Foot Ankle Clin N Am

6 (2001) 839 – 851

Soft tissue coverage options for dorsal

foot wounds
Joseph M. Serletti, MD*, Steven L. Moran, MD*
Division of Plastic Surgery, University of Rochester Medical Center, 601 Elmwood Avenue,
Box 661, Rochester, NY 14642, USA

The dorsum of the foot, like the dorsum of the hand, represents a spe-
cialized surface. The skin and soft tissues of the dorsum of the foot are thin
and pliable allowing for significant excursions during plantarflexion and
dorsiflexion. The deep surface of the dorsal soft tissues also provides a gliding
interface for the movement of the extensor tendon mechanisms. These
important properties of the dorsal soft tissues must be considered when a
method for dorsal surface reconstruction is being selected. Any reconstruction
of the dorsum of the foot also must take into account the normal contour of the
dorsum and the requirements of that contour in wearing normal footwear. Re-
constructions that significantly change the normal contour of the dorsum would
result in the need for specialized footwear, thus limiting the functional result
of the reconstruction. The following article reviews the origin and spectrum
of dorsal soft tissue defects and the selection of reconstructive options for soft
tissue reconstruction.

Initial evaluation
As with any initial medical encounter, the evaluation of the dorsal defect
begins with a comprehensive history and physical examination. Any systemic
illnesses that could affect successful reconstruction, such as diabetes and
coronary artery disease, are carefully noted. Current or premorbid ambulatory
status, symptoms of intermittent claudication, and prior foot and ankle surgery
are critical questions asked during the initial history. The size, exact location,
and exposed structures in the dorsal defect are recorded as are the presence of
palpable pedal pulses. In the absence of a palpable dorsalis pedis or posterior
tibial or both, an office Doppler examination can lead to a reliable initial

* Corresponding authors.

1083-7515/01/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 1 0 8 3 - 7 5 1 5 ( 0 2 ) 0 0 0 0 7 - 4
840 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851

vascular examination. When a significant vascular defect is identified on the

initial examination, noninvasive vascular studies can be helpful in quantifying
the potential effect of this defect on healing or reconstruction in the nondiabetic
patient. An arteriogram is obtained in the diabetic patient and in all patients in
whom clearly identifying the vascular anatomy and vascular abnormalities is
important to satisfactory reconstruction [9]. If portions of the dorsal skeleton
are exposed or if a bony abnormality is present on initial examination, radio-
graphs are obtained routinely. If osteomyelitis is suspected, a radionucleotide
scan or a magnetic resonance imaging may be used to confirm and localize the
extent of this process [24,48].
The satisfactory reconstruction of the lower extremity patient demands in-
terdisciplinary participation, and this begins with the initial evaluation. The foot
and ankle surgeon should evaluate ambulation and skeletal issues. Abnormal
vascularity needs to be evaluated by the vascular surgeon. The coordination of
these services with the plastic surgeon results in optimizing functional results
following successful soft tissue reconstruction.

Origin of the defect

Defects of the dorsum of the foot are usually the result of trauma, tumor,
diabetes, or ischemia. In the beginning of evaluating and selecting for recon-
struction, it is important to recognize that each lower-extremity wound is a
representation of some underlying pathophysiology. In trauma and tumor, the
underlying pathophysiology is a local one. In diabetes and atherosclerosis, the
pathophysiology is systemic. The underlying pathophysiology must be either
corrected or improved to obtain a stable long-term reconstructive result. In
dorsal trauma, serial débridement with ultimate removal of all devitalized tissue
corrects the pathophysiology. Wide resection or wide resection with preoper-
ative or postoperative radiotherapy for selected tumors corrects the pathophysi-
ology for dorsal soft tissue malignancies. It is difficult to relieve completely
systemic pathophysiologies that have led to dorsal defects. The goals in
diabetes and atherosclerosis are to improve these systemically by improved
serum glucose control, cessation of smoking, exercise, aspirin, and control of
hyperlipidemia. With dysvascular dorsal defects, however, lower-extremity
revascularization to the involved angiosome does represent a local method of
correcting an underlying systemic pathophysiology.
The origin of the dorsal defect and its underlying pathophysiology signifi-
cantly affects selections for soft tissue reconstruction. Selections for soft tissue
reconstruction fall broadly into two categories, local flaps or distant (free) flaps.
For only the most superficial defects, a partial-thickness skin graft is used.
Thicker skin grafts are preferred because of their decreased subsequent contrac-
ture and improved durability. A skin graft can be used reliably when the
paratenon is preserved in a dorsal defect; however, skin grafting usually is not
preferred in this setting. Late results from grafting paratenon have included
 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851 841

