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Mert S, Heidekrueger PI, Fuchs B, Nuernberger T, Haas-Lützenberger EM, Giunta RE, Ehrl D, Demmer W. Microvascular Muscle vs. Fascio-Cutaneous Free Flaps for Reconstruction of Plantar Load-Bearing Foot Defects-An International Survey. J Clin Med 2024; 13:1287. [PMID: 38592127 PMCID: PMC10932295 DOI: 10.3390/jcm13051287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The reconstruction of plantar load-bearing foot defects faces many plastic surgeons with a major challenge. The optimal patient- and defect-oriented reconstructive strategy must be selected. Methods: To analyze the current trends and recommendations in reconstruction of plantar load-bearing foot defects, we conducted an international survey among plastic surgeons querying them about their recommendations and experiences. Results: The survey revealed that the most common strategies for reconstruction of the foot sole are locoregional and microvascular free flaps, emphasizing the relevance of plastic surgery. Among microvascular free flaps, muscle and fascio-cutaneous free flaps are by far the most frequently used. The target qualities of the reconstructed tissue to be considered are manifold, with adherence being the most frequently mentioned. We observed a noteworthy correlation between the utilization of muscle flaps and a preference for adherence. In addition, we identified a substantial correlation between the usage of fascio-cutaneous free flaps and further target qualities, such as good skin quality and sensitivity. Conclusions: Our findings provide insights into the clinical reality and highlight important aspects that must be considered in reconstruction of the weight-bearing areas of the foot providing support in the selection of the appropriate therapy.
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Affiliation(s)
- Sinan Mert
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, LMU Munich, 80336 Munich, Germany (W.D.)
| | - Paul I. Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, 93053 Regensburg, Germany
| | - Benedikt Fuchs
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, LMU Munich, 80336 Munich, Germany (W.D.)
| | - Tim Nuernberger
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, LMU Munich, 80336 Munich, Germany (W.D.)
| | | | - Riccardo E. Giunta
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, LMU Munich, 80336 Munich, Germany (W.D.)
| | - Denis Ehrl
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, LMU Munich, 80336 Munich, Germany (W.D.)
- Department of Plastic, Reconstructive and Hand Surgery, Burn Centre for Severe Burn Injuries, Nuremberg Clinics, University Hospital Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Wolfram Demmer
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, LMU Munich, 80336 Munich, Germany (W.D.)
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Free Medial Plantar Flap Versus Free Dorsal Myocutaneous Flap for the Reconstruction of Traumatic Foot Sole Defects. Ann Plast Surg 2021; 84:S178-S185. [PMID: 32294068 DOI: 10.1097/sap.0000000000002373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Trauma can cause large defects in the weight-bearing foot sole. The reconstruction of such defects poses a major challenge in providing a flap that is durable, sensate, and stable. The pedicled medial plantar flap has been commonly used for reconstructing heel and plantar forefoot defects; however, the ipsilateral instep region is usually compromised by trauma. The purpose of this article was to report the use of contralateral free medial plantar flaps for the coverage of weight-bearing plantar defects and to compare these with distant free flaps. METHODS Between 2005 and 2019, 15 patients (10 men and 5 women) with weight-bearing foot plantar defects were treated with a contralateral medial plantar flap, 11 (7 men and 4 women) with either a latissimus dorsi flap or a scapular flap. The average age was 18.07 ± 10.14 years (range, 4-34 years) and 26.55 ± 13.05 years (range, 13-56 years), respectively. Surgery was performed as a primary or secondary reconstruction after a trauma by the same surgical team. RESULTS The mean size of defects was 9.73 ± 3.55 × 6.43 ± 2.8 cm in the contralateral free medial plantar flap group and 17.14 ± 6.84 × 11.41 ± 4.29 cm in the free dorsal flap group. All flaps survived in both groups. In the instep flap group, the appearance was satisfactory, the flap was durable, and tactile sensation was preserved in all patients, and none required a revision procedure. Two patients experienced delayed union of the donor-site grafted skin. In the dorsal flap group, 5 patients complained of a partial necrosis or delayed union at the recipient site, and 9 developed recurrent ulcerations over the weight-\bearing area. Five patients achieved only partial sensation in the flap. CONCLUSIONS The contralateral medial plantar flap provides superior appearance, duration, and sensation over distant muscle flaps, without recurrent ulcerations. However, dorsal myocutaneous flaps may be used as a substitute when the defects are beyond the maximum boundaries of the instep area or are combined with bone loss.
