Fasciocutaneous island flap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot

Soft-tissue deficits over the plantar forefoot, plantar heel, tendo calcaneus, and lower leg are often impossible to cover with a simple skin graft. The previously developed medial plantar fasciocutaneous island flap has been adapted to cover soft-tissue defects over these areas. This fasciocutaneous flap based on the medial plantar neurovascular bundle is capable of providing sensate and structurally similar local tissue. Application of this fasciocutaneous island flap is demonstrated in 12 clinical cases. Successful soft-tissue cover was achieved on the plantar calcaneus (four patients), tendo calcaneus (four patients), lower leg (two patients), and plantar forefoot (two patients). Follow-up ranged from 6 months to 5 years. All flaps were viable at follow-up. Protective sensation was present in 11 of 12 flaps evaluated at 6 months. In addition, all 11 patients were able to ambulate in normal footwear. The medial plantar island flap seems to be more durable than a skin graft, and the donor site on the non-weight-bearing instep is well tolerated. This study demonstrates that the medial plantar fasciocutaneous island flap should be considered as another valuable tool in reconstructive efforts directed at the plantar forefoot, plantar heel, posterior ankle, and lower leg.     

Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area

In this study, 12 cases of reconstruction of the heel and plantar area since 1982 are reviewed. Six nonsensate muscle free flaps and six sensate fasciocutaneous flaps were used, respectively. Categories assessed were the time interval for return to daily living activities, sensation to light touch, pinprick, Semmes-Weinstein monofilament test of the reconstructed area for sensory evaluation; and results of pedograms (maximal pressure, pressure distribution, and total contact area of the plantar surface). Follow-up periods were between 2 and 14 years, with an average of 6 years. Better sensory results and early return to daily living activities were observed in the sensate flap group, but the defects were smaller in this group. Despite the slightly longer time to return to daily living activities and worse sensory results, long-term follow-up showed that patients with nonsensate flaps had no difficulty in performing living activities if they continued to be careful and to use some kind of protective shoes. The results of the pedogram analyses were similar between the two groups with regard to total contact area of the reconstructed foot in relation to the healthy foot. Pressure values of the reconstructed areas in sensate flaps were found to be close to pressure values in the same weight areas of the normal foot. The differences between pressure values of the sensate and nonsensate flaps were statistically significant (p < 0.001). Therefore, in reconstruction of the weight-bearing surface of the foot, each case should be evaluated individually. The reconstructive method should be chosen according to the location and soft-tissue requirements of the defect.     

Forefoot reconstruction by reversed island flaps in diabetic patients

Soft-tissue coverage of the foot is often difficult, especially when the distal third of the foot (dorsal or plantar aspects) is involved. The clinical situation can be further complicated when diabetic patients are affected by painful and unstable wounds of this kind because of the familiar phenomenon of vasculopathy. The purpose of this study was to evaluate the possibility of using distally based foot flaps to cover forefoot defects in diabetic patients. Preoperative selection of patients was the key to this study; those who had other major disease, chronic infection, bone involvement, and/or insufficient foot vascularization were excluded from the study. The authors report a series of 12 diabetic patients in whom the reconstruction of medium-sized defects (ranging from 1.5 x 2.0 cm to 3.0 x 7.0 cm) of the forefoot was performed using distally based dorsalis pedis flaps or medial plantar flaps. The transferred flaps survived and adapted well to the defects, except for one flap in a patient who had a slight venous insufficiency at outset. Wearing their own footwear, patients could walk after 20 to 30 days. After the follow-up period (3 months to 3 years), no skin breakdown in the treated areas was observed. Temporary donor-site pain was reported by medial plantar flap patients, and partial skin graft loss at the donor site occurred in some of the dorsalis pedis patients. The authors suggest that in selected cases, medium-sized soft-tissue defects involving the dorsal aspects or the weight-bearing areas of the diabetic foot can be successfully covered with distally based island flaps.     

Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle

Soft-tissue reconstruction of the dorsum of the foot and ankle has long been a challenge for reconstructive surgeons. Limitations in the available local tissue and donor-site morbidity restrict the options. In an effort to solve these difficult problems, the authors have begun to use a distally based lateral supramalleolar adipofascial flap. This report presents the authors' early experience with seven patients treated with this flap. The patients' ages ranged from 5 to 26 years; four of the patients were male and three were female. The cause of the soft-tissue defects involved acute trauma and chronic scar contracture. The flap and the adjoining raw area were covered with a full-thickness skin graft, and the donor site at the lateral aspect of the leg was closed primarily without grafting. A skin graft was taken from the groin area, which was closed primarily. Compared with the other flaps, this adipofascial flap was thinner and produced less bulkiness to the recipient site and minor aesthetic sequelae to the donor site. It is believed that this flap is versatile and effective and is a good addition to the available techniques used by reconstructive surgeons for coverage of the dorsum of the foot and ankle.     

A fasciocutaneous flap for vaginal and perineal reconstruction

A skin and fascia flap from the medial thigh is proposed for vaginal and perineal reconstruction. Dissection, vascular injection, and radiographs of 20 fresh cadaver limbs uniformly demonstrated the presence of a communicating suprafascial vascular plexus in the medial thigh. Three to four nonaxial vessels were consistently found to enter the proximal plexus from within 5 cm of the perineum. Preservation of these vessels permitted reliable elevation of a 9 X 20 cm fasciocutaneous flap without using the gracilis muscle as a vascular carrier. Fifteen flaps in 13 patients were used for vaginal replacement and coverage of vulvectomy, groin, and ischial defects. Depending on the magnitude of the defect, simultaneous and independent elevation of the gracilis muscle provided additional vascularized coverage as needed. Our experience indicates that the medial thigh fasciocutaneous flap is a durable, less bulky, and potentially sensate alternative to the gracilis musculocutaneous flap for vaginal and perineal reconstruction.     

Reappraisal of island modifications of lateral calcaneal artery skin flap

Reconstruction of soft-tissue defects of the calcaneal region and the heel is very demanding and necessitates, as a rule, a sensate and thin flap. The ideal characteristics of a sensate and thin layer of flap should be combined with a reliable blood supply and minimal morbidity at the donor site. The authors report an updated review of their experience with the use of island modifications of the lateral calcaneal artery skin flap-the lateral calcaneal island flap, the lateral calcaneal V-Y advancement flap, and the bilobed-shaped lateral calcaneal island advancement flap-for the reconstruction of small and medium-sized tissue defects over the exposed calcaneal tendons and calcaneal bones of 18 patients. All of the procedures were performed under spinal or epidural anesthesia. There were no problems associated with flap viability, but the authors have seen necrosis of undermined skin between the lateral malleolus and calcaneal tendon in two cases and a partial loss of skin graft in one case. In this article, the authors discuss some advantages and disadvantages of the use of a lateral calcaneal island flap and its modifications.     

Anatomic basis of plantar flap design

Safe planes exist for plantar incisions that minimize the possibility of subcutaneous nerve injury and are therefore useful in flap design. Nerve branch orientation in the plantar subcutaneous tissue is specific and guides dissection so as to avoid producing anesthesia in weight-bearing areas. An extensive proximal plantar subcutaneous plexus exists that permits elevation of plantar flaps in a superficial plane. This is due to the major contribution that the dorsal circulation makes to the skin of the plantar surface. The blood supply to the non-weight-bearing midsole area is not from the medial plantar artery exclusively. This is a watershed area with important lateral plantar artery and dorsalis pedis artery contributions as well. It is not necessary or desirable to base plantar flaps on a myocutaneous or fasciocutaneous supply with its required deep dissection. Local plantar flaps can be designed to include sensation and abundant blood supply without the need for "subfascial" dissection. Subcutaneous sensory plantar flaps designed in accordance with these principles promise a more ideal solution for the treatment of plantar defects.     

Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study

Over the past 4 years at the Massachusetts General Hospital 18 patients have been treated for extensive defects (mean size 130 cm2) of the foot at or below the medial and lateral malleoli. These patients have been treated with free muscle flaps covered with thick split-thickness skin grafts. Full muscle flap survival has been seen in each patient, and all patients are currently ambulatory. A subgroup of nine patients are weight-bearing directly upon their skin grafts covering transferred muscle. All patients are walking without chronic breakdown over a mean follow-up of over 19 months with the exception of a single patient who has had breakdown in a region of redundant improperly tailored muscle flap. None of the skin grafted muscles has significant cutaneous sensibility. Detailed gait analysis of these patients has confirmed the weight-bearing capabilities of free muscle flaps with skin grafts and has proven to be an excellent method of foot reconstruction evaluation. It would appear from this study that cutaneous sensibility may not be necessary for successful reconstruction of the weight-bearing surface of the foot. This method of reconstruction should be considered when local tissues are not suitable for plantar foot reconstruction.     

The descending branch of the superficial circumflex artery supplying anteromedial thigh skin

This report presents an extended groin flap design that consists of a conventional skin paddle in the groin region and a vertical extension in the anteromedial thigh region, based on the superficial iliac circumflex artery and an unnamed descending branch, respectively. The inferior branch of the superficial iliac circumflex artery that supplies the thigh extension of the flap, spanning approximately the upper half of the thigh region, was found to originate approximately 2 cm from the origin of the superficial iliac circumflex artery. A total of six free and four local flaps were used in 10 patients with ages ranging from 10 to 60 years (average, 45 years). There were six male and four female patients. The free flaps were required for total facial resurfacing, through-and-through cheek defect, and burn scar contractures and traumatic defects of the lower extremity. The local flaps were used for reconstruction of scrotum defect, trochanteric decubitus ulcer, and lower abdominal skin and fascia defects. All 10 flaps survived completely. The groin flap with anteromedial thigh extension offers the following advantages: (1) it is very easy and quick to elevate; (2) a significantly increased volume of tissue is available for reconstruction, based on one axial vessel and being completely reliable; (3) the flap offers two skin paddles that are independently mobile; (4) there is no need for positional change and a two-team approach is possible; and (5) it can be raised as a vertical skin island only. The authors conclude that the groin flap with anteromedial thigh extension is a useful modification for reconstruction of both distant and local defects.     

The thin latissimus dorsi perforator-based free flap for resurfacing

The authors present their experience with "thin" latissimus dorsi perforator-based free flaps for resurfacing defects. Perforator-based free flaps have been used for various kinds of reconstruction by presenting important donor structures. The thin latissimus dorsi perforatorbased free flap included only the skin and superficial adipose layer to reduce its bulkiness by dissection through the superficial fascial plane. This flap was used in 12 clinical cases, without flap necrosis or other serious postoperative complications. All of the patients were examined by preoperative power Doppler ultrasound in the spectral Doppler mode to search for the most reliable perforator. This noninvasive ultrasound technique determines the exact location and course of and ensures the reliable flow of the perforators; therefore, it greatly assists microsurgeons in saving operation time and in selecting the most suitable design for perforator flap reconstruction. We used perforators that were identified several centimeters from the lateral border of the latissimus dorsi muscle. The thin flap dimensions could be safely designed for flaps measuring up to 20 cm in length and 8 cm in width for primary closure of the donor site. Generally, a long pedicle is not required for resurfacing reconstructions, where small recipient arteries in the bed are acceptable for anastomosis with pedicles. However, pedicle dissection to the proximal vessels through the latissimus dorsi muscle was required when it was necessary to match the recipient vein for anastomosis. The authors conclude that this thin latissimus dorsi perforator-based free flap has great potential for resurfacing because of its constant thickness, easy elevation with the help of power Doppler ultrasound information, and proper flap size for moderate defects caused by scar contracture release, superficial tumor ablation, and so on.     

