Instep free flap for plantar soft tissue reconstruction: Indications and options

Abstract

Pedicled instep flaps are frequently used in weight-bearing plantar reconstruction, but may not be available after severe foot injuries. Although free instep flaps offer a viable option, they have scarcely been reported. A posttraumatic plantar forefoot defect was reconstructed with a sensate, instep free flap, because local flaps were not available and defect size did not require a distant free flap, and the current literature was reviewed for therapeutic options. The instep free flap yielded an excellent functional and aesthetic long-term result. In the literature, pedicled instep flaps are advocated for moderate size defects of the weight-bearing heel and sole, while free flaps from distant sites are preferred for large defects. Although skin-grafted muscle flaps and fasciocutaneous flaps yield similar results, reconstruction by like tissues appears favorable. We suggest the instep free flap for weight-bearing plantar foot reconstruction, when pedicled instep flaps are not available and distant free flaps are avoidable.

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

“…In the case 1, although the defect was a candidate for a reverse medial plantar flap, we were concerned about the uncertainty of the venous drainage and felt safer to perform free flap reconstruction. In the case 2, the defect was 18 cm in length, which exceeded the conventional design of medial plantar flap [5]. The peroneal artery perforator (PAP) flap provided a thin and pliable skin [4].…”

“…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.…”

Reconstruction of Weightbearing Forefoot Defects with Digital Artery Flaps

“…Cross-foot instep island flaps can be used but have been associated with an uncomfortable prolonged immobilization and restrained position of the legs (15). A free instep flap could be a solution; however, its great complexity requires a well-experienced microsurgeon (16). The digital artery flap is another ideal alternative for a forefoot defect, because it has similar tissue.…”

Ein Behandlungsalgorithmus zur Weichteilrekonstruktion am Fuß und Sprunggelenk unter Berücksichtigung anatomischer und biomechanischer Gesichtspunkte

“…3, Reihe 2 und 3). Das Prinzip des Ersatzes von Fußsohlehaut durch Fußsohlehaut ("like replaces like") wurde vielfach publiziert und auch bewertet [1,2,40]. Modifikationen und Erweiterung der Anwendung als distal gestielte Lappenplastik machen diese Option umso wertvoller [9,13, 32] und relevant für die Zonen P2 und MT1-5, auch wenn bei der Anwendung dieser neurovaskulären Insellappen- [29,30,35,41].…”