Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

1969;22:143.
4. Buntine JA. Repair of the sole. Med J Aust 1970;1:520.
5. McCraw JB. Selection of alternative local flaps in the leg and foot. Clin Plast Surg 1979;6:227.
6. Buncke HJ, Colen LB. An island flap from the first web space of the foot to cover plantar ulcers. Br J Plast
Surg 1980;33:242.
7. Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr
Surg 1979;64:295.
8. Reiffel RS, McCarthy JG. Coverage of heel and sole defects: a new subfascial arterialized flap. Plast
Reconstr Surg 1980;66:250.

Chapter 544
Medial Plantar Flap
D. MARTIN
B. GOROWITZ
J. M. PERES
J. BAUDET
EDITORIAL COMMENT
The flap works comfortably because of the ability to lengthen the vessels. In this chapter, the authors
describe very clearly their concept of Y-V vessel lengthening. The description of the treatment of the
vessels alone is worth the perusal of the chapter. The technique is also often used by the senior author in
the submental island flap (refer to Chapter 123).
The authors modify the classic medial plantar flap by shifting its vascular supply, to create reverse flow in the
lateral plantar artery and vein. This flap is useful for covering defects in the distal weight-bearing areas of the
foot over a wide range.
INDICATIONS
This modified flap, because of its wider arc of rotation, is suitable for a variety of local defects, extending the
range of flap coverage and allowing it to reach the tips of the toes. It provides excellent cover for the distal
weight-bearing areas of the foot when a classic flap cannot be used, due to anatomic anomalies and/or in
the presence of an unreliable flap blood supply (1, 2, 3, 4, 5, 6, 7, 8, 9).
ANATOMY
The classic medial plantar artery derives its main blood supply from the medial plantar artery, a terminal branch
of the posterior tibial artery. In our modification, reverse blood flow is created from the lateral plantar artery, after
dividing the posterior tibial artery just proximal to its distal bifurcation. Survival of the reverse flow is ensured by
the rich anastomoses that usually occur between the dorsalis pedis and lateral plantar arteries. Venous return is
also lengthened by a similar reverse flow pattern (Fig. 544.1).
FLAP DESIGN AND DIMENSIONS
The flap modification, although not changing typical flap dissection, allows the transfer of the pedicled flap
distally. The authors call this procedure a “reverse flow Y-V pedicle extension of the flap.” The idea is to raise
the flap distally on a branch of the Y-like vascular bifurcation of the posterior tibial artery. Sectioning the trunk at
the bifurcation turns the Y into a V vascular pattern, allowing distal mobilization of the flap on the remaining
branch of the V. The distal range of flap transfer can reach twice the length of the unmodified flap. The arterial
blood supply is provided by reverse flow through the attached remaining branch of the V, and venous drainage is
also ensured (Fig. 544.2).
OPERATIVE TECHNIQUE (FIG. 544.3)

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First, the main trunk of the posterior tibial artery is traced to its bifurcation into the medial plantar and lateral
plantar
arteries, after releasing the abductor muscle of the big toe. Then, the flap is raised in the usual fashion. It is
relatively easy, after dislocating the plantar flexor, to isolate the lateral plantar pedicle. After clamping the
posterior tibial artery to evaluate flow, it is divided just proximal to the bifurcation. Finally, the vascular bundle of
the lateral plantar pedicle is isolated from its accessory nerve, and enough further dissection is carried out to
allow the reverse flow artery island flap to be transferred to its desired site (Figs. 544.4 and 544.5).
FIGURE 544.1 Medial view of the vascular network of the right foot. AP, peroneal artery; ATA, anterior tibial
artery; ATP, posterior tibial artery divided proximal to its bifurcation; LPI, medial plantar flap. (From Martin et al,
ref. 5, with permission.)
FIGURE 544.2 Reverse flow Y-V pedicle extension or elongation of flap. 1, normal flow; 2, reverse flow after
section of the common trunk at the vascular bifurcation; 3, distal range of flap transfer (X); the reach is twice the
length of AB. (From Martin et al, ref. 5, with permission.)

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FIGURE 544.3 Medial plantar flap with lateral plantar pedicle. AH, abductor hallucis; CFP, flexor digitorum
brevis; TP, sectioned tibialis posterior artery.
FIGURE 544.4 Patient with electrical burn of the forefoot and exposure of second metatarsal head. A: Outline of
medial plantar flap. B: Postoperative view on day 3. C: Result at 1 year, showing 11.5-cm flap advancement.
SUMMARY
A modified medial plantar flap, based on the lateral plantar artery and vein with reversed flow, can cover
any area of the foot.
FIGURE 544.5 A: Scar tissue in first metatarsal head region subsequent to skin avulsion. B: Perioperative
view of medial plantar flap based on lateral plantar pedicle. C: Result at 6 months.
References
1. Torii S, Namiki Y, Mori R. Reverse-flow island flap: clinical report and venous drainage. Plast Reconstr
Surg 1987;79:600.

2. Amarante J, Martins A, Reis J. A distally based median plantar flap. Ann Plast Surg 1978;20:468.
3. Amarante J, Martins A, Reis J. A distally based median plantar flap (letter). Plast Reconstr Surg
1987;81:137.
4. Martin D. Le lambeau sous-mental. Ann Chir Plast Esthet 1990;35:480.
5. Martin D, Gorowitz B, Peres JM, Baudet J. Le lambeau plantaire interne a pedicule plantaire exteme. Ann
Chir Plast Esthet 1991;36:544.
6. Martin D, Legaillard P, Bakhach J, et al. L'allongement pediculaire en YV a flux retrograde: moyen pour
doubler l'arc de rotation d'un lambeau sous certaines conditions. Ann Chir Plast Esthet 1994;39:403.
7. Panconi B, Vidal L, Bovet JL, et al. Utilisation du lambeau plantaire interne pour la couverture des pertes
de substance du talon. Ann Chir Plast Esthet 19885;30:78.
8. Baker GL, Newton ED, Franklin JD. Fasciocutaneous island flap based on the medial plantar artery:
clinical applications for leg, ankle and forefoot. Plast Reconstr Surg 1990;85:47.
9. Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr
Surg 1979;64:2295.

