Systematic reappraisal of the reverse-flow medial plantar flap: From vascular anatomical concepts to surgical applications

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Systematic reappraisal of the reverse flow-medial plantar flap: from vascular anatomical concepts to surgical applications D. Guillier MD , M. Cherubino MD , C.M. Oranges MD , S. Giordano MD, PhD , W. Raffoul MD , P.G. di Summa MD,PhD PII: DOI: Reference:

S1748-6815(19)30487-5 https://doi.org/10.1016/j.bjps.2019.10.019 PRAS 6303

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Journal of Plastic, Reconstructive & Aesthetic Surgery

Received date: Accepted date:

24 June 2019 20 October 2019

Please cite this article as: D. Guillier MD , M. Cherubino MD , C.M. Oranges MD , S. Giordano MD, PhD , W. Raffoul MD , P.G. di Summa MD,PhD , Systematic reappraisal of the reverse flow-medial plantar flap: from vascular anatomical concepts to surgical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.10.019

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Title: Systematic reappraisal of the reverse flow-medial plantar flap: from vascular anatomical concepts to surgical applications Authors: 1,2

Guillier D, MD 2,

3

Cherubino M, MD,

4

Oranges CM, MD,

5

Giordano S, MD, PhD,

2

Raffoul W, MD,

2

di Summa PG, MD,PhD

1,2

Department of Plastic Reconstructive and Hand Surgery, Department of Oral and

Maxillofacial Surgery - University Hospital, Boulevard de Lattre de Tassigny F-21000, Dijon, France 2

Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV),

Rue du Bugnon 46, 1011 Lausanne, Suisse 3

Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Varese,

Varese, Italy 4

Department of Plastic and Hand Surgery, University hospital of Basel, Basel, Suisse

5

Department of Plastic and Reconstructive Surgery, University hospital of Turku, Turku,

Finland

Corresponding author: Pietro G di Summa, MD, PhD Consultant Plastic and Reconstructive Surgeon Department of Plastic and Hand Surgery Centre Hospitalier Universitaire Vaudois (CHUV) Rue du Bugnon 46, 1011 Lausanne - Suisse Tel: +41213141111 [email protected]

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Abstract: Introduction: The medial plantar flap in its anterograde form is considered to be the gold standard for heel reconstruction. This flap can be also raised as distally based for the reconstruction of the weight-bearing forefoot. However, terminal branches of the medial plantar artery, together with their connection with distal and dorsal systems can be variable. Our objective was to provide a comprehensive anatomic description that could match all technical possibilities in raising the distally based MPA flap. A systematic review of indications outcomes and complications of the distally based MPA flap is provided. Methods: According to PRISMA criteria, we systematically reviewed previous literature using the MEDLINE database concerning the medial plantar flap from 1977 to November 2018 using the keywords « Medial plantar flap » OR « Medial Plantar Artery ». Anatomic variations, techniques, Indications, outcomes and complications were analyzed. Results: All different vascular pedicles that may be used to vascularize the medial plantar flap were classified. Apart from flap with a proximal flow, five anastomotic connections from the superficial medial plantar artery to plantar arterial network may exist. Four dorso-plantar links supply the plantar network thanks to dorsal vascularization. Literature analysis of outcomes showed how the retrograde medial plantar flap may be unreliable with 14% of venous congestion rate and 9,3% of average flap loss, for a total average flap complications of 18,6%. Conclusion: This review provide the ultimate, clear picture of the complex anastomotic picture of the forefoot, with direct referral to the surgical flap raising techniques, guiding surgeons during challenging reconstructions.

Key words: Medial Plantar Flap; Medial plantar artery; Reverse-flow; Vascular shunts

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Introduction Reconstruction of plantar defects, particularly foot weight bearing areas, is a real challenge, as stable and long-lasting results are of paramount importance for patient’s ambulation. In this area, local flaps are generally the preferred option, despite the limited donor site availability. Indeed, despite the growing diffusion and evolution of microsurgical techniques, free flaps are technically demanding, time-consuming, and cannot be easily popularized in small medical facilities. Firstly described by Mir in 1954 as a cross-foot flap (1), the plantar flap with anterograde vascularization based on the medial plantar artery (MPA) was popularized by Harrison and Morgan in 1981 (2), gaining increasing interest since. This flap presents a particular interest for its ductility, as it can be used pedicled (based on anterograde or retrograde flow), or as free flap, virtually covering all fundamental needs in reconstruction of the plantar foot, including like-with-like tissue replacement, reliability and potential sensation (3). However, vascular territories may be jeopardized after trauma or resections, and a clear understanding of the anatomical variations and anastomotic connections in the foot is mandatory for a successful reconstruction. Indeed, despite a number of reports have investigated the vascular connections between medial and lateral plantar arteries, dorsopalmar anastomotic links and cutaneous perforators, a clear and understandable picture of this area is still missing, particularly concerning the forefoot. This work wants to clearly define key vascular principles of plantar perfusion, leading to better understanding in surgical flap raising. Moreover, a systematic analysis of outcomes and complications of the different forms of the medial plantar flap is presented, to better guide surgeons in such complex reconstructions.

