Why Make Things Complicated When They Can Be Simple? Case Series and Systematic Review on the Reconstruction of Full-Thickness Soft-Tissue Heel Defects

Background/Objectives: Reconstruction of full-thickness soft-tissue defects of the heel can be challenging due to the specific structural and functional demands of this region. Local flaps are often used due to their ability to provide durable and sensate coverage. This case series and systematic review aim to assess their surgical efficacy and reported outcomes, particularly in the context of the rhomboid flap. Methods: A systematic review was conducted in accordance with PRISMA guidelines, using PubMed, Cochrane and EBSCO. Studies published up to March 2026 evaluating local flaps were included, whereas distant pedicled and microvascular flaps were excluded. Defect size, flap types and surgical outcome were extracted and synthesized in a comparative table. In addition, we present four clinical cases of full-thickness soft-tissue heel defects reconstructed with a local rhomboid flap. This retrospective, single-center case series includes patients treated at our institution between January 2023 and March 2026, with initial debridement followed by flap coverage. Results: The four patients had a mean defect size of 4.1 cm2. All defects ultimately healed, though one case demonstrated delayed wound healing. Eventually, neither donor-site morbidity, nor recurrence were observed during a mean follow-up of 7.4 months (range 1 to 17 months). Nine studies were included in the review, encompassing 56 patients. Despite the variety of the studies regarding design and flaps used, all focused on outcomes, including flap survival, complication rate, and functional recovery. Local flaps appear to be a feasible option for this type of soft-tissue defect; however, they seem to be limited to small defects. Conclusions: Local flaps may represent a valuable option for small full-thickness heel defects up to 6 cm2 according to the “like-with-like” principle. They are associated with low surgical morbidity and do not compromise subsequent reconstructive options, making them a reasonable first-line approach. Limitations include the small sample size, retrospective design, the unequal follow-up time, as well as the absence of standardized functional outcome assessment.