All the flaps survived (100%);
however, two cases had distal-tip necrosis. In the earlier cases, a portion of the flaps developed
postoperative venous congestion, which resolved with elevation and release of sutures. Modifications to
minimize venous congestion included lower-limb elevation, immobilizing the ankle in a neutral position, as
well as attention to preventing tension in the pedicle.
SUMMARY
The reverse anterior tibial flap is a useful option for foot and ankle resurfacing. The principal perfusion for
retrograde flow is the lateral plantar artery at the deep plantar artery, supplemented by anastomosis around
the ankle joint. In properly selected cases with no previous damage to the ankle and midfoot blood supply,
the flap-survival rate is excellent. It is therefore prudent to ensure preoperatively that both anterior and
posterior tibial systems are patent, before proceeding with this reconstruction. In our experience, little
donor-site morbidity occurs with careful patient selection. However, postoperative management should take
into account the not-insignificant problem of venous congestion.

FIGURE 539.3 Simultaneous reconstruction of thumb avulsion injury with a free big-toe wrap-around flap
and a pedicled reverse-flow anterior tibial artery flap for the donor site.
References
1. Foucher G, Binhammer P. Plea to save the great toe in total thumb reconstruction. Microsurgery
1995;16:373.
2. St-Laurent JY, Lanzetta M. Resurfacing of the donor defect after wrap around toe transfer with a free
lateral forearm flap. J Hand Surg 1997; 22A:9137.
3. Hamilton RB, O'Brien BM, Morrison WA. The cross toe flap. Br J Plast Surg 1979;32:213.
4. Samson MC, Morris SF, Tweed AEJ. Dorsalis pedis flap donor site: acceptable or not? Plast Reconstr
Surg 1998;102:1549.
5. Dong JS, Peng YP, Zhang YS, et al. Reverse anterior tibial artery flap for reconstruction of foot donor site.
Plast Reconstr Surg 2003;112:1604.
6. Serafin D. The anterior tibial artery flap: discussion by Yousif, N.J. In: Atlas of microsurgical composite
tissue transplantation. Philadelphia: WB Saunders, 1996;459.

7. Wee JTK. Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibial flap: preliminary
report of a new fasciocutaneous flap. Br J Plast Surg 1986;39:327.
8. Satoh K, Yoshikawa A, Hayashi M. Reverse-flow anterior tibial flap type III. Br J Plast Surg 1988;41:624.
9. Rocha JFR, Gilbert A, Masquelet A, et al. The anterior tibial artery flap: anatomic study and clinical
application. Plast Reconstr Surg 1987; 79:396.
10. Crock JG, Morrison WA. Case report: a vascularized periosteal flap: anatomical study. Br J Plast Surg
1992;45:474.

Chapter 540
Reconstruction of The Soft-Tissue Defects of Foot and Ankle With
Neural-Island Flaps
ERHAN SÖNMEZ
ÖZLEM KARATAŞ SILISTIRELI
TUNC SAFAK
EDITORIAL COMMENT
A neural island flap utilizing the blood supply and drainage of the nerve is utilized for areas requiring critical
sensibility. Venous congestion may be a complication when narrowing the long pedicle.
INDICATIONS
Soft-tissue defects of the distal third of the leg and foot have been always a challenging problem for
reconstructive surgeons. Despite major advances in free flap surgery and the revolutionary pedicled flaps,
researchers are still seeking new reconstructive choices for these cases.
Neural-based flaps are one of the most interesting of these choices, particularly in difficult cases that may
not be reconstructed with known techniques (1). Offering the unique advantage of preservation of major
extremity arteries and avoidance of microsurgical techniques, these flaps were quickly popularized,
particularly for lower extremity reconstruction, and renamed as “neurocutaneous flaps” (2, 3, 4, 5, 6),
“neurofasciocutaneous flaps” (7, 8, 9), “neuroadipofascial pedicled fasciocutaneous flaps” (10, 11, 12), and
finally as “neural-island flaps” (13).
ANATOMY
The constant association between the superficial sensory nerves and a rich arterial axis, along with the role of
this network in the perfusion of skin, is the basis for this flap type. Masquelet and colleagues (14) showed that
skin island flaps could be effectively supplied by the vascular axis of superficial nerves in the leg. Although they
were presented as skin flaps based on the perineural vasculature of a specific cutaneous nerve, the pedicle of
these so-called neurocutaneous flaps always included subcutaneous tissue, a distinct perforating artery, and a
cutaneous vein as well (2, 3, 4, 5, 6, 7). However, in 2004, Akyurek et al. (13) introduced the “neural-island flap”
design that designates a robust and reliable skin flap supplied solely by the intrinsic vasculature of its cutaneous
nerve without including any cutaneous vein, fascia, or subcutaneous tissue, after a preliminary surgical delay
procedure is performed.
FLAP DESIGN AND DIMENSIONS
Neural-island flap harvesting is a two-stage procedure, and both stages can be performed under spinal
anesthesia. The patient is placed in a prone position in the first stage of the procedure. The axis of the sural
nerve is marked to design a skin paddle of desired dimensions along the proximal one-third of the calf region.
The flap dimensions can be planned between 4 × 8 cm and 9 × 11 cm. The nerve pedicle is designed with a
pivot point behind the lateral malleolus. The flap harvesting and the sural nerve dissections are performed under
tourniquet control. Surgical technique of neural island flap harvesting has been well described by Akyürek et al.

