RECONSTRUCTIVE SURGERY
Distally Based Abductor Hallucis Adipomuscular Flap for Forefoot Plantar Reconstruction Sanglim Lee, MD, PhD,* Min Bom Kim, MD, PhD,Þ Young Ho Lee, MD, PhD,Þ Jeong Kook Baek, MD,Þ and Goo Hyun Baek, MD, PhDÞ Abstract: Soft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant f laps. The authors successfully used the distally based adipomuscular abductor hallucis f lap for the treatment of 7 patients with soft tissue defect on the plantar forefoot after diabetic ulcer (n = 2), excision of melanoma at the medial forefoot (n = 3), and posttraumatic defects of the plantar forefoot (n = 2). The size of the defects ranged from 6 to 36 cm2. All defects were covered successfully without major complications. The distally based adipomuscular f lap from the abductor hallucis muscle provides a reliable coverage for small and moderate defects of the plantar and medial forefoot. This f lap is often preferable to the use of free f laps because the surgery is rapidly performed and does not require microsurgical expertise. Key Words: abductor hallucis, flap, forefoot, reconstruction, soft tissue defect, adipomuscular flap (Ann Plast Surg 2015;75: 319Y322)
D
espite advances in microvascular and reconstructive surgery, sometimes the repair of soft tissue defects remains a difficult surgical challenge. Particularly soft tissue reconstruction in the lower leg and foot often requires coverage by local or distant f laps because of exposed tendon and bone. Reconstructive options include the use of local cutaneous f laps, fascial or fasciocutaneous f laps, muscle f laps, and free f laps. However, often the radius of extension in the distal direction of local f laps is small, and therefore they are not always suitable for covering defects in this region.1 In addition, free f lap procedures are relatively complex, time consuming, and require microsurgical expertise.2 Recently, reconstruction of plantar defects in the heel has been greatly improved by the use of medial plantar sensory f lap. However, plantar coverage for the forefoot remains a challenge, because the alternatives for f lap coverage are very limited.3Y5 One alternative within the reconstructive spectrum of the forefoot is the abductor hallucis muscle f lap, which was first described by Mathes et al6 and further characterized in detail by others.4,7Y11 There are some reports that showed satisfactory results of distally based abductor hallucis muscle f lap for the medial forefoot defects.4,10 We present our experience with 7 patients who were treated successfully without major complications, using the adipomuscular form of this f lap for packing a soft tissue defect of the medial forefoot.
PATIENTS AND METHODS From April 2004 to June 2010, 7 distally based abductor hallucis adipomuscular f laps have been used for reconstruction of soft Received May 21, 2013, and accepted for publication, after revision, December 8, 2013. From the *Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University; and †Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea. Conflicts of interest and sources of funding: none declared. Reprints: Young Ho Lee, MD, PhD, Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul 110-744, South Korea. E-mail: [email protected]. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503-0319 DOI: 10.1097/SAP.0000000000000116
Annals of Plastic Surgery
tissue and bone defects of the forefoot. Of these, 3 patients were women and 4 were men, with an age range of 28 to 81 years (average, 53 years). The patients were followed up from 6 to 86 months. The defects were caused by debridement of medial sided forefoot after diabetic foot (n = 2), excision of melanoma (n = 3), and posttraumatic defects of the forefoot (n = 2). The size of the defects ranged from 6 to 36 cm2 (average, 18.5 cm2) (Table 1). The operative technique of f lap harvesting was somewhat similar to what was previously described by Schwabegger et al4,10 and is illustrated in Figure 1, but the most different concept of this f lap is that it contains the subcutaneous tissue above the abductor hallucis muscle. Initially after radical debridement of bony and soft tissue or tumor excision, simultaneous soft tissue reconstruction was performed. Before defect coverage, the most distal segmental vascular pedicle from the medial plantar artery, which provides the arterial blood supply for the f lap, was mapped by Doppler preoperatively. The medial plantar artery supplying both the proximal and distal pedicles of the abductor hallucis muscle is a dispensable vessel and thus suitable to be dissected for supplying a distally based abductor hallucis muscle f lap, which receives blood supply from minor and major pedicles in a retrograde fashion from both the dorsal arterial network and the deep plantar system. Preparation of the f lap was performed under tourniquet control and surgical loupes. A zigzag skin incision was marked in the central portion of the proposed f lap