question:Crowe, Christopher S., M.D.; Cho, Daniel Y., M.D., Ph.D.; Kneib, Cameron J., B.S.; Morrison, Shane D., M.D., M.S.; Friedrich, Jeffrey B., M.D.; Keys, Kari A., M.D. Background: Reconstruction of the plantar surface of the foot is challenging because of its distinctive anatomy and microarchitecture. Unfortunately, no single coverage option meets the needs of all patients and defects. A comprehensive literature review is presented to better define available reconstructive options for resurfacing the plantar foot. Methods: A systematic literature search was performed to identify articles relating to reconstruction of the plantar skin and soft tissue. The PubMed, Embase, and Scopus databases were queried for published articles. After the exclusion of duplicate records, 1624 articles were available for review. A total of 280 unique articles were included for analysis, with a total of 2684 individual reconstructions. Results: Of the articles reviewed, 10 percent described a skin grafting technique, 53 percent described a locoregional flap, 32 percent described free tissue transfer, and 5 percent described multiple reconstructive methods. Isolated heel defects were the most frequently reconstructed subunit of the plantar foot (73 percent). The latissimus dorsi muscle was the most commonly used free flap, whereas the reverse sural artery flap was the most commonly used locoregional flap. Protective sensation was noted in most locoregional and free flap reconstructions, regardless of primary neurotization; however, improved two-point discrimination was noted when neurofasciocutaneous flaps were used. Complication rates varied widely, although rates of flap loss approached those of flaps performed at other anatomical sites. Conclusions: Numerous methods exist for reconstructing the plantar surface. Proper flap selection should be determined by the size of the defect, the availability of donor tissue, and the surgeon’s experience and comfort with the reconstructive technique. Coding Perspective for this Article is on Page 1240. From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine. Received for publication April 5, 2018; accepted August 17, 2018. Disclosure: The authors have no financial interest to declare in relation to the content of this article. There was no funding obtained for the production of this article. The challenge of reconstructing the sole of the foot relates to the distinct anatomy and microarchitecture of the plantar surface. First, the weight-bearing foot is capable of withstanding significant compressive forces because of its thickness and deformability. The glabrous skin of the plantar surface consists of a substantial epidermal layer—approximately 1.4 mm thick compared to 0.1 mm in other anatomical regions.1 Numerous subcutaneous lobules of adipose tissue act to absorb and redistribute compressive forces.2 Second, the epidermal-dermal junction is firmly tethered to the plantar aponeurosis by numerous vertical fibrous septa, which act to resist shearing forces tangential to the skin surface. Third, the plantar surface provides a protective sensation capable of inducing avoidance behavior, particularly with regard to repositioning while standing and redistribution of load bearing during ambulation.3 Lastly, the contour and compactness of the plantar surface are important cultural considerations, as they pertain to the ability to wear conventional footwear. When reconstruction is pursued, the primary aim is to establish durable soft-tissue coverage and provide the patient with a reasonable chance at weight-bearing and independent ambulation. Despite being a well-studied topic in plastic surgery, no single coverage option meets the needs of all patients and defects. Instead, the planned reconstruction must take into account the size, location, depth, and cause of the defect. Patient factors—such as presence of comorbidities, neurovascular status, and adjacent tissue quality—are also of considerable importance. A systematic review was performed to identify studies describing techniques, relevant modifications, and outcomes for reconstruction of the plantar surface. All articles were manually sorted and their abstracts screened for exclusion criteria. Duplicate and non-English articles were excluded without further review. Studies that did not describe a surgical intervention, plantar soft-tissue defect, or reconstructive outcome, and nonclinical study designs (e.g., cadaveric, animal, or in vitro models) were excluded. Nonoriginal articles, such as letters, discussions, reviews, meta-analyses, and abstract-only publications were reviewed for background, but were not included in the analysis. Case reports and low-volume case series were included, but were identified as such. Included studies were subcategorized by reconstructive method: skin grafts and dermal substitutes, local and regional flaps, and free tissue transfer. Extracted data included patient age, follow-up duration, reconstruction method, flap tissue composition, defect location, procedural variation, complication type and rate, and sensory analysis. Collectively, isolated heel defects were the most frequently reconstructed subunit of the plantar foot when specified (74 percent). The midfoot was the least frequently reconstructed area (4 percent for isolated injuries and 3 percent for combined injuries involving the forefoot or hindfoot). Grafts were more commonly split-thickness (62 percent) rather than full-thickness (6 percent) or dermal (6 percent). These were used to reconstruct a variety of plantar defects, but were used for the forefoot in greater proportion. For local, regional, and free flap–based reconstructions, suprafascial and fasciocutaneous flaps were the most commonly used tissue composition, making up 82 percent and 57 percent of flap types, respectively. Muscle-only flaps were more often described in studies using free tissue transfer