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Abstract

Background

The medial plantar artery perforator (MPAP) flap is widely used to reconstruct the weight-bearing area of the foot. Traditionally, its donor site is closed using a skin graft, which is associated with several complications, including walking disability. This study aimed to examine our experience with using a super-thin anterolateral thigh (ALT) flap to reconstruct the MPAP flap donor site.

Methods

We examined 10 patients who underwent reconstruction of the MPAP flap donor site using a super-thin ALT flap between August 2019 and March 2021. The vascular pedicle was anastomosed to the proximal end of the medial plantar vessels or the end of the posterior tibial vessels.

Results

All reconstruction flaps survived and all patients were satisfied with the aesthetic appearance. No blisters, ulcerations, hyperpigmentation, or contractures occurred. All patients gained protective sensation in the super-thin ALT flap. The average visual analog scale score for the aesthetic appearance of the reconstructed foot was 8.5 ± 0.7 (range, 8–10). All patients were able to ambulate without aids and could wear regular shoes. The average revised Foot Function Index score was 26.4 ± 4.1 (range, 22–34).

Conclusion

Reconstruction of the MPAP flap donor site using a super-thin ALT flap is reliable and provides satisfactory functional recovery, aesthetic appearance, and protective sensation while minimizing postoperative morbidity.

Keywords

Anterolateral thigh flap super-thin flap perforator flap medial plantar artery flap plantar reconstruction

Introduction

The medial plantar artery perforator (MPAP) flap is widely used to reconstruct the weight-bearing area of the foot and provides stable, durable, and sensate coverage.^1–4 However, direct closure of the donor site is frequently not possible because of poor laxity and mobility of surrounding glabrous skin. Traditionally, the donor site is covered by a split or full thickness skin graft.^5,6 Exposure of the plantar aponeurosis after flap harvesting increases the risks of skin graft failure and delayed wound healing.^7,8 After skin grafting, depression deformity, hyperpigmentation, medial plantar contracture, skin hyperkeratosis, and walking disability may occur.⁹ Furthermore, local nerve irritation may occur if skin grafting is performed directly over the exposed medial plantar nerve and its branches.⁷ An approach to MPAP flap donor site closure with better aesthetic and functional outcomes is needed. The ideal method of reconstruction for defects of the weight-bearing area of the foot should not only reconstruct the defect properly, but also minimize donor site morbidity.^10,11

The super-thin anterolateral thigh (ALT) flap has gained recent popularity in extremity reconstruction surgery.^12–14 This flap is elevated above the superficial fascial plane and has the advantage of providing satisfactory aesthetic reconstruction in one stage, as a secondary defatting procedure is avoided. This study aimed to examine our experience with using the super-thin ALT flap to reconstruct the MPAP flap donor site.

Patients and methods

Ten patients underwent MPAP flap reconstruction of the sole of the foot followed by super-thin ALT flap reconstruction of the MPAP flap donor site in our institution between August 2019 and March 2021. Eight patients were men and two were women. Mean patient age was 49.10 ± 11.54 years (range, 32–66). The indication for reconstruction was crush or avulsion injury in eight patients and foot ulceration in two. Location of defect was forefoot in six patients, mid- and forefoot in one, and heel in three.

The plantar forefoot defect was repaired using a reversed MPAP flap. The heel defect was reconstructed using a contralateral free MPAP flap because the ipsilateral instep area was injured. The plantar mid- and forefoot defect was reconstructed using a contralateral MPAP flap for the forefoot defect and a contralateral ALT flap for the midfoot defect. All MPAP flap donor sites were repaired using super-thin ALT flaps. Patient characteristics are shown in Table 1. This study received institutional review board approval and was performed in accordance with the principles of the Declaration of Helsinki.

Table 1.

Details of all cases.