on the medial aspect of the foot. This incision was made through the skin only reaching subcutaneously, and the dissection was made subcutaneously over the area of the proposed f lap. A stay-suture was placed at each corner of the f lap before it was dissected. The medial border of the muscle was first mobilized until the calcaneal origin was reached. Then, the origin of the abductor hallucis muscle at the calcaneus was detached and the medial plantar vessels were identified. The dissection of the muscle was then continued distally including the medial plantar vessels in the f lap until the distal pedicles were visualized. Proximal branches were clamped temporarily by microvascular clamps for 5 minutes to ensure the vascularity of the distally based muscle f lap as well as the vascularity of the foot. The f lap perfusion was checked by intraoperative Doppler and bleeding from the muscle edge. Then, the medial plantar vessels were ligated and divided. Special care should be taken not to injure the medial plantar nerve during dissections and the insertion of the f lexor hallucis brevis which is functionally important.12 After the f lap insetting, the donor site was closed primarily with the preserved skin, and multiple small silastic drains were inserted. A moist, loose, and 1% framycetin sulfateYimpregnated sterile tulle gauze dressing was simply placed over this f lap until skin grafting was performed. The raw surface of the f lap on the recipient site was covered with a full-thickness skin graft harvest from ipsilateral inguinal area on postoperative days 5 to 7.
RESULTS All f laps survived completely, and no further operations to achieve defect coverage were necessary. Only 1 f lap developed a superficial necrosis in the proximal parts of the flap (Table 1, Fig. 2). This case was treated with debridement and skin graft. Two other flaps that showed hyperkeratosis of wound were managed conservatively
& Volume 75, Number 3, September 2015
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319
Annals of Plastic Surgery
Lee et al
& Volume 75, Number 3, September 2015
TABLE 1. Summary of the Cases Treated by Distally Based Adipomuscular Abductor Hallucis Flap Case
Age, y, Sex
1
54, M
2 3
47, F 81, M
4
65, F
5 6
53, F 28, M
7
45, M
Cause of Defect
Site of Defect
Excision of Medial plantar surface the malignancy Diabetic ulcer Medial plantar surface Diabetic ulcer First metatarsal head medial surface Excision of Central plantar the malignancy Diabetic ulcer Medial plantar surface Posttrauma defect First metatarsal head medial surface Posttrauma defect Central plantar
Defect Size, cm
Defect Depth, cm
Length From the MCT to the DMD, cm
Duration of Follow-Up, mo
Complications
45
2.5
13
18
None
34 3 4.5
2 2
15 14
6 12
None Hyperkeratosis
46
2
17
23
34 66
1.5 2.5
15 13
14 86
43
2
14
36
Partial necrosis of flap Hyperkeratosis Donor-site hematoma None
DMD indicates distal margin of the defect; MCT, medial calcaneal tuberosity.
FIGURE 1. Technique of harvesting the distally based adipomuscular abductor hallucis f lap. A, Preoperative marking of skin incision and presumed abductor hallucis muscle position. B, Skin incision and identifying of abductor hallucis muscle and subcutaneous fat. C, Dissection of the muscle. D, Proximal division of the abductor hallucis from the calcaneal tuberosity. E, Identification of the muscular branches (2 branches) to the abductor hallucis. F, Elevation of the distally based adipomuscular abductor hallucis f lap. Note the preserved distal muscular branch of the medial plantar artery. 320
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* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 75, Number 3, September 2015
Abductor Hallucis Adipomuscular Flaps for Reconstruction
FIGURE 2. Case 2: A 65-year-old female patient for a soft tissue defect on the central plantar area of the forefoot after wide excision of the skin malignancy. A, Defect after radical debridement of soft tissue and tendons. B, Flap filling the defect. C, Partial necrosis on the distal part of the f lap developed. D, The f lap was healed after debridement. E, F, Flap covered with skin graft. Completely healed defect at 17 months after reconstruction without any sign of wound complications.
and healed by secondary intention without further complications or additional operative procedures required. In 1 patient (case 6), a hematoma developed at the donor site, and therefore a revision operation and evacuation of the hematoma was necessary. Donor sites in all other patients healed uneventfully. At last follow-up, all f laps provided stable defect coverage and good contour. No patient needed further f laps for defect reconstruction or a secondary space packing procedure. In our series, all patients were satisfied with the surgical outcome. No disturbance of foot mobility and strength was noticed. The absence of abductor hallucis muscle did not affect the foot function and secondary hallux valgus deformity.
