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.
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.
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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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 (firstname.lastname@example.org) is the president of JCC, a firm specializing in coding consulting services for surgeons, government agencies, attorneys, and other entities.