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45 The Medial Plantar Flap
449
Fig. 45.20 Reverse ow medial plantar ap following inset. Donor
defect was subsequently reconstructed with a split skin graft
Fig. 45.22 Skin marking of malignant melanoma scar requiring wide
local excision
Case Scenario 3 Surgeon TC Teo A 37-year-old man
underwent wide local excision of a malignant melanoma scar
from his palm. A 2.5×2.5cm defect was created and a free
medial plantar ap was chosen to provide a durable recon-
Fig. 45.21 Long-term outcome of reverse ow medial plantar ap to
distal sole
Fig. 45.23 2.5×2.5cm defect on palm following wide local excision
of malignant melanoma
struction that replicated the palmar skin. An end-to-end anastomosis was made to a branch of the ulnar artery (Figs.45.22,
45.23, 45.24, 45.25, 45.26, 45.27a, b).
450
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A. E. J. Trevatt et al.
Fig. 45.24 A free medial plantar ap being raised
Fig. 45.25 A free medial plantar ap. In this case the ap has been
raised without the fascia to keep it as thin as possible
Fig. 45.26 A free medial plantar ap following inset into a branch of
the ulnar artery on the palm
a
b
Fig. 45.27 (a) Long-term outcome of free medial plantar ap to palm.
(b) Long-term outcome of free medial plantar ap to palm
45 The Medial Plantar Flap
45.8 Pearls andPitfalls 45.9 Selected Readings
451
Pearls
• If you require a longer pedicle, make your skin paddle as distal as possible within the non-weight bearing aspect of the foot.
• Where longer pedicle lengths are required, further
mobilisation is possible by dividing or tunnelling
under the abductor hallucis brevis muscle and the
laciniate ligament, and tracing the medial plantar
artery to its origin from the posterior tibial artery.
• If using the medial plantar ap to reconstruct distal
foot defects, consider raising a reverse ow ap. In
these cases, elevation should occur from proximal
to distal and the medial plantar ap is tied off
proximally.
• When dissecting the pedicle, ensure all the fascial
attachments are released to allow for an uninhibited
arc of rotation and to minimise the potential of
kinking in pedicled aps.
• If a thinner ap is required, the ap can be raised
without the plantar fascia. This requires careful dissection of the perforator through the fascia.
Pitfalls
• At the level of the navicular tuberosity there is an
extensive venous plexus. Since the branching pattern of the supercial and deep MPA are variable,
caution must be taken to avoid isolation of the
incorrect arterial supply.
• When raising a sensate ap, transecting the medial
plantar nerve distally sacrices sensation to the
plantar medial distal foot and toes. This can be
avoided by splitting the nerve through intraneural,
extrafascicular dissection.
• During dissection, it is important to preserve the
peritendinous structures overlying the abductor
hallucis. If these are not maintained, the wound
bed will not be suitably vascularised for skin
grafting.
• Take care to ensure you apply only gentle traction
when raising the skin paddle to avoid avulsion of
the deep fascia from the skin.
• Rarely, the deep MPA can be the dominant vessel. It is therefore important to fully appraise the
neurovascular bundle before committing to the
dissection.
• Guillier D, Cherubino M, Oranges CM, Giordano S,
Raffoul W, di Summa PG.Systematic reappraisal of the
reverse-ow medial plantar ap: from vascular anatomical concepts to surgical applications. J Plast Reconstr
Aesthet Surg. 2020;73:421–33.
• This recent review outlines the variations in MPA anat-
omy, along with their frequency.
• Baker GL, Newton ED, Franklin JD. Fasciocutaneous
island ap based on the medial plantar artery. Plast
Reconstr Surg. 1990;85:47–58.
• A selection of 12 clinical cases demonstrating the versatil-
ity of the medial plantar ap in the foot and ankle region.
• Paget JT, Izadi D, Haj-Basheer M, Barnett S, Winson I,
Khan U.Donor site morbidity of the medial plantar artery
ap studied with gait and pressure analysis. Foot Ankle
Surg. 2015;21:60–6.
• A study demonstrating the minimal donor site morbidity
of the medial plantar ap.
• Scaglioni MF, Franchi A, Uyulmaz S, Giovanoli P. The
bipedicled medial plantar ap: vascular enhancement of a
reverse ow Y-V medial plantar ap by the inclusion of a
metatarsal artery perforator for the reconstruction of a forefoot defect—a case report. Microsurgery. 2018;38:698–701.
• A case report demonstrating how venous congestion can
be reduced in reverse ow medial plantar aps by raising
a bipedicled ap.
