Rewith Free Anterolateral Thigh Flap
s strud ankock-abund reade-osoft
that had enlarged during a 1-year period. The patient had 4 nevi,
ral thigh ap with a 6-ion of the descendingwas interposed withnected 1 artery and 26). Subsequently, themproved, because thenormal blood ow.without infection or
ed. Three weeks later,d (Fig. 7). The patient
tine, and vincristine. He couldwalk and runwithout developing ulcersand without relapse of the malignant melanoma 1 year post-operatively (Fig. 8).
Skin defects of the sole have commonly been reconstructed using
Financial Disclosure: None reported.Conict of Interest: None reported.Address correspondence to: Masaki Fujioka, MD, PhD, Department of Plastic and
Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, 1001-1 Kubara 2, Ohmura City 856-8562 Japan.
Contents lists availab
The Journal of Foot
The Journal of Foot & Ankle Surgery xxx (2014) 14A 53-year-old malewas referred to our ofce complaining of nevuson the distallateral plantar weightbearing region of the right foot received 5 chemotherapy sessions consisting of dacarbazine, nimus-congestion, donor site deformity, and reduction of the footcirculation.
We present a case of lateral forefoot wound reconstructioncaused by radical resection of a malignant melanoma using adistally based medial plantar ap and a free anterolateral thigh ap,with a successful outcome and resolution of these disadvantages.
donor defect was covered with a free anterolate 5-cm elliptical skin island (Fig. 4). The T portbranch of the lateral circumex femoral vesselthe transectedmedial plantar vessel, and we conveins using end-to-end anastomosis (Figs. 5 andcongestion of the reversed median plantar ap iinterrupted medial plantar vessel had restored
The viability of the skin aps was favorablenecrosis, and no additional surgery was requirhe could walk without a cane and was dischargedistally as the metatarsal heads (2,3). However, this convenient aphas several problems and disadvantages, including venous
melanoma was repaired with an island reversed median plantar apmeasuring 5 4 cm. The ap seemed to be congestive (Fig. 3). TheThe medial plantar ap providethe plantar foot, posterior heel, anthick glabrous plantar skin and shtaneous tissue (1). For forefoot woopment of a distally based retrograp will enable resurfacing of theE-mail address: email@example.com (M. Fuji
1067-2516/$ - see front matter 2014 by the Americhttp://dx.doi.org/10.1053/j.jfas.2013.12.012reasonable reconstructive option for large lateral plantar forefoot defects. 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
cturally similar tissue tole defects because of itssorbing brofatty subcu-construction, the devel-w medial plantar islandtissue defects located as
measuring 0.8 0.7 cm to 1.5 0.7 cm, that were found to be ma-lignant melanoma by histologic analysis of a biopsy specimen (Fig. 1).
The operation consisted of en bloc resection with a 2-cm marginthat contained the plantar fascia (Fig. 2). He also underwent inguinallymph node resection, because sentinel inguinal lymph node exami-nation had revealed metastasis. The defect after resection of theweightbearing regionwound reconstructionenables the transport of structurally similar tissues to the plantar forefoot. We believe this technique is ainterposing apmelanoma ap
vantages of this ap include that it does not reduce the vascular supply to the foot owing to reconstruction ofthe medial plantar vascular systems, reduces the risk of ap congestion, minimizes donor site morbidity, andMasaki Fujioka, MD, PhD 1,2, Kenji Hayashida, MD3,1Clinical Professor, Department of Plastic and Reconstructive Surgery, Nagasaki University2Director, Department of Plastic and Reconstructive Surgery, Clinical Research Center, NatNagasaki, Japan3 Staff Surgeon, Department of Plastic and Reconstructive Surgery, National Hospital Organ
a r t i c l e i n f o
Level of Clinical Evidence: 4
Keywords:chemotherapyfree ow-through ap
a b s t r a c t
Skin defects of the heel havecoverage has remained a chadescribe a case of malignantsuccessfully with a distally bCase Reports and Series
Reconstruction of Lateral Forefoot Usingoka).
