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Plantar reconstruction using a step-ladder advancement flap
JPRAS Open 13 (2017) 41e45
Contents lists available at ScienceDirect
JPRAS Open journal homepage: http://www.journals.elsevier.com/ jpras-open
Case Report
Plantar reconstruction using a step-ladder advancement flap G. Furubayashi*, M. Sawaizumi, T. Maeda, K. Tanakura The Cancer Institute Hospital of Japanese Foundation For Cancer Research Plastic and Reconstructive Surgery, 3-8-31, Ariake, Koto, Tokyo 135-8550, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 January 2017 Accepted 17 May 2017 Available online 25 May 2017
A medial plantar flap is superior as a sensory flap with regard to tissue wear, prevention of ulcer recurrence, and other such factors. However, a wound at a plantar weight-bearing site is likely to lead to abnormal hyperkeratosis that can cause pain and fissures. In addition, the development of a scar contracture in infant patients can cause failure of normal foot development. To overcome these issues, we developed a method in which an island flap from a nonweight-bearing site is used as a step-ladder advancement plantar flap for moderate-sized tissue loss at a plantar weight-bearing site, followed by primary closure of the flap donor site with suturing to prevent scar contracture and abnormal hyperkeratosis. This technique showed good functional and cosmetic outcomes, as the stepladder-like suture lines were unlikely to cause scar contracture and abnormal hyperkeratosis owing to the staggered scar, leading to pain prevention. © 2017 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Step-ladder advancement plantar flap Medial plantar flap Loss of plantar site V-Y advancement flap
Introduction The plantar weight-bearing site is difficult to treat in many cases when loss of skin and soft tissue occurs. A medial plantar flap from a plantar non-weight-bearing site has been used for moderate-sized tissue loss at the plantar weight-bearing site.1 This flap is superior as a sensory flap with regard to
* Corresponding author. Fax: þ81 3 3520 0141. E-mail address: [email protected] (G. Furubayashi). http://dx.doi.org/10.1016/j.jpra.2017.05.002 2352-5878/© 2017 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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G. Furubayashi et al. / JPRAS Open 13 (2017) 41e45
tissue wear, prevention of ulcer recurrence, and other such factors. However, a wound at a plantar weight-bearing site is likely to lead to abnormal hyperkeratosis that can cause pain and fissures. In addition, development of a scar contracture in infant patients can cause failure of normal foot development. To overcome these problems, we developed a method in which an island flap from a nonweight-bearing site is used as a step-ladder advancement plantar flap for moderate-sized tissue loss at a plantar weight-bearing site, followed by primary closure of the flap donor site with suturing.2 Here, we report the use of this technique in three cases. Operative technique In the step-ladder advancement plantar flap technique, a septal flap that can be prepared on the foot is designed in a form resembling various types of step-ladders and is transferred to the site of tissue loss using VeY advancement. In principle, the flap is designed at a non-weight-bearing site adjacent to the site of tissue loss. Orientation of the skin island is determined by referring to the position of the pedicle vessel, margin of the surrounding skin, and orientation of the furrows. In the case of the foot, a flap is prepared in a non-weight-bearing site. However, in the case of large tissue loss, skin on the tuberosity of the navicular bone is included. A basic form of the flap in VeY advancement is estimated and used as the basis for the step-ladder design. Usually, 4e6 stairs, in which the last stair is a triangle with a sharp angle, are designed. It is preferable to design the flap by dividing each step-ladder into two or three step-ladders (Figure 1). After elevation of an island flap, the flap is transferred to the site of tissue loss by extension in order to repair the loss using the first stair. Next, the wound is closed in such a way that the loss from shifting the first stair is covered by the second stair. The donor site is closed primarily according to VeY advancement. Case report Case 1 A 7-year-old female child developed a 1 1.3 cm synovial sarcoma in the right calcaneal region. As a result of extensive resection, the site of skin loss was 3 3.3 cm, exposing the calcaneus. We used a step-ladder advancement plantar flap from a medial plantar non-weight-bearing site. After the surgery, the flap showed complete engraftment in approximately two weeks, and she began walking with weight bearing, using a splint. One year postoperatively, she had no trouble in running and could return to daily playing activities, and the scar matured. Presently, seven years postoperatively, she has no limitations in her daily living and exercise activities. The growth of the affected foot is equivalent to that of the unaffected foot (Figure 2).