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Chapter 545
Plantar Flaps Based on Perforators of The Plantar
Metatarsal/Common Digital Arteries
ALEXANDRU V. GEORGESCU
ILEANA R. MATEI
MANUEL L. PEREZ
EDITORIAL COMMENT
The procedure provides good local tissue bringing circulation and sensibility. Except for visualization of the
vessel, the flap can be thought of as a subcutaneous pedicle flap. If there is no plantar sensibility to start in
the flap, no improvement in sensibility can be expected.
The uniqueness of the relatively thick, greatly keratinized, and hairless plantar skin makes its reconstruction
challenging. Along with these features, the fascia is strictly adherent to the skin and provides to it fibrous septa.
Moreover, abundant fibrous adipose tissue is found on the forefoot and heel regions (1). All these characteristics
contribute to increased mechanical support, to shared pressure forces during ambulation, and to prevention of a
gliding phenomenon between the skin and underlying tissues (2, 3). Therefore, it becomes more than evident
that the reconstruction of plantar skin in the forefoot should be done by replacing like with like by using plantar
flaps (4).
INDICATIONS
Metatarsal/common digital artery perforator flaps are indicated to cover a variety of small to medium plantar
skin defects, up to 30 cm2, over the metatarsophalangeal joints, including posttraumatic, neuropathic, and
diabetic. The advantages of this flap include the minimal donor site morbidity, which generally does not
involve a weight-bearing area, and the possibility of including of some sensory nerve endings in the pedicle,
which can provide some protective sensibility (4).
ANATOMY (FIG. 545.1)
The plantar forefoot skin represents the fourth subunit in Hidalgo's subunit principle (2). This subunit
corresponds to the metatarsals and phalanges. Both the dorsal and plantar arteries of the foot are terminal
branches of the anterior and posterior tibial arteries. The anterior tibial artery contributes to the blood supply of
the plantar forefoot skin through the deep plantar artery and the posterior tibial artery through lateral and medial
plantar arteries (2, 5). These three arteries, that is, deep, medial, and lateral plantar arteries, create the deep
plantar arch, which gives rise to four plantar metatarsal
arteries, three main perforating branches, and other numerous branches to the skin, fascia, and muscles. A
variation of the blood supply can be found in a few cases, such as the existence of a superficial plantar arch,
which gives origin to the plantar common digital arteries. Both the plantar metatarsal arteries and plantar
common digital arteries give origin to many small and moderately sized septocutaneous perforator vessels.
These perforators reach the skin after passing between the plantar fascia slips. They have a vertical path and

form a subdermal plexus, but not a subcutaneous one (6).
FIGURE 545.1 Schematic presentation of the plantar forefoot skin vascularization.
FIGURE 545.2 Schematic presentation of a propeller perforator flap based on a metatarsal/common digital artery
perforator. A: Flap design. B: Rotation of the flap into the defect. C: Donor site closure by direct suture.
The venous drainage is realized through both superficial and deep veins. The deep veins are represented by
interanastomosing paired veins, which accompany each artery, and the superficial veins drain in a plantar
venous network. Finally, the venous blood drains into the great and small saphenous veins (7). The common
plantar digital nerves, originating from the medial or lateral plantar nerves, give numerous sensory nerve endings
to the skin.

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FIGURE 545.3 Schematic presentation of a V-Y advancement perforator flap based on a metatarsal/common
digital artery perforator. A: Flap design. B: Advancement of the flap into the defect and direct suture of the donor
site.
FLAP DESIGN AND DIMENSIONS (4)
Preoperative identification of the plantar perforator arteries is very difficult, if not impossible, so the final design of
the flap is done intraoperatively, after identification of the perforator vessel. The flap is designed in the long axis
of the forefoot, in a non-weight-bearing area over an intermetacarpal space and the adjacent metacarpals. The
length of the flap is designed to be 1 cm longer than the distance between the perforator and the most distant
point of the defect and its width 0.5 cm wider than the width of the defect.
The flap is designed and used generally as a rotational flap: as a propeller flap if the rotation is between 90 and
180 degrees or as a transposition flap if the rotation is less than 90 degrees (Fig. 545.2). For smaller defects, the
flap can be designed as a transposition flap, the most frequent design being as a V-Y advancement flap (Fig.
545.3). In the attempt to improve the venous drainage, a rotational perforator flap
can also be designed and used as a perforator plus flap, which means to keep a narrow skin pedicle connecting
the flap to the donor site; the drawback of this procedure is the possibility of creating a cone at the rotation point
(Fig. 545.4). The dimensions of such flaps can reach up to 30 cm2.
FIGURE 545.4 Schematic presentation of a perforator plus flap based on a metatarsal/common digital artery

