Reconstruction of distal forefoot burn defect with retrograde medial plantar flap

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.

Plantar forefoot reconstruction: A proposal of a management algorithm based on a case series analysis: Plantar forefoot reconstruction

BACKGROUND

Several loco-regional flaps have been described for plantar forefoot coverage. We, herein, report our single-centre experience in plantar forefoot reconstruction and propose a decision-making process based on the defect's size.

METHODS

This is a retrospective case series study of all patients who underwent plantar forefoot reconstruction in a 10-year period. We propose a treatment algorithm, based on the defect size. Defects are classified into small, moderate and large. Small defects (<10cm²) can be covered with the hemi-pulp toe flap. Patients with moderate defects (10-25cm²) can be treated with the reverse medial plantar artery flap (MPAF) from the instep area. For large defects (>25cm²), we recommend regional flaps, that is the distally based sural flap (DBSF) from the ipsilateral calf, or free flaps, such as the anterolateral thigh flap (ALT) or the skin-grafted gracilis flap.

RESULTS

The data of 51 patients were collected and analysed. The median age was 58 years (range 19-84). Nine patients had small defects and underwent hemi-pulp toe flap reconstruction. Three patients presented with moderate defects that were covered with reverse MPFs. The vast majority of the patients (39 patients) had large defects. Of these, eight cases were treated with DBSF and 31 cases with free flaps. Free flap transfers were successful in 97% of the cases. Overall complication rate was 25%.

CONCLUSION

We conclude that local flaps should be preferred in plantar forefoot reconstruction as they provide like-tissue for small to moderate defects, for large defects regional flaps or free flaps were indicated. A defect-based approach can facilitate the decision-making process.

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.

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.

Distally Based Medial Plantar Flap: A Classification of the Surgical Techniques

The proximally based medial plantar flap is considered to be the reference standard for heel reconstruction. Although less well-studied, a distally based medial plantar flap is a suitable alternative when used to cover a distal foot defect, especially of the hallux, first metatarsal, or metatarsophalangeal joint. Our objective was to provide a complete description and propose a classification of the different surgical procedures used to harvest this flap. A review of the data reported in the MEDLINE database until May 2017 concerning the distally based medial plantar flap was performed. We have illustrated the different surgical procedures through a case series. Three approaches or "types" of flap have been described, and we have proposed a classification for reconstructive surgeons. In type 1, the plantar pedicle is ligatured before division into the medial and lateral plantar artery. In type 2, the medial plantar pedicle is cut proximally just after division. In type 3, the flap is harvested to include the fasciocutaneous perforator vessels, as an advancement flap or a propeller perforator flap. A distally based medial plantar flap affords adequate and reliable coverage of the weightbearing zone. Because the donor site drawbacks are minimal, this flap is a useful option for distal foot reconstruction, and reconstructive surgeons should remember this flap. The type 1 flap appears to be associated with a minimal risk of flap necrosis, even in those with diabetes or arteriopathy, and can cover even the most distal defect.

Reconstruction of the plantar toe with a distal reverse instep sensory island flap

BACKGROUND

Plantar toe ulcers are a challenging surgical problem. There are several methods for reconstruction, but no attention has been given to the preservation of sensation. This report proposes a method to provide protective sensation for the reconstructed area.

PATIENTS AND METHODS

The ulcers of seven patients ranged from 2 × 3 to 7 × 3 cm with defects of the plantar first toe and distal metatarsus, including four burns, a trauma, a diabetic ulcer, and a neuropathy injury reconstructed with a distal reverse instep sensory island (DRISI) flap. The patients were 21-38 years old. The second metatarsus medial nerve was co-opted using the end-to-side method to the adjacent lateral nerve, then its proximal stump provided the donor nerve for the sensation of the flap. Patients were assessed in terms of protective sensory functions, including touch, pain, dermatomeric somatosensory-evoked potentials (SEP), thermal sensation and Semmes-Weinstein monofilament (SWM) light touch.

RESULTS

The flaps ranged from 2 × 3 to 7 × 3 cm. All transferred flaps to the plantar first toe survived. No complications were observed at the donor and flap sites. Patients were followed-up 8-24 months. Except for two cases, all nerves of the donor and flap sites exhibited protective sensation, including positive SEP responses between 44 and 50 ms and positive SWM responses ≤ 3.84.

CONCLUSION

The DRISI flap can be used for the reconstruction of various plantar first toe defects with acceptable protective sensation. End-to-side neurorrhaphy provides a sensory nerve end to subsequent end to end co-optation to the flap nerve for protective sensation.

