Operative Technique in Plastic Surgery – Kevin C.Chung

■ Gait disturbance
■ Pain
■ Unstable scar
FIG 8 • Long-term outcome after reconstruction of a
lateral plantar midfoot defect with the medial plantar
flap.
REFERENCES
1. Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of heel
defects. Plast Reconstr Surg. 1979;64:295-298.
2. Siddiqi MA, Hafeez K, Cheema TA, Rashid HU. The medial plantar artery
flap: a series of cases over 14 years. J Foot Ankle Surg. 2012;51:790-794.
3. Koshima I, Urushibara K, Inagawa K, et al. Free medial plantar perforator
flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg.
2001;107:1753-1758.
4. Huang QS, Wu X, Zheng HY, et al. Medial plantar flap to repair defects of
palm volar skin. Eur J Trauma Emerg Surg. 2015;41:293-297.
5. Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the
role of plain radiography, computed tomography, ultrasonography, magnetic
resonance imaging, and scintigraphy. Semin Plast Surg. 2009;23:80-89.
6. Harrison DH, Morgan BD. The instep island flap to resurface plantar defects.
Br J Plast Surg. 1981;34:315-318.
7. Schwarz RJ, Negrini JF. Medial plantar artery island flap for heel
reconstruction. Ann Plast Surg. 2006;57:658-661.

14
CHAPTER
Reconstruction of Heel and
Plantar Defects: Free Flap
Goo-Hyun Mun and Kyong-Je Woo
DEFINITION
■ Heel and plantar soft tissues perform a special role of weight bearing while
walking or standing. The heel sustains up to 115% of body weight during slow
walking and up to 260% of body weight during running.1
■ Heel and plantar defects may result from several causes such as trauma,
diabetes, infection, peripheral vascular disease, frostbite injuries, and tumor
resections.
■ The goal of reconstruction is aimed at not only providing stable wound healing
but also achieving functional restoration of the salvaged limb and maintaining
acceptable appearance.
ANATOMY
■ The weight-bearing plantar skin is a highly specialized part of the foot that is
able to withstand and absorb the forces exerted during gait or running cycles.
The epidermis and dermis are much thicker in plantar skin (“glabrous skin”)
than in other parts of the body.
■ Subcutaneous fat in combination with the vertical fibrous connective tissue
provides a cushioning effect to weight bearing.
■ The three arteries at the ankle level and their terminating branches in the foot
that can be used as recipient vessels for free flaps include the anterior tibial-
dorsalis pedis artery, posterior tibial-medial and lateral plantar artery, and
peroneal-lateral calcaneal artery.
■ Anterior tibial-dorsalis pedis artery: the dorsalis pedis artery passes under the
extensor retinaculum at the midpoint between the medial and lateral malleoli.
It usually runs across and beneath the extensor hallucis longus (FIG 1A). It

passes to the proximal end of the first intermetatarsal space, where it turns
into the sole between the heads of the first dorsal interosseous to complete the
plantar arch and provides the first plantar metatarsal artery (FIG 1B). In heel
and plantar reconstruction with a free flap, the dorsalis pedis artery can be
reached for the recipient vessel by using a remote incision and subcutaneous
tunneling (FIG 2). The first plantar metatarsal artery can be used in the
plantar forefoot reconstruction (FIG 3).

FIG 1 • A,B. Anterior tibial-dorsalis pedis artery. B.
■ Posterior tibial-medial and lateral plantar artery: posterior tibial artery runs
midway between the medial malleolus and the medial calcaneal tubercle
under the laciniate ligament. It is located between the flexor digitorum longus
and flexor hallucis longus tendons (FIG 4). The posterior tibial artery divides
into the medial and lateral plantar arteries under the origin of the abductor
hallucis. While the medial plantar artery runs between the abductor hallucis
and flexor digitorum brevis (FIG 5), the lateral plantar artery, being usually

larger, travels from medial to lateral position under the proximal third of the
flexor digitorum brevis and then continues distally between flexor digitorum
brevis and abductor digiti minimi (FIG 6).
■ Peroneal-lateral calcaneal artery: peroneal artery terminates into lateral
calcaneal artery around the lateral malleolus (FIG 7). The lateral calcaneal
artery was introduced as a pedicle for local flap, but a recent anatomical
study suggests that it could be used as a recipient blood vessels for free
flap.2,3 The lateral calcaneal artery originates either from peroneal artery
(80.3%), posterior tibial artery (13.1%), or a common branch from both the
peroneal and posterior tibial arteries (6.6%) and runs between lateral
malleolus and Achilles tendon.3,4
■ The principal superficial veins are termed long (great) and short (small)
saphenous veins (FIG 8). The long (great) saphenous vein passes anterior to
the medial malleolus, whereas the short (small) saphenous vein ascends from
the lateral side of the foot. It ascends posterior to the lateral malleolus, passing
along the lateral border of the Achilles tendon. A deep venous system runs
near the corresponding arteries and develops communication with the great
and small saphenous veins. Both deep veins of the corresponding arteries and
the superficial veins can be selected as recipient veins in the foot.
FIG 2 • A. The dorsalis pedis artery was used as a
recipient artery for defect on lateral forefoot. A remote
incision and subcutaneous tunneling was performed to
reach the recipient vessels. B. Microvascular
anastomosis. C. Immediate postoperative photo. D.

Another case with defect on the lateral heel. Dorsalis
pedis vessels were used as recipient vessel through a
remote incision and subcutaneous tunneling. E.
Immediate postoperative photo.
FIG 3 • A,B. First plantar metatarsal artery and veinfor
the recipient vessel.
FIG 4 • A–C. The posterior tibial artery for the recipient
vessel.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough medical history and examinations for sensation and presence of

diabetes, peripheral vascular disease, and existence of osteomyelitis need to be
obtained. Deformities of the foot and a postoperative rehabilitation plan should
also be considered in the selection of reconstruction methods.
■ Vascular anatomy and patency must be evaluated. In this regard, noninvasive
Doppler ultrasound exam is a simple and useful evaluation method. Recently,
computed tomography (CT) or magnetic resonance (MR) angiography methods
are also recommended for vascular imaging.
IMAGING
■ The authors routinely perform preoperative CT angiographic examination of
the lower extremities, except when contraindicated.
■ Bone assessment includes plain radiography and bone scan or MR imaging for
the diagnosis of osteomyelitis.
SURGICAL MANAGEMENT
■ For large and extensive heel and plantar defects, the free flap transfer
procedure is preferred because it can provide a large amount of tissue with
various tissue components for obliterating deep and/or extensive wounds. The
early and definitive reconstruction of compound defects leads to a dramatic
improvement in the rate of lower extremity salvage and restoration of the
weight-bearing function and normal gait pattern.

FIG 5 • A–C. The medial plantar artery for the recipient
vessel.
■ The final choice of most suitable flap depends on the surgeon’s preference and
the patient’s needs. A form of durable, permanent, pain-free, and functionally
and aesthetically satisfying coverage should be achieved in the heel and plantar
reconstruction.

