Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3600_Библиотеки_им_академика_М_И_Перельмана
.pdf
438
D. Nikkhah and N. Kang
Fig. 44.28 Great toe pulp was taken from the lateral border of the
great toe with associated neurovascular structures
Fig. 44.29 2-year outcome of pulp transfer, it is indistinguishable
from contralateral thumb
transplant was performed to preserve IPJ motion and restore
thumb length (Fig.44.32). A dorsal dominant circulation was
identied and anastomosis was performed to the radial artery
at the anatomical snuff box. The patient had a pulp plasty at
Fig. 44.30 Donor site from great toe pulp transfer demonstrates minor
hyperpigmentation
Fig. 44.31 Traumatic amputation of right thumb at level of IPJ
8 months to improve cosmesis. His result at 1 year demonstrates excellent range of motion, sensibility and restoration of
opposition and an acceptable donor site morbidity (Figs.44.33
and 44.34).
44 Great Toe Flaps
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 44.32 Planning of immediate great toe to hand transfer
439
Fig. 44.34 Donor site outcome
Fig. 44.33 Result of transfer at 1year
440
44.8 Pearls andPitfalls
Pearls
• Use a retrograde approach to determine the dominance of the circulation in toe transfer. The advantage of this method over the antegrade approach is
that the surgeon can ascertain if there is a plantar or
dorsal dominant circulation.
• The vessels should be dissected with microsurgical
instruments and side branches ligaclipped with
micro-ligaclips. To avoid thermal injury to the pedicle, a heat sink bipolar technique should be
utilised.
• If the great toe is substantially larger than the thumb
to be reconstructed, the tibial portion of skin, soft
tissue and bone can be removed as a trimmed great
toe. Secondary surgeries such as pulp plasty can
also be performed to debulk the bulbous appearing
pulp of the great toe transfer.
• Once the toe is raised, it is assessed for vascularity
before transfer. In cases where there is vasospasm
and the toe remains white, we recommend warm
water and vasodilators such as lidocaine or
papaverine.
• In an elective great toe transfer, the recipient site
should be prepared with wide exposure to delineate
dorsal veins, tendons, nerves and recipient arteries.
This can be performed with a cruciate incision [9].
We prefer if feasible to do the microsurgery at the
wrist or snuff box as vessels here are larger and the
microsurgical anastomosis is less challenging.
Pitfalls
• Plantar dissection beyond the mid-metatarsal level
can cause substantial morbidity to the foot. The
incision if extended should be kept lateral to the
weight bearing portion of the metatarsal head. We
do extend by splitting the rst web to achieve as
much plantar vessel as possible, as this is an expensive operation, once started we feel we should do
everything to make it work. It is far easier to reconstruct the rst web in the donor foot than to save a
failing toe transfer.
• The surgeon must ensure there is enough tissue to
cover the donor site; it must be well padded and
tension-free. We avoid resecting back the head of
the metatarsal as this can affect gait. The great toe
D. Nikkhah and N. Kang
should not be taken proximal to the base of the
proximal phalanx [9].
• Minimise periosteal stripping when performing
osteosynthesis, and preserve up to 5mm of bone for
interosseous xation or plate xation [9].
• Use a light dressing; avoid circumferential dressing
with Jelonet which can result in a blood cast and
result in venous congestion.
• During the post-operative period, one must keep the
patient warm and well hydrated. Use of brachial
plexus block for the rst 24h can also induce vasodilation and reduce the chances of vasospasm in the
early post-operative period.
44.9 Selected Readings
• Morrison WA, O’Brien BM, MacLeod AM. Thumb
reconstruction with a free neurovascular wrap- around ap
from the big toe. J Hand Surg Am. 1980;5(6):575–83.
• This paper describes a method of thumb reconstruction
with iliac crest bone graft and a neurovascular wraparound ap from the great toe. The authors felt that this
provided acceptable aesthetic outcome but minimising
secondary morbidity at the donor site.
• Wei FC, Chen HC, Chuang DC, Jeng SF, Lin CH.
Aesthetic renements in toe- to- hand transfer surgery.
Plast Reconstr Surg. 1996;98(3):485–90.