References
1. Shanahan RE, Gingrass RP.Medial plantar sensory ap for coverage of heel defects. Plast Reconstr Surg. 1979;64:295.
2. Harrison DH, Morgan BDH. The instep island ap to resurface
plantar defects. Br J Plast Surg. 1981;34:315.
3. Morrison WA, Crabb DM, O’Brien BM, Jenkins A. The instep
of the foot as a fasciocutaneous island and as a free ap for heel
defects. Plast Reconstr Surg. 1983;72:56.
4. Duman H, Er E, Işík S, Türegün M, Deveci M, Nişancí M, Sengezer
M. Versatility of the medial plantar ap: our clinical experience.
Plast Reconstr Surg. 2002;109:1007–12.
5. Erdemir A, Sirimamilla PA, Halloran JP, van den Bogert
AJ.Anelaboratedataset characterizing the mechanical response of
the foot. J Biomech Eng. 2009;131:094502.
6. Baker GL, Newton ED, Franklin JD.Fasciocutaneous island ap
based on the medial plantar artery—clinical-applications for leg,
ankle, and forefoot. Plast Reconstr Surg. 1990;85:47–58.
7. Macchi V, Tiengo C, Porzionato A, Stecco C, Parenti A, Mazzoleni
F, etal. Correlation between the course of the medial plantar artery
and the morphology of the abductor hallucis muscle. Clin Anat.
2005;18:580–8.
8. Rodriguez-Vegas M.Medialis Pedis ap in the reconstruction of
palmar skin defects of the digits: clarifying the anatomy of the
medial plantar artery. Ann Plast Surg. 2014;72:542–52.
452
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. E. J. Trevatt et al.
9. Yoon E-S, Kim D-W, Chun D, Dhong E-S, Koo S-H, Park S-H,
etal. An anatomic study and clinical application of medial pedis
ap in Asians. Ann Plast Surg. 2007;58:517–22.
10. Zhang G-M, Syed SA, Tsai T-M.Anatomic study of a new axial
skin ap based on the cutaneous branch of the medial plantar artery.
Microsurgery. 1995;16:144–8.
11. Koshima I, Narushima M, Mihara M, Nakai I, Akazawa S, Fukuda
N, etal. Island medial plantar artery perforator ap for reconstruction of plantar defects. Ann Plast Surg. 2007;59:558–62.
12. Masquelet AC, Penteado CV, Romana MC, Chevrel JP. The distal anastomoses of the medial plantar artery: surgical aspects. Surg
Radiol Anat. 1988;10:247–9.
13. Song D, Yang X, Wu Z, Li L, Wang T, Zheng H, etal. Anatomic
basis and clinical application of the distally based medialis pedis
aps. Surg Radiol Anat. 2016;38:213–21.
14. Bhandari PS, Sobti C. Reverse ow instep island ap. Plast
Reconstr Surg. 1999;103:1986–9.
Part III
Common Recipient Vessels
Chest Wall Recipient Vessels Access
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PennylouiseHever, DariushNikkhah, AlexandraMolina,
andMartinJones
46
46.1 Indications
The internal mammary (IM) vessels have been used for
microvascular reconstruction since 1947 in oesophageal
reconstruction by Longmire, and later, in the 1970s and
1980s, for free superior gluteal myocutanoeous ap reconstruction post-mastectomy; rst by Fujino and later by
Shaw [1–3]. In 1980, Harashina described a case using the
IM vessels as recipient vessels for a free groin ap reconstruction of the breast following radical excision of a large
cavernous haemangioma [4]. Today the IM vessels remain
the preferred recipient vessels for microvascular breast
reconstruction for their constant anatomy, and ease of
access.
The interest in the IMVs started with the popularisation of
free abdominal tissue for autologous breast reconstruction—
rst with the TRAM ap and later the DIEP—, with the
search for recipient vessels which would permit optimal ap
positioning on the chest, with an adequate pedicle length.
Four sets of possible recipient vessels in the chest were identied: the external carotid/jugular vein tributaries in the neck,
branches of the subscapular artery and vein in the axilla, the
thoracoacromial vessels on the superolateral anterior chest,
and the IM vessels for the central anterior chest. The ones
P. Hever (*) . D. Nikkhah
Royal Free NHS Foundation Trust, London, UK
e-mail: phever@nhs.net
A. Molina · M. Jones
Queen Victoria Hospital NHS Foundation Trust,
East Grinstead, UK
e-mail: alexandramolina@doctors.org.uk
that are routinely used are the branches of the subscapular
vessels (thoracodorsal, long thoracic, and the serratus branch
of the circumex scapular vessels) and the IM vessels.