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Zhang W, Li X, Li X. A systematic review and meta-analysis of perforator flaps in plantar defects: Risk analysis of complications. Int Wound J 2021; 18:525-535. [PMID: 33675188 PMCID: PMC8273610 DOI: 10.1111/iwj.13552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
The purpose of this study was to identify the risk factors for complications of perforator flaps in plantar reconstruction. A systematic review was performed by searching the PubMed, Cochrane Library, MEDLINE, and EMBASE databases from their inception date up to October 2020. Only studies on reconstructing plantar defects with perforator flaps were included, and specific data were required for each patient in the included studies. A total of 14 studies involving 111 flaps were identified and included in the meta‐analysis. Our meta‐analysis identified two risk factors for postoperative complications: flap size over 50 cm2 (risk ratio [RR] = 3.12; P = .02), diabetes mellitus foot (RR = 3.26; P = .03). No significant differences were found regarding heel defects (P = .34), single perforator (P = .57), age older than 60 years (P = .19), chronic aetiology (P = .13), trauma (P = .33), tumour resection (P = .60), ulcer (P = .84), and burn (P = .76). Although more high‐quality studies with adequate sample sizes are needed, this meta‐analysis indicated that flap size over 50 cm2 and diabetes mellitus foot were significant risk factors for postoperative complications of perforator flaps in plantar reconstruction.
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Affiliation(s)
- Wei Zhang
- Department of Plastic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xinyi Li
- Department of Plastic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaojing Li
- Department of Plastic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Treatment of traumatic losses of substance in the foot. ANN CHIR PLAST ESTH 2020; 65:549-569. [PMID: 32753248 DOI: 10.1016/j.anplas.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/26/2020] [Indexed: 11/22/2022]
Abstract
Treatment of traumatic loss of bone and tissue substance in the foot necessitates special consideration of the anatomy and physiology of the segment. The causes of foot trauma are multiple and in many cases violent, leading to progressive tissue deterioration that may require multi-phased debridement. The therapeutic objective is to reconstruct a functional foot permitting painless pushing off, walking and footwear use by restoring a stable bone framework, with resistant covering satisfactorily adjusted to the different zones of the foot. While coverage of the back of the foot must be fine, coverage of the plantar zones will be padded. The reconstructive surgeon shall be particularly attentive to plantar sensitivity. To take up the surgical challenge, it is of paramount importance to fully master a wide-ranging therapeutic arsenal ranging from conventional grafts to composite free flaps in view of proposing the solution most suited to the type, size and location of the loss of substance, all the while striving to generate as few sequelae as possible at the donor site. In order for reconstruction to be successful, multidisciplinary collaboration between plastic surgeons, orthopedists and physician is highly recommended.
