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Island lateral plantar artery perforator flap for reconstruction of weight-bearing plantar areas
Foot and Ankle Surgery 17 (2011) e13–e16
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Island lateral plantar artery perforator flap for reconstruction of weight-bearing plantar areas Emanuele Cigna MD, PhD*, Paolo Fioramonti MD, Pasquale Fino MD, Nicolo` Scuderi MD Department of Dermatology and Plastic Reconstructive Surgery, University of Rome, ‘‘La Sapienza’’, Policlinico Umberto I, 00161 Rome, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 May 2010 Received in revised form 12 July 2010 Accepted 28 July 2010
Reconstruction of the foot often presents difficulties, particularly in weight-bearing areas (WBA). The peculiarities of WBA tissues are rarely found in other regions of the body. The case examined, presents a 72-year-old diabetic patient, with lower-limb arteriopathy, and sensitive and motor neuropathy, with an ulcer in the weight-bearing area of the foot, close to the V metatarsal bone. The plantar defect was reconstructed by using an island V–Y 6 cm 3 cm flap, based on the lateral plantar artery perforators. The postoperative course was smooth and the flap survived completely. The lateral plantar artery perforator flap is minimally invasive and provides a valid alternative for the repair of glabrous plantar defects. ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Perforator flap Foot reconstruction Foot osteomyelitis Lateral plantar artery Plantar defect
1. Background With the development of perforator flaps, it has been discovered that the major pedicle vessels of skin flaps, can be replaced by small perforators. Consequently, muscles and major vessels in musculocutaneous flaps have been preserved, reducing the donor site morbidity, without altering the territories of skin flaps [1–3]. This concept of perforator flaps is continuously applied to develop local flaps in almost every human anatomic region. Among the regions, the anatomical characteristics and properties of the weight-bearing area of the foot are well known, and, in order to avoid complications by using flaps with different anatomical skin characteristics, a reconstruction with similar tissues is always recommended [4,5]. In this paper, we present a case in which the perforators arising from the lateral plantar artery were used to harvest a flap for the reconstruction of a plantar defect.
2. Case report A 72-year-old diabetic patient, with lower-limb arteriopathy and sensitive and motor neuropathy was presented to our attention, with an ulcer in the weight-bearing area of the foot, close to
* Corresponding author at: Department of Dermatology and Plastic Reconstructive Surgery, University of Rome, ‘‘La Sapienza’’, Policlinico Umberto I, Via Federico Barocci 3, 00147 Rome, Italy. Fax: +39 06491525. E-mail address: [email protected] (E. Cigna).
the V metatarsal bone. The wound was circular and 2 cm large (Fig. 1). The patient recounted the development of this ulcer over six years, which first appeared as a small lesion in the plantar site of the left forefoot. The ulcer was treated repeatedly with different advanced dressing with no healing. In November 2007, after repeated culture swab examinations, it was diagnosed as an osteomyelitis, with a local infection by Staphylococcus aureus, Enterococcus faecalis, Serratia fonticola, and Pseudomonas aeruginosa. After multiple antibiotic therapy and a surgical ulcer debridement of the soft tissues a plantar defect of 3 cm 3 cm was reconstructed by using an island V–Y 6 cm 3 cm flap based on the lateral plantar artery perforators (Fig. 2A and B). The postoperative course was uneventful and the flap survived completely (Fig. 3A and B). A postoperative follow-up at 24 months, showed no recurrence of the osteomyelitis, ulcer, or pain in the plantar region. 3. Surgical technique Preoperative imaging techniques, such as Doppler examinations and/or angio-CT scans, are useful to confirm the localization of the perforators of the lateral plantar, arising from the artery. A full-thickness incision of the lateral edge flap, up to the lateral edge of the abductor digiti minimi muscle, is performed. Once the muscle is reached, the flap is carefully undermined, laterally to medially, just above the abductor digiti minimi fascia, until reaching the medial edge of the muscle. Then, the lateral plantar artery perforators are found coming off between the abductor digiti minimi muscle and the flexor digitorum brevis muscle (Fig. 2A). The incision is then completed and the flap is advanced forward, and sutured in a V–Y fashion (Fig. 2B). The surgical time was 45 min.
1268-7731/$ – see front matter ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2010.07.005
[(Fig._1)TD$IG]
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[(Fig._2)TD$IG]
E. Cigna et al. / Foot and Ankle Surgery 17 (2011) e13–e16
Fig. 1. Preoperative view of the ulcer.