No.	Age/sex	BMI kg/m²	Etiology	Location of defects	Flap patten	Size of MPAP flap, cm²	Size of super-thinALT flap, cm²	Thickness of super-thin ALT flap, mm	Complications	VAS score for the aesthetic appearance	Patient’s satisfaction	FFI-R score
1	56/M	27.5	Ulcer	Left plantar heel	Free contralateral MPAP flap	8 × 6	8 × 6	5	ALT flap donor site haematoma	8	Very satisfied	34
2	47/M	27.7	Crush injury	Right plantar forefoot	Reverse MPAP flap	7 × 7	9 × 7	5	N/A	9	Very satisfied	26
3	66/M	19.2	Crush injury	Left plantar forefoot	Reverse MPAP flap	8 × 7	9 × 7	5	N/A	8	Satisfied	32
4	32/M	18.7	Crush injury	Right plantar forefoot	Reverse MPAP flap	6 × 4	7 × 4	4	N/A	8	Satisfied	22
5	32/M	36.4	Avulsion injury	Left plantar mid-and forefoot	Free contralateral MPAP flap	10 × 6	11 × 6	4	N/A	8	Satisfied	23
6	62/M	19.8	Crush injury	Left plantar forefoot	Reverse MPAP flap	8 × 5	9 × 5	3	N/A	8	Very satisfied	24
7	57/F	26.3	Avulsion injury	Right plantar forefoot	Reverse MPAP flap	6 × 5	7 × 5	4	N/A	9	Satisfied	22
8	46/M	28.4	Avulsion injury	Right plantar forefoot	Reverse MPAP flap	6 × 6	7 × 6	4	N/A	8	Satisfied	28
9	43/F	25.3	Ulcer	Left plantar heel	Free contralateral MPAP flap	6 × 4	7 × 4	4	N/A	10	Very satisfied	26
10	50/M	22.4	Avulsion injury	Left plantar heel	Free contralateral MPAP flap	9 × 6	10 × 6	4	N/A	9	Very satisfied	27

Preoperative imaging evaluation

All patients had preoperative x-rays of the injured foot. Firstly, the wounds underwent radical debridement. After the condition of the wounds had stabilized and no infections had intervened, all patients underwent multi-detector row computed tomography angiography before surgery to examine the status of the posterior tibial artery and its two major branches and identify the location of the perforator of the ALT flap. High-frequency color duplex ultrasonography was used to detect the course of the perforator in the adipose layer. The exit point in the deep fascia and the dermis entry point were marked on the skin before surgery.

The exclusion criteria including: (1) terrible lacerations of the lower extremity which may affect distal blood vessels, (2) severe atherosclerosis of the lower extremity vessels, (3) severe diabetes, (4) locally advanced malignant tumors, (5) lower limb malformation, (6) major comorbidities, such as cardiopulmonary, advanced liver disease or other diseases which are not suitable for surgery, (7) extensive plantar defect which cannot be repaired by MPAP solely.

Surgical procedure

The MPAP flap and super-thin ALT flap were designed based on the patient’s defect and perforator location. Two teams worked simultaneously during the operation: one harvested the MPAP flap while the other raised the super-thin ALT flap. The MPAP flap was elevated using a previously described method for coverage of the weight-bearing area of the foot.²

The super-thin ALT flap was harvested using Hong’s method.^15–17 Briefly, the lower and medial incision was made first at the level of the superficial fascia, separating the superficial adipose layer from the deep adipose layer. The flap was then elevated along this plane to identify the perforator. Meticulous hemostasis was maintained, as bleeding during dissection can cause difficulty with identifying tiny perforators. Once the perforator was found, dissection was continued towards the source vessel until a pedicle of sufficient length was obtained. If necessary, primary flap defatting was performed in the superficial adipose layer of the flap periphery. After flap circulation was confirmed, the pedicle was divided and the super-thin ALT flap was transferred to the MPAP flap donor area. The vascular pedicle was anastomosed to the proximal end of the medial plantar vessels or the end of the posterior tibial vessels. If the lateral plantar artery was divided during MPAP flap harvesting, the distal end of the ALT flap pedicle was anastomosed to the lateral plantar artery to restore continuity (Figure 1(a) and (b)).

Figure 1.

Illustrations of super-thin ALT flap transfer for MPAP flap donor site. (a) Reversed MPAP flap for the ipsilateral plantar forefoot defect. The vascular pedicle of the super-thin ALT flap is anastomosed to the proximal end of the medial plantar vessels. (b) Free MPAP flap for the contralateral plantar defect. The proximal end of the ALT flap pedicle is anstomosed to the medial plantar vessels or the posterior tibial vessels, for the latter one, the distal end of the pedicle is anastomosed to the lateral plantar artery to restore continuity.