Free-flap reconstruction of large defects of the scalp and calvarium

Beyond a certain size, full-thickness defects of scalp are not amenable to local flap repair. Staged distant flaps have now been virtually eliminated by free-flap reconstruction. The authors present 12 patients in whom full-thickness scalp defects with an average area of 275 cm2 were reconstructed utilizing free flaps. Nine patients had corresponding large calvarial defects. Ten patients had reconstruction with free latissimus dorsi muscle flaps and overlying skin grafts, and one patient had reconstruction with a scapular free flap. Of the 12 patients, 8 had extirpative surgery for tumor with immediate reconstruction and the remaining 4 had reconstruction for chronic radionecrosis of the scalp, usually associated with infected osteoradionecrosis of the calvarium. Of this latter group, 2 patients underwent simultaneous acrylic cranioplasty. The technique and results are discussed.     

Reconstruction of the radiated partial mastectomy defect with autogenous tissues.

As conservative surgery and radiation therapy have become accepted treatments for early-stage breast cancer, increasing attention has focused on the cosmetic results of this technique. When partial mastectomy--a term which encompasses a diversity of excisional techniques--is followed by radiation therapy, breast defects characterized by parenchymal loss, nipple-areola complex distortion, and cutaneous abnormalities can occur. From 1981 to 1990, eight patients sought reconstructive correction of a radiated partial mastectomy deformity. Patients were from 42 to 70 years of age (mean 49 years). All had breast cancer, except for one patient with diffuse and chronic breast abscesses. Six patients were reconstructed with latissimus dorsi flaps and two with rectus flaps. No patient underwent reconstruction sooner than 1 year after completion of radiation therapy; for the entire group, a mean of 2.6 years elapsed from completion of radiation therapy to flap reconstruction of the breast. Mammograms were obtained on all the breast cancer patients before and after the myocutaneous flap procedure. Follow-up extended from 1 to 9 years after reconstruction (mean 3.6 years) and included both physical examination and serial mammographic evaluations. Myocutaneous flap reconstruction with either latissimus or rectus flaps achieved an aesthetic improvement of the partial mastectomy deformity in all eight patients. Complications consisted only of seroma formation in two patients following latissimus flap reconstruction. Mammographic evaluation revealed fibrofatty degeneration of the soft tissues of both types of flaps, a change that occurs as early as 6 months after operation and appears as a radiolucent area. The feasibility of mammography as a screening adjunct for recurrent cancer in this group of patients is demonstrated. Advantages of this technique of autogenous tissue reconstruction are improvement of contour deformities associated with conservative surgery and radiation therapy, preservation of normal, sensate breast skin, enhancement of symmetry with the contralateral breast, and avoidance of a prosthesis.     

A Comparative Study of Four Types of Free Flaps from the Ipsilateral Extremity for Finger Reconstruction

Aim

To compare the outcomes of finger reconstruction using arterialized venous flap (AVF), superficial palmar branch of the radial artery (SPBRA) flap, posterior interosseous perforator flap (PIPF), and ulnar artery perforator free (UAPF) flap harvested from the ipsilateral extremity.

Methods

We retrospectively reviewed the outcomes for 41 free flaps from the ipsilateral extremity in the reconstruction of finger defects in 41 patients with small/moderate skin defects, including 11 AVFs, 10 SPBRA flaps, 10 PIPFs, and 10 UAPF flaps. Standardized assessment of outcomes was performed, including duration of operation, objective sensory recovery, cold intolerance, time of returning to work, active total range of motion (ROM) of the injured fingers, and the cosmetic appearance of the donor/recipient sites.

