Phẫu Thuật Tạo Hình (Tập 4): Chi Dưới, Thân Mình Và Bỏng – Neligan (Ấn bản 4)

188.e1
Wound comorbidities
Fig. 8.4  Blue toe syndrome. (A,B) Patient presented with severe pain following sudden appearance of several
well-demarcated ischemic lesions involving all 5 digits of the right foot. (C) Right lower extremity angiogram
demonstrating an ulcerated plaque with organized thrombus in the mid-superficial femoral artery. Percutaneous
endovascular intervention was not attempted due to concern over plaque dislodgement and resultant distal embolism.
(D,E) Open thromboendarterectomy with excision of a 1.5 cm occlusive thrombus.
A
B
C
D
E

189
Patient evaluation and diagnosis
implications associated with microvascular thrombosis cannot
be over emphasized. If a diagnosis of thrombophilia is either
known or suspected based on historical information, referral
to a hematologist and/or laboratory screening for commonly
encountered hypercoagulable traits is recommended.34
Patient evaluation and diagnosis
Clinical history
Effective management of foot and ankle wounds is predicated
upon an accurate determination of wound etiology, previ­
ously administered therapies, host comorbidities, and baseline
biomechanics. The origin and age of the wound should be
determined. Traumatic wounds should be defined in terms of
acute versus chronic; high versus low impact; and mechanism
of injury (i.e., biomechanical, thermal, caustic, radiation-
induced, etc.). The patient’s tetanus immunization status
should be obtained and updated as indicated. In chronic
wounds, the age of the wound is important as long-standing
wounds have the potential for malignant transformation (i.e.,
Marjolin’s ulcer). Previous topical therapies must be eluci­
dated, as caustic agents (i.e., hydrogen peroxide, 10% iodine,
Dakin’s solution, etc.) may contribute to wound chronicity.
A careful medical history should be obtained to identify
disease states that negatively affect wound healing (i.e.,
diabetes mellitus, peripheral vascular disease, autoimmune
conditions, immunocompromise, hematologic disorders,
malnutrition, and so on). The presence of rheumatologic auto­
immune conditions such as rheumatoid arthritis, pyoderma
gangrenosum, systemic lupus erythematosus, and scleroderma
are frequently associated with inflammatory wounds that
initially necessitate medical rather than surgical management.
Optimizing coagulopathies (i.e., factor V Leiden, protein C
deficiency, protein S deficiency, anti-thrombin III deficiency,
anomalous factor II, etc.) in patients with vasculitic wounds is
critical for progression of normal wound healing. A complete
list of medications and drug allergies should be obtained, as
medications used in the treatment of autoimmune disease (i.e.,
steroids and/or chemotherapy) frequently impair healing.
Nutritional status must also be optimized to promote healing
(albumin >3.5 g/dL and/or total lymphocyte count >1500).
Smoking significantly decreases local cutaneous blood flow
and should be documented and addressed with each patient.
Given the complexity of various disease processes, multiple
specialties are often called upon to assist in optimizing the
patient’s medical condition in order to improve the chances
of successful wound healing.
Limb function
Assessment of the patient’s current and anticipated level of
activity is important to determine if the leg should be salvaged
and to what extent it should be reconstructed. A poorly func­
tional limb in a young, otherwise active, patient may be
counterproductive, and the patient may in fact do better with
a modified below-knee amputation (Ertl) and a well-adapted
prosthetic. For the less active or non-ambulatory patient, if the
limb is functional or can at least facilitate simple transfers,
salvage – if medically tolerable and technically feasible – is
usually indicated. In contrast, if the limb is non-functional and
cultured skin derivatives (recalcitrant cases) once edema has
improved. Surgical treatment of incompetent saphenous or
lesser saphenous veins or of incompetent perforators can help
relieve local venous hypertension sufficiently to allow healing.
To remain healed, lifetime compression therapy is often
mandatory.
Connective tissue disorders
and thrombophilia
Connective tissue disorders (i.e., systemic lupus erythemato­
sus, rheumatoid arthritis, and scleroderma) are frequently
associated with Raynaud’s disease – a vasospastic condition
that causes intermittent cutaneous ischemia and distal ulcer­
ation. Treatment of these disorders frequently includes the
use of immunosuppressive medications (i.e., steroids and/or
chemotherapeutic agents) to mitigate immune-mediated
destruction of local tissue. Although the wound retarding
effects of steroids can be partially reversed with oral vitamin
A (10 000 U/day while the wound is open), high systemic
doses may counter the therapeutic immunosuppressive effects
of steroids, which would be undesirable in the setting of
autoimmune disease. The use of topical vitamin A (1000 U/g
of ointment) offers a safe and effective alternative to promote
wound healing in these patients. Nevertheless, close coordi­
nation with a rheumatologist is imperative as treatment of
inflammatory and/or vasculitic wounds is principally medical
in nature. Once underlying abnormalities have been identi­
fied and corrected, wound-healing adjuncts such as cultured
dermis/skin equivalents, maggot debridement therapy, and/
or hyperbaric oxygen can be used to stimulate the formation
of healthy granulation tissue. Patience is often required as
these wounds can take in excess of 18 months to heal
completely.
To complicate matters further, nearly 50% of patients with
vasculitic wounds are thrombophilic and have an underlying
propensity for pathologic thrombus formation. The more
common of these hypercoagulable states include factor V
Leiden, anomalous factor II (G202010A mutation), hyperho­
mocysteinemia, antiphospholipid syndrome (lupus antico­
agulant, anticardiolipin, anti-B2-glycoprotein 1), plasminogen
activator inhibitor (PAI)-1 mutation, and deficiencies in anti­
thrombin III, protein C, and/or protein S. The presence of
single or multiple hypercoagulable traits can be particularly
troublesome for patients who may require microvascular
reconstruction, as thrombotic events in these patients tend to
occur more frequently, present later, and are often refractory
to conventional salvage techniques.
A recent review of our institutional data revealed a high
prevalence of subclinical thrombophilia (61%) among patients
undergoing non-traumatic lower extremity reconstruction.
This observation is not entirely surprising given that limb
salvage patients often present with disproportionately higher
rates of comorbidities known to potentiate thrombosis (i.e.,
systemic lupus erythematosus).32 Sixteen percent of these
patients ultimately experienced a thrombotic complication
resulting in flap loss, despite multiple attempts at conven­
tional flap salvage. Indeed, salvage rates following postop­
erative thrombosis as low as 0% have been reported in the
setting of undetected hypercoagulable states.33 Therefore
the importance of identifying thrombophilic patients preop­
eratively and counseling them regarding the poor prognostic

190
SECTION I
CHAPTER 8 • Foot reconstruction
the patient is non-ambulatory, strong consideration should be
given to performing a knee-disarticulation or above-knee
amputation to cure the problem and minimize the risk of
recurrent breakdown and/or development of a life-threatening
infection.
Similarly, the complexity of the reconstruction is largely
influenced by the patient’s health and functional goals. For
the younger patient or athlete who can tolerate a prolonged
microsurgical procedure, restoration of normal function is the
goal. However, a complex reconstruction for a marginally
functional leg is often worse than a well-designed below-knee
amputation with an athletic prosthesis. For the patient who
only uses the leg to transfer, the simplest solution that will
achieve this goal should be pursued, even if it entails sacrific­
ing part of the foot.
Wound assessment
The complete physical exam starts with a careful 3D wound
measurement (length, width, and depth), as well as evalu­
ation of involved tissue types (i.e., epidermis, dermis, sub­
cutaneous tissue, fascia, muscle, tendon, joint capsule, and/
or bone). A metallic probe can be used to assess underlying
skeletal involvement. Direct palpation of bone at the base of
the wound is highly sensitive (87%) and specific (91%) for
the presence of osteomyelitis.35 Diabetic ulcers with an area
greater than 2 cm2 have a 90% chance of harboring osteomy­
elitis, regardless of findings on the probe-to-bone test.36 The
level of tissue necrosis and potential avenues for the spread
of infection (i.e., flexor and/or extensor tendon surfaces) must
be determined. The presence and extent of cellulitis must be
noted and differentiated from dependent rubor by direct leg
elevation above the level of the heart. If cellulitis is present,
the erythema will not resolve with elevation and its border
should be delineated with a marker, and dated and timed
accordingly. This permits the clinician to accurately monitor
the progress of infection and/or response to initial treatment.
Vascular workup
The vascular status of the foot must be accurately evaluated.
The presence of palpable pulses (i.e., dorsalis pedis and/or
posterior tibial artery) signals that blood flow is likely adequate
to promote healing. If pulses are not palpable, however, the
Doppler signal over the posterior tibial artery, dorsalis pedis
artery, and anterior perforating branch of the peroneal artery
should be assessed. Doppler ultrasound allows the surgeon
to evaluate both the quality and direction of flow through
major and minor arteries in the foot, which aids in the design
of reliable local flaps and amputations. In the setting of vas­
cular obstruction, the normal triphasic waveform may dete­
riorate distally to a biphasic waveform with a reversed flow
component, which will become biphasic, monophasic, and
ultimately aphasic as the obstruction becomes more signifi­
cant. All patients with aphasic waveforms and foot wounds
should undergo revascularization before attempts at advanced
reconstruction are made. Triphasic or biphasic flow along the
artery being evaluated indicates normal and adequate blood
flow, respectively. These patients generally do not require
vascular reconstruction. On the other hand, limbs with mono­
phasic flow warrant further investigation and possible referral
to a vascular surgeon, depending on the location of the wound
and complexity of the proposed reconstruction. A monophasic
signal, however, does not necessarily reflect inadequate blood
flow; rather, it can also indicate a lack of vascular tone with
absent distal resistance, as is often seen in calcified vessels.
If non-palpable pulses are monophasic, then formal non-
invasive arterial Doppler studies are indicated. It is important
to obtain pulse volume recordings (PVRs) and segmental
pressures at each level along the lower extremity (high and
low thigh, calf, ankle, metatarsal, and digital cuffs), as both
ankle/brachial indices and absolute pressure measurements
are often unreliable in patients with calcified vessels (Fig.
8.5).37 Non-compressible arterial walls are seen in 5–30% of
diabetics and are caused by mural calcification, which falsely
elevates the values for both tests. A PVR amplitude less than
10 mmHg indicates that ischemia may be present. As digital
arteries are less likely to be calcified, absolute toe pressures
provide an alternative, more accurate prediction of healing
potential in the diabetic foot.38–40 Values less than 30 mmHg
are indicative of severe ischemia and the potential need for
vascular intervention.41 Tissue oxygen pressure levels are
also helpful in determining whether extremity blood flow
is sufficient, with levels less than 40 mmHg suggestive of
inadequate local perfusion. For patients with known vascular
disease and/or those undergoing microvascular reconstruc­
tion, duplex imaging generates useful information. Real time
B-mode imaging and pulsed Doppler provide anatomic, geo­
metric, and velocity data, as well as blood flow measurements
from various locations within the vascular system.
If any of the aforementioned non-invasive tests suggest
ischemia, an arterial imaging study should be obtained to
help evaluate whether a vascular inflow (absent femoral
pulse) and/or outflow (absent distal pulse) procedure is
required. With advances in endovascular techniques, revascu­
larization with dilatation, recanalization, and atherectomy of
stenosed/obstructed arteries can be performed in patients
who would otherwise be poor candidates for open vascular
bypass.42,43 As part of our algorithm for planned microvascular
reconstructions, we obtain a diagnostic angiogram for patients
with non-palpable pulses and absent or monophasic Doppler
signals, in order to provide an accurate assessment of flow to
the distal lower extremity. In situations where intervention is
deemed necessary, targeted percutaneous transluminal angio­
plasty (PTA), with or without stent placement, is employed in
the same setting to restore both direct and peripheral inflow
– thereby obviating the need for separate diagnostic (i.e.,
computed tomographic angiography) and therapeutic proce­
dures. Beyond the more obvious advantage of augmenting
arterial inflow to the recipient site, we utilize targeted PTA to
improve recipient vessel caliber in locations where calcifica­
tions, occlusions, and stenoses often complicate microvascular
anastomosis. Our early results with this protocol have been
encouraging for patients with multi-vessel disease and may
indicate a role for targeted endovascular therapy, as an adjunct
to free tissue transfer, in regions of compromised distal blood
flow (Fig. 8.6
).44
Fig. 8.6 appears online only.
Sensorimotor examination
Sensibility is evaluated with a 5.07 Semmes–Weinstein fila­
ment that represents 10 g of pressure. If the patient cannot feel
the filament, protective sensation is absent and the risk of

190.e1
Patient evaluation and diagnosis
Fig. 8.6  (A) Preintervention angiogram of the distal right lower extremity in a patient with an ischemic plantar-medial foot wound demonstrating complete occlusion of the
posterior tibial artery along with a large mid-level segmental occlusion of the anterior tibial artery (arrow). Additional high-grade stenoses of the proximal anterior tibial and
proximal-to-midperoneal arteries are also noted (asterisk). (B,C) Postintervention angiograms following percutaneous transluminal angioplasty of the anterior tibial and
peroneal arteries revealing widely patent run-off to the foot with no evidence of residual stenosis or occlusion. (From: DeFazio MV, Han KD, Akbari CM, Evans KK. Free tissue
transfer after targeted endovascular reperfusion for complex lower extremity reconstruction: setting the stage for success in the presence of multivessel disease. Ann Vasc
Surg. 2015;29(6):1316.e7–1316.e15.)
A
B
C

191
Patient evaluation and diagnosis
Fig. 8.5  Example of a pulse volume recording and segmental pressures readout demonstrating bilateral posterior tibial artery disease. Note the more severely attenuated,
irregular, and low amplitude waveforms on the left side of the readout (patient’s right lower extremity) as compared to the right (patient’s left lower extremity). BP, Blood
Pressure; DP, Dorsalis Pedis Artery; NC, Non-Compressible; PT, Posterior Tibial Artery; TBI, Toe-Brachial Index.
Gain 29%
R) Femoral
Gain 50%
R) Popliteal
Gain 50%
R) Post-tibial
Gain 50%
R) Dors. pedis
Gain 29%
L) Femoral
Gain 35%
L) Popliteal
Gain 50%
L) Post-tibial
Gain 50%
L) Dors. pedis
Gain 50%
Amp: 25 mm
R) Digit
Doppler
Segmental BP
Segment/brachial index
Brachial
114
112
R
>255
-NC-
72
0.63
83
0.73
72 (PT)
0.63
>255 (DP)
-NC-
(PT) 85
0.75
(DP) >255
-NC-
L
Segment/brachial index
0.63
0.75
TBI

192
SECTION I
CHAPTER 8 • Foot reconstruction
plan the biomechanical components of the required recon­
struction as well as the customized design of subsequent
orthotic devices (Fig. 8.8). Furthermore, this tool can be used
to document and monitor biomechanical changes that occur
following tendon transfer and/or lengthening procedures.
Skeletal assessment
The bony architecture is evaluated by looking at whether the
arch is stable, collapsed, or disjointed. Bone prominence can
occur with collapsed midfoot bones (i.e., Charcot destruction
of the midfoot), osteophyte formation, and/or abnormal bio­
mechanical forces (hallux valgus, hammer toe, etc.). Three-
view plain films of the foot (anteroposterior, oblique, and
lateral) help delineate underlying osseous abnormalities to
guide the formation of an operative plan. Lateral views should
always be weight-bearing to assess the stability and contour of
the bony arch. Calcaneal, sesamoid, and metatarsal head views
may be indicated if local pathology is suspected in those areas.
It is important to remember that radiographic signs of
osteomyelitis lag behind clinical appearance by up to 3 weeks.
Thus the presence of a normal radiograph in the setting of an
infected foot wound does not rule out the diagnosis of osteo­
myelitis. A magnetic resonance imaging (MRI) scan can aid in
earlier detection, as well as the differentiation of osteomyelitis
from Charcot collapse. In general, bone scans are of no
value in the setting of an open wound. The underlying bone
will show increased uptake, regardless of the presence of
breakdown and/or ulceration is significantly increased.
Motor function is assessed by looking at the resting position
of the foot and by testing the strength and active range of
motion of the ankle, foot, and toes.
Gait analysis
Gait abnormalities resulting from musculoskeletal imbalances
are frequently detected in patients evaluated for chronic
wound management. Preoperative assessment of gait, there­
fore, is critical and should include a measure of ankle dorsi­
flexion as well as an F-scan analysis or pressure mapping.
Evaluation for equinus deformity should occur with the leg
held first in complete extension, to keep the gastrocnemius
muscles at their full resting length, and then with the knee
flexed (which reduces stretch/tension on the gastrocnemius)
to assess the soleus muscle (Fig. 8.7
). If the ankle only
dorsiflexes when the knee is flexed, then the gastrocnemius
muscles are responsible for the equinus posture of the foot
and can be released by performing a gastrocnemius recession.
If the ankle remains tight during knee extension and flexion,
then both gastrocnemius and soleus contributions to the
Achilles tendon have to be released, usually percutaneously.
Fig. 8.7 appears online only.
The F-scan gait analysis uses multiple pressure-sensing
surface probes that record pressures on the sole of the foot
during all phases of gait. Areas of excessive compression
during weight-bearing are displayed graphically and help
Fig. 8.8  The normal gait cycle with phase-specific F-Scan pressure mapping and joint motion.
Heel contact
Heel strike
Propulsive
Swing phase
100%
0%
Midstance
Ankle
Subtalar
Knee
Midtarsal
Great toe
Intention
Plantarflexes
Pronates
Flexes
Pronates
Plantarflexes
Cushion impact
Neutral
Pronates
Flex ending
Pronating
Neutral
Adapt to surface
Dorsiflexing
Supinating
Extended
Supinated
Dorsiflexed activity
Plantarflexed passively
Stabilization and balance
Plantarflexed
Supinated
Flexed
Supinated
Dorsiflexing
Rigid propulsive lever
Dorsiflexed
Supinated
Extended
Neutral
Dorsiflexed
Ground clearance
Early midstance
Late midstance
Toe off
Midswing phase
B
C
D
E
A

