Heel Reconstruction Research Articles

Microchirurgie et considérations esthétiques. À propos de deux cas de reconstruction talonnière

With two case reports of heel reconstruction on female patients the authors report the advantages and drawbacks of the two main types of reconstruction: free or regional flaps. Regional flaps are technically easy and reliable but their aesthetic after-effects on the donor site may be disabling, specially on the leg of a female patient. Microsurgery is technically more difficult and presents more complications specially on the lower limb. However, in certain conditions, and with the appropriate choice of donor site, free flaps authorize good quality reconstructions with minimal aesthetic after-effects.

Heel reconstruction by the composite island flap of the lower leg. (Chinese)

Heel reconstruction by the composite island flap of the lower leg. (Chinese)

Early rupture of the arterial anastomoses with free flap survival

The radial forearm flap was developed by Yang’ and originally used to treat post-bum contractures of the face and neck. It has been tiidely used in microsurgical reconstructions, as it is thin, pliable and reliable. Studies of the vascularization of this flap show that it is based on the segmental perforators from the radial artery which are distributed into proximal and distal subgroupsZ’3. By appropriate division the flap can be partitioned into separate subunits, thus providing two or more flaps based on radial vessels4. This enables simultaneous reconstruction of multiple defects leaving a single donor-site defect. The radial artery may be based either proximally or distally. A distally based forearm flap allows elevation and transposition of a relatively large fasciocutaneous flap on a long vascular pedicle. In this case report, we used a split forearm fasciocutaneous flap for simultaneous bilateral heel reconstruction. The vascular leash of the distal flap was orientated for retrograde flow. Most authors feel that a tube flap can be divided 3 weeks after surgery on account of its vascularization from surrounding tissues5. We present a case in which a sufficient vascularization occurred within 12 days.

Acne of the Heel: Acne Vulgaris Complicating a Free Vascularized Latissimus Dorsi Musculocutaneous Flap

An interesting case of acne vulgaris complicating a free vascularized latissimus dorsi musculocutaneous flap used for heel reconstruction is presented. The development of acne in a free musculocutaneous island transfer has not been described before, and we speculate as to its cause. We conclude that quiescent donor site acne scarring may be a contraindication to the use of free skin flap transfer for soft tissue reconstruction.

Reconstruction of heel defects.

In the mechanics of normal walking, the heel plays an important role, and injuries to the heel often result in limitation, and occasionally loss, of that ability. We review the three categories of heel injuries based on their severity and discuss the available methods of treatment for each. We also propose the addition of a fourth category for injuries requiring bony replacement. We discuss the appropriate use of skin grafts, local flaps, pedicle flaps, and vascularized free flaps in heel reconstruction. Successful treatment of heel defects often restores normal and pain-free ambulation.

Heel Reconstruction with the Deep Circumflex Iliac Artery Osteocutaneous Flap

A patient with extensive loss of bone and soft tissue from the right heel is presented. The defect was reconstructed using an osteocutaneous flap based on the deep circumflex iliac vessels. Indications for this procedure include extensive loss of bone and soft tissue precluding the use of local flaps. A 30-month period has elapsed since her reconstruction. A single ulcer developed 13 months postoperatively that healed after flap revision. We feel that tailoring the flap to minimize redundancy at the initial operation, subsequent tissue excision if necessary, and reinnervation augment durability of the flap.

Reconstruction of heel and sole defects by free flaps.

One latissimus dorsi musculocutaneous flap and five radial forearm flaps were used in reconstruction of weight-bearing parts of the heel and sole, the follow-up period being 7 to 38 months. Additional injuries such as forefoot amputations or amputations of the other leg were present in four patients. There was no flap loss. The latissimus dorsi flap proved to be too bulky and showed recurrent ulcerations, several reoperations were necessary, and definite healing has not occurred. The five forearm flaps gave good results, with a walking range from 2 hours to unimpeded walking. Complications included fissuring at the edges of one large flap and a local infection which was successfully treated. Cutaneous sensation returned in all but one flap, where it was reduced preoperatively due to a meningomyelocele. The results indicate that the fasciocutaneous radial forearm flap should be taken into consideration for reconstruction of weight-bearing areas of the heel and sole. Shortcomings of this flap include an unsightly donor defect and possible hair growth on the flap.

Reconstruction of Heel and Sole Defects by Free Flaps

Reconstruction of Heel and Sole Defects by Free Flaps

Microvascular Free Muscle Reconstruction of a Large Plantar Defect

Large plantar defects present a difficult problem in reconstructive surgery. Skin grafts are not durable and most distant flaps are too bulky to allow for ambulation in conventional footwear. Free muscle transfer with skin graft may represent a modality to provide a contoured and durable reconstruction for large plantar defects when local tissue is not available. This study presents a case of sole of foot and distal heel reconstruction with a free microvascular latissimus muscle transfer. The transfer was contoured to fit the defect and then covered with a split-thickness skin graft. Three months following surgery, the patient was walking without assistive devices and using conventional footwear. Now, two and one-half years after surgery, he is employed full-time in a job that entails walking, and has never experienced a tissue breakdown.

TENSOR FASCIA LATA CROSS THIGH MYOCUTANEOUS FLAP FOR HEEL RESURFACING

SUMMARYHeel resurfacing by cross thigh Tensor Facia Lata myocutaneous flap successfully performed in three cases of extensive soft tissue defects has been pre rented.It's an excellent procedure for extensive defects of heel where local myocutaneous flaps from sole may fall short or where the posterior tibial vessels are damaged. It is also a good alternative for heel reconstruction where microsurgical facilities for free flap transfer are not available.

Experiences with the Tensor Fascia Lata Flap

Our experience with 60 TFL flaps is reviewed. The anatomy and the arcs of rotation of this flap are described. Our clinical experience--particularly in reconstruction of the groin and abdominal wall, and in free flap transfers--has been detailed, including the use of a free osteomyocutaneous sensory TFL flap for reconstruction of the heel.

Reconstruction of Heel: Options and Strategies

Soft tissue loss at the weight bearing part of heel is frequently caused by trauma, infection, tumor and burn. Reconstruction becomes a challenge due to limitation of available similar or near similar tissues. Sensation of weight bearing heel is an important consideration prior to reconstruction, also the intact Posterior Tibial arterial blood flow, which becomes the dominant artery for the sole of the foot. We have done heel reconstruction of 30 patients with the Medial Plantar Island flap and 50 patients with Superficial Sural Island flap. Results were very much encouraging in terms of flap survival, durability of coverage and functional outcome. Twenty nine cases of Medial Plantar Island flap survived with excellent weight-bearing function. Among the Medial Plantar Island flap group one flap was lost due to vascular insufficiency in a diabetic patient. All the 50 cases (100%) of Superficial Sural Island flap survived without any flap loss. These flaps need about two years time for adaptive changes to become a smooth weight bearing heel. During this period the reconstructed heel needs to be supported by heel pad or modified shoes. Our study has shown that Medial Plantar Island flap and Superficial Sural Island flap are the two armamentarium for reconstruction of the weight-bearing heel in about all cases of heel defects with excellent to better reconstructive and functional outcome.DOI: http://dx.doi.org/10.3329/bdjps.v1i1.6487Bangladesh Journal of Plastic Surgery (2010) Vol. 1 (1) pp.14-18