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perforator. A: Flap design. Notice the smaller width of the pedicle. B: Rotation of the flap into the defect. Notice
the small cone at the base of the flap. C: Closure of the donor site by skin grafting. D: Closure of the defect by
direct suture.
OPERATIVE TECHNIQUE (4)
The procedure is done under tourniquet. After debridement, one of the edges of the remaining defect is
undermined (Fig. 545.5) or the defect is elongated and the skin is undermined (Fig. 545.6) under magnification
over an intermetacarpal space and two adjacent metatarsals, until a perforator is identified. Now, the flap can be
designed and completely incised, taking care that the distance between the perforator, that is, the pivot point,
and the most distant point of the flap be 1 cm greater than the distance between the perforator and the most
distant point of the defect. Also, the width of the flap must be 0.5 cm greater than the width of the defect.
Preservation of a small cuff of tissue around the perforator will prevent damage to or spasm of such small
vessels and will allow the inclusion of sensitive nerve branches in the pedicle (Figs. 545.5 and 545.6). The flap
must be sutured without tension into the defect. For the V-Y flaps and for the flaps smaller than 20 cm2, the
donor site can be closed by direct suture (Figs. 545.2A, 545.3B, 545.4D, 545.5D, and 545.6D), but for larger
flaps, it must be skin grafted (Fig. 545.4C).
CLINICAL RESULTS (FIGS. 545.5 AND 545.6)
No immobilization is applied and patients are encouraged to walk without weight bearing on the operated foot
after 3 to 4 days. Normal gait resumption is possible after 6 to 8 weeks. In our experience, patients have limited
to no pain immediately after surgery or on long-term follow-up. Flap necrosis has not been observed, and
delayed healing is rare.
Usually, patients with posttraumatic defects and those with diabetes mellitus who have some protective
sensibility experience a minimal relapse rate, but those with neuropathy can develop further ulceration. With
healing, patients are able to wear the same shoes as before surgery.
SUMMARY
The plantar metatarsal/common digital artery perforator flap provides a good and stable functional outcome
with possible sensory recovery of plantar skin defects over the weight-bearing areas of the forefoot.

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FIGURE 545.5 Plantar ulcer over the second metatarsal head. A: Preoperative view. B: After ulcer
excision, the inferior edge of the defect is undermined. C: Identification of a perforator pedicle. Notice the
cuff of tissue kept around the pedicle. D: Postoperative view after the advancement of the flap in a V-Y
manner. (Continued)

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FIGURE 545.5 (Continued) E: Postoperative result after 3 weeks.
FIGURE 545.6 Plantar ulcer over the first metatarsal head. A: Plantar defect over the first metatarsal head
after ulcer release. B: Elongation of the distal edge of the defect and the undermining. (Continued)

FIGURE 545.6 (Continued) C: Identification and isolation of the perforator pedicle. D: Postoperative view at
24 hours. E: Postoperative view after 2 months.
References
1. Draves DJ. Anatomy of the Lower Extremity. Baltimore: Williams & Wilkins, 1986;284-319.
2. Hidalgo DA, Shaw WW. Anatomic basis of plantar flap design. Plast Reconstr Surg 1986;78(5):627-636.
3. Schwarz R. Reverse medial plantar artery flap. Lepr Rev 2006;77(1):69-75.
4. Georgescu AV, Matei IR, Llusa M. Plantar flaps based on perforators of the plantar metatarsal/common
digital arteries. J Reconstr Microsurg 2014;30(7):469-474.
5. Shaw WW, Hidalgo DA. Anatomic basis of plantar flap design: clinical applications. Plast Reconstr Surg
1986;78(5):637-649.
6. Colen LB, Replogle SL, Mathes SJ. The V-Y plantar flap for reconstruction of the forefoot. Plast Reconstr
Surg 1988;81(2):220-228.

7. Blume PA, Key JJ. Local random flaps for soft tissue coverage of the diabetic foot. In: Zgonis T, ed.
Surgical Reconstruction of the Diabetic Foot and Ankle. Philadelphia: Lippincott Williams & Wilkins,
2012;140-165.

Chapter 546
Lateral Supramalleolar Flap
A. C. MASQUELET
M. C. ROMAÑA
EDITORIAL COMMENT
This is an interesting flap that is used for covering the dorsum of the foot, although venous drainage could
be a problem. This probably has been combined in most units with free microvascular muscle flaps.
The lateral supramalleolar flap, raised on the lateral aspect of the lower leg, is very useful for covering defects
involving the lower leg, ankle, and foot.
INDICATIONS
This reliable and versatile flap has many possibilities. It can be used as a rotation flap with a distal hinge
(peninsular flap), which is a quick and easy procedure for covering the distal quarter of the medial aspect of
the leg. A proximally-based pedicled flap has a limited arc of rotation, but is sufficient for covering defects in
the ankle area. Used as a distally-based pedicled flap, it has a wide range that includes the whole dorsum
of the foot, the medial and lateral arches, and the entire heel region. However, although the flap is not
advocated for the weight-bearing area of the heel (the skin of the flap is rather thin and delicate), among the
best indications for its use are defects of the posterior aspect of the heel, and resurfacing of a stump
resulting from a transmetatarsal amputation. A distally-based pedicle flap with a compound pedicle
comprising the vascular axis and a band of subcutaneous fascial tissue can be used for distal defects as far
as the base of the toes. The lateral supramalleolar flap can be used as a sensory flap by suturing the
superficial peroneal nerve to a nerve at the recipient site.
The advantages of the flap are those of any pedicled flap: the rapid and reliable procedure provides an
excellent alternative to a free flap in many instances. The principal disadvantages are the division of the
superficial peroneal nerve and the scar resulting from skin grafting on the lateral aspect of the leg. Usually,
the donor site is quite acceptable, but may be a problem in young women.
ANATOMY (FIG. 546.1)
The vascular supply is provided by the anastomotic arcade of the ankle. The key anatomic vascular structure is
the perforating branch of the peroneal artery, which pierces the interosseous membrane at the distal tibiofibular
angle, just proximal to the anterior tibiofibular ligament (1). It anastomoses at a variable level with the anterior
lateral malleolar artery arising from the anterior tibial artery, courses on the anterior tibiofibular ligament, and
then descends to the level of the sinus tarsi, where it anastomoses with the lateral tarsal artery and small
branches issuing from the lateral plantar artery. Between its emergence from the interosseous membrane and
tibiofibular ligament, the perforating artery gives off one or two ascending branches to the skin of the distal half of
the lateral aspect of the leg, which constitutes the territory of the flap.
The perforating branch of the peroneal artery is accompanied by small venae comitantes. The branch is
sometimes

