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Endgames Picture Quiz

Management of soft tissue defects of the foot

BMJ 2015; 350 doi: (Published 11 March 2015) Cite this as: BMJ 2015;350:h1184
  1. Alexander E J Trevatt, foundation year 2 doctor1,
  2. Richard O Igwe, foundation year 2 doctor2,
  3. Umraz Khan, consultant plastic surgeon3
  1. 1Royal Free London NHS Foundation Trust, Barnet Hospital, Barnet EN5 3DJ, UK,
  2. 2Homerton University Hospital NHS Foundation Trust, London, UK
  3. 3Frenchay Hospital, Frenchay Park Road, Bristol, UK
  1. Correspondence to: alextrevatt{at}

A 57 year old man presented to his general practitioner with a pigmented lesion on the heel of his left foot. He had not previously sought medical advice about the lesion but had recently become worried that it was growing in size. He was fit and well with no medical history of note.

Excision biopsy confirmed that the lesion was a malignant melanoma and he was referred urgently for wide local excision according to melanoma guidelines. The histological margins were clear with no residual disease seen. Staging examinations were negative. The tumour was less than 1 mm thick and there was no evidence of locoregional or distant metastasis. The resultant excision defect measured 4×4 cm and was not amenable to primary closure.

Initially a split skin graft was used to reconstruct the wound. However, this was not durable enough and failed, so a plastic surgeon who specialised in lower limb reconstruction was consulted (fig 1).

Fig 1 Reconstruction of a post-excisional wound on the patient’s left foot


  • 1. Why is wound reconstruction in the foot challenging?

  • 2. What type of reconstruction was used to close the post-excisional wound?

  • 3. What frameworks exist for soft tissue reconstruction and how can they be applied in daily practice?

  • 4. What types of defect can be adequately reconstructed with a split skin graft and when is a flap more appropriate?


1. Why is wound reconstruction in the foot challenging?

Short answer

The foot is subject to weight bearing stresses and requires sensate tissue reconstruction that can withstand the shearing forces present during ambulation. Reconstruction options are limited by the paucity of available adjacent soft tissue.

Long answer

The plantar skin of the foot is perfectly adapted to weight bearing. It is thicker than skin found elsewhere in the body and more heavily keratinised. Deep to the plantar skin is the strong plantar fascia, which provides …

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