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and by us previously (13, 15) (Fig. 540.1).
FIGURE 540.1 The design of a neural-island flap measuring 5 × 10 cm. The skin bridge, which will be left intact
at the end of first stage, is depicted between the arrows.
OPERATIVE TECHNIQUE
The operative procedure is as follows. Initially, the distal part of the sural nerve is identified through a
retromalleolar incision. The direction of the incision is designed proximally toward the skin paddle on the axis of
the sural nerve. The nerve is dissected off the deep fascia until the caudal border of the proposed skin paddle is
reached. The inferior, anterior, and the superior borders of the skin flap are incised down to the deep fascia, and
this fascia is included in the flap. After dissection of the sural nerve, its proximal end is ligated and transected just
at the cranial border of the skin paddle. The sural nerve is dissected starting from the retromalleolar region to the
caudal border of the skin paddle off the deep fascia. The proximal end of the lesser saphenous vein also is
ligated and transected at this point. At the end of flap harvesting, the skin paddle remains as bipedicled, based
on a skin bridge that is 4 cm wide and the sural nerve. Next, the flap is replaced in situ and sutured by 4-0 nylon
sutures for the delay process (Fig. 540.2).
The second stage of the procedure is performed at the end of the 2nd week of the delay period (Fig. 540.3).
Debridement and reconstruction of the soft-tissue defect is accomplished at this stage of the procedure. The
previously planned skin flap is harvested as an island flap based on the sural nerve. A highly vascularized
pedicle with prominent perineural vessels is evident during dissection of the pedicle of the skin paddle. A
fastidious dissection of the sural nerve from the peripheral adhesions is required in order to avoid damaging the
dilated perineural vasculature that is vital for the survival of the skin flap. The island flap is placed into the defect
following proper debridement of the recipient site. The donor site of the skin flap and the soft-tissue defect on the
surface of the pedicle of the flap are covered with a split-thickness skin graft (Fig. 540.4). Primary closure of the
skin flaps on the surface of the neural pedicle of the flap causes venous stasis and should be avoided (Figs.
540.5 and 540.6).
CLINICAL RESULTS
The follow-up periods ranged from 6 to 24 months. The flap dimensions ranged between 4 × 8 cm and 9 ×
11 cm. The average duration of the delay surgery was about 1 hour and that
of reconstructive surgery was 2.5 hours. None of the patients complained of sensory deficits because of
sacrifice of the sural nerve. There was no significant donor site morbidity related to the skin-grafted
surfaces. Full weight bearing was allowed 2 months after the reconstruction of heel defects and 1 month
after the reconstruction of other defects (15).

FIGURE 540.2 At the end of the first stage of the procedure, the skin paddle remains as bipedicled based
on a skin bridge that is 4 cm wide and the sural nerve. Next, the flap is replaced in situ and sutured by 4-0
Nylon sutures for the delay process.
FIGURE 540.3 The neural-island flap is harvested solely on the sural nerve in the second stage. Note the
narrow pedicle width.
FIGURE 540.4 Early postoperative view at the end of first week. Note that the donor site of the skin flap
and the soft-tissue defect on the surface of the pedicle of the flap are covered with a split-thickness skin
graft in order to prevent venous stasis.

FIGURE 540.5 Late postoperative posterior view at the end of 6 months.
FIGURE 540.6 Late postoperative lateral view at the end of 6 months. Note the contour of the heel.
In 16 of 20 (80%) patients, the tissue defects were completely and successfully covered with an
uncomplicated postoperative course. In four (20%) patients, the flaps presented venous congestion, and
intermittent bleeding and leech application were performed for 2 to 3 days postoperatively to these flaps.
Two (10%) of these flaps healed completely without any flap loss. In one patient (5%), because the partial
flap necrosis occurred in distal one-fourth of the flap, skin grafting was performed after 1 week of vacuum-
assisted closure (VAC) application. Total flap necrosis occurred in only one patient (5%) who was suffering
from Buerger disease. This was the only Buerger disease patient in this series. No clinical wound infections
were detected in any of the patients, and all of the patients were discharged on the next day after the first
surgery and 4 days after the second surgery, excepting the patients who required secondary procedures
(15).
We did not include the lesser saphenous vein in the pedicle in our previous reports of the neural island flap
series (13, 15). In 2012, we presented a novel method that increases the venous drainage (16, 17, 18, 19,
20), solving the postoperative venous congestion problem of these flaps, which is summarized as follows:
the sural nerve and the lesser saphenous vein were both isolated during incision of the cranial border of the
skin paddle in the first stage of the flap harvesting. The sural nerve was isolated and transected, but before
ligation of the lesser saphenous vein, a vein stripper was applied (Vein Stripper-1 cable, Intra Special
Catheters Gmbh, Rehlingen-Siersburg, Germany) into the lumen of the vein down to the ankle. During
advancement of the vein stripper along the vein, the operator easily felt the destruction of the valves. This
maneuver was performed in an aim to provide venous superdrainage through the small saphenous vein by
means of disruption of the valves by the vein stripper. Next, the small saphenous vein was transected totally
and ligated at the cranial border of the skin paddle, and the flap was replaced in situ for the delay process.
The second stage of the procedure is the same as mentioned before, but the only difference is that the
lesser saphenous vein is included in the pedicle of the neural-island flap. None of the flaps presented
venous congestion after this maneuver, which is a common problem in the early postoperative period of

nerve-based flaps (16).
SUMMARY
Different methods have been described for reconstruction of the challenging soft-tissue defects of the foot
and ankle. Neuralbased flaps are an interesting clinical choice, particularly in difficult cases that may not be
reconstructed with known techniques. Their popularity is gradually increasing because these flaps offer the
advantage of preservation of major extremity arteries and avoidance of microsurgical techniques. This is a
reliable method for reconstruction of the challenging soft-tissue defects of the foot and ankle, particularly in
problematic cases when local or free tissue transfers are not possible.
References
1. Ozkan O, Akyurek M, Safak T, et al. Neuromuscular and neuromusculocutaneous flaps in the rat. J Plast
Reconstr Aesthet Surg 2006;59:279-290.
2. Bertelli JA, Kaleli T. Retrograde-flow neurocutaneous island flaps in the forearm: anatomic basis and
clinical results. Plast Reconstr Surg 1995;95:851-859.
3. Bertelli JA, Catarina S. Neurocutaneous island flaps in upper limb coverage: experience with 44 clinical
cases. J Hand Surg Am 1997;22:515-526.
4. Cavadas PC. Reversed saphenous neurocutaneous island flap: clinical experience. Plast Reconstr Surg
1997;99:1940-1946.
5. Coskunfirat OK, Velidedeoglu HV, Sahin U, et al. Reverse neurofasciocutaneous flaps for soft-tissue
coverage of the lower leg. Ann Plast Surg 1999;43:14-20.
6. Coskunfirat OK, Velidedeoglu H, Kucukcelebi A. Reversed neurofasciocutaneous flaps based on the
superficial branches of the radial nerve. Ann Plast Surg 1999;43:367-373.
7. Coskunfirat OK, Oksar HS, Ozgentas HE. Effect of the delay phenomenon in the rat single-perforator-
based abdominal skin flap model. Ann Plast Surg 2000;45:42-47.
8. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries of the cutaneous veins and cutaneous
nerves in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial
pedicled fasciocutaneous flap. Plast Reconstr Surg 1998;102:779-791.
9. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries of the lesser saphenous vein and sural
nerve: anatomic study and its clinical applications. Plast Reconstr Surg 1999;103:104-120.
10. Nakajima H, Imanishi N, Fukuzumi S. Vaginal reconstruction with the femoral veno-neuroaccompanying
artery fasciocutaneous flap. Br J Plast Surg 1999;52:547-553.

11. Hyakusoku H, Tonegawa H, Fumiiri M. Heel coverage with a T-shaped distally based sural island
fasciocutaneous flap. Plast Reconstr Surg 1994;93:872-876.
12. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region. A preliminary report.
Scand J Plast Reconstr Surg 1983;17:191-196.
13. Akyürek M, Safak T, Sonmez E, et al. A new flap design: neural-island flap. Plast Reconstr Surg
2004;114:1467-1477.
14. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive
superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115-
1121.
15. Sonmez E, Safak T. Reconstruction of the soft tissue defects of foot and ankle with neural-island flaps:
mono-institutional case series. J Reconstr Microsurg 2011;27:403-408.
16. Sonmez E, Silistireli OK, Karaaslan O, et al. Enhancement of venous drainage with vein stripper for
reversed pedicled neurocutaneous flaps. J Reconstr Microsurg 2013;29:249-254.
17. del Pinal F, Taylor GI. The deep venous system and reverse flow flaps. Br J Plast Surg 1993;46:652-
664.
18. Imanishi N, Nakajima H, Aiso S. A radiographic perfusion study of the cephalic venous flap. Plast
Reconstr Surg 1996;97:408-412.
19. Loonen MP, Kon M, Schuurman AH, et al. Venous bypass drainage of the small saphenous vein in the
neurovascular pedicle of the sural flap: anatomical study and clinical implications. Plast Reconstr Surg
2007;120:1898-1905.
20. Tan O, Atik B, Bekerecioglu M. Supercharged reverse-flow sural flap: a new modification increasing the
reliability of the flap. Microsurgery 2005;25:36-43.

