Plantar reconstruction using a step-ladder advancement flap

A medial plantar flap is superior as a sensory flap with regard to tissue wear, prevention of ulcer recurrence, and other such factors. However, a wound at a plantar weight-bearing site is likely to lead to abnormal hyperkeratosis that can cause pain and fissures. In addition, the development of a scar contracture in infant patients can cause failure of normal foot development. To overcome these issues, we developed a method in which an island flap from a non-weight-bearing site is used as a step-ladder advancement plantar flap for moderate-sized tissue loss at a plantar weight-bearing site, followed by primary closure of the flap donor site with suturing to prevent scar contracture and abnormal hyperkeratosis. This technique showed good functional and cosmetic outcomes, as the step-ladder-like suture lines were unlikely to cause scar contracture and abnormal hyperkeratosis owing to the staggered scar, leading to pain prevention.