ABSTRACT
Whether to provide a sensate plantar weight-bearing flap to reconstruct the foot remains
an unanswered, but frequently asked, question. It has been more than a decade since
Graham and Dellon reviewed this subject. Increasing emphasis on outcome analysis of
microsurgical reconstruction has prompted this new review. All published peer-reviewed
literature related to reconstruction of the plantar surface of the foot was reviewed
to identify whether the flaps were 1) local, regional or distant; 2) innervated or
non-innervated and, if innervated, then 3) identified as to the donor and the recipient
peripheral nerves. Outcome measures included direct measurement of sensibility, development
of ulceration, and activities of daily living. It was concluded that it is still not
possible to determine that innervated flap reconstruction of the weight-bearing portion
of the foot is critical for either durability or ambulation. It is recommended that
the original nerves that innervate the flap be blocked prior to harvest to improve
flap design, i.e., that the flap actually contains the intended nerve. It is recommended
that appropriate donor nerves are selected to innervate the flaps, e.g., the calcaneal
nerve should be used to reinnervate heel reconstructions (rather than the sural nerve),
and medial/lateral plantar branches be used to reinnervate the arch and the forefoot.
Reinnervating a muscle flap with a sensory nerve will permit reinnervation of the
muscle and the overlying skin, but whether this provides a superior result in durability
and gait remains to be seen.
KEYWORDS
Innervated flaps - foot reconstruction
REFERENCES
1
Vasconez L O, Bostwick III J, McCraw J.
Coverage of exposed bone by muscle transposition and skin grafting.
Plast Reconstr Surg.
1974;
53
526-530
2
Lin S D, Chou C K, Lai C S.
Reconstruction of plantar heel defect using reinnervated skin-grafted flexor digitorum
brevis flap.
Br J Plast Surg.
1991;
44
109-112
3
Shanahan R E, Gingrass R P.
Medial plantar sensory flap for coverage of heel defects.
Plast Reconstr Surg.
1979;
64
295-298
4
Shaw W W, Hidalgo D A.
Anatomic basis of plantar flap design: clinical applications.
Plast Reconstr Surg.
1986;
78
637-649
5
Miamoto Y, Ikuta Y, Shigeki S, Yamura M.
Current concepts of instep island flap.
Ann Plast Surg.
1987;
19
97-102
6
Rashid M, Hussain S S, Aslam R, Illahi I.
A comparison of two fasciocutaneous flaps in the reconstruction of defects of the
weight bearing heel.
J Coll Physicians Surg Pak.
2003;
13
216-218
7
Aickel C, Celikoz B, Yuksel F, Ergun O.
Various applications of the medial plantar flap to cover the defects of the plantar
foot, posterior heel, and ankle.
Ann Plast Surg.
2003;
50
498-503
8
McGregor I A.
Less satisfactory experience with the neurovascular island flap.
Hand.
1969;
1
21-25
9
Graham B, Dellon A L.
Sensory recovery in innervated free-tissue transfers: a review.
J Reconstr Microsurg.
1995;
11
157-166
10
Jeng S F, Wei F C.
Distally based sural island flap for foot and ankle reconstruction.
Plast Reconstr Surg.
1997;
99
744-750
11
O'Brien B M, Macleod A M, Hayhurst J E, Morrison W A.
Successful transfer of a large island flap from the groin to the foot by microvascular
anastomoses.
Plast Reconstr Surg.
1973;
52
271-278
12
Ferreira M C, Besteiro J M, Monteiro Jr A A, Zumiotti A.
Reconstruction of the foot with microvascular free flaps.
Microsurgery.
1994;
15
33-36
13
Rainer C, Schwabegger A H, Bauer T et al..
Free flap reconstruction of the foot.
Ann Plast Surg.
1999;
42
595-606
14
Rautio J.
Resurfacing and sensory recovery of the sole.
Clin Plast Surg.
1991;
18
615-626
15
May J W, Halls M J, Simon S R.