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Patients and Methods

The aim of this review was double: recall and clarify anatomical variations in foot vascularization then identify previously published techniques according to resumed anatomy, evaluating their indications, outcomes and complications. In this way, a systematic review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement and structured around existing recommended guidelines. The literature search was conducted using a MeSH(Medical Subject Heading) keyword search of the MEDLINE and OVID databases on PubMed and Medline conducted for articles concerning the medial plantar flap from 1977 to November 2018 using the keywords « Medial plantar flap » OR « Medial Plantar Artery » as search algorithm in order to identify all relevant studies. Additional manual searches of the Embase database on EBSCOhost, Google Scholar Database and the reference list of each screened abstract was undertaken identify additional studies not found in the primary search. Articles were required to be of the following types: case study, case report, case series, clinical trial, prospective study, or retrospective study. Excluded from the analysis were literature reviews, studies describing secondary interventions, treatment or analysis of previous complications, and publications with unclear presentation of surgical procedure, outcomes or complications. All publications were screened manually. Two investigators (D.G, and P.G.d.S.) independently reviewed and extracted data from the papers, according to the predetermined criteria. From the initial number of 177 articles, 53 were finally included (Table 1). Ten articles dealt with about anatomy only (cadaver data) and 43 articles about clinical application with anatomy description. The following informations were documented and

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tabulated for each article: author name(s), year of publication, number of patients, average age of patients, indications, surgical procedures, complications, and outcomes. All surgical variations of medial plantar artery flaps were considered, including: MPA flap, LPA flap, (both anterograde and retrograde), medial plantar artery perforator (MPAP) flap.

Results Among analysed papers, 14 where only anatomic, 29 only clinical and 10 where covering both domains. Papers reporting on anatomical measures and sizes where pulled together in order to establish average data on anatomical features described.

Systematic appraisal of anatomical variations of the forefoot Medial plantar artery Below medial malleolus, the posterior tibial artery (PTA) enters into the calcaneal canal underneath the flexor retinaculum and bifurcates at the level of the transverse septum between the abductor hallucis muscle (AHM) and the flexor digitorum brevis muscles (FDBM) in two branches: the medial (MPA) and lateral plantar arteries (LPA). The mean length of the posterior tibial artery from the tip of the medial malleolus to its division into medial and lateral plantar arteries was (2.7 +/- 0.24 cm) (4), with the medial plantar artery generally smaller than the lateral plantar artery (5). Initially, the MPA courses anteriorly between the FDBM and AHM, where it supplies both muscles. Its runs parallel and below the tendon of the flexor hallucis longus (FHL). At the level of the talus-navicular joint, the MPA divides into a superficial (sMPA) and a deep (dMPA) branch. The mean distance between the origin of the MPA and division is 3+/- 0.5cm (6). The mean caliber of the superficial MPA was larger than the deep MPA, respectively 1.85

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+/- 0.6 mm and 1.40 +/- 0.4 mm, with ratio superficial/deep 1.3 +/- 0.6 (4)(7). The medial plantar nerve accompanies the MPA on the lateral side.

Cutaneous perforators Without distinguish between superficial or deep medial plantar arteries, Yang et al. (8) underlined how the medial plantar artery, in its course down the foot, gives off a series of 1 to 3 septo-cutaneous perforators along the fascial septum arising between the FDBM and AHM. These skin branches are the anatomical basis of the medial plantar flap and medial plantar artery perforator flap as described by Koshima et al (9). These perforators branches are described arising approximately from 1.25, 2.5 and 3.5 cm from the origin of the sMPA (5)(10), with the most proximal probably originating from the MPA (and not sMPA). These perforators retain a mean diameter over 0.5 mm, with a second is always the wider (11)(12)(13)(14). Attinger et al (15) showed perforator flap up to 8 x 12 cm may be harvested based on the middle cutaneous branch of the medial plantar artery without sacrificing the medial plantar artery and plantar aponeurosis. Further unspecified muscular branches are described in various numbers for AHM, FDBM and FHBM.

MPA and Anastomotic connections (AC) According to the examined literature, sMPA divides itself in variable ending collaterals establishing anastomotic links with other systems (4)(16). Such links were reviewed and classified according to their encountered frequency (Table 2 – Figure 1): 

AC 1: In 45% of the cases, the sMPA runs toward the first toe and forms the medial digital halluces artery and occasionally the lateral digital halluces artery.

