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Free medial plantar artery flap for the reconstruction of great toe pulp
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MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e3
CASE REPORT
Free medial plantar artery flap for the reconstruction of great toe pulp R.B. Jyoshid*, Harsha Vardhan, Francis Anto Sushrutha Institute of Plastic Surgery, Elite Mission Hospital, Thrissur, Kerala 680007, India Received 22 October 2013; accepted 21 December 2013
KEYWORDS Pulp defect; Great toe; Free medial plantar artery flap
Summary The great toe is an important body structure both functionally and cosmetically. The defect over the great toe is very challenging to treat. Our patient was a 9-year-old boy, presenting with posttraumatic loss of partial right great toe pulp. The mode of injury was the toe getting caught in the cycle wheel and sustaining amputation of the plantar aspect of the great toe. The great toe with exposed bone was reconstructed with a free medial plantar artery flap, harvested from the same limb. To our best knowledge, this was the first reported case of free medial plantar artery flap used for the reconstruction of great toe defects. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The great toe is ‘god’s unique creation’ in both functional and aesthetic aspects. Reconstruction of the great toe defect is a challenging treat for the plastic surgeon. The options extend from local flaps to free tissue transfer. For small defects, local flaps such as the VeY flap, hatchet flaps, subcutaneous flaps and heterodigital artery flap are described.1 The bigger defects are treated with local flaps such as reverse dorsal metatarsal artery flap, reverse dorsalis pedis artery flap, reverse extensor digitorum brevis flap2 or free flaps such as peroneal and scapular flaps. The pedicled medial plantar artery flap has been described for defects around the heel and forefoot.3 It has
* Corresponding author. Tel.: þ91 8113005557; fax: þ91 0487 236167. E-mail address: [email protected] (R.B. Jyoshid).
also been used as a free flap for finger and thumb defects. To the best of the authors’ knowledge, the free medial plantar artery flap has not yet been used for great toe defects.
Case report A 9-year-old boy presented to the emergency department with a history of the right great toe getting entangled in a cycle wheel sustaining injury to the right great toe. On examination, there was amputation of the pulp of the great toe. The proximal phalanx was exposed, along with the flexor tendon (Figure 1). The amputated part was not fit for replantation. There was no associated injury and the patient was haemodynamically stable. After considering various options, we decided to give a tissue cover in the form of a free medial plantar artery flap. The perforator of the medial plantar artery was marked with the help of a
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.038
Please cite this article in press as: Jyoshid RB, et al., Free medial plantar artery flap for the reconstruction of great toe pulp, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.038
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R.B. Jyoshid et al.
Figure 3
Figure 1 Pre-operative picture showing the defect and the flap marking. P- Marked perforator.
Figure 2 Intra-operative picture. Elevated flap with well shown vascular pedicle.
Flap inset and donor site covered with FTG.
Doppler probe (Figure 1). Under ankle block and tourniquet control, the free medial plantar artery flap (Figure 2) was elevated from the same foot and used to reconstruct the defect (Figure 3). The microsurgical anastomosis of the medial plantar artery was done to the first dorsal metatarsal artery in the first webspace. The venae comitantes were anastomosed to the venae comitantes of the first dorsal metatarsal artery. The donor defect was closed with full-thickness skin graft taken from the amputated part of the great toe (Figure 3). The flap settled well without any problems and the donor area healed uneventfully (Figure 4).
Figure 4 flap.