FIG 6 • A–C. The lateral plantar artery for the recipient
vessel.
■ Free muscle flap versus fasciocutaneous flap: free muscle flap (rectus
abdominis, latissimus dorsi, or gracilis) has been used commonly for extensive
foot defects. A muscle flap has advantages, including the large amount of
tissue availability, and ability to obliterate dead space especially in defects with
irregular contours, where there is greater ease to form three-dimensional (3D)
shapes.5 In contrast, recent clinical studies have demonstrated that
fasciocutaneous flaps (anterolateral thigh, thoracodorsal artery perforator
[TDAP] flap) provide a sufficient amount of bulk, large, and pliable skin flap,
with acceptable donor site morbidities.6,7 The donor site morbidities caused by
harvesting the muscle flap and additional donor site for skin graft can be
avoided by using the fasciocutaneous flap.

FIG 7 • A–D. The lateral calcaneal artery for the
recipient vessel.

FIG 8 • A superficial venous system of the foot.
■ The authors prefer the TDAP flap for many foot defects because it provides
thick skin from the back that has negligible incidence of atherosclerosis of the
vascular pedicle, which is relatively long. Furthermore, the TDAP can be
tailored to include different tissue types such as muscle (latissimus dorsi)
and/or bone (scapula) depending upon the requirements for reconstruction. The
anterolateral thigh flap is also useful when supine position of the patient is
favorable.
■ Muscle-chimeric perforator flap is useful to obliterate dead space when it is
necessary (see FIG 12B,C).

■ Innervated (sensate) flap: although it seems reasonable to assume that plantar
reconstruction requires a sensate flap to avoid recurrent ulceration, there is no
evidence suggesting that innervated flaps on weight-bearing portion of the foot
is superior in terms of rates of ulceration. A noninnervated fasciocutaneous flap
showed progressive improvement in sensitive thresholds, achieving good
protective sensitivity, similar to that of an innervated flap.9
■ The status of an underlying skeletal anatomy is a critical factor in the
durability of the soft tissue reconstruction. Abnormally high pressure points on
the plantar surface lead to the recurrent breakdown after reconstruction, and the
abnormalities should, therefore, be corrected.
■ In the heel and plantar reconstructions, restoration of 3D configuration of the
heel and plantar foot is essential to wear a normal shoe and to regain normal
gait pattern. The primary defatting and wedge resection of the flap facilitates
making 3D configuration.
FIG 9 • A clinical case with malignant melanoma on the
left heel.
Preoperative Planning
■ The patient had a large malignant melanoma on the left heel. Wide excision of
the tumor and reconstruction of the heel were planned (FIG 9).
■ CT angiographic evaluation showed all major vessels of the foot had normal
anatomy with no atherosclerosis or vascular occlusion. The presence of a
sizable lateral calcaneal artery on the patient’s left foot was also confirmed, and
the course could be followed by 3D reconstruction of the CT images (FIG 10).
■ A TDAP flap, instead of an anterolateral thigh flap, was planned to be used for

several reasons in the described case. Lateral position was better than supine
position for both tumor resection and inset of the flap. In addition, it might
have been necessary to perform a skin graft for the anterolateral thigh flap
donor site if the flap was more than 10 cm wide.
FIG 10 • A,B. CT angiographic image of lateral
calcaneal artery.
Positioning
■ The procedure can be performed in the lateral decubitus position, with the
affected leg placed on the upper side. An ipsilateral TDAP flap can be
harvested following tumor resection, without changing the position, at the same
time as dissecting the lateral calcaneal artery as the recipient artery.
■ When the posterior tibial artery is planned to be the recipient vessel, a TDAP
flap is harvested from the contralateral side in a position of lateral decubitus
with the recipient foot placed on lower side (FIG 11).

FIG 11 • Lateral decubitus position for harvesting TDAP
flap on the contralateral side of the defect when the
posterior tibial artery is used as recipient vessel.
Approach
■ When a recipient vessel can be found in the defect, it is approached directly.
Otherwise, an extended incision starting from the defect or a separate incision
with subcutaneous tunneling is used as an approach to preparing the recipient
vessels.
T E C H N I Q U E S
Video p7-c014
00:00 / 00:00

Note: Each step of techniques is included in the video clip.
■ Wound Preparation
■ It is critical that there is complete debridement or excision of pathologic,
necrotic, or infected tissue under tourniquet control (TECH FIG 1).
TECH FIG 1 • A,B. Defect of the heel after tumor
resection.
■ Recipient Vessel Preparation
■ Patency and location of the lateral calcaneal artery for use as the recipient
artery are checked using handheld pencil Doppler.
■ Small saphenous vein is preserved and dissected for use as the recipient
vein.
■ The lateral calcaneal artery runs superficially between lateral malleolus and
the Achilles tendon. The vessel traverses anterior to the calcaneal tendon and
posterior to the small saphenous vein (TECH FIG 2). Opening the extensor
retinaculum and deep fascia exposes the lateral calcaneal artery with its
associated venae comitantes.

TECH FIG 2 • Dissection of lateral calcaneal vessels.
■ Assessment of the Defect
■ After deflating the tourniquet, meticulous hemostasis is performed, which is
followed by irrigation with saline.
■ A template of the exact shape and size of the defect is made by using a
transparent plastic or paper to be used when designing the flap.
■ Wedge-shaped excision of the skin flap is necessary in case of the total heel
resurfacing. The area for planned wedge excision is incorporated when
estimating the flap dimensions.
■ Flap Harvest
■ Outline of the relevant muscle and landmarks are marked on the skin.
■ Perforators are located using handheld pencil Doppler, and the flap is
designed using a template of the defect. The perforator can be located
eccentrically, considering the area of wedge excision (TECH FIG 3A).
■ A limited incision is made, and a suprafascial dissection is performed until
the targeted perforator is identified. Once the perforator is evaluated and
deemed suitable, then the whole skin paddle is elevated and meticulous
intramuscular dissection of pedicle with bipolar forceps is commenced.
■ Motor nerve branches to the muscle are preserved, and the pedicle is divided
when sufficient length is obtained (TECH FIG 3B).
■ A closed suction drain is placed, and the donor site is primarily closed in
layers (TECH FIG 3C).

TECH FIG 3 • A–C. Flap design and elevation.
■ Microanastomosis with Temporary Inset
■ Temporary inset of flap can be performed using a skin stapler.
■ It is critically important to avoid twisting of the pedicle. If excessively long,
the vascular pedicle under the flap is positioned in lazy-S shape to avoid
kinking.
■ The pedicle artery is anastomosed to the lateral calcaneal artery, and the vein
is anastomosed to the short (small) saphenous vein (TECH FIG 4).
■ Vascular clamps are removed after completion of the anastomosis. Warm
saline is applied onto the vessels and flap, and inflow and outflow of the flap
are checked after waiting for several minutes.
■ A thorough microscopic evaluation is conducted to find any bleeding points
along the vascular pedicle.

TECH FIG 4 • Microanastomosis.
■ Final Inset
■ Defatting of the flap is performed before the final inset. The deep fat and
part of the superficial fat may be carefully removed with scissors according
to the required thickness of tissue. Thinning can be done with or without
loupe, but microscope magnification is not usually necessary. This procedure
is important to obtain an optimal contour of the reconstructed foot. The
authors prefer primary (immediate) defatting to secondary (delayed) defatting
because it provides well-contoured reconstruction in one stage, reduces
tension of closure, and is a safe procedure. Alternatively, secondary defatting
is a viable option, which can avoid potential risk of circulatory problem
associated with primary thinning.
■ In contrast to the conventional fasciocutaneous flap that includes deep fat
and fascia, a perforator flap with a thin subcutaneous layer composed of the
superficial fat lobules surrounded by dense fibers allows the skin to anchor
tightly to the surface and to glide less.6,7 Generally, perforator flap is thinned
accordingly to match the contour of adjacent plantar tissue.
■ Redraping of the flap for the final inset is attempted only after the defatting
procedure is completed because this may change the pliability and
extensibility of the flap. Dimensional excess should be corrected at this stage
by careful trimming to obtain durable weight-bearing surface against
anticipated shear forces (TECH FIG 5).
■ The wound is closed over a drain placed under the flap to prevent fluid
collections.

■ Fluffed gauze is gently applied to the flap, but the part of flap including the
location of captured perforator is left exposed for postoperative monitoring
using the handheld pencil Doppler.
TECH FIG 5 • A,B. Inset of the flap after defatting and
wedge-shaped excision.
PEARLS AND PITFALLS
Reconstruction
goal
■ The weight-bearing plantar skin is highly specialized to
withstand and absorb forces exerted during gait or running
cycles.
■ The reconstructive goal is not only to provide stable wound
healing but also to achieve functional restoration of the salvaged
limb with an acceptable appearance.
Flap selection
■ Free muscle flaps (rectus abdominis, latissimus dorsi, and
gracilis) have been commonly selected for the extensive foot
defects.
■ Cutaneous perforator flaps now provide favorable functional and
aesthetic outcomes in heel and plantar reconstruction.
Selection of
recipient
vessel
■ The three named arteries at the ankle level and their terminating
branches can be candidates for recipient vessels; anterior tibial-
dorsalis pedis artery, posterior tibial-medial and lateral plantar
artery, and peroneal-lateral calcaneal artery.
■ CT angiography is a valuable tool to evaluate the arterial and
venous flows and the presence of atherosclerosis.

Assessment of
the defect
■ Before designing the flap, the size and shape of the defect are
measured exactly by making a template.
■ Required vascular pedicle length and flap thickness are also
assessed.
Flap inset
■ Defatting of the flap at the time of insetting is important to
obtain a desirable contour of the reconstructed foot.
Alternatively, secondary defatting is an option.
■ Excessive skin dimension is carefully corrected to have the flap
closely tailored to the defect.
POSTOPERATIVE CARE
■ The leg is elevated to help with edema for a better venous return while the
patient is lying in bed.
■ Care should be taken to avoid any compression along the course of the
superficial vein of the leg when it is used as an outflow vessel.
■ There is no consensus regarding the use of medications for
thromboprophylaxis such as aspirin, heparin, and dextran. The authors do not
routinely use any of these medications but low molecular weight heparin is
given for chemoprophylasix of the venous thromboembolism while patient is
immobilized in bed.
■ For postoperative monitoring, the flap can be checked every 1 to 3 hours for
the first 48 hours, followed by every 4 to 6 hours for the next 48 hours after the
surgery. Monitoring is done by physical examination and handheld pencil
Doppler examination.
■ Diet is usually allowed 24 hours after surgery in the authors’ practice.
■ Although the duration of immobilization time varies based on the orthopedic
and bony status, in general, progressive weight bearing and ambulation are
achieved once the flap maturation is assured. At 2 weeks, compressive garment
is applied to prevent edema of the flap and foot. Bearing weight on the site of
flap is usually allowed in 4 weeks after the surgery.
■ Abnormal weight-bearing patterns and gait abnormalities correlate with the
development of chronic ulcers. An early orthotic use and physical therapy in
rehabilitation unit may prevent ulceration and wound breakdown.
■ Patient education on meticulous foot care with frequent inspections to
recognize any area of wound breakdown is essential for a successful and
durable result.

FIG 12 • A. Total heel reconstruction using TDAP flap.
Posterior tibial vessels were the recipient vessels. B,C.
Reconstruction for small heel defect with muscle-
chimeric TDAP flap. Anterior tibial vessels are the
recipient vessel. D. Reconstruction of the plantar
midfoot with TDAP flap, using lateral plantar vessels as
a recipient vessel. E. Reconstruction of lateral forefoot
with TDAP flap, using posterior tibial vessels as a
recipient vessel through subcutaneous tunneling. F.
Reconstruction of medial forefoot with TDAP flap, using
the first plantar metatarsal vessels as a recipient vessel.

OUTCOMES
■ Microvascular free flap for foot reconstruction is, at present, a safe and reliable
procedure, with high success rate.10 Recently, the plantar reconstruction using
the perforator flaps showed a success rate of between 97.5% and 98.5%, with
acceptable functional and aesthetic outcomes.5,6
■ Microvascular free flap is a reliable reconstructive option for a variety of size
defects on various locations of the heel and plantar foot (FIG 12A). Multiple
tissue components such as cutaneous and chimeric muscle (FIG 12 B,C) can
be used according to tissue requirements.
COMPLICATIONS
■ Vascular complications such as venous and arterial thrombosis.
■ Hematoma: early diagnosis of a hematoma under the flap is critical for its
evacuation to prevent the obstruction of anastomotic site from the expanding
hematoma.
■ Infection.
■ Ulcerations: ulceration is one of the most common complications of free flap
reconstruction of the heel. Although flap-specific factors may contribute to its
development, it is possible that flap extrinsic factors such as the recipient bed,
bony prominence, Contouring of the flap, and footwear may be more
important.
REFERENCES
1. Folman Y, Wosk J, Voloshin A, Liberty S. Cyclic impacts on heel strike: a
possible biomechanical factor in the etiology of degenerative disease of the
human locomotor system. Arch Orthop Trauma Surg. 1986;104:363-365.
2. Chang H, Kwon SS, Minn KW. Lateral calcaneal artery as a recipient pedicle
for microsurgical foot reconstruction. J Plast Reconstr Aesthet Surg.
2010;63:1860-1864.
3. Woo KJ, Park JW, Mun GH. The lateral calcaneal artery as an alternative
recipient vessel option for heel and lateral foot reconstruction. Microsurgery.
2018;38:164-171.
4. Burusapat C, Tanthanatip P, Kuhaphensaeng P, et al. Lateral calcaneal artery
flaps in atherosclerosis: cadaveric study, vascular assessment and clinical
applications. Plast Reconstr Surg Glob Open. 2015;3:e517.
5. May JW Jr, Halls MJ, Simon SR. Free microvascular muscle flaps with skin
graft reconstruction of extensive defects of the foot: a clinical and gait analysis

study. Plast Reconstr Surg. 1985;75:627-641.
6. Hong JP, Kim EK. Sole reconstruction using anterolateral thigh perforator free
flaps. Plast Reconstr Surg. 2007;119:186-193.
7. Jeon BJ, Lee KT, Lim SY, et al. Plantar reconstruction with free thoracodorsal
artery perforator flaps. J Plast Reconstr Aesthet Surg. 2013;66:406-413.
8. Lee KT, Park SJ, Mun GH. Reconstruction outcomes of oncologic foot defect
using well-contoured free perforator flaps. Ann Surg Oncol. 2017;24:2404-
2412.
9. Santanelli F, Tenna S, Pace A, Scuderi N. Free flap reconstruction of the sole
of the foot with or without sensory nerve coaptation. Plast Reconstr Surg.
2002;109:2314-2322.
10. Zhu YL, Wang Y, He XQ, et al. Foot and ankle reconstruction: an experience
on the use of 14 different flaps in 226 cases. Microsurgery. 2013;33:600-604.

