Reappraisal of Island Modifications of Lateral

Calcaneal Artery Skin Flap

M. Erol Demirseren, M.D., Serdar Gokrem, M.D., and Zeki Can, M.D.
Ankara, Turkey

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 flapthe lateral calcaneal
island flap, the lateral calcaneal V-Y advancement flap,
and the bilobed-shaped lateral calcaneal island advancement flapfor the reconstruction of small and mediumsized 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. (Plast. Reconstr. Surg. 113: 1167, 2004.)

tions of the lateral calcaneal artery skin flap for

the reconstruction of soft-tissue defects, mainly
of the calcaneal region and the heel, and discuss advantages and disadvantages of these
modifications.
PATIENTS

AND

METHODS

Patients

Between June of 1995 and March of 2002,

four calcaneal, 11 posterior heel, and three
plantar heel defects of 13 male and 5 female
patients were reconstructed with three island
modifications of the lateral calcaneal artery
skin flapthe lateral calcaneal island flap, the
lateral calcaneal V-Y advancement flap, and the
bilobed-shaped lateral calcaneal island advancement flapat the Department of Plastic
and Reconstructive Surgery, Ankara University
School of Medicine. Causes ranged from diabetic foot ulcer to pressure sore (Table I). The
age range of the patients was between 17 and
56 years, with a mean of 33.94 years. The defect
sizes ranged from 3 3 cm to 6 6 cm. The
postoperative follow-up period ranged from 4
to 24 months, with a mean of 13.72 months. All
of the procedures were performed under spinal or epidural anesthesia (Table II).

Reconstruction of soft-tissue defects of the

calcaneal region and the posterior and plantar
heel is still one of the most challenging problems facing plastic surgeons. Various flap procedures have been described to achieve the
basic requirements, namely, sensation. Among
these procedures, the lateral calcaneal artery
skin flap, which was first described by Grabb
and Argenta,1 is undoubtedly one of the best
methods. Since its publication in 1981, it has
been used with different modifications by different surgeons for the coverage of soft-tissue
defects of the ankle and foot.1 6 All of these
techniques have their strengths and limitations
and their protagonists and critics. In this report, we describe use of some island modifica-

Surgical Anatomy

The lateral calcaneal artery described by

Grabb and Argenta is actually the terminal part
of the peroneal artery and its calcaneal
branches. At the level of the ankle, the peroneal artery lies deeply in the fat between the

From the Department of Plastic and Reconstructive Surgery, Ankara University School of Medicine; the Department of Plastic and Reconstructive Surgery, Ankara Hospital; and the Department of Plastic and Reconstructive Surgery, Ataturk Training and Research Hospital. Received
for publication February 11, 2003; revised May 27, 2003.
DOI: 10.1097/01.PRS.0000110331.78118.AD

1167

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PLASTIC AND RECONSTRUCTIVE SURGERY,

April 1, 2004

TABLE I
Etiologic Summary

Site of Defect

Cause

Calcaneal region

Rupture of calcaneal tendon

and opened wound
Unstable scar over the calcaneal
tendon
Nonhealing wound after an
operation
Avulsion injury from traffic
accident
Diabetic foot ulcer
Pressure sore
Calcaneal fracture and calcaneal
osteomyelitis
Pressure sore

Posterior heel

Plantar heel

No. of
Patients

1
1
2
1
1
9
1
2

Achilles tendon and peroneal tendons. It follows a curve around the lateral malleolus, lying
approximately 1 cm posterior to it. It lies 5 to 8
mm in front of the Achilles tendon, and then
curves downward to a point 30 mm to the tip of
the fibula. Throughout this curved part, it gives
off calcaneal branches that run posteriorly and
inferiorly to form a network beneath the skin,
overlying the lateral, posterior, and inferior surfaces of the calcaneus. Distally, it continues toward the tuberosity of the fifth metatarsal and
there anastomoses with the branches of the lateral plantar artery and the lateral tarsal artery.
Venous drainage of the flap is through the
small saphenous vein, which lies more superficial and anterior to the peroneal artery. The
nerve supply comes from the sural nerve,
which lies just in front of the small saphenous
vein (Fig. 1).7

FIG. 1. Schematic presentation of the lateral calcaneal artery, the small saphenous vein, and the sural nerve.

pedicle. After that, the calcaneal tendon, the

lateral malleolus, the base of the fifth metatarsal bone, and the position and course of the
terminal part of the peroneal artery are
marked. The lateral calcaneal island flap is the
equivalent of the long version of the classic
lateral calcaneal artery skin flap. The defect is
converted to a circle or an ellipse. The size of
the flap is confirmed with a template and
marked on the lateral aspect of the dorsum of
the foot, just below and anterior to the lateral
malleolus (Fig. 2, above).
The lateral calcaneal V-Y advancement flap is
designed in the triangle of tissue in the territory of the lateral calcaneal artery beside the
defect. The distal tip of the flap can be extended approximately 1 cm distal to the base of
the fifth metatarsal bone. The upper and lower
lines of the triangle are bent slightly upward to

Preoperative Planning

For the planning of all modifications, a preoperative Doppler examination is used to assess the patency and localize the position of the

TABLE II
Patient Summary

Site of Defect

Calcaneal region
Posterior heel

Plantar heel

M, male; F, female.