Advantages of the IM vessels include comparable vessel
diameter match, more potent arterial ow, less demand for a
long vascular pedicle, as compared to the vessels in the
axilla, and the avoidance of lateral fullness of the breast.
Disadvantages include the more complex, time-consuming
dissection, vessel wall fragility following radiotherapy treatment, and anatomical variants which preclude their use.
Furthermore, the dissection carries the additional risks of
pneumothorax, intercostal neuralgia, and precludes the
future use of the IMA for coronary artery bypass graft.
Improved results have been demonstrated, however, with
advances in microsurgery, including venous couplers, the
rib-preserving approach, and IMA preserving end-to-side
anastomosis.
46.2 Anatomy
Internal mammary vein anatomy has been widely studied,
most notably by Arnez and Rohrich [5, 6]. Arnez et al.
carried out the rst anatomical study of the IMV in 1995
to assess the feasibility of anastomosis of the DIEP vessels with the IM recipient site. They proved the IM vessels
to be present in all cadavers, and anastomosis to be safe
and feasible. This nding was matched by Rohrich and
other research groups in the years to follow. Only one
notable study has reported the complete absence of the
IMV.This rare nding was recorded by Pradas-Irun etal.
in two patients; one who underwent immediate, and one
delayed breast reconstruction following mastectomy and
radiotherapy [7].
Four different patterns of IMV anatomy were described
by Arnez etal., classifying the relationship of the IMV to the
IMA [3]. The IMV was found medial to the IMA in 95%
cases (types I and II), and lateral to the IMA in 5% (types III
© 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_46
455
456
P. Hever et al.
and IV). IMV division below the fth rib was rare (1–2%
cases). The type I pattern was most common (65%), in which
the IMV ran medial to the IMA, dividing into two venae
comitantes at the level of the third or fourth intercostal space.
The type II pattern was the next most frequently observed
(26%), consisting of a single IMV running medial to the
IMA throughout its course, without division. Type III—the
IMV running lateral to the IMA with division into two venae
comitantes at the level of the third or fourth intercostal
space—and type IV patterns, a single IMV running lateral to
the IMA throughout its course without division, were rare.
Tuinder etal. later reported an additional type V pattern, in
which two IMVs were present, running parallel either side of
the IMA, without further division [8] (Fig.46.1a, b).
46.3 Pre-operative Investigation
In most cases, no pre-operative investigations are required
due to the predictable anatomy of the IM vessels at the level
of the third rib. Pre-operative mapping is therefore usually
reserved for the abdominal wall perforators, to minimize
exposure of the patient to unnecessary radiation. In exceptional cases (e.g. previous chest wall surgery), the diameter
and ow of the IM vessels can be assessed pre-operatively by
colour duplex scanning or CT/MR angiography.
There may be a role for pre-operative chest CT scanning
to measure intercostal space width, to help plan for the ribpreserving vs. rib-sparing recipient vessel harvest technique.
Most surgeons who favour the rib-preserving technique will,
however, always attempt this approach at rst, and only proceed to excise a small segment of rib cartilage if exposure is
not deemed adequate. Routine chest CT is therefore not
common practice.
a
b
46.4 Recipient Vessel Access (A Figure
withSurface Markings)
Since the IMV never divides proximal to the third rib, it is
best approached in the second or third intercostal space;
preferentially in the second intercostal space due to much
more predictable anatomy, with a wider space and single
vein in 80% cases [9] (Fig.46.2).
Traditionally the IMVs are accessed via the removal of
a segment of costal cartilage (the rib-sacricing approach).
This approach provides excellent, reliable exposure of the
vessels, with a wider space for vessel dissection and anastomosis. Several authors, however, have highlighted a
number of disadvantages of this approach, including lon-
Fig. 46.1 (a) Latex injection dissection specimen demonstrating the
anatomy of the IMA along its entire course. (b) Anatomy of the IMA
perforators in relation to the second and third intercostal spaces. The
IMV (arrow) has not yet divided, and therefore is best approached
here (from Chap. 51 and provided by Dr Patanis and Dr Song)
46 Chest Wall Recipient Vessels Access
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Fig. 46.2 Pre-op marking of the second–fourth ribs and corresponding
intercostal spaces
ger post- operative pain and tenderness, and chest wall
deformity [10]. With advances in microsurgery, the ribpreserving approach—rst described by Parrett et al. in
2008—was developed, in which the IM vessels are
accessed directly via the intercostal space, without the
removal of the rib [11]. Signicant advantages of this
approach include reduced recipient site morbidity and
post-operative pain relief requirements, and a potential
radio-protective effect.
