The challenge of reconstructing the sole of the foot relates to the distinct anatomy and microarchitecture of the plantar surface. First, the weight-bearing foot is capable of withstanding significant compressive forces because of its thickness and deformability. The glabrous skin of the plantar surface consists of a substantial epidermal layer—approximately 1.4 mm thick compared to 0.1 mm in other anatomical regions.1 Numerous subcutaneous lobules of adipose tissue act to absorb and redistribute compressive forces.2 Second, the epidermal-dermal junction is firmly tethered to the plantar aponeurosis by numerous vertical fibrous septa, which act to resist shearing forces tangential to the skin surface. Third, the plantar surface provides a protective sensation capable of inducing avoidance behavior, particularly with regard to repositioning while standing and redistribution of load bearing during ambulation.3 Lastly, the contour and compactness of the plantar surface are important cultural considerations, as they pertain to the ability to wear conventional footwear.
Common causes of acute plantar injury include trauma4–6 and burns.7 Often, secondary reconstruction is necessary to correct the late complications of the injured extremity.8,9 Chronic trophic or neuropathic ulceration is another significant cause of pressure-related plantar defects and may be attributable to diabetes, leprosy, acquired or congenital spinal cord abnormalities, and other forms of polyneuropathy.10
When reconstruction is pursued, the primary aim is to establish durable soft-tissue coverage and provide the patient with a reasonable chance at weight-bearing and independent ambulation. Despite being a well-studied topic in plastic surgery, no single coverage option meets the needs of all patients and defects. Instead, the planned reconstruction must take into account the size, location, depth, and cause of the defect. Patient factors—such as presence of comorbidities, neurovascular status, and adjacent tissue quality—are also of considerable importance. A systematic review was performed to identify studies describing techniques, relevant modifications, and outcomes for reconstruction of the plantar surface.
PATIENTS AND METHODS
A comprehensive literature search was performed to identify relevant articles related to reconstruction of the plantar surface (Fig. 1). Three electronic databases—PubMed, Embase, and Scopus—were queried through January of 2017. Search terminology consisted of ‘Foot’ and ‘Reconstruction’ and ‘Surgery’ and either ‘Plantar’ or ‘Heel’ or ‘Sole’ or ‘Bottom.’
All articles were manually sorted and their abstracts screened for exclusion criteria. Duplicate and non-English articles were excluded without further review. Studies that did not describe a surgical intervention, plantar soft-tissue defect, or reconstructive outcome, and nonclinical study designs (e.g., cadaveric, animal, or in vitro models) were excluded. Nonoriginal articles, such as letters, discussions, reviews, meta-analyses, and abstract-only publications were reviewed for background, but were not included in the analysis. Case reports and low-volume case series were included, but were identified as such.
Included studies were subcategorized by reconstructive method: skin grafts and dermal substitutes, local and regional flaps, and free tissue transfer. Extracted data included patient age, follow-up duration, reconstruction method, flap tissue composition, defect location, procedural variation, complication type and rate, and sensory analysis.
A total of 3046 articles were identified on initial query of the databases. After exclusion of duplicate records, 1624 articles were available for review. Non-English, nonoriginal, and nonrelevant studies were then excluded, and 204 clinical studies and 76 case reports were included in the final analysis. Only studies with more than five patients were used to determine rates of complication. Wound healing complications consisted of infection, hematoma, or delayed wound healing in the early postoperative period. The systematic review followed the guidelines as detailed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.11
A total of 280 unique articles were included for analysis, comprising 2684 individual soft-tissue reconstructions of the plantar surface (Table 1). Of the articles reviewed, 37 studies (10 percent) described a skin grafting technique, 53 percent (162 studies) described a local or regional flap, 29 percent (98 studies) described free tissue transfer, and 4 percent (13 studies) described multiple reconstructive methods. (See Table, Supplemental Digital Content 1, which lists all included studies describing split- and full-thickness skin grafts, dermal grafts, dermal substitutes, and fat graft techniques for resurfacing the plantar foot, http://links.lww.com/PRS/D388. See Table Supplemental Digital Content 2, which lists all included studies describing local, regional, and distant flaps for resurfacing the plantar foot, http://links.lww.com/PRS/D389. See Table, Supplemental Digital Content 3, which lists all included studies describing free tissue transfer for resurfacing the plantar foot, http://links.lww.com/PRS/D390.)
