Free sensate medial plantar flap for contralateral plantar forefoot reconstruction with flap reinnervation using end‐to‐side neurorrhaphy: A case report and literature review

Abstract

Reconstruction of weight-bearing plantar defects remains a challenge due to the unique characteristics of the plantar skin and thus the limited available options. The medial plantar flap, either pedicled or free, represents an ideal option, but its use as sensate flap for forefoot defects has been scarcely reported. We present a case of plantar forefoot reconstruction with a free sensate medial plantar flap, with end-to-side coaptation of the cutaneous sensory fascicles of the flap to the medial plantar nerve of the recipient. Last follow-up, at 2 years post-op, verified a very good functional and aesthetic outcome, indicating that the suggested approach may prove the treatment of choice in selected cases of plantar forefoot reconstruction.

An Algorithm for Forefoot Reconstruction With the Innervated Free Medial Plantar Flap

“…Despite the many benefits, few free plantar flap series are reported in the literature, and there are even fewer reported for forefoot reconstruction. [11][12][13][14][15]26 At the time of writing, no case of ipsilateral free plantar flap reconstruction has been reported for forefoot reconstruction, though one was recently described for great toe pulp reconstruction in a young boy. 27 When the ipsilateral instep is available, it should be used to spare the healthy foot and facilitate postreconstructive mobility.…”

“…[11][12][13][14][15] Viscoelasticity of medial plantar skin is comparable to the forefoot; a specialized fat plane and fibrous septal attachments distribute shear forces in healthy patients. 16,17 Increased peak loading pressures and skin stiffness in the diabetic forefoot may predispose to trophic ulcers; relative pliability of medial forefoot skin may improve shear stress distribution.…”

Anatomic basis and clinical application of the distally based medialis pedis flaps

“…Anatomic studies concerning the vascular supply of the medial aspect of the foot were performed to provide plastic surgeons with a new alternative for forefoot reconstruction [14,29,38,48,49].…”

The Lateral Plantar Artery as Recipient Vessel for Microsurgical Lateral Plantar Forefoot Reconstruction: Case Report

“…When the defect is large (>100 cm2) or the foot is severely traumatized, a reconstruction with free flaps is indicated [16]. Although the best flap type has not yet been determined, the instep flap, due to its similar viscoelasticity to the plantar forefoot skin, is undoubtedly the first choice [2,5,16,17] Thin perforator flap (< 6 mm in thickness), composed of small fat lobules invested by dense fibrous septa allowing less gliding, is another optimal choice [4,7]. Furthermore, sensate coverage is available by including branch of medial plantar nerve with the medial plantar flap, which is crucial for plantar defect reconstruction.…”

“…With the advent of microsurgical techniques, free flaps become more and more popularly employed in plantar forefoot reconstruction [1][2][3][4][5][6][7]. Although the choice of an optimal flap is very important, the selection of appropriate recipient vessels is also equally crucial.…”