an College of Foot and Ankle Surgeonversed Medial Plantar Flap
ikako Senju, MD 3
gasaki, Japanl Hospital Organization Nagasaki Medical Center,
ion Nagasaki Medical Center, Nagasaki, Japan
quently been reconstructed using the medial plantar ap; however, forefootge, because the alternatives for ap coverage have been very limited. Weanoma on the lateral forefoot that was radically removed and reconstructedd medial plantar ap, together with a free anterolateral thigh ap. The ad-
le at ScienceDirect
& Ankle Surgery
: www.j fas .orgthe medial plantar ap, which uses skin from a non-weightbearing
s. All rights reserved.
Fig. 1. Preoperative view of the 4 nevi on the lateral forefoot.
M. Fujioka et al. / The Journal of Foot & Ankle Surgery xxx (2014) 142area of the sole, providing excellent texture for sole replacement. (1).However, forefoot coverage has remained a challenge, because thealternatives for ap coverage have been very limited. Small forefootulcers with intact toes can be resurfaced using a digital artery ap, andmedial plantar defects can be covered with laterally basedFig. 2. Intraoperative view of the distallateral plantar weightbearing region after tumorresection with a 2-cm margin. The wound and surrounding skin were stained withindocyanine green to examine the sentinel lymph nodes.fasciocutaneous aps (4). However, the coverage of large forefootdefects, especially those located in the lateral area, has been chal-lenging. To resolve this problem, the distally based medial plantarisland ap has been developed and described for forefoot soft tissuereplacement for chronic plantar ulcerations and burn contracture andafter excision for malignancy (5).
However, this convenient ap involves several problems anddisadvantages. First, venous congestion, which results in partial apnecrosis, could be an inherent disadvantage of a distally basedmedial plantar ap owing to the reversed venular valves (1). Butlerand Chevray (6) reported that 1 of 2 distally based medial plantarisland aps required venous supercharging with an interpositionalvein graft owing to ap congestion. The interposed vein graft alsorequired coverage, usually performed by T-shaped free skin graft-ing in the instep region. Free skin grafting on the vessel also carriesa risk of vascular stoppage, especially if located on the sole.Butler and Chevray (6) provided several recommendations toimprove the vascular problems, including preservation of the per-ivascular fat of the pedicle and skin grafting of the pedicle to avoidcompression.
Second, donor site deformity, resulting in medial plantarcontracture and/or hyperkeratosis, can occur with the skin graft,sometimes causing a walking disability. Medial plantar sensorydisturbance caused by skin grafting directly on nerve can alsodevelop (7).
Fig. 3. Intraoperative view of the reversed median plantar ap, which seemed to becongestive.Finally, a distally based medial plantar ap requires the sacrice ofthe medial plantar vascular system, which reduces the circulation in
Fig. 4. View of the harvested anterolateral thigh ap.
Fig. 5. Intraoperative view of transported anterolateral thigh ap. The T portion of the
Fig. 7. View of the reconstructed foot 3 months after surgery, showing a favorable result.
M. Fujioka et al. / The Journal of Foot & Ankle Surgery xxx (2014) 14 3the foot (8). The medial plantar perforator ap is nutritionallydependent 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 reconstructedwith this useful perforator apwithout transecting themedial plantarartery (7,9). However, it cannot reach the lateral forefoot, because thepivot point of the perforator limits the area to which the perforatorap can be transferred.
The blood ow to the distal foot with a reversed medial plantar
ap vessel was interposed with the transected medial plantar vessel.ap can be maintained normally, owing to reconstruction of thetransected medial plantar vessel by interposing the descending
Fig. 6. Illustration of lateral forefoot reconstruction using a reversed medial plantar apwith a free anterolateral thigh ap.branch of the lateral circumex femoral vessel. Thus, this medialplantar ap is not strictly a distally based or reversed ap.
