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LETTER TO THE EDITOR
Year : 2017  |  Volume : 54  |  Issue : 4  |  Page : 699-700
 

Medial plantar artery perforator flap for reconstruction of the soft tissue defect of heel melanoma


Bhawan Mahaweer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India

Date of Web Publication30-Jul-2018

Correspondence Address:
Dr. Parth Kanaiyalal Patel
Bhawan Mahaweer Cancer Hospital and Research Centre, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_197_17

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How to cite this article:
Patel PK, Tewari S, Khunteta N. Medial plantar artery perforator flap for reconstruction of the soft tissue defect of heel melanoma. Indian J Cancer 2017;54:699-700

How to cite this URL:
Patel PK, Tewari S, Khunteta N. Medial plantar artery perforator flap for reconstruction of the soft tissue defect of heel melanoma. Indian J Cancer [serial online] 2017 [cited 2020 Oct 27];54:699-700. Available from: https://www.indianjcancer.com/text.asp?2017/54/4/699/237887




The skin surface of the hands and feet is 10% of the body surface. Among the cutaneous melanomas, about 30% occur in lower limbs, women are more prone to the development of melanoma in the lower limbs, and foot and ankle lesions comprise 3%–15% of all cutaneous melanomas. Malignant melanoma is common in the foot.[1]

A 55-year-old female, presented with complaints of black-colored lesion at right heel for 5 months and local site pain for 2 months. On examination - approximately 3 cm × 3 cm size black-colored lesion in right heel, slightly on medial aspect without ulceration was seen. A 1.5 mm × 1.5 mm satellite lesion on the medial side just 0.5 cm away from the main lesion without ulceration. No significant inguinal lymphnodes were there. No other lesion anywhere in the body. Biopsy was suggestive of malignant melanoma. Ultrasonography abdomen, chest X-ray, routine blood investigations, and serum lactate dehydrogenase were normal.

Wide Excision of right heel ulcer with right groin node dissection; reconstruction was done by sensate medial plantar island flap with skin grafting. Postoperative period was uneventful and patient was discharged on postoperative day-9. Final Histopathology report was cutaneous malignant melanoma with depth of invasion was 7 mm (HMB45 positive) with all margins unremarkable. All 7 Lymph nodes were negative for metastasis.

Wide excision of melanomas affecting the foot poses significant and challenging problems due to soft tissue coverage, because of the frequent involvement of tendon, and bone and extreme weight - bearing areas. Heel defects are classified into three parts (plantar, posterior, and lateral). Split thickness skin grafting is adequate for only nonweight-bearing defects. Local and regional flaps (medial plantar island flap and superficial sural island flap) are adequate for small weight - bearing areas. Medial plantar flap is the flap of choice in terms of sensation and early ambulation. Tissue type and texture are similar to that of the heel. Microvascular free tissue transfer do provide a reliable method for difficult to cover lower leg wounds. Although free flaps work well in these cases, they are labor intensive, usually bulky, insensate, technically demanding and require intense and costly postoperative care.[2]

The foot represents one of the most usual sites for melanomas. More than 50% of the patients present with lesions of the toes or plantar surface, which generally are thicker than melanomas found elsewhere. The primary objective in management is to achieve optimal local control. Along with this consideration, the functional results and early return to ambulation should be factored into the surgical approach for therapy. The use of medial plantar flap in weight-bearing areas is associated with excellent functional outcomes [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Heel defect with marking of medial plantar artery flap

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Figure 2: Medial plantar artery flap after harvesting and attached through pedicle

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Figure 3: Medial plantar artery flap covering the heel defect

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Figure 4: Final result after 7 days

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The foot represents an unusual site for melanomas. More than 50% of the patients present with lesions of the toes or plantar surface, which generally are thicker than melanomas found elsewhere. The primary objective in management is to achieve optimal local control. Along with this consideration, the functional results and early return to ambulation should be factored into the surgical approach for therapy. The use of medial plantar flap in weight-bearing areas is associated with excellent functional outcomes [Figure 1], [Figure 2], [Figure 3], [Figure 4].



 
  References Top

1.
Keyhani A. Comparison of clinical behavior of melanoma of the hands and feet: A study of 283 patients. Cancer 1977;40:3168-73.  Back to cited text no. 1
    
2.
Dogra B, Priyadarshi S, Nagare K, Sunkara R, Kandari A, Rana K. Reconstruction of soft tissue defects around the ankle and foot. Med J DY Patil Univ 2014;7:603-7.  Back to cited text no. 2
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