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The Journal of Foot & Ankle Surgery 51 (2012) 504–508

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The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

Plantar Heel Reconstruction with a Sensate Plantar Medial Artery MusculocutaneousPedicled Island Flap after Wide Excision of Melanoma

Christopher Bibbo, DO, DPM, FACS, FACFAS, FAAOSChief, Foot and Ankle Section, Department of Orthopaedics, Marshfield Clinic, Marshfield, WI

a r t i c l e i n f o

Level of Clinical Evidence: 4Keywords:calcaneusexternal fixationfatfootneoplasmplastic surgeryskin

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Christopher Bibbo, D

Chief, Foot and Ankle Section, Department of OrthoNorth Oak Avenue, Marshfield, WI 54449.

E-mail address: bibbo.christopher@marshfieldclin

1067-2516/$ - see front matter � 2012 by the Americdoi:10.1053/j.jfas.2012.04.017

a b s t r a c t

Reconstruction of soft tissue defects in the plantar heel pad presents a surgical challenge that requiresreplacing the lost tissue with another tissue having similarly unique physical characteristics. This case reportdescribes a reconstruction of the plantar heel pad after wide excision of a heel melanoma, using a sensateplantar medial artery musculocutaneous pedicled island flap.

� 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.

The plantar heel presents a reconstructive challenge because of theunique structure of its soft tissue, whose highly specialized organi-zation of subcutaneous fat functions to accommodate the highcompressive loads and shearing forces incurred during standing andambulation. Thus, to ensure a durable reconstruction, replacing losttissue with another tissue of similar physical characteristics isessential. Full-thickness restoration of the entire plantar heel padwith preservation of protective sensation is the desired reconstructiveendpoint.

Melanoma of the plantar heel is a neoplasm that typically requireswide peripheral and deep resection margins, resulting in significanttissue loss and often exposure of the calcaneus. The author presentsa case in which reconstruction of the plantar heel pad was achievedwith a sensate plantar medial artery musculocutaneous pedicledisland flap after wide excision of a heel melanoma.

Case Report

An 86-year-old active white man, fully ambulatory in thecommunity, was referred by surgical oncology for evaluation of heelreconstruction before wide excision of a right heel melanoma. Thepatient had presented to the surgical oncology service with a several-month history of a pigmented, ulcerating, plantar heel lesion that

O, DPM, FACS, FACFAS, FAAOS,paedics, Marshfield Clinic, 1000

ic.org

an College of Foot and Ankle Surgeon

failed to respond to therapy provided at a wound clinic (Fig. 1A). Hispast medical history included coronary artery disease, medicallycontrolled ischemic cardiomyopathy, hypertension, and chronic renalfailure. An office biopsy revealed an ulcerativemelanomawith a depthof at least 1.12 mm, and all margins positive. Pathology analysisreported a Clark level 4 lesion with an insignificant mitotic rate andno perineural invasion. A clinical stage II melanoma (T2b N0 M0)was diagnosed. Preoperative staging was negative for metastasis onF-18-flurodeoxyglucose PET with spot CT, and findings were consis-tent with isolated melanoma of the right heel. MRI was precludedbecause of the presence of a cardiac pacemaker, and plain radiographswere unremarkable. In consideration of a negative PETscan, a negativeclinical examination for metastasis, the patient’s age (increasing thelikelihood that lymph node evaluation would reveal microscopicdisease only, and that lymph node dissection and systemic chemo-therapy would be poorly tolerated), the surgical oncologist elected toforego sentinel lymph node biopsy. However, because of the location,rapid growth, and ulceration of the lesion, significant morbidity waslikely to result if the local disease was not addressed.