Free microvascular muscle flaps with skin graft reconstruction of extensive defects
of the foot: a clinical and gait analysis study.
Plast Reconstr Surg.
1985;
75
627-641
16
Yucel A, Senyuva C, Aydin Y, Cinar C, Guzel Z.
Soft tissue reconstruction of sole and heel defects with free tissue transfers.
Ann Plast Surg.
2000;
44
259-268
17
Kuran I, Turgut G, Lutfu L, Ozkan T, Bayri O, Gulgonen A.
Comparison between sensitive and nonsensitive free flaps in reconstruction of the
heel and plantar area.
Plast Reconstr Surg.
2000;
105
574-580
18
Rautio J.
Patterns of recovery of sensibility in free flaps transferred to the foot: a prospective
study.
J Reconstr Microsurg.
1990;
6
37-41
19
Noever G, Bruser P, Koher L.
Reconstruction of heel and sole defects by free flaps.
Plast Reconstr Surg Sept.
1986;
78
345-352
20
Stevenson T R, Mathes S J.
Management of foot injuries with free muscle flaps.
Plast Reconstr Surg.
1986;
78
665-671
21
Graven-Nielsen T, Mense S, Arendt-Nielsen L.
Painful and non-painful pressure sensations from human skeletal muscle.
Exp Brain Res.
2004;
159
273-283
22
Chang K N, DeArmond S J, Buncke Jr H J.
Sensory reinnervation in microsurgical reconstruction of the heel.
Plast Reconstr Surg.
1986;
78
652-664
23
Caffee H H.
Treatment of late ulceration in free muscle flaps to the foot.
Plast Reconst Surg.
1999;
1O3
1247-1249
24
Lister G D.
Use of an innervated skin graft to provide sensation to the reconstructed heel.
Plast Reconstr Surg.
1978;
62
157-161
25
Chang K N, Buncke J H.
Sensory reinnervation in reconstruction of the foot.
Foot Ankle.
1986;
7
124-132
26
Goldberg J A, Trabulsy P, Lineaweaver W C, Buncke H J.
Sensory reinnervation of muscle free flaps for foot reconstruction.
J Reconstr Microsurg.
1994;
10
7-9
27
Bayramicli M, Jackson I T, Herschman B.
Innervation of skin grafts over free muscle flaps.
Br J Plast Surg.
2000;
53
130-136
28
Dellon A L.
Muscle sense or non-sense.
Ann Plast Surg.
1991;
26
444-448
29
Hattori Y, Chuang D C, Lan C T.
Sensory restoration of the skin graft on a free muscle flap: experimental rabbit study.
Plast Reconstr Surg.
2001;
108
132-140
30
Hermanson A, Dalsgaard C J, Arnander C, Lindblum U.
Sensibility and cutaneous reinnervation in free flaps.
Plast Reconstr Surg.
1987;
79
422-427
31
Kauhanen M S, Lorenzetti F, Leivo I V, Tukiainen E.
Asko-Seljavaara SL. Long term morphometric and immunohistochemical findings in human
free microvascular muscle flaps.
Microsurgery.
2004;
24
30-38
32
Sinha A K, Wood M B, Irons G B.
Free tissue transfer for reconstruction of the weight bearing portion of the foot.
Clin Orthop Rel Res.
1989;
242
269-271
33
Sonmez A, Bayramicli M, Sonmez B, Numanoglu A.
Reconstruction of the weight-bearing surface of the foot with non-neurosensory free
flaps.
Plast Reconstr Surg.
2004;
111
2230-2236
34
Santanelli F, Tenna S, Pace A, Scuderi N.
Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation.
Plast Reconstr Surg.
2002;
109
2314-2322
discussion 2323-2324
35
Musharafieh R, Atiyeh B, Macari G, Haidar R.
Radial forearm fasciocutaneous free-tissue transfer in ankle and foot reconstruction:
review of 17 cases.