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

AC 2: Despite high variations observed (27 to 100%) (17)(18), an anastomotic connection is present between the sMPA and the first plantar metatarsal artery rising from deep plantar arch. Attinger et al. (15) described this anastomosis as “cruciate anastomosis”, sometimes named transversal artery of great toe.



AC 3: in 15% for Haven (16) and 66% for Masquelet (17), there are superficial ending branches toward the first toe and a deep branches supplying the second or third toe, thereby crossing the plantar arch (Kamina 2002) through the first and second metatarsal arteries.



AC 4: A direct anastomoses between sMPA and deep plantar arch in 10 to 20% (17)(16).

The second major branch of the MPA is the dMPA, travelling deep and along the medial intermuscular septum between the AHM and the FDBM. In the examined literature, the dMPA was inconstant and absent in 30-45% (10)(6) of the cases, with and a dominant dMPA reported in 10% of the cases (4)(6)(19). Moreover, considering the significant difference in caliber between sMPA and dMPA, this last has been even considered as collateral branch directed to the AHM in 38% of the cases. The connection between dMPA and deep plantar arch is rare 5-12% (AC 5).

Lateral Plantar artery (LPA) The LPA enters the middle compartment of the foot, where it travels obliquely between the FDBM and the quadratus plantar muscle. Lying between the middle and distal third of the foot (averaging 29% of total foot length for Ozer et al (20)), it travels distal to the proximal fifth metatarsal underneath the flexor digiti minimi muscle (FDMM) and turns medially up to proximal metatarsals four three and two, forming the deep plantar arch. 7

Similarly to the medial plantar artery, the LPA gives raise to septocutaneous branches in the skin along the lateral border of the plantar aponeurosis.

Deep plantar artery and deep plantar arch (DPA) A key direct anastomosis between the dorsal and plantar arteries network exist at the proximal first metatarsal interspace thanks to the deep plantar artery (DPA). This artery represents a critical dorsa-plantar shunt connecting the dorsalis pedis artery to the deep plantar arch.

According to the reviewed literature, the contribution between lateral plantar artery and DPA to the plantar arch flow is variable (21)(22)(20)(19)(23) (Table 3): 

Type 1: DPA from dorsal network is the main blood supplier to the deep plantar arch predominating in 63%.



Type 2; Lateral plantar artery is the main blood supplier to the deep plantar arch in 24,5%.



Type 3: both arteries (deep plantar artery and the lateral plantar artery) contributed equally 12,5%.

Four plantar metatarsal arteries emanate constantly from the deep plantar arch. They travel along each metatarsal bone deep to the interossei and the transverse adductor muscles, but superficially to the deep transverse metatarsal ligament. The common plantar digital arteries follow up on two proper plantar digital and join distally linking with the terminal branches of the dorsal metatarsal arteries. A complete superficial plantar arch is weakly represented in literature (0 to 30%) (20)(22)(6)(24). This was described by Masquelet (17) as located between the FDBM and the plantar aponeurosis, formed by interconnections superficial branches of the LPA and the superficial branch of MPA. 8

Dorsal-plantar interconnections A dominant dorsal system, with the first dorsal metatarsal artery larger than the first plantar metatarsal artery, has been described in 50 to 80 percent of feet (25)(26)(27)(28). On the dorsal side of the foot, the first dorsal metatarsal artery from dorsalis pedis artery reaches the DPA in the proximal first metatarsal interspace (link 1 deep plantar artery). As previously mentioned, the dorsal metatarsal artery continues distally giving off digital arteries, meeting the palmar system at the web space (link 2). A peri-articular (metatarso-phalangeal joint) arterial anastomosis is also formed from dorsal and plantar metatarsal arteries (29)(30) (link 3), Finally, a small subdermal arterial plexus exists between the medial dorsal network of the great toe and the sMPA in a medial hemi-circumferential wraparound pattern (link 4). These arteries are of extremely fine caliber (0.1 to 0.2 mm) and are too small to assess with the Doppler probe (31).

Systematic review of outcomes and complications of MPA flaps

Anterograde MPA flap This flap requires distal ligation of the axial vessel (sMPA or dMPA) to allow transfer of the tissue to the heel (Figure 2a). The pivot is the division of posterior tibal artery with a mean pedicle length of 4,25cm. MPA anterograde flap is the gold standard for heel reconstruction, considering the possibility to be harvested as a sensate flap. Literature showed average flap size of 4x6 cm and described up to 8x12cm (8). Few complications were reported (7,8% of cases, table 4) (Table 4a) (32).