Figure 1. Design of a step-ladder advancement plantar flap.
G. Furubayashi et al. / JPRAS Open 13 (2017) 41e45
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Case 2 A 68-year-old woman was diagnosed with malignant melanoma in the calcaneal region. She underwent surgery, and the surgical margin was 2 cm away from a previous scar. We performed extensive resection, including a part of the calcaneal periosteum. The surgical site had tissue loss of 5 4 cm, and for this, a 6-stair step-ladder flap was designed toward the base of the hallux. The flap was elevated as an island flap, including the medial plantar artery and nerve. The donor site was closed with suturing according to VeY advancement. The postoperative condition of the flap was good, and she was able to walk using an arch support. Five years postoperatively, there has been no tumor recurrence, and the sensitivities of the affected and unaffected sides are equivalent (Figure 3A). Case 3 A 51-year-old woman was diagnosed with squamous cell carcinoma in the forefoot. She underwent surgery, and the surgical margin was 1 cm away from a previous scar. The surgical site had tissue loss of 3 4 cm at the base of the hallux, and for this, an 8-stair step-ladder flap was designed toward the medial plantar area in the adjacent region. The flap was elevated as an island flap, including the medial plantar artery, after proximal transection of the artery and was transferred to the peripheral side as a reverse flap. The postoperative condition of the flap was good, and she was able to walk using an arch support. Presently, eight years postoperatively, there has been no recurrence of the tumor, the operative scar has nearly disappeared, and the condition is good (Figure 3B). Discussion A technique involving the use of a plantar flap that is capable of handling weight and friction is important in the reconstruction of the skin and soft tissue of a plantar weight-bearing site. The medial
Figure 2. Case 1: A 14-year-old female patient.
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G. Furubayashi et al. / JPRAS Open 13 (2017) 41e45
Figure 3. (A) Case 2: A 68-year-old female patient. (B) Case 3: A 51-year-old female patient.
plantar flap has the highest utility value for moderate-sized tissue loss in the calcaneal region because it has structures of the skin and subcutaneous tissue similar to those of the weight-bearing site and can be obtained as a sensory flap in the same operative field as that of tissue loss.3 In addition, in the case of using the medial plantar flap as an island flap, skin grafting is usually required after harvesting the flap. Generally, skin grafting in a non-weight-bearing site is considered to cause little problem because it results in no functional disorder. However, hyperkeratosis is likely to develop outside the flap donor site, and the development of a concave deformity owing to a difference in the thickness of the reconstructed tissue is not cosmetically satisfactory (Figure 4).
Figure 4. A concave deformity of the skin graft site with the use of a plantar flap durable to weight and friction.
G. Furubayashi et al. / JPRAS Open 13 (2017) 41e45
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The step-ladder advancement is a method of designing flaps proposed by Johanson et al4 in 1974. The use of a step-ladder-like flap makes the suture line zigzag.5 In the 1980s, Hallock and Dreyer6,7 applied this method to repair loss of the external nose. However, all these reports used local flaps with a wide pedicle. In 1988, Evans et al8 reported the application of step-ladder advancement flaps for fingertip reconstruction. In 2011, Hammouda et al9 used these flaps for fingertip reconstruction. This technique can be applied not only to exposed sites but also to all sites throughout the body. In the lumbar and sacral regions, reconstruction with consideration of reproduction of the natal cleft or outline is possible. In the heel,10 upper eyelid, palm, and dorsum of the hand, the technique prevents scar contracture, allowing the surgeon to obtain good functional and cosmetic outcomes. In the palm and plantar regions, where longitudinal suture lines are likely to cause postoperative scar contracture, the use of a step-ladder flap prevents pain because contractures and abnormal hyperkeratosis are unlikely to develop owing to the staggered scar. Particularly, for performing reconstruction in children, we need to select a method after considering the influence on their growth. It is important to