practice
Medial plantar artery-based perforator
and island flaps: a case series of
applications in sole defects
Background: Soft tissue defects of the plantar foot pose a challenge
to the reconstructive surgeon. The plantar region of the foot has a
unique skin structure, which helps in its paramount functions of
weight-bearing and providing protective sensation. It is best replaced
with tissue of its own kind. The medial plantar artery (MPA) flap fulfils
all the requirements of an ideal replacement for small-to-
medium‑sized defects in the mid plantar and heel region. This study
describes our experience with MPA-based flaps for small-to-
medium-sized defects of the plantar foot.
Method: The study was conducted in a tertiary referral hospital
between April 2017 and March 2020 on patients who presented with
defects on the mid plantar region and heel. MPA perforator (MPAP)
flap or island flap were applied. The donor site was covered with
split-thickness skin grafts.
Results: The study included 21 patients. MPAP flap was applied in
diabetes ● medial plantar artery flap ● medial plantar artery perforator flap
ulcer ● wound ● wound care ● wound healing
R
esurfacing of the plantar foot with its
unique skin type is a difficult challenge for
the reconstructive surgeon.1 The glabrous
skin is distinctive, with a thicker epidermis
and dermis. The subcutaneous layer is also
thicker and bound into compartments by strong vertical
fibrous septae that are densely adherent to the plantar
fascia and the periosteum of the calcaneum.2 A defect
in this region is best reconstructed with skin matching
in thickness and texture by nearby skin with protective
sensation. The heel is the most critical weight-bearing
area, prone to repeated trauma, and requires a soft tissue
cover that can withstand pressure forces.
Various options have been described for reconstruction
of the plantar foot.2–13 Split-thickness skin grafts (STSG)
are a very poor option for this region as they are prone
to pressure dehiscence. Before the advent of
microsurgery, the main flap for coverage of the distal
foot was the cross-leg flap. Reverse-flow flaps, based on
the perforators of the posterior tibial and peroneal
artery, or the distally based sural flap have a limited
Ansarul Haq1, MCh*; Veena Singh1, MCh; Sarsij Sharma1, MCh
*Corresponding author email: dransarulhaq@aiimspatna.org
1 Department of Burns & Plastic Surgery, All India Institute of Medical Sciences (AIIMS)
Patna, Phulwari Sharif, Patna, Bihar 801507, India.
13 0
nine patients and the island flap was applied in 12 patients. The
mean age of the patients was 37.95 years and the mean flap size
was 36.6cm2. All flaps survived well. In two patients, venous
congestion developed which resolved spontaneously, while three
patients had small graft loss which also healed with conservative
treatment. All patients regained protective sensation within five
months of flap coverage.
Conclusion: Based on the MPA, both perforator and island flaps can
be raised due to the fairly constant position of the perforators. These
flaps have the advantage of robust vascularity with the replacement
of identical tissue for weight-bearing functions along with acceptable
aesthetic outcomes. Since they also have the added advantage of
conferring sensation, they can be used as a primary option in cases
of small-to-medium-sized plantar foot defects.
Declaration of interest: The authors have no conflicts of interest.
● perforator flap ● sole defect ●
extent of coverage. Free-flap reconstruction requires
skilled personnel, specialised equipment, and extra
hospital resources and funding. Many patients with
small-to-medium defects over the foot may be
adequately covered with the use of local flaps. Free-flap
surgery might be too extensive for these small defects,
with the additional potential for complications in older
patients with comorbid conditions.
The medial plantar artery (MPA) flap was first
described by Harrison and Morgan. 14 It is a
fasciocutaneous flap based on the MPA which uses skin
from the instep area of the sole, an ideal tissue for
covering defects of the heel and the sole. MPA flap
preserves the innervation of the flap, giving it a
protective sensation.15 This flap can also be based on
the perforators of the superficial branch of the MPA.16
The medial plantar artery perforator (MPAP) flap also
contains a sensory branch which can provide new
sensation to the defect region.5,17
There are studies describing the use of the MPA flap;
however, only a few papers report the use of the MPAP
© 2022 MA Healthcare Ltd
flap. We believe that this, being a sensate flap with
robust vascularity, is an almost ideal skin replacement
for the sole, with minimal donor site morbidity and a
single-stage procedure. It is our first choice for
reconstruction of small-to-medium-sized defects of the
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 practice

Ethical approval and patient consent

Fig 1. Anatomy of the plantar region
Perforators of medial plantar
artery and branches of medial
plantar nerve supplying
overlaying skin
The study was approved by the All India Institute of
Posterior tibial Medical Sciences Patna and performed in accordance
artery and nerve
with the principles of the Declaration of Helsinki.
Written informed consent for surgery was provided by
Medial plantar
artery and nerve the patients, which included written informed consent
for the publication and the use of their photographs.
Inclusion criteria
● Adult patients >18 years of age
● Presence of posterior tibial artery confirmed by
handheld Doppler
● Defects on the plantar foot <50cm2.