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Martin et al (33) and Oberlin et al (34), described reverse flow Y-V pedicle extension of MPA flap (figure 2b). A distally based flap with ligature of the tibial posterior artery is performed before the division into MPA and LPA. This flap has a pedicular vascularization, with anterograde flow into the dorsalis pedis artery and DPA, then a retrograde flow into deep plantar arch and LPA and finally anterograde flow into the MPA. The pedicle is lengthened to form a Y-V shape allowing for distal advancement of the flap, which can attain the forefoot. This flap is very reliable with the drawback of sacrificing a major vascular axis (TP).

Table 3a: (35)(36)(37)(38)(39)(40)(9)(41)(42)(8)(43)(44)(45)(46)(47)(32)(48)(49)

Retrograde flap Bhandari et al. (50) introduced the concept of “reverse flow instep flap” in which the medial plantar skin is retrogradely perfused thanks to the anastomose between the MPA and the first plantar metatarsal artery (cf AC2: also known as cruciate anastomosis by Attinger et al. (15)). The multiple anatomical variations and shunts previously described (AC1 to AC5) explain the different possibilities in raising a distally-based different medial plantar flap (Figure 2c, Table 4b). Different authors focused on the specific source of the reverse flow. The majority of the authors reported a single pedicle, but bi-pedicled or pluri-pedicle are described. Cumulative complications reached almost 20% in litterature (18,6% of cases, table 5). Table 4b: (33)(51)(50)(52)(34)(53)(54)(37)(55)(38)(56)(57)(58)(41)(59)(60)(61)(18)(62)(63)(49)

Perforator flaps

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By dissecting the perforator directed of the skin paddle (MPA-P flap), pedicle length can be significantly increasing up to 53mm (8)(10) in anterograde version. Retrograde version has also been described. When raised as propeller-perforator, the distal forefoot can be covered without need to ligate the MPA and preserving its vascularization (for digital resurfacing: (32) (14) and forefoot resurfacing (49)). However, the main septocutaneous perforator may result tricky to dissect. Indeed, Coruh et al. (55) avoided the skeletonisation of the tiny cutaneous perforators of the medial plantar artery and the cutaneous fascicles of the medial plantar nerve during distally based perforator medial plantar flap elevation.

Discussion Various surgical techniques have been described for soft tissue reconstruction of the plantar area of the foot. These included secondary healing, skin grafts, local and free flaps. The weight-bearing surface is determinant for patient quality of life and reconstruction should ideally reproduce the robust and thick plantar skin, and withstand the stresses and loads it is exposed to on a daily basis. The medial plantar flap is the ideal choice as it provides thin glabrous skin from a nonweight-bearing area. Moreover, it relies on a particularly solid perfusion and it can be harvested including the medial plantar nerve as sensate the flap (64)(65)(32). Discriminating ability in the reconstructed areas has showed to be equivalent to the contralateral side (42). Mahmoud et al (66) emphasized the advantages of anterograde medial plantar flap with significant functional improvement in heel reconstruction when compared to the reverse superficial sural flap (67). Few literatures reported on donor site morbidity, with the exception of Paget et al (68) who underlies weaker push-off from the great toe and kinetics modified foot kinetics.

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Soft tissue defects of the distal plantar forefoot can be technically more challenging, as the same principles of heel apply, with less local options. Free flap are a partial response but imply microsurgical team and should be considered as last option. Locoregional flap, such as a distally based neurocutaneous sural flap or lateral supramalleolar flap have been used with unpredictable outcomes (66)(69). Instead, pedicled reverse-flow flaps based on the medial plantar artery can cover wounds that extend to the metatarsal heads. Different combinations have been described with single or several pedicles including (Figure 3):

Retrograde flaps based on distal based plantar network: - Retrograde sMPA flap based on the anastomosis between sMPA and the first plantar metatarsal artery (Cruciate anastomosis (15)), - Retrograde sMPA flap based on the anastomosis between sMPA and the deep plantar arch

Retrograde flaps based on distal based dorsal network: - Retrograde sMPA flap based on a cutaneous anastomosis between sMPA and the distal medial branch of the first dorsal metatarsal artery - Retrograde sMPA flap based on distal dorso-plantar anastomosis between terminal branches of sMPA and common digital artery (link 2) - Retrograde sMPA flap based on peri-metatarsal joint anastomosis between terminal branches of sMPA and dorsal network (link1)

Combined ante-retrograde flow

- Y-V shape (reverse flow on LPA, antegrade flow on sMPA)

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- Y-V shape associated with cutaneous perforator from the first plantar metatarsal artery (bi-pedicled) of Scaglioni (63).

