Reply: Reconstruction of the Heel, Middle Foot Sole, and Plantar Forefoot with the Medial Plantar Artery Perforator Flap: Clinical Experience with 28 Cases.

Abstract

Sir: We would like to thank Dr. Agko and colleagues for their interest in our recent article entitled “Reconstruction of the Heel, Middle Foot Sole, and Plantar Forefoot with the Medial Plantar Artery Perforator Flap: Clinical Experience with 28 Cases.”1 We substantially agree with the issues raised by the authors, and just a few additional comments are necessary. First, it is true that Orbay and colleagues in their cadaver study2 had already reported the presence of “three or four septocutaneous branches of the medial plantar artery coursing in a septum between the flexor digitorum brevis and abductor hallucis muscle” and we can understand that the statement in our article may have sounded a little pretentious to the readers. However, it is worth noting that Orbay et al. did not provide any additional information other than proving their simple existence. Neither the branch of the medial plantar artery from which they originate (the superficial branch of the medial plantar artery), nor their point of origin or caliber, nor their relevance or selection process in the clinical context are reported in their work. To be exact, in our affirmation, we specified that the number of “suitable” perforators and “their caliber” have not been (previously) described. The “suitability” of a given perforator is to us, from an operative perspective in the clinical context, something considerably different from the mere, decontextualized, presence of a specific vessel or set of vessels in a cadaver study. For this reason, we simply did not mean to take the credit for the discovery of a new anatomical entity that had already been recognized even approximately 20 years before Orbay et al.3 Regarding the second observation made by Agko et al., there is not much we can say other than thanking the authors for pointing out the inaccuracy and clarifying once more the correct terminology related to this complex anatomical region. Dr. Agko et al., in turn, in commenting on our article, state “the deep branch [of the medial plantar artery] courses deep and medial to the abductor hallucis muscle.” The deep branch of the medial plantar artery lies, as far as we know, deep and lateral to the abductor hallucis muscle. A gentle retraction of the muscle is in fact necessary to visualize the vessel that courses between the muscle and the bony margin. Dr. Colen, in the discussion section to our article,4 referring to the medialis pedis flap, mistakenly states that “it is nourished by a lateral branch of the deep medial plantar artery,” that is, indeed nourished by the medial branch of the deep branch.3 This shows once more how, regarding this specific topic, the chances of misspelling and confusion lurk everywhere, and we should pay additional attention in double-checking our articles. DISCLOSURE The authors have no financial conflicts or commercial associations to disclose in relation to the content of this communication. Alberto Franchi, M.D.Mario F. Scaglioni, M.D.Department of Plastic and Hand SurgeryUniversity Hospital ZurichZurich, Switzerland