Bipedicled distally based medial plantar artery perforator flap for forefoot reconstruction: A case report

Reconstruction of soft-tissue defects in the foot weight-bearing area should encompass sensate and robust skin. Regarding forefoot defects, distally based medial plantar artery (MPA) flap is an ideal option. However, considering variation of the terminal branches of the MPA, reverse flow flaps can be unreliable with an increasing risk of venous congestion or insufficient arterial flow. In this report, we present a case of the use of reverse flow MPA flaps with dual flow vascularization. The patient was a 37-year-old female who presented a 7 x 3 cm soft-tissue defect of the right forefoot after wide local excision following melanoma. Reconstruction happened with a perforator distally based bipedicled flap (8 x 4 cm) on the MPA though keeping an enhanced vascularization through both superficial (sMPA) and deep (dMPA) medial plantar arteries. Donor site was closed with skin graft. Patient was discharged from hospital at postoperative Day 10 and healed uneventfully with progressive start walk was possible again. A full weight bearing with normal shoes was possible after 8 weeks. Good healing and no functional impairment were present after 9 months of follow-up. We believe this dual vascularization concept may be adopted when possible to improve the overall circulation of the flap and to prevent risks of vascular insufficiency or vein congestion.