an atlas of flap in limb reconstruction

Extensor flaps
(tibialis anterior and
extensor hallucis
longus)
Introduction
The extensor flaps using tibialis
anterior and extensor longus of
the great toe are less employed
than those for the flexor muscles
of the superficial and deep poste-
rior compartments of the leg.
Nonetheless, they are worthy of
interest for some extended and
narrow defects over the tibial
crest which are difficult to cover
with flexor muscles.
Vascular supply
A Tibialis anterior and extensor
hallucis longus are type IV in the
classification of Mathes and Nahai.
They are nourished by several
short and storeyed arteries which
arise from the anterior tibialis
artery.
Indication
Extensor flaps (tibialis anterior and extensor hallucis longus)
Theoretically, only the lower half
of the muscle can be mobilized
and its viability is maintained by
the upper half. This procedure is
employed for extensor hallucis
longus without dividing the distal
tendon, to spare the function of
the rest of the muscle. This
function is also compensated for
by extensor digitorum brevis.
In contrast, it is not advocated
to release the lower half of tibialis
anterior even if the continuity of
tendon
is
maintained.
The
function of this muscle is vital and
the rotation of the distal half of
the
muscle
can
lead
to
a
functional impairment. Moreover,
the arc of rotation of the distal
half of the muscle is very short.
Thus the best way to employ the
tibialis anterior flap is by the
anterior
advancement
of
the
anterior muscular border like a
curtain to cover a long and
narrow defect over the tibial
crest. This procedure avoids loss
of function of tibialis anterior.
However, adherence may limit the
course of the tendon later.
Thus the indications may be
summarized as follows:
A
1 tibialis anterior
2 anterior tibial artery
• Tibialis anterior flap. Coverage
of the middle third of the tibial
crest by advancement of the
body muscle.
• Extensor hallucis longus flap.
Coverage of the distal third of
the tibial crest by rotation of
the distal half of the muscle.
These two muscles are not
indicated when the anteromedial
aspect of the tibia is exposed.

Transfers from the lower limb
Operative procedure
B The same skin incision is
used for raising the two flaps.
The upper part concerns the
tibialis anterior. The lower part is
for extensor hallucis longus.
M.-SM1110
C Tibialis anterior is identified
and released medially from the
tibia and laterally from the other
muscles of the anterior .compart-
ment of the leg.
C
1
extensor digitorum
longus
2 extensor hallucis
longus
3 tibialis anterior

Extensor flaps (tibialis anterior and extensor hallucis longus)
D
D The muscle is then brought
anteriorly to cover a long skin
defect over the tibial crest. Only a
part of the muscle can be used.
3
2
E Extensor hallucis longus lies
between the tendons of tibialis
anterior and extensor digitorum
communis. The muscular body of
extensor hallucis longus reaches
the superior extensor retinaculum
and sometimes the distal end of
the muscle is located beneath the
retinaculum.
No more than the distal half of
the muscle should be released
from its tendon.
E
1
extensor digitorum longus
2 extensor hallucis longus
3 tibialis anterior
F
The flap is rotated and covers
the distal quarter of the tibial
crest.
F

Transfers from the lower limb
Peroneus flap
Introduction
Only
peroneus
brevis
is
commonly used, as its muscular
fibres
reach the retromalleolar
region
and
its
function
is
supplanted by peroneus longus.
Operative procedure
The limb is slightly internally
rotated by a sandbag under the
ipsilatcral buttock.
A The incision commences at
the midleg and reaches the retro-
malleolar region.
Vascular supply
As for the extensor muscle of the
anterior
compartment,
the
peroneal muscles are supplied by
numerous small and short arteries
arising from the peroneal artery.
Only the distal half of peroneus
brevis can be elevated, maintain-
ing the continuity of the tendon.
Indication
Soft-tissue defects over the fibulal
are rare. The elective indication
for the peroneus brevis flap is
coverage of the distal part of the
Achilles tendon in case of skin
necrosis after tendon repair or
after
a
posterior
traumatic
avulsion.
A

B The skin edges are retracted,
exposing
the
two
peroneal
muscles. Peroneus brevis is identi-
fied by its more distal fibres.
C
1
peroneus brevis, split
2 sural vein and nerve
3 peroneus longus tendon
C The tendon of peroneus
longus which overlies peroneus
brevis is released and retracted.
The distal half of peroneus brevis
is separated from the tendon,
3
B
Peroneus flap
1
peroneus long us tendon
2 peroneus brevis
leaving a small band of aponeu-
rosis to
avoid tearing of the
muscle.
The flap is rotated
backwards to cover the Achilles
tendon.

Transfers from the lower limb
Lateral
supramalleolar
flap
Introduction
The lateral supramafeolar flap is
one of the series of flaps that have
been described in the last decade
and are based on secondary arter-
ies. It is a fasciocutaneous flap
raised on the lateral aspect of the
lower leg and is usually employed
as a distally based pedicled flap.
Indications
The indications depend on the
type of flap.
The peninsular rotation flap
with a distal hinge is used to
cover the distal quarter on the
anteromedial aspect of the leg,
medial malleolus included.
The distally based island flap
has a wide range of coverage,
which includes the
whole
dorsum of the foot, the medial
and the lateral arches and all
the
region
of
the
heel.
Nonetheless, the flap is not
indicated in the weight-bearing
area of the heel, as the flap is
thin
and
the
skin
rather
delicate.
The distally based flap with a
compound pedicle which is
continuous with a vascular axis
and a band of subcutaneous
fascial tissues is indicated in
defects of the extremity located
at the base of the toes.
Vascular supply
A The arterial anatomy of the
flap is based on the anastomotic
arcade of the ankle.
A
1
superficial peroneal nerve
2 extensor digitorum longus
3 perforating branch of peroneal
artery
4 anterior lateral malleolar artery
5 peroneus longus tendon
6 lateral tarsal artery
7 peroneus brevis tendon
8 dorsal metatarsal arteries
9 arcuate artery
1 0 dorsalis pedis artery
11 medial tarsal artery
12 medial branch of deep peroneal
nerve
13 lateral branch of deep peroneal
nerve
1 4 anterior medial malleolar artery
15 extensor hallucis longus tendon
16 anterior tibial artery
17 tibialis anterior tendon
18 deep peroneal nerve