minimize scars and adhesions, and for this, the present technique is likely very effective. The disadvantages of the step-ladder advancement flap include its relatively complex design and technique, as well as the extension of the wound margin. Additionally, primary closure of the donor site requires confirmation of the combination of the ladders in the design step. Conclusion Our step-ladder advancement flap technique shows good functional and cosmetic outcomes. In addition, this technique is useful for the repair of moderate-sized tissue loss at a weight-bearing site. Conflicts of interest There are no conflicts of interest to declare. Funding No funding was obtained for this study. References 1. Sunagawa H, Kanaya F, Futenma C, Kiyama K, Oshiro W, Ibaraki K. Medial plantar flap for skin defects of the weight-bearing area of the foot. Orthop Traumatol. 1999;48:982e985. 2. Sawaizumi M, Fujio K, Maruyama Y, et al. Application of the step advancement plantar flap to repair plantar feet. J Jpn Soc Plast Reconstr Surg. 1998;18:293e298. 3. Shuhei T, Namiki Y, Hayashi Y. Flap coverage of the calcaneal region. J Jpn PRS. 1988;8:120e130. €m H. Surgical treatment of non-traumatic lower lip lesions with special 4. Johanson B, Aspelund E, Breine U, Holmstro reference to the step technique. A follow-up on 149 patients. Scand J Plast Reconstr Surg. 1974;8:232e240. 5. Sullivan DE. “Staircase” closure of lower lip defects. Ann Plast Surg. 1978;1:392e397. 6. Hallock GG, Dreyer TM. The stair-step flap for nasal alar reconstruction. Plast Reconstr Surg. 1984;74:704e707. 7. Hallock GG, Dreyer TM. The stair-step flap for nasal reconstruction. Ann Plast Surg. 1987;18:34e36. 8. Hayashi A, Maruyama Y. Step-advancement island flap for fingertip reconstruction. Br J Plast Surg. 1988;41:105e111. 9. Hammouda AA, El-Khatib HA, Al-Hetmi T. Extended step-advancement flap for avulsed amputated fingertip-a new technique to preserve finger length: case series. J Hand Surg Am. 2011;36:129e134. 10. Hayashi A, Maruyama Y. Stepladder V-Y advancement flap for repair of postero-plantar heel ulcers. Br J Plast Surg. 1997;50: 657e661.
Contents lists available at ScienceDirect
JPRAS Open journal homepage: http://www.journals.elsevier.com/ jpras-open
Case Report
Plantar reconstruction using a step-ladder advancement flap G. Furubayashi*, M. Sawaizumi, T. Maeda, K. Tanakura The Cancer Institute Hospital of Japanese Foundation For Cancer Research Plastic and Reconstructive Surgery, 3-8-31, Ariake, Koto, Tokyo 135-8550, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 January 2017 Accepted 17 May 2017 Available online 25 May 2017
A medial plantar flap is superior as a sensory flap with regard to tissue wear, prevention of ulcer recurrence, and other such factors. However, a wound at a plantar weight-bearing site is likely to lead to abnormal hyperkeratosis that can cause pain and fissures. In addition, the development of a scar contracture in infant patients can cause failure of normal foot development. To overcome these issues, we developed a method in which an island flap from a nonweight-bearing site is used as a step-ladder advancement plantar flap for moderate-sized tissue loss at a plantar weight-bearing site, followed by primary closure of the flap donor site with suturing to prevent scar contracture and abnormal hyperkeratosis. This technique showed good functional and cosmetic outcomes, as the stepladder-like suture lines were unlikely to cause scar contracture and abnormal hyperkeratosis owing to the staggered scar, leading to pain prevention. © 2017 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Step-ladder advancement plantar flap Medial plantar flap Loss of plantar site V-Y advancement flap
Introduction The plantar weight-bearing site is difficult to treat in many cases when loss of skin and soft tissue occurs. A medial plantar flap from a plantar non-weight-bearing site has been used for moderate-sized tissue loss at the plantar weight-bearing site.1 This flap is superior as a sensory flap with regard to
* Corresponding author. Fax: þ81 3 3520 0141. E-mail address: [email protected] (G. Furubayashi). http://dx.doi.org/10.1016/j.jpra.2017.05.002 2352-5878/© 2017 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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G. Furubayashi et al. / JPRAS Open 13 (2017) 41e45
