Foot and ankle soft-tissue deficiencies: who needs a flap?

The patient who needs a flap for a deficit of the foot or ankle soft tissues is any patient who has a break in the integument. While skin grafts often will suffice, if there is a full-thickness loss, particularly over the plantar bony prominence such as the heel or metatarsal, one should strongly consider flaps. In my practice, the flap procedure most commonly performed for the metatarsal region is the V-Y advancement; for the hindfoot, free-tissue transfer; and for the Achilles region, a sural flap. If a lesion is small and the vascular inflow is good, I use free-tissue transfer of a thin skin flap such as a lateral arm flap or a radial forearm flap. For the dorsum of the foot, particularly when there is osteomyelitis or a lesion, or a lateral sidewall lesion, I use a muscle flap. The calcaneus is best served by one of many muscle flaps such as the gracilis.