The heel is an important part of the foot responsible for weight and friction bearing, shock absorption, and as a spring board in walking. In order to effectively carry out these special roles, the skin and subcutaneous tissue of the heel differ significantly from those of other parts of the body. It is particularly difficult to effectively reconstruct soft tissue defects of the heel.
Previously described methods have not always been ideal for heel coverage. Skin grafts placed on the calcaneus or on muscle transposition flaps such as the flexor digitorum brevis, abductor hallucis, and abductor disiti minimi muscles provide a thin and dissimilar surface and the area is subject to ulceration and hyperkeratosis. Distant flaps such as the cross foot, cross leg, cross thigh, and buttock flaps provide a dissimilar and insensitive tissue and involve a prologed hospitalization, multiple procedures and increased morbidity. Microvascular free flaps such as the groin, dorsalis pedis, and scapular free flaps provide a dissimilar and parasitic tissue and may contain excessive fat which should be subsequently defatted. Random plantar flaps provide a functional replacement with similar tissue having adequate sensation. However, these random flaps are not always reliable, have limited motion and leave disfiguring dog-ear deformities.
For ideal heel coverage, the tissue used should be durable, sensitive, reliable, well-padded, and easily movable, and the technique should entail only one operative procedure with minimal donor site morbidity cosmetically as well as functionally. To meet these conditions, the flap should be obtained from the area adjacent to the heel defect and be an arterialized one. For such local arterialized flaps, we utilized in one case a flexor digitorum brevis myocutaneous island flap, in the second case a lateral calcaneal artery skin flap, in the third case an instep fasciocutaneous island flap in addition to a lateral calcaneal artery skin flap, in the next two cases instep fasciocutaneous island flaps, and in the last case a lateral calcaneal artery skin flap. Thus the heel was covered with secsitive and durable tissue to allow good weight and friction bearing, and proper ambulation.
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