The perforating branch of the peroneal artery
pierces the interosseous membrane at the distal
tibiofibular angle about 5 cm proximal to the tip of
the lateral malleolus. It anastomoses at a variable level
with the anterior lateral malleolur artery, which arises
from the anterior tibial artery. It then descends
anterior to the inferior tibiofibular syndesmosis and
anastomoses with the lateral tarsal artery on the
lateral border of the foot.
It is accompanied by a venous network. The perfo-
rating branch is sometimes large and may replace the
dorsalis pedis artery. In this case a pulse can be
palpated over the lateral malleolus. The key basis of
the flap is that the perforating branch gives one or
two branches to the skin of the lateral aspect of the
leg just after crossing the membrane.
These cutaneous branches run anteriorly to the
fibula, course upwards and anastomose with the
vascular network which accompanies the superficial
peroneal nerve. This enters the subcutaneous tissue
at about the junction of the middle and distal third of
the leg and then divides into medial and lateral
branches at the level of the ankle joint.
The principles of the different varieties of the
lateral supramalleolar flap are as follows:
• The rotation flap is based on the continuity of the
perforating branch. The pivotal point of the flap is
formed by the anterior emergence of the perforating
Lateral supramalleolar flap
and cutaneous branches. The rotation flap may be
either a peninsular flap with a distal skin hinge or a
true island flap not requiring the dissection of the
pedicle.
The distally based island pedicled flap is based on
the perforating branch, which is ligated and divided
just proximal to the cutaneous branch to the flap
and released as far as possible in the foot. The
pivotal point of the pedicle is usually the sinus tarsi,
the length of the pedicle being approximately 7
em. The venae comitantes are sufficient to ensure
venous return. The territory of the flap is bounded
laterally by the fibular crest, and medially by the
tendon of tibialis anterior. Distally, the outline of
the flap should include the emergence of the perfo-
rating branch, and proximally the flap reaches the
middle of the leg.
When the perforating branch is interrupted in its
course, it is always possible to elevate the flap. The
skin paddle is designed more proximally in the leg
and a subcutaneous fascial pedicle is dissected from
the emergence of the perforating branch to the
flap. It is also possible to combine a subcutaneous
fascial pedicle with the vascular axis of the perfo-
rating branch until it reaches the sinus tarsi, when
it is viable. The flap is designed at the middle of
the leg and the pedicle is approximately 15 cm in
length. This procedure is valuable for small and
very remote defects of the extremity.

Transfers from the lower limb
Distally based island
pedicled flap
Operative procedure
The patient is supine with a
sandbag
under the ipsilateral
buttock. A tourniquet is applied.
B
B The essential landmark is the
perforating branch as it pierces
the interosseous membrane. It is
identified
on the skin by the
depression in the lower part of
the tibiofibular space which can
be palpated with a finger. The
outline of the flap must include
this landmark, being traced 2-3
cm distal to it. A line of incision is
drawn anterior to the lateral malle-
olus and reaches the depression of
the sinus tarsi on the lateral
aspect of the hindfoot.

C,D
The skin is incised continu-
ously along the anterior margin of
the flap and anterior to the lateral
malleolus.
The pedicle is first
exposed. It is deep to the superior
C
1
landmark of the perforating branch
of the peroneal artery
D
1
extensor retinaculum
2 branches of the superficial peroneal
nerve
Distally based island pedicled flap
extensor retinaculum, which is
incised. The pedicle lies on the
tibiofibular
ligament
and
is
isolated with its surrounding loose
areolar tissue.

Transfers from the lower limb
E,F
The anterior margin of the
flap is progressively reflected,
including the fascia. At the distal
end the superficial peroneal nerve
is divided. The posterior margin
of the flap is temporarily left
intact to avoid tearing the vascu-
lar branches.
The extensor compartment of
the leg is exposed and the
muscles
are
gently
retracted,
exposing the lower part of the
tibiofibular space.
The vascular
structures are thus identified: the
perforating branch, the cutaneous
branches to the flap and the
anastomosis
with the anterior
lateral malleolar artery, which is
usually ligated and divided.
The membrane is then cautiously
incised proximal to the foramen to
free the perforating branch.
E
1
superficial peroneal nerve
2 vascular branch of the flap
3 perforating branch of the peroneal
artery
4 extensor digitorum longus
5 extensor hallucis longus
6 tibialis anterior
F
1 li gature of the
anterior lateral
malleolar artery
2 anterior tibial
artery
3 deep peroneal
nerve
4 inferior tibiofibular
syndesmosis
5 anastomosis with
the lateral tarsal
artery
Sometimes, the anterior malleo-
lar artery is sufficient in diameter
to nourish the flap with an
orthograde
arterial
flow.
The
procedure
is
similar.
The
emergence
of the perforating
branch is ligated and divided
proximal
to
the
cutaneous
1
2
3
branches
and the anastomosis
with the anterior malleolar artery.
The perforating branch is then
ligated and divided distal to the
anastomosis, leaving in contact the
anterior malleolar artery and the
cutaneous branches for the flap.
The flap is thus proximally based.

