足内侧逆行岛状皮瓣修复前足皮肤缺损

目的　研究修复前足皮肤缺损的新方法。方法　在解剖学研究的基础上 ,利用足底内侧动脉终支与第 1跖骨底动脉、足底深动脉及足底深弓的吻合 ,设计逆行足底内侧血管及足内侧皮穿支蒂岛状皮瓣修复前足皮肤缺损创面。结果　临床应用 6例 ,皮瓣面积 4cm× 3cm～ 11cm× 9cm ,血管蒂长 6～ 11cm ,皮瓣全部成活 ,随访 6～ 2 4个月 ,外形与功能改善满意。结论　本皮瓣是修复前足皮肤缺损的最佳选择之一。     

Reconstruction of distal forefoot burn defect with retrograde medial plantar flap

Burn reconstruction of forefoot remains as a difficult challenge, because the local flap alternatives are limited. We evaluated the efficiency of distally based medial plantar fasciocutaneous island flap in the coverage of forefoot defects resulting from release of toe contracture and burn debridement. Four patients with toe contractures and two patients with third degree burn in forefoot were treated between June 2004 and February 2006. The mean follow-up period was 10.4 months. The flaps were elevated as with a fasciocutaneous base on the distal medial plantar artery. The dimensions of the flaps ranged from 4cmx3cm to 5cmx4cm. The skin over the pedicle was included as a part of flap in three cases. Concomitant vein of the pedicle was anastomosed with the first plantar digital vein in four cases. In the early postoperative period, one flap used to cover third degree burn due to high-voltage electric injury was lost completely. We concluded that this flap was an appropriate alternative reconstructive option for the forefoot defect. Including skin and subcutaneous tissue over the pedicle to flap protects the pedicle against kinking and compression. Venous supercharging of the flap improves venous drainage.     

Retrograde-flow medial plantar island flap reconstruction of distal forefoot,toe, and webspace defects

Plantar forefoot defects have been reconstructed using a wide variety of techniques, including skin grafts, local flaps, and free tissue transfer. The distally based, retrograde-flow medial plantar island flap provides coverage with durable plantar skin from the nonweight-bearing instep area to reconstruct defects at the metatarsal heads. This technique requires careful flap dissection, and the anterior reach of the flap is limited by its pedicle length and vascular pivot point location. The authors describe two cases using this flap for reconstruction of tumor resection defects (5 x 6 cm and 5 x 8 cm) involving the distal forefoot, toes, and webspaces. One case required venous supercharging of a congested flap with an interpositional vein graft. Technical aspects of the design, elevation, and inset of the flap that enhance its versatility and reliability are presented. The reverse-flow medial plantar fasciocutaneous island flap should be considered an option for forefoot defects that extend anteriorly onto the metatarsal heads, including defects involving the toes and webspaces.     

利用跖底动脉弓的足底岛状皮瓣修复前足软组织缺损

目的 探讨前足软组织缺损的修复方法。方法 对6例前足软组织缺损患者施行以跖底动脉弓为蒂的逆行足底岛状皮瓣进行修复。结果 随访6个月,皮瓣全部成活,两点辨别觉<10mm。结论 该皮瓣血管蒂长(最长可达18cm),皮肤质地与受区相近,血运可靠,是修复前足软组织缺损的较好方法。     

Distally based perforator medial plantar flap: a new flap for reconstruction of plantar forefoot defects

In this article the author describes 2 cases of a distally based perforator medial plantar flap that were transferred successfully from the nonweight-bearing instep region to the weight-bearing plantar forefoot (defects, 8 x 5 cm and 6 x 5 cm respectively). This flap is nourished solely by perforators of the medial plantar vessels. The advantages of this flap are the protection of the vascular supply of the foot (because both posterior tibial and medial plantar vascular systems are preserved), anterograde flow of the vascular supply (which gives an additional advantage of expecting less venous insufficiency compared with reverse-flow flaps), no dependence on retrograde vascular communications, minimal donor site morbidity, and transport of structurally similar tissues to the plantar forefoot.     