Nakajima et al (70) proposed the concept of veno-neuroadipofascial pedicled fasciocutaneous flaps, which retain a dual blood supply from both the nutrient arteries of the cutaneous nerves and veins (link4). Even in patients with healthy arteries and patent anastomotic arcades, some hazards are difficult to predict. Among them, the venous insufficiency in the reverse flow medial plantar flaps is a matter of concern (with an average of 18,6% of complications with 14% of venous congestion in this review). Moreover, too distally based pedicle versions seem to be more unreliable. The distal third of foot should be the limit of dissection to include the most plantar anastomoses for a retrograde vascularization (20). Indeed, The distal anatomic variations described can explain the risk of arterial hypoperfusion and/or venous congestion. Crushing or traumatism injuries further jeopardize flow, even with positive Doppler exam. Technical issues should be equally considered and have been highlighted in the literature reviewed. When the flap is rotated distally to the forefoot, it can kink and compress the pedicle. Perivascular subcutaneous tissue surrounding the pedicle can be preserved to reduce venous congestion, pedicle injury or twist. Thus, we advise against skeletonisation of the distal medial plantar artery. The skin between the distal pedicle and the defect should be extensively undermined to facilitate wound closure without pedicle compression. Even with a precise and defensive approach, an inadequate retrograde venous return due to the incompetent vein valves can be occurred. Some authors suggested supercharge flap with plantar vein anastomosis on the first plantar digital vein (37) lateral plantar vein (71) or posterior tibial vein (60). Butler et al (53) used interposition vein grafting for additional venous outflow in a salvage procedure.

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Concerning donor site morbidity, skin defect is occasionally closed directly but generally requires a skin graft. Dermal substitutes have been used with improvement of skin trophicity (72). Free flap were described for this indication (13) (73).

After clinical assessment of the defect, patients should be selected for anterograde or retrograde medial plantar flaps. Anatomic variation, comorbidities (diabetes, vascular disease or insufficiency, smoking), precarious vascularization from crushing injuries or surgical resection should be taken into account during the planning, particularly in the retrograde version. Emergency coverage after traumatism with only distal pedicle flap, without appropriate diagnostic workout may lead to unpredictable results. Doppler ultrasonography exam was the most used investigation tool in the literature (74), but Angio-CT or arteriography should be preferred for higher accuracy. Conflict of Interest: none Financial Disclosure: No Ethical approval: n/a Acknowledgements: Authors are grateful to Dr Ciléin Kearns (Artibiotics) for medical illustrations.

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Muscle as a Conjoined or Distally-Based Flap: J Trauma Inj Infect Crit Care. 2005 Oct;59(4):1007–11. 39. Schwarz RJ, Negrini J-F. Medial Plantar Artery Island Flap for Heel Reconstruction: Ann Plast Surg. 2006 Dec;57(6):658–61. 40. Mourougayan V. Medial Plantar Artery (Instep Flap) Flap: Ann Plast Surg. 2006 Feb;56(2):160–3. 41. Oh SJ, Moon M, Cha J, Koh SH, Chung CH. Weight-bearing plantar reconstruction using versatile medial plantar sensate flap. J Plast Reconstr Aesthet Surg. 2011 Feb;64(2):248–54. 42. Wan DC, Gabbay J, Levi B, Boyd JB, Granzow JW. Quality of Innervation in Sensate Medial Plantar Flaps for Heel Reconstruction: Plast Reconstr Surg. 2011 Feb;127(2):723–30. 43. Beidas OE, Tan BK, Petersen JD. The rotational advancement of medial plantar flap for coverage of foot defect: A case report. Microsurgery. 2012 May;32(4):322–5. 44. Bibbo C. Plantar Heel Reconstruction with a Sensate Plantar Medial Artery Musculocutaneous Pedicled Island Flap after Wide Excision of Melanoma. J Foot Ankle Surg. 2012 Jul;51(4):504–8. 45. Siddiqi MA, Hafeez K, Cheema TA, Rashid H. The Medial Plantar Artery Flap: A Series of Cases over 14 Years. J Foot Ankle Surg. 2012 Nov;51(6):790–4. 46. Wright TC, Mossaad BM, Chummun S, Khan U, Chapman TWL. Proximally pedicled medial plantar flap based on superficial venous system alone for venous drainage. J Plast Reconstr Aesthet Surg. 2013 Jul;66(7):e201–4. 47. Oksuz S. Recalcitrant Caustic Burn Wound and Definitive Treatment with Medial Plantar Flap. Turk J Trauma Emerg Surg [Internet]. 2015 [cited 2019 Feb 28]; Available from: http://www.tjtes.org/eng/jvi.aspx?pdir=travma&plng=eng&un=UTD49386&look4= 48. Macedo JLS de, Rosa SC, Neto AV de RF, Silva AA da, Amorim ACS de. Reconstruction of soft-tissue lesions of the foot with the use of the medial plantar flap. Rev Bras Ortop Engl Ed. 2017 Nov;52(6):699–704. 49. Scaglioni MF, Rittirsch D, Giovanoli P. Reconstruction of the Heel, Middle Foot Sole, and Plantar Forefoot with the Medial Plantar Artery Perforator Flap: Clinical Experience with 28 Cases. Plast Reconstr Surg. 2018 Jan;141(1):200–8. 50. Bhandari PS, Sobti C. Reverse Flow Instep Island Flap: Plast Reconstr Surg. 1999 Jun;103(7):1986–9. 51. Bertelli JA, Duarte HE. The Plantar Marginal Septum Cutaneous Island Flap: A New Flap in Forefoot Reconstruction: Plast Reconstr Surg. 1997 Apr;99:1390–5. 52. Salon A, Pouliquen JC. Reconstruction of the great toe in a child using the Y-V pedicle elongation technique for a medial plantar flap. Br J Plast Surg. 1999 Mar;52(2):146–8. 53. Butler CE, Chevray P. Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and webspace defects. Ann Plast Surg. 2002 Aug;49(2):196–201. 54. Takahashi A, Tamura A, Ishikawa O. Use of a reverse-flow plantar marginal septum cutaneous island flap for repair of a forefoot defect. J Foot Ankle Surg. 2002 Jul;41(4):247–50. 55. Coruh A. Distally Based Perforator Medial Plantar Flap: A New Flap for Reconstruction of Plantar Forefoot Defects: Ann Plast Surg. 2004 Oct;53(4):404–8. 56. Uygur F, Duman H, Ulkür E, Noyan N, Çeliköz B. Reconstruction of distal forefoot burn defect with retrograde medial plantar flap. Burns. 2008 Mar;34(2):262–7. 57. Unglaub F, Wolf MB, Dragu A, Forst J, Horch RE, Kneser U. Reconstruction of a 17

