#ClinicalCase: Right heel Cutaneous lesion
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A 56-year-old woman with no significant past medical history presented with a 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.

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 diseases 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.

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. Meticulous dissection was carried out to mobilize the medial plantar neurovascular bundle supplying the flap. The flap was then pedicled into the defect site and loosely inset with nylon suture. The use of SPY Elite (Stryker) verified good perfusion of the flap. The donor site was covered with Integra. The patient was placed in a well-padded Robert Jones splint. She had an uneventful postoperative recovery and was dismissed from the hospital on a postoperative day 2. 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

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.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.

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.

Source: https://www.healio.com/orthopedics/oncology/news/print/orthopedics-today/{cbb25e02-d3b0-4c6c-a04a-5f2f9d0f3b3e}/56-year-old-woman-with-a-right-heel-cutaneous-lesion?page=2
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