Exclusion criteria
● Injured posterior tibial artery
● Large defects on the plantar foot >50cm2.

Abductor We had a protocol of including only small defects on

Flexor digitorum brevis Abductor hallucis digiti minimi the plantar region of the foot as part of our study.
Defects of >50cm2 were excluded and were reconstructed
Lateral plantar artery
with free flaps.
The following variables were studied: age, sex,
coexisting medical conditions, site of defect, dimensions
of defect, mechanism of injury, operating time
Fig 2. The markings and vascular axis of the medial plantar artery flap (skin‑to‑skin), flap viability and complications, and
donor site complications.

Navicular Medial plantar Anatomical considerations

bone artery The plantar region of the foot is mainly supplied by the
Instep area Flap of posterior tibial artery. The posterior tibial artery under
(dotted pink dimensions the cover of the flexor retinaculum divides into a
circle) X and Y smaller medial plantar and a larger lateral plantar artery.
The MPA runs between the abductor hallucis and the
flexor digitorum brevis muscles, supplying both the
muscles, and dividing into a superficial and a deep
branch. The superficial branch runs along the medial
border of the first toe to terminate by anastomosing
with the first dorsal metatarsal artery. In the islanded
MPA flap, the skin of the instep area is elevated as a
fasciocutaneous flap elevating the MPA along with the
pedicle. The MPAP flap is based on the perforators
arising from the superficial MPA. The perforators can be
Vascular axis of Lateral Perforators Wound of found in the line between the abductor hallucis and the
flap (dotted blue plantar from medial dimensions flexor digitorum brevis muscles (Fig 1).
line) artery plantar artery X and Y
Flap design
The basis of the vascular supply of the flap is the MPA.
The islanded MPA flap is raised as a fasciocutaneous flap
heel and mid plantar regions. We describe our along with the medial plantar vessels after tying the
experience with the use of the MPA flap as well as the distal ends. The MPAP flap is raised on perforators
MPAP flap for the reconstruction of the plantar region. arising from the MPA, thus preserving the medial
plantar vessels.
Method The axis of the flap is marked by joining a line from
This descriptive study was conducted at the Department the heel in the midline to the medial sesamoid of the
© 2022 MA Healthcare Ltd

of Burns & Plastic Surgery at the All India Institute of
Medical Sciences Patna, a tertiary referral hospital,
between April 2017 and March 2020. Patients had
undergone MPA flap reconstructions for defects of
the plantar foot.
great toe, which corresponds with the course of
the MPA.
Perforators supplying the skin arise approximately at
one-third the distance between the sustentaculum tali
and the metatarsophalangeal joint. The location of

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 practice

these perforators can be confirmed with a handheld

Fig 3. Elevation of the medial plantar artery perforator flap based on
Doppler. Next, the instep area is marked. The midline perforators from the medial plantar artery
of the plantar foot and the navicular tuberosity
determines the lateral and medial borders, respectively.
Medial plantar
The anterior demarcation is behind the ball of the great vessel and nerve
toe while the posterior border is just anterior to the
Flap elevated based
heel. This area is approximately 10–12cm in length and on perforators of
4–6cm in width. The flap to be elevated can be marked medial plantar
in any suitable region within this area. As the flap will vessels
rotate during insetting into the defect, the flap is
marked so that its length corresponds to the wound
breadth and its breadth corresponds to the wound
length (Fig 2).

Surgical technique
Preoperative considerations
All patients were examined with a preoperative
handheld Doppler for assessment of posterior tibial and
dorsalis pedis artery, and surgery was only performed Distal Wound (to be covered with
when the vascularity was intact. In cases where the perforators medial plantar artery
MPAP flap was planned, the perforators from the ligated perforator flap)
superficial branch of the MPA system were marked with
a pencil Doppler.

Fig 4. The elevation of islanded medial peroneal artery flap along with the
Technique
vessels Flap elevated based on
Surgery is performed under a pneumatic tourniquet
medial plantar vessels
with the patient placed in a supine position and hip
Medial plantar
flexed and externally rotated. The knee is flexed and the
vessel and nerve
leg externally rotated with a towel roll placed under the Abductor
lateral ankle for support. The instep area is demarcated. hallucis
In this region, the flap dimensions are drawn as (retracted)

required, with a maximum of 10–12cm in length and

4–6cm in width.

