Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 248e254

Weight-bearing plantar reconstruction usingversatile medial plantar sensate flap

Suk Joon Oh a,*, Mincheol Moon a, Jeongho Cha a, Sung Hoon Koh a,Chul Hoon Chungb

aDepartment of Plastic and Reconstructive Surgery, Hallym University Sacred Heart Hospital, Hallym University, 896Pyeungandong Donangu Anyangsi Gyeonggido,431-796, Republic of KoreabDepartment of Plastic and Reconstructive Surgery, Kangdong Sacred Heart Hospital, Hallym University, 445 GildongKangdonggu Seoul, 134-701, Republic of Korea

Received 12 February 2010; accepted 11 April 2010

KEYWORDSWeight-bearing plantarreconstruction;Heel reconstruction;Forefoot solereconstruction;Medial plantar flap;Free flap;Island flap

* Corresponding author. Tel.: þ82 3E-mail addresses: sjoh@hallym.or.

1748-6815/$-seefrontmatterª2010Bridoi:10.1016/j.bjps.2010.04.013

Summary The medial plantar flap serves as an ideal tissue reserve for reconstructing theweight-bearing plantar areas as these areas require a sensate and glabrous skin. Furthermore,the flap provides tissue that is structurally similar to the plantar foot as it is also composed ofthick glabrous plantar skin, shock-absorbing fibro-fatty subcutaneous tissue and plantar fascia.

During the past 25 years, 20 patients (10 men, 10 women) with skin and soft-tissue defectsover the weight-bearing plantar foot were treated. They ranged in age from 20 to 70 years(mean, 31.5 years). The causes of the defects were trauma (nZ 14) and malignant tumour(nZ 6); the defects were localised at the heel (nZ 16) and plantar forefoot (nZ 4).

The medial plantar flap was transposed to the defects in three different ways: proximallypedicled sensorial island flaps (n Z 8), distally pedicled sensate island flaps based on thelateral plantar vessel (nZ 3) and neurovascular free flaps (nZ 9). Flap size varied from a widthof 4e8 cm and a length of 6e12 cm. The mean size of the medial plantar flap was 49.5 cm2

(range, 28e96 cm2).The follow-up period ranged from 6 to 80 months (mean, 19.9 months). Partial flap loss was

observed in two proximally pedicled sensorial island flaps and one distally pedicled sensateisland flap. Two free flaps restored normal sensation within 5 years of surgery. Minor skin graftloss at the donor site was observed in seven patients. However, no revision or re-grafting wasperformed. Hyperkeratosis was observed in one case. All patients achieved normal gait within3 months after surgery and none noticed recurred ulceration. Durable, sensate coverage of thedefects was achieved in all patients.

We advocate variable sensate medial plantar flaps for the reconstruction of moderate-sizedefects of the weight-bearing plantar subunits.ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

1 380 3780; fax: þ82 31 380 5980.kr, sjoh46@hotmail.com (S.J. Oh).

tishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Weight-bearing plantar reconstruction 249

The weight-bearing plantar portion of the foot can be sustained crushed feet from car wheels. Eleven traumatic

divided into the heel (hind foot, plantar calcaneus), thelateral plantar foot (midfoot sole) and the plantar forefoot(forefoot sole), excluding the medial plantar (instep) area.The medial plantar area of the foot presents an idealreserve for reconstructing the particular areas that requiresensate and glabrous skin. Plantar skin has characteristicsthat differ from those of the skin covering other parts of thebody. The epidermis and dermis are much thicker, and thefibrous septa binding plantar skin to plantar aponeurosisconstruct fat loculations that produce a shock-absorbingsystem. This special skin-aponeurosis system is crucial forthe weight-bearing area of the foot. In addition, plantarskin has a specific pattern of pigmentation and is highlydurable.

The skin of the medial plantar region of the foot was firstused for reconstruction by Mir y Mir, who transferred thecross-foot medial plantar flap to aid in covering a heeldefect.1 Later reports introduced the medial plantar flap asthe sensate pedicled flap,2 the island fasciocutaneous flap3

and the free fasciocutaneous flap4 for use in covering a heeldefect, whereas others introduced the sensate medialplantar flap as a reverse flow flap based distally on themedial plantar vessel5 and based distally on the lateralplantar vessel6 to cover defects of the forefoot sole.

