Effectiveness of innervated medial plantar flap for reconstruction of soft tissue defects following foot tumor resection_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Wenchao ¹ , GUO Luqi ¹ , HAO Yan ¹ , WANG Liangya ¹ , ZHANG Chao ² , WANG Yun ² , HUANG Jiuzuo ¹ , ZENG Ang ¹ ,  LONG Xiao ¹

1. Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, P. R. China;
2. Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, P. R. China;

Corresponding author：

LONG Xiao, Email: pumclongxiao@126.com

Keywords：

Foot neoplasms; soft tissue defects; medial plantar flap; sensory reconstruction; photon-counting computed tomography angiography

DOI：

10.7507/1002-1892.202506087

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Objective To evaluate the effectiveness of the innervated medial plantar flap for reconstructing soft tissue defects, particularly in the weight-bearing zone, after resection of foot tumors. Methods A retrospective analysis was conducted on 12 patients with malignant skin and soft tissue tumors of the foot treated between October 2023 and December 2024. The cohort included 8 males and 4 females, aged 42-67 years (mean, 57.5 years). Tumor types comprised malignant melanoma (5 cases), squamous cell carcinoma (4 cases), arsenical keratosis (2 cases), and tumor-induced osteomalacia (1 case). Soft tissue defects were located in the heel weight-bearing zone in 10 cases and non-weight-bearing ankle region in 2 cases, with defect sizes ranging from 4.0 cm × 3.0 cm to 6.0 cm × 4.0 cm. Preoperative photon-counting CT angiography (PC-CTA) was performed to assess the medial plantar artery and its perforators. All patients underwent radical tumor resection with confirmed negative margins. The resulting defects were reconstructed using a innervated medial plantar flap incorporating sensory branches of the medial plantar nerve. The flap donor site was covered with a split-thickness skin graft harvested from the ipsilateral inguinal region. Results The operation was successfully completed in all 12 patients. All flaps survived completely without vascular compromise, partial necrosis, or total loss. Incisions healed primarily without dehiscence or infection. Minor skin graft necrosis occurred at the donor site in 3 patients, which healed within 2-3 weeks with routine dressing changes. No donor-site complications (e.g., tendon or nerve injury) occurred. Patients were followed up 2-16 months (mean, 10.3 months). At last follow-up, there was no tumor recurrence. Flaps exhibited good color and texture match with surrounding tissue, restored sensation, and all patients achieved normal weight-bearing activity. Conclusion The innervated medial plantar flap, precisely designed based on PC-CTA localization, provides reliable blood supply and effective sensory restoration. It is an ideal method for reconstructing soft tissue defects after foot tumor resection, especially in the weight-bearing heel region.

1.	Scaglioni MF, Rittirsch D, Giovanoli P. Reconstruction of the heel, middle foot sole, and plantar forefoot with the medial plantar artery perforator flap: Clinical experience with 28 cases. Plast Reconstr Surg, 2018, 141(1): 200-208.
2.	Lohasammakul S, Turbpaiboon C, Chaiyasate K, et al. Anatomy of medial plantar superficial branch artery perforators: Facilitation of medial plantar superficial branch artery perforator (MPAP) flap harvesting and design for finger pulp reconstruction. Microsurgery, 2018, 38(5): 536-543.
3.	曾昂, 乔群, 方柏荣, 等. 增强CT 辅助设计带蒂腹壁下动脉穿支皮瓣的临床应用. 中国修复重建外科杂志, 2008, 22(12): 1426-1429.
4.	Zheng Y, Zhang S, Hong JP, et al. Medial plantar artery perforator kiss flap for salvage of extensive palmar skin defect. Plast Reconstr Surg, 2024, 153(6): 1348-1357.
5.	Liu JF, Zhao LR, Lu LJ, et al. Limb salvage surgery following resection of a melanoma: Foot and ankle reconstruction using cutaneous flaps. Oncol Lett, 2014, 8(5): 1966-1972.
6.	Suh YC, Suh HP, Lee JS, et al. Reconstruction using a perforator free flap after malignant melanoma resection of the ankle and foot. J Surg Oncol, 2017, 116(7): 862-869.
7.	Bae YC, Kim JH, Yi CC. The value of anterolateral thigh free flap for the reconstruction of malignant melanoma of the sole of the foot. Ann Plast Surg, 2024, 92(4): 424-431.
8.	Lee KT, Park SJ, Mun GH. Reconstruction outcomes of oncologic foot defect using well-contoured free perforator flaps. Ann Surg Oncol, 2017, 24(8): 2404-2412.
9.	Suh YC, Kim HB, Brown E, et al. Maximizing the flap inflow in a foot reconstruction: Ultrasonographic evaluation of artery flow in accordance with the angle of the ankle. Plast Reconstr Surg, 2021, 148(2): 258e-261e.
10.	Shah KD, Zhou J, Roper J, et al. Photon-counting CT in cancer radiotherapy: technological advances and clinical benefits. Phys Med Biol, 2025, 70(10): 10TR01. doi: 10.1088/1361-6560/add4ba.
11.	Flores JD, Poludniowski G, Szum A, et al. Clinical photon-counting CT increases CT number precision and reduces patient size dependence compared to single- and dual-energy CT. Br J Radiol, 2025, 98(1169): 721-733.
12.	Watanabe M, Murakami R, Miyauchi R, et al. Utility of preoperative multidetector-row computed tomographic angiography after sublingual nitroglycerin with three-dimensional reconstruction in planning of the anterolateral thigh flap. Plast Reconstr Surg, 2020, 145(2): 407e-411e.
13.	Ahmad Alwi AA, Low CL, Kow RY, et al. Evaluation of feasibility of medial plantar artery flap with computed tomography angiography in diabetic patients: A pilot radioanatomic study. Cureus, 2023, 15(10): e48067. doi: 10.7759/cureus.48067.
14.	裴广楠, 李甲, 滕道练, 等. 重建感觉的游离足底内侧动脉穿支皮瓣修复指端创面的效果分析. 中华显微外科杂志, 2022, 45(5): 534-5385.
15.	王克彬, 尹国瑞, 刘凯, 等. 游离足底内侧皮瓣修复手部掌侧软组织缺损17例. 中华显微外科杂志, 2024, 47(3): 321-324.
16.	Dhamangaonkar AC, Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthop Traumatol, 2014, 15(3): 225-229.
17.	Wang M, Xu Y, Wang J, et al. Surgical management of plantar melanoma: A retrospective study in one center. J Foot Ankle Surg, 2018, 57(4): 689-693.