Modified retrograde‐flow medial plantar island flap for reconstruction of distal dorsal forefoot defects—Two case reports

Soft tissue reconstruction of the distal forefoot and toes poses a difficult problem. Skin grafts are not suitable when deep structures are exposed. Local flaps are not available, particularly for defects of the toes. Free flaps are spared for larger defects. Medial plantar flap has been widely used for plantar defects, especially weight‐bearing surface of the heel. Distally based retrograde‐flow design of this flap allows the transfer of the pedicled flap distally and provides coverage of soft tissue over the metatarsal heads. In this report, we further modified the retrograde‐flow medial plantar island flap to extend its use for distal dorsal forefoot defects. The technique and outcomes of two patients are presented. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.     

Reconstruction of Lateral Forefoot Using Reversed Medial Plantar Flap with Free Anterolateral Thigh Flap

Skin defects of the heel have frequently been reconstructed using the medial plantar flap; however, forefoot coverage has remained a challenge, because the alternatives for flap coverage have been very limited. We describe a case of malignant melanoma on the lateral forefoot that was radically removed and reconstructed successfully with a distally based medial plantar flap, together with a free anterolateral thigh flap. The advantages of this flap include that it does not reduce the vascular supply to the foot owing to reconstruction of the medial plantar vascular systems, reduces the risk of flap congestion, minimizes donor site morbidity, and enables the transport of structurally similar tissues to the plantar forefoot. We believe this technique is a reasonable reconstructive option for large lateral plantar forefoot defects.     

足底内侧逆行岛状皮瓣的解剖与应用

在解剖研究中发现,足底内侧动脉至少有2处与足底动脉弓相联,一是足底内侧动脉主干的远端,通过第一跖底动脉与足深动脉吻合;二是其较大分支——外斜支通过与第2,3趾总动脉的吻合。基于上述发现,设计出足底内侧逆行岛状皮瓣,临床应用3例,皆获成功,效果满意,为前足底负重区缺损的修复提供了一个新的皮瓣。     

足底内侧逆行岛状皮瓣的解剖与应用

在解剖研究中发现，足底内侧动脉至少有２处与足底动脉弓相联，一是足底内侧动脉主干的远端，通过第一跖底动脉与足深动脉吻合；二是其较大分支——外斜支通过与第２，３趾总动脉的吻合。基于上述发现，设计出足底内侧逆行岛状皮瓣，临床应用３例，皆获成功，效果满意，为前足底负重区缺损的修复提供了一个新的皮瓣。     

足底内侧逆行岛状皮瓣的解剖与应用

在解剖研究中发现，足底内侧动脉至少有２处与足底动脉弓相联，一是足底侧动脉主干远端，通过第一跖底动脉与足深动脉吻合；二是其较大分支－外斜支通过与第２，３趾总动脉的吻合，基于上述发现，设计出足底内侧逆行岛状皮瓣，临床应用３例，皆获成功，效果满意，为前足底负重区缺损的修复提供了一个新的皮瓣。     

The bipedicled medial plantar flap: Vascular enhancement of a reverse flow Y–V medial plantar flap by the inclusion of a metatarsal artery perforator for the reconstruction of a forefoot defect—A case report

The pedicled medial plantar (MP) flap is an optimal solution for defects involving the weight‐bearing areas of the foot. However, venous congestion is a frequently encountered complication, especially with the reverse‐flow variants of the flap, and several strategies have been reported in literature both to prevent and to manage it. In this article, we present the use of a medial plantar flap based distally on the lateral plantar artery with the adjunct of an extra metatarsal perforator from the dorsalis pedis artery as a vascular enhancement to avoid the venous congestion and to improve the overall circulation. This bipedicled flap was successfully advanced to cover a 5 × 3 cm soft‐tissue defect located at the level of the first and second metatarsal heads of the right foot resulting from the excision of a squamous cell carcinoma in an 80‐year‐old male patient with a history of cardiovascular disease. The postoperative course was uneventful. The patient was discharged 7 days after the operation and was able to walk after 6 weeks wearing normal shoes. We believe that preserving plantar metatarsal perforators during the harvesting of an MP flap based distally on the lateral plantar artery may be a precious adjunct as it increases blood supply, especially the venous drainage of the flap.     