Chapter 541
Medial Plantar Flap
R. E. SHANAHAN
EDITORIAL COMMENT
This is an excellent flap, particularly for coverage of defects over the calcaneum. The dissection is difficult
and the surgeon is advised to review the anatomy prior to its execution.
Skin defects of the plantar surface of the heel pose a difficult problem for the reconstructive surgeon. In the
absence of subcutaneous tissue, split-thickness skin grafts tend to break down under the influence of pressure
and constant shearing forces, and distant flaps lack sensation and tend to be bulky.
INDICATIONS
The plantar concavity or non-weight-bearing region of the sole has sufficient surface area to cover the
entire plantar surface of the heel. Because the plantar concavity derives its sensory innervation from the
fourth and fifth lumbar nerve roots, innervated flaps from this region are capable of restoring sensation to
heel surfaces that are anesthetic as a result of lesions of the first and second sacral nerve roots. The
medial plantar artery and nerve can be used in designing a plantar transposition flap that is both arterialized
and innervated (1, 2).
ANATOMY
The medial plantar artery is the lesser of two terminal branches of the posterior tibial artery. It arises behind the
origin of the abductor hallucis muscle and courses deep to the plantar fascia between the abductor hallucis and
the flexor digitorum brevis muscles. It gives branches to each muscle and finally terminates in small digital
branches to the medial two or three toes. Throughout its course, it supplies the skin of the medial two thirds of
the plantar concavity through direct cutaneous branches and through musculocutaneous branches by way of the
abductor hallucis. All branches originate deep to the plantar aponeurosis (Fig. 541.1).
The medial plantar nerve arises from the tibial nerve behind the medial malleolus. It accompanies the medial
plantar artery and terminates in one proper digital and three common digital nerves. It provides motor branches
to the abductor hallucis, the flexor digitorum brevis, and the medial lumbricals. Sensory branches perforate the
plantar fasciae and are distributed to the skin of the medial two thirds of the plantar concavity. The plantar
cutaneous fascicles can be separated from the remainder of the nerve by perineurial dissection. The greater
saphenous vein and the venae comitantes provide venous outflow.
OPERATIVE TECHNIQUE
The presence of a patent medial plantar artery should be verified using a Doppler device or arteriography. The
surface design of the flap may be varied according to need. Dissection is begun distally. After the skin incision is
deepened through the plantar fascia, the digital branches of the artery are divided. As dissection is carried
proximally, the plantar cutaneous nerve branches are identified and separated from the medial plantar nerve by
perineurial dissection using magnification, and the arterial branches to the flexor digitorum brevis are divided.

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Finally, as the artery and nerve branches pass proximally beneath the abductor hallucis, this muscle must be
divided near its insertion in order to achieve mobility of the flap. If further mobility is desired, the proximal
attachments of the plantar fascia and the origin of the abductor hallucis also may be divided (Fig. 541.2).
Although the base of the flap need not be wide, an effort should be made to preserve the greater saphenous vein
along with its plantar tributaries. It may be necessary to mobilize the vein by dividing the dorsal tributaries. After
the flap is transferred, the donor area is resurfaced with a split-thickness skin graft.
The principle of using the medial plantar artery and nerve has been further amplified (2) by designing a
neurovascular island flap for covering a 5 × 6 cm plantar heel defect. Figure 541.3 illustrates the design,
execution, and early postoperative result of this innovative procedure.
SUMMARY
The medial plantar flap provides a method of covering skin defects of the plantar surface of the heel. It has
the advantages of being an arterialized sensory flap and is of good quality for the special requirements of
the plantar surface.
FIGURE 541.1 Anatomy of the medial plantar artery. 1, Medial plantar nerve; 2, medial plantar artery; 3,
abductor hallucis; 4, plantar aponeurosis; 5, flexor digitorum brevis; 6, tendon of the abductor hallucis; 7,
divided branches of the medial plantar artery; 8, medial malleolus; 9, skin; 10, subcutaneous tissue; 11,
plantar cutaneous branches of the medial plantar nerve.

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FIGURE 541.2 A: Heel ulcer resulting from injury to the first and second sacral nerve roots. B:
Postoperative result 3 years later. (From Shanahan, Gingrass, ref. 1, with permission.)
FIGURE 541.3 A: A 5 × 6-cm plantar heel defect. B: Early postoperative result using a medial plantar
neurovascular island flap. (From Harrison, Morgan, ref. 2, with permission.)
References
1. Shanahan RE, Gingrass RP. Medial plantar sensory flap for the coverage of heel defects. Plast Reconstr
Surg 1979;64:295.
2. Harrison DH, Morgan BDG. The instep island flap to resurface plantar defects. Br J Plast Surg
1981;34:315.

