SLR - June 2018 - Virginia E. Parks
Reference: 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):200–208.Scientific Literature Review
Reviewed By: Virginia E. Parks, DPM
Residency Program: MedStar Washington Hospital Center, Washington, DC
Podiatric Relevance: Soft-tissue reconstruction of the plantar foot poses a unique challenge due to the limited availability and mobility of the adjacent skin and the need for like properties of thickness and sensitivity on weightbearing surfaces. These characteristics often preclude skin grafting and primary closure. The medial plantar artery perforator flap fulfills the plastic surgery principle to replace “like with like” tissue with minimal donor-site morbidity by harvesting the flap from the nonweightbearing surface of the “instep area” of the foot. The medial plantar artery perforator flap is defined as a perforator flap based on the superficial branch of the medial plantar artery. Additionally, this flap contains a sensory branch of the medial plantar nerve, which provides new sensation to the defect site.
Methods: This is a retrospective cases series of 28 patients who underwent plantar foot soft-tissue reconstruction with the medial plantar artery perforator flap between January 2003 and May 2016. The causes of soft-tissue defects included cancer resection in 18 cases, trauma in two cases and pressure ulcers in eight cases. The defects were located in the heel in 20 patients and in the middle plantar foot and forefoot in four patients. Preoperatively, a Doppler was utilized to detect the perforators of the superficial branch of the medial plantar artery and to confirm patency of the posterior tibial artery and dorsalis pedis artery. All flaps were harvested from the “instep” of the ipsilateral foot and transposed or rotated into the defect sites. Each donor site was closed with a split thickness skin graft.
Results: All but one of the flaps survived completely, yielding a success rate of 96 percent. One medial plantar artery perforator flap was lost due to poor vascular perfusion. The follow-up time ranged from four to 12 months with a mean of nine months. All donor sites were healed with a split thickness skin graft without complication. The author reports full return to function of all flap recipients as well as return to regular footwear and satisfactory cosmetic appearance.
Conclusions: The medial plantar artery perforator flap provides a viable option for reconstruction of small to medium plantar foot weightbearing surface defects. It is advantageous in that it replaces “like with like” soft tissue, which allows for a more functional foot and superior aesthetics. Additionally, this flap has the added potential of supplying new sensation to the site of the defect. However, it is important to select patients carefully and to confirm a patent posterior tibial artery, dorsalis pedis artery and perforators of the superficial branch of the medial plantar artery prior to surgery to maximize the likelihood of success. Therefore, many patients with diabetes and PAD will be less likely to be appropriate candidates for this procedure.