G The posterior margin of the
flap is then incised, including the
fascia,
and reflected anteriorly,
thus
exposing
the
peroneal
muscles. Proximally, the superfi-
cial
peroneal
nerve,
which is
Distally based island pedicled flap
subfascial,
is
divided
and the
proximal end is buried in the
muscles. At this stage, the flap
remains attached only to the
septum that separates the anterior
and the lateral compartment.
G
1
peroneus longus
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Transfers from the lower limb
H,I
The septum is divided close
to the fibula. In the lower part of
the flap, care should be taken to
preserve the cutaneous branches
that lie on the fibula. The release
of the septum at this level should
be carried out subperiosteally.
H
1
release of septum on the fibula
2 peroneus longus
zoiirr.
:., :.
67<.:M~

J
The flap is raised.
The final step is to precisely
isolate the pediele and to release
it as far as the sinus tarsi. When
the flap is isolated it is very impor-
tant to divide the posterior border
of the fascia of extensor digitorum
, R
Mb lewyy
Distally based island pedicled flap
brevis in order to avoid compres-
sion of the pediele. The closure of
the donor site is achieved by
suturing the peroneal and the
extensor muscles together. A split-
skin graft is applied immediately
or a few days later.
J
1
pediele of flap
2 retinaculum, divided
K The arc of rotation allows
coverage of the medial aspect of
the lower leg, the posterior aspect
of the heel and the dorsum and
the borders of the foot.
K

Transfers from the lower limb
Other operative
procedures
L The rotation flap is a very
quick and easy procedure. The
pedicle need not be exposed. A
distal hinge may be maintained.
M
The design of a flap based on
a subcutaneous fascial pedicle.
This procedure is useful when the
perforating artery is viable at its
emergence
but
interrupted
distally.

O For rotation of the flap, the
pivotal point can be constituted
by the emergence of the perforat-
ing branch. If the ramus perforans
courses to this level the pedicle
Distally based island pedicled flap
may include this artery. The total
length of the pedicle (subcuta-
neous fascial and vascular) is very
important and allows coverage of
the bases of the toes.
3
N The subcutaneous fascial
pedicle
is
then
subdermally
dissected.
N
1 subdermal dissection of pedicle
1 fasciocutaneous island
2 subcutaneous fascial pedicle
3 ramus perforans of peroneal artery

Transfers from the lower limb
Neurocutaneous
flaps
Introduction
The basis of these flaps is founded
on the vascular supply of the
sensory superficial nerves which
contribute greatly to the vascular-
ization of the skin. These flaps
can
be
considered
as
`axial
pattern' flaps. The great advan-
tage is the absence of sacrifice of
a main artery of the leg. Moreover,
they are versatile and reliable and
are especially indicated for limited
defects which are not good indica-
tions for other better-known flaps.
Proximally based
saphenous artery
neurocutaneous flap
Indication
The flap is raised on the medial
aspect of the leg. The very long
arc of rotation of the pedicle
allows
coverage
of the small
defects over the anterior aspect of
the knee joint: tibial tuberosity,
infrapatellar ligament, patella.
Vascular supply
The saphenous nerve is supplied
by the vascular network which is
the continuation of the more or
less extended saphenous artery.
Along the entire course of the
nerve this network anastomoses
with arterioles arising from the
deep posterior tibial artery and
delivers many small branches to
the skin. Thus the saphenous
neurocutaneous flap is designed
on the course of the nerve, which
is identified by the long saphe-
nous vein. The pedicle is a subcu-
taneous
fascial
pedicle
which
contains the saphenous nerve and
its vascular network, and the long
vein. The pivotal point of the
pedicle is the inferior border of
sartorius. A distally based flap is
theoretically
possible
but the
vascular network of the nerve is
unreliable in the distal third of the
leg.
Operative procedure
A The flap is outlined on the
medial aspect of the leg, along the
course of the saphenous vein,
which is close to the nerve and its
supply.
A

B Two skin flaps are dissected
B
and retracted to isolate the subcu-
taneous fascial pedicle.
C
1 the fascia is included
C,D
The flap and the pedicle are
raised, including the fascia. Distal
to the flap, the vein is hgated and
divided. The nerve is also divided.
The pedicle is released until the
inferior border of the sartorius.
The arc of rotation allows cover-
age of the crucial zones of the
knee joint (tibial tuberosity, infra-
patellar ligament, patella).
Proximally based saphenous artery neurocutaneous flap
2
3
4
1
subdermal dissection
2 saphenous vein and nerve
D
2
1
subcutaneous fascial pedicle
2 soleus
3 gastrocnemius
4 skin island

Transfers from the lower limb
Distally based sural
artery neuro-
cutaneous flap
Indications
The distally based sural artery
neurocutaneous flap is raised on
the posterior aspect of the calf It
is especially indicated for cover-
age of the posterior aspect of the
heel and the region of the lateral
malleolus.
Vascular supply
This flap is based on the sural
nerve, which pierces the deep
E
1 60
fascia at midcalf. It is accompanied
by the more or less extended well-
defined sural artery, which contin-
ues up to the retromalleolar region
as
a
true
vascular
network.
Numerous
anastomoses
exist
between the peroneal artery and
this vascular axis. The most distal
one is located at a distance of three
fingers' breadth from the tip of the
lateral malleolus and is considered
as the pivotal point of the pedicle.
As with the saphenous flap, the
pedicle is composed of subcuta-
neous tissue and fascia and
contains the sural nerve, its vascu-
lar axis and the sural vein. The flap
cannot be outlined more proxi-
mally than the junction of the two
heads of gastrocnemius because
beyond this level the nerve and its
F
1 sural vein and nerve
2 subdermal dissection
artery are subfascial as far as their
origin in the popliteal fossa.
Operative procedure
E The flap is outlined at the
junction of the relief of the two
heads of gastrocnemius. A line of
incision
is
traced
over
the
presumed course of the sural
nerve and vein.
The pivotal point of the pedicle
is three fingers' breadth proximal
to the tip of lateral malleolus.
F
A distant transverse short
debridement allows the raising of
two skin flaps in order to isolate
the subcutaneous fascal pedicle.