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Chapter 542
Lateral Calcaneal Artery Skin Flap
L. C. ARGENTA
EDITORIAL COMMENT
Of the local flaps around the ankle, this is probably the most reliable, although its usefulness is limited.
The lateral calcaneal artery skin flap is an extremely reliable flap for providing sensate coverage for the posterior
heel in one stage (1). The extended form of the flap reaches the plantar portion of the heel. Because it includes a
random area, however, it is not as reliable as the shorter version.
ANATOMY
The lateral calcaneal artery skin flap is an axial-pattern flap that contains the lateral calcaneal artery, lesser
saphenous vein, and sural nerve (Fig. 542.1). The lateral calcaneal artery is an almost constant terminal branch
of the peroneal artery. Occasionally, it can be present as the terminal branch of the posterior tibial artery. The
artery, paralleled by one or two small veins, is located in the subcutaneous tissue at the level of the lateral
malleolus, within 1 cm lateral to the gastrocnemius tendon. From this point, the artery slowly descends into a
deeper plane to lie immediately over the extensor retinaculum covering the peroneus longus and peroneus brevis
tendons.
FIGURE 542.1 The anatomy of the lateral foot and ankle region. (From Grabb, Argenta, ref. 1, with permission.)
The artery usually bifurcates at this point, and the tributaries branch distally toward the plantar surface of the
heel and toward the head of the fifth metatarsal bone. In most cases, discrete branches of these vessels persist
almost to the head of the fifth metatarsal. In approximately 20% of patients, a rete plexus forms over the
retinaculum and spreads distally.

FIGURE 542.2 The short total axial version of the lateral calcaneal artery skin flap is localized directly over the
artery. The course of the artery has been previously marked out with the aid of a Doppler device. The
dimensions of the flap are determined by the size of the defect. (From Grabb, Argenta, ref. 1, with permission.)
The sural nerve lies anterior to the artery and parallels it. It is almost uniformly within 10 mm of the artery (see
Fig. 542.3).
The Doppler probe has been most useful in determining the patency of the calcaneal artery. In persons who
have been exposed to significant trauma or in cases of severe atherosclerosis, it is important to determine
directional flow, since retrograde flow may occur. Directional Doppler scans or digital occlusion of the dorsalis
pedis and posterior tibial vessels can be used to determine directional flow. In patients in whom the extremities
have been exposed to severe trauma, an angiogram is necessary to ensure that at least one other vessel to the
foot remains intact.
Studies on patients with atherosclerosis demonstrated that the peroneal artery is usually the last vessel of the
trifurcation to be significantly compromised (2, 3, 4, 5). In fact, patients with severe atherosclerosis may have a
significantly enlarged calcaneal artery that functions as a collateral vessel because of occlusion of the remaining
infrapopliteal vessels.
The peroneal artery is rarely involved, even in patients with severe diabetes, although diabetics have more
severe atherosclerotic disease in the infrapopliteal major vessels than nondiabetics. In my experience, diabetics
have suffered fewer complications with the axial portion of the flap than nondiabetics. When the extended portion
of the flap has been employed, however, the risk of complications and infection has been higher than in
nondiabetics.
FIGURE 542.3 The undersurface of the cadaver dissection of the calcaneal artery skin flap. The sural nerve
(arrow) parallels the calcaneal artery. In practice, these vessels need never be visualized, since extensive

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dissection may traumatize them. (From Grabb, Argenta, ref. 1, with permission.)
FLAP DESIGN AND DIMENSIONS
The proximal 8 cm of the flap, that is, the vertical distance between the lateral malleolus and the plantar surface
of the heel, is completely axial. The flap can be extended up to 6 cm more distally by including a random portion
of tissue proximal to the base of the fifth metatarsal.
The position and course of the calcaneal artery is marked on the skin (Fig. 542.2). With the leg dependent, the
course of the lesser saphenous vein is also marked out. The length and width of the desired flap are planned in
reverse, using a cloth pattern over the defect and transposing it to lie over the previously demarcated artery.
The pedicle of both versions of the flap lies immediately above the level of the lateral malleolus. The base of the
flap is usually left intact and optimally should be at least 4 cm wide. On occasion, the flap can be elevated as an
island, but care must be taken to avoid trauma to the lesser saphenous vein during rotation. Because this is an
axial-pattern flap, the distal portion may be wider than the proximal end if necessary.
The short version of the flap (Figs. 542.2 and 542.3) encompasses the vertical distance between the lateral
malleolus and
the plantar heel. If there is an excessive amount of callous or slightly greater length is required, the flap can be
gently curved distally, maintaining the previously marked artery as close to the center of the flap as possible.
FIGURE 542.4 The long version of the calcaneal artery flap includes a distal random area. This flap is useful for
coverage of plantar foot defects. (From Grabb, Argenta, ref. 1, with permission.)
When a larger amount of tissue is necessary to cover areas of the plantar heel, the flap can be extended to
include a random area (Fig. 542.4). In this case, the flap curves distally in the direction of the base of the fifth
metatarsal. Dissections of adult cadavers have revealed that the lateral calcaneal artery is usually 30 mm below
the tip of the malleolus. The curve of the extended flap must be such as to incorporate the vessel as close as
possible to its center.
OPERATIVE TECHNIQUE
Axial-Pattern Flap
Dissection is most easily begun at the lateral aspect of the calcaneal tendon and is carried down distally to the
periosteum of the os calcis. The plane is then developed, leaving the periosteum intact. The anterior incision is
made immediately behind the lateral malleolus and carried down through the subcutaneous tissues. The flap is
mobilized in a retrograde fashion.