4. Discussion Reconstruction of the foot often presents difficulties, particularly in weight-bearing areas (WBA). The peculiarities of WBA tissues are rarely found in other areas of the body. Given the adaptability of the sole, to stress, it exists in that area a delicate balance between physiologic and pathologic changes. In case of stress, due to a sensory neuropathy or a postural deformation after paralysis disturbs, the tissues covering foot are drastically stressed and those areas can become ulcerated particularly below heel and metatarsal head areas [6]. Mir y Mir first, in 1954, introduced the cross-leg medial plantar flap for reconstruction of WBA defect [7]. This is a multistep procedure with a long postoperative care and immobilization [8–11]. In 1979, Shanahan and McCarthy [12] described a pedicled instep flap based on the medial plantar artery and nerve for the reconstruction of the heel defect later refined by Reiffel and McCarthy [13] with anatomical dissections and clinical cases showing several variations of the medial and lateral plantar flaps and by Harrison and Morgan [14]. However these techniques were not intended for the reconstruction of the forefoot plantar defect until they were described the reverse-flow medial and lateral plantar flaps [15–17]. Local flaps as the reverse lateral plantar flap have the advantage of moving healthy tissues from the non-WBA to the defect [18]. However, this flap has the drawbacks of venous congestion and an increased donor site morbidity by transecting a major vessel of the foot. In some cases, this approach requires a skin graft thus adding a donor site morbidity area [18]. Martin et al. in 1994 proposed the possibility of passing different flaps (based on the concept of reverse-flow Y–V pedicle extension of a flap) by using a Y-branch like a vascular bifurcation [19,20]. This approach allows an even more distal advancement of an island flap with a large size. However these flaps require a patent anastomosis between the
Fig. 2. (A) The flap is raised and the lateral plantar artery perforators are visible; (B) the perforator flap advanced in V–Y fashion.
dorsalis pedis and lateral plantar arteries, sacrifice a mayor vessel and, more important for WBA, the transferred skin is insensitive and may led to ulcer the flap [21,22]. In 1995, Masquelet and Romana [23] and Ishikura et al. [24] succeeded in reporting a success in the use of the medialis pedis flap based on a branch from the medial plantar artery for the
[(Fig._3)TD$IG]
E. Cigna et al. / Foot and Ankle Surgery 17 (2011) e13–e16
e15
Microsurgical and supramicrosurgical techniques represent an excellent option providing a reconstruction that chose tissue with similar characteristics with the lesser donor morbidity. However, this approach requires an experienced microsurgical team with facilities, related increased costs and a longer operating time compared to the local flaps. In the presented case there were few possibilities for an adequate reconstruction [8,26–30]. In our opinion, the lateral plantar artery perforator flap has the following advantages: 1. there is no compromise of the dominant inflow source to the foot: both the posterior tibial. The medial and lateral plantar arteries, the dorsalis pedis artery and nerve are left intact; 2. the dissection length of the perforators can be adjusted according to surgical requirements; 3. there is no exposure of plantar sensory nerves and vessels; 4. the flap elevation can be completed within a short operating time. The disadvantages are: 1. a careful dissection with a perforator flap based approach is required to detect and preserve the perforators without damaging them; 2. the flap cannot reconstruct large defect or the WBA. In conclusion, this procedure allows in a single step, in a short surgical time and in a short postoperative care and immobilization, the coverage of a submetatarsal weight-bearing area minimalizing the invasive aspects. Furthermore, it does not require to alter the foot blood inflow and outflow. This reconstruction has the advantages of perforator flaps but avoids the sacrifice of blood vessels, minimises the donor site morbidity and replaces the defect with tissues with identical characteristics of duration and resistance. References
Fig. 3. (A) Two years postoperatively frontal view; (B) two years postoperatively lateral view.
reconstruction of foot soft-tissue defects. In 2001, Koshima reported a free medial plantar artery perforator flap based on the medial plantar artery perforator only [4,25]. This flap can be an island flap for heel coverage and forefoot plantar weight-bearing defects, without transecting the medial plantar or posterior tibial systems. A relatively large medial plantar skin flap can survive based on a tiny perforator.
[1] Koshima I, Soeda S. Inferior epigastric skin flap without rectus abdominis muscle. Br J Plast Surg 1989;42:645–8. [2] Chen HC, Tang YB, Mardini S, Tsai BW. Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators. Microsurgery 2004;24(4):270–80. [3] Granzow JW, Levine JL, Chiu ES, LoTempio MM, Allen RJ. Breast reconstruction with perforator flaps. Plast Reconstr Surg 2007;120(July (1)):1–12. [4] Koshima I, Urushibara K, Inagawa K, Hamasaki T, Moriguchi T. Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg 2001;107:1753–8. [5] Koshima I, Narushima M, Mihara M, Nakai I, Akazawa S, Fukuda N, et al. Island medial plantar artery perforator flap for reconstruction of plantar defects. Ann Plast Surg 2007;59(November (5)):558–62. [6] Gregoire R, Oberlin S. Precis d’Anatomie, 10th ed., Paris: Lavoisier; 1991. p. 222–3. [7] Nis¸anci M, Celiko¨z B, Duman H. Cross-foot island instep flap: a new use of instep skin flap for management of persistent wounds after complex plantar foot reconstruction. Ann Plast Surg 2001;47(August (2)):127–33. [8] Morris AM, Buchan AC. The place of cross-leg flaps in reconstructive surgery of the lower leg and foot: a review of 165 cases. Br J Plast Surg 1978;31:138. [9] Kaplan I. Neurovascular island flap in the treatment of trophic ulceration of the heel. Br J Plast Surg 1969;22:143. [10] Oberlin C, Bastian D, Gre´ant P, Bhatia A. Pedicled flaps for coverage of the limbs. Mumbai: Arihant Book House; 1997. p. 95–8. [11] Emmett AJ. The filleted toe flap. Br J Plast Surg 1976;29:19. [12] Shanahan RS, McCarthy JG. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg 1979;64:295–8. [13] Reiffel RS, McCarthy JG. Coverage of heel and sole defects: a new subfascial arterialized flap. Plast Reconstr Surg 1980;66:250–60. [14] Harrison DH, Morgan BDG. The instep island flap to resurface plantar defects. Br J Plast Surg 1981;34:315–8. [15] Amarante J, Martins A, Reis J. A distally based median plantar flap. Ann Plast Surg 1988;20:468–70. [16] Butler CE, Chevray P. Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and webspace defects. Ann Plast Surg 2002;49: 196–201.
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E. Cigna et al. / Foot and Ankle Surgery 17 (2011) e13–e16
[17] Oberlin C, Vasconcellos ZA, Touam C. Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect. Plast Reconstr Surg 2000;106:874–7. [18] Bhandari MS, Sobti C. Reverse flow instep island flap. Plast Reconstr Surg 1999;103:1986. [19] Martin D, Legaillard P, Bakhach J, Hu W, Baudet J. L’allongement pediculaire en VY a flux retrograde: Un moyen pour doubler l’arc de rotation d’un lambeau sous certaines conditions. Ann Chir Plast Esthet 1994;39:403. [20] Martin D, Gorowitz B, Peres JM, Baudet J. Le lambeau plantaire interne sur pedicule plantaire externe: Un moyen de couverture utilisable sur toute la surface du pied. Ann Chir Plast Esthet 1991;36:544. [21] Oberlin C, Bastian D, Greant P. Les Lambeaux Pedicules de Couverture des Membres. Paris: Expansion Scientifique Francaise; 1994. p. 117–21. [22] Morrison WA, Crabb DM, O’Brien BM, Jenkins A. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 1983;72:56–64. [23] Masquelet AC, Romana MC. The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg 1990;85:765–72.