Collectively, isolated heel defects were the most frequently reconstructed subunit of the plantar foot when specified (74 percent). The midfoot was the least frequently reconstructed area (4 percent for isolated injuries and 3 percent for combined injuries involving the forefoot or hindfoot).
Grafts were more commonly split-thickness (62 percent) rather than full-thickness (6 percent) or dermal (6 percent). These were used to reconstruct a variety of plantar defects, but were used for the forefoot in greater proportion. For local, regional, and free flap–based reconstructions, suprafascial and fasciocutaneous flaps were the most commonly used tissue composition, making up 82 percent and 57 percent of flap types, respectively. Muscle-only flaps were more often described in studies using free tissue transfer when compared to those using local and regional flaps (29 percent versus 9 percent). Osteocutaneous, fascia-only, and chimeric flaps were rarely described.
Skin Grafts and Dermal Substitutes
Split- and Full-Thickness Grafts
Autografting is a long-practiced method of plantar reconstruction (Fig. 2) that is likely more commonly used than evidenced by the literature (Table 2). The decision to skin graft rather than pursue a technique higher on the reconstructive ladder is not always clearly defined.12,13 Several studies claim that the use of glabrous skin from the adjacent weight-bearing surface is superior to nonglabrous sources of tissue,14,15 as it reduces the risk of painful buildup of hyperkeratotic material at the skin graft margin, contracture, and subgraft stenosis.14
Full-thickness skin grafts are can also be harvested from the glabrous instep or from thinning and reinset of an avulsed portion of plantar skin. In the largest study of full-thickness skin grafting to the plantar surface, 81 percent of grafts were completely incorporated at the end of the follow-up period.16 Furthermore, the application of cultured autologous keratinocytes to the plantar surface has proven beneficial in the treatment of diabetic foot ulcers.17,18
Dermal grafting involves harvesting a layer of deepithelialized dermal tissue, which can be skin grafted after a period of incorporation19 or left to reepithelialize by secondary intention.20 The advantage of this method is that dermal elements of glabrous plantar skin can be transferred with minimal donor-site morbidity.
Advances in biomaterials have allowed for the creation of immunologically inert skin substitutes and engineering of autologous skin grafts. These scaffolds provide both growth factor and/or substrate for tissue regeneration. The most commonly used allografts include Apligraf (Organogenesis, Inc., Canton, Mass.)21–23 and acellular dermal matrix (Musculoskeletal Transplant Foundation, Edison, N.J.).24
Local and Regional Flaps
Reverse Sural Flap
The reverse sural flap is a well-studied method of providing coverage for defects of the lower one-third of the leg, ankle, and foot25,26 (Table 3). Limitations regarding plantar defect coverage using the reverse sural flap relate to its reach, tethered by its perforator. More distal reconstructions are achieved by harvesting from the contralateral calf as a version of a cross-leg flap,27 draping the pedicle across the exterior of the lateral ankle and foot with delayed division,28 or design along the axis of the lesser saphenous vein with its accompanying arteries providing the blood supply.29
Flaps as large as 338 cm2 can be obtained by extending the flap proximally to just distal of the popliteal crease,30 and transversely to the midlateral line on either side of the lower leg.31 A fascia-only flap can be elevated to provide low-profile vascularized tissue,32,33 or partial gastrocnemius muscle can be included to add additional bulk.34 Improved sensation can be achieved by means of coaptation of the proximally dissected lateral sural nerve to the common sural distally.32,35 Two-point discrimination in these studies is noted to approach 20 mm; however, approximately one-third of studies mention recovery of at least a deep or protective sensation regardless of neurotization.