CASE REPORTS Case 1 (Patient 1) A 54-year-old man presented with black skin lesion on plantar area of the first metatarsal head, the result of the biopsy was malignant melanoma. After wide excision of the mass, the soft tissue defect and exposed tendons were covered with a distally based adipomuscular abductor hallucis f lap, which was covered with fullthickness skin graft after confirmation of f lap survival. Seven months after defect coverage, the patient is walking and there are no complications. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Case 4 (Patient 4) A 65-year-old female patient was referred for a soft tissue defect on the central plantar area of the forefoot after wide excision of the skin malignancy. The dimension of the defect was 4 6 (24 cm2) with 2 cm depth. An adipomuscular abductor hallucis f lap was elevated and closure of the tendon and soft tissue defect was achieved. The f lap showed partial necrosis at 5 days postoperatively, but satisfactory granulation tissue was grown after serial debridement and skin graft was performed successfully. The patient is now able to walk unaided and without any pain 2 years postoperatively (Fig. 2).
DISCUSSION During the past years, a number of abductor hallucis muscle f laps have been used successfully for reconstruction of infected ulcer, irradiation wounds, and surgical defects in forefoot. However, to the best of our knowledge, application of the adipomuscular abductor hallucis f lap to reconstruct forefoot plantar area defect has never been described. In this report, we demonstrated 2 cases in which the adipomuscular f lap was used successfully. The f lap provides more bulk of soft tissue compared with the conventional abductor hallucis muscle f lap and allows reliable closure of deep dead space in the forefoot plantar area after extensive resection or wound www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
321
Annals of Plastic Surgery
Lee et al
debridement. The adipomuscular portion of the f lap provides wellvascularized bulky tissue to prevent an incidence of serious postoperative complications. Muscle f laps remain often the first choice, when dealing with bone infections associated with osteomyelitis, soft tissue infections, and large cavities. Because common local distally based muscle transpositional f laps have difficulty reaching the forefoot plantar region, these defects are normally treated by free tissue transfer because free muscle f laps provide reliable single-stage coverage.5 However, there are some disadvantages which are associated with the application of free f laps: the donor-site morbidity, increased operation time, use of a major vessel of the leg, and the necessity of microsurgical expertise.2 The major advantages of this muscle f lap are a quick and safe surgery, reliable soft tissue coverage of bone and tendons, with muscle tissue and preservation of major arteries of the leg. Besides, donor-site morbidity is negligible because preserved medial plantar nerve and f lexor hallucis brevis will maintain the function of big toe f lexion.12 The blood supply of the flap is provided by segmental branches of the medial plantar artery, with the first muscular branch of the medial plantar artery after bifurcation to the abductor hallucis muscle. It gives additional 1 to 2 small branches to the muscle distally.13 Moreover, the distal end of the medial plantar artery is communicating with the plantar metatarsal artery.4 These observations are consistent with the findings of the authors. In all our cases, the main distal vascular pedicle could be detected approximately 10 to 15 cm distal of the calcaneal tuberosity. We observed superficial necrosis of the distal part of the f lap only in 1 patient with a central plantar wound after excision of malignancy, which needed secondary debridement and additional skin grafting. We did not observe any complete or nearly complete f lap necrosis in this study, and all defects were reconstructed successfully by the f lap. We suggest that the reliability and survival of the distally based adipomuscular f lap rely on many different factors. Vascular risk factors, age of patients, arc of rotation and kinking of the pedicle area, inadequate preparation, unneeded tunneling of the f lap, as well as tissue trauma due to accidents or irradiation, may negatively inf luence perfusion of the entire f lap. The 2-step surgical approach performed in all our patients requires an additional skin graft. However, many clinical situations such as malignant tumors, severely traumatized extremities, infected wounds, and osteomyelitis require a 2-step or multistep operative