Purpose: Diabetic foot ulcers (DFU) represent a reconstructive challenge. Here we present the “Extracorporeal” free flap for the reconstruction of lower extremity DFUs (Figure.1).

Methods: Following patient optimization, our reconstruction involves standard free flap harvest, end-to-end anastomosis, and inset. We then cover the “hanging” pedicle with a skin graft instead of making extraneous incisions or tunnels within undisturbed tissues that can compress the vessels. While the flap incorporates, the exposed pedicle is protected with a soft dressing. After incorporation, a second-stage surgery is performed which entails pedicle division, flap inset revision, and end-to-end reconstruction of recipient vessel (Figure.2).

Results: This technique was used to reconstruct 10 distal lower extremity DFUs. Defects ranged between 18-23cm2. Defects were reconstructed using the first dorsal metacarpal artery perforator, radial forearm, and anterolateral thigh free flaps. All patients underwent successful flap division with 100% flap survival rate. One patient developed partial necrosis of the flap distal tip that was managed conservatively.

Conclusion: In addition to decreasing the number of incisions, our technique utilizing “extracorporeal” pedicle simplifies flap monitoring and inset, and allows reconstruction of recipient vessel to reestablish distal blood flow, with no substantial increase in required operative skill.