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Assessment of axonal sprouting and motor performance after hypoglossal-facial end-to-side nerve repair: experimental study in rats. Exp Brain Res 2020; 238:1563-1576. [PMID: 32488325 DOI: 10.1007/s00221-020-05835-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
Abstract
Hypoglossal-facial nerve anastomosis (HFA) aims to reanimate denervated mimic muscles with hypoglossal axons when the transected facial nerve is not accessible. The aim of this study was to evaluate the recovery of HFA using a "Y" tube in two variants: (1) the proximal stump of the hypoglossal nerve was entubulated to the "Y" tube (classic "Y" tube HFA) and (2) the "Y" tube was sutured to an epineurial window of a slightly damaged hypoglossal nerve (end-to-side "Y" tube HFA). A total of 48 adult female rats were divided into four groups: intact controls (group 1), sham operated (group 2), classic "Y" tube HFA (group 3) and end-to-side "Y" tube HFA (group 4). The abdominal aorta with both common iliac arteries of isogeneic male rats served as the Y-tube conduit. Animals from group 4 recovered better than those from group 3: the degree of collateral axonal branching (3 ± 1%) was significantly lower than that determined in group 3 (13 ± 1%). The mean deviation of the tongue from the midline was significantly smaller in group 4 (6 ± 4°) than that measured in animals from group 3 (41 ± 6°). In the determination of vibrissal motor function in group 3 and group 4, a decrease in amplitude was found to be - 66% and - 92%, respectively. No differences in the reinnervation pattern of the target muscles were detected. As a result, these surgical models were not determined to be able to improve vibrissal movements. It was concluded that performance of end-to-side "Y" tube HFA diminishes collateral axonal branching at the lesion site, which in turn, promotes better recovery of tongue- and vibrissal-motor performance.
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Liu M, Yang Y, Zhang Y, Yang X, Hu D. Surgical Reconstruction of Complex Distal Foot Defects With Vascularized Fascia Lata. Ann Plast Surg 2019; 84:525-528. [PMID: 31609252 PMCID: PMC7357543 DOI: 10.1097/sap.0000000000002115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Reconstruction of distal foot defect remains a challenge in plastic surgery. The purpose of this report is to present a new procedure that repairs these defects in severe burn patients. Results of application and follow-up in 7 patients were presented.
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Affiliation(s)
- Mengdong Liu
- From the Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an
| | - Yunshu Yang
- From the Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an
| | - Yong Zhang
- Department of Burns Surgery, The Second People's Hospital of Xinxiang, Henan, China
| | - Xuekang Yang
- From the Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an
| | - Dahai Hu
- From the Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an
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Lykoudis EG, Dalianoudis I, Seretis K, Lykoudis GE, Lykissas MG. Single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata: A case report. Microsurgery 2017; 38:318-323. [PMID: 29205488 DOI: 10.1002/micr.30277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/29/2017] [Accepted: 11/17/2017] [Indexed: 11/10/2022]
Abstract
Reconstruction of complex soft tissue defects in the distal lower leg remains challenging, since anatomical constraints limit the local options available in this area. In this report, we present a case of single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata. A 55-year-old patient underwent wide excision of a synovial sarcoma in the distal lower leg, which resulted in a complex defect including the peroneus longus and brevis tendons (10 cm), and the overlying skin (14 × 8 cm). Functional reconstruction was achieved in a single stage with a composite anterolateral thigh flap with vascularized fascia lata of similar dimensions to those of the defect. The fascia lata component of the flap was longitudinally split in two segments. Each of them was rolled up, and that way, two separate vascularized neotendons were created. The neotendons bridged the gap of peroneal tendons, whereas the skin paddle of the flap provided stable soft tissue coverage to the reconstructed tendons. Flap pedicle was anastomosed to the anterior tibial vessels. Early and late postoperative periods were uneventful. Follow up at 1 year postoperatively showed excellent neotendon incorporation, as well as a very good functional and aesthetic outcome. The use of the method described may be a useful alternative in single stage functional reconstruction of composite defects comprising two or even more tendons and the overlying skin.
