Abstract
Diabetic foot ulcers (DFUs) represent a major cause of morbidity, hospitalisation, and lower limb amputation worldwide. Despite advances in wound care, off‑loading strategies, and revascularisation techniques, a subset of patients develop complex soft‑tissue defects that are not amenable to conventional reconstructive approaches. In this context, microvascular free tissue transfer has emerged as an important limb‑salvage strategy. This narrative review synthesises contemporary evidence regarding the role of free tissue transfer in the management of complex DFUs, with a focus on reconstructive outcomes, evolving flap techniques, patient selection, and multidisciplinary care pathways. While early outcomes are promising, much of the supporting evidence derives from small, retrospective series in specialised centres. Patient selection remains a critical determinant of success. Advanced comorbidities, particularly peripheral arterial disease and end‑stage renal disease, significantly influence limb‑salvage outcomes but should not be considered absolute contraindications in isolation. Outcomes are notably poorer in the setting of acute diabetes‑related foot infections compared with chronic non‑healing ulcers, underscoring the heterogeneity of DFU presentations. Increasingly, multidisciplinary orthoplastic pathways incorporating vascular optimisation, aggressive infection control, and coordinated reconstruction have been shown to improve limb‑salvage rates. In conclusion, FTT represents a powerful reconstructive option for carefully selected patients with complex DFUs within a multidisciplinary framework. Future research should prioritise prospective multicentre studies, standardised outcome reporting, and long‑term functional assessment to better define the role of microsurgical reconstruction in modern diabetic foot care.