192.e1
Patient evaluation and diagnosis
Fig. 8.7  Assessment of Achilles tendon tightness in patients with equinovarus
deformity requires that dorsiflexion be tested with (A) the leg held in extension (to
keep the gastrocnemius muscles at their full resting length) and with (B) the knee
flexed (which reduces tension on the gastrocnemius). If the ankle only dorsiflexes
when the knee is flexed, then tightness of the gastrocnemius muscles is responsible
for the equinus posture of the foot and can be released by performing a
gastrocnemius recession. If the ankle remains tight during knee extension and
flexion, then both gastrocnemius and soleus contributions to the Achilles tendon
have to be released, usually percutaneously.
A
B

193
Management
osteomyelitis. A negative bone scan, however, can be useful
in ruling out the proximal spread of infection along the surface
of a long bone. Ultimately, if osteomyelitis is suspected, then
a bone biopsy is indicated (i.e., “gold standard”), utilizing a
separate approach other than through the ulcerated wound.
Most often, however, bone is sampled through the operative
site because it is often present at the base of the debrided
wound. In these instances, unexposed medullary tissue
should be obtained with a previously unused curette and
submitted for both decalcification (in formalin) and culture
(in a few drops of normal saline solution), which is used to
guide sensitivity-directed antibiotic therapy.
Management
Trauma and crush injuries
Crush injuries or ischemic insults to the foot can elevate pres­
sures within myofascial compartments; and, like that in the
leg, compartment syndrome in the foot must be evaluated and
treated if necessary. The signs and symptoms of compartment
syndrome of the foot are similar to those found elsewhere in
the body (i.e., 6 Ps: pain, paresthesia, pallor, paralysis, pulse­
lessness, poikilothermia). Pain out of proportion to the clinical
examination is often the first symptom. Weakness of the toe
flexors/extensors and pain with passive dorsiflexion of the
toes represent important physical signs. Pallor, paresthesia, a
palpably tense compartment, and absent digital pulses on
Doppler assessment eventually occur. Compartment pressure
recordings should be obtained by a physician who under­
stands the compartmental anatomy of the foot.
When measuring pedal compartment pressures, it may be
difficult to determine the compartment in which the pressure
is actually being recorded. If clinical indications are present,
a four-compartment release should be performed.45 The
medial approach to the foot, as advocated by Henry, allows
decompression of all four compartments through a single
incision.46 Mubarak and Hargens advocate two longitudinal
incisions on the dorsum of the foot through which the interos­
seous compartments may be decompressed (analogous to that
in the hand).47 Whitesides anecdotally described compartment
syndrome of the foot, secondary to burns and direct trauma,
and recommended decompression using the medial approach
of Henry.48
For adequate compartment decompression, a curvilinear
incision is made along the medial glabrous junction of the
foot, beginning at the first metatarsal head and extending to
the heel. The skin and fascia are divided, and the incision is
carried down to release the abductor hallucis muscle and its
tendon – thus decompressing the medial compartment.
Retraction of the abductor hallucis towards the plantar surface
exposes the medial intermuscular septum, which is divided
to release the central compartment. The small toe compart­
ment is released next utilizing a linear incision along the
lateral glabrous junction that extends from the fifth metatarsal
head to the calcaneus. Through this incision, the fascia envel­
oping the small toe compartment is released. Decompression
of the interosseous compartment is best achieved through two
linear, dorsal incisions overlying the second and fourth meta­
tarsals. The fascia overlying the four interosseous spaces is
then opened (Fig. 8.9).
Wound infection and directed
antibiotic therapy
Wound infection is characterized by the presence of replicat­
ing microorganisms within a wound, resulting in a subsequent
host response such as erythema, warmth, swelling, pain,
malodor, and purulent drainage. If not recognized and treated
early, the infection will spread systemically leading to fever,
leukocytosis, and possibly sepsis. The line between coloniza­
tion and infection may be minute, so prompt identification is
critical to healing wounds and minimizing complications. For
most microorganisms, a bacterial count (bioburden) of 105
bacteria/g of tissue or greater has been defined as the quan­
titative threshold for wound infection and inhibition of the
wound healing process.49
When managing infected foot wounds, it is important to
determine the source and extent of infection. The erythe­
matous border surrounding the wound should be delineated,
timed, and dated for serial comparison. The original mark is
used as a reference point for determining the effectiveness of
antibiotics and/or prior debridement. Radiographic evalua­
tion of the affected area will help identify skeletal involvement
as well as the presence of soft-tissue gas. If gas is visualized
radiographically within the tissue planes, beyond the imme­
diate location of an open ulcer, gas gangrene is most likely
present and the wound becomes a surgical emergency. Gas is
usually a byproduct of anaerobic bacteria (i.e., Clostridium
perfringens); it tends to be foul smelling and travels along the
fascial planes. Compartment pressures in the affected area
should be assessed, as high pressures in the diabetic foot with
gas gangrene are frequently missed secondary to neuropathy.
If a deep abscess is in question, ultrasound imaging or com­
puted tomography can be very useful to ascertain its size and
location.
If the wound is acutely infected with purulent drainage,
malodor, and/or proximally ascending erythema, immediate
and aggressive debridement is indicated to prevent sepsis,
possible limb loss, or death. The involved compartments of
the extremity should be released if there is any suspicion of
elevated compartment pressures. Wounds with foul-smelling
odors should be debrided sufficiently to get rid of the odor.
Persistent malodor signals the need for further debridement
and excision of any remaining necrotic or infected tissue. It is
important to remember that the presence of gas gangrene is
not an absolute indication for amputation. Aggressive serial
debridement ± adjunctive hyperbaric oxygen can often salvage
enough of the limb to preserve functional integrity. Hyper­
baric oxygen has been shown to be particularly effective in
the control of anaerobic infections.50
Aerobic and anaerobic cultures of the wound should be
obtained during each debridement by taking samples deep
to the surface of the infected tissue and purulence. Superficial
swabs and tissue cultures are of limited use, as they usually
reflect surface flora rather than the underlying bacteria that
are responsible for infection. Broad spectrum antibiotics
should be started after deep tissue cultures are obtained
and subsequently narrowed based on culture results and
sensitivities. It is important to be aware that deep cultures
may miss up to two-thirds of the bacteria species present
within a wound.51 Therefore persisting signs of infection
after 48 h of antibiotic therapy signal a need to reconsider

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SECTION I
CHAPTER 8 • Foot reconstruction
Biofilm
By definition, open wounds are contaminated, meaning
that the bed contains planktonic bacteria and biofilm. Acute
wounds have only 6% biofilm present, whereas chronic
wounds have biofilm in excess of 90%. Biofilm is characterized
as a microbial community embedded within an extracellular
polymeric matrix that is irreversibly adherent to both living
and non-living surfaces.54 This structurally heterogeneous
matrix promotes enhanced cell-to-cell signaling between
bacteria (i.e., quorum sensing), allowing biofilms to grow
and act as independent organisms.55–57 Biofilms require highly
specific growth media that are not commonly found in the
hospital setting, and, as a result, typical specimen cultures
are often inadequate for the positive characterization of bac­
teria.58 Polymerase chain reaction (PCR) technology, however,
permits rapid identification of causative organisms within a
matter of hours. PCR studies of biofilm have identified over
60 different bacterial species, more than 60% of which are
anaerobes. These multi-species colonies coexist at a far lower
energy state and serve as a medium for extrachromosomal
the choice of antibiotics as well as the necessity of further
debridement.
For suspected osteomyelitis, cultures of both debrided
bone and normal proximal bone should be obtained. It may
be helpful to label the osteomyelitic bone culture as “dirty”
and the normal proximal bone culture as “clean” so that the
quality of debridement can be assessed and the length of
antibiotic treatment determined. If a wound is closed and the
“clean” culture is showing no growth (i.e., only healthy bone
remains at the base of the wound), then a 1-week course of
appropriate antibiotic therapy is often sufficient. In contrast,
if the “clean” culture is positive for bacterial growth, then
re-resection of bone or a 6-week course of antibiotics may be
necessary. If the surgeon suspects that the bone left behind
still harbors osteomyelitis despite negative cultures (i.e., cal­
caneus or tibia), then a 6-week or longer course of antibiotic
therapy may be needed to eradicate the infection.52,53 The
appropriate antibiotic choice and duration is best determined
and monitored by an infectious disease specialist, who is also
adept at managing the untoward side effects of prolonged
antibiotic therapy.
Fig. 8.9  (A) Medial instep incision along the glabrous junction releases the great toe compartment. (B) Retraction of the abductor hallucis muscle exposes the medial
intermuscular septum, which is incised to release the central compartment (retracted). (C) Lateral incision along the glabrous junction releases the small toe compartment.
(D) Decompression of the interosseous compartment is best achieved through two linear dorsal incisions overlying the second and fourth metatarsals.
A
D
B
C
Abductor digiti minimi
Medial plantar art
Flexor hallucis brevis
Flexor hallucis longus
Abductor hallucis
Medial plantar nerve
Flexor digitorum longus
Flexor digitorum brevis
Abductor hallucis

195
Management
preserved as it may prove useful at the time of definitive
reconstruction.
The most effective debridement technique consists of tan­
gential excision of all grossly contaminated and devitalized
tissue, until only normal tissue is present. This minimizes the
amount of viable tissue sacrificed while ensuring that only
healthy tissue remains. Gentle tissue handling, sharp dissec­
tion, skin hook retraction, and pinpoint cauterization of
bleeding vessels serve to minimize trauma and promote tissue
viability. One should avoid harmful maneuvers such as crush­
ing skin edges with forceps or clamps, burning tissues with
electrocautery, and/or suture-ligating healthy perivascular
tissues.62 Useful surgical tools include a scalpel blade, Mayo
scissors, curettes, rongeurs, sagittal saw, power burr, and
hydro-surgical debrider (Versajet, Smith & Nephew, Hull,
UK). Serial debridement is performed regularly, and as often
as necessary, until the wound is deemed clean and ready for
closure.61,63,64
Three technical adjuncts can be used in combination to
ensure adequate debridement of the entire wound: (1) topical
staining of the wound with methylene blue, (2) utilizing color
to guide debridement, and (3) tangential excision of senescent
wound margins. Prior to debridement, methylene blue is
liberally applied to the wound base using a cotton tip applica­
tor. This allows the surgeon to adequately address all portions
of the wound by ensuring complete removal of all visibly
stained tissue from the wound base (Fig. 8.10). In addition,
the surgeon must be familiar with normal tissue colors (i.e.,
red, white, and yellow). Using these colors as a guide provides
an endpoint to debridement and helps prevent removal of
healthy tissue.65 Finally, excision of 3–5 mm of marginal tissue
during initial debridement removes senescent cells from
chronic wound edges and permits healthy underlying cells to
progress through the stages of normal wound healing.66
Biomechanical considerations
Biomechanics are a critical part of the reconstructive plan and
may involve bone rearrangement, partial joint removal/
fusion, or tendon lengthening/transfer. Charcot deformities
of the midfoot are often heralded by mild effusions, joint
instability, crepitus, and swelling. If these symptoms are
identified early, conservative treatment with offloading
and casting may prevent the evolution of a fixed midfoot
deformity.67
Ulcers under the metatarsal head(s) occur because biome­
chanical abnormalities place excessive or extended pressure
on the plantar surface of the forefoot during the gait cycle.
Although hammertoes, sesamoids, long metatarsals, and joint
dislocations can be contributing factors, the principle cause of
abnormal weight dispersion is a tight Achilles tendon that
prevents ankle dorsiflexion beyond the neutral position. If
dorsiflexion remains poor with the knee bent or straight,
either the gastrocnemius and soleus contributions to the
tendon or the posterior capsule of the ankle joint may be tight.
If percutaneous release of the Achilles tendon fails to improve
dorsiflexion, then a posterior capsular release of the ankle
joint should be performed. Alternatively, if the ankle only
dorsiflexes when the knee is flexed, then the gastrocnemius
muscles are responsible for the equinus posture of the foot
and a gastrocnemius recession should correct the problem.
Lengthening or release of the tight Achilles tendon results in
DNA plasmids that confer antibiotic resistance up to 1000
times greater than that of planktonic bacteria alone. Within
48 h, the biofilm matures and becomes resistant to both topical
and systemic antibiotic penetration as well as phagocytosis by
the host immune response.59 The colony then spreads pas­
sively through fragmentation (70%) or by active individual
seeding of undifferentiated planktonic cells (30%). Biofilm
causes inflammation of the surrounding tissue, and, while
classic signs of infection may not predominate, increased
pain/tenderness, exudate, abnormal odor, and/or friable
granulation tissue often signal its presence, as well as the need
for aggressive mechanical debridement to stimulate healing
of healthy underlying tissue.
Acute vs. chronic wounds
The goal of treating any wound is to promote healing in a
timely fashion. The first step toward realizing this objective is
to establish a clean and healthy wound base. An acute wound
is defined as a recent wound that has yet to progress through
the sequential stages of wound healing. In the setting of
adequate blood flow, a clean base can be established with
simple debridement techniques and the wound closed either
immediately or following application of a local dressing to
facilitate healing by secondary intention or closure at a later
date. In contrast, a chronic wound is one that is arrested at
some stage of healing (usually the inflammatory stage) and
cannot progress on its own. Converting a chronic wound
to an acute wound mandates the correction of underlying
medical comorbidities (i.e., hyperglycemia, coagulopathies,
changing or modifying drug therapy, etc.), restoration of
adequate blood flow, administration of appropriate antibiot­
ics when indicated, and aggressive wound debridement. If the
wound has responded appropriately, healthy granulation will
appear, edema will decrease, and neo-epithelialization of the
wound edges will occur. Measuring the wound area weekly
is a useful means to monitor progress, as the normal rate of
healing equates to a 10–15% decrease in wound surface area
per week. Assuming any underlying abnormalities have been
corrected (i.e., infection, ischemia, coagulopathy), a healing
rate below that expected may necessitate the incorporation of
adjuncts, such as negative pressure wound therapy (NWPT),
topical growth factors, cultured skin/dermal substitutes,
and/or hyperbaric oxygen.
Surgical preparation of the wound bed
Necrotic tissue, foreign material, and bacteria/biofilm impede
the body’s attempt to heal through the production of prote­
ases, collagenases, and elastases that overwhelm the local
healing process.60 Aggressive mechanical debridement, there­
fore, is essential to overcome these barriers and stimulate
normal healing. Nevertheless, surgical debridement is the
single most underperformed procedure in treating foot and
ankle wounds, secondary to concern over resultant defect
closure.61 Leaving dead or infected tissue or bone behind,
however, leads to subsequent infection and possible amputa­
tion. Tissue with clotted veins or arteries in the dermis or
subcutaneous tissue, liquefied fascia or tendon, and non-
viable bone should all be debrided. Debridement should be
considered complete only when normal bleeding tissue
remains. By the same token, any viable tissue should be

196
SECTION I
CHAPTER 8 • Foot reconstruction
attributable to biomechanical disturbances. Recurrent ulcer­
ation following distal amputation results from musculotendi­
nous imbalance within the foot, which leads to abnormal
posturing (equinovarus deformity), instability, and altered
weight distribution during ambulation. These patients often
rapid healing and long-term protection, decreasing ulcer
recurrence rates by 75% at 7 months and 52% at 25 months,
when compared with contact casting alone (Fig. 8.11).68,69
Patients with prior transmetatarsal amputations and recur­
rent forefoot ulceration are another group whose wounds are
Fig. 8.10  Topical staining of a wound with methylene blue to ensure adequate debridement and removal of surface biofilm. Methylene blue dye is applied liberally to the
wound base using a cotton swab applicator. After debridement, there should be no residual dye left in the wound.
A
B
C
Fig. 8.11  Percutaneous Achilles tendon lengthening. If both the gastrocnemius and the soleus portions of the Achilles tendon are tight, the tendon can be released
percutaneously by making three alternating stab incisions at 3 cm, 6 cm, and 9 cm proximal to the insertion of the Achilles into the calcaneus. A No. 15 blade is inserted
into the central raphe of the tendon and the scalpel turned so that half of the tendon is cut at each site. The ankle is gently dorsiflexed until the tendon releases and
immobilized to promote healing in a lengthened position. This technique provides an increase in Achilles tendon length by approximately 2 cm. (Courtesy of John
Steinberg, DPM; Center for Wound Healing, MedStar Georgetown University Hospital, Washington DC.)
A
B
C