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Affiliation(s)
| | - Ioannis Dalianoudis
- Department of Plastic Surgery, Ioannina University Hospital, Ioannina, Greece
| | | | - George E Lykoudis
- Department of Plastic Surgery, Ioannina University Hospital, Ioannina, Greece
| | - Marios G Lykissas
- Department of Orthopaedic Surgey, Ioannina University Hospital, Ioannina, Greece
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Macedo JLSD, Rosa SC, Rezende Filho Neto AVD, Silva AAD, Amorim ACSD. Reconstrução de lesões de partes moles de pé com o uso de retalho plantar medial. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Macedo JLSD, Rosa SC, Neto AVDRF, Silva AAD, Amorim ACSD. Reconstruction of soft-tissue lesions of the foot with the use of the medial plantar flap. Rev Bras Ortop 2017; 52:699-704. [PMID: 29234654 PMCID: PMC5720857 DOI: 10.1016/j.rboe.2017.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022] Open
Abstract
Objective To study use of the medial plantar flap for reconstruction of the heel and foot. Method The authors share their clinical experience with the use of the medial plantar artery flap for coverage of tissue defects around the foot and heel after trauma. Twelve cases of medial plantar artery flap performed from January 2001 to December 2013 were included. Results Of the 12 patients, ten were male and two were female. The indications were traumatic loss of the heel pad in ten cases and the dorsal foot in two cases. All the flaps healed uneventfully without major complications, except one case with partial flap loss. The donor site was covered with a split-thickness skin graft. The flaps had slightly inferior protective sensation compared with the normal side. Conclusion From these results, the authors suggest that the medial plantar artery flap is a good addition to the existing armamentarium for coverage of the foot and heel. It is versatile flap that can cover defects on the heel, over the Achilles tendon and plantar surface, as well as the dorsal foot. It provides tissue to the plantar skin with a similar texture and intact protective sensation.
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Affiliation(s)
- Jefferson Lessa Soares de Macedo
- Hospital Regional da Asa Norte, Brasília, DF, Brazil.,Escola Superior de Ciências da Saúde, Curso de Medicina, Brasília, DF, Brazil
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Reverse-Flow Lateral Tarsal Island Flap for Covering the Great Toe Donor Site of Wraparound Flap. Ann Plast Surg 2017; 77:445-9. [PMID: 26418775 DOI: 10.1097/sap.0000000000000612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coverage of the great toe donor site of wraparound flap remains a challenge. This report presents the results of using an innervated pedicled reverse-flow lateral tarsal island flap for covering the great toe donor site of wraparound flap. PATIENTS AND METHODS Between 2005 and 2010, 11 reverse-flow lateral tarsal island flaps were used to cover the great toe donor site of wraparound flap in 11 patients. This pedicled flap designed on the lateral tarsal area of foot was based distally on the dorsalis pedis artery; the lateral dorsal pedal cutaneous nerve was incorporated into the reverse-flow lateral tarsal island flap and coapted with the first plantar digital nerve. The donor sites of reverse-flow lateral tarsal island flap were covered with inguinal full-thickness skin grafts. RESULTS All flaps achieved primary healing except for two that suffered from mild venous insufficiency which was managed by conservative intervention. All skin grafts covering the donor site of reverse-flow lateral tarsal island flap healed uneventfully. The mean follow-up was 24 months (range, 18-48 months). The mean hallux metatarsophalangeal-interphalangeal scale score was 92 points (range, 85-97 points) at 6 months postoperatively. The static 2-point discrimination of the reverse-flow lateral tarsal island flap ranged from 6 to 14 mm (mean 10 mm). None of the patients were restricted in standing or walking during follow-up. CONCLUSIONS The reverse-flow lateral tarsal island flap based distally on the dorsalis pedis artery has a constant pedicle that is sufficiently long. This innervated pedicle flap is a reliable option to cover the great toe donor site of wraparound flap with satisfactory functional and cosmetic results and acceptable donor site morbidity.
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Lee SH, An SJ, Kim NR, Kim UJ, Kim JI. Reconstruction of Postburn Contracture of the Forefoot Using the Anterolateral Thigh Flap. Clin Orthop Surg 2016; 8:444-451. [PMID: 27904728 PMCID: PMC5114258 DOI: 10.4055/cios.2016.8.4.444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 09/03/2016] [Indexed: 11/06/2022] Open
Abstract
Background Severe forefoot deformities, particularly those involving the dorsum of the foot, cause inconvenience in daily activities of living including moderate pain on the dorsal aspect of the contracted foot while walking and difficulty in wearing nonsupportive shoes due to toe contractures. This paper presents clinical results of reconstruction of severe forefoot deformity using the anterolateral thigh (ALT) free flap. Methods Severe forefoot deformities were reconstructed using ALT flaps in 7 patients (8 cases) between March 2012 and December 2015. The mean contracture duration was 28.6 years. Results All the flaps survived completely. The size of the flaps ranged from 8 cm × 5 cm to 19 cm × 8 cm. The mean follow-up period was 10 months (range, 7 to 15 months). There was no specific complication at both the recipient and donor sites. There was one case where the toe contracture could not be completely treated after surgery. All of the patients were able to wear shoes and walk without pain. Also, the patients were highly satisfied with cosmetic results. Conclusions The ALT flap may be considered ideal for the treatment of severe forefoot deformity.
