Reconstruction of Defects in the Weight-Bearing Plantar Area Using the Innervated Free Medial Plantar (Instep) Flap

Microvascular Muscle vs. Fascio-Cutaneous Free Flaps for Reconstruction of Plantar Load-Bearing Foot Defects-An International Survey

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.

Spare part's free contralateral medial plantar flap for emergency reconstruction in a bilateral lower legs ballistic trauma

The medial plantar flap is frequently used in heel reconstruction and has been described since 1969. We took care of a 25-year-old patient with a bilateral ballistic trauma and open fractures to the distal third of both legs. Given the seriousness of the damage to the left lower limb, a trans-tibial amputation had to be performed. Concerning the right lower limb, we decided to cover the defect with a spare part's free medial plantar flap thanks to the amputated fragment. The extremity spare tissues principle is already known and described, more particularly concerning hands, in emergency traumatic surgery and in planned surgery, mainly concerning thumb reconstruction, for example for hypoplasia or after traumatic amputation. Apart from an article on the use of foot spare part in the coverage of amputation stumps, no article has reported the use of a foot spare part in reconstructive surgery, even more in traumatic surgery. We believe that the use of an extremity spare tissues should be considered in rare cases where this is possible, in order to reduce donor-site morbidity in the context of reconstructive surgery.

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

Racial and Geographic Disparities in Reconstructive Procedures Following Melanoma Resection

INTRODUCTION

Melanoma occurs most commonly in non-Hispanic White patients; however, Black and Hispanic patients experience greater morbidity and mortality. This study assesses how race and socioeconomic factors influence rates of reconstructive procedures and hospital-based outcomes in melanoma patients.

METHODS

Data were extracted from the National Inpatient Sample database from the years 2010-2015. Patients with melanoma who underwent a reconstructive procedure were identified. Univariate and multivariate logistic regression analysis was used to identify the relationship between dependent variables and various patient/hospital components for patients undergoing reconstructive procedures.

RESULTS

Black and Hispanic patients had a greater length of stay (LOS) than non-Hispanic White patients (OR: 2.252, p = 0.0307, and OR: 2.592, p = 0.0014), and Hispanic patients were less likely to receive more complex reconstructive procedures (OR: 0.449, p = 0.0487). Patients living in rural areas were less likely to receive complex reconstructive procedures than those in both urban teaching and non-teaching hospitals (OR: 3.313, p = 0.0135, and OR: 3.505, p = 0.0074). Pedicled or rotational flaps were less likely to be performed at medium- or large-sized hospitals (OR: 0.610, p = 0.0296, and OR: 0.496, p = 0.0002).

CONCLUSION

Race and socioeconomic factors are important predictors of access to complex reconstructive procedures and hospital-based outcomes following extirpation in melanoma patients.

Medial plantar artery perforator (MPAP) flap is an ideal option for reconstruction of complex soft tissue defect in the finger: Clinical experience from 11 cases

Introduction

Soft tissue defects of fingers are common in reconstructive plastic surgery, and reconstruction of the defects remains challenging for plastic surgeons. In our study, we reported our experience in finger reconstruction with a medial plantar artery perforator (MPAP) flap, especially using a lobulated MPAP flap for the complex multifinger soft defect.

Patients and methods

From the period April 2012 to October 2018, 11 patients (9 males and 2 females) with an average age of 44 years old (ranging from 11 to 58) received finger reconstruction with a free MPAP flap. In total, 11 flaps (8 single-lobulated flaps and 3 two-lobulated flaps) were raised from the ipsilateral or contralateral instep area. Trauma and scar contracture caused hand soft tissue loss in all cases.

Results

The sizes of the flaps ranged from 2×3 to 5×7.5 cm2. All flaps survived intact with no complications. One donor site was closed primarily, and other donor sites were covered with a full-thickness skin graft. The mean follow-up time was 6 months (ranging from 3 to 8 months). During the follow-up period, the patients were satisfied with their appearance without any traces of flap plastic surgery.

Conclusion

The MPAP flap is a reliable and acceptable option for the reconstruction of complex soft tissue defects in the finger. Depending on the two branches of the medial plantar artery, the use of the lobulated MPAP flap holds promise in the treatment of multifinger soft tissue defects.

Wound Healing and Therapy in Soft Tissue Defects of the Hand and Foot from a Surgical Point of View

Wounds and tissue defects of the hand and foot often lead to severe functional impairment of the affected extremity. Next to general principles of wound healing, special functional and anatomic considerations must be taken into account in the treatment of wounds in these anatomical regions to achieve a satisfactory reconstructive result. In this article, we outline the concept of wound healing and focus on the special aspects to be considered in wounds of the hand and foot. An overview of different treatment and dressing techniques is given with special emphasis on the reconstruction of damaged structures by plastic surgical means.