Distally based sural artery neurocutaneous flap
G The flap and the pedicle are
raised, fascia included. Small arter-
ies
arising
from the peroneal
artery
should
be ligated and
divided in the depth of the
pedicle.
H The arc of rotation allows
coverage of the heel. A skin distal
incision is made to bury the
pedicle. The donor site and the
pedicle are covered with a split-
thickness skin graft.

Transfers from the lower limb
Vascularized fibula
transfer
Introduction
The transfer of a free vascularized
fibula is now of much interest in
reconstructioe
surgery
of
the
limbs. The reconstruction of long
bone
defects
by
vascularized
fibula, especially in poorly vascu-
larized beds, has proved its superi-
ority
over
other
methods
of
conventional bone reconstruction.
Many fields of bone and joint
surgery, such as reconstruction
after injury or tumour excision,
have benefited from vascularized
fibula transfer. The removal of the
fibula does not lead to a functional
impairment. However, if the distal
cut is near the ankle joint it is
preferable to fix the distal tibiofibu-
lar joint to stabilize the ankle.
I ndications
• Reconstruction of long bone
defects
of the limbs. The
benefit is pronounced for
defects of more than 5 cm.
• Composite transfer can be
realized
by including lateral
hemisoleus or a skin paddle
supplied by the peroneal artery.
Vascular supply
The fibula is vascularized by the
peroneal
artery.
The
nutrient
artery penetrates the bone at about
the radon of proximal and middle
third. The periosteum and the
muscular insertions contribute to
the blood supply. The proximal
epiphysis is not vascularized by the
fibula; it is supplied by a branch
arising from the anterior recurrent
tibia] artery. Several attempts have
been made to perform vascularized
transfer of proximal epiphysis in
children but clinical results are not
probative
on
the
subsequent
growth of the bone.
From a haemodynamic point of
view, it is better to raise a cuff of
muscles
with the fibula, for
instance flexor hallucis longus or
tibialis posterior. Venous return is
facilitated when the transfer is
revascularized
on -its recipient
site. As far as possible, the distal
arterial
anastomosis should be
done to avoid the tapping of the
blood course in the transfer.
The peroneal artery raised with
the bone can be useful to restore
the continuity of a main vascular
axis of the recipient limb.
Operative procedure
A The approach to raise the
fibula is lateral. The limb is slightly
internally rotated and the knee is
semiflexed.
The
operation is
performed under tourniquet. The
incision reaches practically to the
neck of the fibula.

B The fascia is incised in line
with the skin and the plane is
identified between the soleus and
the peroneal muscles. This plane
is developed.
B
1
soleus
2 peronei
Vascularized fibula transfer
C Retraction of peroneal and
soleus
muscles
allows
the
exposure of the lateral aspect of
the fibula. Anterior to the fibula
the
septum
separating
the
peroneal
and
the
extensor
compartment is incised. Posterior
to the fibula, the arcade of soleus
is released in the upper part.
C
1
fibula
2 septum between lateral and anterior
compartment of the leg
3 peronei

Transfers from the lower limb
D Anteriorly, the retraction of
the
muscles
of
the
anterior
compartment allows exposure of
the intertibiofibular
membrane.
Posteriorly, the release of soleus
exposes the posterior tibial artery
and the origin of the peroneal
artery.
Small
arteries
from
peroneal artery to soleus should
be cauterized.
D
1
soleus
2 flexor hallucis longus
3 peronei
4 tibialis anterior vessels
5 interosseous membrane
6 origin of tibial and peroneal vessels
2
E
The interosseous membrane is
incised close to the fibula. Care
should be taken with the anterior
tibial
vessels
and
nerve.
Posteriorly,
the
flexor hallucis
muscle
is
released
extrape-
riosteally
and
numerous small
vessels issuing from the peroneal
vascular bundle should be cauter-
ized. A small ruff of flexor hallu-
cis muscle can be left attached to
the bone in order to protect the
peroneal vessels.
E
1
release of flexor hallucis
2 incision of membrane
3 peroneal vein
6
5
4
3

F
The retraction of flexor hallu-
F
cis longus allows the exposure of
1
tibial nerve
the
peroneal
vessels
and
the
2 peroneal vessels
posterior tibial nerve. Remember
3 flexor hallucis,
that the posterior tibial vessels are
detached
located medially to the nerve.
Thus the plane of dissection
passes posteriorly between the
peroneal vessels and the posterior
tibial nerve. Anteriorly, it will be
necessary to include in the trans-
fer a cuff of tibialis posterior. This
procedure avoids injury to the
peroneal vessels and will improve
the venous return when the trans-
fer is revascularized.
If the distal anastomosis of the
peroneal artery at the recipient
site is not planned, it is also
preferable to include all of flexor
hallucis longus to improve the
haemodynamic conditions of the
transfer.
2
3
4
5
Vascularized fibula transfer
G
The periosteum is incised and
retracted at the two extremities of
the transfer and a Gigh saw is
passed around the fibula, close to
the bone.
G
1
fibula, cut subperiosteally
2 peroneal vessels
3 tibial nerve
4 soleus
5 flexor hallucis longus
6 tibialis posterior
7 tibialis anterior with tibial anterior
vessels
8 peronei