approach before finally assured defect coverage. Our f lap had some limitations. First, sensate f lap is more ideal for the foot, especially in the plantar surface, but this f lap has no cutaneous nerve. However, the deep sensation of the foot was maintained even after the f lap coverage and the patients could feel to the deep touch sensation. Second, the final coverage should be the skin graft over the f lap. Immediate skin graft coverage over the f lap does not always jeopardize skin survival, but we believed that delayed skin graft could enhance the graft survival because the exudate of the f lap would be decreased and skin graft intake could be more favorable. Moreover, this approach can make surgeons prepare for
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& Volume 75, Number 3, September 2015
uneventful situations, such as partial necrosis, similar to our case in this study. This is the main shortcoming of the procedure, that the f lap must be covered with an additional skin graft. Grafted skin usually easily abraded on the surface over bony prominence. Moreover, the margin between the grafted skin and the normal foot skin had sometimes hypertrophic scar formation which was experienced in our series, but was not serious. Third, although there is no need to sacrifice the lateral plantar artery or dorsalis pedis artery, and the medial plantar artery should not be always ligated, it is advisable to use this f lap with patients without any vascular compromise in the foot. Otherwise, vascular evaluation may be necessary for the safety and success of the f lap surgery. We could demonstrate that the distally based adipomuscular abductor hallucis f lap represents an excellent option for reconstruction of soft tissue defects of the plantar forefoot. An adipomuscular f lap as a modification of the conventional muscle f lap was designed to obliterate a residual dead space and eventually enabled the successful reconstruction of the plantar forefoot defect, and the volume of the f lap was well maintained. REFERENCES 1. Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma. 2000;48:913Y917. 2. Gonzalez MH, Tarandy DI, Troy D, et al. Free tissue coverage of chronic traumatic wounds of the lower leg. Plast Reconstr Surg. 2002;109:592Y600. 3. Takahashi A, Tamura A, Ishikawa O. Use of a reverse-flow plantar marginal septum cutaneous island flap for repair of a forefoot defect. J Foot Ankle Surg. 2002;41:247Y250. 4. Schwabegger A, Shafighi M, Harpf C, et al. Distally based abductor hallucis muscle flap: anatomic basis and clinical application. Ann Plast Surg. 2003; 51:505Y508. 5. Scheufler O, Kalbermatten D, Pierer G. Instep free flap for plantar soft tissue reconstruction: indications and options. Microsurgery. 2007;27:174Y180. 6. Mathes SJ, Nahai F, Friedman V. Clinical Atlas of Muscle and Musculocutaneous Flaps. St Louis, Mo: Mosby; 1979. 7. Schwabegger A, Ninkovic M, Anderl H. Combined fasciocutaneous abductor hallucis-medialis pedis transposition flap for defect coverage of the medial ankle. Ann Plast Surg. 1998;40:71Y75. 8. Attinger CE, Ducic I, Cooper P, et al. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg. 2002;110:1047Y1054; discussion 1055-1047. 9. Ortak T, Ozdemir R, Ulusoy MG, et al. Reconstruction of heel defects with a proximally based abductor hallucis muscle flap. J Foot Ankle Surg. 2005; 44:265Y270. 10. Schwabegger A, Shafighi M, Gurunluoglu R. Versatility of the abductor hallucis muscle as a conjoined or distally-based flap. J Trauma. 2005; 59:1007Y1011. 11. Michlits W, Gruber S, Windhofer C, et al. Reconstruction of soft tissue defects overlying the Achilles tendon using the super extended abductor hallucis muscle flap. J Trauma. 2008;65:1459Y1462. 12. Brenner E. Insertion of the abductor hallucis muscle in feet with and without hallux valgus. Anat Rec. 1999;254:429Y434. 13. Orbay H, Kerem M, Uenlue RE, et al. Vascular anatomy of plantar muscles. Ann Plast Surg. 2007;58:420Y426.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Distally Based Abductor Hallucis Adipomuscular Flap for Forefoot Plantar Reconstruction Sanglim Lee, MD, PhD,* Min Bom Kim, MD, PhD,Þ Young Ho Lee, MD, PhD,Þ Jeong Kook Baek, MD,Þ and Goo Hyun Baek, MD, PhDÞ Abstract: Soft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant f laps. The authors successfully used the distally based adipomuscular abductor hallucis f lap for the treatment of 7 patients with soft tissue defect on the plantar forefoot after diabetic ulcer (n = 2), excision of melanoma at the medial forefoot (n = 3), and posttraumatic defects of the plantar forefoot (n = 2). The size of the defects ranged from 6 to 36 cm2. All defects were covered successfully without major complications. The distally based adipomuscular f lap from the abductor hallucis muscle provides a reliable coverage for small and moderate defects of the plantar and medial forefoot. This f lap is often preferable to the use of free f laps because the surgery is rapidly performed and does not require microsurgical expertise. Key Words: abductor hallucis, flap, forefoot, reconstruction, soft tissue defect, adipomuscular flap (Ann Plast Surg 2015;75: 319Y322)