Over the past 25 years, in a total of 20 patients, we haveused sensate medial plantar flaps in variable designs,depending on the needs of the recipient areas. Thesedesigns include free, proximally pedicled islands, distallypedicled islands based on the lateral plantar vessel andflaps placed in the fasciocutaneous fashion (Table 1). Thisarticle presents the versatility of the medial plantar flap forreconstruction of the heel and forefoot sole.

Materials

Twenty patients (10 men, 10 women) at a mean age of 31.5years (range, 7e70 years) with defects caused by caraccident (nZ 11), machine injury (nZ 2), train accident(nZ 1), malignant melanoma (nZ 4) (Figure 2(c)), squa-mous cell carcinoma (nZ 1) (Figure 2(a)) and sarcoma(nZ 1) were enrolled in the study. Ten pedestrian patients

Table 1 Design of innervated medial plantar flaps with recipie

Design of medial plantar flaps Site of the defects

Proximally based sensate island Total plantar heelPosterior plantar heelAnterior plantar heel

Sensate island based distallyon lateral plantar vessel

Lateral plantar heel

Medial plantar forefoot

Lateral plantar forefoot

Sensate free from contralateralfoot

Total plantar heelTotal plantar forefootMedial plantar forefoot

Total

defects (except one cross-leg flap case) were treated byskin grafting that resulted in frequent ulceration andcontracture; another two traumatic defects were granu-lated wounds.

Defects of the foot were noted on the left in 11 patientsand on the right in nine patients. These defects werelocalised at the total heel (nZ 8) (Figures 2(a) and 3(a)),the posterior heel (nZ 3), the anterior heel (nZ 4), thelateral heel (nZ 1), the total plantar forefoot (nZ 1)(Figure 3(c)), the medial plantar forefoot (nZ 2) and thelateral plantar forefoot (nZ 1) (Figure 2(c)).

The defects of eight heels and one forefoot soleextended ipsilaterally to the medial plantar areas (Figure 3(a)). In addition, the heel defect of one patient continuedinto a wide soft-tissue defect of the ipsilateral leg, whereasthe medial forefoot defect of one patient combined withcrushed amputation of the great toe.

Methods

Patients were preoperatively evaluated by X-ray study andangiography, as well as by Doppler and colour Duplexultrasound scans.

To reconstruct the heel and forefoot sole, we performedneurovascular medial plantar free flaps (nZ 9) (Figure 1(c)),proximally pedicled medial plantar sensate island flaps(nZ 8) (Figure 1(a)) and distally pedicled medial plantarsensate island flaps based on the lateral plantar vessel(nZ 3) (Figure 1(b)) (Table 1). Flap size varied from a widthof 3 to 8 cm and a length of 6 to 12 cm. The mean size of themedial plantar flap was 49.5 cm2 (range, 28e96 cm2).

Recipient defects are prepared and measured afterremoving unstable grafted skin, debriding the granulatedwound and wide tumour ablation. The flap is then designedon the non-weight-bearing medial plantar portion to beslightly larger than the defect size. The designed fas-ciocutaneous flap is elevated to a plane beneath theplantar fascia, whereas the medial plantar vessel remainsattached to the undersurface of the flap. During the flapelevation process, three or four cutaneous nerve fasciclesin the medial plantar flap are delicately peeled off the

nt nerves according to site of the defects

Recipients’ nerve Nerve anastomosis Number

Medial plantar No 2Medial plantar No 3Medial plantar No 3Lateral calcaneal(sural)

End-to-end 1

1st common digital(medial plantar)

End-to-side 1

4th common digital(lateral plantar)

End-to-side 1

Medial calcaneal End-to-end 7Medial plantar End-to-end 1Superficial peroneal End-to-end 1

20

Figure 1 a) Harvested proximally based medial plantar sensate island flap. b) Harvested medial plantar sensate island flap baseddistally on the lateral plantar vessel. c) Harvested medial plantar neurovascular free flap. d) End-to-side anastomosis of medialplantar nerve and fourth common digital nerve.

250 S.J. Oh et al.

surface of the medial plantar nerve (Figure 1(a)). In mostinstances, the proximal abductor hallucis must be dividedand opened along the anterior tarsal tunnel to liberate theneurovascular pedicle.