Type of Modification

No., Sex, and Mean Age

(yr) of Patients

2,
2,
7,
2,

(2
(2
(4
(1

M), 30
M), 26
M, 3 F), 39.5
M, 1 F), 37

Mean Size of
Defects (cm)

33
54
4.57 4.71
4 3.5

Lateral calcaneal island flap

Lateral calcaneal VY advancement flap
Lateral calcaneal island flap
Lateral calcaneal VY advancement flap
Bilobed-shaped lateral calcaneal island
advancement flap
Lateral calcaneal island flap

2, (2 M), 26
1, (1 M), 26

4.5 5
54

Lateral calcaneal VY advancement flap

2, (2 M), 35

3.5 4

Complications

None
None
1 (partial loss of graft)
None
None
1 (marginal necrosis of
undermined skin)
1 (necrosis of undermined
skin)

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LATERAL CALCANEAL ARTERY SKIN FLAP

FIG. 2. Schematic presentation of planning of island modifications of the lateral calcaneal

artery skin flap. (Above, left) Lateral calcaneal island flap for the reconstruction of the calcaneal
and posterior heel region. (Above, right) Lateral calcaneal island flap for reconstruction of the
plantar heel region. (Center, left) Lateral calcaneal V-Y advancement flap for reconstruction of the
calcaneal and posterior heel region. (Center, right) Lateral calcaneal V-Y advancement flap for
reconstruction of the plantar heel region. (Below) Bilobed-shaped lateral calcaneal island advancement flap for reconstruction of the calcaneal and posterior heel region.

fit the wrinkle line of the dorsal foot (Fig. 2,

center).
The bilobed-shaped lateral calcaneal island
advancement flap is designed in the territory of
the lateral calcaneal artery. The defect is con-

verted into a circle. As the semicircle-shaped

first lobe is planned extending tangential to
the defect, a triangle-shaped second lobe is
extended from the first lobe to the base of the
fifth metatarsal bone (Fig. 2, below).

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Operative Technique

The ulcer is excised in a fashion so that the

defect is converted to a circle or an ellipse. For
the preparation of the subcutaneous pedicle, a
longitudinal incision is made between the lateral edge of the Achilles tendon and the posterior aspect of the lateral malleolus and fibula.
The dissection on either site is performed subcutaneously. All the subcutaneous tissue containing the neurovascular pedicle is elevated.
Lateral Calcaneal Island Flap

The circle of the skin is incised and the distal

end of the neurovascular pedicle is ligated and
divided. Dissection of the flap is made from distal
to proximal in supraperiosteal and suprafascial
planes so that the paratenon of the peroneus
longus and brevis tendons and periosteum of the
calcaneal bone are left. After complete elevation,
the flap is transferred to the recipient area under

FIG. 4. (Above, left) Preoperative appearance of chronic

ulcer over the lateral plantar heel. (Above, right) Preoperative
planning of the lateral calcaneal island flap. (Below, left) Early
postoperative appearance. (Below, right) Late postoperative
appearance.

a widely undermined skin tunnel and the donor

site is grafted (Figs. 3 and 4).
Lateral Calcaneal V-Y Advancement Flap

First, the upper edge of the flap is incised

only to the immediate subdermal level. Then,
the lower edge of the flap is incised and carried
down through the subcutaneous tissue. After
ligation and division of the distal end of the
neurovascular pedicle, the flap dissection is
made in a similar fashion in supraperiosteal
and suprafascial planes. After complete elevation, the flap is transferred to the recipient
area and the donor site is closed primarily in a
V-Y fashion (Figs. 5 and 6).
FIG. 3. (Above, left) Preoperative appearance of unstable scar
over the calcaneal tendon. (Above, right) Intraoperative appearance of lateral calcaneal island flap transposition through a
subcutaneous tunnel. (Below, left) Early postoperative appearance. (Below, right) Late postoperative appearance.

