56-year-old woman with a right heel cutaneous lesion
A 56-year-old woman with no significant past medical history presented with 6-month history of a painless right heel cutaneous lesion. On exam, she had a non-tender melanotic lesion measuring approximately 2 cm x 2 cm with irregular borders and central ulceration involving the right medial heel pad (Figure 1). There was no palpable lymphadenopathy and the right lower extremity was neurovascularly intact.
What is your next step in workup of this patient?
Punch biopsy, MRI and PET/CT
Histology from punch biopsy was consistent with malignant melanoma, Breslow depth 1.25 mm. MRI demonstrated an area of signal enhancement involving the skin and associated subcutaneous tissues corresponding with the lesion. PET/CT revealed focal fluorodeoxyglucose (FDG) uptake within the right medial heel consistent with malignant melanoma. There was no evidence of lymphatic spread or other distant metastatic disease (Figure 2).
The patient underwent sentinel node biopsy and wide local excision of the melanoma. The inguinal node returned negative for tumor involvement. A 1.5-cm margin was created around the heel lesion. Subcutaneous fat was taken as the deep margin with preservation of the calcaneal periosteum (Figure 3). All the margins were negative.
How should soft tissue coverage be provided?
See answer on the next page.
Medial plantar artery island flap
The patient was an avid cyclist and, given the location of the soft tissue defect within the weight-bearing portion of the heel, a medial plantar artery island flap was chosen to provide durable and sensate soft tissue coverage.
Medial plantar artery cutaneous perforators were marked with Doppler pencil. A flap approximately 20% larger than the defect was created (Figure 4). Meticulous dissection was carried out to mobilize the medial plantar neurovascular bundle supplying the flap (Figure 5). The flap was then pedicled into the defect site and loosely inset with nylon suture. Use of SPY Elite (Stryker) verified good perfusion of the flap. The donor site was covered with Integra (Integra LifeSciences Corp.) (Figure 6). The patient was placed in a well-padded Robert Jones splint. She had an uneventful postoperative recovery and was dismissed from the hospital on postoperative day 2.
When the patient returned 3 weeks later, the wound was noted to be in excellent condition with continued viability of the flap and granulation tissue formation at the donor site (Figure 7). She was taken for split-thickness skin grafting at the donor site after which she was again placed into a well-padded splint and kept non-weight-bearing. The patient returned after about 1 week and was noted to have 100% take of the skin graft (Figure 8). She was placed in a walking boot and kept non-weight-bearing for an additional 2 weeks. She returned after another month and reported she was doing well and she was ambulating with a cane, however she reported mild tenderness at both the flap and skin graft sites. On exam, her skin graft had completely healed apart from two small eschars and her flap was pink with brisk capillary refill (Figure 9). She returned again after 6 months and reported she had returned to all activities, including cycling. The patient reported some discomfort associated with a scar band at the medial border of her skin graft, as well as bulkiness of the flap at the posterior and superior aspects that led to mild irritation with shoe wear (Figure 10). She was taken for scar revision and flap contouring. At her visit 1 month later, the patient had no complaints and had resumed daily activity and noted no further discomfort with shoe wear. Her wounds were nearly completely healed. The contours of her flap, as well as the medial border of the skin graft, were much improved (Figure 11). She had no evidence of local or systemic tumor recurrence. She was released to full activity without restriction.
Current guidelines from both the National Comprehensive Cancer Network and our institution recommend a wide peripheral (1 cm to 2 cm) and deep (down to, but not including, fascia except in the hands and feet where a deep fascial margin is taken owing to a thin subcutaneous layer in these regions) resection margin in cases of intermediate thickness primary cutaneous melanomas. When localized to the foot, this often leads to significant tissue loss and exposure of underlying bone requiring soft tissue reconstruction. Soft tissue defects of the plantar heel are a particularly challenging problem to manage owing to limited reconstructive options and propensity for transferred tissue breakdown secondary to shear and compressive stresses associated with weight-bearing. In general, the goals of soft tissue reconstruction of the plantar foot are to cover the defect with a durable sensate flap comprised of similar glabrous skin while minimizing donor site morbidity and avoiding sacrifice of major nerves and vessel.
The medial plantar artery island flap was originally described in 1981 and has gained increasing interest as a ductile flap able to meet all of the aforementioned fundamental needs of plantar foot soft tissue reconstruction. Use of this flap has been reported in the plastic surgery literature for a variety of indications including trauma, chronic non-healing ulceration and other wounds, and tumor. However, reports of its use within the orthopedic literature, particularly following tumor resection, are more limited.