Results

All flaps survived completely, and the follow-up duration was 13.5 months. The mean duration of the complete surgical procedure for AVFs was distinctly shorter than that of the other flaps (p<0.05). AVFs were employed to reconstruct skin defects and extensor tendon defects using a vascularized palmaris longus graft in 4 fingers. Digital blood supply was reestablished in 4 fingers by flow-through technique when using AVFs. Optimal sensory recovery was better with AVFs and SPBRA flaps as compared with UAPF flaps and PIPFs (p<0.05). No significant differences were noted in ROM or cold intolerance between the 4 groups. Optimal cosmetic satisfaction was noted for the recipient sites of AVFs and the donor sites of SPBRA flaps. The number of second-stage defatting operations required for AVFs was considerably lesser than that for the other flaps.

Conclusion

All 4 types of free flaps from the ipsilateral extremity are a practical choice in finger reconstruction for small/moderate-sized skin defects. AVFs play an important role in such operations due to the wider indications, and better sensory recovery and cosmetic appearance associated with this method.     

Extremity reconstruction using the free deltoid flap

The deltoid fasciocutaneous flap is a thin, reliable flap that is easily dissected from the posterolateral arm. It has large-caliber vessels and is capable of sensory reinnervation to portions of the flap above the deltoid/triceps groove through the lateral brachial cutaneous nerve. There is little sensory return to the large vascular territory, which can be extended inferiorly below the deltoid triceps groove. The donor site can be closed primarily or skin grafted and when large may be objectionable to some patients. The flap is an excellent choice for extremity soft-tissue reconstruction on the plantar or palmar surfaces. Protective sensibility has returned to all reinnervated flaps. We present our experience in 10 patients with extremity problems.     

Anatomic basis of plantar flap design: clinical applications

Closure of plantar defects with local rotation flaps was studied in 10 patients with 11 plantar defects. Ages ranged from 15 to 66 years, and the average defect was 3.0 X 3.6 cm. Two patients were diabetics. Etiology was variable and included trauma, tumors, and breakdown in patients with anesthetic plantar surfaces. Plantar flaps were designed superficial to the plantar fascia based on the proximal plantar subcutaneous plexus blood supply. Sensation was provided by including the medial calcaneal nerve territory within the flap and by performing a limited intraneural dissection of the medial and lateral plantar nerves. Flaps were medially based, although laterally based designs are also possible when sensation is absent. The follow-up period averaged 20.8 months. Patients with normal sensation preoperatively had full sensation postoperatively and were able to bear weight on the flap without limitation. There was minor breakdown in one patient with incomplete sensation. One patient developed a hematoma. Sensate plantar flaps can be designed superficial to the plantar fascia. These flaps are durable and allow normal weight-bearing on the reconstructed surface.     

Anatomical consideration of reverse-flow island flap transfers from the midpalm for finger reconstruction.

Primary soft-tissue coverage for large palmar defects of the fingers is a difficult problem for cases in which homodigital or heterodigital flaps cannot be used. The aim of this study was to explore the vascular and neural anatomy of the midpalmar area to assess the possibility of reverse island flaps from this area. In 24 cadaver hands perfused with a silicone compound, the arterial pattern of the superficial palmar arch and common palmar digital artery was examined. The cutaneous perforating arteries and nerve branches supplying the midpalmar area were dissected, and the number, location, and arterial diameter of these branches were measured. In six other specimens, the common palmar digital artery was injected to determine the skin territory supplied by the artery. The superficial palmar arch contained the three common palmar digital arteries and its terminal branch coursed along the radial margin of the index metacarpus. This terminal branch had three to six cutaneous perforators (diameter range, 0.1 to 0.5 mm) and supplied the radial aspect of the midpalmar area located over the ulnar half of the adductor pollicis muscles. The midpalmar area was divided into two regions-the proximal and distal-according to the vascular distributions. The proximal region contained dense aponeurosis and thin subcutaneous tissue, and the cutaneous perforators were rather sparse (between three and nine) and had a small diameter (0.1 to 0.3 mm). The distal region, which had loose aponeurosis and abundant subcutaneous tissue, had a rich vascular supply from the common and proper digital artery. Perforating arteries of this region coursed frequently in an oblique fashion and the number of perforators (between eight and 15) and their arterial diameters (diameter range, 0.1 to 0.5 mm) were higher than those of the proximal region. The area of skin perfused by the common palmar digital artery was 5 x 3 cm at the distal midpalmar region. There were three to five cutaneous nerve branches from the palmar digital nerve supplying the midpalmar area. From this study, two different reverse flaps were proposed. First, a 5 x 2 cm flap from the distal midpalmar region was elevated on the basis of the common and proper palmar digital artery. Measurement of the rotation arc revealed that the pivot point of this flap was located at the proximal interphalangeal joint level and could cover the finger pulp of the digits. The second flap candidate was that from the radial aspect of the midpalm, which was supplied by the terminal branch of the superficial palmar arch. In studies with cadaver hands, connection of this artery with the deep arterial system enabled this flap to reach the thumb pulp. These flaps may be a useful reconstruction option for significant palmar soft-tissue loss of the fingers.     