[24] Ishikura N, Heshiki T, Tsukada S. The use of a free medialis pedis flap for resurfacing skin defects of the hand and digits: results in five cases. Plast Reconstr Surg 1995;95:100–7. [25] Koshima I, Nanba Y, Tsutsui T, et al. Takahashi Y. Medial plantar perforator flaps with supermicrosurgery. Clin Plast Surg 2003;30:447–55. [26] Shaw WW, Hidalgo DA. Anatomic basis of plantar flap design: clinical applications. Plast Reconstr Surg 1986;78:637. [27] Harrison DH, Morgan BDG. The instep island flap to resurface plantar defects. Br J Plast Surg 1981;34:315. [28] Oberlin C, Saffar P. Le lambeau en ilot plantaire interne: Etude anatomique et applications chirurgicales. Rev Chir Orthop Reparatrice Appar Mot 1984;70: 151. [29] Morrison WA, Crabb DM, O’Brien BM, Jenkins AL. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 1983;72:56. [30] Oberlin C, Azoulay B, Sarcy JJ. The posterolateral malleolar flap of the ankle: a distally based sural neurocutaneous flap: report of 14 cases. Plast Reconstr Surg 1995;96:400.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Island lateral plantar artery perforator flap for reconstruction of weight-bearing plantar areas Emanuele Cigna MD, PhD*, Paolo Fioramonti MD, Pasquale Fino MD, Nicolo` Scuderi MD Department of Dermatology and Plastic Reconstructive Surgery, University of Rome, ‘‘La Sapienza’’, Policlinico Umberto I, 00161 Rome, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 May 2010 Received in revised form 12 July 2010 Accepted 28 July 2010
Reconstruction of the foot often presents difficulties, particularly in weight-bearing areas (WBA). The peculiarities of WBA tissues are rarely found in other regions of the body. The case examined, presents a 72-year-old diabetic patient, with lower-limb arteriopathy, and sensitive and motor neuropathy, with an ulcer in the weight-bearing area of the foot, close to the V metatarsal bone. The plantar defect was reconstructed by using an island V–Y 6 cm 3 cm flap, based on the lateral plantar artery perforators. The postoperative course was smooth and the flap survived completely. The lateral plantar artery perforator flap is minimally invasive and provides a valid alternative for the repair of glabrous plantar defects. ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Perforator flap Foot reconstruction Foot osteomyelitis Lateral plantar artery Plantar defect
1. Background With the development of perforator flaps, it has been discovered that the major pedicle vessels of skin flaps, can be replaced by small perforators. Consequently, muscles and major vessels in musculocutaneous flaps have been preserved, reducing the donor site morbidity, without altering the territories of skin flaps [1–3]. This concept of perforator flaps is continuously applied to develop local flaps in almost every human anatomic region. Among the regions, the anatomical characteristics and properties of the weight-bearing area of the foot are well known, and, in order to avoid complications by using flaps with different anatomical skin characteristics, a reconstruction with similar tissues is always recommended [4,5]. In this paper, we present a case in which the perforators arising from the lateral plantar artery were used to harvest a flap for the reconstruction of a plantar defect.
2. Case report A 72-year-old diabetic patient, with lower-limb arteriopathy and sensitive and motor neuropathy was presented to our attention, with an ulcer in the weight-bearing area of the foot, close to
* Corresponding author at: Department of Dermatology and Plastic Reconstructive Surgery, University of Rome, ‘‘La Sapienza’’, Policlinico Umberto I, Via Federico Barocci 3, 00147 Rome, Italy. Fax: +39 06491525. E-mail address: [email protected] (E. Cigna).
the V metatarsal bone. The wound was circular and 2 cm large (Fig. 1). The patient recounted the development of this ulcer over six years, which first appeared as a small lesion in the plantar site of the left forefoot. The ulcer was treated repeatedly with different advanced dressing with no healing. In November 2007, after repeated culture swab examinations, it was diagnosed as an osteomyelitis, with a local infection by Staphylococcus aureus, Enterococcus faecalis, Serratia fonticola, and Pseudomonas aeruginosa. After multiple antibiotic therapy and a surgical ulcer debridement of the soft tissues a plantar defect of 3 cm 3 cm was reconstructed by using an island V–Y 6 cm 3 cm flap based on the lateral plantar artery perforators (Fig. 2A and B). The postoperative course was uneventful and the flap survived completely (Fig. 3A and B). A postoperative follow-up at 24 months, showed no recurrence of the osteomyelitis, ulcer, or pain in the plantar region. 3. Surgical technique Preoperative imaging techniques, such as Doppler examinations and/or angio-CT scans, are useful to confirm the localization of the perforators of the lateral plantar, arising from the artery. A full-thickness incision of the lateral edge flap, up to the lateral edge of the abductor digiti minimi muscle, is performed. Once the muscle is reached, the flap is carefully undermined, laterally to medially, just above the abductor digiti minimi fascia, until reaching the medial edge of the muscle. Then, the lateral plantar artery perforators are found coming off between the abductor digiti minimi muscle and the flexor digitorum brevis muscle (Fig. 2A). The incision is then completed and the flap is advanced forward, and sutured in a V–Y fashion (Fig. 2B). The surgical time was 45 min.
1268-7731/$ – see front matter ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2010.07.005
[(Fig._1)TD$IG]
e14
[(Fig._2)TD$IG]
E. Cigna et al. / Foot and Ankle Surgery 17 (2011) e13–e16
Fig. 1. Preoperative view of the ulcer.