• The authors describe techniques to rene both the aes-
thetics and functional outcomes in toe transfers. They
highlight how great toe transfer can be improved by the
reduction of soft tissue, bone, interphalangeal joint, nail
and by secondary pulp reduction and contouring
procedures.
• Gilbert A.Vascular anatomy of the rst web space of the
foot. In: Landi A, editor. Reconstruction of the thumb.
London: Chapman and Hall; 1989. p.1999.
• Cadaveric study that examined the variation of the dor-
sal and plantar metatarsal arteries in 50 cadavers. The
dorsal system is the primary choice for the pedicle of the
great toe owing to its supercial course and long pedicle. However in 10% of cases the dorsal system may be
absent and the plantar system may need to be harvested
as the primary pedicle, which has disadvantages of
being signicantly shorter and often needing lengthening with a vein graft. Gilbert describes the anatomical
subtypes seen in the dorsal and plantar metatarsal
arteries.
44 Great Toe Flaps
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
441
• Wei FC, Silverman RT, Hsu WM.Retrograde dissection
of the vascular pedicle in toe harvest. Plast Reconstr Surg.
1995;96:1211–4.
• Wei and colleagues describe the retrograde approach to
second and great toe harvest, this enables swift identication of whether plantar or dorsal dominance is present in
the toe. Furthermore the authors state it avoids the need
for any pre operative imaging.
• Henry SL, Wei FC.Thumb reconstruction with toe transfer. J Hand Microsurg. 2010;2(2):72–8.
• A technical article from the Taiwanese group illustrating
key techniques and steps in great toe, second toe and
trimmed toe transfer. The authors describe common pitfalls and techniques to avoid difculties.
• Wei FC, Chen HC, Chuang CC, Noordhoff MS.
Reconstruction of the thumb with a trimmed- toe transfer
technique. Plast Reconstr Surg. 1988;82(3):506–15.
• The article describes a new modication of the great toe
transfer, the trimmed toe transfer. The technique involves
reduction of bony and soft tissue elements along the
medial aspect of the great toe in order to produce a
normal- sized thumb. The rst 20 transfers demonstrated
excellent stability, grip strength and pinch strength but a
modest reduction in range of motion at the interphalangeal joint.
• Wei FC, Yim K.Pulp plasty after toe to hand transplantation. Plast Reconstr Surg. 1995;96(3):661–6.
• This retrospective study looked at the effects of pulp plasty
on the appearance and function in 82 digits on 51 patients.
The procedure involves removal of a wedge of tissue from
the centre of the pulp. In this series the procedure was
considered effective in 87% of cases and it improved
appearance and the function of the transplanted digit.
References
1. Cobbett JR. Free digital transfer: report of a case of transfer of
a great toe to replace an amputated thumb. J Bone Joint Surg.
1969;51B:677.
2. Whitworth IH, Pickford MA.The rst toe-to-hand transfer: a thirtyyear follow-up. J Hand Surg Br. 2000;25(6):608–10.
3. Valauri FA, Buncke HJ.Thumb reconstruction—great toe transfer.
Clin Plast Surg. 1989;16(3):475–89.
4. Morrison WA, O’Brien BM, MacLeod AM.Thumb reconstruction
with a free neurovascular wrap-around ap from the big toe. J Hand
Surg Am. 1980;5(6):575–83.
5. Wei FC, Chen HC, Chuang DC, Jeng SF, Lin CH. Aesthetic
renements in toe-to-hand transfer surgery. Plast Reconstr Surg.
1996;98(3):485–90.
6. Strauch B, Yu H-L.Atlas of microvascular surgery. Anatomy and
operative approaches. Stuttgart: Thieme; 1993.
7. Gilbert A.Vascular anatomy of the rst web space of the foot. In:
Landi A, editor. Reconstruction of the thumb. London: Chapman
and Hall; 1989.
8. Wei FC, Silverman RT, Hsu WM.Retrograde dissection of the vascular pedicle in toe harvest. Plast Reconstr Surg. 1995;96:1211–4.
9. Henry SL, Wei FC.Thumb reconstruction with toe transfer. J Hand
Microsurg. 2010;2(2):72–8.