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Affiliation(s)
- Sang Hyun Lee
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sung Jin An
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Nu Ri Kim
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Um Ji Kim
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jeung Il Kim
- Department of Orthopedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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An Algorithm for Forefoot Reconstruction With the Innervated Free Medial Plantar Flap. Ann Plast Surg 2016; 76:221-6. [DOI: 10.1097/sap.0000000000000564] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Song D, Yang X, Wu Z, Li L, Wang T, Zheng H, Hou C. Anatomic basis and clinical application of the distally based medialis pedis flaps. Surg Radiol Anat 2015; 38:213-21. [PMID: 26246341 DOI: 10.1007/s00276-015-1532-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/31/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Soft-tissue defects of the forefoot are difficult to cover adequately, particularly, although multiple options for reconstruction are available. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels to medialis pedis flap viability. METHODS Thirty cadavers were available for this anatomical study. Microdissection was conducted under a microscope, and details of the course and distribution and the communication of the first plantar metatarsal artery with the fascial vascular network of the medial side of the foot were recorded. Clinically, six cases of soft-tissue defects at the forefoot region were reconstructed with distally based medialis pedis flap. RESULTS The perforator of the first plantar metatarsal artery pierces in the superficial fascia of the medial aspect of the foot 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, vascularize the skin of the medial plantar region. The anatomical study showed that the vasculature pattern could roughly be classified into two types. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft. CONCLUSION The perforators of the medialis pedis flap are presented constant. The forefoot region can be repaired by the distally based medialis pedis flap on the perforator of the medial plantar artery of the hallux or the first plantar metatarsal artery perforator with medial plantar vein, medial plantar cutaneous nerve and nutrient vessels.
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Affiliation(s)
- Dajiang Song
- Department of Head and Neck Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.,Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.,Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Xiaodong Yang
- Department of Hand and Foot Surgery, Yiwu Central Hospital, Zhejiang, China
| | - Zedong Wu
- Department of Comparative Medicine, General Hospital of People's Liberation Army Nanjing District, Fujian Medical University, Fuzhou, 350108, China
| | - Lei Li
- Department of Comparative Medicine, General Hospital of People's Liberation Army Nanjing District, Fujian Medical University, Fuzhou, 350108, China
| | - Tianquan Wang
- Department of Comparative Medicine, General Hospital of People's Liberation Army Nanjing District, Fujian Medical University, Fuzhou, 350108, China
| | - Heping Zheng
- Department of Comparative Medicine, General Hospital of People's Liberation Army Nanjing District, Fujian Medical University, Fuzhou, 350108, China.
| | - Chunlin Hou
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China.
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Jordan DJ, Malahias M, Hindocha S, Juma A. Flap decisions and options in soft tissue coverage of the lower limb. Open Orthop J 2014; 8:423-32. [PMID: 25408784 PMCID: PMC4235066 DOI: 10.2174/1874325001408010423] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/03/2014] [Accepted: 05/27/2014] [Indexed: 12/18/2022] Open
Abstract
THE LOWER EXTREMITIES OF THE HUMAN BODY ARE MORE COMMONLY KNOWN AS THE HUMAN LEGS, INCORPORATING: the foot, the lower or anatomical leg, the thigh and the hip or gluteal region. The human lower limb plays a simpler role than that of the upper limb. Whereas the arm allows interaction of the surrounding environment, the legs' primary goals are support and to allow upright ambulation. Essentially, this means that reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of reconstruction, the primary goals are based on the preservation of life and limb, and the restoration of form and function. This paper aims to review current and past thoughts on reconstruction of the lower limb, discussing in particular the options in terms of soft tissue coverage. This paper does not aim to review the emergency management of open fractures, or the therapy alternatives to chronic wounds or malignancies of the lower limb, but purely assess the requirements that should be reviewed on reconstructing a defect of the lower limb. A summary of flap options are considered, with literature support, in regard to donor and recipient region, particularly as flap coverage is regarded as the cornerstone of soft tissue coverage of the lower limb.
