A systematic approach to the failed plastic surgical reconstruction of the diabetic foot

Abstract

Plastic reconstruction for diabetic foot wounds must be approached carefully and follow sound micro-surgical principles as it relates to the anatomy of the designated flap chosen for coverage. First, the surgeon always needs to evaluate the local and general conditions of the presenting pathology and patient, respectively when considering a flap for reconstruction. The flap that is chosen is based on the vascularity, location, and size of the defect. Salvage of the failed flap and revisional reconstructive procedures are very challenging. Often, adjunctive therapies such as hyperbaric oxygen, negative pressure wound therapy, vasodilators, and/or vascular surgery is required. In certain case scenarios, such as patients with poor general health and compromised local vascularity in which revisional flap coverage cannot be performed, the above mentioned adjunctive therapies could be used as a primary treatment to potentially salvage a failing flap.

Modalities of Soft-Tissue Coverage in Diabetic Foot Ulcers

“…As recommended by Ignatiadis et al, 17 who showed that skin grafts are not usually used for a majority of the deeper and severe wounds classified as forms B, C, and D and grades II and III (University of Texas Health Science Center San Antonio Diabetic Wound Classification System), and especially when they are located at the weight-bearing aspect of the foot and without enough subdermic soft tissue between the skin graft and the underlying bone. In these situations, flap cover is recommended.…”

“…If a flap failure occurs, a more complicated flap could follow. 17 Traditionally, patients with diabetes have been considered as relative contraindications for free flap to the lower extremity. This could be due to the misconception that patients with diabetes have a higher incidence of small vessel disease leading to foot ulcers.…”

“…When planning a flap cover, several factors must be taken into account; these include consideration of the extent, location, size, appearance, and depth of the wound (for a deeper wound, a flap cover is usually recommended); exposed structures; the normal tissues available; vascularity of the limb; and many patient factors. 17 A flap can be a random or axial flap. If the blood supply is not derived from a recognized artery but rather comes from many small unnamed vessels (subdermal plexus), the flap is referred to as a random flap.…”

“…17 Typically, successful softtissue reconstruction requires skin grafts 18 or flaps. In the reconstructive ladder, soft-tissue defects with bone or tendon exposure require flap cover.…”