Transfers from the lower limb
H The transfer is isolated and
externally
rotated
to
expose
tibialis posterior.
The muscle is
divided, leaving a cuff inserted on
the
fibula
and protecting the
peroneal vessels and the connec-
tions between the vessels and the
periosteum.
The
peroneal
vessels
are
controlled proximally and distally
to the transfer.
H
1 peroneal vessels, proximal
2 tibial nerve
3 tibialis posterior, split
4 peroneal vessels, distal
1
2
3
4
I
The vessels have been ligated
and divided distally.
The transfer remains attached
by its proximal pedicle, which
will be ligated and divided at its
origin
on the posterior tibial
artery.

17 1615 14
K A skin island is designed at
the middle third of the leg to be
included in the transfer.
8 9
Vascularized fibula transfer
13
12
11
10
J
Cross-section
through
the
middle third of the leg to show
the plane of dissection.
J
1
extensor digitorum longus
2 peroneus brevis
3 peroneus longus
4 fibula
5 flexor hallucis longus
6 soleus
7 gastrocnemius, lateral head
8 sural vein
9 sural nerve
1 0 gastrocnemius, medial head
11 tibial nerve
1 2 posterior tibial vessels
1 3 flexor digitorum longus
14 tibialis posterior
1 5 tibialis anterior
16 anterior tibia[ vessels and nerve
1 7 extensor hallucis longus
K

Transfers from the lower limb
L
The cutaneous pedicle is
located
betwen peroneus and
soleus.
L
1
peroneus longus
2 soleus
3 skin pedicle
M Retraction of the peronei
allows the exposure of the origin
of the skin pedicle and the fibula.
M
1
peroneal vessels
2 fibula
2

Foot
Introduction
The foot is a very particular region. Soft tissue losses
are always a challenge and require specific procedures
according to the features of the different zones of the
distal extremity.
Most of the flaps which can be raised are equally
available to treat defects of the foot or other sites.
Some of these flaps, such as the dorsahs pedis, the
extensor brevis or the medial plantar flap, may be
used as free flaps.
The foot is a very precious donor site for recon-
struction of the digits. Toe to hand transfers have
supplemented surgery of the hand.
We have described the technique of elevation of
the second toe, which is the basic procedure.
Variations and partial transfers can be deduced from
this basic technique.
Dorsalis pedis flap
Introduction
Indications
Dorsalis pedis flap
This flap is one of the earliest described neurovascu-
lar flaps and can be used as a free flap. However, the
development of other types of flaps has reduced its
indications. The functional prejudice at the donor site
is not insignificant.
• Coverage of soft-tissue defects of the foot and lower
third of the leg.
• A free sensory flap.

Transfers from the lower limb
Anatomy
A
The vascular axis of the flap is
the dorsalis pedis artery, which is
a continuation of the anterior
tibial artery, and crosses, from
proximal to distal, the anterior
capsule of the ankle joint, the
talus,
the
navicular
and the
second cuneiform.
The tendon of extensor hallucis
longus lies on its medial side,
whilst the tendons of extensor
digitorum longus and the medial
terminal
branch of the deep
peroneal nerve lie laterally. At the
proximal
end
of
the
first
metatarsal
space,
the
dorsalis
pedis artery passes into the sole of
the foot to join the plantar arch.
Its branches are the tarsal, the
arcuate
and the first dorsal
metatarsal arteries.
The lateral
tarsal artery runs laterally deep to
extensor
digitorum
brevis and
supplies
this
muscle.
The
cutaneous branches, which will
nourish the flap, arise from the
short segment of the artery as it
lies
between extensor hallucis
longus and the first head of exten-
sor
digitorum
brevis.
Some
cutaneous arteries also arise from
the first muscular head of exten-
sor digitorum brevis. The first
dorsal
metatarsal
artery
also
supplies the skin when it lies
superficial
to
the
first
dorsal
interosseous artery.
A
3
1 superficial peroneal nerve
2 extensor digitorum longus
3 perforating branch of peroneal
artery
4 anterior lateral malleolar artery
5 peroneus longus tendon
6 lateral tarsal artery
7 peroneus brevis tendon
8 dorsal metatarsal arteries
9 arcuate artery
10 dorsalis pedis artery
11
medial tarsal artery
12 medial branch of deep peroneal
nerve
13 lateral branch of deep peroneal
nerve
1 4 anterior medial malleolar artery
1 5 extensor hallucis longus tendon
1 6 anterior tibial artery
17 tibialis anterior tendon
1 8 deep peroneal nerve

Applied anatomy
Several
key
points
must
be
emphasized.
• Dissection of the flap is difficult
because
the
tissue
which
connects the artery to the skin
is very thin and the artery lies
directly on the tarsal skeleton.
• The key for raising the digital
portion of the artery is to divide
the tendon of extensor digito-
rum brevis where it inserts into
the tendon of extensor hallucis
longus.
• A safer procedure is to include
the first head of extensor digito-
rum brevis, leaving the flap
with the attached segment of
the lateral tarsal artery.
• When a superficial dorsal inter-
metatarsal artery exists, the terri-
tory of the flap can be extended
to the base of the toes. A super-
ficial artery may be palpable or
identified
by
Doppler
ultra-
sound. When this artery lies
deep to the muscle, it is safer to
limit the distal end of the flap to
the middle of the metatarsals.
• The branches of the superficial
peroneal
nerve
which
are
included in the flap provide
sensation.
Operative procedure
The patient is supine, with a
sandbag
under the ipsilateral
buttock to hold the leg in neutral
position.
B The incision begins proxi-
mally over the distal limb of the
inferior limb of the inferior exten-
sor
retinaculum.
The
medial
border overlaps the tendons of
extensor
hallucis
longus
to
include the vein on the medial
border of the foot, which drains
into
the long saphenous vein
proximally. The lateral border is
lateral to the tendon of extensor
digitorum longus. When the first
metatarsal artery is not palpable,
the distal end of the flap is at the
lex cl
of
the
middle
of
the
metatarsals.
Dorsalis pedis flap

