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Soft Tissue Coverage for the Diabetic Foot

Scott L. Hansen, M.D.Chief, Plastic and Reconstructive Surgery

San Francisco General Hospital

Diabetic foot wounds/ulcers• Neuropathy

– Sensory: loss of protective sensation– Motor: alteration in foot mechanics– Autonomic: dry, cracked skin

• Decreased immune response– Infection

• Peripheral vascular disease– Local hypoxia– **Can’t reconstruct until adequate

perfusion!

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General Management

• Staged debridement's with Vascular, Orthopaedic and Podiatric Surgery• Assess components of defect• Continue until wound clean • Amt. of debridement depends on perfusion

• Wound VAC used as bridge• Amputation vs. Limb salvage vs. preservation

of length

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What we are trying to avoidHansen 2014

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What we are trying to avoidHansen 2014

Result = Amputation

Wound Analysis• Location

• Hindfoot/Midfoot/Forefoot

• Wound size• Components of wound

– Skin -Nerve- Subcutaneous tissue -Cartilage– Muscle -Bone– Vessels

• Etiology• Pressure, non-compliance

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Reconstructive LadderHansen 2014

Healing / Secondary Intention

• Advantage– pulls “like” tissue into wound

• Disadvantage– duration of healing

• Consider for smaller wounds

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Split-Thickness Skin GraftHansen 2014

Indications for Flap Coverage

• Skin graft cannot be used– Exposed cartilage, tendon (without

paratenon), bone, open joints, metal implants

• Flap coverage is preferable– Exposed nerves or vessels, durability

required, multiple tissues required, dead space present

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Principles• The final

reconstruction should be functional– Durable– Maintain Sensation– Contour (not bulky)

Hansen 2014Reconstructive options depend on

location of wound

Hindfoot/Heel/Malleolus

Forefoot

Mid plantar

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Hindfoot & Mid Plantar• Goal is to provide sensate coverage by using like

tissue from non-weight bearing midsole area• <1/3 of heel

• Split & full thickness skin grafts• Sural Flap: Suprafascial rotation flap

• 1/3 to 2/3 of heel• Flexor digitorum brevis muscle turnover flap• Instep island flap

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Hindfoot & Mid Plantar• >2/3 of heel

• Free tissue transfer• Non-weight bearing heel, instep, malleoli

• Skin graft• Rotation flaps• Reverse pedicled fasciocutaneous flaps• Extensor digitorum brevis flap• Abductor hallucis & abductor digiti minimi muscle flap• Free muscle or fasciocutaneous flap if deep

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HindfootCalcanectomy & closure

Hansen 2014 HindfootFlexor digitorum brevis flap

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HindfootFlexor digitorum brevis flap

Blood Supply: Branches of Medial and Lateral Plantar artery

Hansen 2014 Hindfoot Reconstruction Hansen 2014

Hindfoot Reconstruction

Flexor digitorum brevis flap

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HindfootInstep island flap

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Based on branches of the medial plantar artery

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Local rotational flap, Length:Width ratio 2:1

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V to Y AdvancementHansen 2014

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Lateral Supramalleolar FlapHansen 2014

*Supplied by a perforating branch of the peroneal artery

Hansen 2014Lateral Calcaneal Artery Flap

Hansen 2014Lateral Calcaneal Artery Flap Hansen 2014Lateral Calcaneal Artery Flap

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Neurocutaneous Flap

• Sural artery flap• Small artery and vein

supplying the suralnerve

• Pivot point is 5cm proximal to lateral malleolus (peronealartery)

Hansen 2014 Sural FlapHansen 2014

Sural FlapHansen 2014 MidfootV-Y advancement island flaps

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MidfootV-Y advancement flaps

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Plantar rotation flaps• Based on the vascular plexus superficial to the

plantar fascia• Donor site is skin grafted

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Microvascular Transplantation (MVT)• Myriad of Flaps Available

• Muscle• Skin• Combination

• Dead space present• Osteomyelitis• Local tissues not available

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Muscle and Musculocutaneous Flaps

• Latissimus dorsi• Rectus abdominis• Gracilis

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Fasciocutaneous and Perforator Flaps• Radial Forearm Flap• Anterolateral Thigh Flap

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Heel ReconstructionHansen 2014

Muscle vs. fasciocutaneous flap coverage

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Heel ReconstructionHansen 2014 Hindfoot

Latissimus flapHansen 2014

HindfootLatissimus flap

Hansen 2014 HindfootLatissimus free flap

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Perforator FlapHansen 2014

Perforator FlapHansen 2014

Anterolateral thigh flap (ALT): Blood supply- Descending branch of the lateral circumflex

Perforator FlapHansen 2014

Forefoot• Plantar flaps cannot be mobilized distally due

to tethering effect by plantar nerves• Sensate toe flap; unfavorable donor defect• Free tissue transfer provide most stable,

durable coverage– Latissimus dorsi muscle flap

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ForefootRay amputation +STSG

Hansen 2014 ForefootTransmetatarsal amputation

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ForefootTransmetatarsal amputation

Hansen 2014 ForefootTransmetatarsal amputation

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ForefootToe filet flaps

Hansen 2014 ForefootNeurovascular island flaps

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ForefootNeurovascular island flaps

Hansen 2014 ForefootV-Y advancement flaps

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ForefootV-Y advancement flaps

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Large DefectsHansen 2014

Large DefectsHansen 2014

Large DefectsHansen 2014

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Hansen 2014 MidfootAmputation Salvage

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MidfootAmputation Salvage

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Foot Dorsum• Skin grafts• Direct exposed tendon or bone

– Free flaps• Radial forearm/ALT flap• Latissimus muscle• Gracilis flap

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Post-op Management• Foot immobilization post-op

– Consider ex-fix• Protect pressure points• Continue to optimize medical management• Close follow-up

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Conclusions• Team approach = more chance of success• Reconstructive ladder helpful in choosing

reconstruction• Limb salvage prolongs survival of diabetic

patients• Diabetes is NOT a contraindication to local or

free flap reconstruction

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