Weight-bearing Plantar Reconstruction Using a Propeller Flap from the Lateral Plantar Artery Perforators.

Plantar reconstruction, especially in weight-bearing areas, remains one of the biggest challenges for plastic surgeons. The unique anatomy and microarchitecture of this surface pose additional difficulties.

The medial and lateral plantar flaps are very useful in this area because of their reliability; in the case of the medial plantar flap, its extension to non-weight-bearing zones makes it promising for use in such areas. The reverse island flap pedicled with the lateral or medial plantar artery can be used to repair defects of this region.[1,2] However, these techniques sacrifice one of the principal plantar blood vessels.

We present a propeller perforator flap from the lateral plantar artery perforator for repairing a plantar defect without sacrificing principal blood vessels, unlike in the reverse flow technique, where performing ligature (either proximally or distally) of one of the 2 most important vessels of the foot is necessary. An immediate coverage after melanoma excision in a 40-year-old patient was done, and lateral and medial plantar arteries were left intact.

We identified the location of perforators close to defect with a handheld Doppler, and it showed one perforator arising from the plantar artery. We designed the flap centered over this perforator. The surgical excision of the melanoma with wide margins was done by a general surgeon team, and the defect size was 3 × 3 cm.

We started with a medial exploratory incision to the defect, looking for the perforator. The lateral plantar artery perforators are consistently present.[2] The perforators are usually found between the abductor digiti minimi and the flexor digitorum brevis muscle (Fig. 1). Once the perforator is identified, the flap is undermined laterally to medially. In 2010, Cigna[3] described an island lateral artery perforator flap in a V-Y advancement fashion, without altering the foot blood inflow and outflow. We found a limitation covering the defect advancing the flap in a V-Y fashion, despite dissecting the perforator 1 cm.

Fig. 1.

The perforators are usually found between the abductor digiti minimi and the flexor digitorum brevis muscle. The green arrow shows the perforator from the lateral plantar artery.

This limitation was eliminated using a propeller design. The flap was rotated 180 degrees without ligature of any blood vessel, achieving a larger coverage of the defect in this fashion and avoiding kinking of the perforator. The donor site was closed directly and the flap healed without complications, not even with venous congestion (Fig. 2).

Fig. 2.

The propeller perforator flap is supplied by a perforator from the lateral plantar artery. On the left side (A), a yellow cross shows the perforator and the pivot point of the propeller flap. On the right side (B), the final result after 3 months with direct primary closure of the donor site.

This technique is minimally invasive, avoids sacrifice of blood vessels, takes a short surgical time, replaces “like-with-like” with minimal donor site drawbacks, and allows the coverage of wider plantar regions in comparison with the V-Y advancement flap technique.

The disadvantages of this technique are: a careful and sometimes tedious dissection of this flap due to the perforator size and the anatomy of the area. Moreover, it is indicated only in small-to-moderate defects of the weight-bearing areas.

In conclusion, we describe our experience with a propeller perforator flap from the lateral plantar artery, very unusual, with no articles published with the propeller fashion, but a suitable alternative for plantar reconstruction.