Versatility of the medial plantar flap: our clinical experience

The medial plantar flap presents an ideal tissue reserve, particularly for the reconstruction of the plantar and palmar areas, which require a sensate and unique form of skin. In the past 5 years, the authors performed 16 free flaps, 10 locally pedicled flaps, and five cross-leg flaps on 31 patients for the reconstruction of palmar and plantar defects. All flaps transferred to the palmar area survived, providing good color match and sufficient bulkiness. The overall results were satisfactory in terms of function and sensation, and no complications related to flap survival in the plantar area were observed. All flaps used to cover defects in the heel and ankle region adapted well to their recipient areas, and all lower extremities remained functional. Because the medial plantar flap presents glabrous, sensate skin with proper bulkiness and permits the movement of underlying structures, the authors advocate its use and view this procedure as an excellent alternative in the reconstruction of palmar and plantar weight-bearing areas.     

Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect

The authors report a simple, single-step procedure to promote the distal transfer of the instep island flap for coverage of the submetatarsal weight-bearing zone. First described in 1991 by Martin et aI, this procedure remained unknown. As opposed to the medial plantar flap, this technique proposes an instep island flap based on the lateral plantar artery. The inflow and outflow of blood is assured by the anastomosis between the dorsalis pedis and lateral plantar vessels. This approach allows for the transfer of similar tissue and provides adequate coverage of the weight-bearing zone of the distal forefoot.     

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.     

Sixty-four cases of thumb and finger reconstruction using transplantation of the big toe skin-nail flap combined with the second toe or the second and third toes

The purpose of this article is to introduce the results of thumb and finger reconstruction using transplantation of the big toe wraparound flap combined with the second toe or the second and third toes. Between August of 1981 and December of 1998, in a series of 64 cases involving 58 patients with digitless hands, either (1) the thumb and index fingers were reconstructed by transplantation of a big toe wraparound flap combined with the adjacent second toe harvested from the ipsilateral foot; or (2) the thumb, index, and long fingers were reconstructed by transplantation of an ipsilateral big toe wraparound flap combined with the adjacent second and third toes. The phalanx of the new thumb was usually an iliac block. The success rate of this series was 92.2 percent. At long-term follow-up, the average static 2-point discrimination was less than 10 mm. The distance between the tip of the new thumb and the new index finger ranged from 6 to 10 cm (average, 8 cm). Opposition action was nimble and forceful. The patients could lift a 6- to 12-kg weight with their reconstructed digits. All patients were satisfied with their new hands and were able to use them in their daily activities. The transplants for reconstructing the thumb and fingers are harvested from the same foot in a procedure known as one-foot donation. Function of the bilateral digitless hand can be recovered with this procedure.     

The medial sural artery perforator free flap.

The medial sural artery supplies the medial gastrocnemius muscle and sends perforating branches to the skin. The possible use of these musculocutaneous perforators as the source of a perforator-based free flap was investigated in cadavers. Ten legs were dissected, and the topography of significant perforating musculocutaneous vessels on both the medial and the lateral gastrocnemius muscles was recorded. A mean of 2.2 perforators (range, 1 to 4) was noted over the medial gastrocnemius muscle, whereas in only 20 percent of the specimens was a perforator of moderate size noted over the lateral gastrocnemius muscle. The perforating vessels from the medial sural artery clustered about 9 to 18 cm from the popliteal crease. When two perforators were present (the most frequent case), the perforators were located at a mean of 11.8 cm (range, 8.5 to 15 cm) and 17 cm (range, 15 to 19 cm) from the popliteal crease. A series of six successful clinical cases is reported, including five free flaps and one pedicled flap for ipsilateral lower-leg and foot reconstruction. The dissection is somewhat tedious, but the vascular pedicle can be considerably long and of suitable caliber. Donor-site morbidity was minimal because the muscle was not included in the flap. Although the present series is short, it seems that the medial sural artery perforator flap can be a useful flap for free and pedicled transfer in lower-limb reconstruction.     

Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity

Elevated plantar foot pressures during gait in diabetic patients with neuropathy have been suggested to result, among other factors, from the distal displacement of sub-metatarsal head (MTH) fat-pad cushions caused by to claw/hammer toe deformity. The purpose of this study was to quantitatively assess these associations. Thirteen neuropathic diabetic subjects with claw/hammer toe deformity, and 13 age- and gender-matched neuropathic diabetic controls without deformity, were examined. Dynamic barefoot plantar pressures were measured with an EMED pressure platform. Peak pressure and force-time integral for each of 11 foot regions were calculated. Degree of toe deformity and the ratio of sub-MTH to sub-phalangeal fat-pad thickness (indicating fat-pad displacement) were measured from sagittal plane magnetic resonance images of the foot. Peak pressures at the MTHs were significantly higher in the patients with toe deformity (mean 626 (SD 260)kPa) when compared with controls (mean 363 (SD 115) kPa, P<0.005). MTH peak pressure was significantly correlated with degree of toe deformity (r=-0.74) and with fat-pad displacement (r=-0.71) (P<0.001). The ratio of force-time integral in the toes and the MTHs (toe-loading index) was significantly lower in the group with deformity. These results show that claw/hammer toe deformity is associated with a distal-to-proximal transfer of load in the forefoot and elevated plantar pressures at the MTHs in neuropathic diabetic patients. Distal displacement of the plantar fat pad is suggested to be the underlying mechanism in this association. These conditions increase the risk for plantar ulceration in these patients.     

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.