Reconstruction of Foot and Ankle Defects Using Free Lateral Arm Flap: A Retrospective Review of Its Versatile Application

Background

Successful reconstruction of the feet and ankles remains challenging due to limited quantities of soft tissue and laxity. The free lateral arm flap (LAF) is an alternative to conventional flaps and has been widely used due to advancements in its flap characteristics. This study is aimed at utilizing the advantages of this flap to validate its increased applications for foot and ankle defects.

Methods

Twenty patients with various LAF types between May 2011 and May 2020 were enrolled. Clinical data was retrospectively collected, and defect sites were classified according to the subunit principle. We utilized various LAF types, such as LAFs with sensate, extended, osteomyocutaneous, or myocutaneous flaps, as necessary. A two-point discrimination test was performed, and results were statistically compared between flaps.

Results

Among the diverse etiologies of skin defects, chronic inflammation was the most common cause of defects. Various LAF types, including LAFs with fasciocutaneous, extended fasciocutaneous, musculocutaneous, and osteomyocutaneous flaps, were used. The versatility of free LAF helped successfully cover various defects in all cases. Results of the two-point discrimination test were statistically significant between groups.

Conclusions

Free LAF is a unique soft tissue free flap that is more versatile than other flaps, allowing flaps to be continuously modified and applied to various foot and ankle defects under different clinical conditions.

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.

Free Medial Plantar Flap Versus Free Dorsal Myocutaneous Flap for the Reconstruction of Traumatic Foot Sole Defects

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.

Ultrathin free flaps for foot reconstruction: impact on ambulation, functional recovery, and patient satisfaction

BACKGROUND

Plantar reconstruction is a complex procedure due to the paucity of tissue around the foot. Tissues used for reconstruction should provide similar properties, which can be accomplished by using ultra-thin flaps. Validated functional scales may provide essential information regarding patients' evolution.

METHODS

Information concerning a series of 12 cases of plantar reconstruction using ultra-thin free flaps was gathered retrospectively by the authors. Data from preoperative functional scores in Lower Extremity Functional Scale and American Orthopaedic Foot and Ankle Society scale were obtained from clinical records; these were compared to postoperative scores assigned prospectively during follow-up. Differences were determined using Student's t-test for paired samples. Objective measurements concerning evolution (ulceration, footwear usage, sensation), as well as patient satisfaction, were also explored.

RESULTS

The mean follow-up duration was 16.5 (range 12 to 24) months. The Lower Extremity Functional Scale scores mean modified from 39.1 to 60.2, p = 0.004; the American Orthopaedic Foot and Ankle Society scale mean modified from 42.2 to 53.4, p = 0.012. No patient showed plantar ulceration. Protective sensation was achieved in 75% of the patients, and 10 out of 12 could use regular footwear. All patients reported satisfaction with the surgical procedure.

CONCLUSIONS

Ultra-thin flaps for foot reconstruction are related to improvement in functional scales, high rates of patient satisfaction, and use of regular footwear as well as a limited range of complications.

Heel Pad Reconstruction With Medial Plantar Flap

The heel of the foot is covered by highly specialized thick, glabrous skin containing fibroadipose tissue with numerous fibrous septae traversing the subcutaneous tissue, which acts as a shock-absorbent and prevents shearing of the skin. The loss of heel pad would cause interruption of the propelling function of the foot during walking. Therefore, heel pad reconstruction is an important procedure for wound closure in the acute phase and also functional reconstruction in delayed cases. We report a case of heel pad deformity in a patient who presented to us with left heel pain and inability to fully bear weight, which has caused her walking difficulty, following a road traffic accident. She sustained a degloving injury of the left foot and an open fracture of left calcaneum with ruptured Tendon Achilles in which the wound was initially addressed with failed reverse sural flap and the wound was allowed to heal by secondary intention. Delayed heel reconstruction was carried out with a propeller medial plantar flap and split skin graft. Postoperatively, the patient had improved functional and esthetic outcome.

A systematic review and meta-analysis of perforator flaps in plantar defects: Risk analysis of complications

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.

Functional Restoration in Lower Extremity Reconstruction

Daily walking stance benefits the health, whereas lower extremity reconstruction aims to accomplish balanced walking and posture control. If local flap or tendon transfer cannot provide the basic function, microsurgical reconstruction is indicated for bony, soft tissue, and sensation restoration. Wound repair can use every modality and can achieve varying wound coverage results. However, all reconstruction should have functional goals using either local flap or free flap to restore the lost function. With less recipient site secondary damage, microsurgery can provide healthy composite tissue with like-replaces-like approach to create more stable long-term results.