In the reverse flow medial plantar island flap baseddistally on the lateral plantar vessel, the posterior tarsaltunnel must be also opened to liberate the long pedicleafter division of the posterior tibial vessel just above itsbifurcation into two plantar vessels. The pedicle length ofthis flap can measure up to 8 cm in the pivot point of thefourth metatarsal area (Figure 1(b)). This long pedicled flapcan cover the defects of any plantar foot subunits. In ourthree patients, these flaps covered the lateral heel and themedial and lateral plantar forefeet.

Plantar aponeurotic fascia was included in 16 flaps.However, it was excluded from the thin flap that covered thedefects of two anterior and two posterior heels (Figure 1(a)).

Recipient vessels were the posterior tibial artery and itsvenae comitantes in seven free flaps for total heel defects,branches of the thoracodorsal vessel of skin-grafted lat-issimus dorsi and serratus anterior muscles to coverthe anterior leg in one free flap for the heel defect andthe dorsalis pedis vessel in one free flap for a defect of themedial forefoot sole. Microvascular anastomoses of themedial plantar free flap were performed end-to-side in theartery and end to end in two venae comitantes. Ina combined free flap for the defects of the anterior leg and

the heel, we found that the medial plantar vessels on therecipient side were insufficient for microvascular anasto-mosis. Therefore, flow-through anastomosis to the thor-acodorsal artery was performed using interposition veingrafts. These techniques did not disturb circulation withinthe injured foot.

Recipient nerves of the neurovascular free flap were themedial calcaneal nerve (nZ 7), the lateral plantar nerve(nZ 1) and the superficial peroneal nerve (nZ 1). Recipientnerves of the sensate island flap that was based distally onthe lateral plantar vessel were the lateral calcaneal branchof the sural nerve for lateral heel defects, the first commondigital branch of the medial plantar nerve for defects of themedial forefoot sole and the fourth common digital branchof the lateral plantar nerve for defects of the lateral fore-foot sole (Figure 1(d)). In this distally pedicled island flap,the common digital nerves of the medial and lateral plantarnerves were anastomosed with medial plantar nerve fasci-cles of the flaps in an end-to-side fashion (Table 1).

Donor sites were covered with thick split-thickness skingrafts (nZ 18) and full-thickness skin grafts (nZ 2).

Results

Three cases of proximally based island medial plantar flapssufferedpartial flap loss due to venous congestion (nZ 2) andwound infection (nZ 1). Therefore, these flaps required

Figure 2 a) Squamous cell carcinoma at the total heel. b) Photograph taken 18 months after proximally based medial plantarsensate island flap repair. c) Malignant melanoma of the lateral plantar forefoot. d) Photograph taken six months after repair witha medial plantar sensate island flap based distally on the lateral plantar vessel.

Weight-bearing plantar reconstruction 251

debridement and skin re-grafting. Minor skin graft loss at thedonor site was observed in seven patients. No revision or re-grafting was performed, and the graft loss healed spontane-ously.Although10patientsexperienced subjectivepainwhilewalking, this complaint dissipated within three months.

The mean of patients’ follow-up duration was 19.9months (range, 3e80 months). The mean of static two-point discrimination was 17.7 mm (range, 11e20 mm) at 1-year (nZ 7) and 9 mm at 5 years (nZ 2) after implantationof the neurovascular medial plantar free flap, and 20 mm 1year (nZ 3) after the medial plantar sensate island flapwas based distally on the lateral plantar vessel.

All patients achieved normal gait within 3 months aftersurgery and none noted recurred ulceration (Figures 2(b), 2(d), 3(b) and 3(d)). The gait pattern after heel recon-struction changed from the toe-heel to the heel-toe gait inthe direct observation and video records. One case ofhyperkeratosis occurred in skin that was grafted afterpartial loss of the flap; this improved after oral acitretintherapy. Four patients complained of marginal scarfissuring, which was lessened with using functional foot-wear during the follow-up period.

Discussion

Preoperative diagnostic imaging of the arterial system ofthe lower extremities was done by angiography or Doppler

ultrasound is mandatory. Additional investigation of thevenous system by colour Duplex ultrasound is advisable inhigh-risk patients.7,8 Those studies can evaluate the circu-latory disturbances of the foot in severe prior trauma andthe peripheral vascular disease.