D
espite advances in microvascular and reconstructive surgery, sometimes the repair of soft tissue defects remains a difficult surgical challenge. Particularly soft tissue reconstruction in the lower leg and foot often requires coverage by local or distant f laps because of exposed tendon and bone. Reconstructive options include the use of local cutaneous f laps, fascial or fasciocutaneous f laps, muscle f laps, and free f laps. However, often the radius of extension in the distal direction of local f laps is small, and therefore they are not always suitable for covering defects in this region.1 In addition, free f lap procedures are relatively complex, time consuming, and require microsurgical expertise.2 Recently, reconstruction of plantar defects in the heel has been greatly improved by the use of medial plantar sensory f lap. However, plantar coverage for the forefoot remains a challenge, because the alternatives for f lap coverage are very limited.3Y5 One alternative within the reconstructive spectrum of the forefoot is the abductor hallucis muscle f lap, which was first described by Mathes et al6 and further characterized in detail by others.4,7Y11 There are some reports that showed satisfactory results of distally based abductor hallucis muscle f lap for the medial forefoot defects.4,10 We present our experience with 7 patients who were treated successfully without major complications, using the adipomuscular form of this f lap for packing a soft tissue defect of the medial forefoot.
PATIENTS AND METHODS From April 2004 to June 2010, 7 distally based abductor hallucis adipomuscular f laps have been used for reconstruction of soft Received May 21, 2013, and accepted for publication, after revision, December 8, 2013. From the *Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University; and †Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea. Conflicts of interest and sources of funding: none declared. Reprints: Young Ho Lee, MD, PhD, Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul 110-744, South Korea. E-mail: [email protected]. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503-0319 DOI: 10.1097/SAP.0000000000000116
Annals of Plastic Surgery
tissue and bone defects of the forefoot. Of these, 3 patients were women and 4 were men, with an age range of 28 to 81 years (average, 53 years). The patients were followed up from 6 to 86 months. The defects were caused by debridement of medial sided forefoot after diabetic foot (n = 2), excision of melanoma (n = 3), and posttraumatic defects of the forefoot (n = 2). The size of the defects ranged from 6 to 36 cm2 (average, 18.5 cm2) (Table 1). The operative technique of f lap harvesting was somewhat similar to what was previously described by Schwabegger et al4,10 and is illustrated in Figure 1, but the most different concept of this f lap is that it contains the subcutaneous tissue above the abductor hallucis muscle. Initially after radical debridement of bony and soft tissue or tumor excision, simultaneous soft tissue reconstruction was performed. Before defect coverage, the most distal segmental vascular pedicle from the medial plantar artery, which provides the arterial blood supply for the f lap, was mapped by Doppler preoperatively. The medial plantar artery supplying both the proximal and distal pedicles of the abductor hallucis muscle is a dispensable vessel and thus suitable to be dissected for supplying a distally based abductor hallucis muscle f lap, which receives blood supply from minor and major pedicles in a retrograde fashion from both the dorsal arterial network and the deep plantar system. Preparation of the f lap was performed under tourniquet control and surgical loupes. A zigzag skin incision was marked in the central portion of the proposed f lap on the medial aspect of the foot. This incision was made through the skin only reaching subcutaneously, and the dissection was made subcutaneously over the area of the proposed f lap. A stay-suture was placed at each corner of the f lap before it was dissected. The medial border of the muscle was first mobilized until the