Medial Plantar Artery Perforator Flap Research Articles

Soft tissue reconstruction of the fingers with free medial plantar artery perforator flap

Soft tissue reconstruction of the fingers with free medial plantar artery perforator flap

Medial Plantar Artery Perforator Kiss Flap for Salvage of Extensive Palmar Skin Defect.

Flaps based on the medial plantar artery (MPA) accomplish favorable surgical outcomes in palmar resurfacing due to its outstanding texture, pliability and contour, but primary closure could not be achieved at the donor site when the flap was designed to be relatively large. In this study, the kiss technique was employed for the reconstruction of extensive palmar defects which minimized donor site morbidity. A modified flap surgical strategy was systemically developed based on the perforator distribution of the MPA through our cadaver study. Two or three narrow small skin paddles based on MPA were raised and resembled at the recipient site as a larger flap. S-2PD, hypersensitivity and ROM, QuickDASH, gait and patient satisfaction were evaluated 6 months to 12 months postoperation. From June 2015 to July 2021, 20 cases of reconstruction using the medial plantar artery perforator (MPAP) kiss flap were performed for the resurfacing of palmar skin defects. All flaps survived uneventfully with coverage matching the texture and color of the recipients except one flap that exhibited venous congestion and recovered after revision. 12 flaps (60 percent) were double-paddled and 8 flaps (40%) were triple-paddled with a resurfacing area of 27.19cm 2 and 41.1cm 2 respectively. All donor sites achieved primary closure without major complications. Versatile kiss flap combinations were developed based on further understanding of the MPA system. Durable and pliable characters of the MPAP flap provide excellent reconstruction for extensive palmar defects while minimizing donor site complications. Therapeutic, IV.

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

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. 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. 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). 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.

Combined Great Toe Dorsal Nail-Skin Flap and Medial Plantar Flap for Reconstruction of Degloved Finger Loss.

Historically, the degloved finger with the total loss of nails and skin has been resurfaced in two stages. Furthermore, proximal finger amputation requires an additional bone-tendon graft and an expanded great toe wraparound flap transfer for better outcomes. This article recommends a novel strategy to address these problems in a single stage using a dorsal nail-skin flap and medial plantar artery perforator flap. From March of 2015 to June of 2018, nine procedures were performed to resurface with skin loss to the metacarpophalangeal joint level, and three amputated fingers were reconstructed with an extra bone-joint-tendon graft simultaneously. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. A standardized assessment of outcome in terms of sensory, functional, and aesthetic performance was completed. All flaps survived. The contour and length of the reconstructed digits were comparable with the contralateral finger. The mean static two-point discrimination was 11.0 mm (range, 9.0 to 14.0 mm). The average score of the Disabilities of the Arm, Shoulder, and Hand questionnaire and Michigan Hand Outcomes Questionnaire were 2.5 (range, 0 to 5) and 90.1 (range, 82 to 96), respectively. The mean Foot and Ankle Disability Index score was 95.6 (range, 93 to 99). At the last follow-up, the functional and aesthetic outcomes, and the restored sensation, were satisfactory for all fingers. This strategy may provide an alternative for selected patients seeking cosmetic resurfacing and functional reconstruction, preserving a weight-bearing plantar area with less morbidity. Therapeutic, IV.

[Application of groin flap combined with medial plantar artery perforator flap for degree Ⅲ- Ⅳ defects of multiple fingers].