15
CHAPTER
The Reverse Sural Artery
Flap for Lower Extremity
Reconstruction
Ashkaun Shaterian and Amber Leis
DEFINITION
■ The reverse sural artery flap was first described by Donski and Fogdestam1
and later by Masquelet et al.2 and represents a fasciocutaneous flap used in
lower extremity reconstruction.
■ As a one-stage or two-stage operation that does not require microsurgical
techniques, the reverse sural flap is an option available to most reconstructive
and orthopedic surgeons.
ANATOMY
■ The blood supply for the skin paddle of the distal two-thirds of the leg depends
on the sural arteries along its most proximal course and the peroneal artery
perforators more distally.
■ The reverse sural artery flap receives retrograde arterial flow through
septocutaneous perforators that originate from the peroneal artery and directly
anastomose with the superficial sural artery.
■ There are typically two to five perforators located 5 to 7 cm proximal to the
lateral malleolus.3
■ The venous drainage for this flap is composed of a venous network of the
superficial sural vein, the lesser saphenous vein, and the associated veins of the
peroneal artery.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Assessment of the defect begins with evaluation for missing tissues, exposed
vital structures, and presence of underlying orthopedic hardware.

■ If healthy subcutaneous or granulation tissue presides, the wound may be
amenable to skin grafting.
■ If exposure of tendon, artery, vessel, or bone are present, more definitive
coverage with fasciocutaneous or muscle flaps is often necessary.
■ The size of the defect will also influence the reconstructive choice.
■ The reverse sural artery flap can be used to cover defects of the posterior
aspect of heel and Achilles tendon, anterior and lateral ankle, dorsum of the
foot, lateral aspect of the hindfoot, and the anterior crest of lower third of the
leg.
■ Physical exam to evaluate the vascular status of the extremity, and to evaluate
for peripheral artery disease or venous insufficiency, is necessary as they may
influence flap survival.
■ Patient comorbidities of diabetes mellitus, lower extremity venous
insufficiency, and peripheral artery disease have been associated with flap
necrosis and represent relative contraindications.
■ The presence of an occluded anterior or posterior tibial artery does not
represent an absolute contraindication to this flap; however, most consider
occlusion of the peroneal artery to preclude its use.4–6
IMAGING
■ Rarely are radiographs necessary except in the evaluation of bone
abnormalities.
■ Preoperative angiograms are not routinely obtained but may be useful in
patients with pertinent exam findings or in traumatic wounds of the lower
extremity.
SURGICAL MANAGEMENT
Preoperative Planning
■ The reverse sural artery flap is a fasciocutaneous flap that can be designed
with either a complete skin bridge overlying the pedicle or as an island skin
flap with an adipofascial pedicle.
■ Preoperatively, the peroneal perforators and lesser saphenous vein are
identified with Doppler ultrasonography.
■ The lesser saphenous vein is used to determine the oblique axis of the pedicle
and the flap.
■ The flap is designed on the posterior aspect of the calf between the two heads

of gastrocnemius at the junction of upper and middle third of the leg (FIG 1).
■ The dimensions of the flap are determined by the arc of rotation and the size of
the defect; however, a reliable flap should not exceed a ratio of length to width
of pedicle of 4:1.
■ The flap dimensions can reach 15 cm in length and 12 cm in width, but when
the flap is less than 3 to 4 cm wide, the donor site defect can be closed
primarily.
■ The pivot point of the pedicle is dependent on the main perforator and is
located 5 cm or three fingerbreadths proximal to the tip of the lateral malleolus
and posterior to the fibula.
■ The flap may also be designed based on more distal perforators, but the
dissection becomes more risky, the width of pedicle decreases, and reliability
of the flap declines.
FIG 1 • Flap markings for a reverse sural artery flap with
a fasciocutaneous pedicle.
Positioning
■ To provide the best exposure, the patient is placed in a prone or lateral position
depending on the location of the defect.
■ In the lateral position, flexion and adduction of hip and flexion of knee allow
for easier access.
■ The surgeon is positioned on the same side as the flap and the assistant on the
contralateral side.
■ All bony prominences should be well padded and the upper extremities and
neck placed in positions of safety.

Approach
■ The flap is approached from the posterior lower leg after identifying the
vascular pedicle and completing the appropriate markings.
T E C H N I Q U E S
■ Reverse Sural Artery Flap
■ A well-padded lower extremity tourniquet is applied.
■ The skin incision begins along the location of the pedicle and continues
around the proximal edge of the flap (TECH FIG 1A).
■ The subcutaneous tissue is dissected along the pedicle and most proximally
to identify and expose the sural nerve, superficial sural artery, sural vein, and
lesser saphenous vein.
■ At the proximal margin of the flap, the nerve and the vessels are ligated and
divided.
■ The flap including the skin and subcutaneous tissues containing the
neurovascular structures are elevated off the surface of the gastrocnemius
muscle in a subfascial plane to the level of the chosen pivot point (TECH
FIG 1B,C).
■ These tissue layers are elevated as a single fasciocutaneous unit and continue
distally to isolate the pedicle.
■ The pedicle should be at least 2 to 3 cm in width after its dissection from the
surrounding tissues.
■ The pedicle is dissected free at the pivot point, mobilized, and the flap
repositioned to cover the recipient site. It is important that the arc of rotation
does not kink or place undue tension on the pedicle.
■ Transposition of the flap through either a wide subcutaneous tunnel or an
excised skin bridge allows for flap inset.
■ The donor site is closed primarily or covered with a split-thickness skin
graft.
■ At the completion of the case, dressings are applied. The skin graft (if
needed) is covered with nonadherent dressings and antibiotic ointment.
Nonadherent gauze is used to cover suture lines.
■ A well-padded posterior plaster splint with a window for flap monitoring is

applied to cover and protect the surgical site.
TECH FIG 1 • A. Flap dissection with the
fasciocutaneous pedicle incised. B. Flap after inset
(as a second stage following a delay procedure) with
split-thickness skin grafting to the donor site. C.
Reverse sural artery flap after flap dissection and
elevation.
■ Delayed Reverse Sural Artery Flap
■ The delayed reverse sural artery flap aims to improve longitudinal blood
flow along the axial pedicle and decrease flap necrosis and is especially
useful in patients with vascular comorbidities.
■ The described techniques have included raising the flap in the typical
subfascial plane but without incising the proximal portion of the skin island