child’s forefoot defect using a distally based pedicled medial plantar flap. Arch Orthop Trauma Surg. 2010 Feb;130(2):155–8. 58. Tsai J, Liao H-T, Ulusal BG, Chen C-T, Lin C-H. Modified retrograde-flow medial plantar island flap for reconstruction of distal dorsal forefoot defects—Two case reports. Microsurgery. 2010;NA – NA. 59. Hayashi A, Matsumura T, Horiguchi M, Komuro Y, Itoh M, Idezuki T, et al. The Medial Plantar Flap Vascularized by the Reverse Flow Lateral Plantar Artery: A Novel Variation through the Case of Aggressive Digital Papillary Adenocarcinoma of the Sole. J Reconstr Microsurg [Internet]. 2012 Jun 18 [cited 2019 Feb 28]; Available from: http://www.thieme-connect.de/DOI/DOI?10.1055/s-0032-1315769 60. Akita S, Mitsukawa N, Rikihisa N, Kuriyama M, Kubota Y, Hasegawa M, et al. Reconstruction of the great toe using a pedicled medial plantar flap with anterograde venous drainage: Reconstruction of the Great Toe Using a Pedicled Medial Plantar Flap. Microsurgery. 2014 Jul;34(5):398–403. 61. Fujioka M, Hayashida K, Senju C. Reconstruction of Lateral Forefoot Using Reversed Medial Plantar Flap with Free Anterolateral Thigh Flap. J Foot Ankle Surg. 2014 May;53(3):324–7. 62. Javed MU, Josty IC. Salvage of a complex first metatarso-phalangeal joint injury and synchronous reconstruction of medial collateral ligament and soft tissue with a distally based medial plantar artery flap. J Plast Reconstr Aesthet Surg. 2016 Mar;69(3):e61–3. 63. Scaglioni MF, Franchi A, Uyulmaz S, Giovanoli P. The bipedicled medial plantar flap: Vascular enhancement of a reverse flow Y-V medial plantar flap by the inclusion of a metatarsal artery perforator for the reconstruction of a forefoot defect-A case report: SCAGLIONI et al. Microsurgery. 2018 Sep;38(6):698–701. 64. Trevatt AEJ, Filobbos G, ul Haq A, Khan U. Long-term sensation in the medial plantar flap: A two-centre study. Foot Ankle Surg. 2014 Sep;20(3):166–9. 65. Khai Luen K, Wan Sulaiman WA. Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases. J Foot Ankle Surg. 2017 Sep;56(5):1114–20. 66. Mahmoud WH. Foot and Ankle Reconstruction Using the Distally Based Sural Artery Flap Versus the Medial Plantar Flap: A Comparative Study. J Foot Ankle Surg. 2017 May;56(3):514–8. 67. Kalam M, Faruquee S, Rahman S, Uddin H. Reconstruction of Heel: Options and Strategies. Bangladesh J Plast Surg. 1970 Jan 1;1(1):14–8. 68. Paget JT-EH, Izadi D, Haj-Basheer M, Barnett S, Winson I, Khan U. Donor site morbidity of the medial plantar artery flap studied with gait and pressure analysis. Foot Ankle Surg. 2015 Mar;21(1):60–6. 69. Lee J-H, Chung D-W. Reverse lateral supramalleolar adipofascial flap and skin grafting for one-stage soft tissue reconstruction of foot and ankle joint. Microsurgery. 2010 Mar 17;30(6):423–9. 70. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T. Accompanying arteries of the cutaneous veins and cutaneous nerves in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr Surg. 1998 Sep;102(3):779–91. 71. Masuoka T, Kato A. POSTERIOR TIBIAL VEIN AS DRAINAGE VESSEL FOR THE MEDIAL PLANTAR FLAP ON THE LATERAL PLANTAR ARTERY: Plast Reconstr Surg. 2004 Oct;1350–1. 72. Watfa W, di Summa PG, Meuli J, Raffoul W, Bauquis O. MatriDerm Decreases Donor Site Morbidity After Radial Forearm Free Flap Harvest in Transgender Surgery. J 18

