Systematic reappraisal of the reverse-flow medial plantar flap: From vascular anatomical concepts to surgical applications

Reverse-flow Flaps of the Medial Plantar Region: Review of the Literature With Case Report

Background

Many variations of the reverse flap design elevated on the medial plantar region have emerged since its introduction. Our aim was to review the literature to provide a broader understanding of the various iterations of the reversed blood-flow flap raised on the medial plantar region. Second, we wished to appraise the reverse medialis pedis flap by review of the literature and presentation of a case report.

Methods

A review of the literature was conducted regarding the reversed blood-flow flap elevated in the medial plantar region. The diverse types of vascular axis and retrograde blood-flow origin of the reverse flap in the medial plantar region were categorized. A clinical case of the reverse medialis pedis flap with step-by-step flap elevation and description of key landmarks are presented.

Results

Our literature review identified 38 publications pertaining to retrograde flow flaps in the medial plantar region. The reverse-flow anatomy derived from these publications was categorized based on vascular axis (pedicle) and retrograde blood-flow origins; Only 5 publications included the reverse medialis pedis flap in their article while 3 papers focused on detailed anatomic study and case series on this flap.

Conclusions

The reverse medial plantar artery flaps come with multiple flap designs depending on which antegrade flow artery is ligated and what anastomotic vascular origin is supplying the reversed blood flow. The reverse medialis pedis flap based on the superficial medial plantar artery with anastomosis to the first plantar metatarsal artery deserves consideration as an option for small defects of the great toe metatarsophalangeal joint.

Clinical application of free inguinal flaps with retrograde blood supply anastomotic to repair soft tissue defects of extremities

To observe the clinical efficacy of free inguinal flaps with retrograde blood supply anastomosis to repair skin and soft tissue defects in the limbs. A total of 25 patients with soft tissue defects of the limbs treated from January 2019 to December 2021 were selected and repaired with free inguinal flaps anastomotic with retrograde blood supply. All 25 skin flaps survived; 1 patient had skin flap infection and the wound healed gradually after symptomatic treatment, and 1 patient had venous embolism and the skin flap survived after re-anastomosis. The patients were followed up for 6 to 18 months after the operation. After healing, the patient recovered satisfactorily, and the flap had a good appearance, texture, and flexibility; a reoperation was not required. The patient was satisfied with the effect of the treatment. Retrograde vascular anastomosis with the anterolateral femoral perforator flap is safe and reliable for repairing the soft tissue defects of the limbs. It is convenient for micromanipulation and can achieve satisfactory clinical results, and thus is an ideal repair method.

[Application of wrap-around great toe flap combined with medial plantar artery perforator flap for completely degloved fingers]

OBJECTIVE

To investigate the effectiveness of the wrap-around great toe flap combined with medial plantar artery perforator flap (MPAP) for repairing the completely degloved fingers.

METHODS

Between February 2018 and December 2019, 12 patients with the completely degloved fingers caused by machine strangulation were admitted. There were 9 males and 3 females with a median age of 32 years (range, 18-42 years). The injured finger was index finger in 7 cases, middle finger in 3 cases, and ring finger in 2 cases. The skin was avulsed from the metacarpophalangeal joint level, with the intact tendon and joint. The interval between injury and admission was 1-8 hours (mean, 5 hours). All fingers were taken debridement during the emergency operation. The size of the skin defect ranged from 8.0 cm×5.0 cm to 12.0 cm×7.5 cm. After flap thinning, the wrap-around great toe flap (8.0 m×2.0 cm-12.0 cm×3.5 cm) and MPAP (8.0 cm×4.0 cm-12.0 cm×5.5 cm) were used to repair the degloved finger. The donor sites were repaired with the full-thickness skin graft or the flap.

RESULTS

All flaps and skin grafts survived completely without significant complications and the wounds at recipient and donor sites healed by first intention. All patients were followed up 12-16 months (mean, 14 months). The texture, appearance, and color of the affected fingers were close to those of normal fingers, and the nails grew normally. At last follow-up, the mean two-point discrimination of the flap was 9 mm (range, 8-10 mm), and the sensation of the injured finger recovered to S₃-S₄. And 10 cases were rated as excellent and 2 cases as good according to the Michigan Hand Outcomes Questionnaire (MHQ). There was no complication such as pain from walking or skin ulceration at the donor site. The American Orthopaedic Foot and Ankle Society (AOFAS) score was excellent in 9 cases and good in 3 cases.