To investigate the effectiveness of groin flap combined with medial plantar artery perforator flap (MPAP) for degree Ⅲ-Ⅳ defects of multiple fingers. Between January 2018 and June 2019, 12 patients with degree Ⅲ-Ⅳ defects of multiple fingers caused by crushing were admitted. There were 9 males and 3 females with a median age of 29 years (range, 16-42 years). The mean interval between the injury and admission was 3 hours (range, 1-9 hours). The injured fingers of 7 cases were index and middle fingers, 4 cases were middle and ring fingers, and 1 case was index, middle, and ring fingers. All fingers were taken thorough debridement and covered by the vacuum sealing drainage device during the emergency operation. The mean interval between the debridement and flap repairing was 18 hours (range, 12-36 hours). During the first-stage operation, the iliac bone graft was used to reconstruct bone frame, and the proximal interphalangeal (PIP) joint from the foot was transferred as the digital PIP joint, then the thin groin flap and MPAP were tailored to cover the dorsal and palmar defects, respectively. The size of the groin flap was 7.0 cm×4.5 cm-14.0 cm×9.0 cm, and the size of the MPAP was 8.0 cm×4.5 cm-14.0 cm×6.5 cm. The abdominal donor site was directly sutured, and the foot was repaired with full-thickness skin grafting. The flaps were separated into the finger shape at the second-stage. All the flaps survived, and the wounds healed by first intention; the incisions in the donor site healed by first intention, and the skin grafts survived completely. All patients were followed up 12-18 months (mean, 16 months). At last follow-up, the injured finger was similar to the contralateral one in terms of texture, appearance, and color. The mean two-point discrimination was 8 mm (range, 6-10 mm), and the sensate level recovered to the S 3-S 4. According to the Michigan Hand Outcomes Questionnaire (MHQ), the reconstructed hand function was excellent in 8 cases and good in 4 cases. There was no complication in the donor sites. The degree Ⅲ-Ⅳ defects of multiple fingers were repaired by the groin flap and MPAP, and the reconstructed fingers can perform good texture and motion with being sensate, with less sacrifice on the foot.

Medial plantar artery perforator (MPAP) flap is an ideal option for reconstruction of complex soft tissue defect in the finger: Clinical experience from 11 cases.

IntroductionSoft tissue defects of fingers are common in reconstructive plastic surgery, and reconstruction of the defects remains challenging for plastic surgeons. In our study, we reported our experience in finger reconstruction with a medial plantar artery perforator (MPAP) flap, especially using a lobulated MPAP flap for the complex multifinger soft defect.Patients and methodsFrom the period April 2012 to October 2018, 11 patients (9 males and 2 females) with an average age of 44 years old (ranging from 11 to 58) received finger reconstruction with a free MPAP flap. In total, 11 flaps (8 single-lobulated flaps and 3 two-lobulated flaps) were raised from the ipsilateral or contralateral instep area. Trauma and scar contracture caused hand soft tissue loss in all cases.ResultsThe sizes of the flaps ranged from 2×3 to 5×7.5 cm2. All flaps survived intact with no complications. One donor site was closed primarily, and other donor sites were covered with a full-thickness skin graft. The mean follow-up time was 6 months (ranging from 3 to 8 months). During the follow-up period, the patients were satisfied with their appearance without any traces of flap plastic surgery.ConclusionThe MPAP flap is a reliable and acceptable option for the reconstruction of complex soft tissue defects in the finger. Depending on the two branches of the medial plantar artery, the use of the lobulated MPAP flap holds promise in the treatment of multifinger soft tissue defects.

Medial plantar artery flap

Background: The unique ability of the thick glabrous skin of the plantar heel to withstand body weight while also providing protective sensory feedback makes soft-tissue coverage of the plantar heel a particularly challenging aspect of foot reconstruction. In this study, we present the outcomes and complications associated with medial plantar artery perforator (MPAP) flap reconstruction of plantar heel. Methods: The study was a retrospective study conducted over four years, and included 22 patients with soft-tissue injury to the plantar heel. All patients underwent MPAP flap for coverage of the defect. We studied the  mode of injury, defect size, flap size, duration of the procedure, complications associated with the flap and donor site, time to full weight bearing and return of protective sensation and 2-point discrimination in comparison with opposite heel. Results: We studied 22 cases with soft-tissue defects of the heel that included post-traumatic defects (7), non-healing diabetic ulcers (6), trophic ulcers (4) and post- tumor excision defects (melanoma-3, squamous cell carcinoma-2). Mean flap dimension was 24 sq.cm. 18 flaps had complete survival, while 2 flaps had necrosis of the distal edge and 2 flaps underwent complete necrosis. 