Sex Med. 2017 Oct;14(10):1277–84. 73. Jyoshid RB, Vardhan H, Anto F. Free medial plantar artery flap for the reconstruction of great toe pulp. J Plast Reconstr Aesthet Surg. 2014 Jun;67(6):863–5. 74. Bonte A, Bertheuil N, Menez T, Grolleau J, Herlin C, Chaput B. Distally Based Medial Plantar Flap: A Classification of the Surgical Techniques. J Foot Ankle Surg. 2018 Nov;57(6):1230–7.

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Figures and Legends

Figure 1: Anastomotic connections of the plantar foot. (sMPA: superficial Medial Plantar Artery, dMPA: deep Medial Plantar Artery.)

20

21

Figure 2: A- Anterograde flow medial plantar flap B- Y-V medial plantar flap C- Reverse flow instep medial plantar flap

Figure 3: Dorsoplantar arterial links

22

Table 1: Prisma Chart PRISMA CHART – Medial Plantar Flap

Records identified through database searching (n = 177)

Additional records identified through other sources (n = 9)

Records after duplicates removed (n = 186)

Records screened (n = 67)

Full-text articles assessed for eligibility (n = 58)

Records excluded (n = 119) - 24 inadequate languages - 20 on free flap approach - 36 off the subjects - 18 on vascular surgery - 9 lack of data

Full-text articles excluded, with reasons (n = 9): - 3 general commentaries - 4 lack of data - 2 incomplete reviews

Studies included in qualitative synthesis (n = 53)

Studies included in quantitative synthesis (n = 53) - 10 articles about anatomy only - 43 articles about clinical application with anatomy description

23

Table 2: Type and average of plantar anastomotic connections according to the different authors. Anastomotic connections (AC) AC-1

AC-2

AC-3

AC-4 AC-5

Authors, years Haven, 1995 Masquelet, 1988 Macchi, 2005 Masquelet, 1988 Haven, 1995 Gabrielli, 2001 Macchi, 2005 Song, 2015 Masquelet, 1988 Haven, 1995 Gabrielli, 2001 Macchi, 2005 Masquelet, 1988 Haven, 1995 Masquelet, 1988 Haven, 1995 Gabrielli, 2001

Average (%) 45 38 100 15 8 54 26,7 66 15 8 38 17 20 5 12

Total average (%) 41,5

40,74

31,75

18,5

8,5

24

Table 3: Origin of deep plantar arch vascularization.

Source of deep plantar arch anatomy: Vann 1943 Keen 1961 Murakami 1971 Hamada 1994 Gabrielli 2001 Ozer 2005 Average (%) DPA : Dorsalis Pedis Artery, dLPA : deep Lateral Plantar Artery

% of DPA predominant

% of dLPA predominant

80,9 48 47,5 82 72 48 63

15,2 17 12,5 10 22 38 19

DPA and dLPA Equally represented 3,9 35 40 8 6 14 18

25

Table 4a: Relevant data according to anterograde flow into the medial plantar flap.

