The Medial Plantar Artery Flap: A Series of Cases over 14 Years

Coverage of the weightbearing heel poses a unique technical challenge to the reconstructive surgeon. In the present study, we share our clinical experience with the use of the medial plantar artery-based flap for coverage of tissue defects around the heel. Eighteen medial plantar artery flaps performed from January 1996 to December 2009 were included. All the procedures were performed by 2 surgeons at Aga Khan University and Hospital (Karachi, Pakistan) and Bahawal Victoria Hospital (Bahawalpur, Pakistan). Of the 18 patients, 16 were male and 2 were female. The indications were traumatic loss of the heel pad in 13, pressure sores in 2, and unstable plantar scars in 3. All the flaps were raised as sensate fasciocutaneous pedicled flaps based on the medial plantar artery. All the flaps healed uneventfully without major complications. The donor site was covered with a split-thickness skin graft, and we had partial graft loss in 1 case. The sensate flaps had slightly inferior protective sensation compared with the normal side. From our results, we suggest that the medial plantar artery flap is a good addition to the existing armamentarium. It provides tissue to the plantar skin with a similar texture and an intact protective sensation. The technique is easier to master compared with free microvascular flaps and has less risk of any functional donor site morbidity.     

Medial plantar artery perforator flap for soft-tissue reconstruction of the heel

Soft-tissue wounds of the foot and especially the heel are challenging problems for reconstructive surgeons. An important principle that guides heel reconstruction is to provide sensate skin with a similar thickness to resurface the weight-bearing heel and avoid late flap ulceration. Among various techniques to achieve this result, the sensate medial plantar perforator flap is an excellent option, which provides durability to friction, a cushioning effect, and sensation. An anatomic study was performed to clarify the anatomy of the cutaneous perforators of the medial plantar artery and to determine the optimal method of medial plantar artery perforator flap harvest. Fifteen cases of heel reconstruction with the sensate medial plantar perforator flap are presented. The outcome of surgery at a mean follow-up of 12 months is reported. The indications for surgery, operative procedures, advantages and disadvantages, and results are presented. Satisfactory results were obtained with a good color and texture match for heel repair and a good sensory recovery. No functional deficit was found at the donor site.     

Replacing losses in kind: improved sensation following heel reconstruction using the free instep flap

Two similar patients, with extensive defects of the heel treated by free tissue transfer of the contralateral instep, are discussed. Durable coverage and near normal static two-point discrimination were obtained in both. Improved results are attributed to the proximal interfascicular dissection of the medial plantar nerve and implantation into the posterior tibial nerve as the recipient. This flap may be transferred with only relatively minor donor-site complications. The contralateral instep free flap provides an ideal, durable, and sensate heel replacement, particularly when local tissues are unavailable.     

Instep free flap for plantar soft tissue reconstruction: indications and options

Pedicled instep flaps are frequently used in weight-bearing plantar reconstruction, but may not be available after severe foot injuries. Although free instep flaps offer a viable option, they have scarcely been reported. A posttraumatic plantar forefoot defect was reconstructed with a sensate, instep free flap, because local flaps were not available and defect size did not require a distant free flap, and the current literature was reviewed for therapeutic options. The instep free flap yielded an excellent functional and aesthetic long-term result. In the literature, pedicled instep flaps are advocated for moderate size defects of the weight-bearing heel and sole, while free flaps from distant sites are preferred for large defects. Although skin-grafted muscle flaps and fasciocutaneous flaps yield similar results, reconstruction by like tissues appears favorable. We suggest the instep free flap for weight-bearing plantar foot reconstruction, when pedicled instep flaps are not available and distant free flaps are avoidable.     

足底内侧皮瓣在足跟部恶性黑色素瘤的应用

目的探讨足跟部恶性黑色素瘤的手术切除和修复重建的方法。方法5例老年足跟部恶性黑色素瘤患者，手术行局部扩大切除，切缘距病损2cm，深度达跟骨骨膜，足跟部软组织缺损Ф5～9cm，根据缺损大小，用带足底内侧血管神经束的皮瓣移位修复，皮瓣面积8cm×6cm-10cm×8cm。结果5例皮瓣全部成活。随访2年6个月～5年，患者均健在，肿瘤未见局部复发，皮瓣感觉功能良好，患足功能与对侧相比无明显差异。结论足跟部恶性黑色素瘤应行局部扩大切除术，切除范围应距肿瘤边缘不小于2cm为宜，在切缘阴性的基础上进行修复重建，应用足底内侧皮瓣移位修复，临床疗效满意。     