Foot and Ankle Reconstruction Using the Distally Based Sural Artery Flap Versus the Medial Plantar Flap: A Comparative Study

Soft tissue defects around the foot and ankle region often present an awkward problem for plastic surgeons. The medial plantar artery flap raised from the non-weightbearing instep of the plantar foot offers a thick, sensorial, durable, and glabrous skin. The reversed sural artery flap offers a reliable option for coverage with the advantages of a wide arc of rotation, adequate dimensions, and a reliable blood supply. The present study compared the outcomes of the medial plantar artery flap and the distally based sural artery flap in foot and ankle reconstruction. The present comparative cross-sectional study included 30 adult patients with soft tissue defects in the foot and around the ankle, who were divided into 2 equal groups. One group underwent reconstruction with the proximally based island medial plantar artery flap (MPAF). The second group underwent reconstruction with the reversed sural artery flap (RSAF). The operative time and complications were carefully recorded. The surgical outcomes in terms of flap survival, durability of coverage, and functional outcome were assessed for all patients. No significant differences were found between the 2 groups in age, sex, etiology, or site of the defect. The defect size was significantly smaller in the MPAF group than in the RSAF group (22 ± 2.7 cm² versus 66.2 ± 7.7 cm²; p < .001). However, the operative time was significantly longer in the MPAF group than in the RSAF group (100 ± 2.9 minutes versus 80.5 ± 3.1 minutes; p < .001). The flap survived in all cases in the MPAF group, but total flap necrosis occurred in 1 patient in the RSAF group. The mean follow-up period was 13.2 months. Weightbearing was significantly earlier in the MPAF group than in the RSAF group (5.8 ± 0.26 weeks versus 6.9 ± 0.19 weeks; p = .003). None of the 30 patients developed recurrent ulceration. The incidence of complications (33.3% versus 80%) was significantly less in the MPAF group than in the RSAF group (p = .01). Significantly greater improvement was found in the functional outcomes in the MPAF group compared with the RSAF group (p = .004). In conclusion, the MPAF and distally based sural artery flap are the 2 flaps available for foot and ankle reconstruction. However, the MPAF offers better functional outcomes with a lower frequency of postoperative complications. Thus, the sensate MPAF is recommended for reconstruction of moderate-size defects of the foot and ankle region.

Anatomic basis and clinical application of the distally based medialis pedis flaps

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.

Traumatic Forefoot Reconstructions With Free Perforator Flaps

The forefoot is critical to normal walking; thus, any reconstruction of forefoot defects, including the soft tissues, must be carefully done. The free perforator flap, with its physiologic circulation, lower donor site morbidity, and minimal thickness is the most popular technique in plastic and microsurgery, and is theoretically the most suitable for such forefoot reconstruction. However, these flaps are generally recognized as more difficult and time-consuming to create than other flaps. In 41 patients with traumatic forefoot defects, we reconstructed the forefoot integument using 5 types of free perforator flaps. The overall functional and cosmetic outcomes were excellent. Three flaps required repeat exploration; one survived. The most common complications were insufficient perfusion and the need for second debulking. The key to our success was thoroughly debriding devitalized bone and soft tissue before attaching the flap. Forefoot reconstruction with a free perforator flap provides better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used.

Reconstruction of weightbearing forefoot defects with digital artery flaps

Reconstruction of a defect of the weightbearing forefoot region remains a challenging problem owing to the limited alternatives available. The digital artery flap can be used for coverage of defects in the weightbearing forefoot. The present study reports our results using a digital artery flap for reconstruction of soft tissue defects of the weightbearing forefoot in 8 patients. The mean patient age was 35 ± 11.3 years. The etiology of the soft tissue defects included 4 (50%) traumatic events, 2 (25%) dysfunctional scars, and 2 (25%) neuropathic ulcerations. The mean postoperative follow-up duration was 22 ± 11.1 months (range 12 months to 4 years). All 8 flaps survived successfully. The complications included 1 case of delayed healing of a neuropathic ulceration. The digital artery flap is a good alternative for soft tissue defects of the weightbearing forefoot. The surgical techniques for harvesting the flaps are easy to manage.

Reconstruction of great toe soft-tissue defect with the retrograde-flow medial pedis island flap

BACKGROUND

Several investigators have reported their clinical experience with medial pedis flaps for reconstruction of soft-tissue defects of the distal forefoot. However, they had only a few reports where this flap was used to repair soft-tissue defects of the great toe. Thus, reconstruction of soft-tissue defects of the great toe remains a challenge in reconstructive surgery. The authors describe the use of the medial pedis island flap to cover this region.

METHODS

This study was divided into two parts: an anatomic study and clinical application. In the anatomic study, 48 cadaveric feet were injected with latex, and then the main vessels distributed at the medial aspect of the foot were observed. Clinically, retrograde-flow medial pedis island flaps were harvested to cover the soft-tissue defects of the great toe in eight cases.