flap.
■ The skin is closed and 1 to 2 weeks later completely elevated and
transposed.
■ Others have described complete elevation of the flap at the first stage
following flap transfer at the second stage.
■ These staged techniques establish improved flap circulation prior to the
trauma of flap transfer.
■ Supercharged Reverse Sural Artery Flap
■ The supercharged reverse sural artery flap aims to improve venous drainage
and bypass venous valves that prevent retrograde venous outflow.
■ Described techniques include anastomosing the proximal segment of the less
saphenous vein to a vein located at the recipient site or exteriorizing the
proximal segment to allow for intermittent drainage upon signs of vascular
congestion.4
PEARLS AND PITFALLS
Imaging
■ Consider imaging to evaluate the patency of the peroneal artery in
traumatic wounds of the lower extremity.
Technique
■ A longer pedicle will allow for tension-free twisting; excessive pedicle
rotation at the pivot point can result in a kinked pedicle and flap
failure.
■ It is preferable to incise the skin bridge between the pivot point and
recipient site to prevent retractile tissue from compressing the pedicle.
■ The pivot point of the flap can be revised at a later operation (ie,
delayed flaps).
■ The use of a skin pedicle (vs adipofascial) improves venous return but
limits rotation of the flap.
■ A pedicle width of at least 4 cm has been recently shown to improve
venous drainage and flap viability.3
■ The reverse sural flap is often at risk for venous congestion where
impaired venous drainage is thought to be a major contributor to flap
failure. Widening the pedicle, performing a delayed flap, or

supercharging the flap may overcome this problem.
POSTOPERATIVE CARE
■ In the immediate postoperative period, direct pressure on the flap must be
avoided and strict elevation of the lower extremity is instructed.
■ The splint and dressings are removed at 5 to 7 days to allow for complete
evaluation of the flap and assessment of skin graft viability.
■ Prolonged use of a splint beyond the first week is discouraged but may be
continued based on the underlying orthopedic status of the bone.
■ Nonadherent dressings are reapplied and maintained for 2 to 3 weeks.
■ The patient is maintained nonweight bearing for 1 to 2 weeks and restricted
weight bearing for 4 to 6 weeks until flap viability and healing is established.
OUTCOMES
■ The reverse sural artery flap has a low complication profile with 82% of flaps
healing without any flap-related complications on meta-analysis.4
■ Morbidity associated with selection of this flap includes loss of sensation over
the donor site and lateral foot, presence of a donor site scar, and excess foot
bulk that may preclude proper footwear.
COMPLICATIONS
■ Rate of specific complications range in the literature and include partial or
complete flap necrosis, venous congestion, infection, hematoma, delayed
healing, wound dehiscence, and skin graft loss.
■ Patients with vascular comorbidities (ie, diabetes, venous insufficiency,
peripheral artery disease), for example, have a five- to sixfold increase in
complication rate relative to their healthier counterparts.7
■ Age over 40 has also been shown to correlate with flap failure.4,7
REFERENCES
1. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural
region. A preliminary report. Scand J Plast Reconstr Surg. 1983;17(3):191-
196.
2. 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(6): 1115-1121.
3. Sugg KB, et al. The reverse superficial sural artery flap revisited for complex

lower extremity and foot reconstruction. Plast Reconstr Surg Glob Open.
2015;3(9):e519.
4. Follmar KE, Baccarani A, Baumeister SP, et al. The distally based sural flap.
Plast Reconstr Surg. 2007;119(6):138e-148e.
5. Hsieh CH, et al. Distally based sural island flap for the reconstruction of a
large soft tissue defect in an open tibial fracture with occluded anterior and
posterior tibial arteries—a case report. Br J Plast Surg. 2005;58(1):112-115.
6. Jolly GP, Zgonis T. Soft tissue reconstruction of the foot with a reverse flow
sural artery neurofasciocutaneous flap. Ostomy Wound Manage.
2004;50(6):44-49.
7. Baumeister SP, et al. A realistic complication analysis of 70 sural artery flaps
in a multimorbid patient group. Plast Reconstr Surg. 2003;112(1):129-140.

16
CHAPTER
Ankle Reconstruction With
Free Flap
Sean S. Li, Ahmed Suliman, and Deepak M. Gupta
DEFINITION
■ The ankle has limited soft tissue for protection of vital structures, and trauma
or tumor extirpation often leads to exposed tendons, bone, vessels, or nerves.
■ There are few reliable local flaps that can be used for coverage in this area.
■ Impaired blood flow is also typical of the distal lower extremity especially in
high-risk patients with comorbidities such as smoking, diabetes, peripheral
arterial disease, and venous insufficiency, which may result in ulceration,
infection, and necrosis of the soft tissues ultimately requiring free flap
coverage.
■ Due to the complexity of the ankle, reconstruction ideally should be
approached in a multidisciplinary fashion consisting primarily of collaboration
between plastic and orthopedic surgeons but also with consideration of
consultation of infectious disease and vascular surgery.
ANATOMY
■ The ankle is a hinge joint with articulations between the tibia, fibula, and talus.
■ Defects in the ankle commonly expose bone or orthopedic hardware, usually
at the tibia or the medial and lateral malleoli.
■ Five nerves supply the foot and ankle—saphenous, sural, deep peroneal,
superficial peroneal, and tibial nerves.
■ Knowledge of the ankle’s vascular anatomy is essential for limb salvage. The
distal lower extremity’s arterial supply is primarily supplied by three vessels:
posterior tibial (PT), anterior tibial (AT), and peroneal.
■ The AT artery branches from the popliteal artery, and its course across the
ankle is shown (FIG 1, left).

■ The PT and peroneal arteries originate from the tibioperoneal trunk, and their
courses across the ankle are shown (FIG 1, right).
PATHOGENESIS
■ Defects of the ankle requiring free flap reconstruction originate from trauma
(FIG 2), tumor extirpation, and peripheral vascular disease.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Evaluation of the patient begins with history and physical focusing on the
following:
■ Eliciting the etiology of the wound and presence of comorbidities including
smoking, diabetes, obesity, and peripheral vascular disease
■ Assessing the overall function of the patient and considering the potential
outcomes for the patient and bearing in mind the patient’s rehabilitative
potential, motivation, and compliance. Location, size, depth, character of the
wound, and exposed structures
■ Neurological, vascular, and skeletal evaluation of the lower extremities
utilizing physical exam, imaging, and Doppler
IMAGING
■ Plain films of the defect should be obtained to evaluate for fractures and bony
defects with further computed tomography imaging to be considered depending
on complexity of the injury.
■ If physical or Doppler exam reveals inconclusive vascular status or if
peripheral vascular disease is suspected, preoperative arteriography may be
obtained.
■ Computed tomographic angiography (CTA) (FIG 3) can obtain vascular
information valuable for flap planning and assessing the recipient site without
risk of complications associated with arterial puncture of the groin.
■ Selective preoperative CTA may be considered in patients who have lost
peripheral pulses, had a neurological deficit secondary to the injury, or of a
compound fracture that has undergone reduction and external or internal
fixation.2
NON OPERATIVE MANAGEMENT
■ Defects in the ankle that typically require free flap reconstruction have
exposed hardware, tendon devoid of paratenon, vessels, nerves, open joint(s),
or bone denuded of periosteum.