calcaneal origin was reached. Then, the origin of the abductor hallucis muscle at the calcaneus was detached and the medial plantar vessels were identified. The dissection of the muscle was then continued distally including the medial plantar vessels in the f lap until the distal pedicles were visualized. Proximal branches were clamped temporarily by microvascular clamps for 5 minutes to ensure the vascularity of the distally based muscle f lap as well as the vascularity of the foot. The f lap perfusion was checked by intraoperative Doppler and bleeding from the muscle edge. Then, the medial plantar vessels were ligated and divided. Special care should be taken not to injure the medial plantar nerve during dissections and the insertion of the f lexor hallucis brevis which is functionally important.12 After the f lap insetting, the donor site was closed primarily with the preserved skin, and multiple small silastic drains were inserted. A moist, loose, and 1% framycetin sulfateYimpregnated sterile tulle gauze dressing was simply placed over this f lap until skin grafting was performed. The raw surface of the f lap on the recipient site was covered with a full-thickness skin graft harvest from ipsilateral inguinal area on postoperative days 5 to 7.
RESULTS All f laps survived completely, and no further operations to achieve defect coverage were necessary. Only 1 f lap developed a superficial necrosis in the proximal parts of the flap (Table 1, Fig. 2). This case was treated with debridement and skin graft. Two other flaps that showed hyperkeratosis of wound were managed conservatively
& Volume 75, Number 3, September 2015
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
319
Annals of Plastic Surgery
Lee et al
& Volume 75, Number 3, September 2015
TABLE 1. Summary of the Cases Treated by Distally Based Adipomuscular Abductor Hallucis Flap Case
Age, y, Sex
1
54, M
2 3
47, F 81, M
4
65, F
5 6
53, F 28, M
7
45, M
Cause of Defect
Site of Defect
Excision of Medial plantar surface the malignancy Diabetic ulcer Medial plantar surface Diabetic ulcer First metatarsal head medial surface Excision of Central plantar the malignancy Diabetic ulcer Medial plantar surface Posttrauma defect First metatarsal head medial surface Posttrauma defect Central plantar
Defect Size, cm
Defect Depth, cm
Length From the MCT to the DMD, cm
Duration of Follow-Up, mo
Complications
45
2.5
13
18
None
34 3 4.5
2 2
15 14
6 12
None Hyperkeratosis
46
2
17
23
34 66
1.5 2.5
15 13
14 86
43
2
14
36
Partial necrosis of flap Hyperkeratosis Donor-site hematoma None
DMD indicates distal margin of the defect; MCT, medial calcaneal tuberosity.
FIGURE 1. Technique of harvesting the distally based adipomuscular abductor hallucis f lap. A, Preoperative marking of skin incision and presumed abductor hallucis muscle position. B, Skin incision and identifying of abductor hallucis muscle and subcutaneous fat. C, Dissection of the muscle. D, Proximal division of the abductor hallucis from the calcaneal tuberosity. E, Identification of the muscular branches (2 branches) to the abductor hallucis. F, Elevation of the distally based adipomuscular abductor hallucis f lap. Note the preserved distal muscular branch of the medial plantar artery. 320
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* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 75, Number 3, September 2015
Abductor Hallucis Adipomuscular Flaps for Reconstruction
FIGURE 2. Case 2: A 65-year-old female patient for a soft tissue defect on the central plantar area of the forefoot after wide excision of the skin malignancy. A, Defect after radical debridement of soft tissue and tendons. B, Flap filling the defect. C, Partial necrosis on the distal part of the f lap developed. D, The f lap was healed after debridement. E, F, Flap covered with skin graft. Completely healed defect at 17 months after reconstruction without any sign of wound complications.
and healed by secondary intention without further complications or additional operative procedures required. In 1 patient (case 6), a hematoma developed at the donor site, and therefore a revision operation and evacuation of the hematoma was necessary. Donor sites in all other patients healed uneventfully. At last follow-up, all f laps provided stable defect coverage and good contour. No patient needed further f laps for defect reconstruction or a secondary space packing procedure. In our series, all patients were satisfied with the surgical outcome. No disturbance of foot mobility and strength was noticed. The absence of abductor hallucis muscle did not affect the foot function and secondary hallux valgus deformity.