Though this approach provides an attractive alternative to
the rib harvest technique, the narrower access to the recipient
vessels can lead to increased ap ischaemic time and less
available length, should revision anastomosis be required. A
review of comparative studies has not provided a consensus
as to which technique is superior [12]. The rib-preserving
approach may therefore best be reserved for the experienced
microsurgeon.
When alternative methods of autologous breast reconstruction are needed such as the TUG ap, the fourth rib is
often removed due to the short length of its pedicle. This
allows the ap to sit lower on the chest and match the inframammary fold of the other side. When two aps are required
for one breast reconstruction, by removing the fourth rib, the
surgeon has a higher chance of utilizing anterograde anastomoses for the vein.
46.5 Recipient Vessel Dissection: AStep-
by- Step Guide
• Step 1 (Fig.46.3)—In an immediate reconstruction, the
second and third interspaces are marked before the mas-
tectomy by palpating the ribs starting from the clavicle. In
a delayed DIEP, the horizontal mastectomy scar is
reopened down to the pectoralis major muscle.
457
Fig. 46.3 Step 1—In an immediate reconstruction, the second and
third interspaces are marked before the mastectomy by palpating the
ribs starting from the clavicle. In a delayed DIEP, the horizontal mastectomy scar is reopened down to the pectoralis major muscle
• Step 2 (Fig.46.4a, b)—Pec major is split using monopolar diathermy from its insertion at the sternum along a
length of 4–5cm (Fig.46.2a). Any chest wall perforators
which are sizeable are protected for use of recipient vessels (Fig.46.2b—depicted by arrow).
• Step 3 (Fig.46.5)—A self-retaining Traver’s retractor is
inserted to expose the second and third ribs, and sh
hooks are used to retract the medial tissues. An alternative
to sh hooks involves suturing 2.0 Vicryl sutures to the
medial edge of the sternum and using these sutures as a
retractor.
• Step 4 (Fig.46.6a, b)—The anterior perichondrium of the
lower rib is marked and incised with diathermy.
• Step 5 (Fig. 46.7a, b)—The anterior perichondrium is
stripped from the cartilage using a periosteal elevator
(Fig.46.5a). In cases where there is signicant scarring
due to radiotherapy a Mitchells trimmer can be used
(Fig.46.5b). A cardiac Doyenne aids posterior dissection
with gentle pushing medically once inserted into the
correct plane between the posterior perichondrium below
and the rib above.
• Step 6 (Fig. 46.8)—Once the rib has been completely
freed from the posterior perichondrium, it is protected laterally with a Howarth elevator or Cardiac Doyenne elevator before being cut with a knife.
• Step 7 (Fig.46.9a, b)—The rib is then disarticulated from
the sternum, it can be removed as a single piece. If remnants of rib are still present medially; rongeurs can be
458
P. Hever et al.
ab
Fig. 46.4 (a) Step 2—Pec major is split using monopolar diathermy from its insertion at the sternum along a length of 4-5cm. (b) Step 2—Any
chest wall perforators which are sizeable are protected for use of recipient vessels
Fig. 46.5 Step 3—A self-retaining Traver’s retractor is inserted to
expose the second and third ribs, and sh hooks are used to retract the
medial tissues. An alternative to sh hooks involves suturing 2.0 Vicryl
sutures to the medial edge of the sternum and using these sutures as a
retractor
ab
46 Chest Wall Recipient Vessels Access
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a b
Fig. 46.6 (a, b) Step 4– The anterior perichondrium of the lower rib is marked (a) and incised with diathermy (b)
459
Fig. 46.7 (a) Step 5—The anterior perichondrium is stripped from the
cartilage using a periosteal elevator. In cases where there is signicant
scarring due to radiotherapy a Mitchells trimmer can be used. (b) Step
5—A cardiac Doyenne aids posterior dissection with gentle pushing
medially once inserted into the correct plane between the posterior perichondrium below and the rib above
used to remove rib medially until the sternum is reached.
Care must be taken not to over-resect and iatrogenically
remove sternum.
• Step 8 (Fig.46.10a, b)—The posterior perichondrium is
dissected free using bipolar cautery from the underlying
tissues. A damp swab can help to gently push and
develop a plane between the overlying perichondrium
and the vessels underneath. Care must be taken not to
avulse or damage the underlying vessels particularly in
cases where the chest is scarred due to radiotherapy—a
nerve hook can help carefully dissect the perivascular
tissues in these cases. To make the space wider, intercostal muscles are resected superiorly and inferiorly down
Fig. 46.8 Step 6—Once the rib has been completely freed from the
posterior perichondrium, it is protected laterally with a Howarth elevator or Cardiac Doyenne elevator before being cut with a blade
to the second and fourth rib. The vessels are then dis-
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