足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部软组织缺损

目的探讨足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部皮肤软组织缺损的临床效果。方法回顾性分析2015年10月至2020年12月榆林市第二医院烧伤整形手足外科收治的足跟部皮肤软组织缺损患者的临床资料。患者经急诊清创或扩创后,应用足底内侧岛状皮瓣修复足跟部创面,腹股沟游离皮瓣修复足底内侧供区创面,腹股沟供区直接缝合。术后观察皮瓣血运及存活、皮瓣供区愈合情况,并对足跟外形与功能恢复情况进行随访。结果共纳入8例患者,男7例,女1例,年龄20~71岁,平均32.2岁。其中5例为足跟外伤,1例足跟鳞状细胞癌,1例足跟冻伤,1例足跟溃疡。足跟部创面面积4 cm×3 cm~7 cm×6 cm。手术过程顺利,足跟岛状皮瓣及腹股沟皮瓣切取范围较足跟创面扩大0.5~1.0 cm。8例患者术后皮瓣血运良好,创面均一期愈合。术后随访3~12个月,所有患者足跟弹性佳,外形无臃肿,耐磨、耐压,感觉及行走功能满意;足底内侧供区无凹陷,无瘢痕增生及挛缩,无局部皮肤溃疡;腹股沟供区仅见线性瘢痕。结论足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部缺损,足部外观及功能恢复良好,效果满意。     

Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm², and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.     

Free rectus abdominis muscle flap with plantar skingraft--a combined method of aesthetic and functional reconstruction of the heel.

A 16-year-old girl presented with a contusion of the left calcaneus that was treated by combined free rectus abdominis muscle flap and plantar skin graft. The main advantages of this procedure are that it replaces weight-bearing skin of the heel with histologically similar skin from the instep, and the fibrofatty pad of the heel with muscle; it provides a good cosmetic result in the heel, and the scars of the donor site are well-hidden.     

Refinements of medial plantar flap used for covering nonweightbearing ankle and posterior heel defects requiring thin flaps

We present our clinical experiences with the refinements that we applied to avoid circular flap contraction and achieve thin flap coverage in the reconstruction of posterior heel and tendocalcaneal skin defects with medial plantar flap. Eight male patients, aged 18 to 35 (mean 24 years), with nonweightbearing skin defects, were treated with refined medial plantar flaps. All flaps survived and no circulation problem was encountered. The flaps adapted well to the recipient area, and thin and well-contoured skin coverage was achieved by postoperative month 6. As a conclusion, it is possible to reconstruct the nonweightbearing defects needing thin flap by medial plantar flap with adding refinements: (1) adding triangles around the flap, (2) harvesting a thin flap by excluding the thick plantar fascia, (3) harvesting a further thin flap by defatting of the flap, (4) application of pressure to the flap.     

足跟部皮肤恶性肿瘤切除术后皮瓣修复的临床疗效分析

目的探讨足跟部皮肤恶性肿瘤切除术后的创面采用皮瓣修复的临床疗效。方法本组11例患者中，患恶性黑色素瘤者8例、交界痣恶变者2例、慢性溃疡恶变者1例。对所有患者的肿瘤部位首先行距病灶边缘0．5～2．0cm广泛切除，然后分别采用四种不同类型带蒂皮瓣进行修复。结果术后随访患者6个月至3年10个月，所有皮瓣均存活，皮瓣感觉恢复良好，有2例患者肿瘤局部复发。结论为避免肿瘤局部复发，切除足跟部皮肤恶性肿瘤时，需距病灶边缘2cm以上行扩大切除。修复切除后的创面不宜应用局部旋转皮瓣。采用足底内侧皮瓣对足跟部负重功能的修复效果较好，足跟部外侧和内侧的创面可采用足外侧皮瓣或内踝上皮瓣修复。腓肠神经伴营养血管蒂皮瓣可修复整个足跟部创面。     

足底内侧游离皮瓣、肌皮瓣移植修复足跟缺损

我们采用吻合血管、神经的足底内侧游离皮瓣、肌皮瓣移植修复足跟软组织缺损８例，皮瓣全部成活。４～６周后负重行走，经６～２４个月随访，移植皮瓣无１例出现溃疡，感觉恢复良好，两点分辨觉达２．０～３．０ｃｍ。我们强调了神经吻合的重要性，认为皮瓣的感觉恢复是防止溃疡发生、取得远期良好效果的首要条件。     