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very large and, in some cases, may replace the distal part of the anterior tibial artery. In other rare cases, the
perforating branch anastomoses with the anterior tibial artery that courses on the anterior tibiofibular ligament.
For these reasons, an arteriogram is always needed preoperatively.
FIGURE 546.1 Anatomy of the lateral supramalleolar flap. 1, superficial peroneal nerve; 2, fibula; 3, territory of
the flap; 4, cutaneous branch for the flap; 5, ramus perforans; 6, extensor brevis muscle; 7, anterior malleolar
artery; 8, emergence of the ramus perforans; 9, tibialis anterior artery; 10, interosseous membrane; 11, peroneal
artery.
The cutaneous branches issuing from the perforating branch run anteriorly to the fibula and anastomose with the
vascular network that accompanies the superficial peroneal nerve. This enters the subcutaneous tissue at the
junction of the middle and distal thirds of the leg, and divides into medial and lateral branches at the level of the
ankle joint.
These constant anatomic considerations allow clarification of the different varieties of the lateral supramalleolar
flap—the territory of all varieties remains the same. The rotation flap maintains continuity of the perforating
branch, and no vascular dissection is required. The pivotal point of the flap is the emergence of the branch
through the interosseous membrane. The rotation flap may be a peninsular flap with a distal skin hinge, or an
island flap with a very short pedicle that need not be dissected. In both cases, the rotation cannot exceed 90
degrees.
A proximally-based pedicled flap is based on the anterior lateral malleolar artery, when this vessel is suitable.
The perforating branch is ligated and severed just proximal to the cutaneous branches to the flap, and just distal
to the anastomosis with the anterior lateral malleolar artery. In this case, the flap is supplied by the anterior
lateral malleolar artery and through the skin branches issuing from the perforating branch.
A distally-based island pedicled flap is based on the perforating branch, which is ligated and divided just proximal
to the cutaneous branch, and released as far as the sinus tarsi that constitutes the pivot point of the pedicle (2).
The length of the pedicle is approximately 7 cm; the venae comitantes are sufficient to ensure venous return.
When the perforating branch is interrupted in its course distal to the cutaneous branch to the flap, the skin
paddle is designed proximally on the lower half of the leg, and the flap is supplied by a subcutaneous fascial
pedicle. In this case, the pivot point is the emergence of the perforating branch.
It is also possible to combine a subcutaneous fascial pedicle in continuity with the vascular axis of the perforating
branch, until it reaches the sinus tarsi. The flap is designed at the middle of the leg, and the pedicle is
approximately 15 cm in length (3). This procedure is valuable for small and very distal defects of the extremity.

FLAP DESIGN AND DIMENSIONS
The boundaries of the largest flap are proximally, the middle of the leg; anteriorly, the crest of the tibia;
posteriorly, the fibula; and distally, the emergence of the perforating branch. This latter point is identified on the
skin by the depression in the lower part of the tibiofibular space, which can be palpated with a finger. Whatever
the dimensions, the design of the flap should include this landmark, as the outline of the flap is traced 2 to 3 cm
distal to the landmark. Flap dimensions vary according to the proximal limit; the largest flap is about 20 × 8 cm.
OPERATIVE TECHNIQUE
We begin with the standard distally-based pedicled flap. The patient is supine with a sandbag under the
ipsilateral buttock. A tourniquet is applied. The design of the flap, as described above, should include the
landmark of emergence of the perforating artery distally. A line of incision is drawn anterior to the lateral
malleolus and reaches the depression of the sinus tarsi on the lateral aspect of the hindfoot (Fig. 546.2).
FIGURE 546.2 Design of the flap. The distal landmark should include the emergence of the ramus perforans
issuing from the peroneal artery (star). Distal incision is performed to the sinus tarsis, to expose the flap pedicle.
The skin, including the fascia, is incised in continuity along the anterior margin of the flap, and anterior to the
lateral malleolus. A posterior skin hinge is maintained. The pedicle is first exposed, lying deep to the extensor
retinaculum, which is incised. The muscles of the extensor compartment are gently retracted, exposing the lower
part of the tibiofibular space, in order to identify the vascular structures, chiefly, the cutaneous branch to the flap.
The perforating branch is ligated and severed just proximal to the cutaneous branch (Fig. 546.3). It is sometimes
necessary to incise the membrane in order to free the perforating branch. The anastomosis with the anterior
lateral malleolar artery is ligated and divided.
FIGURE 546.3 Ramus perforans of the peroneal artery is ligated and severed just proximal to the cutaneous

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branch supplying the flap. 1, interosseous membrane; 2, cutaneous branch supplying the flap; 3, flap pedicle; 4,
anterior malleolar artery. This latter inconstant vascular axis may be used as the supplying pedicle for a
proximally-based flap.
FIGURE 546.4 Release of the flap from the fibula; the septum is incised. 1, septum; 2, cutaneous branch.
Then, the posterior margin of the flap is incised, including the fascia. The superficial peroneal nerve is severed
proximally, and its proximal end is buried in the muscles; the fascial septum, which attaches the flap to the fibula,
is progressively released from proximal to distal. At the level of the course of the cutaneous branch to the flap,
the septum is subperiosteally released to protect the supplying branches (Fig. 546.4).
The pedicle is isolated with its surrounding loose areolar tissue, until it reaches the sinus tarsi (Fig. 546.5).
The posterior edge of the fascia of the extensor digitorum brevis muscle should be divided, in order to avoid
compression of the pedicle when it is turned. Closure of the donor site is performed by suturing the peroneal and
extensor muscles together. A split-thickness skin graft is applied immediately or a few days later.
For a rotation flap, no dissection or ligature is required in what is a rapid and reliable procedure. The design of
the flap should include the tendon of emergence of the perforating branch.
FIGURE 546.5 The flap and its pedicle are raised. 1, extensor and peroneal muscles are sutured together to
provide a well-vascularized bed for the graft; 2, stump of the severed ramus perforans.