The Lower Extremity Reconstruction Service (C.B.) was consultedto provide plantar heel reconstruction after wide excision of themelanoma. Physical examination revealed a large, ulcerating, pig-mented lesion of the right plantar heel, situated lateral to the midlinebisection of the heel. Plantar sensation was intact, and positiveDoppler signals along the course of the plantar medial and lateralplantar arteries were present (Fig. 1B). A modified Allen’s test(compression of dorsalis pedis and posterior tibial arteries, followedby release of the dorsalis pedis artery only) demonstrated adequateperfusion to the entire hallux via the dorsalis pedis artery and the firstmetatarsal perforating artery. No popliteal or inguinal adenopathy

s. All rights reserved.

Fig. 1. (A) Clinical photograph of an ulcerated melanoma of the right plantar heel. (B) Clinical photograph of proposed wide excision margins (purple circle/arrows). Note that the lesion islateral to midline of the heel, and a wide excision margin extends up onto the lateral side of the heel pad.

C. Bibbo / The Journal of Foot & Ankle Surgery 51 (2012) 504–508 505

was present, and no satellite lesions or visible skip lesions wereobserved. A plan for heel reconstruction was devised, using a sensateplantar medial artery pedicled island flap, and federal reconstructionwith skin grafting of the donor site, accompanied by applicationof a fine wire external fixator to allow early mobilization andweightbearing.

The surgical oncology procedure included wide excision with2 cmþ margins and temporary negative pressure wound therapy(NPWT) (V.A.C.�; KCI, San Antonio, TX) coverage (Fig. 2). Final

Fig. 2. (A) Clinical photograph of heel defect immediately after surgical oncologic excision of plaof outline of plantar medial artery flap that accounts for flap retraction. The abductor hallucis

histologic analysis revealed a Clark level 4, Breslow thickness 3.83mm,ulcerated, superficial, spreading type malignant melanoma with noperineural invasion, satellitosis, tumor embolization, or regression.Final staging was T3B NX M0, stage IIB.

The patient returned for plantar heel reconstruction immediatelyafter the final pathology report was available. The wound encom-passed the entire width of the heel, resulting in a large, deep defect,offset from midline, and an exposed calcaneus. A plantar medialartery flap was outlined, accounting for flap retraction after elevation,

ntar heel lesion. (B) Clinical photograph of wide excision specimen. (C) Clinical photographmuscle was chosen to fill the deep void of the defect.

Fig. 4. (A) Clinical photograph of completely elevated flap and vascular pedicle tracedback to bifurcation from posterior tibial artery (vessel loops) to ensure an untethered arcof rotation and easy reach to the defect (arrow). (B) Clinical photograph of flap rotationand size-fit into defect; note the abductor hallucis muscle included in the flap (arrows).

Fig. 3. (A) Clinical photograph of elevation of the flap includes the plantar fascia and theabductor hallucis muscle (arrow). (B) Clinical photograph of intraneural splitting of hal-lucal digital nerve (white arrow) to retain a sensate flap via nerve fascicles that supply theflap skin (yellow arrows). Neurovascular pedicle (blue circles) remains well-preserved andshould not be skeletonized.

C. Bibbo / The Journal of Foot & Ankle Surgery 51 (2012) 504–508506

as well as the need for additional tissue composite (abductor hallucismuscle) to accommodate the very deep soft tissue defect (Fig. 2C).Under tourniquet control (exsanguination by simple leg elevation),the flap was first elevated distally, then the plantar medial artery wasisolated and ligated; lateral elevation included the plantar fascia,whereas medial elevation included the abductor hallucis muscle(Fig. 3A). The digital nerve to hallux was identified, and intraneuralextra-fascicular dissection allowed the nerve to be split longitudinally,with the dorsal portion of the nerve remaining in continuity with thehallux, whereas the plantar fascicles of the nerve were sectioned atthe distal flap margin. The proximal segment of the split nerve wasadditionally secured with fine epineural sutures to the septum con-taining the perforating vessels emanating from the plantar medialartery (Fig. 3B). Next, the plantar medial artery was dissected to itstake-off from the posterior tibial artery, and traced back through anextensile incision to ensure adequate mobilization of the vascularpedicle (Fig. 4A). Upon completion of flap elevation, arc of rotationand ease of pedicle mobility were ensured (Fig. 4B). The flap was insetover the defect, and to avoid constriction of the vascular pedicle, thepedicle was not tunneled. After imbrication of the short flexors with

the short great toe flexors to cover the flexor hallucis longus tendonand decrease dead space, the donor site was covered with IntegraBilayer Neodermal Matrix (Integra Life Science, Plainfield, NJ). Toavoid any constriction of the vascular pedicle, Integra was also placedover the vascular pedicle (Fig. 5), followed by an NPWT device set at75 mm Hg suction on intermittent mode.