Medial plantar artery perforator flap: the medial

incision is made initially parallel to the abductor
hallucis muscle. The incision is deepened to the
underlying fascia, and dissection proceeds in the
lateral direction where the perforators can be identified
in the intermuscular septum between the abductor
hallucis and the flexor digitorum brevis muscle. The Medial plantar
vessel ligated Wound (to be covered with
dissection is deepened until the perforators arising
distally islanded medial plantar artery flap)
from the MPA are reached. The lateral border of the
flap is then incised and dissected, taking care not to
injure the perforators. There is usually a branch from
the medial plantar nerve which further divides into
two branches—one supplying the medial side of the covered with STSG and tie-over dressing is performed.
great toe and the other to the instep area which is The limb is splinted for two weeks.
included with the flap. After the perforator has been
skeletonised the flap can be transposed or rotated on Results
its axis to reach the defect (Fig 3). The MPA flap was used to reconstruct defects over the
heel and mid plantar region in 21 patients (12 pedicled
Islanded medial plantar artery flap: to raise the islanded and nine perforator flaps). The results of our study have
MPA flap, the perforators are not skeletonised, and been summarised in Table 1. Of the total, 15 patients
© 2022 MA Healthcare Ltd

dissection is performed up to the medial plantar vessels
and nerve. The medial plantar vessels and nerve are
ligated distally and the flap is raised, including the
medial plantar vessels (Fig 4).
After the flap is set into the defect, the donor site is
were male and six female. The mean age of the patients
was 37.95 years (range :19–58 years). Of the patients,
three patients had diabetes, four had associated
hypertension, one patient was both hypertensive and
diabetic, and four patients had a history of chronic

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 practice

Table 1. Descriptive patient data

Patient Age/ Co- Aetiology Location Flap Flap type Operating Flap Donor site Protective
Sex morbidities of defect size, cm time complications complications sensation
(cm2) (minutes) restored
1 25/M – Pressure sore Heel 8×5 (40) Islanded 110 – – 2 months
MPA flap
2 34/M – Post-traumatic Heel 9×5 (45) Islanded 124 – Partial SSG loss LFU after 2
with MPA flap months
osteomyelitis
3 44/F HTN Pressure sore Heel 7×4 (28) MPAP flap 96 – 2 months
4 52/F HTN SCC Midplantar 10×5 (50) MPAP flap 90 – – 2 months
5 37/M Smoking Post-traumatic Heel 8×4 (32) Islanded 98 – – 3 months
with MPA flap
discharging
sinus
6 52/M Smoking SCC Heel 8×4 (32) Islanded 108 – – 2 months
MPA flap
7 24/M – Pressure sore Heel 9×5 (45) MPAP flap 104 – – 2 months
8 30/M – Post-traumatic Midplantar 9×5 (45) MPAP flap 122 Venous – 3 months
congestion
9 36/F – Pressure sore Heel 8×4 (32) MPAP flap 98 – – 2 months
10 58/M HTN, DM SCC Midplantar 9×4 (36) Islanded 106 – Partial SSG loss 5 months
MPA flap
11 30/M Smoking Pressure sore Heel 7×4 (28) Islanded 110 – – 3 months
MPA flap
12 54/M HTN SCC Midplantar 8×4 (32) MPAP flap 92 – – LFU after 1
month
13 46/M DM Pressure sore Heel 8×4 (32) Islanded 120 – – 3 months
MPA flap
14 38/M Smoking Post-traumatic Midplantar 7×5 (35) MPAP flap 110 Venous – 3 months
hard-to-heal congestion
ulcer
15 44/M DM Post-traumatic Midplantar 9×4 (36) MPAP flap 90 – – 4 months
hard-to-heal
ulcer
16 32/F – Pressure sore Heel 8×5 (40) Islanded 100 – – 2 months
MPA flap
17 21/M – Post-traumatic Heel 8×5 (40) Islanded 104 – – LFU after 1
with MPA flap month
osteomyelitis
18 21/F – Pressure sore Heel 7×4 (28) MPAP flap 92 – Partial SSG loss 2 months
19 19/M – Post-traumatic Heel 9×5 (45) Islanded 106 – – 1 month
with MPA flap
discharging
sinus
20 48/F DM Pressure sore Midplantar 8×5 (40) Islanded 98 – – 5 months
MPA flap
21 52/M HTN Post-traumatic Heel 7×4 (28) Islanded 110 – – 2 months
hard-to-heal MPA flap
ulcer
DM—diabetes mellitus; F—female; HTN—hypertenssion; LFU—lost to follow-up; M—male; MPA—medial plantar artery; MPAP—medial plantar artery perforator; SCC—squamous cell
carcinoma; SSG—split-thickness skin graft