contracture, involving hyperextension of the toes and recurrent breakdown of the

skin graft. For these reasons, local or distant tissues typically are used in dorsal
defects with exposed paratenon [1– 4,29].
In traumatic dorsal soft tissue wounds, the relations, attachments, and
vascularity between the defect and the surrounding local soft tissues have been
altered. Although a local soft tissue reconstruction may be available, further
changes in local vascularity and further scarring incurred in dissection may make
a local choice suboptimal. A free flap for a traumatic dorsal soft tissue defect has
the advantage of not further disturbing any of the surrounding soft tissue
attachments while adding increased vascularity to the defect site by way of
the flap itself [42,45]. Tumor defects usually result in significant exposure of
tendons, ligaments, and joints of the dorsum of the foot. Local choices for such
extensive defects are limited. Local choices also have the disadvantage of dis-
rupting local vascularity and soft tissue relations. Such dissection increases the
potential area for local recurrence and, in selected tumors, increases the area to be
treated with postoperative radiotherapy. Free-tissue transfer for dorsal tumor
defects has the same advantages as in its use in traumatic defects in that it limits
to further dissection at the defect site and provides additional vascularity from the
flap. Defects of the dorsum of the foot from diabetes are uncommon. Most
diabetic wounds are found on the plantar weight-bearing surface of the foot.
When encountered, diabetic dorsal defects are seen usually in combination with
arterial insufficiency or as a result of a diabetic foot infection that originated in
the toes, web spaces, or plantar metatarsal heads. A dorsal defect from a diabetic
foot infection is usually an extensive skin loss with significant skeletal exposure
most often requiring a free flap for coverage [19,31]. Ischemic dorsal defects
usually require revascularization of the involved angiosome in addition to soft
tissue reconstruction. Local flaps here also have the disadvantage of disrupting
local vascularity, which may have immediate or late consequences for patients
with arterial insufficiency.

Local flaps
Local flaps can provide effective and rapid coverage of small defects on the
dorsum of the foot. These flaps can spare the patient the stress of a lengthy
operative procedure and have minimal donor-site morbidity. These pedicled flaps
depend on the local vascularity, which may be altered owing to peripheral
vascular disease or trauma. In those situations in which the regional vascularity is
in question or when composite tissue is needed for a functional reconstruction,
the authors often proceed to free-tissue transfer.
Local flaps for dorsal foot reconstruction include the extensor digitorum brevis
muscle flap, the retrograde dorsalis pedis flap, the retrograde peroneal flap, the
lateral superior malleolar flap, and the sural artery flap [1]. The extensor
digitorum brevis muscle flap has a single pedicle arising from the lateral tarsal
artery. The muscle consists of four slips and is approximately 4.5 cm  6.0 cm in
842 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851

the adult foot. The flap may be designed in a retrograde fashion on the basis of
the distal dorsalis pedis artery [20,21].
The lateral supramalleolar flap is vascularized through a cutaneous branch of
the anterior perforating branch of the peroneal artery. It is raised on retrograde
flow, from the anterior tibial artery through the lateral malleolar branch, with the
pedicle being located at the anterior tibiofibular ligament. The maximal length of
the pedicle is 7 to 8 cm [26,49]. The distally based sural neurocutaneous flap is
vascularized through the neurovascular network running along the sural nerve.
This blood flow to this nerve with its associated artery arises from the lateral
malleolar arteries that arise from the peroneal artery. This flap may be taken as a
fasciocutaneous or pure fascial flap. The flap is centered over the course of the
sural nerve. For preoperative design of the flap, the sural artery may be identified
with a handheld Doppler device. The skin paddle can reportedly reach 6 cm to
8 cm in width and 10 cm to 12 cm in length. To avoid injuring the perforating
pedicle, stop the dissection 4 cm to 5 cm above the lateral malleolus; however,
the posterior intermuscular septum may be opened to increase the arc of rotation
around the perforator from the peroneal artery. The flap can be tunneled sub-
cutaneously to reach the metatarsal heads [16,33,49,55].
The authors’ preference has been for the sural artery island flap, as it can
provide excellent coverage with a minimal donor defect. The flap is fairly easy to
dissect and has a long pedicle length, making it a superior local flap compared
with other regional flaps of the leg and foot. Its use does not sacrifice any of the
major vessels to the foot, as in comparison with the peroneal artery flap. Recent
reports have shown that the sural artery island flap may be used reliably in selected
patients with lower-extremity trauma and peripheral vascular disease [14,49].