After 1 week of tissue in-growth into the neodermis, a fenestratedfull-thickness skin graft large enough to cover the donor and pediclesites was harvested from the leg and placed over the neodermis(Fig. 6A). An NPWT device set at 75 mm Hg continuous-mode suction(at a low setting to avoid pedicle compromise) was placed, and thefull-thickness skin draft donor site was closed primarily. At the same

Fig. 5. Clinical photograph of flap (white arrow) inset into plantar heel defect. Skinsubstitute (yellow arrow) has been placed over the donor site and pedicle. Drains are usedliberally.

Fig. 6. (A) Clinical photograph of heel after full-thickness skin grafting of donor site over vascuwires are well away from vascular structures. Negative-pressure wound therapy device in placebottom of the external fixator to allow the plantar surface of the foot to float off the surface o

C. Bibbo / The Journal of Foot & Ankle Surgery 51 (2012) 504–508 507

operative setting, a TruLok (Orthofix, McKinney, TX) fine wire trans-articular external fixator was placed (Fig. 6B), allowing immediatepostoperative mobilization with crutches, with strict elevation whensitting or lying. At 8 weeks postoperative, complete healing of the flapand skin graft permitted removal of the external fixator, and thepatient was transitioned into a soft shoe with a cushioned insert. Atthe 2-year follow-up visit, the patient remained disease free and wasambulating in the community with a soft shoe insert. Two-pointdiscrimination and light touch were comparable with the unin-volved side, and the great toe, lesser toes, and plantar heel pad flapexceeded the Semmes-Weinstein protective sensation level (Fig. 7).

Discussion

Melanomas present less frequently in the heel (30%) than otherareas of the body, are often diagnosed at a later age (mean 67 years),and have an equal sex distribution (1). Typically, the plantar heelaccounts for a little over 50% of plantar foot locations, and the lesion iscomposed mainly of acral lentiginous melanoma, whereas superficialspreading melanoma of the heel has been shown to account forapproximately 3% of plantar heel melanomas (1). Furthermore,superficial spreading melanomas typically present as thin rather thanthick melanomas (77% vs. 7%, respectively) (2). However, in this case,the patient presented with a thick (3.83 mm) superficial spreadingmelanoma of the heel.

The heel fat pad poses significant challenges in reconstruction. It iscomposed of a thick epidermal/dermal layer, and a specialized layer ofsubcutaneous fat comprised of lipids containing a higher percentageof unsaturated fatty acids than other bodily fat deposits (3), all ofwhich are contained within specialized closed-cell septae (4,5), andwhich are further arranged into a specialized sequence of rows andridges (6). This structure functions as a buffer against the compressionand shear forces sustained by the plantar heel pad. These forces, inconjunction with a loss of cutaneous sensation within donor tissue,

lar pedicle (arrows). (B) Clinical photograph of heel after fine wire external fixator placed;over skin graft to donor site. A “dummy ring” or nonskid walking post is then added to thef the floor during ambulation.

Fig. 7. (A and B) Clinical photograph of foot at 2 years postoperative. Flap is robust, and donor site over arch remains intact. Note fine hair growth on donor site skin graft, which iscosmetically acceptable to the patient. Protective sensation remains intact to the flap and all toes.