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Affiliation(s)
- Daniel J Jordan
- Department of Plastic Surgery, Whiston Hospital, Liverpool, UK L35 5DR, UK
| | - Marco Malahias
- Department of Plastic Surgery, Heart of England NHS Foundation Trust, UK
| | - Sandip Hindocha
- Department of Plastic Surgery, Whiston Hospital, Liverpool, UK L35 5DR, UK
| | - Ali Juma
- Department of Plastic Surgery, Countess of Chester Hospital, Chester, UK
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[Long-term functional evaluation of complex traumatic heel defects reconstructed by flap in children]. ANN CHIR PLAST ESTH 2014; 61:44-54. [PMID: 25301288 DOI: 10.1016/j.anplas.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 09/07/2014] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Complex heel injuries in children are rare and their management requires coverage combining resistance and thinness, to allow walking and footwear. The objective of this study was to create a decision-making algorithm for heel defect in children. MATERIALS Children received for heel defect, reconstructed with flap in our plastic surgery unit of Bordeaux with a follow-up greater than 10 years were investigated. Three children operated between 1999 and 2003 were included. A free contralateral reinnervated medial plantar flap, a free latissimus dorsi flap and a lateral supramalleolar flap were performed. Patients were reviewed in consultation to assess quality of reconstruction and functional outcomes. Three scores were used, the Foot Function Index (FFI), the AOFAS Ankle and Hindfoot Scale and the Maryland Foot Score. RESULTS No growth disorder has been found. Scores greater than 80 for the Maryland Foot Score and AOFAS Ankle and Hindfoot Scale and less than 10 for the FFI were very satisfactory in cases 1 and 3. We found pain and greater functional impairment in the second case. CONCLUSIONS "Like-with-like" reconstruction remains the gold standard, whether in loco-regional or free flap. The fasciocutaneous flaps allow custom reliable coverage with little donor site morbidity. Loco-regional flaps remain easily accessible but donor site sequelae are not negligible.
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Liu L, Zhou Y, Cao X, Cao X, Cai J. Heel reconstruction with free instep flap: a case report. J Med Case Rep 2014; 8:319. [PMID: 25260532 PMCID: PMC4181468 DOI: 10.1186/1752-1947-8-319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/31/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction Reconstruction of weight-bearing heel defects remains a challenge because of the unique characteristics of the plantar skin. Though numerous surgical reconstructive options have been reported, the instep flap represents an ideal option and seems to be more acceptable to patients than others. However, when the heel defect expands to the instep area, the ipsilateral instep is not available for flap elevation. A free instep flap harvested from the contralateral foot can be a good solution, but this method has been scarcely reported. Case presentation A 41-year-old Asian man presented to our institution with a soft-tissue lesion in the weight-bearing heel and instep area. His heel was reconstructed with a free instep flap from the other foot, end-to-side anastomosis of its medial plantar artery to the recipient posterior tibial artery and end-to-side coaptation of the cutaneous sensory fascicles of the flap to the medial plantar nerve. Conclusion The flap survived successfully, and no ulceration occurred in the flap. At the last follow-up appointment at 30 months post-surgery, a very good functional and aesthetic outcome was verified, indicating that the suggested approach may prove to be the treatment of choice in selected cases of weight-bearing heel reconstruction.
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Affiliation(s)
- Lifeng Liu
- Orthopedic Department, General Hospital of Jinan Military Command, No,25, Shifan Road, Jinan 250031, China.