Combined great toe dorsal nail-skin flap and medial plantar flap for one-stage reconstruction of degloved finger

BackgroundHistorically, the degloved finger with the total loss of nail and skin had been resurfaced with an expanded great toe wrap-around flap transfer for better outcomes. The purpose of this study aims to present our experience with a related modified design, with total preservation of a weight-bearing plantar skin. MethodFrom April 2016 to September 2019, nine fingers (5 index and 4 middle fingers) in nine cases, with skin loss to the base of the proximal phalangeal or metacarpophalangeal (MCP) joint level, were reconstructed with combined great toe dorsal nail-skin flap and medial plantar artery perforator (MPAP) flap. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. The cutaneous nerves were preserved within both flaps. Standardized assessment of outcome in terms of sensory, functional, and esthetic performance of the reconstructed fingers was completed. ResultsFlap survival was achieved in all cases. The contour of the reconstructed digits was comparable with the contralateral one. The fingers were available for a mean follow-up of 28 months (ranged, 22-39 months). The mean dimension of the great toe dorsal nail-skin flap was 8.5 × 4.0 cm (ranged, 6.5 × 3.5-11.0 × 4.5 cm). The average size of the MPAP flap was 6.5 × 4.5 cm (ranged, 5.0 × 3.5-8.0 × 5.5 cm). At the last follow-up, the functional and aesthetic consequences were satisfactory, as well as the restored sensory. ConclusionReconstruction of degloved fingers with the great toe dorsal nail-skin flap combined MPAP flap, preserving a plantar weight-bearing area, results in excellent contour and functional outcome. Donor-site morbidity in the foot was minimal.

[Application of wrap-around great toe flap combined with medial plantar artery perforator flap for completely degloved fingers].

To investigate the effectiveness of the wrap-around great toe flap combined with medial plantar artery perforator flap (MPAP) for repairing the completely degloved fingers. Between February 2018 and December 2019, 12 patients with the completely degloved fingers caused by machine strangulation were admitted. There were 9 males and 3 females with a median age of 32 years (range, 18-42 years). The injured finger was index finger in 7 cases, middle finger in 3 cases, and ring finger in 2 cases. The skin was avulsed from the metacarpophalangeal joint level, with the intact tendon and joint. The interval between injury and admission was 1-8 hours (mean, 5 hours). All fingers were taken debridement during the emergency operation. The size of the skin defect ranged from 8.0 cm×5.0 cm to 12.0 cm×7.5 cm. After flap thinning, the wrap-around great toe flap (8.0 m×2.0 cm-12.0 cm×3.5 cm) and MPAP (8.0 cm×4.0 cm-12.0 cm×5.5 cm) were used to repair the degloved finger. The donor sites were repaired with the full-thickness skin graft or the flap. All flaps and skin grafts survived completely without significant complications and the wounds at recipient and donor sites healed by first intention. All patients were followed up 12-16 months (mean, 14 months). The texture, appearance, and color of the affected fingers were close to those of normal fingers, and the nails grew normally. At last follow-up, the mean two-point discrimination of the flap was 9 mm (range, 8-10 mm), and the sensation of the injured finger recovered to S3-S4. And 10 cases were rated as excellent and 2 cases as good according to the Michigan Hand Outcomes Questionnaire (MHQ). There was no complication such as pain from walking or skin ulceration at the donor site. The American Orthopaedic Foot and Ankle Society (AOFAS) score was excellent in 9 cases and good in 3 cases. Treating for the completely degloved fingers, the wrap-around great toe flap combined with MPAP can obtain good effectiveness in the respect of the sensation, function, and appearance.

