Clin Orthop Surg.  2010 Dec;2(4):244-249. 10.4055/cios.2010.2.4.244.

Soft Tissue Reconstruction of the Foot Using the Distally Based Island Pedicle Flap after Resection of Malignant Melanoma

• Kang HG
• Kim JH
• Cho HS
• Han I
• Oh JH
• Kim HS

• KMID: 1719326
• DOI: http://doi.org/10.4055/cios.2010.2.4.244

Abstract

BACKGROUND
We report on our experience with using a distally based island flap for soft tissue reconstruction of the foot in limb salvage surgery for malignant melanoma patients.
METHODS
A distally based sural flap was used for 10 cases for the hindfoot reconstruction, and a lateral supramalleolar flap was used for 3 cases for the lateral arch reconstruction of the mid- and forefoot after wide excision of malignant melanomas.
RESULTS
The length of the flap varied from 7.5 cm to 12 cm (mean, 9.6 cm) and the width varied from 6.5 cm to 12 cm (mean, 8.8 cm). Superficial necrosis developed in four flaps, but this was successfully treated by debridement and suture or a skin graft. All thirteen flaps survived completely and they provided good contour, stable and durable coverage for normal weight bearing.
CONCLUSIONS
The distally based sural flap is considered to be useful for reconstructing the hindfoot, and the lateral supramalleolar flap is good for reconstructing the lateral archs of the mid- and forefoot after resection of malignant melanoma of the foot.

Keyword

Malignant melanoma; Distally based sural flap; Lateral supramalleolar flap

MeSH Terms

Adult
Aged
Female
Foot/*surgery
Foot Diseases/*surgery
*Free Tissue Flaps
Humans
Limb Salvage
Male
Melanoma/*surgery
Middle Aged
Reconstructive Surgical Procedures/methods
Skin Neoplasms/*surgery

Figure

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  Fig. 1 Case 3. (A) The patient was referred from a regional hospital with a pathologic report of malignant melanoma on the heel. (B) After wide excision, an 8 × 8 cm defect was present. (C) The sural flap pedicle contains the sural artery and nerve and lesser saphenous vein. (D) The pivotal point of the pedicle is three fingers breadth proximal to the tip of the lateral malleolus. (E, F) A delayed full thickness skin graft on the flap donor site and an opened pedicle tunnel were performed with concomitant ipsilateral inguinal lymph node dissection at the time of skin harvest at 15 days postoperatively.

• 

  Fig. 2 Case 5. (A) Malignant melanoma with ulceration was confirmed through biopsy at a regional hospital. (B) Wide excision resulted in a 12 × 9 cm defect on the lateral arch of the mid and lateral foot. (C) The skin paddle is designed according to the arterial anastomotic arcade of the ankle. (D) The lateral supramalleolar flap pedicle contains the superficial peroneal nerve and the perforating branch of the peroneal artery that anastomoses with the anterior lateral malleolar artery, and it continues into the foot and then it anastomoses with the lateral tarsal artery. (E) Flap transposition and suture of the pedicle tunnel were performed after placing indwelling drains. (F) Temporary trans-ankle joint pinning is shown. (G) Superficial necrosis of the flap developed, which may have been caused by the initial pedicle tunnel closure, but this was successfully treated by debridement and a full thickness skin graft. (H) The photograph was taken at 10 months postoperatively, and the lateral contour of the foot has been well restored.

Reference

1. Sommerlad BC, McGrouther DA. Resurfacing the sole: long-term follow-up and comparison of techniques. Br J Plast Surg. 1978. 31(2):107–116.

2. Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast Reconstr Surg. 2002. 109(2):583–591.

3. Kneser U, Bach AD, Polykandriotis E, Kopp J, Horch RE. Delayed reverse sural flap for staged reconstruction of the foot and lower leg. Plast Reconstr Surg. 2005. 116(7):1910–1917.

4. Demiri E, Foroglou P, Dionyssiou D, et al. Our experience with the lateral supramalleolar island flap for reconstruction of the distal leg and foot: a review of 20 cases. Scand J Plast Reconstr Surg Hand Surg. 2006. 40(2):106–110.

5. Voche P, Merle M, Stussi JD. The lateral supramalleolar flap: experience with 41 flaps. Ann Plast Surg. 2005. 54(1):49–54.

6. May JW Jr, Rohrich RJ. Foot reconstruction using free microvascular muscle flaps with skin grafts. Clin Plast Surg. 1986. 13(4):681–689.

7. Clark N, Sherman R. Soft-tissue reconstruction of the foot and ankle. Orthop Clin North Am. 1993. 24(3):489–503.

8. Ferreira MC, Besteiro JM, Monteiro Junior AA, Zumiotti A. Reconstruction of the foot with microvascular free flaps. Microsurgery. 1994;15(1):33-6. 15(1):33–36.

9. Balch CM, Buzaid AC, Soong SJ, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol. 2001. 19(16):3635–3648.

10. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region: a preliminary report. Scand J Plast Reconstr Surg. 1983. 17(3):191–196.

11. Hasegawa M Jr, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap. Plast Reconstr Surg. 1994. 93(5):1012–1020.

12. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg. 1992. 89(6):1115–1121.

13. Torii S, Namiki Y, Mori R. Reverse-flow island flap: clinical report and venous drainage. Plast Reconstr Surg. 1987. 79(4):600–609.

14. Masquelet AC Jr, Beveridge J, Romana C, Gerber C. The lateral supramalleolar flap. Plast Reconstr Surg. 1988. 81(1):74–81.

15. Tan O Jr, Atik B, Bekerecioglu M. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap. Microsurgery. 2005. 25(1):36–43.

16. Langstein HN, Chang DW, Miller MJ, et al. Limb salvage for soft-tissue malignancies of the foot: an evaluation of freetissue transfer. Plast Reconstr Surg. 2002. 109(1):152–159.

17. Dubois RW Jr, Swetter SM, Atkins M, et al. Developing indications for the use of sentinel lymph node biopsy and adjuvant high-dose interferon alfa-2b in melanoma. Arch Dermatol. 2001. 137(9):1217–1224.