The neuromuscular structures lie in the deep surface of the subcutaneous tissues and can be visualized if the
dissection is too superficial. Optimally, the vessels are never exposed and therefore not traumatized.
Dissection is carried out in a retrograde fashion to the level of the lateral malleolus. The Doppler probe can be
used intraoperatively when the tourniquet is avoided to ensure that the vessel is incorporated within the flap.
Immediately above the malleolus, the calcaneal artery begins to plunge to a deeper level. A minimal amount of
dissection can facilitate rotation, but deeper dissection may be perilous.
Rotation to the defect is then performed, and the flap is inset. No deep sutures are used. A small silicone drain is
left in the bed of the lesion, especially if underlying bone has been removed. A split-thickness skin graft is placed
over the donor defect and immobilized with a tieover dressing.
Postoperatively, the patient is kept in bed with the leg elevated for 5 to 7 days. This prolonged elevation
minimizes skin graft loss as well as dehiscence of the flap secondary to edema.
Extended Flap
Initial dissection is identical to that for the short flap. Three to 5 mm anterior to the lateral calcaneal tendon, the
dissection leaves the periosteal plane and continues distally on the lateral aspect of the abductor digiti minimi
muscle and the peroneal retinaculum overlying the peroneus longus and peroneus brevis tendons. This flap is
dissected, leaving the distal end of the flap uncut.
Once total undermining has been accomplished, an atraumatic vascular clamp is placed across the distal end of
the flap and fluorescein is given intravenously. In approximately 60% of all nondiabetic patients, there is
adequate fluorescence immediately so that the flap can be divided and rotated. In cases where fluorescein does
not reach the distal margin, the flap is sutured back into place and the distal end is divided in stages. Division is
begun 5 to 7 days after the first operation. It is important that the patient remain in bed after the initial operation
while waiting for the delay procedures.
When the extended flap is rotated, the donor defect is again covered with a split-thickness skin graft. I have not
allowed patients to place full weight on the heel that has been covered with an extended flap for a period of 6
weeks to avoid shear. During this period, a splint is important to maintain a 90-degree position of the foot.
CLINICAL RESULTS
This flap has proven effective and reliable even in older patients with atherosclerotic occlusive disease and
diabetes. If the calcaneal artery has been present on Doppler examination and has antegrade flow, there
have been no significant complications with the short version of the flap. Similarly, when the extended
version of the flap has been adequately delayed, there have been few complications.
Postoperative infection, especially in diabetics, has been the most frequent complication. Prophylactic
antibiotics have not significantly decreased the incidence of these effects. Shearing of the flap from the
underlying bed has been observed if ambulation is begun prior to complete healing.
Two of my patients have undergone amputations of toes and a portion of the foot several years after the
lateral calcaneal artery flap because of progressive diabetes. In both patients, there has been no evidence
that the flap was compromised.
All the patients who have had sensation in the distribution of the sural nerve have maintained sensation
postoperatively and have been able to discriminate pinprick and pressure within the flap. I have experienced
no breakdown of the transposed flap despite frequent trauma in the heel area.
This operation, to my knowledge, has been performed on two children. The location of the vessels and
technique have been similar to those in adults.

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SUMMARY
The lateral calcaneal artery skin flap can be used to provide sensory skin coverage to the heel in one
stage. Occasionally, the extended form of the flap may need a delay procedure to cover the plantar aspect
of the heel.
References
1. 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 1981;68:723.
2. Wessler S, Schlesinger MJ. Studies in peripheral arterial occlusive disease: I. Methods and pathologic
findings in amputated limbs. Circulation 1953; 7:641.
3. Conrad MD. Large and small artery occlusion in diabetics and nondiabetics with severe vascular disease.
Circulation 1967;36:83.
4. Haimovici, H. Patterns of arteriosclerotic lesions of the lower extremity. Arch Surg 1967;95:918.
5. Barner HB, Kaiser GC, Willman VL. Blood flow in the diabetic leg. Circulation 1971;43:391.