Soft-tissue reconstruction for recalcitrant diabetic foot wounds

Thirty-three consecutive patients with plantar soft-tissue defects were managed by a single surgeon (EDN) with reconstruction by a medial plantar artery (MPA)-based flap. Foot defects resulted from a combination of abnormal weightbearing distribution and neuropathy secondary to diabetes mellitus in all patients. A retrospective study of diabetic patients from 1984 to 1997 with foot defects reconstructed with a MPA-based flap were reviewed. Thirty-three patients (age 55 +/- 9) with an average tissue deficit of 13 +/- 9 cm2 had MPA reconstruction of the heel (n = 8), midfoot (n = 23), and forefoot (n = 2). The mean follow-up was 19 months (range, 3 months-5 years). There were four minor complications, including marginal flap necrosis or localized infection, although all healed uneventfully. There were six major complications resulting in loss of the flap and proximal amputation. Out of seven patients, there were 12 rerotations of the previously rotated flap. Various techniques for reconstruction of plantar foot defects have been described in the literature. Utilizing glabrous skin for reconstruction of these defects is appealing for its unique shear and pressure-resisting properties. Surgical management of diabetic foot defects with the medial plantar artery flap is an effective means of soft tissue reconstruction.     

Various applications of the medial plantar flap to cover the defects of the plantar foot,posterior heel,and ankle

The medial plantar fasciocutaneous flap provides structurally similar tissue to plantar foot, posterior heel, and ankle defects with its thick glabrous plantar skin, shock-absorbing fibrofatty subcutaneous tissue, and plantar fascia. During the past 4 years, 24 patients (20 men, 4 women) with skin and soft-tissue defects over the plantar foot, posterior heel, or ankle were treated. They ranged in age from 20 to 42 years (mean, 24 y). The medial plantar flap was transposed to the defects in four different ways: proximally pedicled sensorial island flaps (N = 18), reverse-flow island flaps (N = 2), free flaps (N = 2), and cross-foot flaps (N = 2). Flap size varied from a width of 2 to 5.5 cm and a length of 5 to 7.5 cm. The follow-up period ranged from 2 to 18 months (mean, 9 mo). Partial flap loss was observed in one free flap and one reverse-flow island flap. Partial skin graft lost in the donor site required regrafting in one patient. Durable, sensate coverage of the defects was achieved in all patients.     

足底内侧逆行岛状皮瓣修复前足底顽固性溃疡

目的　为临床前足底顽固性溃疡的修复提供一种方法。　方法　自 1 998年起 ,应用以足底内侧血管束远端为蒂的足底内侧逆行岛状皮瓣修复前足底顽固性溃疡 5例 ,同期矫正局部畸形 ,皮瓣切取范围 3.5～ 5.0 cm×4.0～ 5.5 cm,术后注意皮瓣区近期不负重 ,保持清洁干燥。　结果　皮瓣全部成活 ,随访 6～ 1 4个月 ,皮瓣质地好 ,可见较厚角化层 ,但皮瓣痛觉迟钝 ,患足可负重行走 ,溃疡无复发。　结论　以足底内侧动静脉为蒂的逆行岛状皮瓣血运好 ,适用于修复前足底顽固性溃疡     

Free sensate medial plantar flap for contralateral plantar forefoot reconstruction with flap reinnervation using end‐to‐side neurorrhaphy: A case report and literature review

Reconstruction of weight‐bearing plantar defects remains a challenge due to the unique characteristics of the plantar skin and thus the limited available options. The medial plantar flap, either pedicled or free, represents an ideal option, but its use as sensate flap for forefoot defects has been scarcely reported. We present a case of plantar forefoot reconstruction with a free sensate medial plantar flap, with end‐to‐side coaptation of the cutaneous sensory fascicles of the flap to the medial plantar nerve of the recipient. Last follow‐up, at 2 years post‐op, verified a very good functional and aesthetic outcome, indicating that the suggested approach may prove the treatment of choice in selected cases of plantar forefoot reconstruction. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.     