Transfers from the lower limb
D The incision around the flap
is then completed.
D
1 deep peroneal nerve
2 dorsalis pedis artery and veins
3 superficial peroneal nerve
4 extensor hallucis longus
C
The vessels of the pedicle are
isolated via the incision over the
medial ankle joint. The subcuta-
neous
tissues
are
dissected,
preserving the branches of the
superficial peroneal nerve. The
skin edges are reflected to identify
the vein. The inferior limb of the
retinaculum is incised and the
artery found medial to the tendon
of extensor hallucis longus.
C
1
extensor retinaculum
2 superficial peroneal nerve
3 vein of the medial border
4
3

E
1
plunging branch of the
dorsalis pedis artery
2 tendon of extensor digitorum
brevis
3 tendon of extensor hallucis
longus
F
The first metatarsal space is
explored to identify the superfi-
cial artery. If it exists, the artery is
ligated and divided, the proximal
stump being fixed to the proximal
flap. The deep branch of the
dorsalis pedis artery is identified.
F
1 first dorsal Intermetatarsal artery
2 ligature of the deep branch (plunging
branch) of the dorsalis perk artery
1 2 3
2
Dorsalis pedis flap
E
Medially, venous branches are
ligated and the border of the flap
is dissected as far as the tendon of
extensor
hallucis
longus.
This
tendon is retracted medially, and
the tendon of extensor digitorum
brevis
is divided just lateral to
extensor hallucis longus and fixed
to the deep aspect of the flap. The
distal branches of the superficial
peroneal nerve are divided.

Transfers from the lower limb
G Laterally, the flap is progres-
sively raised and care should be
taken to preserve the loose, vascu-
larized
areolar
tissue
over the
extensor tendons which provides
a bed for the skin graft.
G
1
extensor hallucis longus tendon
2 dorsalis pedis vessels
H Extensor digitorum longus is
retracted laterally, exposing exten-
sor digitorum brevis. The first
head of the muscle can be left
connected with the superficial
tissues and separated from the
rest of the muscle. The lateral
tarsal artery is ligated deep to the
muscle. When the medial portion
of the muscle is not included in
the flap, the motor nerve should
be spared.
H
1
superficial peroneal nerve
2 extensor hallucis longus tendon
3 deep peroneal nerve
4 motor nerve to extensor digitorum
brevis
5 lateral dorsal artery
6 extensor digitorum brevis
7 extensor digitorum longus

9
8
7
6
5
4
2
J
Dorsalis pedis flap
1
deep peroneal nerve
2 motor branch to extensor dlgltorum
brevis
3 extensor digitorum brevis
4 arcuate artery
5 lateral tarsal artery
6 deep peroneal nerve, sensory
branch
7 dorsalis pedis vessels
8 superficial peroneal nerve
9 extensor hallucis longus tendon
1, J
At this stage of the dissec-
tion, the flap remains attached to
the foot only by the deep connec-
tion of the artery that lies on the
tarsal bone and by the distal point
that enters the proximal end of
the first metatarsal space to gain
access to the sole of the foot.
The distal end of the artery is
ligated and divided, and the artery
is freed from its bed, taking care
to leave it attached to the flap.
The first dorsal intermetatarsal
artery is ligated, divided and
raised with the flap when it is
superficial. When the artery is
deep in the interosseous muscle,
the dorsalis pedis is ligated and
divided at the level of its plunging
plantar branch.
1
dorsalis pedis artery
2 first dorsal intermetatarsal artery

Transfers from the lower limb
K
The dorsalis pedis flap can be
used as a free or as a pedicled
island flap. The tendons of exten-
sor digitorum longus and extensor
hallucis
longus
are
sutured
together and a split-thickness skin
graft is applied to cover the donor
site.

Extensor digitorum
brevis flap
Introduction
The extensor digitorum brevis
flap is not commonly used. It is,
however, worthy of interest in
some specific indications for
coverage in the perimalleolar area.
When it is pedicled on the
anterior tibial artery, the arc of
rotation is very important. The
free muscle transfer has yet to be
utilized for functional restoration
of the hand or face.
Indications
The pedicled island flap may be
based on three arteries.
• When the muscle is pedicled on
the lateral tarsal artery, the arc
of rotation is limited, but allows
coverage of the premalleolar
area.
The advantage is the
absence of sacrifice of a main
artery.
When the muscle is pedicled on
the anterior tibial artery, any
site on the leg can theoretically
be reached.
The muscle can also be distally
based on the dorsalis pedis
artery. After ligation of the
anterior
tibial
artery,
the
dorsalis pedis artery is released
as far as the perforating branch
in
the intermetatarsal space.
The flap can cover defects of
the dorsum on the metatar-
sophalangeal (MP) joint of the
great toe.
Anatomy and vascular
supply
Extensor
digitorum
brevis
is
attached to the anterior superolat-
eral surface of the calcaneum and
the stem of the inferior extensor
retinaculum. It slants distally and
medially across the dorsum to end
in four tendons. The medial part
is
a distinct strip ending in a
tendon which crosses the dorsalis
pedis
artery superficially
and
Extensor digitorum brevis flap
reaches the base of the first
phalanx of the hallux. There is no
tendon for the fifth toe.
The blood supply comes from
the lateral tarsal artery, which is a
lateral branch of the dorsalis pedis
artery. The lateral tarsal artery
runs deep to the muscle and
anastomoses
with
the
ramus
perforans of the peroneal artery.
Sometimes, the lateral part of
the muscle, corresponding to the
fourth toe, is almost entirely
supplied by the ramus perforans
of the peroneal artery. Thus the
elevation
on the lateral dorsal
artery may lead to a partial necro-
sis of the transfer.
Nerve supply is from the lateral
terminal
branch of the deep
peroneal nerve.
Operative procedure
A A gently curved incision is
made on the dorsum of the foot,
allowing the exposure of the end
of the anterior tibiahs artery and
the muscle and its tendon.