The sural artery flap is prone to edema and venous congestion, the incidence of which can be partially decreased with flap delay.36,37 Partial flap loss can occur at a rate as high as 22 percent38 with the rate of other wound healing complications ranging between 0 and 36 percent.
The instep flap is another workhorse flap that provides glabrous tissue from the non–weight-bearing medial plantar region for the resurfacing of adjacent defects (Fig. 3). The majority of described defects were present exclusively on the hindfoot (92 percent), but a number of studies demonstrated effective coverage of the midfoot39 and forefoot.40 The dissection can be performed in a way that includes abductor hallucis41 or flexor digitorum brevis42 for added bulk. The instep flap is generally described for coverage of smaller defects, although flaps as large as 90 cm2 have been reported.43
An advantage of the instep flap is the routine inclusion of the medial plantar nerve with the flap, thus providing immediate sensation.44 Qualitative studies analyzing the neurologic properties of the instep flap have demonstrated the preservation of sensation in the flap.45–47 Partial flap loss occurred infrequently (0 to 15 percent).46 The occurrence of other wound healing complications ranged between 0 and 35 percent.46,48–50
Local Suprafascial Flaps and Tissue Expansion
Reported local tissue rearrangements for plantar defects include V-Y advancement,51–53 rotational,54,55 transposition,55 “reading man,”56 unilobed and bilobed cutaneous flaps,57–59 and others. Generally, local plantar flaps are appropriate for small defects.
Immediate, intraoperative expansion is achieved by passing needles through the dermis of the wound margin and using suture or dental wire to progressively approximate the edges.60,61 More traditional expansion using an internal tissue expander device has also been reported by expanding ankle tissue.62
Intrinsic Muscle Flaps
Intrinsic muscle flaps are infrequently used for plantar reconstruction, because of the availability of other suprafascial and fasciocutaneous reconstructions and the resultant loss of function with the sacrifice of a muscle. Concerns regarding postoperative gait abnormality preclude the routine use of these muscle flaps.63
Toe Island and Fillet Flaps
The toe island flap is a small cutaneous flap based on the proper digital artery. Although mostly used to resurface forefoot ulcerations (79 percent), several instances of islanded toe flaps are reported for coverage of midfoot64 and hindfoot defects.65 This is achieved by dissecting the pedicle back to the lateral or medial plantar artery, depending on the donor toe selected.
Flap size is limited and only suitable for small defects. A unicortical portion of metatarsal can be incorporated into the flap design for reconstructing osseus defects.66 The digital nerve is routinely included with the vascular pedicle to provide immediate sensation with the transferred skin, with two studies describing normal sensibility postoperatively.67,68 There were no instances of partial flap necrosis, although wound complications varied widely from series to series and are noted to be between 068 and 50 percent.69
The filleted toe flap, like the toe island flap, relies on perfusion from the digital arteries. In this method, a functionless toe undergoes removal of its skeletal elements for coverage of a plantar defect proximal to the donor site. All described reconstructions focused on resurfacing the forefoot. The size of the fillet flap depends entirely on the digit(s) sacrificed.70 Except for a single case of complete flap necrosis,71 complications of fillet flaps were uncommon.
