Author(s): Owais Ahmed,1 Sobia Yasmeen,2 Imran Khan,3 Farkhandah Muhammad Iqbal,4 Mirza Shehab Afzal Beg,5 Zenab Shahzad6 et al
Pages: 7-11 | DOI: https://doi.org/10.5455/pjps.m20241201.573348
Background: Heel defect has remained a challenging situation for reconstructive surgeons. In large post traumatic defects, the goal is to provide a sensate and stable soft tissue coverage, especially for the weight- bearing part of the heel. The paucity of local tissue options makes the scenario difficult to deal with.
Objective: This study is aimed to reconstruct large defect, involving both the weight-bearing and non- weight-bearing part of the heel by combining two regional flaps.
Methodology : A retrospective study, comprising of 11 patients from January 2016 to December 2019 with large traumatic heel defects, operated in our setup with combined medial plantar and reverse sural artery flap within 72 hours of injury. Follow up period was 6 months postoperatively.
Results: All flaps survived well except one reverse sural flap, which was congested and later debrided and 2 had distal edge necrosis which were managed conservatively. All the reverse sural flaps were noted to have lymphedema, but only 3 patients opted for debulking surgery. The functional outcome was excellent, with all the patients being able to walk normally, both barefoot and with footwear. The weight-bearing area was sensate, a clear advantage of utilizing instep skin.
Conclusion: In our experience, the combined strategy of utilizing local tissue for large heel defects, not only provides a sensate, stable, and reliable coverage but also avoids the lengthy procedure of free tissue transfer that in the end would not be able to give similar results.
Keywords | Complex heel defects, Sural flap, Medial plantar flap.
1. Yücel A, Senyuva C, Aydin Y, Cinar C, Güzel Z. Soft- tissue reconstruction of sole and heel defects with free tissue transfers. Ann Plast Surg. 2000;44(3):259-68; discussion 268-9.
2.Duman H, Er E, Işík S, Türegün M, Deveci M, Nişancí M, Sengezer M. Versatility of the medial plantar flap: our clinical experience. Plast Reconstr Surg. 2002; 109 (3):1007-12.
3. Uysal AC, Uraloglu M, Orbay H, Ortak T, Sensoz O. An alternative method of vein anastomosis with fibrin glue. Ann Plast Surg.
4. Roblin P, Healy CM. Heel reconstruction with amedial plantar V-Y flap. Plast Reconstr Surg. 2007;119(3): 927-32.
5. Sommerlad BC, McGrouther DA. Resurfacing the sole: long-term follow-up and comparison of techniques. Br J Plast Surg. 1978;31(2):107-16.
6. Valenti P, Masquelet AC, Romana C, Nordin JY. Tech- nical refinement of the lateral supramalleolar flap. Br J Plast Surg. 1991;44(6):459-62.
7. Khan FH, Beg MSA, Obaid-Ur-Rahman. Medial Plantar Artery Perforator Flap: Experience with Soft-tissue Coverage of Heel. Plast Reconstr Surg Glob Open. 2018 14;6(12):e1991.
8. Masquelet AC, Romana MC. The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg. 1990; 85(5):765-72.
9. Mahmoud WH. Foot and Ankle Reconstruction Using the Distally Based Sural Artery Flap Versus the Medial Plantar Flap: A Comparative Study. J Foot Ankle Surg. 2017;56(3):514-518.
10. Zheng L, Zheng J, Dong ZG. Reverse sural flap with an adipofascialextensionfor reconstruction of soft tissue defects with dead spaces in the heel and ankle. Eur J Trauma Emerg Surg. 2016;42(4):503-511.
11. Sugg KB, Schaub TA, Concannon MJ, Cederna PS, Brown DL. The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction. Plast Reconstr Surg Glob Open. 2015 22;3(9):e519.
12. Mojallal A, Wong C, Shipkov C, Bailey S, Rohrich RJ, Saint-Cyr M, Brown SA. Vascular supply of the distally based superficial sural artery flap: surgical safe zones based on component analysis using three-dimen- sional computed tomographic angiography. Plast Re- constr Surg. 2010;126(4):1240-1252.