Flow Antér ograd e

Arteria l origin(s )

Author, year

MPA

Dumont, 2001

MPA MPA

MPA

MPA-P

Schwarc z, 2006 Mouroug ayan, 2006 Koshima , 2007

MPA

Oh, 2011

MPA

MPA

MPA MPA-P MPA MPA-P MPA

MPA MPA MPA-P

Total

Duman, 2002 Acikel, 2003 Schwabe gger, 2005

Wan, 2011 Yang, 2011 Beidas, 2012 Bibbo, 2012 Siddiqi, 2012 Wright, 2013 Oksuz, 2015

Patie Age Width of skin nts (avera flap (average in (n) ge) cm)

Length of skin flap (average in cm)

Indications Achille's tendon Heel and Achille's tendon Heel and ankle

Complications

1

65

2.5

4.5

10

X

X

X

18

24

3.75

6.25

3

64

3

4

51

50

X

X

Heel Heel and Achille's tendon

12

46

5.8

8.5

Heel

no

3

20

2

4

Heel

8

31,5

5.5

9

3

60

6

9

Heel Heel and medial ankle

no 2 venous congestion and one wound infection

15

38

6

7,5

1

19

3.5

1

86

18

20,2

Heel

no

X

X

Heel

no

1

21

X

X

11

38,5

3,7

4,4

12

32

X

X

54 41 (286)

4

5

4 (1,5-7)

6 (5-12)

24

18

146

no

X

X

Scaglioni , 2018

1 partial skin flap necrosis 3 infections / 6 delayed healing / 1 flap necrosis

X

X

MPA-P

no

4.5

43

MPA

no

no

1

Gu, 2016 Macedo, 2017

no

Heel Lateral plantar foot

Medial ankle Anterior ankle Heel Heel and ankle Heel and medial plantar

Comment

no

no

Superficial venous system included

no no 1 partial skin flap necrosis

no 15 events

26

Table 4b: Relevant data according to retrograde flow into the medial plantar flap.

Flo w Ret rog rad e

Age Autho Pati (ave r, ents rage Arterial origin(s) year (n) )

Deep plantar arch + LPA Distal sMPA First plantar metatarsal artery Deep plantar arch + LPA Deep plantar arch + LPA

Martin , 1991 Bertell i, 1997 Bhand ari, 1999 Salon, 1999 Oberli n, 2000

Plantar metatarsal Butler, arteries 2002 Takah ashi, Distal sMPA 2002

Deep plantar arch

Acikel , 2003

Dorsalis pedis + deep plantar arch Dorsal arterial network + plantar metatarsal artery

Coruh, 2004 Schwa begger , 2005

Plantar metatarsal Yugur arteries , 2008 Ungla ub, Distal sMPA 2009 Deep plantar arch + LPA Deep plantar arch + LPA Deep plantar arch + LPA

Tsai, 2010 Oh, 2011 Hayas hi, 2012

Deep plantar arch + LPA

Akita, 2014

fujiok a, Distal MPA 2014 Plantar metatarsal Song, arteries 2015

Distal MPA Deep plantar arch + LPA + plantar metatarsal artery

Distal sMPA-P Tot al

Javed, 2016 Scagli oni, 2017 Scagli oni, 2018

21

Width of skin flap (average in cm)

Length of skin flap (average in cm)

Indications

Complications

X

X

X

X

X

X

4

17

2.6

4.5

Forefoot

no

1

45

3.5

4

1

8

X

X

1

25

6

8

Distal plantar foot First plantar metatarsal head First plantar metatarsal head

no

no

no

2

71.5

5

7

1

52

3

5

4

24

2

3

2

37.5

4

7

Plantar 1 venous forefoot congestion First plantar metatarsal head no First plantar metatarsal 1 partial skin flap head and great necrosis due to toe venous congestion Plantar metatarsal head no

1

68

6

8

Medial forefoot

2

55

3.5

6

Plantar forefoot First plantar metatarsal head Fisrt dorsal metatarsal joint Plantar forefoot First plantar metatarsal head Plantar forefoot and great toe

1

53

4

5

Lateral forefoot

6

25

2,8

5,9

1

17

X

X

1

80

4.5

8

2

63 39 (380)

2,75

3.5

4 (2-6)

6 (2,5-9)

6

23.3

3.5

4.5

1

10

X

X

2

39

3

4

3

31.5

5.5

9

1

21

6

6.5

38

Forefoot First plantar metatarsal head First plantar metatarsal head

Forefoot

Comment

Microvascular interposition vein graft for venous congestion

1 partial skin flap necrosis Comittant vein 1 skin flap anastomoses with first necrosis due to plantar digital vein in 4 venous congestion cases

no

no no Venous congestion Venous congestion

1 venous congestion

Venous anastomosis for anterograde drainage Venous anastomosis for anterograde drainage with ALT free-flap

no

no

no 1 flap failure by arterial insuffisiency

8 events

27

Table 5: Complications rate and details according to input flow into the medial plantar flap. MPA flap Anterograde flow

Total complications 15/193 (7,8%)

Retrograde flow

8/43 (18,6%)

Detailed complications 2 venous congestions 8 partial skin necrosis 4 infections 6 venous congestions 1 arterial lack 1 Partial skin necrosis

MPA: Medial Plantar Artery

28