3 weeks post operative picture with well settled
Please cite this article in press as: Jyoshid RB, et al., Free medial plantar artery flap for the reconstruction of great toe pulp, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.038
+
MODEL
Free medial plantar artery flap for great toe pulp
Discussion The great toe is essential to maintain gait and stability during running and walking. While reconstructing great toe defects, we should keep in mind both cosmesis and function. The plantar aspect of the great toe has glaborous skin and its loss is difficult to treat. Various methods of reconstruction have been tried in the past with mixed results. Compared to the plantar defect, the options to treat the dorsal defects are more. The dorsal great toe defect can be managed with the reverse dorsal metatarsal artery flap, with fairly good cosmesis, despite a visible scar on the dorsum of the foot.4 Cihan et al.5 have used the pedicled heterodigital artery flap from the second toe to reconstruct the great toe tip. The amount of tissue which can be borrowed from the second toe may not be sufficient for a total or near-total loss of the pulp of the great toe. The use of a free flap is a good option for the great toe defect reconstruction, especially for the plantar area due to the scarcity of the local flap options. Yoshida et al.,6 in their study, have used free tissue cover in the form of the peroneal artery flap (including perforator peroneal artery flap) and scapular flap to reconstruct the great toe and concluded that the functional and cosmetic outcomes were satisfactory. The use of a reverse medial plantar metatarsal artery flap for the plantar toe defect has been described in the literature. Xu et al.7 in their study mention that the cosmesis and sensation over the flaps were satisfactory. Koshima et al.8 have analysed the use of the perforatorbased medial plantar artery flap for forefoot and heel defects and came out with excellent results. The free medial plantar artery flap has been used for finger and thumb pulp defects due to its structural similarity.9 Yokoyama et al.10 used a free medial plantar artery flap as a venous flap for volar oblique amputation of the fingertip and obtained excellent results. In our patient, the defect was on the plantar aspect, the medial plantar artery flap was ideal, giving a ‘like with like’ match. The advantages of the medial plantar artery flap were the donor site in the non-weight-bearing part of the sole of foot and wellhidden scar. In our case, we experienced added advantages such as raising the flap from the same foot and completing the surgery under ankle block in spite of the patient being a 9-year-old boy. To the best of our knowledge, this is the
3 first reported case of medial plantar artery free flap for the great toe defect.
Conclusions The medial plantar artery free flap is a viable option for plantar great toe defects.
Conflict of interest/funding None.
References 1. Luca V, Victor U, Andrea S, Masetto L. Subcutaneous tissue flaps for hallux covering. J Orthoped Traumatol 2010;11:61e5. 2. Koul AR, Patil RK, Philip VK. Coverage of defects over toes with distally based local flaps: a report of four cases. Indian J Plast Surg 2008 JaneJun;41(1):62e6. 3. Acikel C, Celikoz B, Yuksel F, Ergun O. Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle. Ann Plast Surg 2003 May;50(5): 498e503. 4. Cheng MH, Ulusal BG, Wei FC. Reverse first dorsal metatarsal artery flap for reconstruction of traumatic defects of dorsal great toe. J Trauma 2006 May;60(5):1138e41. 5. Cihan S, Huseyin K, Celalettin S, Yalcin K, Ersin U. Reconstruction of the great toe tip defect with a pedicled heterodigital artery flap. Aesthet Plast Surg 2013;37(2):421e3. 6. Yoshida A, Yajima H, Murata K, et al. Post-traumatic big toe reconstruction using free flaps. J Reconstr Microsurg 2006 May; 22(4):255e60. 7. Xu YB, Liu YC. Reversed plantar metatarsal artery island flap for coverage of the plantar defects at the first and second toes. Zhonghua Zheng Xing Wai Ke Za Zhi 2012 Mar;28(2):110e2. 8. Koshima I, Narushima M, Mihara M, et al. Island medial plantar artery perforator flap for reconstruction of plantar defects. Ann Plast Surg 2007 Nov;59(5):558e62. 9. Lai CH, Lai CS, Huang SH, Lin SD, Chang KP. Free medial plantar artery perforator flaps for the resurfacing of thumb defects. Ann Plast Surg 2010 Dec;65(6):535e40. 10. Yokoyama T, Tosa Y, Hashikawa M, Kadota S, Hosaka Y. Medial plantar venous flap technique for volar oblique amputation with no defects in the nail matrix and nail bed. J Plast Reconstr Aesthet Surg 2010 Nov;63(11):1870e4.