Other Local and Regional Flaps
A number of other local and regional flaps have been described to reconstruct the plantar surface, although with limited frequency compared with other methods of reconstruction. These include the medial crural,72,73 cross leg,74 ipsilateral thigh,75 dorsalis pedis,76 lateral supramalleolar,77 lateral calcaneal,78 pedicled fibula,79 peroneus brevis,80,81 and tibialis anterior flaps.82
Free Tissue Transfer
In the setting of acute trauma, the plantar surface may be avulsed. If the posterior tibial vessels or their more distal branches can be located and are deemed viable, primary revascularization may be attempted. Unfortunately, heel pad replantation carries a substantial risk of failure and is generally attempted when the avulsion occurs in the subfascial plane.4,83
Suprafascial and Fasciocutaneous Flaps
The use of free tissue transfer for lower extremity reconstruction is particularly useful for large and three-dimensional defects, distal wounds, secondary reconstruction, exposure of vital structures, and osteomyelitis of the foot.84,85 Suprafascial and fasciocutaneous flaps made up the majority of reported microvascular reconstructions (57 percent of free flap reconstructions overall) (Table 4). The relevant features of these free flaps are the ability to monitor a skin paddle, the variable thickness and pliability of transferred tissue, the ability to “bank” defatted plantar skin for delayed transfer,86,87 and the possibility of obtaining fine cutaneous sensibility by primary coaptation of donor nerve.46,47,88–91 Deep pressure sensation is commonly reported regardless of flap type92; however, fine touch and two-point discrimination are possible with cutaneous-based flaps when primary neurorrhaphy is performed. Whether improved sensation correlates with decreased rates of pressure ulceration is debatable.46,82
The anterolateral thigh (Fig. 4) and radial forearm flaps were the most frequently reported free flaps by a large margin. The anterolateral thigh flap is generally bulky, but may be thinned to 4 to 6 mm without an increased risk of flap necrosis.89 The cutaneous paddle of the anterolateral thigh flap has a maximum reported area of 375 cm2 in the plantar literature.93 The surface of the anterolateral thigh flap may also be split on its individual perforators for improved contouring and coverage of complex plantar defects.94 Bulk can be added by inclusion of vastus lateralis95 or tensor fasciae latae.90
The radial forearm flap is thin and pliable and generally does not require secondary debulking to wear normal footwear. Like the anterolateral thigh flap, the radial forearm flap can be harvested with a large surface area.96 Both the anterolateral thigh and radial forearm flaps may be elevated as neurocutaneous flaps with inclusion of the lateral femoral cutaneous nerve93,95,97 and medial96,98 or lateral antebrachial cutaneous nerves.99,100
The medial plantar flap can also be harvested from the contralateral foot for microvascular anastomosis. Again, the advantage of this flap is the inclusion of thick plantar skin with its dense fibrous septa.101,102 The size of this flap can be expanded by extension onto the medial and dorsal aspect of the foot.103
Other fasciocutaneous free flaps include temporalis,104 scapular/parascapular,105,106 lateral arm,107 deltoid,108,109 dorsalis pedis,110 intercostal artery perforator,111 medial sural artery perforator,112 lateral calcaneal,113 saphenous,114 posteromedial thigh,115 anteromedial thigh,116 ulnar forearm,117 and fillet of foot flaps.118
Overall, fasciocutaneous free flaps have rates of partial and complete flap necrosis similar to those of fasciocutaneous reconstruction of other regions. Wound healing complications range from 0 to 50 percent, but do not seem to be related to any single reconstructive method.
Muscle and Musculocutaneous Flaps
Free muscle flaps have historically been regarded as superior to fasciocutaneous flaps for reconstruction of lower extremity wounds. This was based in part on earlier clinical studies comparing flap types,114,119 and experimental data demonstrating the superior vascularity,120,121 cellular contribution to fracture healing,122–124 and immunologic properties of muscle flaps.125,126 More recent trials have concluded that there is no statistical difference in outcomes between flap types.125–128
In this review, the latissimus dorsi was the most frequently reported muscle-based flap (Table 5). The latissimus was the largest flap129 and can provide total plantar coverage if necessary (Fig. 5). Even larger surface areas are possible if serratus muscle is included.129 It may be raised with a cutaneous paddle130 or grafted primarily. Other muscle flaps reported in the literature include rectus abdominis,131,132 gracilis, serratus,109,133 tensor fasciae latae,134 biceps femoris,135 and medial triceps brachii.136
Osteocutaneous and Chimeric Flaps
Reconstructions for plantar defects with deficient calcaneal bone may be raised as composite flaps with any combination of bone, muscle, fascia, and/or skin. This is most often achieved using a deep circumflex iliac artery flap with tricortical iliac crest.137–139 Sartorious tendon may also be included for reconstruction of Achilles tendon defects.140 Alternatively, free fibular flaps have been used to restore the bony architecture of the foot as well.141
Lastly, the thoracodorsal artery perforator flap is a fasciocutaneous flap with chimeric options that may be used to reconstruct extensive and composite defects of the sole.142 Several articles describe the thoracodorsal artery perforator flap with inclusion of partial latissimus dorsi,143 serratus fascia,144 or scapula145 on a separate pedicle for improved resurfacing of compound plantar defects.