1. Scaglioni MF, Rittirsch D, Giovanoli P. Reconstruction of the heel, middle foot sole, and plantar forefoot with the medial plantar artery perforator flap: Clinical experience with 28 cases. Plast Reconstr Surg, 2018, 141(1): 200-208.
2. Lohasammakul S, Turbpaiboon C, Chaiyasate K, et al. Anatomy of medial plantar superficial branch artery perforators: Facilitation of medial plantar superficial branch artery perforator (MPAP) flap harvesting and design for finger pulp reconstruction. Microsurgery, 2018, 38(5): 536-543.
3. 曾昂, 乔群, 方柏荣, 等. 增强CT 辅助设计带蒂腹壁下动脉穿支皮瓣的临床应用. 中国修复重建外科杂志, 2008, 22(12): 1426-1429.
4. Zheng Y, Zhang S, Hong JP, et al. Medial plantar artery perforator kiss flap for salvage of extensive palmar skin defect. Plast Reconstr Surg, 2024, 153(6): 1348-1357.
5. Liu JF, Zhao LR, Lu LJ, et al. Limb salvage surgery following resection of a melanoma: Foot and ankle reconstruction using cutaneous flaps. Oncol Lett, 2014, 8(5): 1966-1972.
6. Suh YC, Suh HP, Lee JS, et al. Reconstruction using a perforator free flap after malignant melanoma resection of the ankle and foot. J Surg Oncol, 2017, 116(7): 862-869.
7. Bae YC, Kim JH, Yi CC. The value of anterolateral thigh free flap for the reconstruction of malignant melanoma of the sole of the foot. Ann Plast Surg, 2024, 92(4): 424-431.
8. Lee KT, Park SJ, Mun GH. Reconstruction outcomes of oncologic foot defect using well-contoured free perforator flaps. Ann Surg Oncol, 2017, 24(8): 2404-2412.
9. Suh YC, Kim HB, Brown E, et al. Maximizing the flap inflow in a foot reconstruction: Ultrasonographic evaluation of artery flow in accordance with the angle of the ankle. Plast Reconstr Surg, 2021, 148(2): 258e-261e.
10. Shah KD, Zhou J, Roper J, et al. Photon-counting CT in cancer radiotherapy: technological advances and clinical benefits. Phys Med Biol, 2025, 70(10): 10TR01. doi: 10.1088/1361-6560/add4ba.
11. Flores JD, Poludniowski G, Szum A, et al. Clinical photon-counting CT increases CT number precision and reduces patient size dependence compared to single- and dual-energy CT. Br J Radiol, 2025, 98(1169): 721-733.
12. Watanabe M, Murakami R, Miyauchi R, et al. Utility of preoperative multidetector-row computed tomographic angiography after sublingual nitroglycerin with three-dimensional reconstruction in planning of the anterolateral thigh flap. Plast Reconstr Surg, 2020, 145(2): 407e-411e.
13. Ahmad Alwi AA, Low CL, Kow RY, et al. Evaluation of feasibility of medial plantar artery flap with computed tomography angiography in diabetic patients: A pilot radioanatomic study. Cureus, 2023, 15(10): e48067. doi: 10.7759/cureus.48067.
14. 裴广楠, 李甲, 滕道练, 等. 重建感觉的游离足底内侧动脉穿支皮瓣修复指端创面的效果分析. 中华显微外科杂志, 2022, 45(5): 534-5385.
15. 王克彬, 尹国瑞, 刘凯, 等. 游离足底内侧皮瓣修复手部掌侧软组织缺损17例. 中华显微外科杂志, 2024, 47(3): 321-324.
16. Dhamangaonkar AC, Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthop Traumatol, 2014, 15(3): 225-229.
17. Wang M, Xu Y, Wang J, et al. Surgical management of plantar melanoma: A retrospective study in one center. J Foot Ankle Surg, 2018, 57(4): 689-693.

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