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FIGURE 546.6 Variation of the lateral supramalleolar flap. The skin paddle is designed at the middle third of the
leg. A subdermal dissection allows raising a subcutaneous fascial pedicle. 1, skin paddle; 2, subdermal
dissection. Two flaps are elevated to delimit the subcutaneous fascial pedicle. Pedicle length can be increased
by freeing the vascular pedicle beyond the emergence of the ramus perforans.
A distally-based island flap with subcutaneous fascial pedicle is useful when the perforating artery is viable at its
emergence, but is interrupted distally. In this case, the pivot point of the pedicle is related to the emergence of
the perforating branch. The subcutaneous fascial pedicle is subdermally dissected to 2 cm in width (Fig. 546.6).
If the perforating artery is viable until the sinus tarsi, it can be dissected in continuity with the subcutaneous
fascial pedicle. The total pedicle length is about 15 cm when a small flap is raised at the middle of the leg (Fig.
546.7).
A proximally-based island flap can be utilized when the defect is around the ankle joint. The flap can be raised on
the anterior lateral malleolar artery. The territory of the flap is the same as that of a distally-based flap.
FIGURE 546.7 Arc of rotation allows coverage of defects on the dorsal aspect of the MP joints.

FIGURE 546.8 Clinical case. A: Avulsion of the dorsum of the foot. B: Elevation of flap with a subcutaneous
fascial pedicle. The pivot point of the pedicle in this case is the emergence of the ramus perforans. C: Flap at the
recipient site. D: Final result.
CLINICAL RESULTS
More than 60 lateral supramalleolar flaps have been used by our group, with practically all the regions of
the foot involved. The best indications for use of this flap were defects involving the dorsum of the foot and
the posterior aspect of the heel, which require supple skin (Fig. 546.8). The postoperative course should be
managed very cautiously. The foot should be elevated for 5 days postoperatively, and walking is allowed
only progressively to avoid flap congestion. An immediate venous congestion of the flap will result from any
operative errors. Compressive garments can be used after complete healing.
We would emphasize the following several important points. The flap is not suitable for resurfacing the
weight-bearing area of the heel. The rotation flap is very useful for covering defects of the distal quarter of
the leg; a peninsular subcutaneous fascial flap can be used to avoid the skin graft at the donor site.
Sensibility of the flap can be restored by suturing the peroneal nerve to a nerve at the recipient site. This
procedure is valuable, if the flap is designed in the lower part of the leg, which is supplied by the superficial
peroneal nerve.
SUMMARY
The lateral supramalleolar flap, often offering an alternative to a free flap, is reliable and versatile. It can be
used for a variety of defects in the foot, ankle, and lower part of the leg.
References

1. Romaña MC, Masquelet AC. Vascularization of the inner border of the foot: Surgical applications. Surg
Radiol Anal 1988;11:177.
2. Masquelet AC, Romaña MC. The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg
1990;85:765.
3. Ishikura N, Heshiki T, Israkada S. The use of a free medialis pedis flap for resurfacing skin defects of the
hand and digits: results in five cases. Plast Reconstr Surg 1995;95:100.

Chapter 547
Sural Flap
A. C. MASQUELET
The sural flap has gained popularity by proving its validity for reconstruction around the ankle and foot. Its main
advantages are an extensive mobility and versatility, without sacrificing important arteries. The safe and
relatively short technical procedure is easily transmitted to young surgeons. Most of the reported complications
can be avoided by a careful selection of indications and a rigorous technique. In the past, this flap had several
nomenclatures: neurocutaneous flap, distally based superficial sural artery flap, reverse sural island flap, and
lesser saphenous sural veno-neuro adipofascial flap. Nevertheless, sural flap is a simple description that is now
well accepted.
INDICATIONS
Elective indications for the sural flap concern the posterior aspect of the heel and Achilles tendon, the
anterior and lateral aspects of the ankle, the dorsum of the foot, the lateral aspect of the hindfoot, and the
anterior crest of the lower third of the leg (1, 2, 3). Relative indications of the sural flap are coverage of the
totality of the heel and of defects of the medial aspect of the lower leg. These two areas are not too distant
from the pivot point, but their coverage might involve kinking of the pedicle, or the flap might provoke partial
arterial insufficiency or a difficulty in venous return.
ANATOMY
The sural artery issues from the popliteal artery (1, 4, 5). It joins the sural nerve coursing between the two heads
of the gastrocnemius and follows the lateral edge of the Achilles tendon. The sural artery is intimately connected
with the sural nerve and plays an important role in supplying the skin of the lower and middle posterior leg. It
terminates with the lateral supramalleolar branch of the fibular artery and posterior tibial artery. A pair of comitant
veins travel with the sural artery.
The sural nerve descends in close association with the lesser saphenous vein, coursing posterior to the lateral
malleolus, to innervate the lateral side of the foot and the fifth toe. The vascularization of the nerve is ensured by
the sural artery in the proximal third of the leg and by an arterial fascial plexus issuing from the perforators of the
fibular artery.
Approximately four to eight perforators arise from the fibular artery, pierce the crural fascia, and give rise to
several branches that join adjacent perforators, forming an interconnecting vascular suprafascial plexus that
extends from the proximal part of the leg to the posterior margin of the lateral malleolus. A larger perforator is
located approximately 5 cm proximal to the lateral malleolus (Fig. 547.1). After giving off the anterior perforator
that pierces the interosseous membrane, the distal portion of the fibular artery gives off a posterior lateral
malleolar branch and more distally, the lateral calcaneal artery.
FLAP DESIGN AND DIMENSIONS
Considering the anatomic structures involved, the flap pedicle includes superficial and deep fascia, sural nerve,
lesser saphenous vein, and sural artery. The lesser saphenous vein is generally used to determine the axis of
the pedicle (3). The pivot point of the pedicle is the main perforator, located 5 cm proximal to the lateral
malleolus, as it is the most reliable. The two more distal perforators issuing from the posterior lateral malleolar