The plantar surface is divided into weight-bearingsubunits that include the anterior heel, the lateral foot andthe forefoot, and non-weight-bearing subunits, namely theinstep area and the posterior heel.9 However, we dividedthe heel (total, anterior, posterior and lateral heel), lateralfoot and the forefoot (total, medial and lateral forefoot)according to the location of defects.

Although skin grafts are usually sufficient for recon-structing the non-weight-bearing instep, mechanicallyresistant and sensate local or free flaps are preferred fordefects of the heel, lateral foot and plantar forefoot toprovide durable coverage. Accordingly, the location of thedefect, its size, associated injuries of the underlyingmusculoskeletal structures, co-morbidities as well aspersonal preferences of the patient and surgeon influencethe choice of the reconstructive procedure.9

Medial plantar flaps are fasciocutaneous flaps from thenon-weight-bearing instep area.1e3,10,11 They can be raisedas pedicled flaps,2e5,11e16 cross-foot flaps,1,10,17 or freeflaps,6,7,12,18 and include the same anatomical features thatare unique to the plantar skin, namely a thin layer ofsubcutaneous fat and dense fibrous septae anchoring the

Figure 3 a) Skin grafted defect of the total heel. b) Photograph taken 18 months after neurovascular medial plantar free flaprepair. c) Recurred ulcerative defect of the plantar forefoot after a cross-leg flap. d) Photograph taken 6 years after neurovascularmedial plantar free flap repair.

252 S.J. Oh et al.

skin to the underlying fascia.3 4,12This flap can be trans-ferred to ipsilateral defects of the heel and sole as a prox-imally2,3,11 or distally5,14e16 pedicled island flap and tocontralateral defects as a cross-foot flap10,17 or freeflap.4,7,18 Although instep flaps are regarded as the firstchoice for heel reconstruction, their use is limited by thesize of the defect, the severity of prior trauma andperipheral vascular disease.3,4,11e13

We performed eight surgeries of proximally sensatemedial plantar island flaps and seven cases of the neuro-vascular medial plantar free flaps for the reconstruction ofheel defects. One patient required a sensate medial plantarflap based distally on the lateral plantar artery to cover thedefect of the lateral heel.

When defects of the plantar foot are larger than 100 cm2

in size or are associated with injury and chronic infection ofthe underlying musculoskeletal structures, skin graftedmuscle,8,19e24 musculocutaneous25,26 and distant skin freeflaps8,25,27,28 can be considered for the reconstruction ofthe heel and plantar forefoot. Muscle flaps are favoured fordeep irregular defects, especially after bony debridement,because of their ability to fill dead space. They may besuperior to fasciocutaneous flaps in the presence of chronicinfection and osteomyelitis.29e31 Protective sensation isimportant for flap durability in weight-bearing areas andhas been reported repeatedly in muscle flaps and fas-ciocutaneous flaps alike.8,20,32, 33 Muscle free flaps,

however, are limited by functional impairment. Distantfasciocutaneous flaps may leave unsightly scars or contourdeformities. The medial plantar flap is advantageousregarding donor-site morbidity.

Several options are available for reconstructing theplantar forefoot. The filleted toe flap,34 reverse flow flexordigitorum brevis muscle island flap,35 plantar marginalseptum cutaneous island flap,36 distally based perforatormedial plantar flap,37,38 distally based insensate medialplantar island flaps,5,14e16,39 the insensate medial plantarflap based distally on the lateral plantar artery6 andinsensate medial plantar free flap9 were all described foruse in defects of the forefoot.

One disadvantage of a distally based medial plantarisland flap is that when it is used in a severely injured foot,the distal vascular network cannot be relied on to ensurethe necessary retrograde blood flow. Another disadvantageis the limited size of the island flap and the risk of venouscongestion.15 Venous perfusion appears to be inadequate inthe distally based medial plantar flap; venous drainage canbe augmented by supercharging the flap.16,39

The advantage of an insensate medial plantar flap baseddistally on the lateral plantar vessel is the possibility ofperforming a single-step procedure to transfer a flapcapable of covering any areas of tissue loss in the weight-bearing area of the forefoot. The disadvantages are thenecessity of a patent anastomosis between the dorsalis pedis

Weight-bearing plantar reconstruction 253

and lateral plantar arteries and the insensitivity of the skintransferred.6 We report two patients with a sensate medialplantar flap based distally on the lateral plantar artery andtwo patients with a sensate medial plantar free flap forreconstruction of moderate-size defects of the forefoot.