197
Management
we utilize a ventilated, closed-system dressing that permits
unrestricted migration of maggots in a well-oxygenated, sani­
tary, and low-maintenance environment (Fig. 8.12
). The
dependent portion of the construct is suspended freely for
48–72 h to prevent mechanical crush and promote free-range
debridement of necrotic tissues.
Fig. 8.12 appears online only.
Once the wound is clean and adequately vascularized,
NPWT using a vacuum-assisted closure (VAC) device can
help expedite healing by secondary intention. NPWT increases
local blood flow, reduces tissue edema, controls bacterial
proliferation, and catalyzes the formation of granulation
tissue.74,75 Level-one data demonstrate the ability of NPWT
to hasten healing and reduce amputation rates in the setting
of diabetic foot wounds.76 Furthermore, because the VAC is
changed every 48–72 h, the wound is less susceptible to cross
contamination when compared to the normal level of contami­
nation that occurs when the dressing is changed two or three
times each day. NPWT with instillation (NPWTi) represents
an important evolution in the management of complex acute/
chronically infected wounds, those with underlying osteomy­
elitis, and wounds with exposed orthopedic hardware and/or
joint implants, among others.77 NPWTi is a novel therapy that
combines negative pressure (−125 to −150 mmHg) with auto­
mated, intermittent instillation of a topical wound solution
(antimicrobial vs. saline) of set volume (until sponge is visibly
saturated), dwell time (10–20 min), frequency (every 1.5–2 h),
and duration (2–10 days). In a retrospective, historical, cohort-
controlled trial examining the impact NPWT with (n=68) and
without (n=74) instillation, NPWTi was shown to reduce the
total number of operative procedures, expedite the time to
wound closure, and shorten the length of hospital stay when
compared with NPWT alone. The percentage of wounds closed
prior to discharge and a qualitative improvement in Gram-
positive cultures were also observed with NPWTi.78 Future
questions that remain to be answered pertain to the optimal
volume and solution for instillation, dwell time, and duration
of therapy, which should be assessed through appropriately
conducted, high-powered, randomized controlled trials.
If the wound fails to show signs of healing despite being
clean and having adequate blood flow, providing biologically
active coverage, such as platelet-derived growth factor
(Regranex, Ortho-McNeil-Janssen Pharmaceuticals, Raritan,
NJ, USA) or cultured skin substitutes (Apligraf, Organogen­
esis Inc., Canton, MA, USA; Dermagraft, Advanced Tissue
Sciences, La Jolla, CA, USA), may facilitate more rapid
healing.79–82 The formation of new tissue over exposed healthy
bone or tendon can also be stimulated through the application
of a dermal regenerative template (Integra, Integra Life­
Sciences, Plainsboro, NJ, USA), with or without VAC support,
and allowing it to revascularize over the course of 2–3 weeks.
The newly incorporated dermis can then be skin grafted with
a thin autograft to provide coverage. Finally, level-one evi­
dence has demonstrated the ability of systemic hyperbaric
oxygen therapy (HBOT) to reduce amputation rates and
promote granulation of certain complicated, non-healing
wounds.83,84 HBOT stimulates local angiogenesis in the wound
bed, promotes collagen cross-linking and extrusion from cells,
and potentiates the ability of macrophages/granulocytes to
kill bacteria. Any and/or all of these modalities may prove
valuable when used in concert with more traditional recon­
structive strategies.
require Achilles tendon lengthening and/or tibialis anterior
tendon transfer to restore proper biomechanical balance.70
Alternatively, chronic heel ulceration may occur following a
previously undetected injury to the Achilles or from overcor­
rection during a prior Achilles tendon lengthening procedure.
Reconstruction mandates some form of shortening and/or
strengthening of this important musculotendinous unit.
For patients with normal dorsiflexion and ulceration caused
by metatarsal head prominence, the affected metatarsal
head(s) can be elevated superiorly (2–3 mm) with “floating”
neck osteotomies and internal fixation.71 The resultant pres­
sure relief is usually sufficient to promote healing by second­
ary intention. When forefoot ulceration occurs over the fifth
metatarsal head, resection through the metatarsal neck is
recommended. This may be accomplished either through the
debrided wound (in deeply penetrating ulcers) or through a
longitudinal, tendon-splitting, dorsal incision. The first meta­
tarsal is debrided only if it is exposed at the ulcer base.
Complete resection of the first metatarsal is not recommended
as it destabilizes the medial column, resulting in excessive
weight transfer to the adjacent metatarsal head. Instead, resec­
tion of the plantar flare of the first metatarsal head is preferred
to minimize bony prominence while preserving biomechani­
cal stability.
Wound healing adjuncts
After initial debridement to clean, healthy tissue, it is impor­
tant to prevent subsequent build up of metalloproteases that
destroy naturally produced growth factors. Bacterial biofilm
and proteinaceous debris that form on the wound surface
must be removed at regular intervals. This can be done by
scrubbing the wound daily with soap or using wet-to-dry
dressings. In between debridements, topical antibiotics
can help reduce the bacterial load. Bacitracin is most useful
for minimally infected wounds, mupirocin for methicillin-
resistant Staphylococcus aureus (MRSA) contamination, and
silver sulfadiazine or gentamicin ointment for Pseudomonas
infections. For most contaminated wounds, antibiotic beads,
1% acetic acid, silver sulfadiazine, mafenide acetate, and
Iodosorb work well. Short-term use of quarter- or half-strength
Dakin’s solution may be appropriate for temporizing heavily
contaminated and/or necrotic wounds in patients who require
medical optimization prior to operative debridement. An
absorbent dressing (i.e., alginate, hydrofiber, foam, hydrocol­
loid, etc.) with bactericidal ingredients (silver or iodine) is
effective for heavily exudative wounds.
For patients who are poor operative candidates, maggot
debridement therapy (MDT), using larvae of the blowfly
Phaenicia sericata, is a proven, cost-effective alternative for
treating drug-resistant, chronically infected wounds.72 MDT
serves to enhance healing through selective debridement of
necrotic tissues and reduction of bacterial burden. A recent
meta-analysis evaluating the safety and effectiveness of MDT
revealed significant improvements in both the rate and effi­
ciency of chronic wound healing, longer antibiotic-free
intervals, and a lower amputation risk among patients with
diabetic foot ulcers.73 Nevertheless, the prospect of maggot
escape, failure to control secretions, and use of tenuous/labor-
intensive dressings often precludes the use of maggots in
geometrically complex locations. For circumferential lower
extremity wounds and/or those complicating the foot/ankle,

197.e1
Management
Fig. 8.12  Construction of a closed-system habitat to facilitate free-range maggot
debridement therapy for multiple necrotic ulcers involving the dorsal/plantar
surfaces of the foot as well as the interstices of the webspaces. Maggots are
introduced through the ventilation port, which is sealed with polyester chiffon
netting to ensure continuous oxygen penetration. An internal collection chamber is
lined with multiple layers of super-absorbent gauze and suspended to prevent
pooling of secretions that can irritate the skin and/or lead to barrier disruption.
Chiffon netting
Ventilation port
Perforated cloth tape
Collection chamber

198
SECTION I
CHAPTER 8 • Foot reconstruction
dehiscence, infection, flap failure, and progressive tissue
necrosis. Therefore, prior to closure, it is essential to ensure
that the patient’s medical comorbidities and abnormal wound
parameters have been corrected and signs of inflammation
have resolved. Negative postdebridement cultures along with
resolution of pain, wrinkled skin edges, healthy granulation,
and neo-epithelialization signal that a wound is ready for
reconstruction.
Options for closure are numerous and depend on the
patient’s health, size and location of the wound, presence
of exposed vital structures (i.e., tendon, bone, joint space,
and neurovascular structures), surgeon experience, and
availability/quality of local tissues. These options include (1)
healing by secondary intention, (2) delayed primary closure,
(3) skin graft, (4) local flap(s), (5) pedicled flap(s), (6) free
tissue/composite tissue transfer, or any combination thereof.
In the absence of exposed vital structures, certain wounds
(i.e., large, irregular, and/or potentially contaminated) can be
left to heal by secondary intention through the application of
daily dressing changes, wound healing adjuncts, HBOT, and/
or NPWT. If surgical closure is indicated and feasible, the
freshly debrided wound should be pulse lavaged and new
sterile instruments brought into the field to avoid recontami­
nation of the wound bed. Quantitative cultures of the instru­
ments used to debride the wound yield up to 103 bacteria, and
their use during closure would needlessly increase the risk for
postoperative infection.
Delayed primary closure is easier to accomplish when
tissue edema and induration have resolved. The VAC device
can be very helpful in this endeavor. After primary closure, it
is important to ensure that relevant arterial pulses have not
diminished due to an excessively tight closure. If the closing
tension is too high, the wound can be closed serially, or the
residual gap can be left to heal secondarily with the aide of
NPWT. For larger wounds, internal VAC – utilizing a partially
buried sponge and tension sutures to gradually approximate
the skin edges – collapses the wound cavity and facilitates
tension-free closure at a later date (Fig. 8.14). An adequate
soft-tissue envelope can also be created by removing underly­
ing bone. This occurs in partial foot amputations where just
enough bone is removed to facilitate delayed primary closure
(Fig. 8.15
). Correcting a Charcot midfoot collapse by remov­
ing the arch and fusing the metatarsals to the hindfoot also
allows for loose approximation of plantar soft-tissue defects.
In all cases, use of deep sutures during closure should be
avoided as they could potentiate re-infection. Simple vertical
mattresses with monofilament suture (i.e., nylon, polypropyl­
ene, etc.) are least likely to harbor bacteria.
Fig. 8.15 appears online only.
Skin grafting can be used to close most foot and
ankle wounds that possess a healthy granulating surface (Fig.
8.16
). In the setting of inhospitable wound beds (i.e., tendon
or bone), a collagen lattice framework, such as Integra (Integra
Lifesciences, Plainsboro, NJ, USA), can be used to generate a
healthy, vascularized neodermis capable of accepting a graft.
Recipient bed preparation is optimized by shaving off the
superficial granulation tissue to remove any residual bacteria
within the interstices of granulating buds. The skin graft can
be meshed at a 1 : 1 ratio or pie crusted to prevent build up of
fluid that could preclude graft adherence. The use of low
continuous suction NPWT (−75 mmHg), as a dressing for the
first 3–5 days, will maximize skin graft take.91 On the
External fixation
Postoperatively, strict offloading and elevation of the extrem­
ity are critical to eliminate edema, promote healing, and help
control infection. For many patients, however, 100% compli­
ance with offloading and immobility is unrealistic, and the
temptation to prematurely ambulate or bear weight – even for
simple transfers – leads to repetitive shear and torque about
mobile joints with ultimate wound breakdown. Furthermore,
decubitus pressure from prolonged immobility may result
in delayed healing and/or new ulceration. External fixation
has an established role in the treatment of fractures and
osteomyelitis.85–87 The ability to immobilize the skeletal frame­
work without utilizing internal hardware – which is contra­
indicated in the setting of infected/contaminated wounds
– has led to the salvage of limbs that previously required
amputation.88 The Ilizarov frame, in particular, provides
superior immobilization and has been shown to shorten
healing times, decrease pin track infections, and promote
early weight-bearing through the addition of a protective
plantar foot plate.89
In addition, motion along a joint underlying a soft-tissue
reconstruction is often responsible for dehiscence or delayed
wound healing. A 6-year review of our own institutional data
identified 24 consecutive patients in whom external fixation
was utilized solely for protection following soft-tissue recon­
struction. For patients placed in multiplanar vs. monoplanar
fixation, the overall limb salvage rates were 83% and 73%,
respectively.90 Soft-tissue reconstructions in our series included
primary closure, skin grafts, and local flaps. For larger recon­
structions involving either a free flap or sural artery perforator
flap, an Ilizarov frame is ideal as it not only suspends the foot
and heel in good skeletal alignment but also protects the flap
from external pressure and/or any potential trauma. As
patient compliance with alternative offloading schemes aver­
ages approximately 20% at our institution, we have found
external fixation to be a useful adjunct to ensure adequate
healing of complex soft-tissue reconstructions involving the
foot and ankle (Fig. 8.13
).
Fig. 8.13 appears online only.
Surgical techniques for
soft-tissue reconstruction
Options for wound closure
Although the vascular anatomy of the foot and ankle was
discussed in detail previously, it is worth re-emphasizing the
critical significance of the angiosome model and its implica­
tions for guiding successful reconstruction. Understanding
the boundaries of each angiosome as well as the vascular
interconnections between source arteries provides the basis
for logically, rather than empirically, designed incisions for
tissue exposure and/or planned reconstructions or amputa­
tions that preserve maximal blood flow to promote healing of
surgical wounds. Aside form hemodynamic considerations,
the timing of reconstruction plays an equally important
role in ensuring successful outcomes and minimizing
complications after wound closure. Aggressive attempts
at premature closure lead to increased rates of incisional

198.e1
Surgical techniques for soft-tissue reconstruction
Fig. 8.13  For larger reconstructions involving mobile and/or weight-bearing
surfaces of the foot and ankle, external fixation with an Ilizarov frame is ideal in that
it not only provides superior immobilization of the ankle but also suspends the foot
and heel, maintains skeletal alignment, and protects the reconstruction from
external pressure and potential trauma.

198.e2
SECTION I
CHAPTER 8 • Foot reconstruction
Fig. 8.15  (A) Medial foot defect. (B) Lisfranc
amputation with rotation of a laterally-based plantar
flap for closure. (C) Dry gangrenous necrosis of the
plantar foot and toes resulting in loss of the majority of
the plantar soft tissues. (D) Transmetatarsal amputation
was performed with preservation of a dorsal soft-tissue
flap and use of a skin graft to facilitate closure.
A
B
C
D

198.e3
Surgical techniques for soft-tissue reconstruction
Fig. 8.16  (A) Fibrogranular wound with fibrotic scar tissue overlying the left Achilles tendon and medial malleolus. (B) Healthy granulating wound bed following serial
debridement and interval negative pressure wound therapy. (C) Complete take of a partial-thickness skin graft.
A
B
C

199
Surgical techniques for soft-tissue reconstruction
a cutaneous perforator can be Dopplered at the base of, or
within, the planned flap, the length-to-width ratio may be
increased. To ensure tension-free coverage, the flap should be
designed in the area of maximal tissue mobility and slightly
larger than the defect to be covered. A force of 25 mmHg
causes enough venous congestion for flap necrosis unless the
tension is released within 4 h.96 If the flap remains pale at
inset, it should be rotated back into its bed and delayed for
4–7 days while it develops more robust blood supply. During
that time, NPWT can be used to cover the open wound in
order to minimize edema and ensure that wound edges
remain malleable. Finally, we have found that the application
of incisional NPWT, for 3–5 days postoperatively, helps to
ensure local flap viability by decreasing venous congestion.97
Pedicled flaps of the foot and ankle require more sophisti­
cated anatomic knowledge to dissect and have higher periop­
erative complication rates, although equivalent long-term
success as free tissue transfer. Free flaps to the foot and ankle,
however, carry the highest failure rate in the microsurgical
literature and must be planned carefully.98,99 Vascular calcifica­
tion and large zones of injury in the lower extremity often
contribute to flap failure. Whenever possible, end-to-side
anastomosis to the recipient artery and two-vein anastomoses
should be performed to preserve maximal blood flow to the
distal limb and optimize venous drainage from the flap,
respectively.
The free flap donor site is chosen based on the size and
location of the wound, the length of pedicle needed, and the
functional and aesthetic demands of the region to be recon­
structed. Levin and colleagues reviewed the Duke experience
with lower extremity free tissue transfer and proposed a
weight-bearing plantar surface of the foot, glabrous skin
grafts, harvested at 30/1 000 of an inch, provide a thicker
alternative that can better resist the shear forces applied
during ambulation.92,93 The instep provides an ideal donor site
and should, itself, be grafted with a thin autograft (10/1 000
of an inch) to speed up healing following graft harvest. If
compliance is an issue, consideration should be given to
placing an Ilizarov frame with a protective footplate until the
plantar graft has healed completely. Innervated full-thickness
skin grafts have also been employed in select patients utiliz­
ing defatted skin flaps from the sural nerve territory, great toe,
and/or forearm.94
Fig. 8.16 appears online only.
Local random flaps consist of tissue with an unidentified
blood supply that is either rotated about a pivot point, trans­
posed, or advanced into an adjacent defect. They comprise
various sizes and shapes (square, rectangular, rhomboid,
semi-circular, or bilobed) as well as tissue compositions (skin,
fat, fascia, etc.). Only exposed bone, tendon, and/or joint need
flap coverage, while skin grafts are often sufficient to cover the
remaining soft-tissue deficit. The combination of limited local
flap and skin graft frequently obviates the need for larger
pedicled flaps or free tissue transfer. An appropriately designed
local flap can improve surgical exposure of underlying tissues,
bone, joints, and tendon – obviating the need for additional
incisions. Furthermore, local flaps can provide coverage of
wounds within the tight confines of an external fixator.
The ratio of length-to-width is critical for the survival of
random pattern flaps.95 Because the capillary beds supplying
the skin of the foot and ankle are not as dense as in the face,
this ratio should not exceed 1 : 1 to 1 : 1.5 in dimension. If
Fig. 8.14  Use of the internal vacuum-assisted closure technique to enable delayed primary closure of a large anterior knee wound following removal of infected hardware,
debridement, and placement of an antibiotic spacer in a patient with a failed total knee arthroplasty. Negative pressure wound therapy, using a partially buried sponge,
minimizes soft-tissue edema and accelerates wound contraction. Gradual approximation of the skin edges is achieved through use of vertical mattress polypropylene tension
sutures, placed along the entire length of the wound, to facilitate soft-tissue creep. The dressing is changed every 3–5 days until tension-free approximation of the wound
margins is possible.
A
B
C