J Reconstr Microsurg.
2001;
12
147-150
36
Rautio J, Kekoni J, Hamalainen H, Harma M, Asko-Seljavaara S.
Mechanical sensibility in free and island flaps of the foot.
J Reconstr Microsurg.
1989;
5
119-125
37
Potparic Z, Rajacic N.
Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated
free flaps.
Br J Plast Surg.
1997;
50
176-181
38
Dellon A L.
Discussion: free flap reconstruction of the sole of the foot with or without sensory
nerve coaptation.
Plast Reconstr Surg.
2002;
109
2323-2324
39
Chicarelli A N, Price G J.
Complete plantar foot coverage with the free neurosensory radial forearm flap.
Plast Reconstr Surg.
1986;
89
94-98
40
Nurse M A, Nigg B M.
The effect of changes in foot sensation on plantar pressure and muscle activity.
Clin Biomech.
2001;
16
719-727
41
Sienko Thomas S, Supan T.
A current comparison of biomechanical terms.
J Pros Orthotics.
1990;
2
107-110
42
Benito-Ruiz J, Toon T, Guisantes-Pintos E, Monner J, Serra-Renom J M.
Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps.
Ann Plast Surg.
2004;
52
380-384
43
Chen S L, Chen T M, Chou T D, Chen S G, Wang H J.
The distally based lesser saphenous venofasciocutaneous flap for ankle and heel reconstruction.
Plast Reconst Surg.
2002;
110
1664-1672
44
Jeng S F, Wei F C, Kuo Y R.
Salvage of the distal foot using the distally based sural island flap.
Ann Plast Surg.
1999;
43
499-505
45
Morrison W A, Crabb D M, O'Brien B M, Jenkins A.
The instep of the foot as a fasciocutaneous island and as a free flap for heel defects.
Plast Reconstr Surg.
1983;
72
56-65
46
Rashid M, Hussain S S, Aslam R, Illahi I.
A comparison of two fasciocutaneous flaps in the reconstruction of defects of the
weight bearing heel.
J Coll Physicians Surg Pak.
2003;
13
216-218
47
Yildirim S, Akan M, Akoz T.
Soft-tissue reconstruction of the foot with distally based neurocutaneous flaps in
diabetic patients.
Ann Plast Surg.
2002;
48
258-264
48
Wyble E J, Yakuboff K P, Clark R G, Neale H W.
Use of free fasciocutaneous and muscle flaps for reconstruction of the foot.
Ann Plast Surg.
1990;
24
101-108
49
Harris P G, Letrosne E, Caoette-Laberge L, Egerszegi E P.
Long-term follow-up of coverage of weight bearing surface of the foot with free muscular
flap in a pediatric population.
Microsurgery.
1994;
15
424-429
50
Hallock G G, Rice D C, Keblish P A, Arangio G A.
Restoration of the foot using the radial forearm flap.
Ann Plast Surg.
1988;
20
14-25
51
Duncan M J, Zuker R M, Manktelow R T.
Resurfacing weight bearing areas of the heel. The role of the dorsalis pedis innervated
free tissue transfer.
J Reconstr Microsurg.
1985;
1
201-208
52
Lorea P, Vercruysse N, Coessens B C.
Use of gracilis muscle free flap for reconstruction of chronic osteomyelitis of foot
and ankle.
Acta Orthop Belg.
2001;
67
267-273
53
Selmanpakoglu N, Guler M, Sengezer M, Turegun M, Isik S, Demirogullari M.
Reconstruction of foot defects due to mine explosion using muscle flaps.
Microsurgery.
1998;
18
182-188
54
Stevenson T F, Mathes S J.
Management of foot injuries with free muscle flaps.
Plast Reconstr Surg.
1986;
78
665-669
Ivica DucicM.D. Ph.D.
Department of Plastic Surgery, Georgetown University Hospital
3800 Reservoir Road, N.W., Washington, D.C. 20007