when compared to those using local and regional flaps (29 percent versus 9 percent). Osteocutaneous, fascia-only, and chimeric flaps were rarely described. Dermal grafting involves harvesting a layer of deepithelialized dermal tissue, which can be skin grafted after a period of incorporation19 or left to reepithelialize by secondary intention.20 The advantage of this method is that dermal elements of glabrous plantar skin can be transferred with minimal donor-site morbidity. Flaps as large as 338 cm2 can be obtained by extending the flap proximally to just distal of the popliteal crease,30 and transversely to the midlateral line on either side of the lower leg.31 A fascia-only flap can be elevated to provide low-profile vascularized tissue,32, 33 or partial gastrocnemius muscle can be included to add additional bulk.34 Improved sensation can be achieved by means of coaptation of the proximally dissected lateral sural nerve to the common sural distally.32, 35 Two-point discrimination in these studies is noted to approach 20 mm; however, approximately one-third of studies mention recovery of at least a deep or protective sensation regardless of neurotization. The sural artery flap is prone to edema and venous congestion, the incidence of which can be partially decreased with flap delay.36, 37 Partial flap loss can occur at a rate as high as 22 percent38 with the rate of other wound healing complications ranging between 0 and 36 percent. Reported local tissue rearrangements for plantar defects include V-Y advancement,51–53 rotational,54, 55 transposition,55 “reading man,”56 unilobed and bilobed cutaneous flaps,57–59 and others. Generally, local plantar flaps are appropriate for small defects. The toe island flap is a small cutaneous flap based on the proper digital artery. Although mostly used to resurface forefoot ulcerations (79 percent), several instances of islanded toe flaps are reported for coverage of midfoot64 and hindfoot defects.65 This is achieved by dissecting the pedicle back to the lateral or medial plantar artery, depending on the donor toe selected. The filleted toe flap, like the toe island flap, relies on perfusion from the digital arteries. In this method, a functionless toe undergoes removal of its skeletal elements for coverage of a plantar defect proximal to the donor site. All described reconstructions focused on resurfacing the forefoot. The size of the fillet flap depends entirely on the digit(s) sacrificed.70 Except for a single case of complete flap necrosis,71 complications of fillet flaps were uncommon. Overall, fasciocutaneous free flaps have rates of partial and complete flap necrosis similar to those of fasciocutaneous reconstruction of other regions. Wound healing complications range from 0 to 50 percent, but do not seem to be related to any single reconstructive method. Lastly, the thoracodorsal artery perforator flap is a fasciocutaneous flap with chimeric options that may be used to reconstruct extensive and composite defects of the sole.142 Several articles describe the thoracodorsal artery perforator flap with inclusion of partial latissimus dorsi,143 serratus fascia,144 or scapula145 on a separate pedicle for improved resurfacing of compound plantar defects. The ability of a reconstructed plantar surface to withstand compressive and shearing forces is a primary goal of repair. Despite progressive weight-bearing protocols, off-loading inserts, and counseling regarding avoidance of static, unrelieved pressure, breakdown can still occur. If ulceration progresses, secondary reconstruction or even amputation may be necessary. For skin graft– and dermal substitute–based reconstructions, the time to ulceration is much shorter than for fasciocutaneous and muscle-based flaps (Table 6). Overall, the mean rate of ulceration is 6 to 11 percent; however, individually reported rates vary widely from study to study. Jeng and Wei state that the question of which technique is best for plantar reconstruction “resolves itself not into a measure of method but rather of the surgeon’s ability to select the right method.”4 A comprehensive algorithm for selecting the appropriate reconstructive technique is presented (Fig. 6). These approaches to resurfacing the plantar foot represent a culmination of our institutional experience, existing algorithms,4, 12, 84 and evidence as listed in the above discussion. Despite the vast number of plantar reconstructions reported in recent decades, few sizable studies exist, and rates of complication vary widely even for identical flap types. This is especially true for studies describing long-term outcomes. No single reconstructive method meets the needs of all patients and defects. Instead, stable, functional, and aesthetic coverage of the sole of the foot can be achieved through a number of surgical means. As is the paradigm in the majority of reconstructive operations, each case should be evaluated individually and the surgical method should be chosen according to the location and requirements of the defect, available donor sites, and surgeon preference and experience. 1. Thoolen M, Ryan TJ, Bristow I. 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Disclosure: Dr. Janevicius ([email protected]) is the president of JCC, a firm specializing in coding consulting services for surgeons, government agencies, attorneys, and other entities. Plastic and Reconstructive Surgery143(4):1223-1244, April 2019. Articles in PubMed by Christopher S. Crowe, M.D. Articles in Google Scholar by Christopher S. Crowe, M.D. Other articles in this journal by Christopher S. Crowe, M.D. What were the rates of flap loss for fasciocutaneous free flaps compared to those performed at other anatomical sites? Overall, fasciocutaneous free flaps have rates of partial and complete flap necrosis similar to those of fasciocutaneous reconstruction of other regions.

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