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and lateral calcaneal branches are likely to provide a pivot point for the pedicle (6). Nonetheless, dissection is
more risky at this level, and the width of the pedicle is limited.
The standardized sural flap is designed as follows. The skin island is designed on the posterior aspect of the calf
at the junction of the two heads of the gastrocnemius. The pivot point of the pedicle and the source supplying the
flap is the most reliable perforator. The pedicle is a strip of adipofascial tissue, including subdermal tissue, lesser
saphenous vein, sural nerve, and deep fascia (1, 3, 4, 7). The ratio of length to width of the pedicle is
approximately 4:1.
FIGURE 547.1 The suprafascial courses of the sural nerve and the lesser saphenous vein. The deep course of
the fibular artery demonstrates the emergence of the perforators. The larger perforator, which is usually the pivot
point of the pedicle, is located approximately 5 cm proximal to the lateral malleolus. 1, Sural nerve; 2, lesser
saphenous vein; 3, the larger perforator; 4, perforator from the posterior malleolar branch; 5, perforator from the
lateral calcaneal artery.
Some points should be reemphasized. The pivot point is approximately 5 cm proximal to the lateral malleolus and
posterior to the fibula. The axis of the pedicle is oblique and can be located precisely by the course of the lesser
saphenous vein. The length of the pedicle is determined by the arc of rotation required. However, a reliable
adipofascial pedicle should not exceed the ratio of 4:1 (i.e., if the pedicle length is 12 cm, the width is about 3
cm). The design of the skin island is in continuity with the pedicle. The dimensions of the flap can reach 15 cm in
length and 12 cm in width.
OPERATIVE TECHNIQUE
A prone position is indicated only when the defect is located at the posterior aspect of the heel or the lateral
aspect of the ankle. In other cases, the patient lies in a supine position, the ipsilateral buttock slightly elevated.
Flexion and adduction of the hip and flexion of the knee allow raising the flap in a rather comfortable position
while the whole anterior aspect of the ankle and the medial side of the leg remain easily accessible.
The flap is outlined approximately at the junction of the two heads of the gastrocnemius. The precise location of
the skin paddle depends on the length of pedicle required. The pivot point of the pedicle is about three finger-
breadths proximal to the tip of the lateral malleolus. The line of incision is traced over the course of the sural
nerve and lesser saphenous vein, which may have been identified previously with Doppler ultrasound (Fig.
547.2).
A distal transverse short debridement, resulting in an H-shaped incision, allows the raising of two skin flaps to

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isolate the adipofascial pedicle. In cases of a thick subcutaneous layer, it is advisable to leave a thin layer of
adipose tissue connected with the two skin flaps. The pedicle is isolated by two parallel incisions, fascia
included, before raising the flap (Fig. 547.3).
Once the pedicle is isolated, the flap, with fascia included, is raised. Small arteries arising from the fibular artery
should be ligated and divided within the adipofascial pedicle. Note that these small perforators can be used as a
pivot point for a more proximal pedicled flap (8), with the aim of covering any part of the middle third of the leg
(Fig. 547.4). The arc of rotation allows easy coverage of the posterior aspect of the heel. The skin bridge is
incised to bury the pedicle. The donor site and the exposed aspect of the pedicle are covered with a split-
thickness skin graft (Fig. 547.5).
FIGURE 547.2 Flap design and landmark of the pivot point.
FIGURE 547.3 The adipofascial pedicle is isolated, including the nerve and vein. 1, Sural nerve and vein; 2,
subdermal dissection.
The postoperative course should be carefully evaluated. Excessive pressure on the pedicle or on the flap must
be avoided. An external device, with pins in the distal tibia

and foot, is a reliable procedure that facilitates postoperative compliance, allows maintenance of the ankle joint
and permits easy changing of the dressing (3). Slight elevation of the lower extremity is possible, avoiding any
contact of the flap that could result in partial or total necrosis.
FIGURE 547.4 Raising the flap and its pedicle including the fascia. Small perforators from the fibular artery
should be ligated and severed. These proximal perforators can be used as pivot points for a more proximally
designed flap. 1, Deep fascia.
FIGURE 547.5 Recipient site and pedicle covered with split-thickness skin graft.
CLINICAL RESULTS
Although the sural artery flap has received favorable judgments in the literature, the clinical success rate
has been diversely reported. The rate of complications ranges from 5% to 36%, and includes partial or
complete necrosis of the flap, infection, hematoma, delayed healing, and skin-graft necrosis on the flap
margins (2, 3, 4, 5, 7, 9). Venous congestion and arterial insufficiency may be obvious explanations for
complications. However, technical errors are often the main causes, especially among inexperienced
surgeons, and can easily be avoided if the following possible causes of trouble are kept in mind.
The flap has been designed in a much too proximal location or the adipofascial pedicle is not large
enough.
The lesser saphenous vein and the sural nerve are not included in the pedicle.
The twisting of the base of the pedicle at the pivot point is too tight.
The flap or the connections between the flap and the pedicle are angulated at the recipient site.

