Anatomic basis of plantar flap design: clinical applications

Closure of plantar defects with local rotation flaps was studied in 10 patients with 11 plantar defects. Ages ranged from 15 to 66 years, and the average defect was 3.0 X 3.6 cm. Two patients were diabetics. Etiology was variable and included trauma, tumors, and breakdown in patients with anesthetic plantar surfaces. Plantar flaps were designed superficial to the plantar fascia based on the proximal plantar subcutaneous plexus blood supply. Sensation was provided by including the medial calcaneal nerve territory within the flap and by performing a limited intraneural dissection of the medial and lateral plantar nerves. Flaps were medially based, although laterally based designs are also possible when sensation is absent. The follow-up period averaged 20.8 months. Patients with normal sensation preoperatively had full sensation postoperatively and were able to bear weight on the flap without limitation. There was minor breakdown in one patient with incomplete sensation. One patient developed a hematoma. Sensate plantar flaps can be designed superficial to the plantar fascia. These flaps are durable and allow normal weight-bearing on the reconstructed surface.     

Fasciocutaneous island flap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot

Soft-tissue deficits over the plantar forefoot, plantar heel, tendo calcaneus, and lower leg are often impossible to cover with a simple skin graft. The previously developed medial plantar fasciocutaneous island flap has been adapted to cover soft-tissue defects over these areas. This fasciocutaneous flap based on the medial plantar neurovascular bundle is capable of providing sensate and structurally similar local tissue. Application of this fasciocutaneous island flap is demonstrated in 12 clinical cases. Successful soft-tissue cover was achieved on the plantar calcaneus (four patients), tendo calcaneus (four patients), lower leg (two patients), and plantar forefoot (two patients). Follow-up ranged from 6 months to 5 years. All flaps were viable at follow-up. Protective sensation was present in 11 of 12 flaps evaluated at 6 months. In addition, all 11 patients were able to ambulate in normal footwear. The medial plantar island flap seems to be more durable than a skin graft, and the donor site on the non-weight-bearing instep is well tolerated. This study demonstrates that the medial plantar fasciocutaneous island flap should be considered as another valuable tool in reconstructive efforts directed at the plantar forefoot, plantar heel, posterior ankle, and lower leg.     

The medial adiposofascial flap of the leg: anatomical basis and clinical applications

Despite recent advances in microsurgical techniques, coverage of lower leg defects by locoregional flaps remains indicated in selected cases. The interest in these types of flaps has improved because recent clinical work advocates that fascial and fasciocutaneous flaps can be well indicated for bone coverage. The anatomical study of the medial adiposofascial flap is presented in this article. The flap is based on the rich vascular network supplied by the saphenous artery and the posterior tibial artery perforators. This flap can be harvested on the anteromedial aspect of the leg and can be mobilized to cover defects located between the patella and the heel. This multiple blood supply makes it possible to harvest this flap in various ways, so various defects can be covered. To confirm and prove the versatility and clinical value of this flap, the authors have studied a series of 22 cases in which this flap was used for coverage of lower leg defects. For these defects, especially when situated in the lower third or around the heel and ankle, coverage by a free flap is most often the only proposed solution. However, the authors have obtained excellent results in the majority of these cases, avoiding a free flap procedure. Moreover, in this way, the option of using a free flap remains possible if needed. There is minimal donor-site morbidity and a high functional and aesthetic outcome, making this flap a first-choice flap in selected cases of lower leg defects.     

Our clinical experience with fibula free flap

Oral cancer incidence in Hungary is strikingly high, even by international standards. In most cases the tumours are to be treated in advanced stage. Hence it follows that we are often forced to remove a part of the mandible, too. We usually use a fibula free flap to reconstruct the bone deficiency. In this paper we report on our clinical experience with fibula free flap.     

Anatomic basis of plantar flap design

Safe planes exist for plantar incisions that minimize the possibility of subcutaneous nerve injury and are therefore useful in flap design. Nerve branch orientation in the plantar subcutaneous tissue is specific and guides dissection so as to avoid producing anesthesia in weight-bearing areas. An extensive proximal plantar subcutaneous plexus exists that permits elevation of plantar flaps in a superficial plane. This is due to the major contribution that the dorsal circulation makes to the skin of the plantar surface. The blood supply to the non-weight-bearing midsole area is not from the medial plantar artery exclusively. This is a watershed area with important lateral plantar artery and dorsalis pedis artery contributions as well. It is not necessary or desirable to base plantar flaps on a myocutaneous or fasciocutaneous supply with its required deep dissection. Local plantar flaps can be designed to include sensation and abundant blood supply without the need for "subfascial" dissection. Subcutaneous sensory plantar flaps designed in accordance with these principles promise a more ideal solution for the treatment of plantar defects.     

The medial gastrocnemius muscle flap: a local free flap

A new application of the medial gastrocnemius muscle flap has been described. Lengthening of the sural vascular pedicle was obtained using interposition vein grafts. This allowed coverage of a larger defect than that which could have been obtained with the tethered muscle and without further insult to the already disturbed lower extremity anatomy. The principle of pedicle lengthening can be used to increase the arc of rotation of various other muscle, myocutaneous, skin, or bone flaps and thereby increase their usefulness.     

The ulnar recurrent fasciocutaneous island flap: reverse medial arm flap

A new island fasciocutaneous flap raised on the inner medial surface of the upper arm has been used for reconstruction of soft-tissue defects of the elbow. The blood supply to this flap comes from the fasciocutaneous perforators of the ulnar recurrent vessels. This unique vascular arrangement allows for safe transference of the upper medial skin to the elbow region. This flap has been used to cover nine defects in eight patients, and results have been good. Except for one case of sensory disturbance, there were no complications or loss of overlying skin. It is a relatively quick and simple procedure involving only one stage that adequately corrects the skin defect around the elbow region and does not require prolonged splinting.     

The V-Y plantar flap for reconstruction of the forefoot

Stable reconstruction of the forefoot remains a formidable challenge. The present study reviews our experience with a flap of plantar skin and fascia advanced in a V-Y manner to cover metatarsal head ulcers. Although this technique was used in a variety of clinical situations, 71 percent of the 38 patients were diabetic with neurotrophic wounds. The anatomic basis for flap design is reported based on 10 fresh cadaver dissections. Flap survival was 100 percent. Ulcer recurrence was related to the problems inherent in the hypesthetic foot. We feel that judicious manipulation of the bony architecture along with weight-dispersion shoe inserts assists in preventing recurrent ulceration.     

Versatility of the sural fasciocutaneous flap in the coverage of lower extremity wounds

The distally based sural nerve flap is an excellent option for covering defects of the lower third of the leg. It allows rapid, reliable coverage of defects extending as far distally as the forefoot. The flap can be elevated under a tourniquet in relatively bloodless fashion without sacrificing a major vessel to the foot. Its use is described in a variety of defects in 11 patients, ranging in age from 3 to 64 years. The flap was used bilaterally in one case and in cross-leg fashion in another. All defects were covered with no major complications, and none of the patients required a blood transfusion. One flap experienced a small amount of distal marginal necrosis, which was excised and closed primarily. The technical aspects of flap elevation are emphasized.