4. Discussion Reconstruction of the foot often presents difficulties, particularly in weight-bearing areas (WBA). The peculiarities of WBA tissues are rarely found in other areas of the body. Given the adaptability of the sole, to stress, it exists in that area a delicate balance between physiologic and pathologic changes. In case of stress, due to a sensory neuropathy or a postural deformation after paralysis disturbs, the tissues covering foot are drastically stressed and those areas can become ulcerated particularly below heel and metatarsal head areas [6]. Mir y Mir first, in 1954, introduced the cross-leg medial plantar flap for reconstruction of WBA defect [7]. This is a multistep procedure with a long postoperative care and immobilization [8–11]. In 1979, Shanahan and McCarthy [12] described a pedicled instep flap based on the medial plantar artery and nerve for the reconstruction of the heel defect later refined by Reiffel and McCarthy [13] with anatomical dissections and clinical cases showing several variations of the medial and lateral plantar flaps and by Harrison and Morgan [14]. However these techniques were not intended for the reconstruction of the forefoot plantar defect until they were described the reverse-flow medial and lateral plantar flaps [15–17]. Local flaps as the reverse lateral plantar flap have the advantage of moving healthy tissues from the non-WBA to the defect [18]. However, this flap has the drawbacks of venous congestion and an increased donor site morbidity by transecting a major vessel of the foot. In some cases, this approach requires a skin graft thus adding a donor site morbidity area [18]. Martin et al. in 1994 proposed the possibility of passing different flaps (based on the concept of reverse-flow Y–V pedicle extension of a flap) by using a Y-branch like a vascular bifurcation [19,20]. This approach allows an even more distal advancement of an island flap with a large size. However these flaps require a patent anastomosis between the
Fig. 2. (A) The flap is raised and the lateral plantar artery perforators are visible; (B) the perforator flap advanced in V–Y fashion.
dorsalis pedis and lateral plantar arteries, sacrifice a mayor vessel and, more important for WBA, the transferred skin is insensitive and may led to ulcer the flap [21,22]. In 1995, Masquelet and Romana [23] and Ishikura et al. [24] succeeded in reporting a success in the use of the medialis pedis flap based on a branch from the medial plantar artery for the
[(Fig._3)TD$IG]
E. Cigna et al. / Foot and Ankle Surgery 17 (2011) e13–e16
e15
Microsurgical and supramicrosurgical techniques represent an excellent option providing a reconstruction that chose tissue with similar characteristics with the lesser donor morbidity. However, this approach requires an experienced microsurgical team with facilities, related increased costs and a longer operating time compared to the local flaps. In the presented case there were few possibilities for an adequate reconstruction [8,26–30]. In our opinion, the lateral plantar artery perforator flap has the following advantages: 1. there is no compromise of the dominant inflow source to the foot: both the posterior tibial. The medial and lateral plantar arteries, the dorsalis pedis artery and nerve are left intact; 2. the dissection length of the perforators can be adjusted according to surgical requirements; 3. there is no exposure of plantar sensory nerves and vessels; 4. the flap elevation can be completed within a short operating time. The disadvantages are: 1. a careful dissection with a perforator flap based approach is required to detect and preserve the perforators without damaging them; 2. the flap cannot reconstruct large defect or the WBA. In conclusion, this procedure allows in a single step, in a short surgical time and in a short postoperative care and immobilization, the coverage of a submetatarsal weight-bearing area minimalizing the invasive aspects. Furthermore, it does not require to alter the foot blood inflow and outflow. This reconstruction has the advantages of perforator flaps but avoids the sacrifice of blood vessels, minimises the donor site morbidity and replaces the defect with tissues with identical characteristics of duration and resistance. References
Fig. 3. (A) Two years postoperatively frontal view; (B) two years postoperatively lateral view.
reconstruction of foot soft-tissue defects. In 2001, Koshima reported a free medial plantar artery perforator flap based on the medial plantar artery perforator only [4,25]. This flap can be an island flap for heel coverage and forefoot plantar weight-bearing defects, without transecting the medial plantar or posterior tibial systems. A relatively large medial plantar skin flap can survive based on a tiny perforator.