200
SECTION I
CHAPTER 8 • Foot reconstruction
tarsal vessel should be elevated with the muscle as its origin
is divided off the lateral calcaneus. The four slips of muscle
are broad and thin (4.5 x 6 cm in adult), making the flap useful
for relatively small wounds (Fig. 8.17).101 If need be, the EDB
muscle can also be raised as a distally-based reverse-flow
muscle flap supplied by a distal branch of the dorsalis pedis
receiving retrograde flow from the lateral plantar artery.
However, its arc of rotation in this direction is rather limited.
Lateral supramalleolar flap
The lateral supramalleolar flap is most useful for coverage of
bony defects that accompany loss of soft tissue over the lateral
malleolus and anterior ankle. The flap should be distally
based as the blood supply is derived from skin perforators off
the anterior perforating branch of the peroneal artery as it
pierces the interosseous membrane 5 cm proximal to the tip
of the lateral malleolus. Cutaneous vessels then course proxi­
mally, anterior to the fibula, and anastomose with the vascular
network that accompanies the superficial peroneal nerve. The
perforating branch of the peroneal artery is located with a
hand-held Doppler, and the base of the flap should be centered
at this point. Flap width includes the fasciocutaneous tissue
between the fibula and the tibia. The length should be adequate
to reach the lateral malleolus (6–8 cm) or more distally as
dictated by wound location (Fig. 8.18).7
Most often, the flap is developed as a distally based fascial
flap, and its surface is then skin grafted. The incision is made
centrally over the space between the fibula and the tibia so
that skin flaps may be elevated off the deep fascia. The fascia
is then incised along its medial margin and progressively
reflected until the perforating branch is seen. Branches of the
superficial peroneal nerve course within the fascia and must
be divided to permit safe elevation and rotation. Final release
of the flap requires an incision through the lateral margin and
release of its attachments to the septum that separates the
anterior and lateral muscular compartments. When harvested
in this manner, the donor site may be closed directly.
For more distally based wounds of the anterior ankle/
proximal dorsal foot, the anterior perforating branch is ligated
proximally to increase flap reach. The flap then becomes
dependent on retrograde flow from the lateral malleolar
artery to the anterior perforating branch, and thus patency of
this vessel as well as the anterior tibial artery must be con­
firmed prior to flap harvest. Donor site healing with this
approach, however, can be problematic and may require the
use of neo-dermis, subsequent skin grafting, and ankle immo­
bilization to ensure successful graft take.
Free tissue transfer
Large dorsal foot and ankle wounds with exposed tendon
and/or bone require thin, pliable tissues for proper shoe
fitting. In addition, these wounds have the highest aesthetic
demand, and thus replacement of tissue with flaps that
possess a cutaneous component will provide durable cover­
age and improved overall appearance when compared to
those that require skin grafting.100 Vascularized tendon or
bone can be incorporated to accommodate specific reconstruc­
tive demands. Flaps that have proven to be very successful in
this region include the lateral arm, radial forearm, and para­
scapular fasciocutaneous flaps. Perforator flaps, such as the
subunit principle to guide donor site selection.100 The authors
noted that ill-conceived flap designs may be subject to break­
down, interfere with proper foot wear, and/or prevent efficient
ambulation. True to all free flap reconstructions, emphasis
should be placed on creating a biomechanically stable frame­
work (i.e., removal of bony prominences, arch reconstruction,
etc.) followed by meticulous flap inset under appropriate
tension (i.e., height should be level with surrounding tissue).
Patient education and close longitudinal monitoring will help
identify complications that may jeopardize flap integrity and
permit early intervention to improve the likelihood of func­
tional flap salvage.
Regardless of the type of flap used for a given defect, an
accurate assessment of blood flow is mandatory. For local
flaps, a Dopplerable perforator should be included in the base
of the flap. With pedicled flaps, the dominant branch supply­
ing the flap should be patent. For free flaps, there should be
an adequate recipient artery and vein(s). If there is any ques­
tion, a duplex scan, magnetic resonance angiogram, or con­
ventional angiogram must be obtained prior to surgery.
Reconstruction by anatomic location
Given that the reconstructive options for foot and ankle
wounds vary by location, it is best to differentiate between
five distinct anatomic regions: (1) anterior ankle and dorsal
foot, (2) plantar forefoot, (3) plantar midfoot, (4) plantar
hindfoot and medial/lateral ankle, and (5) Achilles region.
The following discusses some of the key biomechanical con­
siderations, workhorse flap options, and salvage amputations
specific to each region.
Anterior ankle and dorsal foot
Soft tissue around the foot and ankle is sparse and has limited
flexibility. In the presence of healthy granulation tissue,
defects in this region can be successfully treated with simple
skin grafts. If the paratenon covering the extensor tendons
is absent or insufficient, a dermal regenerate template (i.e.,
Integra) can be used with or without NPWT. Local flaps (i.e.,
rotation, rhomboid, bilobed, or transposition) may be useful
for small defects. For larger wounds, however, pedicled flaps
are often necessary. The most useful of these are the EDB
muscle and lateral supramalleolar flaps. The dorsalis pedis
flap, which can be proximally or distally based, is rarely used
because the skin-grafted donor site is often problematic for
ambulatory patients who wear shoes.
Extensor digitorum brevis muscle flap
The EDB is a type II muscle that may be transposed proximally
to cover anterior ankle, proximal dorsal foot, and/or lateral
malleolar wounds. Its dominant blood supply is derived from
the lateral tarsal artery, which branches off the dorsalis pedis
artery at the distal extensor retinaculum. Exposure is obtained
through a dorsal curvilinear incision that communicates with
the wound to be closed. As long as the dorsalis pedis has
antegrade blood flow, it can be divided distal to the lateral
tarsal artery to increase the arc of rotation for muscle transpo­
sition; however, this is not recommended in diabetics with
peripheral vascular disease. The lateral minor tarsal branches
are ligated as the dissection proceeds proximally. The lateral

201
Reconstruction by anatomic location
flap harvest. The lateral arm flap, based on the posterior radial
collateral vessels, can be harvested as a sensate flap (lower
lateral cutaneous nerve) with a relatively long vascular pedicle
(up to 14 cm).105 For larger defects, the flap can be extended
to include the skin overlying the elbow. The parascapular flap
(Fig. 8.21) is supplied by the circumflex scapular artery and is
an adequate choice for large defects.106,107 The flap is insensate
and often requires secondary debulking. It can also be har­
vested as an adipofascial flap and skin grafted to yield a
thinner, more pliable soft-tissue construct.108
Plantar forefoot
The area distal to the midshaft of the metatarsals is referred
to as the forefoot. Local flaps play a major role in reconstruct­
ing deep wounds of the distal third of the foot. Toe ulcers and
gangrene are best treated with limited amputations that pre­
serve viable tissue so that the remaining toe will be as long as
possible when closed. Attempts to preserve at least the proxi­
mal portion of the proximal phalanx of the second, third, and
fourth toes should be made so that it can serve as a spacer to
prevent central collapse of adjacent toes into the empty space.
If the hallux is involved, maximal length preservation should
anterolateral thigh (ALT) flap, have also been utilized with
excellent functional and aesthetic results (Fig. 8.19). This flap
is based on perforators originating from the descending
branch of the lateral circumflex femoral system and can
supply large quantities of fasciocutaneous tissue on a safe and
reliable pedicle with minimal donor site morbidity.102 In
patients who are overweight, bulky fasciocutaneous and/or
perforator flaps may necessitate secondary flap debulking 3–4
months after the initial procedure. Alternatively, the use of a
thin fascial flap, surfaced with a skin graft, may be more
effective at facilitating single-stage reconstruction in obese
patients.
The radial forearm flap (Fig. 8.20) is an excellent option for
dorsal foot wounds.103,104 The flap is thin, pliable, and can be
harvested with a sensory nerve (lateral antebrachial cutane­
ous nerve). The palmaris longus can also be included to
reconstruct missing extensor tendons if necessary. Further­
more, the radial artery with its venous comitantes provides
an excellent vascular pedicle of up to 14 cm in length. If inset
properly at the time of transfer, the flap rarely needs to be
tailored. Despite these favorable qualities, the donor site can
be problematic, and an Allen’s test must be performed to
ensure adequate ulnar-based perfusion to the hand prior to
Fig. 8.17  Extensor digitorum brevis muscle flap. This type II muscle derives its dominant blood supply from the lateral tarsal artery, which is a branch off the dorsalis
pedis artery. The dorsalis pedis can be divided distal to the origin of the lateral tarsal vessels to increase the arc of rotation for muscle transposition. The four slips of
muscle are broad and thin, measuring 4.5 x 6 cm in the adult, making the flap useful for relatively small wounds.
A
B
Extensor retinaculum
Lateral tarsal
artery
Dorsalis pedis
artery
Dorsalis pedis
artery
Extensor hallucis
brevis muscle
Extensor hallucis
brevis muscle
Extensor digitorum
brevis muscle
Extensor digitorum
brevis muscle
Skin incision

202
SECTION I
CHAPTER 8 • Foot reconstruction
advanced (i.e., V-Y), rotated, or transposed – either singly or
in pairs – to close wounds as large as 4–5 cm3 with exposed
bone, joint, and/or tendon. Preferably, the flap is harvested
from the side that is most mobile and that has a definable
perforator at its base. Thus four possible designs exist: proxi­
mally or distally based and medial or lateral to the wound.
The plantar fascia along the edge of the flap must be com­
pletely incised and care taken to divide the septal attachments
to the underlying metatarsals in order to maximize flap
mobility. Occasionally, the defect is large enough such that
tissue from opposing sides is needed for closure. Whatever is
not covered by the flap(s) is then skin grafted. NPWT can be
placed on the entire construct for 3–5 days to ensure both
be the goal given its critical role in ambulation. Most often,
plantar and dorsal flaps of the proximal toe remnant can be
fashioned for simple closure. If additional soft tissue is needed
an adjacent toe may be filleted and transposed. Some of the
more reliable options for forefoot repair include local fascio­
cutaneous flaps, the fillet of toe flap, and the neurovascular
island flap.109,110
Local fasciocutaneous flaps
Vertical perforating vessels located throughout the plantar
aspect of the foot facilitate the design of many different local
flaps. Forefoot skin, fat, and fascia may be elevated and
Fig. 8.18  Lateral supramalleolar flap. (A) Full-
thickness anterior ankle wound with outline of a
supramalleolar flap. The anterior perforating branch of
the peroneal artery is located with a hand-held
Doppler, and the base of the flap should be centered at
this point. Flap width includes the fasciocutaneous
tissue between the fibula and the tibia. (B) Harvest of
the lateral supramalleolar flap. (C) Rotation and flap
inset. The donor site is surfaced with a split-thickness
skin graft. (D) Final appearance 1-year postoperative.
A
B
C
D

203
Reconstruction by anatomic location
frequently centered over the lateral neurovascular bundle of
the hallux. Elevation occurs distal to proximal at the level of
the plantar phalangeal periosteum. Identifying the digital
neurovascular bundle in the webspace permits a more proxi­
mal dissection for increased mobility. A connecting incision is
made from the webspace to the debrided wound in order to
transpose the flap. Depending on the flap size, the donor site
is closed either directly or with a skin graft.111,112 Both the fillet
of toe flap and the neurovascular island flap are effective for
wounds up to 2–3 cm in diameter. A complete preoperative
vascular assessment of the extremity is mandatory to ensure
adequate distal perfusion prior to flap harvest.
Free tissue transfer
The most controversial area of reconstruction centers on the
weight-bearing surfaces of the foot (i.e., plantar forefoot and
heel). There is still some debate as to whether plantar fascio­
cutaneous flaps or muscle flaps with skin grafts better with­
stand the stresses imposed by ambulation. Fasciocutaneous
flaps offer the advantage of durable skin coverage with pre­
served tendon glide and easier re-elevation to access antibiotic
spacers and/or underlying hardware. On the other hand,
muscle flaps provide a more robust blood supply to the recipi­
ent site, making them better suited for coverage of previously
optimal graft take and flap survival. These flaps can also be
applied to the plantar midfoot, hindfoot, malleoli, and dorsum
of the foot for defect coverage (Fig. 8.22).
Fillet of toe flap
The fillet of toe flap is useful for small webspace ulcers and
distal forefoot wounds (Fig. 8.23). Under tourniquet control,
the flap is elevated, beginning distally, by removing the entire
nail complex. Depending on the desired arc of rotation, a
dorsal, medial, or lateral incision is made to expose the under­
lying phalanges, which are subsequently removed with care
taken to preserve the plantar digital vessels. The volar plates
and flexor/extensor tendons are removed to improve flap
pliability. A connecting incision is made to permit transposi­
tion of the flap into an adjacent defect. If necessary, more
proximal dissection of the plantar neurovascular structures
may extend the flap’s arc of rotation to more proximal loca­
tions. The flap works best with the first or fifth toes; however,
the reach of this flap is frequently less than anticipated.
Neurovascular island flap
An alternative, more elegant variation is the neurovascular
island flap, where part of the toe pulp and its digital artery is
raised without having to sacrifice the entire toe. This flap is
Fig. 8.19  Anterolateral thigh flap. A 71-year-old male with a left total ankle arthroplasty presented 6 weeks after deltoid tendon allograft reconstruction with an infected
open wound and exposed underlying hardware. (A) Intraoperative photograph following serial debridement of infected soft tissue, bone, and tendon allograft. Exposed
hardware is seen fixated to the distal tibia and medial malleolus along with a large overlying soft-tissue deficit. (B) Transfer of an anterolateral thigh fasciocutaneous free
flap to the recipient site defect. End-to-side anastomosis was performed between the posterior tibial artery and the descending branch of the lateral circumflex femoral
artery. (C) Evaluation at 1-year follow-up demonstrating durable coverage and excellent aesthetic contour of the medial malleolus.
A
B
C

Fig. 8.20  Radial forearm free flap. (A) Dorsal foot defect following wide resection of a soft-tissue sarcoma including partial excision of the extensor digitorum longus
tendon. (B) Innervated radial forearm free flap with palmaris longus tendon outlined on the volar distal forearm. (C) Transfer and inset of the composite flap into the
recipient-site. End-to-end anastomosis between the radial artery and dorsalis pedis artery was performed along with sensory nerve coaptation between the lateral
antebrachial cutaneous and the superficial peroneal nerves to establish protective sensibility to the flap. The palmaris longus graft was used to reconstruct the extensor
tendon defect. (D) Evaluation at 1 year demonstrating excellent aesthetic contour of the dorsal foot.
A
B
C
D
Fig. 8.21  Parascapular flap. This patient sustained a traumatic injury to her foot and ankle as a child, leaving her with a painful, unstable platform. Adequate soft-tissue
cover was needed before ankle fusion could be performed. (A) Chronic, unstable soft-tissue scarring. (B) A parascapular flap was harvested from her left back. The
descending branch of the circumflex scapular artery was anastomosed end-to-side into the anterior tibial artery. (C) Secondary flap debulking with liposuction was
performed after 6 months.
A
B
C

205
Reconstruction by anatomic location
breakdown. Levin advocates a modified insetting technique
that incorporates a well-approximated, sigmoidal/tangential
closure (i.e., “vest-over-pants”), which is more resistant to the
effects of shearing than a simple transverse approximation.
The long-term durability and excellent functional outcomes
observed with muscle flaps and skin grafts for plantar surface
reconstruction have been well characterized by May and col­
leagues as well as others.116,117
Commonly utilized muscle flaps for this region include the
rectus abdominus, gracilis, and serratus anterior muscle. The
infected wounds.113 In the setting of exposed bone and/or
chronic osteomyelitis, muscle flaps can be used to obliterate
dead space and aid in the delivery of neutrophils and paren­
teral antibiotics to the site of infection.114,115 Furthermore, in
their series of 165 lower extremity free flaps, Hollenbeck et al.
found that plantar flaps containing a cutaneous paddle were
more prone to late ulceration along the interval between the
flap and the native plantar skin.100 This suggests that differ­
ences in mobility at the flap interface, rather than tissue
composition within the flap, may be more predictive of late
Fig. 8.22  (A) Design of a medially-based V-Y advancement flap for closure of a plantar midfoot defect. The
direction of the flap is dependent on the mobility of local tissues and the presence of definable perforators.
(B) The plantar fascia along the edge of the flap is completely incised. Blood supply to the V-Y flap is derived
from direct underlying perforators. For that reason, the flap should never be undermined. (C) Maximum
advancement on the plantar aspect of the foot is approximately 2 cm. (D) Completely healed V-Y flap at 6 months
follow-up.
A
B
C
D

206
SECTION I
CHAPTER 8 • Foot reconstruction
A word of caution regarding the use of the latissimus dorsi flap:
while this flap is an attractive option in many other parts of
the body, the functional loss of this muscle must be carefully
weighed in lower extremity patients who are often crutch-
and/or wheelchair-dependent for a prolonged period of
time.122
Forefoot amputations
Reconstructive surgeons managing patients with foot ulcer­
ation should be well-versed in the options available for fore­
foot amputation, as these procedures often yield the simplest
means to provide stable soft-tissue closure and bipedal ambu­
lation. For large ulcers involving the metatarsal head and
distal shaft, consideration should be given to partial ray
amputation. Resection of the more independent first or fifth
rectus abdominus muscle flap (Fig. 8.24) provides thin and
broad coverage, is easy to harvest, and has an excellent pedicle
with minimal donor site morbidity.118 The gracilis muscle (Fig.
8.25) is also an excellent choice for foot and ankle reconstruc­
tion.119,120 It should be harvested from the ipsilateral thigh to
limit all incisions to the same extremity. The pedicle is some­
what shorter than that of the rectus abdominus muscle, and
thus, depending on the location of the defect and recipient
vessels, its utility may be limited. This flap is most useful for
heel wounds where micro-anastomoses can be performed
to the nearby posterior tibial vessels. Alternatively, using
the bottom two or three slips of the serratus anterior muscle
(Fig. 8.26) provides adequate soft-tissue coverage with a
pedicle length upwards of 18 cm.121 Therefore wounds on the
plantar surface can be reconstructed with anastomoses to the
foot’s dorsal circulation.
Fig. 8.23  Fillet of toe flap. (A) Infected first submetatarsal ulcer with underlying
osteomyelitis in a patient with hallux valgus deformity. (B) Defect created by
excision of the infected ulcer and debridement of the first metatarsal head. A fillet of
hallux flap is raised with care taken to preserve the digital neurovascular bundles.
(C) Rotation and inset of the flap into the distal plantar defect. (D) Completely
healed fillet of toe flap with excellent contour at 1-year follow-up.
A
B
C
D