Transfers from the lower limb
B The subcutaneous tissue is
cautiously opened to identify and
to spare the lateral branch of the
superficial peroneal nerve.
B
1
retinaculum
2 extensor tendons
3 lateral branch of superficial peroneal
nerve
G The inferior extensor retinac-
ulum and the fascia are incised in
order to expose and to mobilize
the tendons of extensor digitorum
longus.
C
1
superficial peroneal nerve, lateral
branch

Extensor digitorum brevis flap
D The tendons are released
from the underlying muscle.
D
1
superficial peroneal nerve, lateral
branch
2 extensor digitorum brevis
3 extensor tendons
4 extensor hallucis longus tendon
E
The retraction of the extensor
tendons laterally allows exposure
of the medial part of extensor
digitorum brevis and the dorsalis
pedis artery.
E
1
dorsalis pedis vessels
2 tendon to first toe
3
medial tarsal vessels
4 deep peroneal nerve

Transfers from the lower limb
F
The tendon for the hallux is
cut and the muscle is retracted.
The motor nerve and the origin of
the
lateral
tarsal
artery
are
exposed.
F
1
deep peroneal nerve
2 motor branch to extensor digitorum
brevis
3 lateral tarsal artery
4 tendon to first toe, cut
5 dorsalis pedis artery
6 extensor hallucis longus tendon
7 medial tarsal artery
G On the lateral side of the
extensor tendons, the muscle is
released from the calcaneus.
G
1
release of insertion
2
3

Extensor digitorum brevis flap
H
The anastomosis between the
ramus perforans of the peroneal
artery and the lateral tarsal artery
is ligated and divided. The deep
aspect of the muscle is released
progressively.
Care
should
be
taken to avoid injury to the vascu-
lar pedicle.
H
1
lateral tarsal artery, cut
2 dorsalis pedis artery
3 medial tarsal artery, cut
I
The muscle is passed beneath
the
extensor tendons to be
isolated on the lateral tarsal artery.
1 deep peroneal nerve
2 dorsalis pedis vessels
3 arcuate vessels
4 dorsalis pedis vessels

Transfers from the lower limb
J
The distal tendons are cut.
It is not necessary to preserve
the tendons when the muscle is
employed for covering a defect.
K The flap is pedicled on the
lateral tarsal artery or the anterior
tibialis artery according to the arc
of rotation needed.
Sometimes the fourth head of
the muscle is not well supplied by
the lateral tarsal artery and it
should be excised.
K
1 medial tarsal artery, stump
2 dorsalis pedis artery, stump
3 lateral tarsal artery, stump
4 arcuate artery

Medial plantar flap
Introduction
Soft-tissue
defects
of the foot
remain a difficult problem in
reconstructive
surgery.
The
medial plantar flap is ideal for
covering the heel, although the
technique is difficult. The high
quality of the skin is suitable for
repairing the weight-bearing area
of the heel.
Indication
• Coverage of the weight-bearing
area of the heel.
Anatomy
The medial plantar flap is raised
from the non-weight-bearing area
of the plantar arch. It is based on
the medial plantar artery, which is
a distal branch of the posterior
tibial artery. It divides into a deep
branch
which
runs
medially
adjacent to the tarsal bones and a
superficial
branch
which runs
between abductor hallucis and
flexor digitorum brevis.
Cutaneous branches arise from
the
intermuscular
space;
the
artery is accompanied by a venous
network and the medial plantar
nerve, which supplies one or two
small branches to the skin of the
plantar arch.
The medial plantar flap is a
sensory flap. Preoperative arteri-
ography is essential, as the medial
plantar artery can be absent.
Operative procedure
A The design of the flap is
limited by the boundaries of the
non-weight-bearing area of the
foot.
The weight-bearing areas are
the heel, the metatarsal heads, the
lateral
arch and,
medially;
the
inferior border of the medial arch.
Medial plantar flap
A

Transfers from the lower limb
B
Medially, the incision exposes
the fascia which covers abductor
hallucis. Posterior to the medial
malleolus, the flexor retinaculum
is incised to expose the posterior
tibial artery. The origin of the
medial plantar artery is identified
at the proximal border of abduc-
tor hallucis.
B
1 flexor retinaculum
2 posterior tibial artery
C
The medial margin of the flap
is gently reflected, thus exposing
the muscle.
C
1 posterior tibial artery and veins
2 abductor hallucis
2