Please cite this article in press as: Jyoshid RB, et al., Free medial plantar artery flap for the reconstruction of great toe pulp, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.038
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e3
CASE REPORT
Free medial plantar artery flap for the reconstruction of great toe pulp R.B. Jyoshid*, Harsha Vardhan, Francis Anto Sushrutha Institute of Plastic Surgery, Elite Mission Hospital, Thrissur, Kerala 680007, India Received 22 October 2013; accepted 21 December 2013
KEYWORDS Pulp defect; Great toe; Free medial plantar artery flap
Summary The great toe is an important body structure both functionally and cosmetically. The defect over the great toe is very challenging to treat. Our patient was a 9-year-old boy, presenting with posttraumatic loss of partial right great toe pulp. The mode of injury was the toe getting caught in the cycle wheel and sustaining amputation of the plantar aspect of the great toe. The great toe with exposed bone was reconstructed with a free medial plantar artery flap, harvested from the same limb. To our best knowledge, this was the first reported case of free medial plantar artery flap used for the reconstruction of great toe defects. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The great toe is ‘god’s unique creation’ in both functional and aesthetic aspects. Reconstruction of the great toe defect is a challenging treat for the plastic surgeon. The options extend from local flaps to free tissue transfer. For small defects, local flaps such as the VeY flap, hatchet flaps, subcutaneous flaps and heterodigital artery flap are described.1 The bigger defects are treated with local flaps such as reverse dorsal metatarsal artery flap, reverse dorsalis pedis artery flap, reverse extensor digitorum brevis flap2 or free flaps such as peroneal and scapular flaps. The pedicled medial plantar artery flap has been described for defects around the heel and forefoot.3 It has
* Corresponding author. Tel.: þ91 8113005557; fax: þ91 0487 236167. E-mail address: [email protected] (R.B. Jyoshid).
also been used as a free flap for finger and thumb defects. To the best of the authors’ knowledge, the free medial plantar artery flap has not yet been used for great toe defects.
Case report A 9-year-old boy presented to the emergency department with a history of the right great toe getting entangled in a cycle wheel sustaining injury to the right great toe. On examination, there was amputation of the pulp of the great toe. The proximal phalanx was exposed, along with the flexor tendon (Figure 1). The amputated part was not fit for replantation. There was no associated injury and the patient was haemodynamically stable. After considering various options, we decided to give a tissue cover in the form of a free medial plantar artery flap. The perforator of the medial plantar artery was marked with the help of a
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.038
Please cite this article in press as: Jyoshid RB, et al., Free medial plantar artery flap for the reconstruction of great toe pulp, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.038
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MODEL
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R.B. Jyoshid et al.
Figure 3
Figure 1 Pre-operative picture showing the defect and the flap marking. P- Marked perforator.
Figure 2 Intra-operative picture. Elevated flap with well shown vascular pedicle.
Flap inset and donor site covered with FTG.
Doppler probe (Figure 1). Under ankle block and tourniquet control, the free medial plantar artery flap (Figure 2) was elevated from the same foot and used to reconstruct the defect (Figure 3). The microsurgical anastomosis of the medial plantar artery was done to the first dorsal metatarsal artery in the first webspace. The venae comitantes were anastomosed to the venae comitantes of the first dorsal metatarsal artery. The donor defect was closed with full-thickness skin graft taken from the amputated part of the great toe (Figure 3). The flap settled well without any problems and the donor area healed uneventfully (Figure 4).
Figure 4 flap.
3 weeks post operative picture with well settled
Please cite this article in press as: Jyoshid RB, et al., Free medial plantar artery flap for the reconstruction of great toe pulp, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.038
+
MODEL
Free medial plantar artery flap for great toe pulp
Discussion The great toe is essential to maintain gait and stability during running and walking. While reconstructing great toe defects, we should keep in mind both cosmesis and function. The plantar aspect of the great toe has glaborous skin and its loss is difficult to treat. Various methods of reconstruction have been tried in the past with mixed results. Compared to the plantar defect, the options to treat the dorsal defects are more. The dorsal great toe defect can be managed with the reverse dorsal metatarsal artery flap, with fairly good cosmesis, despite a visible scar on the dorsum of the foot.4 Cihan et al.5 have used the pedicled heterodigital artery flap from the second toe to reconstruct the great toe tip. The amount of tissue which can be borrowed from the second toe may not be sufficient for a total or near-total loss of the pulp of the great toe. The use of a free flap is a good option for the great toe defect reconstruction, especially for the plantar area due to the scarcity of the local flap options. Yoshida et al.,6 in their study, have used free tissue cover in the form of the peroneal artery flap (including perforator peroneal artery flap) and scapular flap to reconstruct the great toe and concluded that the functional and cosmetic outcomes were satisfactory. The use of a reverse medial plantar metatarsal artery flap for the plantar toe defect has been described in the literature. Xu et al.7 in their study mention that the cosmesis and sensation over the flaps were satisfactory. Koshima et al.8 have analysed the use of the perforatorbased medial plantar artery flap for forefoot and heel defects and came out with excellent results. The free medial plantar artery flap has been used for finger and thumb pulp defects due to its structural similarity.9 Yokoyama et al.10 used a free medial plantar artery flap as a venous flap for volar oblique amputation of the fingertip and obtained excellent results. In our patient, the defect was on the plantar aspect, the medial plantar artery flap was ideal, giving a ‘like with like’ match. The advantages of the medial plantar artery flap were the donor site in the non-weight-bearing part of the sole of foot and wellhidden scar. In our case, we experienced added advantages such as raising the flap from the same foot and completing the surgery under ankle block in spite of the patient being a 9-year-old boy. To the best of our knowledge, this is the
3 first reported case of medial plantar artery free flap for the great toe defect.
Conclusions The medial plantar artery free flap is a viable option for plantar great toe defects.
Conflict of interest/funding None.
References 1. Luca V, Victor U, Andrea S, Masetto L. Subcutaneous tissue flaps for hallux covering. J Orthoped Traumatol 2010;11:61e5. 2. Koul AR, Patil RK, Philip VK. Coverage of defects over toes with distally based local flaps: a report of four cases. Indian J Plast Surg 2008 JaneJun;41(1):62e6. 3. Acikel C, Celikoz B, Yuksel F, Ergun O. Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle. Ann Plast Surg 2003 May;50(5): 498e503. 4. Cheng MH, Ulusal BG, Wei FC. Reverse first dorsal metatarsal artery flap for reconstruction of traumatic defects of dorsal great toe. J Trauma 2006 May;60(5):1138e41. 5. Cihan S, Huseyin K, Celalettin S, Yalcin K, Ersin U. Reconstruction of the great toe tip defect with a pedicled heterodigital artery flap. Aesthet Plast Surg 2013;37(2):421e3. 6. Yoshida A, Yajima H, Murata K, et al. Post-traumatic big toe reconstruction using free flaps. J Reconstr Microsurg 2006 May; 22(4):255e60. 7. Xu YB, Liu YC. Reversed plantar metatarsal artery island flap for coverage of the plantar defects at the first and second toes. Zhonghua Zheng Xing Wai Ke Za Zhi 2012 Mar;28(2):110e2. 8. Koshima I, Narushima M, Mihara M, et al. Island medial plantar artery perforator flap for reconstruction of plantar defects. Ann Plast Surg 2007 Nov;59(5):558e62. 9. Lai CH, Lai CS, Huang SH, Lin SD, Chang KP. Free medial plantar artery perforator flaps for the resurfacing of thumb defects. Ann Plast Surg 2010 Dec;65(6):535e40. 10. Yokoyama T, Tosa Y, Hashikawa M, Kadota S, Hosaka Y. Medial plantar venous flap technique for volar oblique amputation with no defects in the nail matrix and nail bed. J Plast Reconstr Aesthet Surg 2010 Nov;63(11):1870e4.
Please cite this article in press as: Jyoshid RB, et al., Free medial plantar artery flap for the reconstruction of great toe pulp, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.038