SLR - August 2021 - Kristen M. Brett

Ultrathin Free Flaps for Foot Reconstruction: Impact on Ambulation, Functional Recovery, and Patient Satisfaction 

Reference: Kushida-Contreras BH, Gaxiola-Garcia MA. Ultrathin Free Flaps for Foot Reconstruction: Impact on Ambulation, Functional Recovery, and Patient Satisfaction . Journal of Plastic Surgery and Hand Surgery. 2021 Mar 26.

Level of Evidence: Level IV

Scientific Literature Review

Reviewed By: Kristen M. Brett, DPM
Residency Program: Regions Hospital/HealthPartners Institute – St. Paul, MN

Podiatric Relevance: Large skin deficits on the foot and ankle can be devastating to patients and affect their ability to ambulate. The complexity of soft tissue repair and adequate coverage has been reported to be the most difficult in the final one third of the lower extremity as tissue is limited and has a high functional demand. Bulky reconstructive measures are not suitable fixation options as the foot requires specific attention to the plantar contour to allow the proper wear of shoe gear. This study retrospectively analyzes a series of plantar reconstruction cases using ultrathin flaps to aid in wound coverage. The goal of the study was to characterize the impact of the ultrathin flap coverage on ambulation, functional recovery, and patient satisfaction. 

Methods: A level IV retrospective review was performed on all patients who received an ultra-thin anterolateral thigh (ALT) free flap for plantar foot coverage. The functional status of each patient was assessed using scores in the Lower Extremity Function Scale (LEFS) and the American Orthopaedic Foot and Ankle Society Scale (AOFAS). Assessment of complications including ulceration of the plantar surface, conformation of the flap, and sensation was evaluated. Postoperative shoegear and patient’s satisfaction was also recorded. 

Results: A total of 12 patients were treated with free ultrathin ALT flap for plantar skin defect between 2018 and 2019. Plantar defects were a result of either a plantar melanoma (seven), posttraumatic defect (four), or a diabetic foot (one). Mean follow up was 16.5 (range 12-24) months. Preoperative means for LEFS and AOFAS were both increased postoperatively with a difference that was statistically significant. A single complication of recurrent seroma occurred, which was corrected with drainage and elastic compress. No complications of healing donor sites was reported. Postoperatively, no patients developed additional plantar ulceration and no further thinning of flap was required. Nine out of 12 patient’s maintained protective sensation with monofilament testing. Ten out of 12 patients returned to normal shoe gear while one was using slippers and one was using insoles not prescribed by a podiatrist. 

Conclusions: The findings from this study demonstrated that subjective and objective improvement was noted postoperatively after ultrathin ALT flap was use to reconstruct the plantar foot. The procedure lead to improvement in functional scales, high rates of patient satisfaction, and the use of normal shoe gear postoperatively without added complications to the plantar flap or donor site. The authors concluded that the use of thin flaps for foot reconstruction avoids secondary debulking procedures which allows the patients return to normal activities of daily life. Although this procedure poses a technical challenge and require a specific skill set, this study demonstrated that an ALT free flap offers an effective and favorable reconstructive option for limb salvage. 

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