C. Bibbo / The Journal of Foot & Ankle Surgery 51 (2012) 504–508508

raise additional reconstructive concerns. Thus, despite its popularity,the reverse sural flap is a suboptimal choice for reconstruction of theplantar heel, particularly for diabetic and other at-risk patients. Inthese patients, a calcaneoplasty may be preferable to a thin flap suchas the reverse sural flap, which may quickly break down and ulcerate.The plantar medial artery flap, however, provides a composite oftissues very similar to that of the plantar heel, with the donor sitebeing relatively expendable (7). Therefore, plantar medial artery flapsdesigned as rotation flaps and V-Y advancement flaps are excellentchoices for reconstructing adjacent defects, although they may belimited in providing full coverage of non-adjacent tissue because oflimited excursion. Elevation of an island plantar medial artery flapbased on a proximal vascular pedicle affords greater reach of the flap.The addition of a sensory component via the inclusion of a split nervetechnique can then provide all the tissue properties desired in softtissue reconstruction of the plantar heel. In the elderly, the plantartissue may be atrophied, so to ensure durability and provide a thicktissue composite, elevation of a musculocutaneous flap may behelpful.

In the present case, the lead author provided soft tissue coverage ofthe plantar heel pad with a sensate plantar medial artery muscu-locutaneous proximally based pedicled island flap. Plantar flaps inelderly and other at-risk patients often require prolonged non–weightbearing until the flap has sufficiently matured (defined asingrowths to the recipient bed) to prevent flap failure from compres-sion and shear forces. In this patient, however, immediatemobilizationand early weightbearing was made possible by the use of a fine wireexternal fixator. In an effort to provide a more robust donor sitecovering, a full-thickness skin graft was prepared with the Versajet(Smith & Nephew, Memphis, TN) skin graft preparation technique (8).

At 2 years follow-up, the patient was free of local and systemicdisease, walked independently in shoes with a soft longitudinalinsert, and maintained nearly identical sensory thresholds comparedwith the heel of the un-involved limb. Furthermore, the halluxmaintained protective sensation. In conclusion, the sensate plantarmedial artery flap is a valuable technique that may provide durablesoft tissue reconstruction of the plantar heel with retentionof protective sensation. Plantar surface offloading with the use ofa fine wire external fixator can assist with mobilization and earlyweightbearing of the patient who undergoes flap reconstruction ofthe plantar surface of the foot.

References

1. Kato T, Suetake T, Tabata N, Takahashi K, Tagami H. Epidemiology and prognosis ofplantar melanoma in 62 Japanese patients over a 28-year period. Int J Dermatol38(7):515–519, 1999.

2. DemierreMF, ChungC,MillerDR, Geller AC. Early detectionof thickmelanomas in theUnited States: beware of the nodular subtype. Arch Dermatol 141(6):745–750, 2005.

3. Buschmann WR, Hudgins LC, Kummer F, Desai P, Jahss MH. Fatty acid compositionof normal and atrophied heel fat pad. Foot Ankle 14(7):389–394, 1993.

4. Jahss MH, Michelson JD, Desai P, Kaye R, Kummer F, Buschman W, Watkins F,Reich S. Investigations into the fat pads of the sole of the foot: anatomy andhistology. Foot Ankle 13(5):233–242, 1992.

5. Snow SW, Bohne WH. Observations on the fibrous retinacula of the heel pad. FootAnkle Int 27(8):632–635, 2006.

6. Campanelli V, Fantini M, Faccioli N, Cangemi A, Pozzo A, Sbarbati A. Three-dimen-sional morphology of heel fat pad: an in vivo computed tomography study. J Anat219(5):622–631, 2011. doi:10.1111/j.1469-7580.2011.01420.x. Epub 2011 Aug 17.

7. WanDC,Gabbay J, LeviB, Boyd JB,Granzow JW.Qualityof innervation in sensatemedialplantar flaps for heel reconstruction. Plast Reconstr Surg 127(2):723–730, 2011.

8. Bibbo C. Versajet� Hydrosurgery technique for the preparation of full thicknessskin grafts & the creation of retrograde split thickness skin grafts. J Foot Ankle Surg49:404–407, 2010.

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