[1] Koshima I, Soeda S. Inferior epigastric skin flap without rectus abdominis muscle. Br J Plast Surg 1989;42:645–8. [2] Chen HC, Tang YB, Mardini S, Tsai BW. Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators. Microsurgery 2004;24(4):270–80. [3] Granzow JW, Levine JL, Chiu ES, LoTempio MM, Allen RJ. Breast reconstruction with perforator flaps. Plast Reconstr Surg 2007;120(July (1)):1–12. [4] Koshima I, Urushibara K, Inagawa K, Hamasaki T, Moriguchi T. Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg 2001;107:1753–8. [5] Koshima I, Narushima M, Mihara M, Nakai I, Akazawa S, Fukuda N, et al. Island medial plantar artery perforator flap for reconstruction of plantar defects. Ann Plast Surg 2007;59(November (5)):558–62. [6] Gregoire R, Oberlin S. Precis d’Anatomie, 10th ed., Paris: Lavoisier; 1991. p. 222–3. [7] Nis¸anci M, Celiko¨z B, Duman H. Cross-foot island instep flap: a new use of instep skin flap for management of persistent wounds after complex plantar foot reconstruction. Ann Plast Surg 2001;47(August (2)):127–33. [8] Morris AM, Buchan AC. The place of cross-leg flaps in reconstructive surgery of the lower leg and foot: a review of 165 cases. Br J Plast Surg 1978;31:138. [9] Kaplan I. Neurovascular island flap in the treatment of trophic ulceration of the heel. Br J Plast Surg 1969;22:143. [10] Oberlin C, Bastian D, Gre´ant P, Bhatia A. Pedicled flaps for coverage of the limbs. Mumbai: Arihant Book House; 1997. p. 95–8. [11] Emmett AJ. The filleted toe flap. Br J Plast Surg 1976;29:19. [12] Shanahan RS, McCarthy JG. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg 1979;64:295–8. [13] Reiffel RS, McCarthy JG. Coverage of heel and sole defects: a new subfascial arterialized flap. Plast Reconstr Surg 1980;66:250–60. [14] Harrison DH, Morgan BDG. The instep island flap to resurface plantar defects. Br J Plast Surg 1981;34:315–8. [15] Amarante J, Martins A, Reis J. A distally based median plantar flap. Ann Plast Surg 1988;20:468–70. [16] Butler CE, Chevray P. Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and webspace defects. Ann Plast Surg 2002;49: 196–201.
e16
E. Cigna et al. / Foot and Ankle Surgery 17 (2011) e13–e16
[17] Oberlin C, Vasconcellos ZA, Touam C. Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect. Plast Reconstr Surg 2000;106:874–7. [18] Bhandari MS, Sobti C. Reverse flow instep island flap. Plast Reconstr Surg 1999;103:1986. [19] Martin D, Legaillard P, Bakhach J, Hu W, Baudet J. L’allongement pediculaire en VY a flux retrograde: Un moyen pour doubler l’arc de rotation d’un lambeau sous certaines conditions. Ann Chir Plast Esthet 1994;39:403. [20] Martin D, Gorowitz B, Peres JM, Baudet J. Le lambeau plantaire interne sur pedicule plantaire externe: Un moyen de couverture utilisable sur toute la surface du pied. Ann Chir Plast Esthet 1991;36:544. [21] Oberlin C, Bastian D, Greant P. Les Lambeaux Pedicules de Couverture des Membres. Paris: Expansion Scientifique Francaise; 1994. p. 117–21. [22] Morrison WA, Crabb DM, O’Brien BM, Jenkins A. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 1983;72:56–64. [23] Masquelet AC, Romana MC. The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg 1990;85:765–72.
[24] Ishikura N, Heshiki T, Tsukada S. The use of a free medialis pedis flap for resurfacing skin defects of the hand and digits: results in five cases. Plast Reconstr Surg 1995;95:100–7. [25] Koshima I, Nanba Y, Tsutsui T, et al. Takahashi Y. Medial plantar perforator flaps with supermicrosurgery. Clin Plast Surg 2003;30:447–55. [26] Shaw WW, Hidalgo DA. Anatomic basis of plantar flap design: clinical applications. Plast Reconstr Surg 1986;78:637. [27] Harrison DH, Morgan BDG. The instep island flap to resurface plantar defects. Br J Plast Surg 1981;34:315. [28] Oberlin C, Saffar P. Le lambeau en ilot plantaire interne: Etude anatomique et applications chirurgicales. Rev Chir Orthop Reparatrice Appar Mot 1984;70: 151. [29] Morrison WA, Crabb DM, O’Brien BM, Jenkins AL. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 1983;72:56. [30] Oberlin C, Azoulay B, Sarcy JJ. The posterolateral malleolar flap of the ankle: a distally based sural neurocutaneous flap: report of 14 cases. Plast Reconstr Surg 1995;96:400.