RECONSTRUCTIVE

Heel Reconstruction with a Medial Plantar

V-Y Flap
Paul Roblin, F.R.C.S.(Plast.)
Ciaran M. J. Healy, F.R.C.S.
(Plast.)
London, United Kingdom
Background: Full-thickness defects to the plantar surface of the foot present a
challenge to the reconstructive surgeon. Skin grafts and a variety of flap pro-
cedures have been described to resurface this site, but not all achieve a return
to normal foot function. For the plantar surface of the heel, the previously
described medial plantar flap can produce successful results. However, this
method leaves a donor site, which requires skin grafting. This is a report of a
modification of the medial plantar flap into a V-Y configuration that allows direct
closure of the donor site.
Methods: Three defects of the plantar surface of the heel were resurfaced: case
1, a spina bifida patient with a 45-mm-wide debrided pressure sore; and cases
2 and 3, patients with defects resulting from wide excisions of melanomas that
were 47 and 57 mm wide, respectively. Patients in cases 2 and 3 were reviewed
at 1 year for mobility, gait, and sensation in the flap.
Results: The patients in cases 2 and 3 were able to attain full, unrestricted
mobility and objectively near-normal sensation of the resurfaced skin. In the
patient in case 1, a problematic pressure sore was healed after an intermediate
period of wound dehiscence, with a robust, bulky flap.
Conclusions: This modified flap retains the advantages of the traditional medial
plantar flap while minimizing its donor-site problems. It has permitted satis-
factory long-term functional results, optimizing restoration of foot function, and
is a useful option that can be considered for resurfacing the problematic plantar
surface of the heel. (Plast. Reconstr. Surg. 119: 927, 2007.)

R
esurfacing the sole of the foot, with its
unique skin type, presents a challenge to the
reconstructive surgeon.1 The glabrous epi-
dermis and dermis are thicker than in other re-
gions of the body, and a thick subcutaneous fat
layer is bound into compartments by strong verti-
cal fibrous septa that are densely adherent to the
plantar fascia and the periosteum of the calcaneum.
A full-thickness defect in this area ideally
should be reconstructed with durable sensate
tissue and leave minimal scarring. The nearer to
this goal the reconstructive technique is, the
higher the likelihood that normal foot function
will be achieved. A wide range of techniques
have been used, although few have yielded en-
tirely satisfactory results.
From the Department of Plastic Surgery, St. Thomas’
Hospital.
Received for publication May 26, 2005; accepted October 24,
2005.
Poster presented at the Fifth World Conference on Melanoma,
in Venice, Italy, February 28 through March 3, 2001.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000242484.54997.9e
We present three cases to illustrate a new tech-
nique for resurfacing defects of the plantar sur-
face of the heel. The medial plantar flap is fre-
quently used at this site2,3 and takes advantage of
the fact that the skin on the instep of the foot is
non–weight-bearing. A split skin graft is re-
quired to close the donor site, though, which
can be problematic for the patient. To over-
come this, a V-Y islanded flap was designed,
based on the same neurovascular system, per-
mitting direct donor-site closure. This report
outlines the clinical course and long-term out-
come of this technique.
PATIENTS AND METHODS
The blood supply of the plantar surface of the
foot is derived from the posterior tibial artery,
which divides into the medial and lateral plantar
arteries after passing posterior to the medial mal-
leolus. The medial plantar artery courses deep to
the origin of the abductor hallucis muscle and
proceeds in the cleft between the abductor hal-
lucis and the flexor digitorum brevis muscles. It
supplies the medial plantar skin by means of per-
forators that pass on either side of the abductor

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 Plastic and Reconstructive Surgery • March 2007

hallucis muscle and as myocutaneous perforators
through it.3 Distally, perforators pass through the
dividing slips of the plantar fascia to supply the
subdermal plexus. Over the proximal two-thirds of
the plantar fascia and the area over the calca-
neum, there are no direct perforating vessels.
Here, vessels course around the lateral and the
medial borders of the fascia to supply the subder-
mal plexus.4 Distally, the medial plantar artery
divides into its digital branches.2
Sensation to the skin of the instep is supplied
by the medial plantar nerve which, after its origin
from the posterior tibial nerve, is closely related to
the medial plantar artery. Proximally, cutaneous
divisions branch off the main trunk to supply the
skin of the instep.2,5
The medial plantar flap in this report was de-
signed in a V-Y fashion, allowing it to move prox-
imally. Under general anesthesia, with tourniquet
control and using loupe magnification, the flap
was outlined and the skin incisions were made
(Fig. 1). These were extended through the fascia,
which was included in the flap. Medially, the ab-
ductor hallucis brevis muscle was exposed and the

