作者：Zelken JA, Chih-Hung Lin
文章發表：Annals of Plastic Surgery. 76(2):221–226
大綱：由於有剪力的向量(是一種與表面成正切方向作用，而引起滑動或扭轉變形的作用力)，前腳比後腳更容易出現營養性潰瘍。修復足底潰瘍和其他前足缺陷是一項艱鉅的挑戰。我們贊成以神經支配的游離足底內側皮瓣來取代患處，並給予皮瓣保護功能。我們調查了迄今為止所有最大系列的皮瓣的可行性，並首次描述了同側皮瓣轉移。方法：在2009年至2013年之間，對7例前足缺損患者進行了神經支配的游離足底內側皮瓣治療。 4名男性和3名女性的平均年齡為35.1歲（範圍為8-50歲）。適應症是創傷和腫瘤缺陷覆蓋後的繼發性重建。平均缺損為5×7厘米（範圍為4-6厘米×6-10厘米）。使用對側皮瓣進行治療4例，同側皮瓣3例。結果：皮瓣平均大小為8.1±1.6厘米×5.9±1.2厘米。沒有手術後期併發症、靜脈充血或動脈供血不足。臨床上對患者進行了38.5個月的追蹤（範圍為6個月至10年）。足底皮瓣重建7個月後，一名患者死於轉移性疾病併發症；兩名患者進行了感官測試和步態分析，外觀令人滿意，走動恢復正常，在每種情況下都有保護感。有2名患者，在後續修復中切除了角化過度的組織。結論：對顯微外科技術醫師來說，經神經支配的游離內側足底瓣是覆蓋足前額中至大型缺損的有效且可行的選擇。它在我們的前足重建方法中佔有一席之地。
BACKGROUND:
Because of shearing forces, the forefoot is more prone to trophic ulcers than the heel. Reconstruction of trophic ulcers and other forefoot defects is a vexing challenge. We favor the innervated free medial plantar flap to replace like-with-like and confer protective sensation. We investigate the feasibility of this flap with the largest series to date and the first to describe ipsilateral flap transfer.
METHODS:
Between 2009 and 2013, 7 patients with forefoot defects were treated with innervated free medial plantar flaps. The average age of 4 men and 3 women was 35.1 years (range, 8-50 years). Indications were secondary reconstruction after trauma and coverage of oncologic defects. The mean defect was 5 × 7 cm (range, 4-6 cm × 6-10 cm). Four patients were treated with contralateral flaps and 3 with ipsilateral flaps using interposition vein graft.
RESULTS:
The mean flap size was 8.1 ± 1.6 cm × 5.9 ± 1.2 cm. There was no perioperative complication, venous congestion, or arterial insufficiency. Patients were followed clinically for 38.5 months (range, 6 months to 10 years). One patient died from complications of metastatic disease 7 months after plantar flap reconstruction. Two patients underwent sensory testing and gait analysis. The appearance was satisfactory, ambulation returned to normal, and there was protective sensation in every case. In 2 cases, hyperkeratotic tissue was excised in revision procedures.
CONCLUSIONS:
The innervated free medial plantar flap is an attractive and feasible option for coverage of medium-to-large defects of the plantar forefoot in the hands of a skilled microsurgeon. It has a place in our algorithmic approach to forefoot reconstruction.
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