Durability of Plantar Reconstruction
The ability of a reconstructed plantar surface to withstand compressive and shearing forces is a primary goal of repair. Despite progressive weight-bearing protocols, off-loading inserts, and counseling regarding avoidance of static, unrelieved pressure, breakdown can still occur. If ulceration progresses, secondary reconstruction or even amputation may be necessary. For skin graft– and dermal substitute–based reconstructions, the time to ulceration is much shorter than for fasciocutaneous and muscle-based flaps (Table 6). Overall, the mean rate of ulceration is 6 to 11 percent; however, individually reported rates vary widely from study to study.
Selecting a Reconstructive Method
Jeng and Wei state that the question of which technique is best for plantar reconstruction “resolves itself not into a measure of method but rather of the surgeon’s ability to select the right method.”4 A comprehensive algorithm for selecting the appropriate reconstructive technique is presented (Fig. 6). These approaches to resurfacing the plantar foot represent a culmination of our institutional experience, existing algorithms,4,12,84 and evidence as listed in the above discussion.
Despite the vast number of plantar reconstructions reported in recent decades, few sizable studies exist, and rates of complication vary widely even for identical flap types. This is especially true for studies describing long-term outcomes. No single reconstructive method meets the needs of all patients and defects. Instead, stable, functional, and aesthetic coverage of the sole of the foot can be achieved through a number of surgical means. As is the paradigm in the majority of reconstructive operations, each case should be evaluated individually and the surgical method should be chosen according to the location and requirements of the defect, available donor sites, and surgeon preference and experience.
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108. Russell RC, Guy RJ, Zook EG, Merrell JC. Extremity reconstruction using the free deltoid flap. Plast Reconstr Surg. 1985;76:586–595.
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Coding perspective provided by Dr. Raymond Janevicius is intended to provide coding guidance.
The following Current Procedural Terminology codes are used in plantar reconstruction:
- 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/ or feet; defect 10 cm2 or less
- 14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/ or feet; defect 10.1 cm2 to 30.0 cm2
- 14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 cm2 to 60.0 cm2
- +14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 cm2, or part thereof
- 14350 Filleted finger or toe flap, including preparation of recipient site
- 15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 cm2 or less
- +15121 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 cm2
- 15135 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 cm2 or less
- +15136 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 cm2
- 15240 Full-thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 cm2 or less
- +15241 Full-thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 cm2, or part thereof
- 15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 cm2; first 25 cm2 or less wound surface area
- +15276 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 cm2; each additional 25 cm2 wound surface area, or part thereof
- 15277 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 cm2
- +15278 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 cm2; each additional 100 cm2 wound surface area, or part thereof
- 15738 Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
- 15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel
- 15756 Free muscle or myocutaneous flap with microvascular anastomosis
- 15757 Free skin flap with microvascular anastomosis
- 20955 Bone graft with microvascular anastomosis; fibula
- 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe
- 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest
- 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal
- Split- and full-thickness grafts 15120, +15121, 15240, +15241
- Dermal grafting 15135, +15136
- Dermal substitutes 15275, +15276, 15277, +15278
- Reverse sural flap 15738
- Instep flap 15738
- Local suprafascial flaps 14040, 14041, 14301, +14302
- Intrinsic muscle flaps 15738
- Toe island flap 15740
- Toe fillet flap 14350
- Free suprafascial and fasciocutaneous flaps 15757
- Free muscle and musculocutaneous flaps 15756
- Osteocutaneous flaps 20969, 20970, 20972
- Free fibular flap 20955
Disclosure: Dr. Janevicius ([email protected]) is the president of JCC, a firm specializing in coding consulting services for surgeons, government agencies, attorneys, and other entities.