Bilobed-Shaped Lateral Calcaneal Island

Advancement Flap

Ulcer excision and flap preparation are performed as for the lateral calcaneal V-Y advancement flap. The semicircularly planned first

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LATERAL CALCANEAL ARTERY SKIN FLAP

FIG. 5. (Above, left) Preoperative appearance of chronic ulcer over the calcaneal
tendon and preoperative planning of the lateral calcaneal V-Y advancement flap. (Above,
right) Intraoperative appearance of the lateral calcaneal V-Y advancement flap ready for
advancement to the defect. (Below, left) Early postoperative appearance. (Below, right)
Late postoperative appearance.

lobe is advanced to the circular defect and the

triangular second lobe provides primary closure of the donor site (Fig. 7).
RESULTS

We have seen no problems associated with viability of the flap such as arterial insufficiency or
venous congestion in any of these modifications.
At follow-up ranging from 4 months to 2 years,
the reconstructed areas were stable and sensate.
In two cases treated with the lateral calcaneal
island flap and the V-Y advancement flap, we
saw necrosis of undermined skin between the
lateral malleolus and the calcaneal tendon.
One of them healed in 2 weeks with daily
wound care. However, the other one was reconstructed with partial-thickness skin grafting
(Fig. 6, below, right). One patient treated with a
lateral calcaneal artery island flap had partial loss
of the skin graft that subsequently healed in 3
weeks. All patients complained of paraesthesia
over the lateral part of the dorsum of the foot,
which gradually subsided in 4 to 8 months.
DISCUSSION

Reconstruction of soft-tissue defects of the

distal third of the leg, ankle, and heel poses a
continued challenge to plastic surgeons. The

calcaneal region and the posterior and plantar

heel especially are exposed to pressure, friction, and shearing forces. There are many
methods for reconstruction of these regions.
For this purpose, methods ranging from skin
grafts to microsurgical flaps have been used,
each with some advantages and disadvantages,
for many years.8 16 Use of the lateral calcaneal
island flap avoids disadvantages such as inappropriate graft take associated with skin grafting, insensate coverage, a two-stage procedure
associated with the cross-foot flap, a paucity of
expandable local tissue associated with local
skin flaps, sacrifice of main arteries and nerves
(medial and lateral plantar arteries and
nerves), disruption of sensory innervation of
the weight-bearing plantar area associated with
muscle flaps, insensate coverage, venous congestion, and need for an extended dissection
associated with the sural flap and the need for
skilled personal and sophisticated equipment
associated with microsurgical flaps. We can add
the avoidance of need for extended dissection,
skilled personal, and sophisticated equipment
to the classic advantages of the lateral calcaneal
artery flap including no sacrifice of the main
artery of the foot, reliable venous drainage,
and a thin and sensory flap.

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PLASTIC AND RECONSTRUCTIVE SURGERY,

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FIG. 6. Preoperative appearance of chronic ulcer over the plantar heel and
preoperative planning of the lateral calcaneal V-Y advancement flap. (Above, left)
Plantar view. (Above, right) Lateral view. (Below, left) Early postoperative appearance. (Below, right) Late postoperative appearance.

Island modification has been described to

prevent the problems associated with classic
lateral calcaneal artery skin flaps such as kink
in the pedicle, dog-ear deformity, and the need
for sacrificing the normal skin bridge for flap
insetting.2 It also has a greater arc of rotation.
With its 360-degree arc of rotation, island modification may be used to cover soft-tissue defects even anterior to the medial malleolus.17
We had previously reported our experience
with this modification.18
Island modification could not solve the problems associated with the donor-site area. Because the donor site requires skin grafting,
future contour deformity is inevitable in both
the lateral calcaneal artery skin flap and its
island modification.19 Another disadvantage of
the island lateral calcaneal flap is the possible
compression over the pedicle by the skin
bridge between the donor site and the recipient site. This compression could compromise

the circulation of the flap. The lateral calcaneal V-Y advancement flap eliminates these disadvantages.6 Using this method, the need for
donor-site skin grafting, skin bridge, and compression is avoided. Thus, the contour of the
foot is restored and donor-site morbidity is
diminished. Nevertheless, the most striking advantage of this modification appears when it is
used for the reconstruction of small or medium-sized plantar heel defects, because the reconstruction of distinct plantar heel skin can
be achieved not with similar but with the same
tissue. The only disadvantage of this modification may be the decreased greater arc of rotation; thus, it could not be used for the reconstruction of tissue defects of distant regions
such as the medial malleolus. In addition to
the advantages of the V-Y advancement flap,
our proposed bilobed-shaped lateral calcaneal
island advancement flap has two more advantages: the semicircularly planned first lobe fits

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LATERAL CALCANEAL ARTERY SKIN FLAP

FIG. 7. (Above, left) Preoperative appearance of chronic ulcer over the calcaneal bone and
preoperative planning of the bilobed-shaped lateral calcaneal island advancement flap.
(Above, right) Intraoperative appearance of bilobed-shaped lateral calcaneal island advancement flap ready for advancement to the defect. (Below, left) Early postoperative appearance.
(Below, right) Late postoperative appearance.

exactly to the circular defect, and the triangular second lobe provides easier primary closure
of the donor site.
CONCLUSION

The lateral calcaneal artery flap should still

be considered as one of the first-line options
for the reconstruction of small or mediumsized calcaneal, posterior, and plantar heel defects, with its well-known advantages.
Serdar Gokrem, M.D.
Azerbaycan Cad. 25/3
Bahelievler, Ankara, Turkey
sergokrem@hotmail.com
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