The heel pad is composed of a thick epidermal/dermal layer with specialized underlying subcutaneous fat, which imparts this tissue the ability to withstand the compressive and shear forces associated with weight-bearing. Thus, when reconstructing defects in this region, transferred tissue must have similar histologic characteristics for long-term durability. The medial plantar region or instep is generally non-weight-bearing, yet it retains the unique weight-bearing histologic characteristics of the plantar foot. In a series by Jia-Xiang Gu, MD, PhD, and colleagues, seven patients underwent medial plantar artery island flap reconstruction following melanoma resection; all patients went on to heal uneventfully without infection, venous congestion, partial flap necrosis or the need for further surgery and, at mean follow-up of 20 months, all patients were satisfied and had flaps that were in good condition.
Soft tissue reconstruction in the heel pad region should provide protective sensation. In the case of the medial plantar artery flap, the nerve branch supplying the skin paddle may be easily harvested and transferred with the flap, thus preserving protective sensation. Derrick C. Wan, MD, and colleagues, in a review of three patients treated with medial plantar artery island flaps for soft tissue defects of the heel, found that sensation, including sharp pain, vibration, deep pressure, cold perception, light touch and two-point discrimination was identical in the flap to that of the contralateral instep.
Any soft tissue reconstructive procedure should have minimal donor site morbidity. Several authors have reported patients returning to normal footwear and desired activity without limitation following medial plantar artery island flap. J.T. Paget and colleagues objectively looked at donor site morbidity with gait and pressure analysis; they discovered objectively weaker push-off through the hallux, although this was well tolerated by patients.
In summary, the medial plantar artery island flap is ideally suited for reconstructing defects of the heel pad. It provides a durable reconstruction due to its histologic characteristics that are similar to the heel pad, preserved sensation and minimal donor site morbidity. We present a case of medial plantar artery island flap for soft tissue coverage after resection of melanoma. Increased awareness of this proven reconstruction option within the orthopedic community would be beneficial.
- Acikel C, et al. Ann Plast Surg. 2003;doi:10.1097/01.SAP.0000044141.35292.A7
- Bibbo C. F Foot Ankle Surg. 2012; doi:10.1053/j.jfas.2012.04.017.
- Grotz TE, et al. Mayo Clin Proc. 2011;doi:10.4065/mcp.2011.0059.
- Gu JX, et al. J Foot Ankle Surg. 2017;doi:10.1053/j.jfas.2016.11.022.
- Guillier D, et al. J Plast Reconstr Aesthet Surg. 2020;doi:10.1016/j.bjps.2019.10.019.
- Harrison DH, et al. Br J Plast Surg. 1981;doi:10.1016/0007-1226(81)90019-9.
- Khan FH, et al. Plast Reconstr Surg Glob Open. 2018;doi:10.1097/GOX.0000000000001991.
- Oh SJ, et al. J Plast Reconstr Aesthet Surg. 2011;doi:10.1016/j.bjps.2010.04.013.
- Paget JT, et al. Foot Ankle Surg. 2015;doi:10.1016/j.fas.2014.09.009.
- Scaglioni MF, et al. Plast Reconstr Surg. 2018;doi:10.1097/PRS.0000000000003975.
- Siddiqi MA, et al. Foot Ankle Surg. 2012;doi:10.1053/j.jfas.2012.06.003.
- Wan DC, et al. Plast Reconstr Surg. 2011;doi:10.1097/PRS.0b013e3181fed76d.
- Wang M, et al. J Foot Ankle Surg. 2018;doi:10.1053/j.jfas.2017.12.004.
- Yang D, et al. Ann Plast Surg. 2011;doi:10.1097/SAP.0b013e3181f9b278.
- For more information:
- Matthew T. Houdek, MD, and Joshua D. Johnson, MD, can be reached at department of orthopedic surgery, Mayo Clinic, and Steven L. Moran, MD, can be reached at division of plastic and reconstructive surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Houdek’s email: firstname.lastname@example.org. Johnson’s email: email@example.com. Moran’s email: firstname.lastname@example.org.
- Edited by Joshua D. Johnson, MD, and Nicholas A. Trasolini, MD. Johnson is a chief resident in the department of orthopedic surgery at Mayo Clinic in Rochester, Minnesota. He will be a musculoskeletal oncology fellow at MD Anderson following residency. Trasolini is the administrative chief resident in the department of orthopedic surgery at Keck Medical Center of the University of Southern California and will be a sports medicine fellow at Rush University Medical Center following residency. For information on submitting Orthopedics Today Grand Rounds cases, please email: email@example.com.
Disclosures: Moran reports he is a paid consultant for and receives IP royalties from Integra. Johnson and Houdek report no relevant financial disclosures.