10. Nikkhah D, Martin N, Pickford M.Paediatric toe-to-hand transfer:
an assessment of outcomes from a single unit. J Hand Surg Eur.
2016;41(3):281–94.
The Medial Plantar Flap
AlexanderE.J.Trevatt, MiguelA.Johnson,
andTiewC.Teo
45
45.1 Introduction
The medial plantar ap was rst described by Shanahan and
Gingrass in 1979 [1] who transposed the medial plantar ap
based on an artery and nerve pedicle, to reconstruct heel
defects. It was later described as an island fasciocutaneous
ap by Harrison and Morgan in 1981 [2]. Morrison et al.
subsequently described its use as a free ap [3]. It is a particularly versatile ap that can be used to provide ‘like for
like’ reconstruction in the foot and ankle, with minimal
donor site morbidity. It is ideally suited for defects in the foot
and ankle region, where the stresses of ambulation require
any reconstruction to provide durable sensate coverage. It is
also an excellent option in the palmar region, where providing a sensate, durable reconstruction is particularly important. Duman et al. [4] demonstrated the versatility of the
medial plantar ap in the palmar region by harvesting it with
abductor hallucis muscle to simultaneously reconstruct
defects of the thenar skin and muscle.
About 80% of standing body weight is supported by the
heel, with the remainder supported by the metatarsals and
distal sole [5]. Despite being essentially non-weight bearing,
the medial plantar region retains the characteristics of the
rest of the plantar region. The glabrous plantar skin is perfectly adapted for weight bearing and contains vertical
brous septa, which extend from the fascia to the dermis,
absorbing shock and resisting shear [6]. Medial plantar aps
can therefore provide durable coverage of defects in the foot
and ankle, without affecting gait.
A. E. J. Trevatt (*) · M. A. Johnson · T. C. Teo
Queen Victoria Hospital, East Grinstead, UK
45.2 Anatomy
Inferior to the medial malleolus, the posterior tibial artery
enters the calcaneal canal and bifurcates at the level of the
transverse septum between the abductor hallucis muscle and
the exor digitorum brevis muscle, into the medial and lateral plantar arteries. The mean length of the posterior tibial
artery from the base of the medial malleolus to its bifurcation
point is 2.7cm [7].
On branching from the posterior tibial artery, the medial
plantar artery (MPA) rst passes superior to the abductor hallucis, before moving between it and the exor digitorum brevis, where it supplies both muscles. It then runs inferiorly to
the exor hallucis longus tendon, before bifurcating into
supercial and deep branch at the level of the talus-navicular
joint. The mean length of the MPA from origin to bifurcation
is 3cm [8]. The supercial branch of the MPA usually has a
larger calibre (average of 1.85mm) than the deep branch
(1.4 mm) [9]. The deep MPA is inconsistent and may be
absent in up to 30–45% of cases [7].
Throughout its course, the MPA and supercial MPA provides 1–3 small perforators to the skin. These perforators
have a mean diameter of 0.5mm [10] and can be used as the
basis of the MPA perforator ap [11].
The supercial MPA makes a number of variable anastomotic connections. There is usually a connection with the
rst plantar metatarsal artery (27–100%) [12, 13] which can
be used to raise a reverse ow medial plantar ap [14]. There
are often connections to the plantar arch via the rst and second metatarsal arteries and there is a direct anastomosis with
the deep plantar arch in up to 20% of cases [12].
The medial plantar nerve accompanies the medial plantar
artery. It is a cutaneous sensory branch of the posterior tibial
nerve, providing sensation to the medial plantar skin. It can
be incorporated into the medial plantar ap to provide a sensate reconstruction. Concomitant veins also accompany the
medial plantar artery, in addition to larger calibre subcutaneous tributaries of the great saphenous vein.
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_45
443
444
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. E. J. Trevatt et al.
45.3 Pre-operative Investigation
Preoperative imaging is not routinely required, although CT
angiography may be useful where there are concerns regarding the patency of the medial plantar artery, such as in
peripheral vasculopathy or previous trauma.
In our experience, a handheld pencil Doppler is usually
sufcient to localise the medial plantar artery and its
perforators.
