title: An Algorithm for Forefoot Reconstruction With the Innervated Free Medial Plantar Flap.
abstract: BACKGROUND
  Because of shearing forces, the forefoot is more prone to trophic ulcers than the heel. Reconstruction of trophic ulcers and other forefoot defects is a vexing challenge. We favor the innervated free medial plantar flap to replace like-with-like and confer protective sensation. We investigate the feasibility of this flap with the largest series to date and the first to describe ipsilateral flap transfer.
  
  
  METHODS
  Between 2009 and 2013, 7 patients with forefoot defects were treated with innervated free medial plantar flaps. The average age of 4 men and 3 women was 35.1 years (range, 8-50 years). Indications were secondary reconstruction after trauma and coverage of oncologic defects. The mean defect was 5 × 7 cm (range, 4-6 cm × 6-10 cm). Four patients were treated with contralateral flaps and 3 with ipsilateral flaps using interposition vein graft.
  
  
  RESULTS
  The mean flap size was 8.1 ± 1.6 cm × 5.9 ± 1.2 cm. There was no perioperative complication, venous congestion, or arterial insufficiency. Patients were followed clinically for 38.5 months (range, 6 months to 10 years). One patient died from complications of metastatic disease 7 months after plantar flap reconstruction. Two patients underwent sensory testing and gait analysis. The appearance was satisfactory, ambulation returned to normal, and there was protective sensation in every case. In 2 cases, hyperkeratotic tissue was excised in revision procedures.
  
  
  CONCLUSIONS
  The innervated free medial plantar flap is an attractive and feasible option for coverage of medium-to-large defects of the plantar forefoot in the hands of a skilled microsurgeon. It has a place in our algorithmic approach to forefoot reconstruction.
authors.affiliation: From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University Taipei, Taiwan.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Zelken
authors.forename: Chih-Hung
authors.initials: CH
authors.lastname: Lin
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D002648:Child; D005260:Female; D018409:Foot Injuries / Q000601:surgery*; D005545:Forefoot, Human / Q000294:innervation* / Q000601:surgery*; D058752:Free Tissue Flaps / Q000294:innervation*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods; D019651:Plastic Surgery Procedures / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult