A, Vasopressor-induced necrosis in bilateral feet. Due to contralateral transmetatarsal amputation, every effort was made to preserve bony architecture. B, After transmetatarsal amputation and temporary coverage. C and D, Anterolateral thigh vascularized free flap was used. Debulking was required to allow for reasonable shoe wear. This amputation and graft are indicated when preservation of bony architecture is paramount, and caution is required when deep infection or arteriosclerosis is present.