Free-tissue transfer
The advantages of free-tissue transfer for the reconstruction of dorsal defects
includes a broad selection of donor tissues, including composite reconstructions;
limiting further dissection; soft tissue disruption and scarring at the recipient site;
and increasing vascularity to the recipient site directly from the flap. The
disadvantages of free-flap dorsal reconstructions include increased operative time
with the potential for increased patient morbidity and mortality, functional and
aesthetic effect at the donor site, and increased technical requirements. Soft tissue
selections for free-flap dorsal reconstruction include muscle with skin graft,
fasciocutaneous flaps, and fascial flaps with skin graft [12].

Free muscle flaps

The first free-flap dorsal reconstructions used muscle with skin graft. Muscles
commonly used in free-flap dorsal reconstruction include the rectus abdominis,
the latissimus dorsi, the serratus, and the gracilis. The rectus abdominis
traditionally was harvested through a paramedian approach, and the full width
 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851 843

of the muscle was removed. The rectus abdominis usually is harvested on the
basis of the inferior epigastric vessels [7,28]. Currently, the rectus abdominis is
harvested through a Pfannenstiel approach, and only the lateral longitudinal
portion of the muscle required for the size of the defect is removed [35,40]. These
alterations are performed to improve the aesthetics of the donor scar and to
preserve some rectus muscle for potential residual function. The inferior
epigastric vessels are dissected to their origins at the external iliacs, providing
for significant pedicle length and usually a single inferior epigastric vein (Fig. 1).

Fig. 1. Reconstruction of dorsal foot wound following diabetic foot infection in a patient with sig-
nificant peripheral vascular disease. The patient underwent a free-tissue transfer with a rectus ab-
dominus muscle flap and skin graft following a distal vascular bypass. Notice how the muscle flap
atrophies over time to provide adequate contour to the dorsum of the foot.
844 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851

The latissimus dorsi muscle usually is harvested through an oblique incision

beginning in the axilla and extending across the mid portion of the muscle in an
inferomedial direction. Dorsal defects usually do not require the entire muscle
unless the distance from the site of usable recipient vessels to the end of the
dorsal defect is long. In this instance, the length of the latissimus muscle can be
useful in overcoming these length requirements. For the more typical defect, the
proximal portion of the latissimus or a functional split latissimus can be used
[11,50]. The thoracodorsal vessels usually are dissected to their origin at the
subscapular vessels. If additional vessel diameter is required, the scapula
circumflex vessels can be divided, and the subscapular vessels can be taken at
their origin at the axillary vessels. This maneuver does not provide much
additional length but does provide for a significant increase in vessel diameter.
Recent alterations in the harvest of the latissimus include a limited axillary
incision and an endoscopic harvest of the remaining portions of the muscle [23].
The gracilis and serratus flaps represent a more ideal muscle choice for dorsal
coverage. Their size and width more accurately fit the typical dorsal defect [36].
The functional loss of these muscle units compared with the latissimus and rectus
abdominis is considerably more limited. The gracilis donor site and recipient site
can be limited to one extremity. The disadvantages of the gracilis over the other
muscle choices are shorter pedicle length and smaller vessel diameters. The
serratus, however, provides a lengthy pedicle and can be taken as a composite
graph, which may include bone or fascia [18,27,41,51].
Muscle flaps remain considerably bulky immediately after surgery and for at
least several months postoperatively. Most patients with dorsal reconstruction
using a free muscle flap are slow to resume independent ambulation and require
alterations in their footwear for months, if not permanently. Muscle flaps are
primarily used when there is significant soft tissue loss and contamination such as
after a diabetic foot infection or significant trauma. Once the skin graft is well
taken and there are no open areas of granulating muscle, patients are fitted with a
custom compression garment. Regular use of this garment hastens the resolution
of the soft tissue swelling and contour abnormalities seen with free-muscle
reconstruction of the dorsum of the foot [42,47].

