Eur J Plast Surg (1998) 21:358±361
B.C. Coessens ´ E. Vandeweyer ´ F.C. Urbain
Microsurgical reconstruction of small soft tissue defects
on the lateral side of the calcaneal region
Received: 14 October 1997 / Accepted: 6 May 1998
B.C. Coessens (
) ´ E. Vandeweyer ´ F.C. Urbain
Department of Plastic Surgery, Brugmann University Hospital,
Free University, Place A. van Gehuchten, 4, B-1020 Brussels,
Abstract Soft tissue defects of the ankle are a challeng-
ing problem. Local flaps have several disadvantages be-
cause of functional and/or cosmetic problems. Free flaps,
by nature, allow a greater choice of donor sites and there-
fore minimize problems resulting from local flap harvest-
ing. Passing the vascular pedicle between the tibia and the
Achilles tendon for anastomoses on the posterior tibial
vessels can maintain satisfactory ankle contour. Three
cases of free flap reconstruction of the lateral aspect of
the calcaneal region are presented and the surgical ap-
proach is detailed. All the patients were able to wear nor-
mal shoes after the reconstruction.
Key words Soft tissue defects ´ Ankle ´ Free flaps ´
Restoration of an adequate three-dimensional shape of the
calcaneus after fracture often requires open osteosynthesis
. Local factors such as edema and severe crush will
lead, in some cases, to wound dehiscence and possible se-
vere complications. Soft tissue reconstruction in the case
of exposed osteosynthesis material and/or fracture site is
mandatory and can be accomplished by either pedicled
or free flaps. The use of free flaps in the reconstruction
of severe crush injuries of the foot and ankle region is
now a well-accepted method [4, 15, 17±19, 21].
Even for smaller defects, the advantages of free flaps
have to be taken into account when choosing a recon-
structive option. Free muscle flaps combine the advantage
of well-vascularized tissue in contaminated wounds 
and the absence of potential complications encountered
with local flap donor sites.
Passing the vascular pedicle between the tibia and the
Achilles tendon with anastomoses of the posterior tibial
vessels can maintain foot and ankle contour.
The use of free muscle flaps in the reconstruction of
soft tissue defects limited to the lateral side of the calca-
neal region is presented in three consecutive clinical cases
and the specific surgical approach is described.
Materials and methods
Under tourniquet, access to the recipient vessels is provided through
a 10 cm straight line incision starting from the ankle above the pos-
terior tibial vessels and extending to the distal third of the internal
aspect of the leg. The recipient vessels are isolated under optical
The plane between the Achilles tendon and the distal part of the
tibia is dissected bluntly, this is facilitated by plantar flexion of the
foot (Fig. 1).
Complete debridement of the soft tissue defect is carried out and
is extended to the space between the lateral malleolus and the Achil-
les tendon. This connects the external soft tissue defect with the tun-
nel to the recipient vessels (Figs. 1, 2).
The choice of muscle flap is dictated by the extend of the soft
tissue defect and the possibility for simultaneous dissection of both
recipient and donor areas. The gracilis muscle flap is chosen for de-
fects less than 5 10 cm. For larger defects a segmental rectus abdo-
minis flap may be harvested. Both donor areas are easy to dissect
with minimal morbidity and do not necessitate changing the pa-
tient's position intraoperatively.
When positioning the flap on the recipient site, the muscle is
gently delivered from the internal incision to the external recipient
site. In so doing, the passage will first have to accommodate all
the muscle bulk. This ensures that the tunnel is wide enough for
the pedicle and also it leaves the muscle's vascular pedicle behind,
that is close to the recipient vessels.
The anastomoses are performed end-to-side for the artery and
end-to-end for the veins.
Plantar flexion of the foot is maintained for ten days.
Three patients, aged 24, 39, 71 years old, were referred for soft tis-
sue loss on the external aspect of the ankle and foot after calcaneal
fracture with subsequent exposure of the fracture site and wound