tissue wear, prevention of ulcer recurrence, and other such factors. However, a wound at a plantar weight-bearing site is likely to lead to abnormal hyperkeratosis that can cause pain and fissures. In addition, development of a scar contracture in infant patients can cause failure of normal foot development. To overcome these problems, we developed a method in which an island flap from a nonweight-bearing site is used as a step-ladder advancement plantar flap for moderate-sized tissue loss at a plantar weight-bearing site, followed by primary closure of the flap donor site with suturing.2 Here, we report the use of this technique in three cases. Operative technique In the step-ladder advancement plantar flap technique, a septal flap that can be prepared on the foot is designed in a form resembling various types of step-ladders and is transferred to the site of tissue loss using VeY advancement. In principle, the flap is designed at a non-weight-bearing site adjacent to the site of tissue loss. Orientation of the skin island is determined by referring to the position of the pedicle vessel, margin of the surrounding skin, and orientation of the furrows. In the case of the foot, a flap is prepared in a non-weight-bearing site. However, in the case of large tissue loss, skin on the tuberosity of the navicular bone is included. A basic form of the flap in VeY advancement is estimated and used as the basis for the step-ladder design. Usually, 4e6 stairs, in which the last stair is a triangle with a sharp angle, are designed. It is preferable to design the flap by dividing each step-ladder into two or three step-ladders (Figure 1). After elevation of an island flap, the flap is transferred to the site of tissue loss by extension in order to repair the loss using the first stair. Next, the wound is closed in such a way that the loss from shifting the first stair is covered by the second stair. The donor site is closed primarily according to VeY advancement. Case report Case 1 A 7-year-old female child developed a 1 1.3 cm synovial sarcoma in the right calcaneal region. As a result of extensive resection, the site of skin loss was 3 3.3 cm, exposing the calcaneus. We used a step-ladder advancement plantar flap from a medial plantar non-weight-bearing site. After the surgery, the flap showed complete engraftment in approximately two weeks, and she began walking with weight bearing, using a splint. One year postoperatively, she had no trouble in running and could return to daily playing activities, and the scar matured. Presently, seven years postoperatively, she has no limitations in her daily living and exercise activities. The growth of the affected foot is equivalent to that of the unaffected foot (Figure 2).
Figure 1. Design of a step-ladder advancement plantar flap.
G. Furubayashi et al. / JPRAS Open 13 (2017) 41e45
43
Case 2 A 68-year-old woman was diagnosed with malignant melanoma in the calcaneal region. She underwent surgery, and the surgical margin was 2 cm away from a previous scar. We performed extensive resection, including a part of the calcaneal periosteum. The surgical site had tissue loss of 5 4 cm, and for this, a 6-stair step-ladder flap was designed toward the base of the hallux. The flap was elevated as an island flap, including the medial plantar artery and nerve. The donor site was closed with suturing according to VeY advancement. The postoperative condition of the flap was good, and she was able to walk using an arch support. Five years postoperatively, there has been no tumor recurrence, and the sensitivities of the affected and unaffected sides are equivalent (Figure 3A). Case 3 A 51-year-old woman was diagnosed with squamous cell carcinoma in the forefoot. She underwent surgery, and the surgical margin was 1 cm away from a previous scar. The surgical site had tissue loss of 3 4 cm at the base of the hallux, and for this, an 8-stair step-ladder flap was designed toward the medial plantar area in the adjacent region. The flap was elevated as an island flap, including the medial plantar artery, after proximal transection of the artery and was transferred to the peripheral side as a reverse flap. The postoperative condition of the flap was good, and she was able to walk using an arch support. Presently, eight years postoperatively, there has been no recurrence of the tumor, the operative scar has nearly disappeared, and the condition is good (Figure 3B). Discussion A technique involving the use of a plantar flap that is capable of handling weight and friction is important in the reconstruction of the skin and soft tissue of a plantar weight-bearing site. The medial
Figure 2. Case 1: A 14-year-old female patient.