All perforator aps were available for resurfacing the instepdonor site and interposing the vessels for the interposing ap.However, a reliable T-shaped branching system of the pedicle withappropriate diameters can be found in the subscapular or lateralcircumex femoral vessels (10). The subscapular arterial system hasseveral branches, including the branch to the serratus anteriormuscle ap, scapular ap, and latissimus dorsi musculocutaneousap, which can be used as free ow-through aps (11). The lateralcircumex femoral arterial system, which is a pedicle of the ante-rolateral thigh ap, is another source of the T-anastomosis pedicle,because it has a long descending branch and a reliable proximaltransverse branch (12).
For our patient, we chose the anterolateral thigh ap because ofits advantages. These advantages included that it provides a rela-tively thin skin paddle suitable for instep coverage, the descendingbranch of the lateral circumex femoral vessel is large enough formicro-anastomosis and provides a sufcient length for inter-positioning, and the absence of position changes enables ap har-vesting and recipient preparation to be performed by 2separate teams simultaneously (13). This technique can be per-formed free of venous problems, and no vascular compromise of thefoot has developed, with minimal donor site problems; these arepotential advantages compared with conventional combinationmethods.
In conclusion, the distally based medial plantar ap with freeanterolateral thigh ap should be the primary choice for reconstruc-tion, especially for large lateral plantar forefoot defects.Fig. 8. View of the transferred free ap 1 year after surgery, showing a favorable result.
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2. Takahashi A, Tamura A, Ishikawa O. Use of a reverse-ow plantar marginal septumcutaneous island ap for repair of a forefoot defect. J Foot Ankle Surg 41:247250,2002.
3. Bhandari PS, Sobti C. Reverse ow instep island ap. Plast Reconstr Surg103:19861989, 1999.
4. Curtin JW. Functional surgery for intractable conditions of the sole of the foot.Plast Reconstr Surg 59:806811, 1977.
5. Schwarz R. Reverse medial plantar artery ap. Lepr Rev 77:6975, 2006.6. Butler CE, Chevray P. Retrograde-ow medial plantar island ap reconstruction of
distal forefoot, toe, and web space defects. Ann Plast Surg 49:196201, 2002.7. Koshima I, Narushima M, Mihara M, Nakai I, Akazawa S, Fukuda N, Watanabe Y,
Nakagawa M. Island medial plantar artery perforator ap for reconstruction ofplantar defects. Ann Plast Surg 59:558562, 2007.
8. Oberlin C, Accioli de Vasconcellos Z, Touam C. Medial plantar ap based distally onthe lateral plantar artery to cover a forefoot skin defect. Plast Reconstr Surg106:874877, 2000.
9. Coruh A. Distally based perforator medial plantar ap: a new ap forreconstruction of plantar forefoot defects. Ann Plast Surg 53:404408, 2004.
10. Kim JT, Kim CY, Kim YH. T-anastomosis in microsurgical free ap reconstruction:an overview of clinical applications. J Plast Reconstr Aesthet Surg 61:11571163,2008.
11. Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapularthoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg37:574576, 1984.
12. Xu DC, Zhong SZ, Kong JM, Wang GY, Liu MZ, Luo LS, Gao JH. Appliedanatomy of the anterolateral femoral ap. Plast Reconstr Surg 82:305310,1988.
13. Ao M, Nagase Y, Mae O, Namba Y. Reconstruction of posttraumatic defectsof the foot by ow-through anterolateral or anteromedial thigh apswith preservation of posterior tibial vessels. Ann Plast Surg 38:598603,1997.
M. Fujioka et al. / The Journal of Foot & Ankle Surgery xxx (2014) 144
Reconstruction of Lateral Forefoot Using Reversed Medial Plantar Flap with Free Anterolateral Thigh FlapCase ReportDiscussionReferences