Comparing Free and Pedicled Flaps for Leg, Ankle and Heel Reconstruction: An Analysis of Outcomes, Complications and Flap Selection Considerations.

Background/Objectives: Reconstruction of defects in the ankle, foot and heel is complex because of the limited availability of local tissue and multiple comorbidities like diabetes mellitus and peripheral vascular disease. Even though free and pedicled flaps are widely used, their comparative effectiveness remains incompletely defined. Methods: This study presents a narrative analysis of 21 studies. From each study, we extracted data related to flap type, characteristics of the patient, indications, and outcomes: flap survival, limb salvage, functional recovery and complications. Results: Free flaps were mainly used for the management of large, complex, infected, or weight-bearing plantar defects and generally showed high rates of survival (~95-97%) with good functional outcomes and limb salvage rates. On the other hand, pedicled flaps and perforator-based flaps were principally used for small-to-medium defects and showed comparable survival rates in selected cohorts (up to ~98-100%), although direct comparison is limited by differences in defect complexity and patient selection. Overall, the functional outcomes appeared comparable across techniques in appropriately selected patients. However, long-term complications, such as ulceration in weight-bearing heel regions, remained frequent (reported rates were up to 39-41% in some free flap series). Sensory recovery and vascular status were key elements of long-term success, often exceeding flap type in predicting outcomes. Conclusions: Both free and pedicled flaps are effective options for reconstructing lower limb defects when appropriately indicated. While pedicled flaps remain preferred for smaller defects and high-risk patients, free flaps are generally better suited for extensive and more complex defects. The outcomes are influenced by several factors: individualized reconstruction strategy, characteristics of the defects, vascular status and patient comorbidities.