Medial Plantar Fasciocutaneous Flap Reconstruction for Load-Bearing Foot Defects in Patients With Acral Melanoma

Acral lentiginous melanoma (ALM) is a rare subtype of malignant melanoma that usually involves the weight-bearing plantar area. Plantar defect reconstruction has traditionally been performed with skin grafts or free flaps. This study examined the efficacy and safety of a medial plantar artery perforator flap (MPAPF) for plantar defect reconstruction after wide excision of an ALM. Twenty-five patients who underwent reconstruction with a MPAPF between 2011 and 2021 were enrolled in this study. The defects were classified into 6 plantar zones. Demographic and clinical data were retrospectively analyzed. Reconstruction with medial plantar fasciocutaneous island flaps was performed in all cases, except for 4 patients who had lesions in forefoot, which required free medial plantar flaps. Defects in lateral and posterior heel were more likely to present with venous congestion and require longer healing times and revision surgery (P < 0.05). The average follow-up period was 49 months. Four and 5 patients developed local recurrence and distant metastasis, respectively. Four cases of hyperkeratosis and paresthesia were documented, but there were no cases of ulceration or wound dehiscence. None of the cases required secondary debulking procedures. The MPAPF is safe and effective for plantar defect reconstruction among patients with ALM. Meticulous dissection and adequate tunneling are needed, particularly for defects in the lateral and posterior heel, to minimize flap congestion and revision operations.

Medial plantar artery-based perforator and island flaps: a case series of applications in sole defects.

Soft tissue defects of the plantar foot pose a challenge to the reconstructive surgeon. The plantar region of the foot has a unique skin structure, which helps in its paramount functions of weight-bearing and providing protective sensation. It is best replaced with tissue of its own kind. The medial plantar artery (MPA) flap fulfils all the requirements of an ideal replacement for small-to-medium-sized defects in the mid plantar and heel region. This study describes our experience with MPA-based flaps for small-to-medium-sized defects of the plantar foot. The study was conducted in a tertiary referral hospital between April 2017 and March 2020 on patients who presented with defects on the mid plantar region and heel. MPA perforator (MPAP) flap or island flap were applied. The donor site was covered with split-thickness skin grafts. The study included 21 patients. MPAP flap was applied in nine patients and the island flap was applied in 12 patients. The mean age of the patients was 37.95 years and the mean flap size was 36.6cm2. All flaps survived well. In two patients, venous congestion developed which resolved spontaneously, while three patients had small graft loss which also healed with conservative treatment. All patients regained protective sensation within five months of flap coverage. Based on the MPA, both perforator and island flaps can be raised due to the fairly constant position of the perforators. These flaps have the advantage of robust vascularity with the replacement of identical tissue for weight-bearing functions along with acceptable aesthetic outcomes. Since they also have the added advantage of conferring sensation, they can be used as a primary option in cases of small-to-medium-sized plantar foot defects.

Medial Plantar Artery Perforator Flap: Experience with Soft-tissue Coverage of Heel.

Background:Soft-tissue coverage is a challenge to the ankle and foot reconstructive surgeon due to its unique requirement of simultaneously withstanding body weight and to provide sensory feedback. We share our experience of medial plantar artery perforator (MPAP) flap, which provides a robust sensate coverage to heel defects.Methods:Three-year retrospective study, which included soft-tissue injury to heel. All patients underwent MPAP flap for the coverage of the defect. Patients' demographic, mode of injury, defect size, flap size and survival, time to start weight bearing, return of protective sensations, and comparative 2-point discrimination with opposite heel were studied.Results:We studied 16 cases with heel soft-tissue injuries. Fifteen had motor vehicle accident, and 1 had chronic diabetic wound. Mean surface area of flap was 4 × 5 cm. Except 1 flap, 15 flaps had complete survival and provided reliable wound coverage with comparable normal sensation as on other foot.Conclusion:We suggest that MPAP flap, when available, is a good local tissue for heel wounds coverage.