Fig. 1. (Above) Photograph of the patient in case 3, showing a 45 ⫻ 25-mm

defect following debridement of an unhealed pressure sore on the plantar sur-
face of the left heel. The design of the V-Y islanded medial plantar flap is shown.
(Center) The V-Y islanded medial plantar flap has been raised. The pedicle is
demonstrated. (Below) The V-Y islanded medial plantar flap has been inset prox-
imally into the excision defect.

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Volume 119, Number 3 • Heel Reconstruction with a V-Y Flap

medial plantar neurovascular bundle identified

between this and the flexor digitorum brevis mus-
cle. Through the lateral incision, the flexor digi-
torum brevis muscle was exposed on its lateral
border and the medial plantar neurovascular bun-
dle again identified and preserved in the flap.
Distally, the medial plantar artery was divided
and the flap raised from distal to proximal in the
plane between the muscle layer and the fascia,
incorporating the artery. Interfascicular dissec-
tion of the medial plantar nerve preserved digital
nerves and muscle branches and retained cutane-
ous branches in the flap. All the fascial septa along
the length of the flap were divided to allow suffi-
cient mobilization of the flap proximally into the
defect, with primary closure of the donor site.

CASE REPORTS
Case 1
A 29-year-old man with paraplegia secondary to spina bifida
presented with a 10-month history of a nonhealing ulcer on the
minimally sensate plantar surface of the left heel. He was able
to mobilize by partial weight-bearing with the aid of crutches.
The wound was debrided to leave a defect, down to bone,
measuring 45 ⫻ 25 mm. The plantar defect was resurfaced with
a proximally based V-Y medial plantar neurovascular island flap
(Fig. 1). He was discharged with the suture lines intact but then
began weight-bearing immediately despite advice to refrain
from doing so. The flap inset dehisced along the lateral border.
This was managed conservatively with regular dressings and by
3 months was completely healed. Despite repeated requests, the
patient failed to attend further reviews, which may indicate that
there have been no further problems with the foot.
Case 2
A 67-year-old woman with type II diabetes (diet-controlled)
presented with a biopsy-proven melanoma in situ (showing foci
suspicious for invasion) on the plantar surface of the heel of the
left foot. The lesion was 10 ⫻ 9 mm, with a further pigmented
lesion (2 ⫻ 3 mm) at its distal border. These were excised en
bloc, down to fascia with a 1-cm margin, leaving a 47-mm-
diameter plantar defect (Fig. 2, above), which was also resur-
faced with a proximally based V-Y medial plantar neurovascular
island flap (Fig. 2, center).
The patient was fully weight-bearing at 2 months and walking
with a normal gait at 5 months. At 1-year review (Fig. 2, below),
walking distance was unrestricted with the aid of a silicone insert
to reduce scar sensitivity. On examination, the patient’s sensory
localization was accurate; light and sharp touch were distin- Fig. 2. Case 1. (Above) A 47-mm-diameter defect following wide
guished; two-point discrimination6 was 14 mm on the left and excision of a melanoma and adjacent lesion on the plantar sur-
12 mm on the right foot; and Semmes-Weinstein monofilament face of the left foot. Patent blue dye injected for simultaneous
threshold testing7 was 4.56 for both feet. The patient’s gait was sentinel lymph node biopsy is seen coursing through the adja-
normal and the footprint pattern revealed an even weight dis-
cent cutaneous lymphatic channels. The design of the V-Y flap
tribution for both feet (Fig. 3).
based on the medial plantar neurovascular bundle has been
Case 3
marked. (Center) The V-Y islanded medial plantar flap has been
A 55-year-old woman presented with a biopsy-proven acral
lentiginous melanoma on the plantar surface of the right heel, incised and isolated on its pedicle before being advanced prox-
with a Breslow thickness of 3 mm and Clark level IV invasion. imally into the heel defect. (Below) The healed V-Y islanded me-
The 1.5-cm-diameter lesion was excised down to fascia, with a dial plantar flap 1 year postoperatively.
2-cm margin, leaving a defect 57 mm in diameter. The plantar
defect was resurfaced with a proximally based V-Y medial plan-
tar neurovascular island flap. The edges of the flap were loosely