13. Imanishi N, Nakajima H, Fukuzumi S, Aiso S. Venous drainage of the distally based lesser saphenous-sural veno-neuroadipofascial pedicled fasciocutaneous flap: a radiographic perfusion study. Plast Reconstr Surg. 1999;103(2):494-8.
14. Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg. 2003;112(1):129-40; discussion 141-2
15. Langat AS, Wan Sulaiman WA, Mat Johar SFN. Heel Pad Reconstruction With Medial Plantar Flap. Cureus. 2021 19;13(3):e13987.
16. Benito-Ruiz J, Yoon T, Guisantes-Pintos E, Monner J, Serra-Renom JM. Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps. Ann Plast Surg. 2004;52(4):380-4.
17. Goil, Pradeep, Pankaj Sharma, Manojit Midya, and Gautam Prakash. “The lateral supramalleolar flap: a reliable option for lower leg and foot reconstruction.” Int J Res Orthop 4, no. 5 (2018): 715-19.
18. McCraw JB, Furlow LT Jr. The dorsalis pedis arteria- lized flap. A clinical study. Plast Reconstr Surg. 1975; 55(2):177-85.
19. Grabb WC, Argenta LC. The lateral calcaneal artery skin flap (the lateral calcaneal artery, lesser saphenous vein, and sural nerve skin flap). Plast Reconstr Surg. 1981;68(5):723-30.
20. Furukawa M, Nakagawa K, Hamada T. Long-term complications of reconstruction of the heel using a digitorum brevis muscle flap. Ann Plast Surg. 1993; 30(4):354-8.
21. Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg. 1979;64(3):295-8
22. Sharma RK, Parashar A, Makkar SS. Split clavicular myoosseous flap for laryngotracheal reconstruction. Ann Plast Surg. 2007;58(3):347; author reply 347.
23. Shaw WW, Hidalgo DA. Anatomicbasis of plantar flap design: clinical applications. Plast Reconstr Surg. 1986; 78(5):637-49.
24. Wright TC, Mossaad BM, Chummun S, Khan U, Chap- man TW. Proximally pedicled medial plantar flap based on superficial venous system alone for venous drainage. J Plast Reconstr Aesthet Surg. 2013;66(7):e201-4.
25. Wu H, Sheng JG, Zhang CQ. Free Medial Plantar Flap Connectionwitha Posterior Tibial Artery Flap in Recon- struction of Fore-Mid Foot Skin Defect. Plast Reconstr Surg Glob Open. 2016 28;4(11):e1091.
26. Tan O, Atik B, Bekerecioglu M. Supercharged reverse- flow sural flap: a new modificationincreasing the relia- bility of the flap. Microsurgery. 2005;25(1):36-43.
27.Uygur F, Duman H, Ulkür E, Noyan N, Celiköz B. Reconstruction of distal forefoot burn defect with retro- grade medial plantar flap. Burns. 2008;34(2):262-7.
28.Benito-Ruiz J, Yoon T, Guisantes-Pintos E, Monner J, Serra-Renom JM. Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps. Ann Plast Surg. 2004;52(4):380-4.
29. Siddiqi MA, Hafeez K, Cheema TA, Rashid HU. The medial plantar artery flap: aseries of cases over 14 years. J Foot Ankle Surg. 2012;51(6):790-4.
All published material becomes the sole property of the Pakistan Journal of Plastic Surgery, copyrighted by the Pakistan Association of Plastic Surgeons (PAPS). By submitting an article or brief communication, all authors agree to these conditions.
During the submission process, all authors have required to complete a copyright transfer agreement, “Author Consent form” By completing the copyright transfer agreement, you are transferring copyright of figures, tables, videos, and the content of the manuscript to the Pakistan Association of Plastic Surgeons (PAPS).
If you do not wish to or cannot transfer copyright of some or all of your content, please contact the editorial office at pjpspakistan@gmail.com.