Postoperative management and rehabilitation

A standard postoperative protocol that included antibiotics, anticoagulation, and promotion of circulation was implemented in all patients. Patients were maintained on bed rest with foot elevation for 1 week. The ankle was immobilized with a plaster cast in mild plantar flexion for 2 weeks. The patient was then asked to perform daily functional exercises that gradually progressed from dangling exercises without weight bearing to partial weight bearing at 4 weeks. Full weight-bearing rehabilitation exercises commenced at 6 weeks.

Figure 2.

A 43-year-old female (case 9) was referred for treatment of an unstable scar on the left plantar heel that resulted from a degloving injury 10 years previously. After debridement and vacuum-assisted treatment, a contralateral medial plantar artery perforator (MPAP) flap was planned for reconstruction of the heel. (a) The soft tissue defect was 6 cm × 4 cm after debridement. (b) The donor site defect after MPAP flap harvesting exposed the digital nerve of the medial side of the great toe and a portion of the plantar aponeurosis. (c) A super-thin anterolateral thigh (ALT) flap measuring 7 cm × 4 cm was designed to cover the MPAP flap donor site. (d) The thickness of the super-thin ALT flap was 4 mm. (e) Immediate result after super-thin ALT flap insetting. (f) Appearance at the donor and recipient sites 14 months after surgery.

Figure 3.

A 47-year-old male (case 2) with a right foot crush injury experienced traumatic amputation of four toes and had a plantar forefoot soft tissue defect. (a) Design of the reversed medial plantar artery perforator (MPAP) flap. (b) and (c) The MPAP flap was 7 cm × 7 cm in size. (d) A super-thin anterolateral thigh (ALT) flap measuring 9 cm × 7 cm was designed to cover the MPAP flap donor site. (e) The thickness of the ALT flap was 5 mm. Its pedicle was anastomosed to the proximal stump of the medial plantar vessels. (f) Appearance 15 months after surgery showed good contours at the donor and recipient sites.

Outcomes

Donor site complications, flap contour, ulcer formation, and sensory recovery were evaluated during clinical follow-up. A visual analog scale score was used to assess the cosmetic appearance of the flap, with zero indicating the worst cosmetic outcome and 10 indicating the best. Foot function was evaluated using the revised Foot Function Index (FFI) scoring system, which ranges from 20 (no difficulty) to 80 (severe difficulty).¹⁸

Results

Super-thin ALT flap for reconstruction of the MPAP donor-site was successful in all 10 patients. Mean body mass index was 25.17 ± 5.41 kg/m² (range, 18.7–36.4). The size of the MPAP flap donor sites ranged from 6 cm × 4 cm–10 cm × 6 cm; accordingly, the size of the super-thin ALT flaps ranged from 7 cm × 4 cm–11 cm × 6 cm. The average super-thin ALT flap thickness was 4.20 ± 0.63 mm (range, 3–5). All ALT flap donor sites were directly closed. The total operative time was 255–420 min (average, 372 min).

All flaps survived completely after reconstruction without partial necrosis or venous congestion. In one patient, a haematoma occurred in the ALT flap donor site on postoperative day 5, which was evacuated at bedside; the MPAP flap donor site healed primarily without complication. Mean follow-up was 13 months, (range, 12–15). The appearance of the super-thin ALT flap was satisfactory without excessive bulk in all patients. No patient required secondary debulking for cosmetic or shoe wear reasons. No blisters, ulcerations, hyperpigmentation, or contractures occurred. All patients gained protective sensation in the super-thin ALT flaps. Other than the hematoma reported above, no donor site complications were noted. All ALT donor sites healed with an aesthetically acceptable linear scar. Mean visual analog scale score for aesthetic appearance of the reconstructed foot was 8.5 ± 0.7 (range, 8–10). All patients were able to ambulate without aid and could wear regular shoes. Mean revised Foot Function Index score was 26.4 ± 4.1 (range, 22–34). (Figures 2 and 3)

Discussion

The MPAP flap is widely used for reconstruction of the weight-bearing area of the foot and provides excellent results.^2,6,19 Although donor site morbidity is minimal, skin grafting of the donor site can result in complications^4,20–23 including depression deformity, hyperpigmentation, medial plantar contracture, hyperkeratosis, and walking disability.^7,24 The grafted area is not robust with thick skin and may not withstand the shear and stress forces to which it is exposed on a daily basis.²⁵ Moreover, direct skin grafting of the plantar aponeurosis increases the potential for graft loss. In the distal part of the donor site, the medial plantar nerve branches are often exposed; skin grafting directly over the nerve can cause sensory disturbance or nerve irritation.^26,27 Paget et al. demonstrated that skin grafting in the foot instep causes significant pressure changes in the great toe and heel and a 39.1% decrease in Foot Function Index score; they also reported nerve pain at the donor site.²⁸ Another study reported pigmentation and cicatricial contracture at the donor site, which might impact aesthetics and function.²¹ For these problems, using a second flap to minimize morbidity associated with the MPAP flap donor site is ideal.