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 Plastic and Reconstructive Surgery • March 2007
Fig. 3. (Left) Imprints of paint from the left foot (operated on)
when walking on an even surface, 1 year postoperatively. (Right)
Imprints of paint from the right foot (not operated on) when
walking on an even surface, 1 year postoperatively.
opposed to the edges of the defect and the donor defect was
closed directly. In the early postoperative period, sutures along
the border of the flap were released to relieve venous conges-
tion. This left a raw area that required a period of dressing with
the vacuum-assisted closure pump8 to achieve complete heal-
ing.
After initial partial weight-bearing, the patient was able to
fully bear weight at 2 months postoperatively. At 1-year review,
the patient was able to walk 3 miles comfortably, and apart from
using a wider shoe fitting, had experienced no other problems.
On examination, sensory localization was accurate; light and
sharp touch were distinguished; two-point discrimination was
20 mm on the right and 15 mm on the left; and Semmes-
Weinstein monofilament threshold testing was 4.3 for both feet.
The patient’s gait was normal and the footprint pattern re-
vealed an even weight distribution (Fig. 4).
DISCUSSION
A variety of techniques have evolved for re-
constructing defects of the plantar surface of the
foot. Sommerlad and McGrouther reviewed a
number of these and found that no one particular
technique was superior or ideal. Most patients
walked with an altered gait and avoided weight-
bearing on the resurfaced plantar area (particu-
larly the heel). Complications included pain, de-
creased mobility, ulceration, and hyperkeratosis.1
Skin grafts9,10 have met with limited success
and can lead to problems such as skin breakdown
930
Fig. 4. One year after a V-Y medial plantar flap to resurface a
57-mm defect on the right heel from a wide excision of a mela-
noma. (Left) Imprints of paint from the left foot (not operated on)
when walking on an even surface, 1 year postoperatively. (Right)
Imprints from the right foot (operated on) when walking on an
even surface.
and hyperkeratosis,1,11 although thicker grafts may
be superior.12 Small areas of tissue loss can be
covered by innervated local random pattern su-
prafascial transposition or rotation flaps,13,14 but
poor tissue laxity in this area limits their size.3 In
the distal foot, V-Y flaps based on perforating ves-
sels are useful but have limited excursion, al-
though two opposing flaps can be used for larger
defects.4 The dimensions of the three defects pre-
sented here were greater than 45 mm on the plan-
tar surface of the heel. Our aim was to resurface
this weight-bearing area with durable, sensate skin
to achieve gait and weight distribution that were as
near normal as possible.
Proximally, over the heel, the reduced density
of perforators limits the usefulness of the flaps
already mentioned. Fillet flaps of the toes15–17 or
neurovascular islanded flaps from the lateral side
of the hallux (which retains the hallux)12,18 are
useful but in the normal configuration would not
reach the heel and are of limited size.3 The cross-
instep flap,19 the cross-foot flap,20 and the cross-leg
flap21 are options but are insensate and require
immobilization postoperatively. Larger high-en-
Volume 119, Number 3 • Heel Reconstruction with a V-Y Flap
ergy injuries require free tissue transfer with either
muscle or fasciocutaneous flaps.22–24 At the heel,
local pedicled muscle flaps12,25 are available, but
neurovascular fasciocutaneous flaps are prefera-
ble because they do not disturb the muscle layer
and may become more adherent to the perios-
teum of the calcaneum, thus preventing any dis-
concerting movement or shearing between the
layers.5
Shanahan and Gingrass were the first to use
the skin of the instep when they described the
medial plantar sensory flap to resurface the heel2;
shortly afterward, this was modified as an islanded
pedicle flap.3 Further modifications have been the
inclusion of muscle,3,25,26 a reverse-flow island flap
design for more distal defects,17 and a free flap
to cover defects on the contralateral heel.5 Sim-
ilar flaps based on the lateral plantar neurovas-
cular bundle have also been described.5–13 The
medial design is preferable, as it uses the instep
skin, has a wide arc of rotation, and maintains
intact tissue over the weight-bearing fifth meta-
tarsal head.12
The traditional design of the medial plantar
artery flap necessitates skin grafting of the donor
site2 which, although a non–weight-bearing area,
is potentially problematic. In addition, if it is not