Chapter 543
Plantar Artery-Skin-Fascia Flap
R. S. REIFFEL
When resurfacing defects on the plantar surface of the foot, consideration must be given to the specialized
nature of the missing tissue. Restoration may be more desirable than a skin graft (1, 2, 3, 4, 5, 6, 7). The thick
and unyielding nature of plantar skin makes rotation of a wide-based flap difficult. The design of an arterialized
flap eliminates any constraints on the size of the skin pedicle and permits reliable transfer of large amounts of
skin and subcutaneous tissue. Moreover, incorporation of nerves in the pedicle maintains sensibility in the
reconstructed part (8).
INDICATIONS
Defects on the plantar aspect of the calcaneus can be covered easily with a proximally based flap (see Fig.
543.4). With greater flap rotation, defects on the posterior surface of the calcaneus, including the level of
insertion of the Achilles tendon, also can be reliably covered. The distally based flap can be used to cover
defects over the metatarsal head region (see Fig. 543.5); however, this flap cannot provide sensory
coverage because it is distally based.
ANATOMY
Arterial Supply
The posterior tibial artery supplies three main plantar vessels. The lateral plantar artery crosses the foot in the
plane between the flexor digitorum brevis and the quadratus plantae muscles (Fig. 543.1). In roughly the central
third of the foot, it turns in a medial direction, passing deep to the oblique head of the adductor hallucis muscle to
form the plantar arch. The termination of the plantar arch is the deep plantar artery, which passes between the
first and second metatarsals to reach the dorsalis pedis artery. Connections also exist between the plantar arch
and the medial plantar artery. Common digital arteries originate from the plantar arch and supply the toes. Small
vessels perforate the overlying flexor digitorum brevis muscle and plantar fascia in a vertical direction to connect
the lateral plantar artery with the overlying skin.
The medial plantar artery courses distally superficial to the quadratus plantae and deep to the abductor hallucis
and flexor digitorum brevis muscles. After connecting with the plantar arch, it terminates in the big toe.
The calcaneal artery perforates the flexor digitorum brevis muscle and plantar fascia near their origin from the os
calcis. Thereafter, while passing in a posterior direction, it branches to supply the weight-bearing calcaneal skin.
Nerve Supply
The lateral plantar, medial plantar, and calcaneal nerves follow the same course as that described for the
equivalent arteries, with one exception. The lateral plantar nerve supplies only the lateral one and one-half toes,
with the medial plantar nerve supplying the remainder.
FLAP DESIGN AND DIMENSIONS
The fact that blood may reach the lateral plantar artery either antegrade from the posterior tibial artery or
retrograde from the plantar arch makes the design of two lateral plantar artery skin-muscle-fascia arterialized

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flaps possible.
Proximally Based Flap
If the artery is divided distally just before it becomes the plantar arch, a proximally based flap may be designed
whose point of rotation is located just anteromedial to the os calcis (Fig. 543.2). A 10-cm-long, 7-cm-wide flap
can be designed easily. The posterior margin of the flap is generally the defect to be reconstructed. The lateral
margin should be on the side of the foot, off the weight-bearing surface. The medial margin
curves sharply back toward the medial malleolus, making the skin pedicle narrow. Special care should be taken
not to extend the distal margin of the flap onto the metatarsal head weight-bearing skin. The secondary defect,
either closed primarily or resurfaced by a split-thickness skin graft, is located between the calcaneal and
metatarsal head weight-bearing areas.
FIGURE 543.1 The lateral plantar nerve and artery cross the foot between the flexor digitorum brevis and
quadratus plantae muscles, sending perforating branches through the plantar fascia to the skin of the central
third of the foot. The calcaneal artery courses in a posterior direction to supply the posterior third of the foot. The
deep plantar artery connects the dorsalis pedis artery with the plantar arch, which also receives a major supply
from the lateral plantar artery and a minor supply from the medial plantar artery.

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FIGURE 543.2 Proximally based flap. The lateral plantar artery is divided just proximal to the plantar arch. The
branches of the lateral plantar nerve that supply the flap are split longitudinally from the remainder of that nerve.
The flexor digitorum brevis muscle and plantar fascia are divided proximally from the calcaneus and distally at
the level of the skin incision, which is located just proximal to the metatarsal head weight-bearing region.
Distally Based Flap
Division of the lateral plantar artery near its origin from the posterior tibial artery allows the design of a second
flap whose blood supply is retrograde from the plantar arch (Fig. 543.3). The flap may be designed with the
same dimensions as previously described, with care being taken to plan the medial and lateral incisions slightly
on the sides of the foot, off the weight-bearing surface. In addition, the tip of the flap (posterior skin incision) must
not extend onto the calcaneal weight-bearing area. The skin pedicle is kept narrow. With a rotation point
overlying the plantar arch, the flap may be used to resurface defects of the metatarsal head region (see Fig.
543.5). The secondary defect lies once again in a non-weight-bearing area, anterior to the calcaneus.
OPERATIVE TECHNIQUE
Prior to ligation of the lateral plantar artery either proximally or distally, patency of both the dorsalis pedis and
posterior tibial arteries must be established. One should, either by manual palpation or with the aid of a Doppler
flowmeter, ascertain that neither pulse disappears when the other vessel is manually occluded. In doubtful
cases, an arteriogram may be helpful. If both of the preceding vessels are not patent, surgical division
of the lateral plantar artery may interrupt the only collateral blood supply to a major portion of the foot and is,
therefore, inadvisable.