Reconstruction of extensive plantar forefoot defects with free anterolateral thigh flap

PURPOSE

The aim of the soft tissue reconstruction of plantar forefoot should yield weight-bearing function and aesthetic contour, which poses a significant challenge for reconstructive surgeons to provide an appropriate flap according to the "like for like" reconstructive principle. Local flaps and pedicled flaps have been described for the reconstruction of small- to medium-sized defects of plantar forefoot and achieved optimal results. However, reconstruction of extensive defects of plantar forefoot is rarely investigated. In this study, we present our experience using the free anterolateral thigh (ALT) flap in the reconstruction of extensive defects of plantar forefoot.

METHODS

Between November 2011 and April 2017, 9 patients were treated for extensive soft tissue defects in the plantar forefoot areas with ALT flaps. The mean age at the time of surgery was 39.3 years (range, 25-64 years).

RESULTS

The follow-up period ranged from 12 to 77 months, with a mean of 31 months. All flaps survived well, and the patients were satisfied with the aesthetic and functional results. The size of the flaps ranged from 63 to 455 cm, with a mean of 197.7 cm. Seven patients with no bony involvement began to gradually weight-bear at 3 weeks postoperatively. During the follow-up time, postoperative ulceration at the reconstructed weight-bearing areas was not encountered.

CONCLUSION

The ALT flap is a reliable option for treatment of extensive defects of plantar forefoot, resulting in an optimal functional and aesthetic outcome. Even when a total plantar loss exits, excellent results can be achieved.

Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application

BACKGROUND

The posterior tibial artery perforator (PTAP) flap is a useful tool for reconstruction of soft tissue defects in the leg. However, the size and reliability of the flap largely depends on the quality of the perforator by which the flap is supplied, and the sensory recovery of the flap is limited. In this study, the anatomy of the saphenous nerve branches and their accompanying vessels was investigated, and a free extended PTAP flap with the neurovascular plexus of a saphenous nerve branch was designed for large soft tissue and sensory reconstruction in a series of clinical cases.

METHODS

Sixteen adult cadaveric legs perfused with red latex in the femoral artery were dissected. The number and location of the saphenous nerve branches and the features of their accompanying vessels were dissected and studied. From January 2016 to December 2017, six patients with soft tissue defects ranged from 8 × 2.5 cm to 21 × 4 cm were repaired by the free extended PTAP flap. The patients' average age was 48 years. The causes of the defects included machine injuries in three patients and traffic injuries in the other three. The defects located at the hand in three cases, foot in two cases, and ankle in one case. The flap was designed based on the perforators of the posterior tibial artery and included a branch of saphenous nerve. The perforator pedicle and the nerve branch were connected to the vessels and nerve in the recipient site, respectively.

RESULTS

The saphenous nerve gave off 5.8 ± 1.1 branches, with a relatively constant one issuing 8.1 ± 0.7 cm distal to the medial femoral condyle. Every nerve branch had an accompanying vessel, which connected with the PTAPs and supplied the skin. The size of the flap ranged from 10 × 3.5 cm to 23 × 5 cm. All of the flaps survived completely without complications. Follow-up varied from 6 to 12 months. All the patients obtained cold/hot sensation and pain sensation. The results of Semmes-Weinstein monofilament test ranged from 4.31(2 g) to 5.46 (26 g), and the 2-point discrimination test varied from 20 to 35 mm.

CONCLUSION

The free extended PTAP flap, containing the saphenous nerve branch and its accompanying vessels, may be an alternative for large soft tissue reconstruction with improved sensation recovery.

A Systematic Review and Meta-Analysis of the Pressure-Induced Vasodilation Phenomenon and Its Role in the Pathophysiology of Ulcers

BACKGROUND

Physiologic studies show that tissue perfusion increases during moderate amounts of tissue compression. This is attributed to sensory nerves initiating a vasodilatory cascade referred to as pressure-induced vasodilation.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies investigating perfusion during pressure exposure longer than 10 minutes. Retrieved studies were assessed using the Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies. Results were pooled with random effects models. The body of evidence was rated using the Office of Health Assessment and Translation approach.

RESULTS

Twenty-nine articles were included, of which 19 articles were included in meta-analyses. The evidence indicates that moderate amounts of tissue compression have the capacity to increase perfusion in healthy humans by 46 percent (95 percent CI, 30 to 62 percent). Using the Office of Health Assessment and Translation approach, the authors found a high level of confidence in the body of evidence. Pressure-induced vasodilation blockade was associated with increased pressure ulcer formation. Pressure-induced vasodilation was impaired by neuropathy and by the drugs diclofenac and amiloride.

CONCLUSIONS

This systematic review and meta-analysis indicates that healthy humans have the capacity to increase local perfusion in response to mechanical stress resulting from tissue compression. Because pressure-induced vasodilation is mediated by sensory nerves, pressure-induced vasodilation emphasizes the importance of sensory innervation for durable tissue integrity. Pressure-induced vasodilation impairment seems to provide a complementary explanation for the susceptibility of neuropathic tissues to pressure-induced lesions.