45.4 Flap Design andMarkings
The medial plantar ap skin island should be centred around
the strongest cutaneous perforator in the non-weight bearing
aspect of the foot.
A large area can be raised including, if needed, part of the
medial foot (Fig.45.1). The posterior tibial artery is palpated
just posterior to medial malleolus. Using the handheld
Doppler, it is traced as it runs distally and branches into the
medial plantar artery. A straight line is drawn connecting the
posterior tibial artery at the medial malleolus to the plantar
aspect of the rst metatarsal space. This is divided into thirds
with the main perforator generally being found at the junction of the middle and distal third (Fig.45.2).
45.5 Flap Raise/Elevation: AStep-by-Step
Guide
1. Positioning. The patient is placed in the lateral decubitus
position (Fig.45.3), or supine with the knee exed, and
the foot is elevated on a sandbag. A thigh tourniquet is
applied. The medial malleolus along with the posterior
tibial artery and skin paddle is marked preoperatively.
2. Skin Flap Elevation. The skin ap is raised from distal
to proximal along the lateral plantar border down to plantar fascia (Fig.45.4). If you have dopplered the pedicle
Fig. 45.1 Landmarks drawn before medial plantar ap transfer. Large
aps incorporating almost all of the non-weight bearing instep can be
raised
Fig. 45.2 A line is drawn from the posterior tibial artery at the level of
the medial malleolus to the plantar aspect of the rst metatarsal space.
The main perforators are generally found two-thirds of the way along
this line
Fig. 45.3 The patient is placed in the lateral decubitus position and the
ap is designed
Fig. 45.4 The skin incision is made along the lateral border of the ap,
down to the plantar fascia. In this case, the triangular skin incisions over
the pedicle have also been made. The course pedicle was previously
identied using doppler
ab
45 The Medial Plantar Flap
445
and are happy with its course, you can also make the skin
incisions over the pedicle at this point.
3. Reection of Plantar Fascia. The plantar fascia is lifted
to expose the medial plantar neurovascular bundle
(Fig.45.5) and the pedicle is appraised. The medial plantar neurovascular bundle can be found in the cleft between
the abductor hallucis brevis and exor digitorum brevis
muscles. The distal end of the vessels are tied off and
divided.
4. Dissection of Medial Plantar Nerve. Dissection of the
medial plantar nerve should be performed at this stage.
The nerve should be separated from the neurovascular
bundle until the branch to the ap is identied (Fig.45.6a).
At this point, this branch is followed back to the trunk of
the nerve and an intraneural dissection is performed to
separate it from the trunk (Fig. 45.6b). Dissection is
supercial to the muscles and just deep to the plantar fascia. The nerve is raised along with the pedicle of the ap.
5. Pedicle Dissection (Fig.45.7). Following division of the
distal end of the medial plantar vessels, the ap is raised
from distal to proximal at the level between the plantar
fascia and the exor digitorum brevis. The length of pedicle needed will dictate how much we dissect the pedicle.
Dissection often stops where the vessels emerge from the
lateral border of abductor hallucis brevis. The pedicle
may be further dissected proximally towards the posterior
tibial artery to increase length where needed. At this
point, if raising as a free tissue transfer, the pedicle can be
clipped and divided at its origin. Following careful
dissection, the medial plantar border of the skin is incised
to island the skin ap on its pedicle.
6. Flap Inset. The ap is inset using 4–0 monocryl
(Fig.45.8). If performing free tissue transfer, anastomoses can be performed prior to this either as end-to-end or
end-to-side, depending on the size of the recipient vessel.
We routinely insert a passive corrugator drain.
Fig. 45.7 The pedicle is carefully dissected until adequate length and
Fig. 45.5 The plantar fascia is reected and a relatively avascular plain
found
mobility it achieved. Care is taken to remove all fascial attachments that
would hinder mobility
Fig. 45.6 (a) The medial plantar nerve is identied and carefully separated from the vessels. (b) The medial plantar nerve is traced back until
cutaneous branches to the skin paddle are identied. At this point intraneural dissection is performed to separate it from the trunk
446
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 45.8 The ap is inset and a passive corrugator drain is inserted
A. E. J. Trevatt et al.
3. Dissection of Medial Plantar Nerve. The main trunk of
the nerve is identied and is separated from the pedicle
using Debakey forceps and Tenotomy scissors. A combination of sharp and blunt dissection continues until you
see a cutaneous branch to the skin. This branch is then
followed back to the main trunk of the nerve. Intraneural
dissection is then performed to release the branch from
the trunk. This is an important part of raising a sensate
ap, otherwise the nerve would restrict movement of the
ap. We usually continue the intraneural dissection until
we have enough length to allow the ap to move the
desired distance.