Versatility of the abductor hallucis muscle as a conjoined or distally-based flap

Soft tissue coverage of the medial ankle and foot remains a difficult, challenging, and often frustrating problem to patients as well as surgeons. To our knowledge, the abductor hallucis muscle flap is not frequently used and only a few well documented cases were found in literature. The purpose of this paper is to report and to present the long-term results of a series of four patients who underwent reconstruction of foot and ankle defects with the abductor hallucis muscle flap.In two cases, the abductor hallucis muscle flap was transposed in combination with a medialis pedis flap to cover a medial ankle defect, whereas in another case it was combined with a medial plantar flap. In this latter case, the muscle flap served to fill up a calcaneal dead space after osteomyelitis debridement, whereas the cutaneous flap was used to replace debrided skin at the heel. The abductor hallucis flap was used as a distally-based turnover flap to cover a large forefoot defect in a fourth case. Follow-up period ranged between 18 and 64 months (mean 43.3). In the early postoperative period, two flaps healed completely In two patients marginal flap necrosis occurred which was subsequently skin grafted. No donor-site complication occurred in any of the patients. In all cases, protective sensation of the skin was satisfactory as early as 6 months. In two cases mild hyperkeratosis at the skin graft border to the sole skin (non-weight bearing area of medial plantar and medialis pedis flap donor site) was present, but probably related to poor foot care. All patients were fully mobile as early as 3 months after treatment. In the long-term follow-up (43.3 months), all flaps provided with durable coverage. Functional gait deficit due to consumtion of the abductor hallucis muscle was not apparent.Our long-term results demonstrated that the abductor hallucis muscle flap is a versatile, and reliable flap suitable for the reconstruction of foot and ankle defects. Utilizing the abductor hallucis muscle as a pedicled flap (distally or proximally-based) with or without conjoined regional fasciocutaneous flaps offers a successful and durable alternative to microsurgical tree flaps for small to moderate defects over the calcaneus region, medial ankle, medial foot, and forefoot with exposed bone, tendon, or joint.     

Are reverse flow fasciocutaneous flaps an appropriate option for the reconstruction of severe postburn lower extremity contractures?

Full thickness burns involving the lower extremity can result in severe contractures, which impair extremity functions if they are not managed with proper treatment and rehabilitation. After release of postburn contracture of the knee, ankle, and metatarsophalangeal joints, defects often require coverage by flaps. Twelve distally based reverse flow flaps were performed for lower-extremity reconstruction after release of postburn flexion contractures. All of the patients were male and their age ranged from 20 to 23 years, with a mean age of 21. After the release of the contractures, 3 flaps were used based on the location of the contractures. The reverse flow anterolateral thigh flap was used for knee reconstruction (n = 4, 33%). The reverse flow sural flap was used for ankle reconstruction (n = 4, 33%), and the reverse flow medial plantar flap was used for metatarsophalangeal reconstruction (n = 4, 33%). The sizes of the flap varied from 2 to 17 cm wide and 3 to 18 cm in length. All defects were covered successfully. Reverse fasciocutaneous tissue transfer to reconstruct the soft tissue defects provide early motion. Sufficient contracture release is achieved without displacement of anatomic landmarks. The reverse-flow flap is a reasonable and reliable choice for each joint level in the lower extremity.     

