Steal syndrome from a superficial circumflex iliac perforator artery flap in a patient with a hypoplastic posterior tibial artery and severe diabetic peripheral artery disease

The use of free flaps in lower extremity reconstructive surgery has seen growing adoption for treating tissue loss in patients with diabetes mellitus and peripheral artery disease as a means for limb preservation. The superficial circumflex iliac perforator artery (SCIP) flap is one of the most commonly utilized flaps in foot reconstruction and has demonstrated benefits over amputation. Patients with impaired vascular and neurologic function are predisposed to complications following lower extremity reconstructive surgery, particularly ischemia in the angiosomes of the arteries used for flap anastomosis. We present the case of a patient who underwent successful SCIP flap reconstruction of the calcaneus but developed gangrene in the forefoot region supplied by a hypoplastic posterior tibial artery in subsequent months. The changes in tissue oxygenation and hemoglobin distribution of the foot are shown using spatial frequency domain imaging throughout the flap healing process and eventual tissue necrosis.