The ALT flap is a workhorse soft tissue flap for various defects throughout the body that can be used for instep coverage. However, the traditional flap is too thick and bulky for this location. Another option is the super-thin ALT flap, which uses the superficial fascia as the dissection plane.^12,14 This modified flap can provide a satisfactory aesthetic appearance and avoids the need for a secondary defatting procedure. We do not use this thin flap in the reconstruction of weight-bearing region defects directly, because the thin flap is not robust compared to the MPAP flap. It may not be able to withstand the shear and pressure forces which it is subjected to on a daily basis. We suggest the weight-bearing region should be reconstructed by ‘like with like’. So, we consider the super-thin ALT flap is suitable as the secondary flap for the MPAP flap donor site. To the best of our knowledge, MPAP flap donor site reconstruction using the super-thin ALT flap has not been previously reported.

In our study, the soft tissue defect of the weight-bearing area of the foot was reconstructed using a MPAP flap and the MPAP flap donor site was repaired using a super-thin ALT flap, all in one stage. A secondary defatting procedure was not required in any patient. This method minimized MPAP flap donor-site morbidity and enabled primary healing of the donor site without delay, which enhances patient recovery. The appearance of the super-thin ALT flap reconstruction was full and without hyperpigmentation. Furthermore, this method eliminates the risk of nerve irritation related to skin grafting. One stage reconstructive surgery reduced patient pain and financial burden.

No major complications occurred in our patients. The mean thickness of our super-thin ALT flaps was approximately 4.2 mm, which is a thickness well-suited for instep area defects. The super-thin ALT flap provided satisfactory aesthetic recovery to the foot as well, as all visual analog scale scores were eight or higher. Although the nerve of the ALT flap was not coapted, the sensory nerve branches from the wound bed can grow into the flap because the flap is thin and has good blood supply. Protective sensation was observed in the reconstructed instep area in all 10 patients. We use caliper type two-point discriminator to test the two-point discrimination of the super-thin flap. The patients can perceive the touching, but cannot accurately distinguish between two points. Another key advantage of the super-thin ALT flap technique is the ability to reconstitute the continuity between the posterior tibial artery and its lateral plantar branch if required.^4,29 Although using a free super-thin ALT flap for MPAP flap donor site reconstruction certainly increases operative time and technical difficulty, the overall increase in operative time is insignificant provided that two surgical teams are utilized. We have to admit that this is one of the drawbacks of our approach.

We suggest that this technique can be mainly applied in patients whose proximal medial plantar or posterior tibial artery must be divided during harvesting of the MPAP flap, and the proximal vessel stumps can be used for recipient vessels. For those whose MPAP flap transfer is based on an antegrade pedicle, such as ipsilateral MPAP flap transfer to the plantar heel, it is feasible to anastomose the ALT pedicle to the posterior tibial artery in an end-to-side manner.

There are several limitations to this study. First of all, it is a small-sample retrospective study. There was also no control group in which the traditional skin graft was used for the donor site of MPAP flap. And vascular anastomosis requires excellent surgical skills. Furthermore, postoperative vascular crisis is worthy of attention in the reconstruction procedure.

Conclusion

Footnotes

Author contributions

Jian-dong Zhou wrote the manuscript and performed the data collection. Xing-fei Zhang and Tong-long Xu provided advises of modification. Wen-bo Yang performed the data analysis. Ya-jun Xu provided the main design of this study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Research Program of Wuxi Health Commission (grant M202156).

ORCID iDs

Wen-bo Yang

Ya-jun Xu

References

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Super-thin anterolateral thigh flap for reconstruction of the medial plantar artery perforator flap donor site

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Patients and methods

Preoperative imaging evaluation

Surgical procedure

Postoperative management and rehabilitation

Outcomes

Results

Discussion

Conclusion

Footnotes

Author contributions

Declaration of conflicting interests

Funding

ORCID iDs

References