A reverse ulnar hypothenar flap for finger reconstruction

A reverse-flow island flap from the hypothenar eminence of the hand was applied in 11 patients to treat palmar skin defects, amputation injuries, or flexion contractures of the little finger. There were three female and eight male patients, and their ages at the time of surgery averaged 46 years. A 3 x 1.5 to 5 X 2 cm fasciocutaneous flap from the ulnar aspect of the hypothenar eminence, which was located over the abductor digiti minimi muscle, was designed and transferred in a retrograde fashion to cover the skin and soft-tissue defects of the little finger. The flap was based on the ulnar palmar digital artery of the little finger and in three patients was sensated by the dorsal branch of the ulnar nerve or by branches of the ulnar palmar digital nerve of the little finger. Follow-up periods averaged 42 months. The postoperative course was uneventful for all patients, and all of the flaps survived without complications. The donor site was closed primarily in all cases, and no patient complained of significant donor-site problems. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer, as indicated by 5 mm of moving two-point discrimination. A reverse island flap from the hypothenar eminence is easily elevated, contains durable fasciocutaneous structures, and has a good color and texture match to the finger pulp. This flap is a good alternative for reconstruction of palmar skin and soft-tissue defects of the little finger.     

Free medial plantar perforator flaps for the resurfacing of finger and foot defects

In this article, three cases in which free medial plantar perforator flaps were successfully transferred for coverage of soft-tissue defects in the fingers and foot are described. This perforator flap has no fascial component and is nourished only by perforators of the medial plantar vessel and a cutaneous vein or with a small segment of the medial plantar vessel. The advantages of this flap are minimal donor-site morbidity, minimal damage to both the posterior tibial and medial plantar systems, no need for deep dissection, the ability to thin the flap by primary removal of excess fatty tissue, the use of a large cutaneous vein as a venous drainage system, a good color and texture match for finger pulp repair, short time for flap elevation, possible application as a flow-through flap, and a concealed donor scar.     

Innervated radial thenar flap combined with radial forearm flap transfer for thumb reconstruction

A radial thenar flap combined with radial forearm flap was used for the reconstruction of the ipsilateral thumb in four patients. Vascular supply of the combined flap was based on the radial artery and extending the vascular pedicle to the superficial palmar branch of the radial artery. The flap was sensated by the palmar branch of the superficial radial nerve. The size of the flap averaged 15 x 5 cm and the innervated region of the thenar eminence was an area approximately 5 x 3 cm located over the proximal parts of the abductor pollicis brevis and opponens pollicis muscles. The flap was transferred as a free flap in three patients and as an advancement flap in one patient. The flaps survived completely without complications. Satisfactory restoration of sensation was achieved in the flap area, as shown by 6 mm of average moving two-point discrimination. This combined flap may be a feasible reconstructive option for large palmar defects of the fingers such as degloving injuries.     

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept.By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps).Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery.Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients.On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.