4. Pedicle Dissection. The MPA pedicle is dissected using
both sharp and bipolar dissection. We prefer to tie off the
pedicle distally, as ligaclips can be felt when weight bearing. Tenotomy scissors and Debakey forceps are used,
along with bipolar diathermy where needed. We use
vessel loops to retract vessels where necessary. The end
point of dissection is where the lateral plantar artery
branches, to avoid overly devascularising the foot. It has
been reported however that if a longer pedicle is required,
dissection can continue proximal to this, provided the
dorsalis pedis is viable. However, in these cases we would
opt for alternative solutions where there is less vascular
disruption to the foot.
5. Flap Inset. We routinely insert a passive corrugator drain
where using this ap to reconstruct foot and ankle defects.
This is to minimise the risk of a haematoma putting pressure on the pedicle.
Fig. 45.9 The defect is reconstructed with a split skin graft and a bolster dressing is applied
7. Donor Site Reconstruction. The donor site defect is
reconstructed with a split skin graft. This is bolstered
with a dressing (Fig.45.9) and the leg is elevated overnight. A window is made into the dressing to allow frequent monitoring of the ap.
45.6 Core Surgical Techniques inFlap
Dissection
1. Skin Flap Elevation. This is done with a blade to incise
the skin, followed by a nger switch diathermy. Care is
taken to avoid avulsing the skin from the underlying
fascia.
2. Reection of Plantar Fascia. The fascia is incised with a
ten blade and is held with either a Kilner retractor
(catspaw) or skin hooks. Once you have incised the plantar fascia there is a relatively avascular plane which leads
down to the vessels.
45.7 Clinical Scenario
Case Scenario 1 Surgeon TC Teo A 52-year-old man underwent excision of a malignant melanoma from his heel. A
5×5cm defect was created and a medial plant ap was chosen
for reconstruction to provide a durable, sensate, like for like
reconstruction. The ap was raised as a pedicled ap and was
able to comfortably reach the defect. A good long-term outcome
was achieved, with the patient returning to normal ambulation
(Figs.45.10, 45.11, 45.12, 45.13, 45.14, and 45.15).
Case Scenario 2 Surgeon TC Teo A 41-year-old man
underwent excision of a persistent verruca on the distal sole
of his foot which had frequently recurred. A 3×4cm defect
was created that would have been too distal for a standard
pedicled medial plantar ap. Instead a reverse ow pedicled
medial plantar ap was raised and used to reconstruct the
defect. The donor site was reconstructed with a split skin
graft. This denitively treated the verruca with the patient
suffering no further recurrences (Figs.45.16, 45.17, 45.18,
45.19, 45.20, and 45.21).
45 The Medial Plantar Flap
447
Fig. 45.10 A malignant melanoma requiring excision from the weight
bearing aspect of the heel
Fig. 45.11 Post-excision defect along with skin markings for pedicled
medial plantar ap
Fig. 45.13 Pedicled medial plantar ap easily reaching heel defect
Fig. 45.14 Long-term outcome of pedicled medial plantar ap to heel
Fig. 45.12 Medial plantar ap raised on its pedicle, just before inset
Fig. 45.15 Long-term outcome of pedicled medial plantar ap to heel
448
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. E. J. Trevatt et al.
Fig. 45.16 Recurrent verruca on distal sole
Fig. 45.18 Reverse ow medial plantar ap raised from proximal to
distal
Fig. 45.17 Pre-operative skin markings for reverse ow medial plantar ap
Fig. 45.19 Reverse ow medial plantar ap fully raised, just before
inset
Соседние файлы в папке Библиотека им академика М.И. Перельмана