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18
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Tan O, Aydin OE, Demir R, Barin EZ, Cinal H, Algan S. Neurotized sural flap: An alternative in sensory reconstruction of the foot and ankle defects. Microsurgery 2014; 35:183-9. [PMID: 25196975 DOI: 10.1002/micr.22325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The sensory reconstruction of the lower extremity is one of the main goals in lower extremity reconstruction. Reconstructive options endowing sensory recovery are limited. The aim of this report is to evaluate the neurotized sural flap in reconstruction of foot and ankle defects. PATIENTS AND METHODS Seven cases that were operated for foot and ankle skin defects with the neurotized sural flap were reported. The largest flap was 10 cm × 14 cm in size. Median age was 38 years. Four defects were on the heel, two were on the ankle, and one was on the dorsum of the foot. The sural nerve was coaptated to a recipient nerve in seven patients. RESULTS All flaps survived totally. Follow-up time ranged between 9 and 29 months. All cases had hot-cold perception and two-point discrimination at average 14 ± 1.63 mm at 6th month. Sensory conduction test revealed very low action potentials related to stimulation of the flap. CONCLUSION The neurotized sural flap is a versatile modification, for the sensory reconstruction of the moderate size foot and ankle defects.
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Affiliation(s)
- Onder Tan
- Plastic Reconstructive and Aesthetic Surgery Department, Ataturk University Faculty of Medicine, Erzurum, Turkey
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19
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Akita S, Mitsukawa N, Rikihisa N, Kuriyama M, Kubota Y, Hasegawa M, Koizumi T, Ishigaki T, Uchida Y, Satoh K. Reconstruction of the great toe using a pedicled medial plantar flap with anterograde venous drainage. Microsurgery 2014; 34:398-403. [DOI: 10.1002/micr.22234] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 01/17/2014] [Accepted: 01/24/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Shinsuke Akita
- Department of Plastic and Reconstructive Surgery; Chiba Cancer Center; Chiba City Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery; Chiba University, Faculty of Medicine; Chiba City Japan
| | - Naoaki Rikihisa
- Department of Plastic and Reconstructive Surgery; Chiba Rosai Hospital; Chiba City Japan
| | - Motone Kuriyama
- Department of Plastic and Reconstructive Surgery; Kochi Medical School Hospital; Nankoku City Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery; Chiba University, Faculty of Medicine; Chiba City Japan
| | - Masakazu Hasegawa
- Department of Plastic, Reconstructive and Aesthetic Surgery; Chiba University, Faculty of Medicine; Chiba City Japan
| | - Tomoe Koizumi
- Department of Plastic, Reconstructive and Aesthetic Surgery; Chiba University, Faculty of Medicine; Chiba City Japan
| | - Tatsuya Ishigaki
- Department of Plastic and Reconstructive Surgery; Chiba Cancer Center; Chiba City Japan
| | - Yuuki Uchida
- Department of Plastic, Reconstructive and Aesthetic Surgery; Chiba University, Faculty of Medicine; Chiba City Japan
| | - Kaneshige Satoh
- Department of Plastic, Reconstructive and Aesthetic Surgery; Chiba University, Faculty of Medicine; Chiba City Japan
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20
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Okada M, Saito H, Kazuki K, Nakamura H. Combined medialis pedis and medial plantar fasciocutaneous flaps for coverage of soft tissue defects of multiple adjacent fingers. Microsurgery 2014; 34:454-8. [DOI: 10.1002/micr.22222] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 12/17/2013] [Accepted: 12/26/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Mitsuhiro Okada
- Department of Orthopedic Surgery; Osaka City University Graduate School of Medicine; Osaka Japan
| | - Hidehiko Saito
- Department of Orthopedic Surgery; Seirei Hamamatsu Hospital; Hamamatsu Shizuoka Japan
| | - Kenichi Kazuki
- Department of Orthopedic Surgery; Osaka City General Hospital; Osaka Japan
| | - Hiroaki Nakamura
- Department of Orthopedic Surgery; Osaka City University Graduate School of Medicine; Osaka Japan
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