The flap has been placed at the recipient site before deflating the tourniquet, which causes difficulties in
flap reperfusion.
The pedicle is passed subcutaneously through retractile tissue, which leads to hyperpressure on the
pedicle.
It may be difficult to suture the flap to the surrounding fibrous tissue because of the thickness of the
subcutaneous layer of the flap.
Technical guidelines to avoid the surgical mistakes or conditions mentioned should be emphasized.
The lesser saphenous vein and arterial perforator should be identified by Doppler ultrasound. If the
lesser saphenous vein cannot be located, this may be an indication for a delay in the procedure (10).
The ratio of length to width of the pedicle should not exceed 4:1.
The pedicle should be long enough to allow loose twisting.
The use of a tourniquet must be carefully assessed in arteriosclerotic patients.
The flap should be placed without angulation. For this reason, repair of the weight-bearing area of the
heel is a risky indication. Conversely, the repair of the totality of the heel may require an excision of the
greater tuberosity of the calcaneus to avoid flap angulation.
It is preferable to incise the skin bridge between the pivot point and the recipient site. The use of a “skin
tail” overlying the pedicle seems to improve venous return but limits rotation of the pedicle (9). Flap
transposition through a subcutaneous tunnel with the aid of an intraoperative soft-tissue expander has
been proposed (11).
The skin-to-skin suture of a bulky flap implies performance of extensive mobilization of the recipient area
and planning the design of the flap initially larger than the defect.
The postoperative course is facilitated by the use of an external device or a posterior plaster splint,
providing a posterior chamber to avoid excessive pressure.
COMORBIDITY
Age alone is not a risk factor by itself. The risk factors mentioned include diabetes mellitus, venous insufficiency,
and peripheral arterial disease (3). If all three factors are present, the risk of a necrotic flap is very high.
However, comorbidity with any of these diseases should not present an absolute contraindication, but one
should understand that association of one or two risks with a technical error will lead to unavoidable necrosis.
SUMMARY
With respect for the technical guidelines, and despite the limitations implied by the risk factors of
comorbidity, the sural artery flap is a valuable tool for reconstruction of the lower extremity. In many cases, it
remains the last alternative to an amputation.
References
1. Masquelet AC, Romaña MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive
superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115.
2. Raveendran S, Perera D, Happuharachchi T, Yoganathan V. Superficial sural artery flap: a study in 40
cases. Br J Plast Surg 2004;57:266.

3. Baumeister SP, Spierer R, Erdmann D, et al. A realistic complication analysis of 70 sural artery flaps in a
multimorbid patient group. Plast Reconstr Surg 2003;129:129.
4. Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast Reconstr Surg 2002;109:583.
5. Hollier L, Sharma S, Babigumira E, Klebuc M. Versatility of the sural fasciocutaneous flap in the coverage
of lower extremity wounds. Plast Reconstr Surg 2002;110:1673.
6. Zhang FH, Chang SM, Lin SQ, et al. Modified distally based sural neuro-veno-fasciocutaneous flap:
anatomical study and clinical applications. Microsurgery 2005;25:543.
7. Akhtar S, Hameed A. Versatility of the sural fasciocutaneous flap in the coverage of lower third leg and
hind foot defects. J Plast Reconstr Aesthet Surg 2006;59:839.
8. Ozalp T, Masquelet AC, Bégué T. Septocutaneous perforators of the peroneal artery relative to the fibula:
anatomical basis of the use of pedicled fasciocutaneous flaps. Surg Radiol Anat. 2006;28:548.
9. Noack N, Hartmann B, Kuntscher M. Measures to prevent complications of distally based neurovascular
sural flaps. Ann Plast Surg 2006;57:37.
10. Kneser U, Bach A, Polykandriotis E, et al. Delayed reverse sural flap for staged reconstruction of the foot
and lower leg. Plast Reconstr Surg 2005; 116:1910.
11. Buluç L, Tosun B, Sen C, Sarlak A. A modified technique for transposition of the reverse sural artery flap.
Plast Reconstr Surg 2006;117:2488.

Chapter 548
Dorsalis Pedis Flap
L. T. Furlow JR.
The dorsalis pedis flap consists of the skin, subcutaneous tissue, and the most superficial layer of fascia of the
dorsum of the foot supplied by the dorsalis pedis artery through its subcutaneous branches between the first and
second toe long extensor tendons. Sensory innervation can be maintained through the superficial and deep
peroneal nerves. My experience with the dorsalis pedis flap is as a local attached flap, either as an island or with
a skin bridge, for foot and ankle coverage (1). It has found more use as a free flap owing to its thinness and its
potential for reestablishment of sensation through neurorrhaphy (2, 3, 4).
INDICATIONS
The dorsal pedis flap is useful for coverage of defects of the medial and lateral aspects of the foot and the
front and both sides of the ankle. It has provided excellent cover for both malleoli. Although the saphenous
veins are long enough, the dorsalis pedis artery may have to be lengthened by a graft to permit the flap to
cover heel or Achilles tendon defects (5). Distal foot coverage by basing the flap on the perforating branch
of the dorsalis pedis with reverse flow from the posterior tibial artery supplying the flap was described
recently (6).
FIGURE 548.1 Pertinent anatomy encountered in flap dissection.
Disadvantages of the flap include a relatively difficult and tedious dissection, during which it is distressingly
easy to dissect the flap from its artery, and a sensory deficit of the entire dorsum of the foot. There is a
potential for healing problems in the donor site if complete paratenon cover of the extensor tendons is not
maintained to ensure skin graft “take.”
If the foot is not supplied by both the posterior tibial and dorsalis pedis arteries, the flap should not be used.
After flap elevation, the dorsalis pedis is required for flap survival and the posterior tibial artery is required
for foot survival. Unfortunately, these requirements remove the dorsalis pedis flap from consideration in the
large number of ischemic ulcerations about the foot with which we are faced.

