title: Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature.
abstract: BACKGROUND
  Defects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed.
  
  
  METHODS
  An extensive review of the English literature was performed on PubMed using the following key-words: "Achilles region", "heel", "soft-tissue reconstruction", "flaps", "grafts" and "dermal substitutes".
  
  
  RESULTS
  A total of 69 complete papers were selected, covering the last thirty years' literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review.
  
  
  CONCLUSIONS
  The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally-based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.
authors: Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato, Università degli Studi di Milano, San Donato Milanese, Via Morandi, 30 - 20097, Milan, Italy. Electronic address: ilmarchesiandrea@gmail.com.
authors: A
authors: A
authors: Marchesi
authors: Department of Plastic and Reconstructive Surgery, University of Udine, Udine, Italy.
authors: P C
authors: PC
authors: Parodi
authors: Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato. Università degli Studi di Milano, San Donato Milanese, Milan, Italy.
authors: M
authors: M
authors: Brioschi
authors: Department of Reconstructive Plastic Surgery-Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy.
authors: M
authors: M
authors: Riccio
authors: Department of Medical and Surgery Specialties, Section of Plastic Surgery, University of Catania, Catania, Italy.
authors: R E
authors: RE
authors: Perrotta
authors: Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy.
authors: M
authors: M
authors: Colombo
authors: Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy.
authors: G M
authors: GM
authors: Calori
authors: Department of Plastic and Reconstructive Surgery. I.R.C.C.S. Policlinico San Donato, Università degli Studi di Milano, San Donato Milanese, Milan, Italy.
authors: L
authors: L
authors: Vaienti
mesh_terms: D000125:Achilles Tendon / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D019651:Plastic Surgery Procedures / Q000379:methods; D017695:Soft Tissue Injuries / Q000473:pathology / Q000601:surgery*; D013524:Surgical Flaps; D013708:Tendon Injuries / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D014945:Wound Healing
keywords: Achilles region; Debridement; Defects; Flaps; HBOT; Management; Reconstructive ladder; Soft-tissue; Wounds