SLR - March 2017 - Meredith Ward
Reference: Wu H, Sheng JG, Zhang CQ; Free Medial Plantar Flap Connection with a Posterior Tibial Artery Flap in Reconstruction of Fore–Mid Foot Skin Defect. Plast Reconstr Surg Glob Open. 2016 Nov 28; 4(11)e1091.Scientific Literature Review
Reviewed By: Meredith Ward, DPM
Residency Program: St. Francis Hospital and Medical Center, Hartford CT
Podiatric Relevance: Patients presenting with loss of tissue and skin from the forefoot can be difficult to manage using local flaps or skin grafting. Skin grafting is not a permanent solution for weightbearing surface, and local flaps are limited size-wise. The purpose of this article was to present a free posterior tibial artery flap in connection with a medial plantar artery flap to repair a large forefoot skin defect across a weightbearing surface.
Methods: This article presents the anatomic design and methods used to harvest and implant a free posterior tibial artery flap as well as a medial plantar artery flap on a 43-year-old patient. The free flaps were obtained from the contralateral limb using careful anatomic dissection and were implanted over the defect, care taken to anastomose the vessels of the dorsal foot to the free flap vasculature. The defect from the graft harvest site was covered with split thickness skin grafts.
Results: One patient, a 43-year-old male who had a traumatic forefoot injury, was followed in this case. The patient initially had significant tissue loss with exposed metatarsal, dorsal and plantar tendons. He underwent flap placement following partial forefoot amputation and healed well. He was followed for seven years, and in that time, the flap showed good texture, weightbearing capacity, sensation and integration into the plantar forefoot. The donor site also showed adequate skin coverage. The patient remains active without discomfort to either foot and has no problems with his daily activities.
Conclusions: Free flaps can offer more expansive coverage to large pedal injuries. However, this does not come without risk to the donor site or without risk of vasculature or nerve damage at the time of harvest/implantation. The connected flap presented in this article offers a larger skin coverage ability for a healthy, vascularly intact patient. This is a flap that we could use for some of our traumatic injuries to the distal foot, which require extensive skin coverage. The patient must be aware that extensive recovery and scarring to bilateral lower extremities would result from this surgery, as well as the possibility of flap failure.