207
Reconstruction by anatomic location
Fig. 8.24  Rectus abdominus free flap for posterior hindfoot coverage. (A) Traumatic crush injury to the posterior hindfoot with overlying eschar. (B) Clean granular wound
and viable heel pad following serial debridement and negative pressure wound therapy. (C,D) Medial and lateral views 6 months after definitive coverage with a rectus
abdominus free flap and split-thickness skin graft.
A
B
C
D
Fig. 8.25  Gracilis flap. (A) Medial plantar foot defect following wide resection of
cutaneous melanoma. (B) Defect was reconstructed with a free gracilis muscle flap.
The donor vessels were anastomosed end-to-end with the medial plantar artery and
vein. (C) Atrophy of the muscle flap over time resulted in acceptable contour for
footwear and ambulation.
A
B
C

208
SECTION I
CHAPTER 8 • Foot reconstruction
Fig. 8.26  Serratus anterior muscle flap. This diabetic patient sustained a plantar-lateral foot ulceration secondary to Charcot collapse of the midfoot. (A) The wound was
aggressively debrided resulting in a large soft-tissue defect along the lateral weight-bearing surface of the foot. (B) The lower three slips of the serratus anterior muscle
were harvested as a free flap to provide soft-tissue coverage. (C) The reconstructed foot has remained completely healed after 10 years.
A
B
C
metatarsal will cause less biomechanical disruption than
resection of the second, third, or fourth metatarsals, because
the central three rays operate as a cohesive unit. Given their
importance in ambulation, all efforts should be made to pre­
serve as much metatarsal length as possible.
If ulcers are present under several metatarsal heads, or if
resection of one head results in ulceration at an adjacent
metatarsal head, a pan-metatarsal head resection should be
considered. Additionally, if more than two toes with accom­
panying metatarsal heads have to be resected, a transmetatar­
sal amputation is indicated. To maintain biomechanical
stability, care should be taken to preserve the normal parabola,
with the second metatarsal being the longest. If performed
correctly, transmetatarsal amputation provides an excellent
functional level for most patients.123 No formal prosthetic/
orthotic is necessary, and the patient may wear normal shoes
with a small distal insert. Attention, however, must be paid
to avoid equinovarus deformity from loss of the extensors,
which often leads to recurrent lateral plantar ulceration.
Usually, the Achilles tendon is lengthened to avoid this com­
plication. Alternatively, the extensor and flexor tendons of the
fourth and fifth toes can be tenodesed while the ankle is
in neutral position so that distal forefoot dorsiflexion is
preserved.
Plantar midfoot
The midfoot is defined as the region between the proximal
tarsal row and the midshaft of the metatarsals. It comprises
the medial non-weight-bearing arch as well as the more lateral
weight-bearing soft tissues. Bony prominences associated
with midfoot wounds should be resected judiciously. Medial
instep wounds result from deformities of the first metatarsal
base, medial cuneiform, and navicular bones. Lateral wounds
are often secondary to prominence of the fifth metatarsal base
and/or cuboid bones. Limited midfoot fusions should be
strongly considered if they will prevent joint subluxation and
thereby promote more uniform weight distribution.
More commonly, ulcers on the medial/lateral plantar
midfoot are caused by Charcot collapse of the plantar arch. If
the underlying shattered bone has healed and is stable, then
resection of excess bone can be accomplished via a medial or
lateral approach and the ulcer can be left to heal secondarily
or covered with a glabrous skin graft and/or local flap. An
unstable midfoot skeleton can be excised using a wedge exci­
sion and the arch recreated by fusing the proximal metatarsals
to the talus and calcaneus via an Ilizarov frame. Shortening
of the skeletal midfoot usually permits wound closure either
primarily or with a local flap.
Local fasciocutaneous flaps
Small wounds in this region may be closed using any of
the options discussed previously for the forefoot (i.e., V-Y
advancement, bilobed, rhomboid, transposition, etc.). Local
V-Y flaps can be advanced up to 1.5 cm to help close a defect,
whereas defects as large as 3 cm in diameter can be closed
using double-opposing V-Y flaps. For slightly larger defects,
a simple medially-based rotation flap or the pedicled medial
plantar fasciocutaneous flap (described in the hindfoot section
below) offer effective and versatile options for wound closure.
Neurovascular island flap
The neurovascular island procedures described previously
are useful for the coverage of 2–3 cm defects. This repair

209
Reconstruction by anatomic location
tendon lengthening or a simple Achilles tenectomy (remov­
ing 1–2 cm of tendon) should be performed at the time of
amputation. Closure is most often achieved using the plantar
tissue. Postoperatively, the patient’s foot is placed in slight
dorsiflexion until the wound has healed. Although custom
footwear will be required, patients generally return to their
previous ambulatory level with little, if any, increase in energy
expenditure.125
The Chopart amputation involves separating the talus and
calcaneus from the navicular and cuboid. A modified version
can be performed by splitting the midfoot at the juncture
between the navicular/cuboid and the cuneiform bones. With
the Chopart procedure, the insertions of both the peroneal
tendons and the tibialis anterior tendon will be disrupted,
impairing dorsiflexion and foot eversion. A distal Achilles
tenectomy (1–2 cm) or a combined Achilles tendon lengthen­
ing and tibialis anterior tendon transfer to the lateral talus/
calcaneus is, therefore, mandatory to prevent ulceration.
When healed, a calcaneal–tibial rod can be used to further
stabilize the ankle. Postoperatively, the limb is cast in slight
dorsiflexion for 4–6 weeks.126
Plantar hindfoot and medial/lateral ankle
Plantar heel defects or ulcers are among the most difficult of
all wounds to treat. Reconstruction should provide durable
soft-tissue coverage for safe weight-bearing while permitting
near normal ankle motion. More than any other region in the
foot, the surgeon must consider both form and function when
managing wounds in this area. Tendons from muscles of the
superficial/deep posterior and lateral compartments of the
leg traverse this region as they enter the foot. The posterior
tibial artery and tibial nerve lie between the flexor digitorum
longus and the flexor halluces longus tendons, posterior to
the medial malleolus. These structures, along with the tibialis
posterior tendon, travel beneath the laciniate ligament (flexor
retinaculum) to enter the foot. The sural nerve and lateral leg
compartment musculature also pass posterior to the lateral
malleolus on their way to the foot. Loss of tissue in this region
can be catastrophic and may permanently cripple the patient
or mandate a below-knee amputation. A variety of reconstruc­
tive options are available based on the precise location of the
defect.
Intrinsic muscle flaps
Three intrinsic foot muscles may be used individually or
together to repair small wounds of the hindfoot region: the
abductor hallucis brevis (AHB), flexor digitorum brevis (FDB),
and abductor digiti minimi (ADM) muscles.127–130
Abductor hallucis brevis muscle flap
The AHB is a type II muscle that, despite its limited bulk,
provides useful coverage of the medial plantar heel and
medial malleolus (Fig. 8.27
). It is elevated through an inci­
sion along the medial glabrous junction. The tendon is divided
distally, and the muscle is separated from the medial head of
the flexor halluces brevis. Because the dominant blood supply
enters the muscle proximally, as branches from the medial
plantar artery, the more distal pedicles can be safely ligated.
If an increase in the arc of rotation is needed, the medial
plantar artery may be ligated distal to the proximal muscle
necessitates a more proximal dissection of the vessels and
nerves from the plantar surface of the foot. If the dominant
circulation is from the first dorsal metatarsal artery, division
of the deep transverse metatarsal ligament will be necessary
to permit adequate flap transfer and inset.
Local muscle flaps
If muscle is needed, a pedicled flexor digiti minimi brevis flap
(laterally) or a flexor hallucis brevis flap (medially) can be
useful. The flexor digiti minimi brevis is a type II muscle that
receives its dominant pedicle at the lateral plantar artery take-
off of the digital artery to the fifth toe and can be used to cover
defects over the proximal fifth metatarsal. The flexor halluces
brevis muscle has a similar (type II) vascular anatomy but can
be harvested on a much longer pedicle, as an island flap on
the medial plantar artery, to reach defects as far as the proxi­
mal ankle. Other useful muscle flaps for medial and lateral
defects include the pedicled abductor hallucis flap and abduc­
tor digiti minimi flap, respectively (both described in the
hindfoot section below).
Free tissue transfer
The plantar instep of the foot is of relatively low functional
and aesthetic importance. It can be reliably resurfaced using
thin, pliable fasciocutaneous or perforator flaps (i.e., radial
forearm, parascapular, ALT, etc.). The contralateral sensate
free instep flap, based on the medial plantar neurovascular
bundle, provides tissue of matching quality for excellent
functional and aesthetic results. Larger defects on weight-
bearing surfaces should be reconstructed with free muscle
flaps and skin grafts for improved long-term stability, as
described previously. Great care should be taken to tailor the
flap so that it is inset at the same height as the surrounding
tissue.
Midfoot amputations
Deformities at the tarsometatarsal junctions (Lisfranc’s joint)
occur when a shortened gastrocnemius–soleus complex alters
normal ankle motion. The inability to dorsiflex the ankle
places undue strain across Lisfranc’s joint during gait, which
leads to increased compensatory motion, joint breakdown,
and resultant midfoot deformity. In the absence of protective
sensation (i.e., diabetes, peripheral neuropathy), soft-tissue
ulceration becomes inevitable.124 Midfoot amputations may be
the preferred “repair” in patients who are not candidates for
reconstruction. The procedure is simple and may be performed
rapidly without the significant morbidity associated with
more complex reconstructions. When executed properly, a
functional limb that provides a stable platform for ambulation
may be salvaged. The two most common forms of midfoot
amputation are the Lisfranc and Chopart amputations.
The Lisfranc amputation involves the removal of all meta­
tarsals with the exception of the very proximal remnant of
the second metatarsal, which serves as a keystone area and
should be preserved if possible. The direction of blood flow
along the dorsalis pedis and lateral plantar artery should be
evaluated. Absence of antegrade flow through either man­
dates preservation of the perforator connecting the two at
that level. To prevent a delayed equinovarus deformity, a
split anterior tibial tendon transfer to the cuboid with Achilles

209.e1
Reconstruction by anatomic location
Fig. 8.27  Abductor hallucis brevis flap. Local flaps are particularly useful for
coverage of ankle defects with exposed tendon and/or bone. (A,B) In this case, the
tibiotalar junction could not be completely covered with a local transposition flap.
(C,D) An abductor hallucis brevis muscle flap was rotated posteriorly into the
residual defect and covered with a split-thickness skin graft. (E) Follow-up at 1 year
demonstrating complete healing without breakdown and acceptable final contour.
A
B
C
D
E

210
SECTION I
CHAPTER 8 • Foot reconstruction
Further mobilization is possible by harvesting the flap on the
lateral plantar artery and continuing the pedicle dissection to
its origin within the tarsal tunnel; however, this approach is
not routinely recommended. The muscle is then turned on
itself (180°) to fill the posterior/plantar defect.
Abductor digiti minimi muscle flap
Despite its limited size, the ADM is the workhorse flap for
lateral heel and distal lateral ankle wounds (Fig. 8.29). It is
mobilized via an incision along the lateral glabrous junction.
This type II muscle is detached from the lateral fifth metatar­
sophalangeal joint by dividing the tendinous insertion. It is
then elevated off the flexor digiti minimi to the level of the
proximal fifth metatarsal. The minor pedicles enter the muscle
medially. Its dominant blood supply enters at the medial
proximal corner of the muscle and is derived from the lateral
pedicle and dissection continued to its origin off of the poste­
rior tibial artery.
Fig. 8.27 appears online only.
Flexor digitorum brevis muscle flap
The FDB muscle can be useful for heel pad reconstruction,
especially if used to fill an existing defect that can be covered
by intact glabrous skin from the heel (Fig. 8.28). It is a type II
muscle whose blood supply is derived from branches off both
the medial and lateral plantar arteries, with the latter usually
being dominant. The lateral plantar artery courses deep to the
proximal muscle belly where the dominant pedicle enters the
muscle. A midline plantar foot incision through the skin and
plantar fascia is used to harvest the muscle. The four flexor
tendons are divided distally and the muscle is dissected
proximally off the underlying quadratus plantae muscle.
Fig. 8.28  Flexor digitorum brevis flap for heel pad reconstruction. (A) Plantar heel ulcer in a diabetic patient with
calcaneal gait. (B) Outline of the flexor digitorum brevis flap drawn on the plantar surface of the foot. (C) A
midline plantar foot incision is used to harvest the muscle, and the four flexor tendons are divided distally. The
muscle is then dissected proximally and turned on itself (180°) to fill the plantar heel defect. (D) Coverage of the
flap is provided through skin grafting or advancement of intact glabrous skin from the heel as shown.
A
B
C
D

211
Reconstruction by anatomic location
to preserve flap sensation and avoid damaging the medial
trunk to the hallux. The dissection plane is superficial to the
muscles (just deep to the plantar fascia) and includes the deep
fascial septa separating the AHB and FDB, which is intimately
associated with the vascular pedicle. For most reconstruc­
tions, the dissection may stop where the vessels emerge from
the lateral border of the AHB muscle. Further mobilization is
possible by dividing this muscle and the laciniate ligament
and tracing the medial plantar artery to its origin from the
posterior tibial artery. If additional pedicle length is needed,
the lateral plantar artery can be divided; although, this is not
recommended.
Heel pad flaps
Posterior heel wounds often result from prolonged decubitus
pressure and usually signify severe vascular disease involv­
ing both the posterior tibial and the peroneal arteries. Soft
tissue closure can be achieved using a medially- or laterally-
based suprafascial flap of the heel pad. The lateral calcaneal
flap, in particular, is useful for posterior calcaneal and distal
Achilles defects. Its length can be increased (i.e., extended
lateral calcaneal flap) by creating an L-shaped design that
extends posterior and inferior to the lateral malleolus. The
flap is based on the lateral calcaneal artery and is harvested
with the lesser saphenous vein and sural nerve to provide
plantar artery. The origin of the muscle can be divided off the
lateral calcaneus for improved mobilization and the donor
site is typically closed primarily. For larger defects, it can be
used in conjunction with either or both of the muscles dis­
cussed above.
Medial plantar artery flap
This fasciocutaneous flap provides the most versatile solution
for medial or plantar heel reconstruction, providing tissue of
similar quality (Fig. 8.30). It was originally described 40 years
ago by Taylor and Hopson.131 Mir had used it over 20 years
earlier as a cross-foot flap from the instep of the opposite
extremity.132 A flap as large as 6 x 10 cm can be harvested with
ease; however, the donor site must be skin-grafted. Therefore
it is important to ensure that the instep is not a primary
weight-bearing surface (i.e., Charcot collapse), as this would
be a relative contraindication to using this flap.133,134
The flap is outlined over the medial instep of the foot
and centered on the medial plantar artery using a hand-held
Doppler. The distal extent of the flap is incised first through
the skin and plantar fascia. The medial plantar neurovas­
cular bundle is readily identified in the cleft between the
AHB and the FDB muscles. The vessels are divided distally
and elevated with the flap. If the patient is sensate, an intra­
neural dissection of the medial plantar nerve is performed
Fig. 8.29  Abductor digiti minimi flap. (A) Debrided lateral calcaneal wound with
exposed underlying bone. (B) The abductor digiti minimi flap is elevated from distal
to proximal through a linear incision along the lateral glabrous junction, transposed
into the adjacent defect, and resurfaced with a split-thickness skin graft. (C) Stable
wound coverage is observed after 2 years.
A
B
C

212
SECTION I
CHAPTER 8 • Foot reconstruction
begins along its cephalic margin. Through this incision, the
lesser saphenous vein and sural nerve are identified superfi­
cial and deep to the deep fascia, respectively. Both structures
are ligated so that they may be elevated along with the flap
and underlying deep fascia. The margins of the flap pedicle
should lay 2–3 cm on either side of the Dopplered lesser
saphenous vein. Harvesting the overlying skin with the
pedicle minimizes torque on the vein as it rotates 180° during
inset. The arc of rotation will provide coverage of the lateral/
medial ankle and posterior heel/Achilles region. In a well-
vascularized extremity, the pedicle can be divided after 3–4
weeks to improve contour of the lower leg. Depending on flap
size, the donor site may be closed primarily or covered with
a split-thickness skin graft.
While this flap is particularly useful in patients who are not
candidates for free tissue transfer, its complication rate is high
and primarily related to venous congestion. This can be mini­
mized if the flap is harvested with 3 cm of tissue on either
side of the pedicle and with the overlying skin intact.136 Prob­
lems with venous congestion can be further mitigated by
cutaneous sensation. Nevertheless, the utility of the lateral
calcaneal flap is limited by its difficult harvest, poor donor
site, and restricted arc of rotation.
Sural artery flap
The retrograde or reverse sural flap is a versatile neurofascio­
cutaneous flap that is useful for ankle and posterior heel
defects (Fig. 8.31).135 Occasionally, a median superficial sural
artery is seen coursing with the sural nerve; however, in most
cases, the flap is supplied by an arterial plexus of vessels that
travel along the sural nerve and receive retrograde flow from
a peroneal perforator located 5 cm above the lateral malleolus.
The artery and sural nerve first course above the fascia and
then dive deep to the fascia at the midcalf, while the accom­
panying lesser saphenous vein remains above the fascia.
The flap is outlined over the raphe between the two heads
of the gastrocnemius muscle. A line is drawn from the inferior
edge of the flap to the pivot point for the pedicle approxi­
mately 5 cm proximal to the lateral malleolus. Flap elevation
Fig. 8.30  Medial plantar artery flap. (A) Open distal tibial fracture. (B) Design of a
medial plantar artery fasciocutaneous flap along the instep. (C) Elevation of the flap
on the medial plantar pedicle. (D) Viable flap and skin grafted donor site.
A
B
C
D