A simple way to secure the distally based fascio-cutaneous flap of the leg: the lesser sapheneous-greater sapheneous vein anastomosis. Report of 15 clinical cases

PURPOSE: The distally based fasciocutaneous flaps of the leg are very useful for the treatment of skin defects at the lower third of the leg and the foot, but the venous congestion due to the reverse flow can be responsible of necrosis at the distal part of the flap. The anastomosis of the lesser saphenous vein which is included in the flap's dissection to the greater saphenous vein near the defect avoid this venous congestion and the necrosis of the most useful part of the flap for the coverage of these defects. MATERIAL AND METHODS: From January 1999 to June 2005, 15 patients aged between 22 and 64 years old have benefited for the treatment of soft tissue defects secondary to trauma with a mean diameter of 7 x 10 cm and located in 7 cases at the lower third of the leg and in 8 cases at the posterior side of the heel, from distally based posterior fasciocutaneous flaps where the venous reverse flow has been changed in a physiological one by the terminolateral anastomosis between the lesser and greater saphenous vein. The dissection of these flaps was classical except that the lesser saphenous vein was dissected 6 cm beyond the proximal part of the flap in the popliteal region. RESULTS: In all these flaps, there was no venous congestion and no arterial problems. With a mean follow-up of 40 months, the coverage's quality of these defects was very satisfactory. No sequellae are reported. CONCLUSION: The anastomosis between the lesser and the greater saphenous veins seems to eliminate the main source of failure of the distally based fasciocutaneous flap of the leg and can reinforce the indications of these flaps for the treatment of such defects.     

Modified distally based peroneal artery perforator flap for reconstruction of foot and ankle

The distally based sural fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. Here we report on a series of cases of foot and ankle reconstruction with a modified distally based sural flap. The vascular pedicle of the flap includes an axial perforator branch of the peroneal artery and two concomitant veins. This modified distally based perforator flap, measuring around 17 x 6 cm to 30 x 10 cm in size, was transferred for coverage of foot and ankle soft-tissue defects in 7 cases. All flaps survived completely. Neither arterial ischemia nor venous congestion was noted. As compared to other distally based sural flaps with neuro-veno-adipo-fascial pedicles, this modified sural flap with a thin perforator pedicle is easily rotated. The flap can obtain abundant blood supply through both axial perforator and longitudinal chain-linked vascular plexuses, and does not have the venous reflow problem. In conclusion, the invention of this perforator fasciocutaneous flap provides a valuable tool for repair of foot and ankle soft-tissue defects.     

两种足内侧皮瓣修复前足皮肤缺损的疗效分析

[目的]总结足内侧隐神经营养血管皮瓣(隐神经组)与?母趾底内侧动脉皮穿支血管蒂隐神经营养血管皮瓣(穿支蒂组)逆行修复前足皮肤缺损的疗效。[方法]2005年3月～2010年10月,采用隐神经组皮瓣和穿支蒂组皮瓣逆行修复前足皮肤缺损各16例、20例,对两组移植皮瓣术后淤血、坏死、愈合、负重后肿胀消退、感觉恢复等分析对比。[结果]隐神经组皮瓣淤血8例,表浅及以上坏死6例,Ⅱ期愈合6例;穿支蒂组皮瓣淤血2例,表浅坏死1例,Ⅱ期愈合1例。随访7月～19个月,平均12个月,负重后皮瓣均不同程度肿胀,隐神经组平均1.6个月消肿,穿支蒂组平均0.8个月消肿;感觉恢复:隐神经组S1 2例,S2 5例,S3 4例,S3+3例,S4 2例;穿支蒂组S2 1例,S3 3例,S3+7例,S4 9例。从皮瓣淤血、坏死、愈合、负重后消肿情况及感觉恢复等方面对比穿支蒂组优于隐神经组(P<0.05)。[结论]?母趾底内侧动脉皮穿支血管蒂隐神经营养血管皮瓣逆行修复前足皮肤缺损并发症少,功能恢复好,修复质量高,安全可靠。