The Journal of Foot & Ankle Surgery xxx (2014) 1–4

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Case Reports and Series

Reconstruction of Lateral Forefoot Using Reversed Medial Plantar Flap with Free Anterolateral Thigh Flap Masaki Fujioka, MD, PhD 1, 2, Kenji Hayashida, MD 3, Chikako Senju, MD 3 1

Clinical Professor, Department of Plastic and Reconstructive Surgery, Nagasaki University, Nagasaki, Japan Director, Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan 3 Staff Surgeon, Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan 2

a r t i c l e i n f o

a b s t r a c t

Level of Clinical Evidence: 4

Skin defects of the heel have frequently been reconstructed using the medial plantar flap; however, forefoot coverage has remained a challenge, because the alternatives for flap coverage have been very limited. We describe a case of malignant melanoma on the lateral forefoot that was radically removed and reconstructed successfully with a distally based medial plantar flap, together with a free anterolateral thigh flap. The advantages of this flap include that it does not reduce the vascular supply to the foot owing to reconstruction of the medial plantar vascular systems, reduces the risk of flap congestion, minimizes donor site morbidity, and enables the transport of structurally similar tissues to the plantar forefoot. We believe this technique is a reasonable reconstructive option for large lateral plantar forefoot defects. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.

Keywords: chemotherapy free flow-through flap interposing flap melanoma flap weightbearing region wound reconstruction

The medial plantar flap provides structurally similar tissue to the plantar foot, posterior heel, and ankle defects because of its thick glabrous plantar skin and shock-absorbing fibrofatty subcutaneous tissue (1). For forefoot wound reconstruction, the development of a distally based retrograde-flow medial plantar island flap will enable resurfacing of the soft tissue defects located as distally as the metatarsal heads (2,3). However, this convenient flap has several problems and disadvantages, including venous congestion, donor site deformity, and reduction of the foot circulation. We present a case of lateral forefoot wound reconstruction caused by radical resection of a malignant melanoma using a distally based medial plantar flap and a free anterolateral thigh flap, with a successful outcome and resolution of these disadvantages. Case Report A 53-year-old male was referred to our office complaining of nevus on the distal–lateral plantar weightbearing region of the right foot that had enlarged during a 1-year period. The patient had 4 nevi,

Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Masaki Fujioka, MD, PhD, Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, 10011 Kubara 2, Ohmura City 856-8562 Japan. E-mail address: [email protected] (M. Fujioka).

measuring 0.8  0.7 cm to 1.5  0.7 cm, that were found to be malignant melanoma by histologic analysis of a biopsy specimen (Fig. 1). The operation consisted of en bloc resection with a 2-cm margin that contained the plantar fascia (Fig. 2). He also underwent inguinal lymph node resection, because sentinel inguinal lymph node examination had revealed metastasis. The defect after resection of the melanoma was repaired with an island reversed median plantar flap measuring 5  4 cm. The flap seemed to be congestive (Fig. 3). The donor defect was covered with a free anterolateral thigh flap with a 6 5-cm elliptical skin island (Fig. 4). The T portion of the descending branch of the lateral circumflex femoral vessel was interposed with the transected medial plantar vessel, and we connected 1 artery and 2 veins using end-to-end anastomosis (Figs. 5 and 6). Subsequently, the congestion of the reversed median plantar flap improved, because the interrupted medial plantar vessel had restored normal blood flow. The viability of the skin flaps was favorable without infection or necrosis, and no additional surgery was required. Three weeks later, he could walk without a cane and was discharged (Fig. 7). The patient received 5 chemotherapy sessions consisting of dacarbazine, nimustine, and vincristine. He could walk and run without developing ulcers and without relapse of the malignant melanoma 1 year postoperatively (Fig. 8). Discussion Skin defects of the sole have commonly been reconstructed using the medial plantar flap, which uses skin from a non-weightbearing

1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2013.12.012

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Fig. 3. Intraoperative view of the reversed median plantar flap, which seemed to be congestive.

Fig. 1. Preoperative view of the 4 nevi on the lateral forefoot.

area of the sole, providing excellent texture for sole replacement. (1). However, forefoot coverage has remained a challenge, because the alternatives for flap coverage have been very limited. Small forefoot ulcers with intact toes can be resurfaced using a digital artery flap, and medial plantar defects can be covered with laterally based

Fig. 2. Intraoperative view of the distal–lateral plantar weightbearing region after tumor resection with a 2-cm margin. The wound and surrounding skin were stained with indocyanine green to examine the sentinel lymph nodes.

fasciocutaneous flaps (4). However, the coverage of large forefoot defects, especially those located in the lateral area, has been challenging. To resolve this problem, the distally based medial plantar island flap has been developed and described for forefoot soft tissue replacement for chronic plantar ulcerations and burn contracture and after excision for malignancy (5). However, this convenient flap involves several problems and disadvantages. First, venous congestion, which results in partial flap necrosis, could be an inherent disadvantage of a distally based medial plantar flap owing to the reversed venular valves (1). Butler and Chevray (6) reported that 1 of 2 distally based medial plantar island flaps required venous supercharging with an interpositional vein graft owing to flap congestion. The interposed vein graft also required coverage, usually performed by T-shaped free skin grafting in the instep region. Free skin grafting on the vessel also carries a risk of vascular stoppage, especially if located on the sole. Butler and Chevray (6) provided several recommendations to improve the vascular problems, including preservation of the perivascular fat of the pedicle and skin grafting of the pedicle to avoid compression. Second, donor site deformity, resulting in medial plantar contracture and/or hyperkeratosis, can occur with the skin graft, sometimes causing a walking disability. Medial plantar sensory disturbance caused by skin grafting directly on nerve can also develop (7). Finally, a distally based medial plantar flap requires the sacrifice of the medial plantar vascular system, which reduces the circulation in

Fig. 4. View of the harvested anterolateral thigh flap.

