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Deldar et al. Plast Aesthet Res 2022;9:13 https://dx.doi.org/10.20517/2347-9264.2021.100 Page 5 of 16

thrombosis (DVT). The ideal recipient vein can be determined preoperatively based on reflux studies and
high venous pressure. If high venous reflux is detected, a different recipient venous system with less disease
[46]
burden can be chosen . Our group has previously reported that venous insufficiency (defined as < 0.5 s of
[46]
reflux) was detected in 39% of patients, and DVT was found in 6.78% of patients undergoing FTT .
Identification of both arterial and venous disease prior to FTT allows for optimization of recipient arterial
and venous selection to yield free flap success.

Angiosomes of the foot and ankle
Taylor and Palmer introduced the angiosome concept, separating the body into distinct three-
[48]
dimensional blocks of tissue and overlying skin fed by “source” arteries. The senior authors (Attinger CE
and Evans KK) described six angiosomes of the foot and ankle that originate from three main arteries
[49]
[Figure 2]. Blood flow to the foot and ankle is redundant because of the multiple arterial-arterial
connections between the three main arteries .
[49]

[50]
Application of the angiosome theory is important in reconstructive success of the foot and ankle .
Knowledge of the vascular anatomy of the foot and ankle can guide the effective revascularization of
occluded arteries [49,51] . Incisions in the foot and ankle should be made between angiosome boundaries to
limit perfusion compromise. Detailed descriptions of the vascular anatomy and angiosomes of the lower leg,
foot, and ankle have been explained elsewhere [50,52-54] .

Local flaps for LE reconstruction
[55]
In general, flap coverage is the reconstructive choice for wounds with exposed tendon, joint, or bone . The
primary goal of the lower leg, foot, and ankle reconstruction is to preserve function, centered on
ambulation. Local flaps can improve blood flow to the defect and provide a surface for subsequent skin
[50]
grafting . Historically, the gastrocnemius and soleus muscle flaps have provided dependable coverage of
lower limb defects [56,57] . The gastrocnemius local flap with skin graft has been widely used for reconstruction
of knee and proximal leg defects [Figure 3]. The soleus muscle flap can provide reliable soft-tissue coverage
of middle and lower leg defects [57,58] . In select patients, the medial sural artery perforator (MSAP) flap is
useful as a pedicled or free flap to cover knee or leg defects. It is based on perforators from the medial sural
artery, which are dissected through the gastrocnemius muscle [Figure 4].
[59]

Fasciocutaneous flaps can also be used for coverage of the knee, leg, and posterior heel. The reverse sural
artery flap offers coverage of distal leg and heel defects when microsurgery is not feasible; however, venous
[60]
congestion and distal flap loss are common complications [Figure 5]. Perforator-based local flaps, such as
propeller or keystone flaps, have expanded the repertoire for lower limb reconstruction. Figure 6 depicts a
saphenous artery perforator-based rotation advancement flap. Moreover, the perforator-plus flap, a
modification of the classic perforator-based fasciocutaneous flap, offers dual blood supply to the flap from
the dissected perforator plus the retained cutaneous base . By keeping the base of the flap attached, the
[61]
subdermal plexus augments arterial inflow, improves venous outflow, and shortens the arc of flap
rotation . AlMugaren et al. recently published an algorithm for the reconstruction of LE defects.
[56]
[62]
Disadvantages of local flaps include limited bulk and reach .
[55]
Local flaps for foot reconstruction
Local muscle flaps can be used for coverage of small foot defects (3 cm × 6 cm or less) that are within reach
[55]
of the local flap . At our center, we primarily use three intrinsic foot muscles for coverage of diabetic foot
wounds: (1) abductor hallucis (AH); (2) abductor digiti minimi (ADM); and (3) flexor digitorum brevis
(FDB) [Figures 7-9]. To harvest each of these flaps, the incisions are made along the border of adjacent