足内侧跨供区皮瓣游离移植修复虎口创面

目的 探索能兼顾功能与外形的修复虎口创面的新方法。方法 设计足内侧跨越足背与足底内侧2个皮瓣供区的跨供区皮瓣移植，足底皮肤修复手掌侧皮肤，足背皮肤修复虎口背侧区皮肤。结果 临床应用9例全部成功，功能恢复正常，外形近似正常，术后3年，跨供区皮瓣中的足背皮肤外形与手背皮肤相同。足底内侧皮瓣完全同化成手掌皮肤并且在原有位置上重新产生了掌横纹。结论 足内侧跨供区皮瓣移植修复虎口创面，既能恢复虎口功能，又能恢复虎口区的外形。     

足底内侧游离皮瓣、肌皮瓣移植修复足跟缺损

我们采用吻合血管、神经的足底内侧游离皮瓣、肌皮瓣移植修复足跟软组织缺损8例,皮瓣全部成活。4～6周后负重行走,经6～24个月随访,移植皮瓣无1例出现溃疡,感觉恢复良好,两点分辨觉达2.0～3.Ocm。我们强调了神经吻合的重要性,认为皮瓣的感觉恢复是防止溃疡发生、取得远期良好效果的首要条件。     

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.     

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.     

Heel coverage by a plantar myocutaneous island pedicle flap

Defects of the heel represent a difficult reconstructive problem. Previously described methods have not always been ideal especially for the posterior heel. The weight-bearing functional requirements of the heel tissue over the calcaneus are a sensitive, well padded, durable cover. The technique of choice should provide local similar tissue plus involve a single reliable operative procedure. Skin grafts placed on the calcaneus or on a muscle transposition flap, such as the flexor digitorum brevis, abductor hallucis, or abductor digiti minimi muscle, provide a thin, insensitive, and dissimilar surface. The cross-foot, cross-leg, cross-thigh, and buttock flaps provide more bulk and thicker skin. These flaps involve a prolonged hospitalization, multiple procedures, increased morbidity, and insensitive tissue. The dorsal foot island flap and microvascular free flaps are a one-stage procedure with less morbidity. The donor tissue is still too dissimilar to provide the protection and durability to this area. Random plantar flaps have provided a functional replacement with similar tissue having adequate sensation. However, these random flaps are not always reliable, have limited motion, and are limited usually to small defects. Recently the myocutaneous flap has been proposed using the flexor digitorum brevis muscle. This neurovascularized flap is larger and more reliable. Our dissection study of plantar tissue using microlatex injected feet has expanded the plantar flap for easier heel coverage and provided a predictable flap area. By mobilizing the pedicle proximally to the posterior tibial artery, the flap has an expanded coverage arc. Thus the heel is covered with a sensitive and durable tissue to allow weight bearing, frictional trauma, and ambulation.     

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.     

Use of a reverse-flow plantar marginal septum cutaneous island flap for repair of a forefoot defect.

Soft-tissue reconstruction of the foot frequently requires flap coverage to preserve exposed tissues such as bones, joints, tendons, and weight bearing areas. Recently, reconstruction of skin defects in the heel has been greatly improved by use of the medial plantar sensory flap. However, forefoot coverage remains a challenge, since the alternatives for flap coverage are very limited. A case report is presented of a 52-year-old man with a chronic forefoot ulcer, successfully covered with a plantar marginal septum cutaneous island flap. This recently reported technique, which utilizes a reversed-flow flap based on the superficial branch of the medial division of the medial plantar artery, is relatively easy and disadvantages to the donor site are minimal.     

Island medial plantar artery perforator flap for reconstruction of plantar defects

Three cases in which island medial plantar artery perforator flaps were successfully transferred for coverage of the plantar defects are described. This perforator flap is different from the medial plantar flap based on the medial plantar artery. The flap has no fascial component and is nourished only with the perforator of the medial plantar vessel. Therefore, transection of the medial plantar artery is usually unnecessary. This flap can cover defects on the forefoot and heel without transaction of the medial plantar system. The advantages of this flap are no need for deep or long dissection for the medial plantar vessel, no exposure of the plantar sensory nerve, a short time for flap elevation, minimal donor-site morbidity, relatively large flap survival, and no damage of both the posterior tibial and medial plantar neurovascular systems.     

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.