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

Defects in the weight-bearing region of the foot sole can represent a substantial restriction in quality of life and pose a challenge for reconstructive plastic surgery. The purpose of this article is to report the authors' experience with the use of the medial plantar artery perforator flap for reconstruction of defects of the foot sole in three different regions: heel, middle foot sole, and plantar forefoot. From January of 2003 to May of 2016, 28 patients (13 male and 15 female patients) with an average age of 54 years (range, 12 to 84 years) underwent reconstruction with 28 medial plantar artery perforator flaps. Twenty-six flaps were harvested as pedicle perforator flaps and two as free perforator flaps. All flaps were raised from the ipsilateral instep area. The defect locations included the heel (20 cases), middle foot sole (four cases), and forefoot (four cases). The causes of reconstruction were tumors in 18 patients, decubitus in eight patients, and trauma in two patients. The flap sizes varied from 2.5 × 2.5 cm to 5.5 × 9.5 cm. All of the flaps survived completely after surgery, apart from one. The donor sites were all covered with a split-thickness skin graft. Follow-up observations were conducted for 4 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results. The medial plantar artery perforator flap can be considered an optimal method of foot sole reconstruction not only for covering the weight-bearing area of the heel but also for the middle and forefoot plantar region. Therapeutic, IV.

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

Norfolk, Virginia From the Division of Plastic and Reconstructive Surgery, Eastern Virginia Medical School. Received for publication August 14, 2017; accepted August 17, 2017. Disclosure:The author has no financial interest to declare in relation to the content of this Discussion or of the associated article. Lawrence B. Colen, M.D., 6261 East Virginia Beach Boulevard, Suite 100, Norfolk, Va. 23502, [email protected]

Radical resection of a venous malformation in middle finger and immediate reconstruction using medial plantar artery perforator flap: A case report

Reconstruction of complex defects resulting from radical resection of venous malformation occurring in other digits except the thumb is challenging because a thin and durable flap is required to achieve optimal reconstruction without functional impairment. Here, we describe an alternative reconstruction technique in a young patient. A 15-year-old female patient with venous malformation of the left 3rd finger was treated by radical excision of the tumor including involved skin, distal phalanx, and nail bed followed by reconstruction with free medial plantar artery perforator flap and split thickness nail bed graft from the great toe. Twenty-nine months after surgery, the reconstructed finger showed a acceptable aesthetic result without tumor recurrence and excellent restoration of motor function. This method can be considered as an useful alternative option for management of the digital venous malformation in other digits except the thumb. Indications and technical aspects of this method are discussed in this report.

Medial Plantar Artery Perforator Flap for Soft-Tissue Reconstruction of the Heel

Soft-tissue wounds of the foot and especially the heel are challenging problems for reconstructive surgeons. An important principle that guides heel reconstruction is to provide sensate skin with a similar thickness to resurface the weight-bearing heel and avoid late flap ulceration. Among various techniques to achieve this result, the sensate medial plantar perforator flap is an excellent option, which provides durability to friction, a cushioning effect, and sensation. An anatomic study was performed to clarify the anatomy of the cutaneous perforators of the medial plantar artery and to determine the optimal method of medial plantar artery perforator flap harvest. Fifteen cases of heel reconstruction with the sensate medial plantar perforator flap are presented. The outcome of surgery at a mean follow-up of 12 months is reported. The indications for surgery, operative procedures, advantages and disadvantages, and results are presented. Satisfactory results were obtained with a good color and texture match for heel repair and a good sensory recovery. No functional deficit was found at the donor site.

Free Medial Plantar Artery Perforator Flaps for the Resurfacing of Thumb Defects

Destruction of the thumb secondary to trauma presents a much more significant influence on daily living than do injuries to the other digits. Various surgical techniques contribute to repair distal defects of the fingers, especially thumb reconstruction. Seven patients received free medial plantar artery perforator (MPAP) flaps to resurface the palmar defects of their thumbs. The flaps can be harvested with or without the main trunk of the medial plantar artery. The perforator of the MPAP flap was anastomosed to a proper digital artery, and the superficial vein of the flap was anastomosed to the dermal vein of the injured finger. These thumbs had no severe length discrepancy or metacarpophalangeal joint injuries. All patients underwent examinations including static 2-point discrimination, moving 2-point discrimination, and Semmes-Weinstein Test Score 6 months after reconstructive surgery. All tests were carried out by the same occupational therapist 6 months after reconstructive surgery. Five male and 2 female patients were selected for free MPAP flap reconstruction from May 2006 to September 2007. The mobility of the fingers was not restricted after surgery. Six flaps survived completely, and 1 flap partially failed because of venous congestion. Sensory restoration was ideal for all 7 MPAP flaps. The MPAP flap is a suitable choice for reconstructing palmar defects of the fingers, with less donor site morbidity. The cushiony character of the MPAP flap is anatomically similar to the pulp tissue of fingers, and sensory restoration is ideal compared with that of other reconstructive methods. Technical difficulty is focused on anastomosis of perforators (diameter ≤0.8 mm).