Flaps transferred to insensate areas are more prone todamage because of the lack of deep pressure sensation andunfavourable weight distribution.33 We used medial plantarinnervated flaps for defects in all patients.

The plantar aponeurosis to cover defects of the posteriorheel could be spared during flap dissection.9 Flap dissec-tions of four patients spared the plantar fascia in themedial plantar island flap to cover defects of the anteriorand posterior heel.

Inclusion of cutaneous nerve fascicles of the medialplantar nerve does not impair tactile sensation permanently.However, sensation of the toes may temporarily be dimin-ished due to neurapraxia.7 All sensate flaps restored tactileand protective sensation after surgery. The medial plantarisland and free flaps were well-integrated into the heels andthe plantar surface of the forefeet, without signs of scarinstability or skin breakdown. The grafted donor defect atthe medial plantar area showed a stable skin cover overtime. Walking ability and gait pattern appeared normal inthe direct observation and video records of our patients.

Finally, the highly specialised sensate skin of the medialplantar flap with high resilience to pressure and frictionmay yield an improved long-term functional outcomecompared with skin or muscle flaps from distant sites. Weadvocate the contralateral medial plantar neurovascularfree flap for reconstruction of complex defects of theplantar forefoot and heel in selected cases, when ipsilat-eral pedicled instep flaps are not available and distant skinor muscle free flaps can be avoided. If ipsilateral pedicledmedial plantar flaps are available, we advocate thefollowing: (1) proximally based neurovascular island flapsfor reconstruction of defects of the heel and (2) medialplantar neurovascular flaps based distally on the lateralplantar vessel for reconstructing the defect of any weight-bearing portions, except the medial heel, when blood flowbetween the dorsalis pedis and lateral plantar arteries ispatent. Their flap sizes are limited to 96 (12� 8) cm2.

Conflicts of interest

None.

Sources of funding

None.

References

1. Mir y Mir L. Functional graft of the heel. Plast Reconstr Surg1954;14:444e50.

2. Shanahan RE, Gingrass RP. Medial plantar sensory flap forcoverage of heel defects. Plast Reconstr Surg 1979;64:295e8.

3. Harrison DH, Morgan BD. The instep island flap to resurfaceplantar defects. Br J Plast Surg 1981;34:315e8.

4. Morrison WA, Crabb DM, O’Brien BM, et al. The instep of thefoot as a fasciocutaneous island and as a free flap for heeldefects. Plast Reconstr Surg 1983;72:56e63.

5. Amarante J, Martins A, Reis J. A distally based median plantarflap. Ann Plast Surg 1988;20:468e70.

6. Oberlin C, Accioli de Vasconcellos Z, et al. Medial plantar flapbased distally on the lateral plantar artery to cover a forefootskin defect. Plast Reconstr Surg 2000;106:874e7.

7. Acikel C, Celikoz B, Yuksel F, Touam C. Various applicationsof the medial plantar flap to cover the defects of the plantarfoot, posterior heel, and ankle. Ann Plast Surg 2003;50:498e503.

8. Yucel A, Senyuva C, Aydin Y, et al. Soft-tissue reconstruction ofsole and heel defects with free tissue transfers. Ann Plast Surg2000;44:259e68.

9. Scheufler O, Kalbermantten D, Pierer G. Instep free flap forplantar soft tissue reconstruction: indications and options.Microsurgery 2007;27:174e80.

10. Taylor GA, Hopson WL. The cross-foot flap. Plast Reconstr Surg1975;55:677e81.

11. Reiffel RS, McCarthy JG. Coverage of heel and sole defects:a new subfascial arterialized flap. Plast Reconstr Surg 1980;66:250e60.

12. Harrison DH. The instep of the foot as a fasciocutaneous islandand as a free flap for heel defects. Plast Reconstr Surg 1983;72:64e5. discussion.

13. Miyamoto Y, Ikuta Y, Shigeki S, et al. Current concepts of instepisland flap. Ann Plast Surg 1987;19:97e102.

14. Baker GL, Newton ED, Franklin MD. Fasciocutaneous island flapbased on the medial plantar artery: clinical applications forleg, ankle and forefoot. Plast Reconstr Surg 1990;85:47e58.