CASE REPORTS Case 1 (Patient 1) A 54-year-old man presented with black skin lesion on plantar area of the first metatarsal head, the result of the biopsy was malignant melanoma. After wide excision of the mass, the soft tissue defect and exposed tendons were covered with a distally based adipomuscular abductor hallucis f lap, which was covered with fullthickness skin graft after confirmation of f lap survival. Seven months after defect coverage, the patient is walking and there are no complications. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Case 4 (Patient 4) A 65-year-old female patient was referred for a soft tissue defect on the central plantar area of the forefoot after wide excision of the skin malignancy. The dimension of the defect was 4 6 (24 cm2) with 2 cm depth. An adipomuscular abductor hallucis f lap was elevated and closure of the tendon and soft tissue defect was achieved. The f lap showed partial necrosis at 5 days postoperatively, but satisfactory granulation tissue was grown after serial debridement and skin graft was performed successfully. The patient is now able to walk unaided and without any pain 2 years postoperatively (Fig. 2).
DISCUSSION During the past years, a number of abductor hallucis muscle f laps have been used successfully for reconstruction of infected ulcer, irradiation wounds, and surgical defects in forefoot. However, to the best of our knowledge, application of the adipomuscular abductor hallucis f lap to reconstruct forefoot plantar area defect has never been described. In this report, we demonstrated 2 cases in which the adipomuscular f lap was used successfully. The f lap provides more bulk of soft tissue compared with the conventional abductor hallucis muscle f lap and allows reliable closure of deep dead space in the forefoot plantar area after extensive resection or wound www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
321
Annals of Plastic Surgery
Lee et al
debridement. The adipomuscular portion of the f lap provides wellvascularized bulky tissue to prevent an incidence of serious postoperative complications. Muscle f laps remain often the first choice, when dealing with bone infections associated with osteomyelitis, soft tissue infections, and large cavities. Because common local distally based muscle transpositional f laps have difficulty reaching the forefoot plantar region, these defects are normally treated by free tissue transfer because free muscle f laps provide reliable single-stage coverage.5 However, there are some disadvantages which are associated with the application of free f laps: the donor-site morbidity, increased operation time, use of a major vessel of the leg, and the necessity of microsurgical expertise.2 The major advantages of this muscle f lap are a quick and safe surgery, reliable soft tissue coverage of bone and tendons, with muscle tissue and preservation of major arteries of the leg. Besides, donor-site morbidity is negligible because preserved medial plantar nerve and f lexor hallucis brevis will maintain the function of big toe f lexion.12 The blood supply of the flap is provided by segmental branches of the medial plantar artery, with the first muscular branch of the medial plantar artery after bifurcation to the abductor hallucis muscle. It gives additional 1 to 2 small branches to the muscle distally.13 Moreover, the distal end of the medial plantar artery is communicating with the plantar metatarsal artery.4 These observations are consistent with the findings of the authors. In all our cases, the main distal vascular pedicle could be detected approximately 10 to 15 cm distal of the calcaneal tuberosity. We observed superficial necrosis of the distal part of the f lap only in 1 patient with a central plantar wound after excision of malignancy, which needed secondary debridement and additional skin grafting. We did not observe any complete or nearly complete f lap necrosis in this study, and all defects were reconstructed successfully by the f lap. We suggest that the reliability and survival of the distally based adipomuscular f lap rely on many different factors. Vascular risk factors, age of patients, arc of rotation and kinking of the pedicle area, inadequate preparation, unneeded tunneling of the f lap, as well as tissue trauma due to accidents or irradiation, may