Tunneling the Pedicle: A Novel Technique for Free Flap Reconstruction in Plantar Forefoot Wounds

Free flap reconstruction has become the standard of care for managing critical foot defects, particularly in diabetic forefoot plantar wounds. Key considerations in achieving optimal outcomes include minimizing flap failure risk, restoring foot shape without excessive bulk, and reducing donor site morbidity. However, reconstructing plantar forefoot ulcers presents a unique challenge due to the distance between the defect and recipient vessels, such as the posterior tibial artery (PTA) or anterior tibial artery (ATA). Conventionally, large and bulky flaps are required to bridge this gap, often resulting in suboptimal reconstruction.To address these challenges, we have developed a novel technique involving flap pedicle tunneling to utilize the medial plantar artery (MPA) as the recipient vessel. Using this approach, six cases of plantar forefoot defects were successfully reconstructed with anterolateral thigh (ALT) free flaps. All patients recovered uneventfully without complications, ambulating within 7 days postoperatively. Within 1 month, they regained their premorbid ambulatory status with customized footwear, without requiring secondary flap debulking. Tunneling the pedicle and performing anastomosis to the MPA provides a superior method for managing small- to medium-sized plantar forefoot defects. This technique offers a robust yet appropriately sized soft tissue reconstruction that is both functionally superior and aesthetically favorable compared to conventional approaches.