truly islanded, a dog-ear deformity is left.3 The V-Y
design of the flap overcomes these two problems
and retains the advantages of the flap. Division of
all the vertical fibrous septa attaching the flap to
underlying tissues achieved unrestricted move-
ment of the pedicle, as with the original design. If
the pedicle is restricting further excursion, addi-
tional freedom could be obtained by division of
the abductor hallucis muscle.
As in the standard flap design, the flap is sen-
sate. Although the necessity of sensation for nor-
mal foot function has been questioned by some,1,12
it appears to result in an earlier return to normal
gait and function24,27,28 and has contributed to the
effectiveness of the medial plantar flap.2,5 Intrafas-
cicular dissection was performed to retain sensa-
tion in the flap and ensured that the nerve fibers
did not restrict flap movement. An obvious
plane between the nerves allowed straightfor-
ward proximal dissection, enabling identifica-
tion and protection of the distally coursing dig-
ital nerves. The patients in cases 2 and 3 did not
comment on any altered distal sensation or func-
tion and on objective examination had retained
sensation in the flap comparable to that of the
contralateral foot.
In this series of cases, a V-Y modification of the
traditional medial plantar flap has been shown to
be successful in resurfacing the plantar surface of
the heel. It is a type C, septofasciocutaneous type
flap,29 that has allowed the closure of three po-
tentially problematic wound defects, with adjacent
glabrous skin. In addition to providing sufficient
tissue bulk, sensation comparable to that of the
contralateral foot was achieved. This gave the pa-
tients in cases 2 and 3 the optimal chance of
achieving a normal gait, and was demonstrated by
these two patients who had full mobility with a
normal gait. For the patient in case 1, tissue of
good durability and bulk was imported, optimiz-
ing the likelihood of long-term healing of a pres-
sure sore. With this technique, local muscle flaps
have also been retained for future use.
Possible limitations of this flap should be con-
sidered before its use and are illustrated by the
complications seen in this series. There were two
complications. A congested flap (case 3) was main-
tained by removing sutures to reduce the tension
on the flap which, after a period of conservative
management, healed with good long-term results.
This indicates that there is a limit to the size of the
wound (57 mm in this case) that can be resur-
faced. To avoid placing scars on the weight-bear-
ing metatarsophalangeal joint area of the hallux,
there is a limit to the distal extent of the flap
design. In addition, ideally, the long axis of the
flap should be twice the radius of the defect it is
resurfacing,30 which may impose a limit on the
dimensions of the flap. Therefore, more distally
placed or larger defects will not be suitable for
reconstruction with this flap. In this series, suffi-
cient proximal excursion of the flap was possible
to allow it to reach the proximal border of the
plantar surface of the heel.
In the patient in case 1, poor patient compli-
ance led to a period of delayed healing. For those
with decreased plantar sensation, a sufficient pe-
riod is required to allow complete healing. Fol-
lowing this, regular inspection must be performed
to identify problems with the wound or scar at an
early stage. Caution may be required in patients
with peripheral vascular disease.
Because of the site of excision defects, place-
ment of scars on the weight-bearing surface may
be unavoidable. These are potentially problematic
because of pain and wound dehiscence. One pa-
tient required a silicone insert (to reduce scar
sensitivity), but this enabled her to walk for long
periods.
CONCLUSIONS
The V-Y modification of the medial plantar
artery, as illustrated in these three cases, success-
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 Plastic and Reconstructive Surgery • March 2007
fully resurfaced the difficult plantar heel area with
appropriate sensate plantar tissue and allowed do-
nor-site closure. This has permitted satisfactory
long-term functional results, optimizing restora-
tion of foot function, with minimal donor-site
problems. This flap is a useful option that can be
considered for reconstruction of the problematic
area on the plantar surface of the heel.
Paul Roblin, F.R.C.S.(Plast.)
3 Coombe Neville
Warren Road
Kingston-Upon-Thames
Surrey KT2 7HW, United Kingdom
paulroblin@doctors.org.uk
DISCLOSURE
There are no disclosures or conflicts of interest for
either author.
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