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Fig. 7. View of the reconstructed foot 3 months after surgery, showing a favorable result.

Fig. 5. Intraoperative view of transported anterolateral thigh flap. The T portion of the flap vessel was interposed with the transected medial plantar vessel.

the foot (8). The medial plantar perforator flap is nutritionally dependent only on the perforator of the medial plantar vessel; thus, the posterior tibial and medial plantar vessels can be left intact. Forefoot skin defects located on the medial side can be reconstructed with this useful perforator flap without transecting the medial plantar artery (7,9). However, it cannot reach the lateral forefoot, because the pivot point of the perforator limits the area to which the perforator flap can be transferred. The blood flow to the distal foot with a reversed medial plantar flap can be maintained normally, owing to reconstruction of the transected medial plantar vessel by interposing the descending

Fig. 6. Illustration of lateral forefoot reconstruction using a reversed medial plantar flap with a free anterolateral thigh flap.

branch of the lateral circumflex femoral vessel. Thus, this medial plantar flap is not strictly a distally based or reversed flap. All perforator flaps were available for resurfacing the instep donor site and interposing the vessels for the interposing flap. However, a reliable T-shaped branching system of the pedicle with appropriate diameters can be found in the subscapular or lateral circumflex femoral vessels (10). The subscapular arterial system has several branches, including the branch to the serratus anterior muscle flap, scapular flap, and latissimus dorsi musculocutaneous flap, which can be used as free flow-through flaps (11). The lateral circumflex femoral arterial system, which is a pedicle of the anterolateral thigh flap, is another source of the T-anastomosis pedicle, because it has a long descending branch and a reliable proximal transverse branch (12). For our patient, we chose the anterolateral thigh flap because of its advantages. These advantages included that it provides a relatively thin skin paddle suitable for instep coverage, the descending branch of the lateral circumflex femoral vessel is large enough for micro-anastomosis and provides a sufficient length for interpositioning, and the absence of position changes enables flap harvesting and recipient preparation to be performed by 2 separate teams simultaneously (13). This technique can be performed free of venous problems, and no vascular compromise of the foot has developed, with minimal donor site problems; these are potential advantages compared with conventional combination methods. In conclusion, the distally based medial plantar flap with free anterolateral thigh flap should be the primary choice for reconstruction, especially for large lateral plantar forefoot defects.

Fig. 8. View of the transferred free flap 1 year after surgery, showing a favorable result.

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References 1. Acikel C, Celikoz B, Yuksel F, Ergun O. Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle. Ann Plast Surg 50:498–503, 2003. 2. 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 41:247–250, 2002. 3. Bhandari PS, Sobti C. Reverse flow instep island flap. Plast Reconstr Surg 103:1986–1989, 1999. 4. Curtin JW. Functional surgery for intractable conditions of the sole of the foot. Plast Reconstr Surg 59:806–811, 1977. 5. Schwarz R. Reverse medial plantar artery flap. Lepr Rev 77:69–75, 2006. 6. Butler CE, Chevray P. Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and web space defects. Ann Plast Surg 49:196–201, 2002. 7. Koshima I, Narushima M, Mihara M, Nakai I, Akazawa S, Fukuda N, Watanabe Y, Nakagawa M. Island medial plantar artery perforator flap for reconstruction of plantar defects. Ann Plast Surg 59:558–562, 2007.

8. Oberlin C, Accioli de Vasconcellos Z, Touam C. Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect. Plast Reconstr Surg 106:874–877, 2000. 9. Coruh A. Distally based perforator medial plantar flap: a new flap for reconstruction of plantar forefoot defects. Ann Plast Surg 53:404–408, 2004. 10. Kim JT, Kim CY, Kim YH. T-anastomosis in microsurgical free flap reconstruction: an overview of clinical applications. J Plast Reconstr Aesthet Surg 61:1157–1163, 2008. 11. Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapular– thoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg 37:574–576, 1984. 12. Xu DC, Zhong SZ, Kong JM, Wang GY, Liu MZ, Luo LS, Gao JH. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg 82:305–310, 1988. 13. Ao M, Nagase Y, Mae O, Namba Y. Reconstruction of posttraumatic defects of the foot by flow-through anterolateral or anteromedial thigh flaps with preservation of posterior tibial vessels. Ann Plast Surg 38:598–603, 1997.

Reconstruction of lateral forefoot using reversed medial plantar flap with free anterolateral thigh flap.

Skin defects of the heel have frequently been reconstructed using the medial plantar flap; however, forefoot coverage has remained a challenge, becaus...
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