213
Reconstruction by anatomic location
deep sensory pathways, good return of sensibility is often
seen in non-innervated flaps by 1 year.116,140,141 If neurotization
of a plantar flap is to be attempted, then proximal dissection
of the sensory nerve to a healthier region should be performed
to facilitate coaptation without disrupting intact nerve
branches.
Hindfoot amputations
The presence of calcaneal osteomyelitis in patients who have
limited ambulatory capacity or significant comorbidities may
warrant vertical calcanectomy to remove bony prominences/
diseased bone and develop soft-tissue envelopes to simplify
wound closure. Although patients can still ambulate with
a partially resected calcaneus, disinsertion of the Achilles
tendon mandates the use of custom orthotics.
Syme first described amputation at the ankle in 1843.143 The
Syme’s amputation has a definite role in hindfoot reconstruc­
tion and should be considered in the setting of severe osteo­
myelitis involving the talus and/or calcaneus, in patients who
are poor candidates for free tissue transfer, and in diabetic
patients with prior contralateral lower extremity amputation.
The procedure involves amputation through the distal tibia/
fibula, just above the ankle mortise. The talus and calcaneus
are carefully removed, leaving behind a vascularly intact heel
pad, which is anchored to the anterior surface of the osteoto­
mized distal tibia to provide durable and secure soft-tissue
delaying the flap by a few days after ligating the proximal
lesser saphenous vein and sural artery.137,138 The insetting of
the flap is critical to avoid kinking of the pedicle. Offloading
of the flap and heel during the healing phase may be simpli­
fied by using an Ilizarov-type frame. The major donor deficit
of this flap is the loss of sensibility along the lateral aspect of
the foot, while the skin-grafted depression in the posterior calf
may pose a problem should the patient undergo a below-knee
amputation in the future.
Free tissue transfer
The hindfoot represents an area of high functional and low
aesthetic demand. The same principles apply to the plantar
heel as for other weight-bearing regions of the foot. Namely,
free muscle flaps surfaced with a skin graft offer a durable
and well-contoured reconstruction, capable of withstanding
the shear forces of repeated ambulation. Nevertheless, several
fasciocutaneous (i.e., radial forearm, lateral arm, parascapular,
etc.) and/or perforator flaps (i.e., ALT) have been used suc­
cessfully as well. With many of these flaps, sensory nerve
coaptation to disrupted calcaneal sensory branches may be
performed at the time of reconstruction to improve early
sensibility.139–141 However, outcomes and overall benefit of this
added procedure remain controversial. Some studies report
no differences in flap survival or re-ulceration rates between
neurotized and non-neurotized flaps.142 In the setting of intact
Fig. 8.31  Reverse sural artery perforator flap for coverage of a chronic, unstable
wound over the lateral malleolus. (A) Initial flap elevation. (B) The flap is harvested
with 3 cm of tissue on either side of the pedicle keeping the overlying skin intact to
minimize torque on the vein as it rotates 180° during inset. (C) In a well-vascularized
extremity, the pedicle can be divided after 3–4 weeks to improve contour of the
lower leg. Depending on flap size, the donor site may be closed primarily or covered
with a split-thickness skin graft.
A
B
C

214
SECTION I
CHAPTER 8 • Foot reconstruction
To this end, composite free tissue transfer with a vascularized
tendon construct facilitates single-stage reconstruction with
contoured, well-vascularized soft-tissue coverage that can
withstand a dynamic workload and promote adequate tendon
glide with ambulation.145,146
At our institution, the composite ALT flap with vascular­
ized fascia lata is the preferred method for reconstructing
combined tendocutaneous defects of the Achilles (Fig. 8.32).
The fascial sheet of the composite flap is rolled into a tendon-
like structure and fixed to the proximal and distal remnants
of the Achilles, utilizing multiple non-absorbable, interrupted
sutures (Fig. 8.33). If no distal stump is available, the graft is
fixed to the calcaneus with a suture anchor. Proximal fixation
is accomplished with the ankle joint at 90°. Postoperatively,
the ankle is immobilized in the neutral position with an
external fixation device for 4 weeks. This construct – which
combines the advantages of flexibility in flap design, good
skin quality, and minimal donor site morbidity – has been
shown in limited series to achieve acceptable ankle power,
strength, and range of motion, with improved satisfaction and
quality-of-life scores after 1 year.147,148
Postoperative care
Patients who have undergone foot reconstruction require a
structured, graduated rehabilitation program that is tailored
to their functional goals and capabilities. Follow-up should be
frequent and involve a multidisciplinary team of specialists
(i.e., plastic surgery, vascular surgery, orthopedic surgery,
podiatry, infectious disease, primary care, and prosthetist/
orthotist) who are available to participate in the patient’s care.
Experienced nursing personnel adept at all aspects of wound
assessment and care play an integral role as well.
In general, patients are not allowed to bear weight on the
operated foot for 4 weeks if the plantar surface was involved.
This is of paramount importance to ensure uneventful healing.
The use of strict bed rest and/or crutches, walkers, non-
mechanized wheelchairs, or rollabouts varies with the nature
of the procedure performed and the physical ability and
coordination of the patient. Local flaps typically require 1 day
of elevation, skin grafts 3–5 days, and free flaps up to 2 weeks.
During the bed-rest phase, use of low molecular weight
heparin significantly reduces the risk of thromboembolic
events. Control of pedal edema is important and may be
accomplished through a combination of elevation, NPWT
(3–5 days), and/or gentle compression wraps once dependent
positioning of the limb is permitted. Sutures are generally
removed at 3 weeks in healthy patients, 4 weeks in diabetics,
and 6 weeks in patients with renal failure.
With the help of a pedorthotist, appropriate orthotic devices
can be prescribed to offload specific parts of the plantar foot.
For dorsal wounds, patients are allowed to ambulate far
sooner, provided they use a dressing that protects the recon­
struction. During healing, a monorail external fixator or
Ilizarov frame can be used to immobilize the ankle joint or
offload plantar/heel wounds, respectively. The L’Nard splint,
or multipodus boot, provides a less invasive option for
offloading the heel and immobilizing the ankle joint. For
patients who are weight-bearing and ambulatory, the CAM
walker boot provides effective immobilization and allows the
degree of equinus at the ankle to be adjusted. Following
coverage. The procedure can be modified by leaving a 1 cm
thick wedge of plantar calcaneal cortex attached to the heel
pad and fusing this structure to the distal tibia. Large medial
and lateral “dog ears” can be revised during a second opera­
tion to minimize tension during initial wound closure. A
dorsal flap may be required to facilitate closure if the plantar
soft tissues have been compromised by extensive wounds or
scars.
For diabetic patients with prior contralateral limb loss,
Syme’s amputation provides a stable, tailored platform for
weight-bearing and ambulation. These patients generally
require minimal physical therapy for gait training, and energy
expenditure (oxygen uptake, velocity of cadence, and stride
length) is consistently better than that measured for both
below-knee and above-knee amputees.144 It is for this specific
population that the Syme’s amputation is most useful. The
key to long-term success with this procedure is having an
experienced prosthetist who is skilled at creating well-
designed Syme’s prostheses.
Achilles region
Wounds involving the posterior hindfoot/Achilles region can
be problematic. There are five principles that must be fol­
lowed in repairing wounds of this unique location: (1) preserve
Achilles tendon function, (2) avoid joint/tendon contractures,
(3) restore normal anatomy/contour, (4) reconstruct soft-tissue
deficiencies, and (5) select donor tissues based upon the
specific requirements of the wound. Unfortunately, regional
tissue deficits as well as vascular compromise and scarring in
this region often preclude attempts at primary wound closure
or local tissue rearrangement. Isolated soft-tissue defects with
intact paratenon can be managed with a simple skin graft. For
defects involving exposed tendon, adequate local wound care
and/or NPWT will promote healthy granulation, which can
be left to heal secondarily or subsequently skin grafted. The
use of a dermal regenerate template (i.e., Integra), with or
without NPWT, can provide a healthy dermal layer to facili­
tate coverage with a thin autograft. Both the VAC and the
Ilizarov frame can be used to immobilize and offload wounds
around the ankle joint to prevent shear forces from disrupting
the healing process.
Local fasciocutaneous flaps
As described above, the extended lateral calcaneal flap and/
or reverse sural flap can be used to provide coverage of small-
to-moderate defects in the Achilles region. However, given
the inherent difficulties associated with their use (i.e., limited
coverage, higher complications, donor site morbidity, etc.),
these flaps are typically reserved for patients who have failed
previous grafts and are poor candidates for more advanced
reconstructive techniques (i.e., free tissue transfer).
Free tissue transfer
Combined defects involving the Achilles tendon and overly­
ing soft tissue pose a significant challenge. Successful recon­
struction mandates an accurate evaluation of the patient’s
preinjury functional status, medical comorbidities, and ambu­
latory prognosis. For younger, more active patients, functional
demands often necessitate a stable gait cycle with normalized
range of motion and restoration of power and plantar flexion.

215
Summary
Fig. 8.32  Composite anterolateral thigh/vascularized fascia lata reconstruction of a combined tendocutaneous defect of the Achilles was undergone by a 32-year-old male.
(A) Segmental loss of the Achilles tendon with large overlying soft-tissue deficit. (B) Transfer of the free fasciocutaneous flap and rolled fascia lata to the recipient site. The
neo-tendon construct (arrow) is secured to the proximal and distal remnants of the native Achilles using multiple, non-absorbable, interrupted sutures. (C,D) Evaluation at
1-year follow-up demonstrating functional range of motion, contour, and aesthetic result of the reconstructed side. (From: DeFazio MV, Hand KD, Iorio ML, et al. Combined
free tissue transfer for the management of composite Achilles defects: functional outcomes and patient satisfaction following thigh based vascularized reconstruction with a
neotendon construct. J Reconstr Microsurg. 2014;30(6):431–440.)
A
B
C
D
tendon lengthening or transfer, patients should be kept non-
weight-bearing for 1 week and in a CAM walker for the next
5 weeks. If compliance is a concern, wrapping the CAM
walker in cast material can be helpful. Once healed, the patient
will require accommodative shoe wear as well as a course of
physical/occupational rehabilitation to regain the strength
and mobility needed to live independently at home. If dia­
betic, vigilant follow-up with a podiatrist for routine preven­
tive foot care is mandatory.
Outcomes
Establishment of a multidisciplinary clinic that provides
comprehensive care to patients with diabetic foot ulcers is
central to the success of any limb salvage protocol. Such a
clinic should be equipped to coordinate diagnosis, offloading,
and outpatient preventative care; perform revascularizations,
debridements, and reconstructive procedures; aggressively
treat infections; and manage medical comorbidities within a
multidisciplinary forum.149 New ulceration, when it occurs,
will be detected earlier and lead to management that is more
effective at promoting limb preservation. History has demon­
strated that routine evaluation and treatment by a compre­
hensive multidisciplinary team improves the quality and
cost-effectiveness of care and can reduce amputation rates by
36–86%.150–158 These findings mirror the senior author’s own
20-year experience managing complex lower extremity
wounds in the setting of a multidisciplinary referral center for
advanced limb salvage.
Internationally, recurrence rates for healed diabetic foot
ulcers range from 60–80%. The importance of offloading and
biomechanical stability in the promotion of wound healing
and sustained long-term closure has been emphasized previ­
ously. However, it is difficult to properly maintain offloading
with the use of orthotics alone. In one of the author’s own
investigations, surgical correction of underlying biomechani­
cal abnormalities (i.e., resection of bony prominences, repair
of Charcot midfoot deformities, Achilles tendon lengthening,
etc.) at the time of wound closure led to a reduction in ulcer
recurrence rates from 25% to 2% over an average follow-up
of 5 years.
Summary
Complex lower extremity reconstruction and functional limb
salvage is predicated upon the institution of a multidisci­
plinary collaboration between members of a comprehensive
wound care team. Successful healing requires, at a minimum,
the presence of adequate local blood flow, a clean wound base,
and a biomechanically stable framework to prevent recurrent

216
SECTION I
CHAPTER 8 • Foot reconstruction
breakdown. Reconstruction of chronic wounds should only
be undertaken after the debrided wound manifests signs of
healing. The repair is then dictated by the size and location of
the wound as well as the patient’s goals, functional capacity,
vascular status, and medical comorbidities. Most wounds will
benefit from simple surgical techniques (i.e., NPWT, delayed
primary closure, skin grafting, etc.), while few require more
sophisticated modalities (i.e., local, pedicled, or free flaps).
Postoperatively, appropriate offloading and rehabilitation,
frequent follow-up, and preventative care will minimize
complications and promote long-term functional indepen­
dence. The principles and techniques outlined in this chapter
will serve to enhance healing, function, quality-of-life, and
survival in patients who face major amputation as the
alternative.
Fig. 8.33  (A) Free anterolateral thigh flap with associated strip of vascularized
fascia lata following harvest. (B) The fascial strip is then rolled to form a
neo-tendon construct, which is secured to the proximal and distal remnants of the
native Achilles tendon. (From: DeFazio MV, Hand KD, Iorio ML, et al. Combined free
tissue transfer for the management of composite Achilles defects: functional
outcomes and patient satisfaction following thigh based vascularized reconstruction
with a neotendon construct. J Reconstr Microsurg. 2014;30(6):431–440.)
A
B
Bonus images for this chapter can be found online at

Fig. 8.2 Effects of elevated serum glucose on blood flow and tissue perfusion.
Fig. 8.4 Blue toe syndrome. (A,B) Patient presented with severe pain following
sudden appearance of several well-demarcated ischemic lesions involving all 5
digits of the right foot. (C) Right lower extremity angiogram demonstrating an
ulcerated plaque with organized thrombus in the mid-superficial femoral artery.
Percutaneous endovascular intervention was not attempted due to concern over
plaque dislodgement and resultant distal embolism. (D,E) Open
thromboendarterectomy with excision of a 1.5 cm occlusive thrombus.
Fig. 8.6 (A) Preintervention angiogram of the distal right lower extremity in a
patient with an ischemic plantar-medial foot wound demonstrating complete
occlusion of the posterior tibial artery along with a large mid-level segmental
occlusion of the anterior tibial artery (arrow). Additional high-grade stenoses of
the proximal anterior tibial and proximal-to-midperoneal arteries are also noted
(asterisk). (B,C) Postintervention angiograms following percutaneous
transluminal angioplasty of the anterior tibial and peroneal arteries revealing
widely patent run-off to the foot with no evidence of residual stenosis or
occlusion. (From: DeFazio MV, Han KD, Akbari CM, Evans KK. Free tissue
transfer after targeted endovascular reperfusion for complex lower extremity
reconstruction: setting the stage for success in the presence of multivessel
disease. Ann Vasc Surg. 2015;29(6):1316.e7–1316.e15.)
Fig. 8.7 Assessment of Achilles tendon tightness in patients with equinovarus
deformity requires that dorsiflexion be tested with (A) the leg held in extension
(to keep the gastrocnemius muscles at their full resting length) and with (B) the
knee flexed (which reduces tension on the gastrocnemius). If the ankle only
dorsiflexes when the knee is flexed, then tightness of the gastrocnemius
muscles is responsible for the equinus posture of the foot and can be released
by performing a gastrocnemius recession. If the ankle remains tight during knee
extension and flexion, then both gastrocnemius and soleus contributions to the
Achilles tendon have to be released, usually percutaneously.
Fig. 8.12 Construction of a closed-system habitat to facilitate free-range
maggot debridement therapy for multiple necrotic ulcers involving the dorsal/
plantar surfaces of the foot as well as the interstices of the webspaces.  
Maggots are introduced through the ventilation port, which is sealed with
polyester chiffon netting to ensure continuous oxygen penetration. An internal
collection chamber is lined with multiple layers of super-absorbent gauze and
suspended to prevent pooling of secretions that can irritate the skin and/or lead
to barrier disruption.
Fig. 8.13 For larger reconstructions involving mobile and/or weight-bearing
surfaces of the foot and ankle, external fixation with an Ilizarov frame is ideal in
that it not only provides superior immobilization of the ankle but also suspends
the foot and heel, maintains skeletal alignment, and protects the reconstruction
from external pressure and potential trauma.
Fig. 8.15 (A) Medial foot defect. (B) Lisfranc amputation with rotation of a
laterally-based plantar flap for closure. (C) Dry gangrenous necrosis of the
plantar foot and toes resulting in loss of the majority of the plantar soft tissues.
(D) Transmetatarsal amputation was performed with preservation of a dorsal
soft-tissue flap and use of a skin graft to facilitate closure.
Fig. 8.16 (A) Fibrogranular wound with fibrotic scar tissue overlying the left
Achilles tendon and medial malleolus. (B) Healthy granulating wound bed
following serial debridement and interval negative pressure wound therapy.  
(C) Complete take of a partial-thickness skin graft.
Fig. 8.27 Abductor hallucis brevis flap. Local flaps are particularly useful for
coverage of ankle defects with exposed tendon and/or bone. (A,B) In this case,
the tibiotalar junction could not be completely covered with a local transposition
flap. (C,D) An abductor hallucis brevis muscle flap was rotated posteriorly into
the residual defect and covered with a split-thickness skin graft. (E) Follow-up
at 1 year demonstrating complete healing without breakdown and acceptable
final contour.