FIGURE 543.3 Distally based flap. The lateral plantar artery is divided just anterior to the calcaneus. The lateral
plantar nerve is left in situ. The flexor digitorum brevis muscle and plantar fascia are divided as before. Deep
dissection in the region of the plantar arch should be avoided. Exposure of the deep structures in this diagram is
for explanatory purposes only.
Excision of the lesion or pressure sore, including all infected or desiccated bone, and lowering of bony
prominences such as the anterior lip of the calcaneus are performed first.
Whether a proximally or distally based flap is planned, dissection always commences with the lateral incision, in
the middle third of the foot. The skin and subcutaneous tissues are sharply incised. After the underlying plantar
fascia has been divided parallel to the skin incision, the undersurface of that fascia is bluntly explored for any
identifiable perforating vessels. Once any vessel is found, no matter how small, it should be bluntly traced
proximally to the lateral plantar artery. If one encounters the long toe flexor tendons, the plane of dissection is too
deep.
Once the lateral plantar artery has been identified, it is mobilized in association with the overlying plantar fascia
and skin (Fig. 543.4B). Blunt dissection along the artery will expose its accompanying venae comitantes and the
lateral plantar nerve, all of which must be preserved.
To achieve flap mobility, the numerous fibrous septa attaching the plantar fascia to the metatarsals must be
divided. Traction on the flap tightens the septa and allows their easy palpation. After blunt dissection along the
neurovascular bundle to protect the artery and nerve, the septa are carefully divided. The skin incision is
elongated, further flap rotation is achieved, and more septa are identified and divided. The plantar fascia and the
flexor digitorum brevis muscles must be divided both at their origins from the calcaneus and at the level of the
distal transverse skin incision (see Fig. 543.2).
In the case of a proximally based flap, the lateral plantar artery is divided between ligatures just before it turns
medially to become the plantar arch. In the case of a distally based flap, that same vessel is divided just anterior
to the calcaneus (see Fig. 543.3). On some occasions, when only a small amount of flap rotation is required, it
may be possible to mobilize and stretch the vessel sufficiently to make its division unnecessary. In such cases,
division should be avoided (Fig. 543.5). All the vascular connections between the lateral plantar artery and the
overlying skin are preserved. Deep muscular branches are divided between small stainless steel hemostatic
clips. In the case of a proximally based flap, the lateral plantar nerve may be split longitudinally. Perforating

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branches may therefore be included with the overlying flap while sensibility of the lateral toes is preserved.
Because retrograde nerve pathways do not exist, no branches of the nerve are included with the distally based
flap.
The processes of elongating the skin incision, protecting the neurovascular pedicle between, dividing the fibrous
septa, and rotating the flap are continued until the flap can be transferred into its desired position without any
tension. The skin pedicle can be made as narrow as necessary to eliminate tension or dog-ear formation, as the
flap is of an axial nature.
The skin is closed over a low-vacuum, soft suction catheter. If the secondary defect cannot be closed primarily
without tension, it is covered with a split-thickness skin graft.
The suction catheter is removed after 2 to 3 days or when drainage decreases to 5 to 10 ml in any 24-hour
period. Elevation of the foot is maintained for 1 week if no skin graft was required or for 2 weeks if grafting was
necessary. Ambulation on crutches is begun at that point. Progressive weight bearing is begun, culminating in
full weight bearing 1 or 2 weeks later, as tolerated.
CLINICAL RESULTS
If the preoperative analysis of the vascular system has been accurate, and if care is taken not to injure the
lateral plantar artery during the process of flap elevation, no flap ischemia should be expected. Diabetics
with small-vessel disease may exhibit delayed healing of incisions and skin grafts, but no hematomas,
infections, wound breakdowns, or instances of necrosis should be expected unless surgical technique has
been improper.
Neuroma symptoms in ambulatory patients may be troublesome at first, but they diminish with time and with
desensitization training. Special insoles may be added temporarily to the shoe to redistribute pressure away
from the nerve. No loss of stability seems to result from division of the plantar fascia. The long-term effect of
division of one of the major pathways of blood to the plantar arch, especially with the possible formation of
atherosclerosis in the remaining pathways, is not known.
SUMMARY
The plantar artery flap is an axial flap that can be used to provide durable cover for plantar and calcaneal
defects. The proximally based flap is innervated, whereas the nerve must be divided in order to mobilize the
distally based flap.