Innervated Free Flaps for Foot Reconstruction: A Review

ABSTRACT

Whether to provide a sensate plantar weight-bearing flap to reconstruct the foot remains an unanswered, but frequently asked, question. It has been more than a decade since Graham and Dellon reviewed this subject. Increasing emphasis on outcome analysis of microsurgical reconstruction has prompted this new review. All published peer-reviewed literature related to reconstruction of the plantar surface of the foot was reviewed to identify whether the flaps were 1) local, regional or distant; 2) innervated or non-innervated and, if innervated, then 3) identified as to the donor and the recipient peripheral nerves. Outcome measures included direct measurement of sensibility, development of ulceration, and activities of daily living. It was concluded that it is still not possible to determine that innervated flap reconstruction of the weight-bearing portion of the foot is critical for either durability or ambulation. It is recommended that the original nerves that innervate the flap be blocked prior to harvest to improve flap design, i.e., that the flap actually contains the intended nerve. It is recommended that appropriate donor nerves are selected to innervate the flaps, e.g., the calcaneal nerve should be used to reinnervate heel reconstructions (rather than the sural nerve), and medial/lateral plantar branches be used to reinnervate the arch and the forefoot. Reinnervating a muscle flap with a sensory nerve will permit reinnervation of the muscle and the overlying skin, but whether this provides a superior result in durability and gait remains to be seen.