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G. Furubayashi et al. / JPRAS Open 13 (2017) 41e45
Figure 3. (A) Case 2: A 68-year-old female patient. (B) Case 3: A 51-year-old female patient.
plantar flap has the highest utility value for moderate-sized tissue loss in the calcaneal region because it has structures of the skin and subcutaneous tissue similar to those of the weight-bearing site and can be obtained as a sensory flap in the same operative field as that of tissue loss.3 In addition, in the case of using the medial plantar flap as an island flap, skin grafting is usually required after harvesting the flap. Generally, skin grafting in a non-weight-bearing site is considered to cause little problem because it results in no functional disorder. However, hyperkeratosis is likely to develop outside the flap donor site, and the development of a concave deformity owing to a difference in the thickness of the reconstructed tissue is not cosmetically satisfactory (Figure 4).
Figure 4. A concave deformity of the skin graft site with the use of a plantar flap durable to weight and friction.
G. Furubayashi et al. / JPRAS Open 13 (2017) 41e45
45
The step-ladder advancement is a method of designing flaps proposed by Johanson et al4 in 1974. The use of a step-ladder-like flap makes the suture line zigzag.5 In the 1980s, Hallock and Dreyer6,7 applied this method to repair loss of the external nose. However, all these reports used local flaps with a wide pedicle. In 1988, Evans et al8 reported the application of step-ladder advancement flaps for fingertip reconstruction. In 2011, Hammouda et al9 used these flaps for fingertip reconstruction. This technique can be applied not only to exposed sites but also to all sites throughout the body. In the lumbar and sacral regions, reconstruction with consideration of reproduction of the natal cleft or outline is possible. In the heel,10 upper eyelid, palm, and dorsum of the hand, the technique prevents scar contracture, allowing the surgeon to obtain good functional and cosmetic outcomes. In the palm and plantar regions, where longitudinal suture lines are likely to cause postoperative scar contracture, the use of a step-ladder flap prevents pain because contractures and abnormal hyperkeratosis are unlikely to develop owing to the staggered scar. Particularly, for performing reconstruction in children, we need to select a method after considering the influence on their growth. It is important to minimize scars and adhesions, and for this, the present technique is likely very effective. The disadvantages of the step-ladder advancement flap include its relatively complex design and technique, as well as the extension of the wound margin. Additionally, primary closure of the donor site requires confirmation of the combination of the ladders in the design step. Conclusion Our step-ladder advancement flap technique shows good functional and cosmetic outcomes. In addition, this technique is useful for the repair of moderate-sized tissue loss at a weight-bearing site. Conflicts of interest There are no conflicts of interest to declare. Funding No funding was obtained for this study. References 1. Sunagawa H, Kanaya F, Futenma C, Kiyama K, Oshiro W, Ibaraki K. Medial plantar flap for skin defects of the weight-bearing area of the foot. Orthop Traumatol. 1999;48:982e985. 2. Sawaizumi M, Fujio K, Maruyama Y, et al. Application of the step advancement plantar flap to repair plantar feet. J Jpn Soc Plast Reconstr Surg. 1998;18:293e298. 3. Shuhei T, Namiki Y, Hayashi Y. Flap coverage of the calcaneal region. J Jpn PRS. 1988;8:120e130. €m H. Surgical treatment of non-traumatic lower lip lesions with special 4. Johanson B, Aspelund E, Breine U, Holmstro reference to the step technique. A follow-up on 149 patients. Scand J Plast Reconstr Surg. 1974;8:232e240. 5. Sullivan DE. “Staircase” closure of lower lip defects. Ann Plast Surg. 1978;1:392e397. 6. Hallock GG, Dreyer TM. The stair-step flap for nasal alar reconstruction. Plast Reconstr Surg. 1984;74:704e707. 7. Hallock GG, Dreyer TM. The stair-step flap for nasal reconstruction. Ann Plast Surg. 1987;18:34e36. 8. Hayashi A, Maruyama Y. Step-advancement island flap for fingertip reconstruction. Br J Plast Surg. 1988;41:105e111. 9. Hammouda AA, El-Khatib HA, Al-Hetmi T. Extended step-advancement flap for avulsed amputated fingertip-a new technique to preserve finger length: case series. J Hand Surg Am. 2011;36:129e134. 10. Hayashi A, Maruyama Y. Stepladder V-Y advancement flap for repair of postero-plantar heel ulcers. Br J Plast Surg. 1997;50: 657e661.