negatively inf luence perfusion of the entire f lap. The 2-step surgical approach performed in all our patients requires an additional skin graft. However, many clinical situations such as malignant tumors, severely traumatized extremities, infected wounds, and osteomyelitis require a 2-step or multistep operative approach before finally assured defect coverage. Our f lap had some limitations. First, sensate f lap is more ideal for the foot, especially in the plantar surface, but this f lap has no cutaneous nerve. However, the deep sensation of the foot was maintained even after the f lap coverage and the patients could feel to the deep touch sensation. Second, the final coverage should be the skin graft over the f lap. Immediate skin graft coverage over the f lap does not always jeopardize skin survival, but we believed that delayed skin graft could enhance the graft survival because the exudate of the f lap would be decreased and skin graft intake could be more favorable. Moreover, this approach can make surgeons prepare for
322
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& Volume 75, Number 3, September 2015
uneventful situations, such as partial necrosis, similar to our case in this study. This is the main shortcoming of the procedure, that the f lap must be covered with an additional skin graft. Grafted skin usually easily abraded on the surface over bony prominence. Moreover, the margin between the grafted skin and the normal foot skin had sometimes hypertrophic scar formation which was experienced in our series, but was not serious. Third, although there is no need to sacrifice the lateral plantar artery or dorsalis pedis artery, and the medial plantar artery should not be always ligated, it is advisable to use this f lap with patients without any vascular compromise in the foot. Otherwise, vascular evaluation may be necessary for the safety and success of the f lap surgery. We could demonstrate that the distally based adipomuscular abductor hallucis f lap represents an excellent option for reconstruction of soft tissue defects of the plantar forefoot. An adipomuscular f lap as a modification of the conventional muscle f lap was designed to obliterate a residual dead space and eventually enabled the successful reconstruction of the plantar forefoot defect, and the volume of the f lap was well maintained. REFERENCES 1. Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma. 2000;48:913Y917. 2. Gonzalez MH, Tarandy DI, Troy D, et al. Free tissue coverage of chronic traumatic wounds of the lower leg. Plast Reconstr Surg. 2002;109:592Y600. 3. Takahashi A, Tamura A, Ishikawa O. Use of a reverse-flow plantar marginal septum cutaneous island flap for repair of a forefoot defect. J Foot Ankle Surg. 2002;41:247Y250. 4. Schwabegger A, Shafighi M, Harpf C, et al. Distally based abductor hallucis muscle flap: anatomic basis and clinical application. Ann Plast Surg. 2003; 51:505Y508. 5. Scheufler O, Kalbermatten D, Pierer G. Instep free flap for plantar soft tissue reconstruction: indications and options. Microsurgery. 2007;27:174Y180. 6. Mathes SJ, Nahai F, Friedman V. Clinical Atlas of Muscle and Musculocutaneous Flaps. St Louis, Mo: Mosby; 1979. 7. Schwabegger A, Ninkovic M, Anderl H. Combined fasciocutaneous abductor hallucis-medialis pedis transposition flap for defect coverage of the medial ankle. Ann Plast Surg. 1998;40:71Y75. 8. Attinger CE, Ducic I, Cooper P, et al. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg. 2002;110:1047Y1054; discussion 1055-1047. 9. Ortak T, Ozdemir R, Ulusoy MG, et al. Reconstruction of heel defects with a proximally based abductor hallucis muscle flap. J Foot Ankle Surg. 2005; 44:265Y270. 10. Schwabegger A, Shafighi M, Gurunluoglu R. Versatility of the abductor hallucis muscle as a conjoined or distally-based flap. J Trauma. 2005; 59:1007Y1011. 11. Michlits W, Gruber S, Windhofer C, et al. Reconstruction of soft tissue defects overlying the Achilles tendon using the super extended abductor hallucis muscle flap. J Trauma. 2008;65:1459Y1462. 12. Brenner E. Insertion of the abductor hallucis muscle in feet with and without hallux valgus. Anat Rec. 1999;254:429Y434. 13. Orbay H, Kerem M, Uenlue RE, et al. Vascular anatomy of plantar muscles. Ann Plast Surg. 2007;58:420Y426.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