Free fasciocutaneous flaps

Free fasciocutaneous flaps for dorsal foot reconstruction have several advan-
tages over free-muscle reconstructions. Patients reconstructed with fasciocuta-
neous flaps can return to ambulating more quickly because there is no need to
wait for attached skin graft to take or for areas of delayed healing to contract as
seen with muscle flaps. Fasciocutaneous flaps provide for almost normal contour
in the immediate postoperative setting and normal contour once fully matured.
The need for altered footwear is far more limited with these reconstructions and
rarely permanent compared with muscle flaps. Fasciocutaneous flaps may be
considered for almost all dorsal foot defects. These flaps are also sufficiently
supple, allowing for significant mobility with the surrounding structures, with
 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851 845

excellent return to function for most patients. The most common fasciocutaneous
flap for dorsal reconstruction is the radial forearm flap (Fig. 2) [32,43,52]. The
skin island usually is located in the distal third of the volar surface of the forearm.
The skin island can be designed to incorporate the cephalic vein and the lateral

Fig. 2. (A) Reconstruction of a lawnmower defect with a sensate radial forearm flap. (B) The patient
was able to return to water-skiing 6 months following the reconstruction.
846 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851

antebrachial cutaneous nerve. From the proximal end of the skin island an in-
cision is made to the antecubital fossa. From this incision, the radial artery and
venae comitantes along with the cephalic vein and the sensory nerve are dis-
sected. The venae comitantes usually can be dissected proximally to a point where
it becomes a single large vein. The cephalic vein and the single venae comitantes
can be anastomosed separately, providing for complete venous drainage of the
flap [10,15,30]. The dorsum of the foot has numerous sensory nerves that allow
for providing a sensate free-flap dorsal reconstruction. Either a transected dorsal
sensory nerve or an expendable dorsal sensory nerve is anastomosed to the lateral
antebrachial cutaneous nerve [8,13].
The main disadvantage of the radial forearm flap is the donor-site deformity
[37]. It is rare that the donor defect can be closed directly, and this is limited to
small dorsal defects and small radial forearm flaps. Full-thickness skin grafts
are used now because of their improved long-term appearance [22,46].
Correction of the resultant donor site has included placement of a tissue
expander under the remaining dorsal skin with subsequent expansion and
removal of the skin graft. This usually requires multiple procedures, and the
results have been limited. Adipofascial radial forearm flaps have been used to
avoid the need for a donor-site skin graft. With this flap, skin flaps are raised,
leaving adipose tissue on the forearm fascia. The forearm fascia with the
overlying adipose tissue is raised with the radial artery and venae commitantes
[5,25]. This flap is transferred and skin grafted. A linear scar remains on the
volar surface of the forearm instead of an area of the skin graft. For most, the
radial forearm flap provides the most ideal flap for reconstruction of dorsal foot
defects, although the donor defect remains problematic.
A recent alternative to the radial forearm flap is the thoracodorsal perforator
flap (TAP-flap). This flap provides a thin pliable tissue, and its donor site often
may be closed primarily [17]. For any patients in whom the donor defect is a
considerable disadvantage, contoured muscle flaps and early compression may
be preferred.
In tumor and trauma, defects may involve other tissues including tendon and
bone. For composite defects, consideration should be given to composite re-
constructions. For defects involving dorsal skin and extensor tendons, the radial
forearm flap with the flexor carpi radialis and palmaris longus can be used as
vascularized tendon grafts (Fig. 3) [8,13,44]. In defects involving bone and dorsal
soft tissues, the radial forearm flap can be harvested with a segment of vas-
cularized radius for bony reconstruction; however, this flap has been associated
with subsequent fractures of the radius [37]. The serratus muscle flap may be
harvested with rib to reconstruct concomitant metatarsal or soft tissue deficits. It
also may be taken with fascia to provide a gliding surface for tendons [18,27].