Free medial plantar artery perforator flap for finger pulp reconstruction: Report of a series of 10 cases

Treatment of composite tissue loss in the finger pulp is often difficult. The purpose of this report is to present our experience on using medial plantar artery perforator flap for repair of finger pulp defects and to restore fingertip sensation after traumatic injury. The free medial plantar artery perforator (MPAP) flaps were performed for digital pulp reconstruction in ten patients (eight fingertips and two thumbtips) between June, 2006 and December, 2007. This flap blood supply was perforator vessel of medial plantar artery, which was through the intermuscular septum between the abductor hallucis muscle and the flexor digitorum muscle. The recipient vessels were digital artery and dorsal digital vein. The flap was not reinnervated during transfer procedures. The donor sites were closed primarily in all cases. Flap size ranged from 15 x 25 mm to 60 x 20 mm. All flaps were survival. Partial loss occurred in one flap, due to venous congestion caused by excessive stitch tension. The donor sites healed unevenfully in eight cases, but mild wound dehiscence occurred in two cases. The follow-ups ranged from 6 to 29 months with the mean of 18.1 months. The mean of s-2PD and m-2PD were 8.8 mm and 6.8 mm at patients' last visits, respectively. MPAP flaps are good in terms of general morbidity, cosmetic results, and durability. This flap is a valuable alternative method of repairing the glabrous finger pulp and tip defects.

Free Medial Plantar Artery Perforator (MPAP) Flap for the Resurfacing of Finger Defect-Report of Two Cases

Background: Finger destruction secondary to trauma represents a much more significant influence on the activity of daily living. Various surgical techniques contribute to cover the distal defect of the finger. Aim and Objectives: We would like to introduce a find-designed perforator skin flap to reconstruct the finger defects. Material and Method: Two patients received free medial plantar artery perforator (MPAP) flaps to resurface the palmar defects of fingers. The flaps were harvested without interrupting the circulation of the medial plantar artery. The flap perforator was anastomosed to proper digital artery and the superficial vein of the MPAP flap was anastomosed to dermal vein of the injured finger which had no severe length discrepancy or metacarpophalangeal joint injury. Results: One male and one female patient were arranged for free MPAP flap reconstruction in March and August 2007. The mobility of the fingers was not restricted after surgery. One flap survived completely with no vascular compromise. Another flap encountered venous congestion and only partially failed (30% loss) after salvage. Conclusion: The MPAP flap is a suitable choice to reconstruct defect of the finger with less donor site morbidity. The cushiony characteristic of the MPAP flap is anatomically similar to the pulp tissue of fingers. Technical difficulty is focused on anastomosis of perforators (diameter≦ 0.8mm) and limited access of concomitant vein. With the many advantages of the MPAP flap, it is worthy of application to more reconstruction needs, particularly for finger defects.

Island Medial Plantar Artery Perforator Flap for Reconstruction of Plantar Defects

Three cases in which island medial plantar artery perforator flaps were successfully transferred for coverage of the plantar defects are described. This perforator flap is different from the medial plantar flap based on the medial plantar artery. The flap has no fascial component and is nourished only with the perforator of the medial plantar vessel. Therefore, transection of the medial plantar artery is usually unnecessary. This flap can cover defects on the forefoot and heel without transaction of the medial plantar system. The advantages of this flap are no need for deep or long dissection for the medial plantar vessel, no exposure of the plantar sensory nerve, a short time for flap elevation, minimal donor-site morbidity, relatively large flap survival, and no damage of both the posterior tibial and medial plantar neurovascular systems.