4
D
E
Medial plantar flap
D The fascia of abductor hallu-
cis is included in the flap. The
medial digital nerve of the great
toe can be seen immediately distal
to the inferior border of the
muscle.
1
medial digital nerve to great toe
E The muscle is cautiously
divided,
exposing the
medial
plantar artery. The key to the
dissection is then to identify the
medial digital nerve of the great
toe distally.
1
posterior tibial artery and veins
2 flexor hallucis longus tendon
3 abductor hallucis
4 medial digital nerve to the great toe

Transfers from the lower limb
F
The nerve is progressively
dissected from distal to proximal
and separated from the superficial
branch of the medial plantar
artery which remains connected
to the flap.
F
1
li gature of the pedicle to
abductor hallucis
2 lateral plantar artery and
veins
3 medial plantar artery and
veins
4 abductor hallucis, divided
G
Proximally, the common trunk
of the medial plantar nerve is also
dissected from the artery. One or
two branches supply the flap and
these are identified. In order to
G
1
intraneural dissection of
the branch
2 tibial nerve
3 sensory branch to the
flap
4
provide a long pedicle, an intra-
neural dissection of these branches
is
required.
The medial plantar
artery is ligated distal to the flap
and the proximal end is sutured to
3
2
the flap; the deep branch of the
medial plantar artery is ligated. The
neurovascular bundle is released
up to the bifurcation of the poste-
rior tibial vessels.

H
Medial plantar flap
H,I
The lateral margin of the
flap is freed without necessarily
including the plantar aponeurosis.
Nonetheless, it is easier to
include the plantar aponeurosis,
although it makes the flap less
pliable. Care should be taken to
conserve the loose connective
tissue between the neurovascular
bundle and the flap.
1 plantar aponeurosis
1
li gature of pedicles to flexor
digitorum brevis

Transfers from the lower limb
J The arc of rotation provided
by the pedicle allows the weight-
bearing area and the posterior
aspect of the heel to be covered.
Closure of the wound is achieved
by suturing abductor hallucis to
flexor digitoru n brevis and apply-
ing a split-skin graft, after excision
of the exposed part of the plantar
aponeurosis.
J

Medialis pedis flap
Introduction
The medialis pedis flap is a fascio-
cutaneous flap raised on the
medial border of the foot. Its
blood
supply
is
interstitial.
Indications for the flap are restric-
tive but elective.
Indication
A
The medialis pedis flap is of
limited size. It is rather thin,
more so than the medial plantar
flap, and the skin is supple.
The
flap has two elective
indications, which are defects
over the tip of the medial malle-
olus and defects over the inser-
tion of the Achilles tendon,
which cannot be reached by a
peroneus flap.
The arc of rotation also allows
coverage of the medial aspect
of the calcaneum. The donor
site cannot be primarily sutured
and will be covered with a skin
graft.
A contraindication to the eleva-
tion of the flap is the existence
of a very prominent tuberosity
of the navicular, which would
cause
a
chronic
ulceration
when covered with a skin graft.
1 posterior tibial artery
2 tibial nerve
3 lateral plantar artery
4 medial plantar artery
5 cutaneous branch
6 superficial branch
7 abductor hallucis
Vascular supply
A The flap is based on a
constant and reliable cutaneous
branch arising from the medial
plantar artery, which forms the
pedicle of the flap. The medial
plantar artery arises from the
posterior tibial artery in the retro-
malleolar region. At the level of
the plantar vault, deep to abduc-
tor hallucis, the medial plantar
artery divides into a superficial
and a deep branch.
The superficial branch is well
known and is the basis of the
medial
plantar flap. The deep
branch continues along the medial
border of the foot and runs deep to
the tarsal bone to anastomose with
the dorsal vascular network. Just
Medialis pedis flap
before plunging under the tarsal
bones, the deep brunch delivers a
cutaneous
branch
which runs
upwards, ties on the distal end of
the tibialis posterior tendon, runs
back to the tuberosity of the navic-
ular, and then runs in an oblique
direction parallel to the medial
border of the foot, penetrating the
subcutaneous tissue.
The
cutaneous
branch
sometimes arises from the trunk
of the medial plantar artery. This
variation is not important for the
technique of elevation, as the
essential and constant landmark is
the passage
of the cutaneous
branch on the tibialis posterior
tendon. The pedicle is dissected
up to the origin of the medial
plantar artery.

Transfers from the lower limb
Operative procedure
B The flap is outlined on the
medial border of the foot, includ-
ing
the
prominence
of
the
tuberosity of the navicular and the
slight depression which identifies
the terminal part of the tibialis
posterior tendon.
C The terminal portion of the
tibialis posterior artery is exposed
just
proximal to the posterior
edge of abductor hallucis. The
posterior border of the flap is
incised. On the anterior part the
fascia is incised in line with the
skin.
C
1 tibialis posterior vessels
B

D
E
Medialis pedis flap
D The flap is progressively
raised and retracted from anterior
to posterior. The dissection, in
depth, is performed close to the
tuberosity of the navicular and the
tendon of posterior tibialis. The
dissection is pursued until the
deep branch plunging under the
navicular is seen.
The flap remains attached by its
posterior hinge. Then the fascia of
abductor hallucis is incised.
1
supplying branch to flap
2 tuberosity of navicular bone
3 tibialis posterior tendon
4 incision of fascia
E
Abductor hallucis is retracted,
which allows the exposure and
the identification of the vascular
structures.
The superficial branch of the
medial plantar artery, the pedicle
to abductor hallucis and the distal
portion of the deep branch of the
medial plantar artery are succes-
sively ligated and divided.
1
superficial branch of medial plantar
artery
2 medial plantar artery
3 lateral plantar artery
4 posterior tibial artery