smoking. In nine patients, the underlying aetiology was application of the skin graft was 104 minutes. All of the
© 2022 MA Healthcare Ltd

pressure sores, eight patients had post-traumatic soft
tissue defects and four patients had malignancy
affecting parts of the soles. The average flap size was
36.6cm2 (range: 28–50cm2). The average operating time
from the start of incision until the completion of the
flaps survived without any complications except for
venous congestion in two patients in whom the MPAP
flap was used, which eventually resolved with
conservative management. In three patients, there was
a small STSG loss over the donor site which healed with

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 practice

Fig 5. Case 1: A 25-year-old male patient with a non-healing ulcer over right heel with marked flap (a); ulcer has been
excised and the medial plantar artery flap raised as an islanded flap (b); flap inset into the defect after placement of
suction drain (c); donor site covered with split-thickness skin graft (d); wound healed at three months with acceptable
cosmetic appearance and no donor site or flap complications (e)

a b

c d e

regular dressings. Patients were advised to carry out
limb elevation and splint application for two weeks.
The flaps healed well and the colour matches were
good. All patients developed protective sensation
within five months. None of the patients complained
about the donor site scar. All patients returned to their
original jobs and were satisfied with the functional
results and cosmetic appearance. Eventually, they could
also wear regular footwear.
Representative cases
Case 1
A 25-year-old male patient presented with complaints of
© 2022 MA Healthcare Ltd
sensation and and surgery was planned. Wide excision of
the undermined edges was performed, resulting in a
defect of 6×5cm. An islanded MPA flap of 8×5cm was
elevated (Fig 5a and 5b). A split was made in the soft
tissue from the edge of the wound to the vascular pedicle
to accommodate the flap. The flap was inset after
adequate haemostasis (Fig 5c) and an STSG from the
thigh was applied over the donor site (Fig 5d). The patient
achieved satisfactory sensation at four months and was
competently able to do his routine activities (Fig 5e).
Case 4
A 54-year-old female patient presented with complaints

a non-healing ulcer over the heel of 3×2cm associated
with altered sensation. The patient was evaluated and
diagnosed as a case of Hansen’s disease, for which the
patient underwent multidrug therapy. Upon completion
of treatment, the patient had gained some protective
of a non-healing ulcer of 3×2cm over the mid plantar
region of eight months’ duration (Fig 6a). The wound
was biopsied and diagnosed as a case of squamous cell
carcinoma. Wide local excision of the wound was
performed, resulting in a defect of 6×5cm. A perforator

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Fig 6. Case 4: A 54-year-old female patient with a non-healing ulcer over the midsole region diagnosed as a squamous cell
carcinoma (a); wide local excision of ulcer and identification of the perforator in the septum between the abductor hallucis
and flexor digitorum brevis marked by a white asterisk (b); medial plantar artery (MPA) perforator flap has been elevated
after perforator dissection to the MPA vessels and propelled into the defect (c); flap has been inset after haemostasis and
donor site covered by split-thickness skin graft (d); wound healed at three months with no complications (e)

a b

c d e

was found in the septum between the abductor hallucis
and flexor digitorum brevis (Fig 6b), which was carefully
dissected to the medial plantar vessels and upon which
a flap of 8×5cm was elevated (Fig 6c). The flap was inset
after meticulous haemostasis and an STSG was applied
to the donor region (Fig 6d). The patient recovered well,
without any complications (Fig 6e).
Discussion
Reconstruction of soft tissue defects in the plantar
region is challenging for the reconstructive surgeon.
The replacement of thick glabrous tissue of the plantar
perforators of the posterior tibial and peroneal artery
seldom reach the plantar foot. Distally based sural flaps
can reach defects of the heel but there is always a chance
of distal necrosis of the flap, and it requires a prolonged
hospitalisation as it is a two-step procedure.19,20 Free-
flap surgery requires considerable microvascular
expertise, special instrumentation and facilities, such as
microscopes, as well as carrying the associated
morbidities of prolonged surgery. Before the advent of
microsurgery, large defects of the foot were usually
covered with cross-leg flaps which were the workhorse
flaps in these situations. In our setup, free flaps are
© 2022 MA Healthcare Ltd

foot is an arduous task. Even a small defect in this
region can impact quality of life to a great extent.
Surfacing with a skin graft is a poor option as, due to
repeated trauma, it undergoes skin breakdown and
hyperkeratosis.1,18 Reverse-flow flaps based on the
usually reserved for patients who have a much larger
soft tissue defect and cross-leg flaps for similar patients
with contraindications to free‑flap surgery.
In our view, small-to-medium-sized defects with an
area <50cm2 (roughly the area of the instep) are best