■ These defects if managed nonoperatively will not heal and can potentially lead
to further tissue loss, osteomyelitis, loss of function, or amputation.
SURGICAL MANAGEMENT
■ The goal of reconstruction is to achieve a healed wound to allow function.
■ In the ankle, the aims are to allow the patient to wear normal footwear, avoid
bulky flaps, and return to weight bearing and ankle motion.
■ Selection of flaps is based on morbidity of the donor site and accessibility of
local tissue.
■ Regardless of the flap selection, the principles for reconstruction include
adequate debridement, restoring skeletal support, and anastomosing of the
flap vessels outside of the zone of injury.3

FIG 1 • Left: the anterior tibial artery course across the
ankle.1 Right: the posterior tibial artery and peroneal
artery course across the ankle.1

FIG 2 • A. Exposed bone of medial malleolus, denuded
of the periosteum, chronic inflammation, and scarring of
surrounding soft tissues. B. Necrotic bone within medial
malleolus wound.
FIG 3 • CTA shows normal angiogram of bilateral thighs
and three vessel runoff of the legs.
■ After the evaluation of the patient as a whole in regard to their systemic
conditions, socioeconomic factors, extent of injury, and rehabilitative potential,
a decision for amputation versus salvage can be made.
■ The decision for free flap reconstruction goes hand-in-hand with the patient’s
orthopedic injuries and potential for functional recovery.
■ Scores such as the Mangled Extremity Severity Score (MESS), Predictive
Salvage Index, and the Limb Salvage Index can be used to assist in the
decision-making for amputation versus salvage.4
■ Absolute indications for amputation include complete disruption of the

posterior tibial nerve in adults and crush injuries with warm ischemia time
greater than 6 hours.
■ Relative indications of amputation include serious associated polytrauma,
severe ipsilateral foot trauma, and prolonged anticipated course to soft tissue
coverage and tibial reconstruction.
Preoperative Planning
■ If reconstruction is indicated, the following must be considered:
■ Bony stability is first established by utilizing external or internal fixation
devices.
• External devices are usually preferred if there is significant bone loss or
bone devascularization.
■ In contaminated wounds, multiple stages of debridement may be required
until an adequate wound bed without devitalized or infected tissues is
achieved.
• Vacuum-assisted closure decreases need for dressing changes and can
promote healing.5
• Osteomyelitis can follow severe open fractures with massive contamination
or devascularized tissue; management includes resection of dead or infected
bone, flap coverage with obliteration of dead space, and antibiotic
treatment.6
■ Timing of reconstruction
• If the general condition of the patient and the status of the wound are
adequate, definitive coverage should not be delayed.
• Ideally, the wound should be covered in the first week after injury in the
acute phase as further delay causes the wound to enter into the subacute and
chronic phases when there is a higher rate of infectious complications and
flap failure.7,8
■ Zone of injury9
• Many lower extremity wounds result from high-energy trauma that creates a
significant “zone of injury.”
• This zone is highly thrombogenic and extends beyond what is
macroscopically evident.
• Failure to recognize the true extent of the zone is a leading cause of
microsurgical anastomotic failure.
• Within this zone, there is increased friability of the vessels and increased

perivascular scar tissue.
• Selecting a recipient vessel outside of this zone of injury with good vessel
wall pliability and high-quality blood flow from the transected end of the
vessel is essential for successful microsurgical anastomosis.
■ Coverage after tumor extirpation
• Free flap reconstruction must withstand radiation therapy and/or
chemotherapy with the goal of preserving function and achieving an
acceptable appearance and function.
• Close cooperation with oncologists and knowledge of prognosis/risk of
recurrence/survival, tumor characteristics, behavior, and adjuvant treatment
is necessary to plan for the correct type of reconstructive procedure.
■ Exposed hardware
• Traditionally management involved irrigation and debridement, antibiotics,
and removal of hardware.
• However, if the hardware is clinically stable, exposure is less than 2 weeks,
the infection is controlled, and the hardware is utilized for bony
consolidation, then the likelihood of salvage with soft tissue coverage is
increased.10
■ Reconstruction in patients with a two- or one-vessel extremity
• Consider vascular bypass surgery.
• End-to-side anastomosis during free flap reconstruction can preserve the
existing main arteries.
• A flow-through free flap can be utilized where an anastomosis is made both
proximally and distally to vessels in the leg (FIG 4).
• Some have reported that an anastomosis can technically also be made to a
distal stump of a recipient vessel to rely on arterial backflow11; however,
this should be a last resort and consideration should be made for possible
low flow state.
■ Muscle versus fasciocutaneous free flaps
• Controversy exists over selecting the type of flap for lower extremity
defects.

FIG 4 • The flap has been anastomosed end-to-end to
the posterior tibial artery. After flowing through, another
end-to-end anastomosis allows circulation to the foot
through the posterior tibial artery via the rectus femoris
branch.
• Reconstruction of wounds with muscle flaps has been shown experimentally
to have increased blood flow and antibiotic delivery, increased oxygen
tension, increased phagocytic activity, and decreased bacterial counts when
compared to fasciocutaneous flaps.12
• Arguably muscle flaps are technically less challenging, can fill larger
defects, and can be harvested with decreased operative time compared with
fasciocutaneous flaps (eg, vastus lateralis flap versus anterolateral thigh
flap).13
• Donor site morbidity of muscle flaps can be greater than fasciocutaneous
flaps depending on the muscle selected.
• Selection of a flap depends on the defect, condition of the wound, goals of
reconstruction, and surgeon and patient preference.
Positioning
■ Patient positioning in free flap surgery is an important issue that needs to be
considered preoperatively. Most cases can be done in supine, supine frog leg,
or lateral decubitus position.
■ The goal is to avoid unnecessary repositioning of the patient intraoperatively
in order to save anesthetic and operative time.
■ The location of the defect or choice of recipient vessels may determine the

positioning of the patient and to some extent, the flap choice.
■ For example, anterior defects favor the use of the anterolateral thigh flap,
gracilis flap, rectus abdominis flap, etc.
■ Posterior tibial recipient vessels (medial leg approach) may favor either supine
or lateral decubitus position and the concordant flap choices.
Approach
■ The approach to flap harvest depends on the flap selection and considering the
positioning of the patient as noted above.
■ The approach to the ankle wound depends on the location of the defect and
selection of recipient vessels.
■ The posterior tibial artery is the most commonly used recipient vessel.
■ It is easily accessible by a medial approach and is found between the deep
posterior and superficial posterior compartments. In other terms, it is deep to
the soleus muscle.
■ The most favorable positioning for the patient is either lateral or with frog leg
positioning.
■ It is the preferred vessel for defects of the posterior or medial ankle.
■ It may also be used for lateral defects, and there are several options for
pedicle routing, such as under the Achilles tendon.
■ The anterior tibial artery is the second most commonly used recipient vessel.
■ It is easily accessible in the anterior compartment.
■ The most favorable positioning of the patient is supine.
■ Some may favor the anterior tibial vessels for defects of the anterior and
lateral ankle.
■ The peroneal artery is usually the last choice for recipient vessel because of
difficulty of accessibility, which may require removal of fibular bone.
■ The two major superficial veins of the lower extremity are the great and small
saphenous veins, which run superficial to the fascia cruris.
■ The great saphenous vein is accompanied by the saphenous nerve and is
located anterior to the medial malleolus.
■ The small saphenous vein arises from the lateral side of the foot, posterior to
the lateral malleolus, and passes along the border of the Achilles tendon.
■ Any superficial vein with adequate caliber can be used as a recipient vein in
addition to the venae comitantes of the major arteries.
■ Anastomosis of two recipient veins for each artery is optional. If undertaken,

