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

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The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

Case Reports and Series

Reconstruction of Lateral Forefoot Using Reversed Medial Plantar Flapwith Free Anterolateral Thigh Flap

Masaki Fujioka, MD, PhD 1,2, Kenji Hayashida, MD3, Chikako Senju, MD 3

1Clinical Professor, Department of Plastic and Reconstructive Surgery, Nagasaki University, Nagasaki, Japan2Director, Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center,Nagasaki, Japan3 Staff Surgeon, Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan

a r t i c l e i n f o

Level of Clinical Evidence: 4

Keywords:chemotherapyfree flow-through flapinterposing flapmelanoma flapweightbearing regionwound reconstruction

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Masaki Fujioka, MD,

Reconstructive Surgery, National Hospital Organization1 Kubara 2, Ohmura City 856-8562 Japan.

E-mail address: mfujioka@nmc.hosp.go.jp (M. Fuji

1067-2516/$ - see front matter � 2014 by the Americhttp://dx.doi.org/10.1053/j.jfas.2013.12.012

a b s t r a c t

Skin defects of the heel have frequently been reconstructed using the medial plantar flap; however, forefootcoverage has remained a challenge, because the alternatives for flap coverage have been very limited. Wedescribe a case of malignant melanoma on the lateral forefoot that was radically removed and reconstructedsuccessfully with a distally based medial plantar flap, together with a free anterolateral thigh flap. The ad-vantages of this flap include that it does not reduce the vascular supply to the foot owing to reconstruction ofthe medial plantar vascular systems, reduces the risk of flap congestion, minimizes donor site morbidity, andenables the transport of structurally similar tissues to the plantar forefoot. We believe this technique is areasonable reconstructive option for large lateral plantar forefoot defects.

� 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.

The medial plantar flap provides structurally similar tissue tothe plantar foot, posterior heel, and ankle defects because of itsthick glabrous plantar skin and shock-absorbing fibrofatty subcu-taneous tissue (1). For forefoot wound reconstruction, the devel-opment of a distally based retrograde-flow medial plantar islandflap will enable resurfacing of the soft tissue defects located asdistally as the metatarsal heads (2,3). However, this convenient flaphas several problems and disadvantages, including venouscongestion, 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 flap and a free anterolateral thigh flap,with a successful outcome and resolution of these disadvantages.

Case Report

A 53-year-old malewas referred to our office complaining of nevuson the distal–lateral plantar weightbearing region of the right footthat had enlarged during a 1-year period. The patient had 4 nevi,

PhD, Department of Plastic andNagasaki Medical Center, 1001-

oka).

an College of Foot and Ankle Surgeon

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 themelanoma was repaired with an island reversed median plantar flapmeasuring 5 � 4 cm. The flap seemed to be congestive (Fig. 3). Thedonor defect was covered with a free anterolateral thigh flap with a 6-� 5-cm elliptical skin island (Fig. 4). The T portion of the descendingbranch of the lateral circumflex femoral vessel was interposed withthe transectedmedial plantar vessel, and we connected 1 artery and 2veins using end-to-end anastomosis (Figs. 5 and 6). Subsequently, thecongestion of the reversed median plantar flap improved, because theinterrupted medial plantar vessel had restored normal blood flow.

The viability of the skin flaps was favorable without infection ornecrosis, and no additional surgery was required. Three weeks later,he could walk without a cane and was discharged (Fig. 7). The patientreceived 5 chemotherapy sessions consisting of dacarbazine, nimus-tine, and vincristine. He couldwalk and runwithout developing ulcersand without relapse of the malignant melanoma 1 year post-operatively (Fig. 8).

Discussion

Skin defects of the sole have commonly been reconstructed usingthe medial plantar flap, which uses skin from a non-weightbearing

s. All rights reserved.

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

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

M. Fujioka et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–42

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

Fig. 2. Intraoperative view of the distal–lateral 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 flaps (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 flap has been developed and described for forefoot soft tissuereplacement for chronic plantar ulcerations and burn contracture andafter excision for malignancy (5).

However, this convenient flap involves several problems anddisadvantages. First, venous congestion, which results in partial flapnecrosis, could be an inherent disadvantage of a distally basedmedial plantar flap owing to the reversed venular valves (1). Butlerand Chevray (6) reported that 1 of 2 distally based medial plantarisland flaps required venous supercharging with an interpositionalvein graft owing to flap 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).

Finally, a distally based medial plantar flap requires the sacrifice ofthe medial plantar vascular system, which reduces the circulation in

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

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

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) 1–4 3

the foot (8). The medial plantar perforator flap 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 flapwithout transecting themedial plantarartery (7,9). However, it cannot reach the lateral forefoot, because thepivot point of the perforator limits the area to which the perforatorflap can be transferred.

The blood flow to the distal foot with a reversed medial plantarflap 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 flapwith a free anterolateral thigh flap.

branch of the lateral circumflex femoral vessel. Thus, this medialplantar flap is not strictly a distally based or reversed flap.

All perforator flaps were available for resurfacing the instepdonor site and interposing the vessels for the interposing flap.However, a reliable T-shaped branching system of the pedicle withappropriate diameters can be found in the subscapular or lateralcircumflex femoral vessels (10). The subscapular arterial system hasseveral branches, including the branch to the serratus anteriormuscle flap, scapular flap, and latissimus dorsi musculocutaneousflap, which can be used as free flow-through flaps (11). The lateralcircumflex femoral arterial system, which is a pedicle of the ante-rolateral thigh flap, 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 flap because ofits advantages. These advantages included that it provides a rela-tively thin skin paddle suitable for instep coverage, the descendingbranch of the lateral circumflex femoral vessel is large enough formicro-anastomosis and provides a sufficient length for inter-positioning, and the absence of position changes enables flap 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 flap with freeanterolateral thigh flap should be the primary choice for reconstruc-tion, especially for large lateral plantar forefoot defects.

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

M. Fujioka et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–44

References

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