Free fascial flaps

Free fascial flaps with skin graft help to overcome some of the limitations of
free muscle flaps and free fasciocutaneous flaps. Selections for free fascial flaps
 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851 847

Fig. 3. Reconstruction of soft tissues of dorsum and underlying extensor tendons with a radial forearm/
flexor carpi radialis free-tissue transfer following sarcoma resection. Patient regained active
dorsiflexion following reconstruction.

include the temporoparietal fascia, the scapular fascia, and the posterior rectus
sheath peritoneum. Free fascial flaps with skin graft provide for early and long-
term excellent contour results without the need for altered or customized
footwear. The return to independent ambulation is not as rapid as seen in
fasciocutaneous flaps because of the need to allow for skin graft take and
appropriate healing. The fascial flaps also provide a gliding surface that allows
for excursion of the extensor tendon mechanisms and generally good return to
range of motion and function [54]. Although contour remains excellent with these
flaps, their thinness may call into question their durability. Generally, problems
with recurrent breakdown have not been seen.
The temporoparietal fascial flap is based on the superficial temporal vessels
and the donor scar is designed within the hair-bearing scalp. Alopecia from scalp
elevation has occurred, but newer techniques now allow for endoscopic harvest
of this flap [53]. The superficial temporal artery may be small and is prone to
spasm after its initial dissection. The spasm usually corrects itself with time. The
superficial temporal vein is usually thin walled and may need to be dissected into
the upper portion of the parotid gland to obtain a larger diameter vessel. Another
848 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851

advantage of this flap is that it can be harvested with the patient in the supine
position, allowing for easy two-team simultaneous surgery [6,38].
The scapular fascia of the scapular or parascapular flap is thicker than the
temporoparietal fascia with larger diameter donor vessels [34]. The main
disadvantage of this flap is patient position for harvesting. The posterior rectus
sheath-peritoneum flap can be harvested with the patient in the supine position
[39]. The inferior epigastric vessels are the donor vessels to this flap and can be
dissected to their origin at the iliacs, providing large diameter vessels and
excellent pedicle length. The main disadvantage of this flap is its communication
with the abdominal cavity once the flap is harvested, with the potential for
prolonged ileus and bowel injury or obstruction and possible hernia formation.

Recipient vessel site

The most common recipient vessel site for free-flap dorsal reconstruction is
the distal anterior tibial vessels. From the dorsal defect, a curvilinear incision
crosses the ankle joint and extends up the anterior compartment. Dissection then
enters the fascia of the anterior compartment, and the tibialis anterior tendon and
the extensor hallucis longus tendon are identified. Self-retaining retractors are
placed to separate these two tendons, the tibialis medially and the extensor
hallucus laterally. Between these two muscle bellies lie the anterior tibial artery,
its venae comitantes, and the deep branch of the peroneal nerve. Arterial
anastomoses are performed end-to-side, and venous anastomoses are performed
end to end. If at the time of inset, the closure of the incision in the anterior leg
skin is of concern where it overlies the vessels and anastomoses, a small portion
of the tibialis anterior muscle belly or the extensor hallucis muscle belly is shaved
off of the tendon. The muscle then is used to cover the vessels, leaving the
overlying skin open. The exposed muscle is covered with a split-thickness skin
graft. If the anterior tibial vessels are unavailable, the posterior tibial vessels or
the peroneal vessels are used. In using the posterior tibials, there should be
adequate pedicle or flap length to negotiate coming around the medial malleolus.
In using the peroneal vessels, a portion of the distal fibula is removed. The distal
6 cm of the distal fibula must be preserved for ankle stability; therefore, the
recipient site is at least 6 cm above the ankle. Here again, the flap length and
pedicle length must be able to accommodate the distance between this peroneal
recipient site and the distal end of the dorsal defect.

Summary
The soft tissue of dorsum of the foot consists of a thin pliable surface that
allows for significant excursion and tendon gliding. Reconstructive options must
preserve these important functions and allow for reasonable contour so the patient
may wear a shoe postoperatively. Special attention must be given to the
mechanism of injury and overlying pathophysiology involved with each wound.
 J.M. Serletti, S.L. Moran / Foot Ankle Clin N Am 6 (2001) 839–851 849

Local flaps can provide adequate wound coverage in settings in which the
vasculature and subcutaneous structures have been preserved. In wounds in
which the regional vascularity is compromised or in which tendon and bone have
been lost, a free-tissue transfer can provide for more substantial coverage. The
multiple options available with free-tissue transfer allows for the possibility of
composite tissue transfer, including vascularized bone or tendon, and the ability
to create a sensate flap with excellent contour.

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