RESULTS

An anatomic study revealed that the arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis were responsible for the blood supply of the medial region of the foot. The diameter of the pedicle was great, and the pedicle was longer than previously reported. In terms of clinical application, all flaps were successful, without any significant complications.

CONCLUSIONS

Using the arterial circle under the first metatarsophalangeal joint, the medial pedis island flap has a reliable retrograde blood supply. This flap should be considered as a preferential way of reconstructing soft-tissue defects of the great toe.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Surgical technique: repair of forefoot skin and soft tissue defects using a lateral tarsal flap with a reverse dorsalis pedis artery pedicle: a retrospective study of 11 patients

BACKGROUND

Various authors have proposed flaps to reconstruct traumatic forefoot skin and soft tissue defects, especially with exposure of tendon and/or bone although which is best for particular circumstances is unclear.

DESCRIPTION OF TECHNIQUE

The indications for the technique were a forefoot defect area of no more than 8-cm × 8-cm and a well-preserved lateral tarsal (LT) donor site. The injured tendons were repaired using tendon grafts. The free dorsalis pedis flap was outlined by centering it on the cutaneous branch of the LT artery and tailoring it to the size of the wound, allowing 0.5-cm margins in length and width. The flap was rotated around the plantar perforating branch of the dorsalis pedis artery (DPA) to cover the forefoot defect. The lateral dorsalis pedis cutaneous nerve was anastomosed with the recipient plantar nerve stump. The donor site was covered with an inguinal, full-thickness skin graft.

PATIENTS AND METHODS

Traumatic forefoot skin and soft tissue defects with exposure of the tendon and/or bone involving 11 feet in 11 patients (mean age, 32 years) were covered using a LT flap with a reversed DPA pedicle. Three patients with forefoot defects underwent emergency repair within 8 hours of injury, whereas eight patients required delayed repair. All patients were followed up for at least 6 months (mean, 13 months; range, 6-24 months).

RESULTS

All flaps survived uneventfully, except for two that had superficial marginal necrosis or severe venous insufficiency. All skin grafts covering the donor sites survived and all wounds healed. None of the patients had restricted standing or walking at followups. The two-point discrimination was 4 mm to 10 mm at 6 months postoperative. The mean hallux-metatarsophalangeal-interphalangeal scale score was 93 points (range, 87-98 points).

CONCLUSIONS

Our observations suggest the LT flap with a reversed DPA pedicle is a reasonable option for repair of traumatic forefoot skin and soft tissue defects with exposure of tendon and/or bone but a well-preserved LT donor site and is associated with minimal morbidity.

Reverse flow digital artery pedicle flap for closure of diabetic forefoot ulceration

Digital artery pedicle flap is a useful surgical technique for coverage of plantar foot defects. For diabetic forefoot ulcers that are subject to recurrence despite consistent care, this flap can provide long-term durable closure. The authors provide a case report and overview of this innovative reconstructive procedure.

The effect of epidural anaesthesia on the reverse-flow fasciocutaneous flap: an experimental study in rabbits

BACKGROUND

The reverse-flow fasciocutaneous flap has been popularised as a feasible alternative to reconstruction of the post-burn contractures around lower-extremity joints. The effect of epidural anaesthesia (EA) on the haemodynamics of reverse-flow fasciocutaneous flap (RFFF) has not yet been investigated. Therefore, it was our primary objective to determine how EA impacts on vascular haemodynamics and tissue perfusion.

MATERIALS AND METHODS

This study included 30 New Zealand white rabbits. The reverse-flow saphenous fasciocutaneous island flap in rabbit model was used. In group I (n=10), epidural catheterisation of the rabbits were performed and they received an epidural infusion of 0.1 ml kg(-1) 0.125% bupivacaine 12-h periods until the 10th day. In group II (n=10), epidural catheterisation of the rabbits was performed and they received an epidural infusion of 0.1 ml kg(-1) isotonic sodium chloride solution. In group III (n=10), epidural catheterisation of the rabbits was not performed. Intra-arterial blood pressure (IABP) and intravenous blood pressure (IVBP) was recorded at time intervals of 5, 15, 30 and 60 min, respectively, after tourniquet release on the first and 10th day. Microcirculatory flow was measured by laser Doppler flowmetry at 2, 4, 6, 8 and 10 days in all the groups.

RESULTS

Throughout the experiment, the flaps showed complete survival. A significant difference was noted in the microcirculatory flow measurements in the flap surfaces between group I and groups II-III throughout the experiment (p<0.05). A significant difference was noted in IVBP and IABP between group I and groups II-III (p<0.05). On the first and the 10th day, however, there were no significant differences between groups II and III (p>0.05).

CONCLUSION

EA improves blood flow to RFFF and prevents the progression of venous congestion.