it is preferable to anastomose to separate drainage systems (eg, one deep vein
and one superficial vein).
T E C H N I Q U E S
■ Vastus Lateralis
■ Take into account all of the preoperative factors as noted in the preoperative
planning section.
■ Assess the defect.
■ Approach your recipient vessel as mentioned in the various approaches
above, and dissect back to healthy vessel outside of the zone of injury
(TECH FIG 1A). Use of tourniquet may be considered.
■ Elevate the flap as previously described.13
■ With the patient positioned supine, a line is drawn between the anterior
superior iliac spine and the superolateral corner of the patella on the donor
thigh.
■ An incision is then made along the middle third of the line. Carry the
incision through the muscle fascia until the interval between the rectus
femoris and the vastus lateralis is identified. Extend the incision as needed
as you go along. Take care to identify any branches of the lateral cutaneous
femoral nerve so as not to injure them.
■ Separate the rectus femoris and vastus lateralis and identify and preserve
the pedicle (the descending branch of the lateral circumflex femoral artery),
which is generally visible along the medial border of the vastus lateralis.
■ Perform a lateral subfascial dissection superficial to the muscle until the
width of muscle flap needed has been visualized. Continue this dissection
proximal and distal along the superficial surface of the muscle until the
dimensions of muscle flap needed have been achieved.
■ Identify the motor nerve branches, which typically enter the midportion of
the muscle; only sacrifice branches directly involved in the transferred
portion of muscle.
■ Dissect the pedicle from distal to proximal. Continue the dissection until
adequate pedicle length and vessel caliber has been obtained. One may
encounter vascular branches to the vastus intermedius or rectus femoris,

which can typically be sacrificed. Nerve branches should be spared.
■ Divide the muscle along the required dimensions. Ligate and divide the
pedicle when the recipient area is ready.
■ Perform your anastomosis (TECH FIG 1B) and inset the flap (TECH FIG
1C). Consider use of penrose drains around the microvascular anastomoses.
Some additional de-epithelialization or resection of leg skin may be required
to accommodate flap and/or pedicle lie.
■ Harvest split-thickness skin graft for the flap. Meshing of the skin graft may
be considered (TECH FIG 1D).
■ The donor site can usually be closed primarily over closed suction drains.
TECH FIG 1 • A. The posterior tibial artery and two
venae comitantes have been dissected proximal to the
zone of injury. B. The descending branch of the lateral
circumflex femoral artery has been dissected (blue
loop) to its origin along with the rectus femoris branch
(red loop). C. The flap has been anastomosed in flow
through configuration outside the zone of injury. The
inset is partially completed with Vicryl sutures.
Intervening leg skin was subsequently de-
epithelialized to accommodate flap and pedicle lie. D.
The flap has been inset and covered with a meshed

split-thickness skin graft.
■ Anterolateral Thigh (ALT)
■ Take into account all of the preoperative factors as noted in the preoperative
planning section.
■ Assess the defect.
■ Approach your recipient vessel as mentioned in the various approaches
above, and dissect back to healthy vessel outside of the zone of injury. Use of
tourniquet may be considered.
■ Elevate the flap as previously described.14
■ With the patient positioned supine, a line is drawn between the anterior
superior iliac spine and the superolateral corner of the patella on the donor
thigh.
■ Draw a 3-cm circle centered at the midpoint of this line. Map the cutaneous
perforators with a portable, handheld pencil Doppler probe. The majority of
perforators will be found in the inferolateral quadrant of this circle.
■ The flap is centered over the location of these vessels, and its long axis
should be parallel to that of the thigh. The maximum width of the flap is
judged with a pinch test.
■ Incise the medial border of the proposed flap and continue dissection deep
and through the muscle fascia until you have identified fibers of rectus
femoris.
■ Continue the subfascial dissection from medial to lateral. Take care to
identify the interval between vastus lateralis and rectus femoris and not
cross it. At this point, the dissection should be slowed so that one can
identify and preserve any septocutaneous or musculocutaneous perforators
corresponding to the cutaneous Doppler signals.
■ Once the dominant perforator(s) have been identified, these are carefully
dissected distal to proximal, to either free them from the vastus lateralis
muscle or include them with a cuff of muscle.
■ Incise the skin paddle along its lateral aspect. Perform a subfascial
dissection to the dissected perforators.
■ Depending on the vascular configuration, vastus lateralis muscle can also
be dissected on a separate branch if a chimeric flap is needed.
■ Dissect the pedicle from distal to proximal. Continue the dissection until

adequate pedicle length and vessel caliber has been obtained. One may
encounter vascular branches to the vastus intermedius or rectus femoris,
which can typically be sacrificed. Nerve branches should be spared.
■ Ligate and divide the pedicle when the recipient area is ready.
■ Perform your anastomosis and inset the flap.
■ The anterolateral thigh (ALT) donor site can usually be undermined and
closed primarily over closed suction drains. The maximum width of the flap
is judged with a pinch test. Donor sites that cannot be primarily closed may
be skin grafted. Others have reported closing large donor sites using adjacent
tissue transfer techniques.
■ Gracilis
■ Take into account all of the preoperative factors as noted in the preoperative
planning section.
■ Assess the defect.
■ Approach your recipient vessel as mentioned in the various approaches
above and dissect back to healthy vessel outside of the zone of injury. Use of
tourniquet may be considered.
■ Elevate the flap as previously described.15
■ With patient supine, position the lower limb in external hip rotation, and
knee and hip in flexion as needed. Palpate the adductor longus tendon in
the medial thigh.
■ The gracilis is posterior to the adductor longus. An incision is marked two
to three finger breadths posterior to the adductor longus tendon. Keep in
mind that the neurovascular pedicle enters the muscle approximately 10 cm
below its bony origin.
■ An optional distal incision at the knee can be made to transect the distal
tendon if the entire length of the flap is needed.
■ Carry the proximal incision down through the fat and muscular fascia to
the muscle. Take care to identify the greater saphenous vein during this step
and protect it by retracting if necessary.
■ Dissect superficial to the gracilis muscle to expose its surface.
■ Identify the interval between gracilis and adductor longus. Enter the
interval carefully to identify the pedicle—the medial circumflex femoral
artery and veins.