217
Summary
5. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg.
1987;40:113–141. The authors introduce the concept of the “angiosome”,
which is a 3D unit of tissue fed by a single source artery. The authors
evaluated the blood supply to the skin and underlying tissues in fresh
cadaver models using ink injection studies, direct dissection, perforator
mapping, and radiographic analysis. The blood supply was shown to be a
continuous 3D network of vessels supplying all tissue layers through
multiple interconnections. The authors plotted an average of 374 major
perforators in each subject. This arterial roadmap of the body provides the
basis for the logical planning of incisions and flaps, and helps to define
the tissues available for composite transfer.
6. 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(suppl):S261–S293. Understanding the angiosomes of the foot
and ankle as well as the interaction among their source arteries is
clinically useful in reconstructive surgery, especially in the presence of
peripheral vascular disease. The authors performed 50 cadaver dissections
with methyl methacrylate arterial injections to further define the
angiosomes of the lower extremity. They demonstrated six distinct
angiosomes of the foot and ankle originating from three main arteries.
Blood flow to the foot and ankle is redundant due to multiple arterial–
arterial connections between these three major source vessels. Using a
Doppler ultrasound probe and selective occlusion, it is possible to
determine the patency of these interconnections as well as the direction of
blood flow. This step is critical to the planning of vascularly reliable
reconstructions, safe exposures, and the most effective revascularization
strategy for a given wound.
8. Neville RF, Attinger CE, Bulan EJ, et al. Revascularization of a
specific angiosome for limb salvage: does the target artery matter?
Ann Vasc Surg. 2009;23:367–373. The authors conducted a retrospective
comparison of outcomes for 52 non-healing lower extremity wounds that
required tibial bypass, through either direct revascularization (n=27) to
the artery feeding the ischemic angiosome or indirect revascularization
(n=25) to an artery unrelated to the ischemic angiosome. Overall, 77% of
wounds progressed to healing and 23% failed to heal with resultant
amputation. For patients in the direct revascularization cohort, the rates
of healing and amputation were 91% and 9%, respectively. In contrast,
patients who underwent indirect revascularization experienced a 62%
healing rate, with 38% of wounds ending in amputation. The authors
concluded that direct revascularization of the angiosome specific to the
anatomy of the wound leads to higher rates of healing and limb
salvage.
17. Dellon AL, Mackinnon SE. Chronic nerve compression model for
the double crush hypothesis. Ann Plast Surg. 1991;26:259–264.
61. Steed DL, Donohoe D, Webster MW, et al. Effect of extensive
debridement and treatment on the healing of diabetic foot ulcers.
J Am Coll Surg. 1996;183:61–64.
69. Mueller MJ, Sinacore DR, Hastings MK, et al. Effect of Achilles
tendon lengthening on neuropathic plantar ulcers, a randomized
clinical trial. J Bone Joint Surg Am. 2003;85:1436–1445. Limited ankle
dorsiflexion has been implicated as a contributing factor to plantar
forefoot ulceration and wound chronicity in patients with diabetes
mellitus. The authors compared outcomes for 64 patients with diabetes
mellitus and a neuropathic plantar ulcer who were treated with total
contact casting with and without Achilles tendon lengthening. After two
years, the risk for recurrence following Achilles tendon lengthening was
52% less than that for total contact casting alone. The authors concluded
that Achilles tendon lengthening should be considered an effective
strategy to reduce recurrence of neuropathic plantar forefoot ulceration in
patients with diabetes mellitus and limited ankle dorsiflexion.
74. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new
method for wound control and treatment: clinical experience. Ann
Plast Surg. 1997;38:563–576.
100. Hollenbeck ST, Woo S, Komatsu I, et al. Longitudinal outcomes
and application of the subunit principle to 165 foot and ankle free
tissue transfers. Plast Reconstr Surg. 2010;125:924–934. It is known
that ill-conceived flap designs may be subject to breakdown, interfere
with proper footwear, and/or prevent efficient ambulation. The authors
reviewed their experience with 165 lower extremity free tissue transfers
and proposed a subunit principle to guide donor site selection based on
region-specific functional and aesthetic demands. Flap survival was 92%,
and the overall limb salvage rate was approximately 97.6%. In diabetics,
the flap survival and limb salvage rates were 80% and 83%, respectively.
Although not statistically predictive, the authors found that plantar flaps
containing a cutaneous paddle were more prone to late ulceration along
the interval between the flap and the native plantar skin when compared
to muscle flaps covered with a skin graft.
148. DeFazio MV, Han KD, Iorio ML, et al. Combined free tissue
transfer for the management of composite Achilles defects:
functional outcomes and patient satisfaction following thigh-based
vascularized reconstruction with a neotendon construct. J Reconstr
Microsurg. 2014;30:431–440.
156. Driver VR, Madsen J, Goodman RA. Reducing amputation rates in
patients with diabetes at a military medical center: the limb
preservation service model. Diabetes Care. 2005;28:248–253.
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5. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg.
1987;40:113–141. The authors introduce the concept of the “angiosome”,
which is a 3D unit of tissue fed by a single source artery. The authors
evaluated the blood supply to the skin and underlying tissues in fresh
cadaver models using ink injection studies, direct dissection, perforator
mapping, and radiographic analysis. The blood supply was shown to be a
continuous 3D network of vessels supplying all tissue layers through
multiple interconnections. The authors plotted an average of 374 major
perforators in each subject. This arterial roadmap of the body provides the
basis for the logical planning of incisions and flaps, and helps to define
the tissues available for composite transfer.
6. 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(suppl):S261–S293. Understanding the angiosomes of the foot
and ankle as well as the interaction among their source arteries is
clinically useful in reconstructive surgery, especially in the presence of
peripheral vascular disease. The authors performed 50 cadaver dissections
with methyl methacrylate arterial injections to further define the
angiosomes of the lower extremity. They demonstrated six distinct
angiosomes of the foot and ankle originating from three main arteries.
Blood flow to the foot and ankle is redundant due to multiple arterial–
arterial connections between these three major source vessels. Using a
Doppler ultrasound probe and selective occlusion, it is possible to
determine the patency of these interconnections as well as the direction of
blood flow. This step is critical to the planning of vascularly reliable
reconstructions, safe exposures, and the most effective revascularization
strategy for a given wound.
7. Masqualet AC, Beveridge J, Romana C. The lateral supramalleolar
flap. Plast Reconstr Surg. 1988;81:74–81.
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156. Driver VR, Madsen J, Goodman RA. Reducing amputation rates in
patients with diabetes at a military medical center: the limb
preservation service model. Diabetes Care. 2005;28:248–253.
157. Trautner C, Haastert B, Mauckner P, et al. Reduced incidence of
lower-limb amputations in the diabetic population of a German
city, 1990–2005: results of the Leverkusen Amputation Reduction
Study (LARS). Diabetes Care. 2007;30:2633–2637.
158. Krishnan S, Nash F, Baker N, et al. Reduction in diabetic
amputations over 11 years in a defined U.K. population: benefits
of multidisciplinary team work and continuous prospective audit.
Diabetes Care. 2008;31:99–101.

SECTION II • Trunk Surgery
9 
Comprehensive trunk anatomy
Michael A. Howard and Sara R. Dickie
SYNOPSIS
■ Many workhorse flaps and reconstructive pursuits involve the trunk.
■ Familiarity with the vascular relationships and tissue types within this
anatomy is integral to a plastic surgeon.
■ What follows is a detailed anatomy of the trunk including the chest,
abdomen, back, and perineum.
Access the Historical Perspective section and Fig. 9.1
online at

Basic science and disease process:
embryology of the trunk
In the third week of gestation, formation of the axial skeleton
begins. The bony skeleton, muscles, fascia, and skin are
derived from mesodermal somites bordering the central
notochord. Pluripotent mesenchymal cells differentiate into
fibroblasts, osteoblasts, and chondroblasts and other progeni­
tor cells that will build the tissues of the fetal body. The axial
skeleton consists of skull, vertebral column, ribs, and sternum.
The appendicular skeleton includes the pelvic and pectoral
girdles. The skeleton begins to chondrify in the 6th week of
gestation. The process of ossification can last from a few
months gestation until young adulthood. Progenitor skeletal
muscle cells divide into dorsal (epaxial) and ventral (hypaxial)
divisions along with a corresponding spinal nerve. The exten­
sor muscles of the vertebral column, derived from the epaxial
myotomes, are innervated by posterior rami of the spinal
nerves. All of the other muscles of the trunk are derived from
the hypaxial myotomes and are innervated by the ventral
rami. Most skeletal muscles are fully developed by birth.3
Angiogenesis begins in the 3rd week of gestation. Primor­
dial blood vessels begin to form in the extraembryonic mes­
enchyme of the yolk sac. Mesenchymal cells differentiate into
angioblasts, forming aggregate blood islands. These begin to
coalesce into primitive endothelium. Near the end of the 3rd
week, this same process is evident within the embryo itself,
and by the beginning of the 4th week, the embryo has a
functional circulatory system.3 At birth, the main vessels and
perforators to the skin are present. The entire body is lined by
superficial fascia4 that lies just below the dermis and is sur­
rounded by varying amounts of adipose tissue. It serves to
encase, support, and protect the fatty and muscular layers of
the body and to support the overlying skin in the dynamic
movements of the underlying muscle. In certain areas it is
adherent to the deep fascia or periosteum, and at these places
the body contour is defined by creases and convexities. Where
there are bulges and plateaus the connections between super­
ficial and deep systems are looser. As an individual grows,
vessels stretch from their origins, usually in areas near joints
or fixed fascial planes of the body. Taylor noted that areas that
were mobile had cascades of arterial supply that tended to
originate from the fixed areas distant from the tissue supplied
by the vessel. He asserted that these perforators were present
at birth and grew along the fascial planes and stretched as the
individual grew and developed.2
Back
The back provides support for the head and shoulders while
walking upright. Near the midline, the paraspinous muscles
run in a vertical fashion and are mainly responsible for spinal
support and protection. Moving laterally and superficially,
muscles become broad and are responsible for movement
of neck, shoulders, hips, and extremities. Dense adhesions
between the superficial fascia and the skin of the back prevent
shearing of the tissues. The spine has dense fascia surround­
ing the spinal processes, which attaches to the dermis. This
creates the central midline. There are several notable, bony

218.e1
Historical perspective
Historical perspective
Multiple authors sited in plastic surgical literature have
attempted to classify bone, muscles, fascia, and skin, based on
the vascular supply to these tissues and the flaps that can be
derived from them. Few of these has held more steadfast than
Mathes and Nahai’s classification of the vascular anatomy of
muscles (Fig. 9.1)1 and Ian Taylor’s angiosomes of the skin.2
Today, these authors provide the basis for much of the current
understanding of tissue and vascular anatomy that is the key
to successful plastic and reconstructive surgery.
Fig. 9.1  Mathes and Nahai Classification of the vascular anatomy of muscle. Type I, single vascular pedicle; type II, dominant pedicle(s) plus minor pedicles; type III, two
dominant pedicles; type IV, segmental pedicles; type V, dominant pedicle plus secondary segmental pedicles. (From Mathes SJ, Nahai F. Classification of the vascular
anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981; 67(2):177–187.)
Type I
Type II
Type III
Type IV
Type V

219
Back
muscle (see Fig. 9.3). The superior or Grynfeltt triangle is
created by the 12th rib superiorly, the quadrates lumborum
medially, and the internal oblique laterally. The floor is com­
prised of the transversalis muscle (not shown). No vessels or
named nerves travel through these spaces. The lumbocostoab­
dominal triangle is formed by the external oblique, the serratus
posterior inferior, the erector spinae, and the internal oblique.
Muscles6
The trapezius is a large flat muscle that crosses many joints and
has multiple actions on the neck, back, and shoulder includ­
ing elevation, retraction, and rotation of the scapula. Typically
it is divided into superior, middle, and inferior portions.
Medially it is attached to the spinous processes of C7–T12
vertebrae, the superior nuchal line, and ligamentum nuchae.
Laterally, it attaches to the lateral third of the clavicle, the
medial acromion process, and the scapular spine. This is the
only muscle of the back innervated by a cranial nerve. Upon
exiting the skull, the spinal accessory nerve pierces the sterno­
cleidomastoid muscle and passes through the posterior cervi­
cal triangle. It enters the trapezius muscle 5 cm above the
clavicle, sending a branch to the upper portion of the muscle.
The remainder of the nerve runs caudally along the anterior
border of the muscle until the fibers desiccate inferiorly. The
trapezius receives sensory innervation from cervical nerves
C3 and C4. Typically described, the trapezius has Mathes and
Nahai type II vascular anatomy receiving blood supply from
branches of the transverse cervical artery, which will be
described in greater detail later.
The levator scapulae originates from transverse processes of
C1–C4 and inserts on the superior part of medial border of
scapula. It is innervated by dorsal scapular nerve and spinal
nerves C3 and C4, and its blood supply is via the dorsal
scapular artery. Its main action is elevation of the scapula and
depression of the glenoid.
The Rhomboid major and minor lay between the medial
borders of the scapula to the spinous processes of C7–T5
vertebrae. Their action is to retract the scapula, depress the
glenoid, and fix the scapula to the thoracic wall. They are
innervated by the dorsal scapular nerve, and blood supply is
mainly via the dorsal scapular artery.
The supra and infraspinatus muscles originate in their
respective scapular fossa and insert into the superior and
middle facet of the greater tubercle of the humerus. They are
innervated by the suprascapular nerve and receive blood
supply from the suprascapular and branches of the circumflex
scapular arteries. They act to help abduct the arm and stabilize
the humerus in the glenoid cavity.
The subscapularis originates in the subscapular fossa and
inserts at the lesser tubercle of the humerus. It is innervated
by the subscapular nerve. It serves to medially rotate and
adduct the arm. Its blood supply is via the subscapular artery.
The teres minor originates at the superior lateral border of
scapula and inserts into the inferior facet of greater tubercle
of humerus. It is innervated by the axillary nerve and receives
blood supply via a branch of the circumflex scapular artery.
It assists in lateral rotation of the arm.
The teres major originates at the dorsal surface of inferior
angle of scapula and inserts into the intertubercular groove of
humerus. It is innervated by lower subscapular nerve and
receives blood supply via branches of the circumflex scapular
landmarks in the neck and back region: palpable at the base
of the neck is the vertebra prominens of the C7 spinous
process. The root of the scapular spine is at the level of T3,
and the angle of scapula is at T7. Typically, the spinous process
of T12 is palpable. The bilateral iliac crest forms the hips at
the level of L4. The posterior inferior iliac spine is parallel to
S2 (Fig. 9.2).
The thoracolumbar fascia is the investing fascia of the back.
It encases the paraspinous muscles as well as the quadrates
lumborum. It is continuous with the nuchal fascia of the neck,
attaches medially to the spinous processes of the thoracic
vertebrae, laterally to the angles of the ribs, and inferiorly to
the posterior iliac spine. It is supplied by the lumbar and
thoracic perforators, as well as the distal end arteries of the
superior gluteal artery inferiorly and the thoracodorsal artery
superiorly.5
The broad, flat latissimus muscle can usually be seen on
both sides of the lower midback in thin, muscular individuals.
The posterior axillary fold is formed by its tendon as it crosses
from the back to insert on the humerus. The triangular space
of the posterior axilla is defined by the teres minor superiorly,
teres major inferiorly, and the long head of the triceps laterally
(Fig. 9.3). Through it courses the circumflex scapular artery
and two venae comitantes.
There are two spaces referred to as the lumbar triangle.
These are areas of the back that do not contain all of the
muscular layers. The inferior or petit triangle is bound by the
latissimus medially, the external oblique laterally, and the iliac
crest inferiorly. Its base is comprised of the internal oblique
Fig. 9.2  Surface anatomy and vascular angiosomes of back and buttock. (1)
Transverse cervical, (2) suprascapular, (3) acromiothoracic, (4) circumflex scapular,
(5) posterior intercostals, (6) thoracodorsal, (7) lumbar perforators, (8) lateral
sacral perforators, (9) superior gluteal, (10) deep circumflex iliac, (11) internal
pudendal, (12) inferior gluteal.
1
2
3
4
5
6
7
8
9
10
12
11