KEYWORDS

Innervated flaps - foot reconstruction

REFERENCES

• 1 Vasconez L O, Bostwick III J, McCraw J. Coverage of exposed bone by muscle transposition and skin grafting.  Plast Reconstr Surg. 1974;  53 526-530
• 2 Lin S D, Chou C K, Lai C S. Reconstruction of plantar heel defect using reinnervated skin-grafted flexor digitorum brevis flap.  Br J Plast Surg. 1991;  44 109-112
• 3 Shanahan R E, Gingrass R P. Medial plantar sensory flap for coverage of heel defects.  Plast Reconstr Surg. 1979;  64 295-298
• 4 Shaw W W, Hidalgo D A. Anatomic basis of plantar flap design: clinical applications.  Plast Reconstr Surg. 1986;  78 637-649
• 5 Miamoto Y, Ikuta Y, Shigeki S, Yamura M. Current concepts of instep island flap.  Ann Plast Surg. 1987;  19 97-102
• 6 Rashid M, Hussain S S, Aslam R, Illahi I. A comparison of two fasciocutaneous flaps in the reconstruction of defects of the weight bearing heel.  J Coll Physicians Surg Pak. 2003;  13 216-218
• 7 Aickel C, Celikoz B, Yuksel F, Ergun O. Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle.  Ann Plast Surg. 2003;  50 498-503
• 8 McGregor I A. Less satisfactory experience with the neurovascular island flap.  Hand. 1969;  1 21-25
• 9 Graham B, Dellon A L. Sensory recovery in innervated free-tissue transfers: a review.  J Reconstr Microsurg. 1995;  11 157-166
• 10 Jeng S F, Wei F C. Distally based sural island flap for foot and ankle reconstruction.  Plast Reconstr Surg. 1997;  99 744-750
• 11 O'Brien B M, Macleod A M, Hayhurst J E, Morrison W A. Successful transfer of a large island flap from the groin to the foot by microvascular anastomoses.  Plast Reconstr Surg. 1973;  52 271-278
• 12 Ferreira M C, Besteiro J M, Monteiro Jr A A, Zumiotti A. Reconstruction of the foot with microvascular free flaps.  Microsurgery. 1994;  15 33-36
• 13 Rainer C, Schwabegger A H, Bauer T et al.. Free flap reconstruction of the foot.  Ann Plast Surg. 1999;  42 595-606
• 14 Rautio J. Resurfacing and sensory recovery of the sole.  Clin Plast Surg. 1991;  18 615-626
• 15 May J W, Halls M J, Simon S R. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study.  Plast Reconstr Surg. 1985;  75 627-641
• 16 Yucel A, Senyuva C, Aydin Y, Cinar C, Guzel Z. Soft tissue reconstruction of sole and heel defects with free tissue transfers.  Ann Plast Surg. 2000;  44 259-268
• 17 Kuran I, Turgut G, Lutfu L, Ozkan T, Bayri O, Gulgonen A. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area.  Plast Reconstr Surg. 2000;  105 574-580
• 18 Rautio J. Patterns of recovery of sensibility in free flaps transferred to the foot: a prospective study.  J Reconstr Microsurg. 1990;  6 37-41
• 19 Noever G, Bruser P, Koher L. Reconstruction of heel and sole defects by free flaps.  Plast Reconstr Surg Sept. 1986;  78 345-352
• 20 Stevenson T R, Mathes S J. Management of foot injuries with free muscle flaps.  Plast Reconstr Surg. 1986;  78 665-671
• 21 Graven-Nielsen T, Mense S, Arendt-Nielsen L. Painful and non-painful pressure sensations from human skeletal muscle.  Exp Brain Res. 2004;  159 273-283
• 22 Chang K N, DeArmond S J, Buncke Jr H J. Sensory reinnervation in microsurgical reconstruction of the heel.  Plast Reconstr Surg. 1986;  78 652-664
• 23 Caffee H H. Treatment of late ulceration in free muscle flaps to the foot.  Plast Reconst Surg. 1999;  1O3 1247-1249
• 24 Lister G D. Use of an innervated skin graft to provide sensation to the reconstructed heel.  Plast Reconstr Surg. 1978;  62 157-161
• 25 Chang K N, Buncke J H. Sensory reinnervation in reconstruction of the foot.  Foot Ankle. 1986;  7 124-132
• 26 Goldberg J A, Trabulsy P, Lineaweaver W C, Buncke H J. Sensory reinnervation of muscle free flaps for foot reconstruction.  J Reconstr Microsurg. 1994;  10 7-9
• 27 Bayramicli M, Jackson I T, Herschman B. Innervation of skin grafts over free muscle flaps.  Br J Plast Surg. 2000;  53 130-136
• 28 Dellon A L. Muscle sense or non-sense.  Ann Plast Surg. 1991;  26 444-448
• 29 Hattori Y, Chuang D C, Lan C T. Sensory restoration of the skin graft on a free muscle flap: experimental rabbit study.  Plast Reconstr Surg. 2001;  108 132-140
• 30 Hermanson A, Dalsgaard C J, Arnander C, Lindblum U. Sensibility and cutaneous reinnervation in free flaps.  Plast Reconstr Surg. 1987;  79 422-427
• 31 Kauhanen M S, Lorenzetti F, Leivo I V, Tukiainen E. Asko-Seljavaara SL. Long term morphometric and immunohistochemical findings in human free microvascular muscle flaps.  Microsurgery. 2004;  24 30-38
• 32 Sinha A K, Wood M B, Irons G B. Free tissue transfer for reconstruction of the weight bearing portion of the foot.  Clin Orthop Rel Res. 1989;  242 269-271
• 33 Sonmez A, Bayramicli M, Sonmez B, Numanoglu A. Reconstruction of the weight-bearing surface of the foot with non-neurosensory free flaps.  Plast Reconstr Surg. 2004;  111 2230-2236
• 34 Santanelli F, Tenna S, Pace A, Scuderi N. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation.  Plast Reconstr Surg. 2002;  109 2314-2322 discussion 2323-2324
• 35 Musharafieh R, Atiyeh B, Macari G, Haidar R. Radial forearm fasciocutaneous free-tissue transfer in ankle and foot reconstruction: review of 17 cases.  J Reconstr Microsurg. 2001;  12 147-150
• 36 Rautio J, Kekoni J, Hamalainen H, Harma M, Asko-Seljavaara S. Mechanical sensibility in free and island flaps of the foot.  J Reconstr Microsurg. 1989;  5 119-125
• 37 Potparic Z, Rajacic N. Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps.  Br J Plast Surg. 1997;  50 176-181
• 38 Dellon A L. Discussion: free flap reconstruction of the sole of the foot with or without sensory nerve coaptation.  Plast Reconstr Surg. 2002;  109 2323-2324
• 39 Chicarelli A N, Price G J. Complete plantar foot coverage with the free neurosensory radial forearm flap.  Plast Reconstr Surg. 1986;  89 94-98
• 40 Nurse M A, Nigg B M. The effect of changes in foot sensation on plantar pressure and muscle activity.  Clin Biomech. 2001;  16 719-727
• 41 Sienko Thomas S, Supan T. A current comparison of biomechanical terms.  J Pros Orthotics. 1990;  2 107-110
• 42 Benito-Ruiz J, Toon T, Guisantes-Pintos E, Monner J, Serra-Renom J M. Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps.  Ann Plast Surg. 2004;  52 380-384
• 43 Chen S L, Chen T M, Chou T D, Chen S G, Wang H J. The distally based lesser saphenous venofasciocutaneous flap for ankle and heel reconstruction.  Plast Reconst Surg. 2002;  110 1664-1672
• 44 Jeng S F, Wei F C, Kuo Y R. Salvage of the distal foot using the distally based sural island flap.  Ann Plast Surg. 1999;  43 499-505
• 45 Morrison W A, Crabb D M, O'Brien B M, Jenkins A. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects.  Plast Reconstr Surg. 1983;  72 56-65
• 46 Rashid M, Hussain S S, Aslam R, Illahi I. A comparison of two fasciocutaneous flaps in the reconstruction of defects of the weight bearing heel.  J Coll Physicians Surg Pak. 2003;  13 216-218
• 47 Yildirim S, Akan M, Akoz T. Soft-tissue reconstruction of the foot with distally based neurocutaneous flaps in diabetic patients.  Ann Plast Surg. 2002;  48 258-264
• 48 Wyble E J, Yakuboff K P, Clark R G, Neale H W. Use of free fasciocutaneous and muscle flaps for reconstruction of the foot.  Ann Plast Surg. 1990;  24 101-108
• 49 Harris P G, Letrosne E, Caoette-Laberge L, Egerszegi E P. Long-term follow-up of coverage of weight bearing surface of the foot with free muscular flap in a pediatric population.  Microsurgery. 1994;  15 424-429
• 50 Hallock G G, Rice D C, Keblish P A, Arangio G A. Restoration of the foot using the radial forearm flap.  Ann Plast Surg. 1988;  20 14-25
• 51 Duncan M J, Zuker R M, Manktelow R T. Resurfacing weight bearing areas of the heel. The role of the dorsalis pedis innervated free tissue transfer.  J Reconstr Microsurg. 1985;  1 201-208
• 52 Lorea P, Vercruysse N, Coessens B C. Use of gracilis muscle free flap for reconstruction of chronic osteomyelitis of foot and ankle.  Acta Orthop Belg. 2001;  67 267-273
• 53 Selmanpakoglu N, Guler M, Sengezer M, Turegun M, Isik S, Demirogullari M. Reconstruction of foot defects due to mine explosion using muscle flaps.  Microsurgery. 1998;  18 182-188
• 54 Stevenson T F, Mathes S J. Management of foot injuries with free muscle flaps.  Plast Reconstr Surg. 1986;  78 665-669