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covered with the MPA flap. It has the advantages of
limited donor site morbidity along with robust
vascularity, an easy-to-learn technique with a short
operating time, and acceptable aesthetic results.
Shanahan and Gingrass were the first to use the skin
of the instep area for coverage of a heel defect when
they described the medial plantar sensory flap in 1979.5
Harrison and Morgan later modified the flap (1981) into
the islanded pedicle flap, the more popular form in
which it is used now.14 Attinger et al.21 described how
the sole is perfused by the MPA and the lateral plantar
artery in their corresponding angiosome.
The MPAP flap is based on the perforators which arise
from the superficial branch of the MPA.22 It has been
reported in the literature that the location of the
perforators of the MPAP flap is fairly constant, and is
present between the abductor hallucis muscle and the
flexor digitorum brevis muscle in the proximity of the
navicular bone.16,17,23 Moreover, a sensory branch from
the medial plantar nerve can be incorporated into the
flap for sensation.15 It is important to mention that the
pedicled MPA flap is based on the deep branch of the
MPA contrary to the MPAP flap.16 Only a few reports
have described the use of the MPAP flap for plantar foot
sole reconstruction.16 Modifications of the flap have
been described, such as the inclusion of muscle.24,25
Bhandari et al. have described the instep flap based on
the reverse-flow.26 Morrison et al. have reported a free
sensory instep flap with MPA for use in heel defects.9
We performed 21 reconstructions of the sole with the
MPA flap. In nine of these reconstructions, we based the
flap on the perforator of the superficial MPA (MPAP
flap). Of these defects, five were in the mid plantar
region where the flap after dissection was either used as
a propeller flap or transposed into the defect.
The MPA flap is mainly used for defects in the heel
region but it also has its advantages when the MPAP flap
is used for reconstruction of the mid plantar region.
References
1 Sommerlad BC, McGrouther DA. Resufracing the sole: long-term
follow-up and comparison of techniques. Br J Plast Surg 1978;
31(2):107–116. https://doi.org/10.1016/S0007-1226(78)90057-7
2 Roblin P, Healy CMJ. Heel reconstruction with a medial plantar V-Y flap.
Plast Reconstr Surg 2007; 119(3):927–932. https://doi.org/10.1097/01.
prs.0000242484.54997.9e
3 Bach AD, Leffler M, Kneser U et al. The versatility of the distally based
peroneus brevis muscle flap in reconstructive surgery of the foot and lower
leg. Ann Plast Surg 2007; 58(4):397–404. https://doi.org/10.1097/01.
sap.0000239842.24021.e4
4 Peek A, Giessler GA. Functional total and subtotal heel reconstruction
with free composite osteofasciocutaneous groin flaps of the deep
circumflex iliac vessels. Ann Plast Surg 2006; 56(6):628–634. https://doi.
org/10.1097/01.sap.0000205768.96705.1e
5 Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of
heel defects. Plast Reconstr Surg 1979; 64(3):295–298. https://doi.
org/10.1097/00006534-197909000-00001
6 Ulusal BG, Lin YT, Ulusal AE, Lin CH. Reconstruction of foot defects
with free lateral arm fasciocutaneous flaps: analysis of fifty patients.
© 2022 MA Healthcare Ltd
Microsurgery 2005; 25(8):581–588. https://doi.org/10.1002/micr.20176
7 Yücel A, Ŝenyuva C, Aydin Y et al. Soft-tissue reconstruction of sole and
heel defects with free tissue transfers. Ann Plast Surg 2000; 44(3):259–
269. https://doi.org/10.1097/00000637-200044030-00003
8 Baker GL, Newton ED, Franklin JD. Fasciocutaneous island flap based
on the medial plantar artery: clinical applications for leg, ankle, and
forefoot. Plast Reconstr Surg 1990; 85(1):47–58. https://doi.
JOURNAL OF WOUND CARE VOL 31, NO 2, FEBRUARY 2022
practice
Firstly, the medial plantar vessels do not have to be
ligated distally and so are spared as the flap is based on
the perforators of the medial plantar vessels. Next, as
the MPAP flap is an innervated flap, it provides
protective sensation earlier and much better than a skin
graft. As the flap has thicker tissue it gives more