15. Bhandari PS, Sobti C. Reverse flow instep island flap. PlastReconstr Surg 1999;103:1986e9.

16. Butler CE, Chevray P. Retrograde-flow medial plantar islandflap reconstruction of distal forefoot, toe, and webspacedefects. Ann Plast Surg 2002;94:196e201.

17. Nisanci M, Celikoz B, Duman H. Cross-foot island instep flap:a new use of instep skin flap for management of persistentwounds after complex plantar foot reconstruction. Ann PlastSurg 2001;47:127e33.

18. Nohira K, Shintomi Y, Sugihara T, et al. Replacing losses in kind:improved sensation following heel reconstruction using thefree instep flap. J Reconstr Microsurg 1989;5:1e6.

19. Lukash FN. Microvascular free muscle reconstruction of a largeplantar defect. Ann Plast Surg 1985;15:252e6.

20. May Jr JW, Halls MJ, Simon SR. Free microvascular muscle flapswith skin graft reconstruction of extensive defects of the foot:a clinical and gait analysis study. Plast Reconstr Surg 1985;75:627e41.

21. Stevenson TR, Mathes SJ. Management of foot injuries withfree muscle flaps. Plast Reconstr Surg 1986;78:665e71.

22. May Jr JW, Rohrich RJ. Foot reconstruction using free micro-vascular muscle flaps with skin grafts. Clin Plast Surg 1986;13:681e9.

23. Reath DB, Taylor JW. The segmental rectus abdominis free flapfor ankle and foot reconstruction. Plast Reconstr Surg 1991;88:824e8.

24. Selmanpakoglu N, Guler M, Sengezer M, et al. Reconstructionof foot defects due to mine explosion using muscle flaps.Microsurgery 1998;18:182e8.

25. Noever G, Bruser P, Kohler L. Reconstruction of heel and soledefects by free flaps. Plast Reconstr Surg 1986;78:345e52.

26. Tamura A, Takeuchi Y, Yamakage A. Reconstruction of plantarheel defects with free gracilis musculocutaneous flap. J FootAnkle Surg 1994;33:274e7.

27. Weinzweig N, Davies BW. Foot and ankle reconstruction usingthe radial forearm flap: A review of 25 cases. Plast ReconstrSurg 1998;102:1999e2005.

28. Ulusal BG, Lin YT, Ulusal AE, et al. Reconstruction of footdefects with free lateral arm fasciocutaneous flaps: analysis offifty patients. Microsurgery 2005;25:581e8.

254 S.J. Oh et al.

29. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap inchronic osteomyelitis: experimental and clinical correlation.Plast Reconstr Surg 1982;69:815e29.

30. Calderon W, Chang N, Mathes SJ. Comparison of the effect ofbacterial inoculation in musculocutaneous and fasciocuta-neous flaps. Plast Reconstr Surg 1986;77:785e94.

31. Milanov NO, Adamyan RT. Functional results of microsurgicalreconstruction of plantar defects. Ann Plast Surg 1994;32:52e6.

32. Chang KN, DeArmond SJ, Buncke Jr HJ. Sensory reinnervationin microsurgical reconstruction of the heel. Plast Reconstr Surg1986;78:652e64.

33. Potparic Z, Rajacic N. Long-term results of weight-bearing footreconstruction with non-innervated and reinnervated freeflaps. Br J Plast Surg 1997;50:176e81.

34. Emmett AJ. The filleted toe flap. Br J Plast Surg 1976;29:19e21.35. Sakai S. A distally based island first dorsal metatarsal artery

flap for the coverage of a distal plantar defect. Br J Plast Surg1993;46:480e2.

36. Bertelli JA, Duarte HE. The plantar marginal septum cutaneousisland flap: a new flap in forefoot reconstruction. PlastReconstr Surg 1997;99:1390e5.

37. Coruh A. Distally based perforator medial plantar flap: a newflap for reconstruction of plantar forefoot defects. Ann PlastSurg 2004;53:404e8.

38. Koshima I, Narushima M, Mihara M, et al. Island medial plantarartery perforator flap for reconstruction of plantar defects.Ann Plast Surg 2007;59:558e62.

39. Uygur F, Sever C, Evinc R, et al. Reverse flow flap use in upperextremity burn contractures. Burns 2008;34:1196e204.