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SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
and elevates the ribs during inspiration. The inferior serratus
posterior originates at the spinous processes T11–L3 and the
thoracolumbar fascia and inserts on the inferior border of ribs
9–12. It is innervated by intercostal nerves 9–11 and the sub­
costal nerve and serves to depress the ribs on expiration.
The paraspinous muscles are referred to as the intrinsic
muscles of the back, spanning from occiput to sacrum. They
are intricate muscles that interconnect the spinous and
transverse processes of the vertebral bones with the ribs and
primarily support and protect the spinal column. Their move­
ments include spinal rotation and lateral bending of neck.
Innervation is via dorsal primary rami of the spinal nerves.
There are three layers of the paraspinous muscles: a deep
layer referred to as the transversospinal group (semispinalis,
multifidus, rotators); an intermediate layer, the erector spinae
group (spinalis, interspinalis, intertransverse, longissimus,
and iliocostalis); and a superficial layer, the spinotransverse
and thoracodorsal arteries. Its action is to adduct and medi­
ally rotate the arm.
The latissimus muscle originates at the medial attachment
to spinous processes of T7–T12, thoracolumbar fascia, and the
iliac crest. It inserts on the intertubercular groove of the
humerus. It is innervated by thoracodorsal nerve and func­
tions to extend, adduct, and medially rotate the shoulder. The
main vascular pedicle is the thoracodorsal artery, with seg­
mental blood supply arising from intercostals and lumbar
perforators medially. The latissimus dorsi is described as
Mathes and Nahai type V muscle.
The serratus posterior (superior and inferior) are extrinsic
muscles of back that lie in an intermediate layer between
paraspinous and more superficial latissimus and trapezius
muscles. The superior portion of serratus posterior originates
at the spinous process of C7–T3 and inserts on the superior
border of ribs 2–5. It is innervated by intercostal nerves 2–5
Fig. 9.3  Superficial and deep musculature of the back showing vascular relationships. (a) The triangular space is defined by the teres minor, teres major, and long head of
the triceps muscle; (b) lumbar triangle of petit; (c) lumbocostoabdominal triangle.
Axillary artery
Thoracodorsal artery
Thoracodorsal artery
Angular branch
Scapular bone branches
Suprascapular artery
Suprascapular artery
Thyrocervical trunk
Transverse cervical artery
(superficial branch)
Transverse cervical artery
Transverse cervical artery
(deep branch)
Circumflex scapular
artery
Circumflex scapular
artery
Serratus branch
Serratus branch
Lateral branch
Axillary artery
Trapezius
Levator scapulae
Rhomboid major
Rhomboid minor
Supraspinatus
Infraspinatus
Teres major
Teres minor
a
b
c
Latissimus
dorsi
Serratus posterior
inferior
Serratus anterior
External oblique
Deltoid
Long head triceps
Gluteus maximus
Paraspinous
Transverse branch

221
Chest
group (splenius cervicis and capitis). The blood supply to
these muscles is segmental stemming from posterior branches
of intercostals, lumbar, and sacral arteries, classifying these
muscles as Mathes and Nahai type IV.
Vascular anatomy
The suprascapular artery is a branch of the thyrocervical trunk.
It travels anterior to the trapezius along the shoulder and
supplies the upper scapula and the scapular muscles.
The dominant blood supply to the trapezius is via branches
of the transverse cervical artery. Originating from the thyrocer­
vical trunk, it passes through the posterior triangle of the
neck to the anterior border of the levator scapulae muscle.7
Here, it divides into deep and superficial branches. Upon
entering the muscle the superficial branch divides again into
an ascending and descending branch. It is the descending
branch, sometimes referred to as the superficial cervical artery
(SCA), which supplies the middle and lateral portions of the
trapezius. Once the deep branch separates from the superfi­
cial branch, it courses below the levator scapulae to the
undersurface of the rhomboids. A perforating branch emerges
from between the rhomboid muscles and becomes the main
supply to the trapezius inferior to scapular spine (see Fig.
9.3). The deep branch, also referred to as the dorsal scapular
artery (DSA), supplies the lower middle and inferior portion
of the trapezius and the skin paddle above and lateral to it
overlying the latissimus. Through the years there have been
many anatomic studies attempting to define the blood supply
to the trapezius. Some of the confusion arises simply from
nomenclature. In 2004, Hass published a large cadaver study,
finding, in nearly 45% of specimens, the DSA arose from the
subclavian artery or costocervical trunk. In the remaining
55%, the DSA formed a trunk with the SCA and/or the
suprascapular artery. The trapezius also receives segmental
blood supply medially from the intercostal arteries 3–6,
leading some investigators to classify this muscle as Mathes
and Nahai type V.8
The subscapular artery arises from the third portion of the
axillary artery and branches into the circumflex scapular and
the thoracodorsal arteries. Occasionally the circumflex scapu­
lar arises directly from the axillary artery. The circumflex scapu­
lar artery passes through the triangular space and gives off
perforating branches to the superior lateral border of the
scapula. There is rarely a defined medullary branch; however,
a segment of bone measuring 10–14 cm along the lateral
border can usually be harvested reliably on these small per­
forators.9 The main artery goes on to divide into a small
ascending branch, which is occasionally absent, and more
robust transverse and descending branches. These supply the
scapular and parascapular flaps, respectively. These arteries
run in the subcutaneous plane and are paralleled by two
venae comitantes. The venous outflow follows the subscapu­
lar system and eventually drains into the axillary vein.10
After branching from the subscapular artery, the thoracodor­
sal artery passes along the deep surface of the latissimus and
continues caudally 1–4 cm posterior to the lateral border of the
muscle. As the artery descends, a branch or branches supply
the lower portion of serratus anterior. After this, it divides
into a lateral (or descending) branch and a transverse (or
horizontal) branch. Angrigiani described three musculocuta­
neous perforators that reliably left the lateral branch of the
thoracodorsal artery piercing the latissimus muscle and sup­
plying the skin and subcutaneous tissue of the lateral infra­
scapular back. The proximal perforator exits 8 cm below the
posterior axillary fold and 1–4 cm posterior to the lateral
border of the muscle. Other smaller perforators were found
along a similar trajectory inferiorly and obliquely located
along the lateral border of the latissimus (see Fig. 9.3).11
Seneviratne et al. described the angular artery as a branch
from the subscapular system that supplied the lower lateral
segment and the angle of the scapula. It can arise from the
latissimus or serratus branch of the thoracodorsal artery or at
a trifurcation with both vessels. From its origin to where it
penetrates the bone measures approximately 7 cm and is reli­
ably found between the teres minor and serratus anterior on
its way to the dorsal surface of the scapular angle. This artery
allows a strip of bone up to 3 cm of the lateral scapular angle
and 6 cm of the vertebral surface to be harvested as a compos­
ite graft with muscle, fascia, or skin.12
The intercostal and lumbar arteries supply much of the skin
and musculature of the midback. Perforators emerging from
these vessels pass through the paraspinous muscles in three
adjacent columns that parallel the spinous processes laterally
at 3, 5, and 8 cm. These segmental perforators have longitudi­
nal anastomotic connections to one another.13
The superior gluteal artery arises from the internal iliac artery
and passes through the greater sciatic foramen. At approxi­
mately 6 cm below the PSIS and 4–5 cm lateral to the sacral
midline, the artery passes between the gluteus medius and
piriformis muscle to enter the gluteus maximus. It sends
nutrient branches to the muscle and continues to the overly­
ing skin and soft tissue. The inferior gluteal artery also arises
from the internal iliac artery. It passes through the lesser
sciatic foramen, inferior to the piriformis muscle, to supply
the lower gluteal skin and soft tissue (Fig. 9.4).
Chest
The clavicle and manubrium create the cranial border of the
chest. The midpoint of the clavicle defines a plumb line drawn
down the anterior chest and is referred to as the midclavicular
line. The xiphoid and the synchondrosis of ribs 7–10 create
the caudal border of the chest. The diaphragm is attached to
the posterior surfaces of the xiphoid process and the lower six
ribs and costal cartilages. Laterally, the chest is bordered by
the anterior axillary fold, which is created by the pectoralis
major tendon as it inserts on the humerus (Fig. 9.5). The del­
topectoral triangle is pierced by the cephalic vein as it joins the
axillary vein, bound medially by the clavicle, superiorly by
the deltoid, and inferiorly by the pectoralis major muscle.
Spanning the triangle and coursing beneath the pectoralis
major is the clavipectoral fascia, a thick, dynamic fascial sling.
Lateral to the triangular space is the quadrangular space of the
axilla. Its boundaries include the teres major inferiorly, teres
minor and subscapularis superiorly, the long head of triceps
medially, and the surgical neck of the humerus laterally.
Through it passes the posterior circumflex humeral artery and
axillary nerve.5
The nipple–areolar complex is located slightly lateral to the
midclavicular line and at or near the fourth rib. Innervation
of the nipple is by the fourth intercostal nerve, and blood

222
SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
nodes drain the medial mammary gland and the medial chest
wall.
Muscles6
The pectoralis major is a fan-shaped muscle with a sternal and
a clavicular origin. The middle and inferior portion originate
at the sternum and costal cartilages of ribs 2–6. The clavicular
head originates at the medial clavicle. The muscle inserts into
the lateral edge of the intertubercular groove of the humerus
(Fig. 9.7). It is innervated by the lateral and medial pectoral
nerves. Its action is to adduct and medially rotate the humerus
and draw the shoulder anteriorly. The blood supply is Mathes
and Nahai type V. The dominant pedicle is the pectoral branch
of the thoracoacromial trunk. Secondary blood supply is via
the internal mammary artery perforators along its medial
border. Laterally, it receives perforators from the thoracic
intercostal vessels and some branches from the lateral thoracic
artery.
The pectoralis minor is a flat fan-shaped muscle that sits
below the pectoralis major. It originates lateral to the costal
cartilage of ribs 2–5 and inserts as the coracoid process of the
scapula. The main innervation is by medial pectoral nerve and
occasionally by a small branch of the lateral pectoral nerve.15
Along with serratus anterior and the rhomboids, the pectoralis
minor stabilizes the scapula against the chest wall. The blood
supply is variable but has been reported to arise from three
sources. The thoracoacromial and lateral thoracic arteries
supply is via perforators from the internal mammary artery
at the fourth rib as well as the intercostal arteries and the end
arteries of the thoracodorsal and thoracoacromial arteries. For
females, depending on the size, shape and ptosis of the breast
the nipple could be any distance from the fourth rib, but the
neurovascular supply remains consistent. The milk ridge
refers to a primitive line of ectodermal tissue extending from
the axilla to the groin. At any point along this line, breast and
nipple tissue can develop. During embryologic development
this line appears and subsequently involutes; however, rem­
nants of this tissue can give rise to supernumerary nipples or
ectopic breast tissue.14
The superficial fascia that lies just below the skin and
subcutaneous tissue is present in the chest as it is in the rest
of the body. Over the area of the breast this fascia splits into
a superficial and a deep layer (Fig. 9.6). These layers support
the breast parenchyma and glandular tissue against the chest
wall. Running perpendicular between these two layers and
into the deep fascia of the chest are Cooper’s ligaments. These
suspensory ligaments support the breast parenchyma yet
allow breast mobility. They stretch with growth of the breast
during puberty, pregnancy, and weight changes. Loss of
elastic fibers in Cooper’s ligaments leads to breast ptosis. The
superficial fascia of the chest transitions into Scarpa’s fascia
as it enters the abdomen below the level of the bony thorax.
There are 20–30 axillary lymph nodes draining most of the
mammary gland and the anterolateral chest wall as well as
the posterior thoracic and scapular regions. The parasternal
Fig. 9.4  Superficial and deep musculature of the buttock showing vascular relationships of superior and inferior gluteal artery.
Superior gluteal
perforators
Inferior gluteal
perforators
Gluteus medius
Gluteus medius
Gluteus minimus
Superior gluteal artery
Inferior gluteal artery
Gluteus maximus (reflected)
Piriformis

223
Chest
4–6. The medial chest wall is supplied by branches of the
internal mammary artery. The lateral and superior chest wall
is supplied by branches of the subclavian and axillary vessels.
The internal mammary artery branches from the subclavian
artery and runs 1–2 cm lateral to the sternum on the inner
surface of the thoracic cavity. Perforating vessels arise at each
intercostal space 2–6 and pass superior to the rib margin.
These perforators then pass through the pectoralis major at its
sternal origin and supply the anterior chest wall and the
medial breast parenchyma. Typically the perforator from the
2nd or 3rd interspace is larger than the others and is referred
to as the principal perforator.18
The axillary artery begins as the subclavian artery passes
out of the chest past the first rib and ends as it enters the arm
passing the teres major, becoming the brachial artery. It is
classically divided into three parts having specific branches
originating from each. The first part is medial to the pectoralis
minor tendon as it inserts onto the acromion, giving rise to
the superior thoracic artery. The second part is behind the
tendon and gives rise to the thoracoacromial trunk and the
lateral thoracic artery. The third part is lateral to the tendon
and gives off the subscapular artery and the anterior and
posterior humeral circumflex arteries (see Fig. 9.7).
The superior thoracic artery is a small vessel that courses
medially to the pectoralis minor. It occasionally gives off a
muscular branch along the intercostal muscles of the 1st and
2nd rib. It has anastomosis with perforators from these ribs.
provide the main and the most consistent blood supply. The
superior thoracic artery, a direct branch of the axillary artery,
has also been reported to supply this muscle.16 Mathes and
Nahai originally classified this muscle as class III.
The serratus anterior lies below and lateral to the pectoralis
major on the anterolateral aspect of the thorax. It originates
on ribs 1–9 and inserts on the anterior surface of the medial
border of the scapula. Its action is to protract and superiorly
rotate the scapula, holding it against the chest wall. Innerva­
tion is via the long thoracic nerve, which runs superficial to
the muscle along its course.17 The serratus has a dual blood
supply to its upper and lower muscular slips from the lateral
thoracic and thoracodorsal system, classifying it as Mathes
and Nahai type III.
The intercostal muscles include the external, internal, and
innermost intercostal muscles, which are layered muscles
between each rib. They are layered such that fibers from each
pass in opposite directions aiding in expansion and compres­
sion of the ribs during respiration. The neurovascular bundles
supplying these muscles run on the inferior surface of the rib
between the internal and innermost intercostal muscle.
Vascular anatomy
Blood supply to the skin and soft tissues of the anterior chest
is derived from a highly interconnected network of named
vessels and choke anastomoses. The lateral and inferior pec­
toralis margins are supplied by perforators from the posterior
intercostal arteries and the anterior intercostal arteries of ribs
Fig. 9.5  Surface anatomy and vascular angiosomes of the chest and abdomen.
(1) Clavicular branch thoracoacromial trunk, (2) acromial branch thoracoacromial
trunk, (3) deltoid branch thoracoacromial trunk, (4) internal mammary perforators,
(5) pectoral branch thoracoacromial trunk, (6) superior epigastric, (7) intercostal
perforators, (8) deep inferior epigastric, (81) superficial inferior epigastric (overlying
angiosome of DIEP) (9), (10) deep circumflex iliac, (11) superficial circumflex iliac.
9
10
11
8
7
6
5
4
1
3
2
81
Fig. 9.6  Superficial (green) and deep (gray) fascia of the chest wall and breast.
(A) Pectoralis major. (B) Pectoralis minor.
A
B

224
SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
vessels enter the underlying rib and periosteum allowing the
muscle to be harvested with bone for composite flaps. Varia­
tions in blood supply to this muscle have been reported in
that the lateral thoracic artery occasionally supplies the lower
portion of the muscle.20 Perforators from the lateral thoracic
artery supply the skin and subcutaneous tissue of the supero­
lateral thorax and lateral breast parenchyma.
The subscapular artery leaves the third portion of the axil­
lary artery and within 1–4 cm gives rise to circumflex scapular
and the thoracodorsal arteries. The prior passes through the
triangular space of the back. The thoracodorsal proceeds
caudally, providing a branch to the serratus anterior, then
passes to the undersurface of the latissimus dorsi muscle. The
serratus branch runs superficial to the muscle along with
the long thoracic nerve and provides segmental branches to
the lower five slips of that muscle.
The thoracoacromial trunk gives rise to four branches: the
clavicular, acromial, deltoid, and pectoral. The pectoral branch
supplies the pectoralis major muscle and the superior portion
of pectoralis minor. It originates below the pectoralis minor,
passing medially and penetrating the clavipectoral fascia
6–10 cm lateral to the sternoclavicular joint. As it travels along
the undersurface of the pectoralis major, small perforating
branches pass through the muscle and supply the overlying
skin of the superior and lateral chest. The pectoral artery is
paralleled by two venae comitantes, which coalesce near the
clavicle and enter the axillary or subclavian vein as a single
vessel. This is usually within 1–2 cm of where the thoracoac­
romial trunk arises from the second portion of the axillary
artery.19
The lateral thoracic artery supplies the upper four to five
slips of the serratus anterior muscle. Smaller penetrating
Fig. 9.7  Superficial and deep musculature of the chest and upper abdomen showing vascular relationships.
Thyrocervical trunk
I
I
II
II
III
III
Transverse cervical artery
Suprascapular artery
Superior thoracic
artery
Thoracoacromial trunk
Pectoral branch
Acromial branch
Deltoid branch
Clavicular branch
Lateral thoracic artery
Subscapular artery
Thoracodorsal artery
Axillary artery
Perforators
Serratus branch
Internal mammary artery
Superior epigastric artery
1st part
2nd part
3rd part
Strap muscles
Sternocleidomastoid
Trapezius
Deltoid
Pectoralis major
Pectoralis minor
Pectoralis minor tendon
Serratus anterior
Teres major
Subscapularis
Latissimus dorsi
Biceps brachii
External oblique
Internal oblique
Transversus abdominus
Superior thoracic
Lateral thoracic
Intercostal
Internal mammary
Pectoral branch
Rectus abdominus
g
g
h
h
i
i
j
j
k
k