■ Dissect the pedicle from distal to proximal. Continue the dissection until
adequate pedicle length and vessel caliber has been obtained. One may
encounter vascular branches to the adductor longus, which can be
sacrificed. Nerve branches should be spared.
■ Divide the muscle along the required dimensions. Ligate and divide the
pedicle when the recipient area is ready.
■ Perform your anastomosis and inset the flap.
■ Harvest split-thickness skin graft for the flap.
■ The donor site can usually be closed primarily over closed suction drains.
■ Rectus Abdominis
■ Take into account all of the preoperative factors as noted in the preoperative
planning section.
■ Assess the defect.
■ Approach your recipient vessel as mentioned in the various approaches
above, and dissect back to healthy vessel outside of the zone of injury.
■ Elevate the flap as previously described.16
■ With the patient supine, the muscle can be exposed through a midline
vertical, paramedian vertical, or lower transverse incision with the total
length of the incision depending on the amount of muscle harvested.
■ Dissect down to the level of the rectus sheath, ligating perforators as they
are found.
■ Divide the rectus sheath longitudinally and elevate the fascia medially and
laterally taking care to tease off the inscriptions without damaging the
muscle fibers.
■ Identify the deep inferior epigastric artery and its accompanying veins at
the lateral edge of the inferior muscle within the fatty tissue. Dissect the
pedicle from distal to proximal. Continue the dissection until adequate
pedicle length and vessel caliber has been obtained.
■ Divide the muscle along the required dimensions. Ligate and divide the
pedicle when the recipient area is ready.
■ Perform your anastomosis, and inset the flap.
■ Harvest split-thickness skin graft for the flap.
■ Close the fascia with nonabsorbable suture. Close the donor site wound
primarily. Use drains as needed.

■ Latissimus Dorsi
■ Take into account all of the preoperative factors as noted in the preoperative
planning section.
■ Assess the defect.
■ Approach your recipient vessel as mentioned in the various approaches
above, and dissect back to healthy vessel outside of the zone of injury.
■ Elevate the flap as previously described.17
■ The flap harvest is usually done in lateral decubitus position with
appropriate padding. The ipsilateral arm may also be prepped into the
operative field depending on surgeon preference. The current authors prefer
to use a padded and draped Mayo stand to position the arm.
■ The latissimus is marked by finding the surrounding landmarks—scapular
tip superiorly, iliac crest inferiorly, spinous processes medially.
■ Choice of skin incision also depends on surgeon preference and size of flap
needed. Incisions made include transverse (to hide within a bra line),
oblique (extending from posterior axillary fold over the middle of the
muscle belly), or vertical (uncommon).
■ Expose the latissimus by dissecting the skin and subcutaneous tissues off
the muscle all the way to all its edges. Dissect the submuscular plane taking
care not to elevate the serratus muscle or fat pad. It is easiest to being this
dissection anteriorly or superiorly.
■ Release the insertions near the midline of the back and then inferiorly.
Proceed with the submuscular dissection from distal to proximal toward the
axilla. The pedicle can be visualized along the deep surface of the muscle
as one approaches the axilla.
■ Identify the branch to the serratus muscle. Ligate it if necessary. The
circumflex scapular branch may also be ligated if additional pedicle length
or larger caliber is needed.
■ Trim the muscle along the required dimensions. Ligate and divide the
pedicle (including the thoracodorsal nerve) when the recipient area is ready.
■ Reposition the patient if necessary.
■ Perform your anastomosis and inset the flap.
■ Harvest split-thickness skin graft for the flap.
■ Close the donor site over suction drains.

PEARLS AND PITFALLS
Amputation vs
limb salvage
■ Consider limb salvage on a case-to-case basis. If a long,
protracted course for limb salvage is anticipated, consider the
benefit of early mobilization and physical therapy after
amputation.
Zone of injury
■ Microsurgical anastomosis outside the zone of injury is critical to
success.
Timing of
reconstruction
■ If possible, reconstruction within 7 days in the acute period leads
to higher incidence of flap survival.
Sequence of
salvage
■ Bony stability, thorough debridement to achieve favorable wound
bed, flap reconstruction.
Flap selection
■ Select a flap with sufficient pedicle length to anastomose outside
the zone of injury, does not require intraoperative repositioning,
and has acceptable donor site morbidity.
POSTOPERATIVE CARE
■ Immobilization of the extremity and bed rest is recommended for 5 to 14 days
postoperatively.
■ Dangling of the leg is then initiated, with increasing frequency and length
continuously while the flap is carefully watched for swelling, congestion, or
increasing pain.
■ Compression stockings or wraps are applied after 4 weeks and continued for
approximately 6 months.
OUTCOMES
■ The goal is a healed wound, return to activity, and acceptable contour (FIG 5).
■ Functional outcomes largely depend on the extent of the patient’s injuries.
■ Prognosis for bony union and adequate neurovascular recovery must be
considered.
■ Patient compliance is important for best long-term results.
■ Patients at high risk for amputation can be advised that reconstruction
typically results in 2-year outcomes equivalent to those of amputation.18

FIG 5 • The goal is a healed wound, return to activity,
and acceptable contour.
COMPLICATIONS
■ Osteomyelitis
■ Chronic pain
■ Nonunion
■ Flap failure
■ Contour abnormality
■ Donor site morbidity
■ Amputation
REFERENCES
1. Attinger CE, Evans KK, Bulan E, et al. Angiosomes of the foot and ankle and
clinical implications for limb salvage: reconstruction, incisions, and
revascularization. Plast Reconstr Surg. 2006;117:261s-293s.
2. Duymaz A, Karabekmez FE, Vrtiska TJ, et al. Free tissue transfer for lower
extremity reconstruction: a study of the role of computed angiography in the
planning of free tissue transfer in the posttraumatic setting. Plast Reconstr
Surg. 2009;124:523-529.
3. Serafin D, Voci VE. Reconstruction of the lower extremity. Microsurgical
composite tissue transplantation. Clin Plast Surg. 1983; 10:55-72.
4. Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr Surg.
2010;125:582-588.
5. Reddy V, Stevenson TR. MOC-PS(SM) CME article: lower extremity
reconstruction. Plast Reconstr Surg. 2008;121:1-7.

6. Anthony JP, Mathes SJ. Update on chronic osteomyelitis. Clin Plast Surg.
1991;18:515-523.
7. Godina M. Early microsurgical reconstruction of complex trauma of the
extremities. Plast Reconstr Surg. 1986;78:285-292.
8. Byrd HS, Cierny G III, Tebbetts JB. The management of open tibial fractures
with associated soft-tissue loss: external pin fixation with early flap coverage.
Plast Reconstr Surg. 1981;68:73-82.
9. Arnez ZM. Immediate reconstruction of the lower extremity—an update. Clin
Plast Surg. 1991;18:449-457.
10. Viol A, Pradka SP, Baumeister SP, et al. Soft-tissue defects and exposed
hardware: a review of indications for soft-tissue reconstruction and hardware
preservation. Plast Reconstr Surg. 2009;123:1256-1263.
11. Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue
transfer to the lower extremity. Plast Reconstr Surg. 1999; 103:1937-1948.
12. Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial
inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr
Surg. 1986;77:785-794.
13. Kaminsky AJ, Li SS, Copeland-Halperin LR, Miraliakbari R. The vastus
lateralis free flap for lower extremity gustilo grade III reconstruction.
Microsurgery. 2017;37:212-217.
14. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An
experience with 672 anterolateral thigh flaps. Plast Reconstr Surg.
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15. Franco MJ, Nicoson MC, Parikh RP, Tung TH. Lower extremity
reconstruction with free gracilis flaps. J Reconstr Microsurg. 2017; 33:218-
224.
16. Bunkis J, Walton RL, Mathes SJ. The rectus abdominis free flap for lower
extremity reconstruction. Ann Plast Surg. 1983;11: 373-380.
17. May JW Jr, Lukash FN, Gallico GG III. Latissimus dorsi free muscle flap in
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