CONCLUSION

Treating for the completely degloved fingers, the wrap-around great toe flap combined with MPAP can obtain good effectiveness in the respect of the sensation, function, and appearance.

[A systematic approach to plastic surgical foot reconstruction]

BACKGROUND

Soft tissue defects of the foot are very common sequelae after trauma and require an individual reconstructive approach.

OBJECTIVE

Recommendations for the treatment of soft tissue injuries to the foot are given.

MATERIAL AND METHODS

The criteria of soft tissue reconstruction, postoperative follow-up and complications are first discussed before the therapeutic approach is explained depending on the reconstruction site. Case examples are given for illustration.

RESULTS

Decision making for soft tissue reconstruction of the foot is based on the location, the 3‑dimensional extent of the defect, the patient requirements and concomitant diseases. Standardized treatment algorithms are usually applied that need to be adapted according to individual patient factors. Randomized and local pedicled flaps can be applied for foot reconstruction; however, these options involve a significant risk of complications. Consequently, free flaps are frequently indicated after appropriate preoperative diagnostics of the perfusion of the foot. Due to the vast variety of donor sites, free flaps allow an individualized reconstruction, which is adapted to local and patient requirements.

CONCLUSION

Precise preoperative reconstructive planning and analysis of the vascularization form the foundation for a successful soft tissue reconstruction of the foot. The aims of the individualized approach to soft tissue reconstruction of the foot are stable soft tissue coverage, resistance to weight bearing of the sole of the foot, the ability to wear normal shoes and maintenance of sensibility.

Application of Digital Subtraction Angiography in Reconstruction of Plantar Forefoot With Reverse Medial Plantar Flap

ABSTRACT

The reverse medial plantar flap (RMPF) raised from the nonweight-bearing region of the plantar foot represents a viable option for the soft tissue defect in planter forefoot. The anatomical basis of RMPF is the complex anastomotic branches between medial plantar artery (MPA) and deep plantar arch. Those anastomotic branches have high variation rate and may be damaged by trauma such as electric injury. Therefore, it is very important to know whether those anastomotic branches are present and intact before harvesting RMPF. Five patients with soft tissue defect in planter forefoot were enrolled into the study. The digital subtraction angiography (DSA) was performed to evaluate the plantar hemodynamics in the ipsilateral foot. The RMPF was harvested only after the anastomotic connections between MPA and deep plantar arch was confirmed. Anastomosis between superficial branch of MPA and deep plantar arch was observed in all DSA examinations. All 5 patients received the repair of soft tissue defect in plantar forefoot with RMPF. All flaps survived completely. The DSA can effectively evaluate the blood supply basis of RMPF and provide imaging evidence for the design and harvest of the flap. The main anatomical basis of RMPF is the anastomotic connections between superficial branch of MPA and deep plantar arch.

Anterior tibial artery injury is not the contraindication of medial plantar flap: digital subtraction angiography evidence and clinical application

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF.

Bipedicled distally based medial plantar artery perforator flap for forefoot reconstruction: A case report

Reconstruction of soft-tissue defects in the foot weight-bearing area should encompass sensate and robust skin. Regarding forefoot defects, distally based medial plantar artery (MPA) flap is an ideal option. However, considering variation of the terminal branches of the MPA, reverse flow flaps can be unreliable with an increasing risk of venous congestion or insufficient arterial flow. In this report, we present a case of the use of reverse flow MPA flaps with dual flow vascularization. The patient was a 37-year-old female who presented a 7 × 3 cm soft-tissue defect of the right forefoot after wide local excision following melanoma. Reconstruction happened with a perforator distally based bipedicled flap (8 × 4 cm) on the MPA though keeping an enhanced vascularization through both superficial (sMPA) and deep (dMPA) medial plantar arteries. Donor site was closed with skin graft. Patient was discharged from hospital at postoperative Day 10 and healed uneventfully with progressive start walk was possible again. A full weight bearing with normal shoes was possible after 8 weeks. Good healing and no functional impairment were present after 9 months of follow-up. We believe this dual vascularization concept may be adopted when possible to improve the overall circulation of the flap and to prevent risks of vascular insufficiency or vein congestion.