protection from wear and tear than a skin graft.
Additionally, many hard-to-heal wounds are better
covered with a flap as it improves the blood supply of
the wound bed, aiding in better healing. The flap also
performs better in maintaining the contour of the
plantar foot. Therefore, the MPA flap can even be used
in wounds of the mid plantar region for the above
reasons. The disadvantage of the MPAP flap is the
resulting limited mobility, so it can only be used in
defects adjacent to the instep area. Another small
disadvantage is the possibility of congestion in the flap
as the perforators may kink while the flap is being inset
into the defect. The largest flap harvested was 50cm2,
almost equivalent to the instep area. All the flaps
survived, except two MPAP flaps which showed signs of
venous congestion on day one but both resolved
spontaneously by day four with conservative
management. Minor STSG loss in the donor area
occurred in three cases, which also healed with regular
dressings. Protective sensations developed in all cases in
a maximum of five months. There were no complications
of long-term graft loss, pain, contracture or hypertrophic
scarring of the donor site in any of the patients.
Conclusion
In summary, the MPA flap can be elevated both as an
islanded pedicled flap as well as the perforator flap. The
perforators are fairly constant in position, making this
flap a first choice for small-to-medium defects of the
sole. The flap is well vascularised, sensate and provides
identical tissue to the sole in a single-stage surgery with
minimal donor site morbidity. JWC
org/10.1097/00006534-199001000-00009
9 Morrison WA, Crabb DM, O’Brien BM, Jenkins A. The instep of the foot
as a fasciocutaneous island and as a free flap for heel defects.
Plast Reconstr Surg 1983; 72(1):56–63. https://doi.
org/10.1097/00006534-198307000-00013
10 Kim ES, Hwang JH, Kim KS, Lee SY. Plantar reconstruction using the
medial sural artery perforator free flap. Ann Plast Surg 2009; 62(6):679–
684. https://doi.org/10.1097/SAP.0b013e3181835abf
11 Kuran I, Turgut G, Bas L et al. Comparison between sensitive and
nonsensitive free flaps in reconstruction of the heel and plantar area.
Plast Reconstr Surg 2000; 105(2):574–580. https://doi.
org/10.1097/00006534-200002000-00015
12 Ortak T, Ozdemir R, Ulusoy MG et al. Reconstruction of heel defects
with a proximally based abductor hallucis muscle flap. J Foot Ankle Surg
2005; 44(4):265–270. https://doi.org/10.1053/j.jfas.2005.04.001
13 Taylor GA, Gilbert Hopson WL. The cross-foot flap. Plast Reconstr Surg
1975; 55(6):677–681. https://doi.org/10.1097/00006534-197506000-00005
14 Harrison DH, Morgan BD. The instep island flap to resurface plantar
defects. Br J Plast Surg 1981; 34(3):315–318. https://doi.
org/10.1016/0007-1226(81)90019-9
15 Mourougayan V. Medial plantar artery (instep flap) flap. Ann Plast Surg
2006; 56(2):160–163. https://doi.org/10.1097/01.sap.0000190830.71132.b8
16 Yang D, Yang JF, Morris SF et al. Medial plantar artery perforator flap
for soft-tissue reconstruction of the heel. Ann Plast Surg 2011; 67(3):294–
298. https://doi.org/10.1097/SAP.0b013e3181f9b278
17 Wan DC, Gabbay J, Levi B et al. Quality of innervation in sensate
137
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“mega-high” flap: a study of 20 consecutive flaps for lower-limb

Reflective questions
● What is the best flap for small-to-medium defects of the
heel, and why?
● How can the medial plantar artery (MPA) flap be raised as a
perforator flap?
● Are the donor site morbidities acceptable to patients in
whom sole defects are covered with MPA/MPA perforator
flap? Please give reasons for your answer.
medial plantar flaps for heel reconstruction. Plast Reconstr Surg 2011;
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S.T.R.I.D.E:
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Have you ever heard a patient saying: ‘I tried it and compression
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https://doi.org/10.12968/jowc.2019.28.Sup6a.S1
© 2022 MA Healthcare Ltd

13 8 JOURNAL OF WOUND CARE VOL 31, NO 2, FEBRUARY 2022

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