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ANATOMY
The dorsalis pedis flap is classified as an axial flap, which it is not. It must be emphasized that the dorsalis pedis
flap is a random subcutaneous flap resting on but only tenuously connected to its axial artery, the dorsalis pedis
(Fig. 548.1).
FIGURE 548.2 Variations in the origin and course of the first dorsal metatarsal artery.
The dorsalis pedis artery is the extension of the anterior tibial that enters the foot beneath the extensor
retinaculum of the ankle, where it lies immediately on the tarsal bones. From proximal to distal in the tarsal
region, the dorsalis pedis gives off the lateral tarsal artery, the medial tarsal artery or arteries, and the arcuate
artery, which courses laterally at approximately the tarsometatarsal level. Unfortunately, all these branches
course deep to the extensor tendons of the foot and so cannot be elevated with the flap.
As the dorsalis pedis artery reaches the first intermetatarsal space, it dips plantarward through the interosseous
muscles to join the plantar arch and gives off its terminal branch, the first dorsal metatarsal artery, to the first web
space. The origin of the first dorsal metatarsal artery is the most important variable in the arterial anatomy of the
flap (Fig. 548.2). In about 80% of feet, the first dorsal metatarsal artery arises superficially or just within the
interosseous muscle, but in the other 20% it is given off more deeply in the intermetatarsal space and must rise
back through the interosseous musculature to supply the web space (2, 3). The tiny branches of the dorsalis
pedis artery that directly supply the flap have been studied (4).
There are three routes of venous return for the flap. The greater and lesser saphenous veins form the dorsal
venous arch within the substance of the flap and course toward the medial and lateral malleoli, respectively.
Either of these veins may be preserved if a skin pedicle is left, or the flap will survive on the dorsalis pedis venae
comitantes.
The first web space area of the flap is supplied by the deep peroneal nerve, which accompanies the dorsalis
pedis artery, becoming superficial at its terminal bifurcation. The remainder of the dorsal skin of the foot is
supplied by the superficial peroneal nerve through its medial and intermediate dorsal cutaneous branches.
The critically important pedestal of tissue connecting the dorsalis pedis artery and the flap lies between the
extensor hallucis longus tendon and the extensor digitorum longus tendon to the second toe. The extensor
hallucis brevis muscle and tendon course obliquely through this pedestal superficial to the dorsalis pedis-first
dorsal metatarsal artery and deep peroneal nerve.
It is important to establish the proximal patency of both the posterior tibial and dorsalis pedis arteries by palpation
or Doppler examination. Because pulsation of the dorsalis pedis may be transmitted distally through its plantar
arch anastomosis, pulsation or flow must be demonstrated in four circumstances: (1) With the dorsalis pedis
pulse finger-occluded on the dorsum of the foot, pulsation should be felt just proximal in the vessel. (2) Pulsation
in the dorsalis pedis should be palpable when the posterior tibial artery is finger-occluded. These two maneuvers

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indicate patency of the anterior tibial artery. (3) When the dorsalis pedis is finger-occluded, pulsation in the
posterior tibial artery should be palpable, indicating its patency. (4) It is of interest but not critical to flap or foot
survival to note whether pulsation is present in the dorsalis pedis distally when it is finger-occluded over the
dorsum of the foot, indicating strong flow from the plantar arch through the perforating branch. This maneuver
would of course be critical if the flap were to be distally based on retrograde flow through the perforating branch
of the dorsalis pedis artery (6).
FLAP DESIGN AND DIMENSIONS
The flap may include the skin of the entire dorsum of the foot extending from the web spaces to the extensor
retinaculum and across the entire breadth of the dorsum of the foot. The flap may be elevated with the proximal
skin pedicle to include either the greater or lesser saphenous veins or as an island. The maximum flap size is
approximately 12 × 12 cm. Coverage requirements usually allow use of a smaller flap that should be centered
over the dorsalis pedis artery in the proximal end of the intermetatarsal space.
I have been quick to delay the flap, primarily under three circumstances:
1. If the first dorsal metatarsal artery cannot be elevated with the flap.
2. If skin more than 2.5 cm from the dorsalis pedis artery, particularly in the lateral direction, is required.
3. I am more likely to delay an island flap than one with a proximal skin pedicle.
OPERATIVE TECHNIQUE
The weak link of the dorsalis pedis flap is the vascular supply between the axial dorsalis pedis artery and the
subcutaneous flap. Because of the tenuous nature of this connection, necrosis of all or a part of the flap is quite
possible in the presence of a bounding dorsalis pedis pulse. Every precaution must be taken to avoid elevating
the flap from the dorsalis pedis artery, which is distressingly easy to do, and to preserve the tiny connecting
vessels within the soft tissue between the extensor hallucis longus and extensor digitorum longus tendons (Fig.
548.3).
The dissection is done under tourniquet control, but the limb is elevated without wrapping so that some blood will
remain in the vessels to be dissected. Five or six wraps of an Ace bandage around the knee will limit the thigh
blood coming through the femoral medullary canal beneath the tourniquet.
Although others begin elevation of the flap medially or proximally, I prefer to begin in the first web area by
elevating the distal-medial corner of the flap and identifying and dividing the first dorsal metatarsal artery (Fig.
548.4). The tie on the flap end of the vessel is left long and is used to elevate
the flap. The superficial fascia overlying the extensor tendons is elevated with the flap, leaving a filmy layer of
paratenon over the extensor tendons. The first dorsal metatarsal artery is followed into the intermetatarsal space,
as necessary into the interosseous muscle, until the perforating branch of the dorsalis pedis artery is found.
Elevation of the lateral portion of the flap is carried proximally, leaving paratenon on the extensor tendons. All
soft tissue between the extensor hallucis longus and extensor digitorum longus tendon margins and the first
dorsal metatarsal artery must be elevated with the flap, including the extensor hallucis brevis tendon, which is
divided and left within the flap.

FIGURE 548.3 The flap elevated, supplied by fine vessels from the dorsalis pedis artery between the extensor
hallucis longus and second toe extensor digitorum longus tendons.
FIGURE 548.4 Distal identification of first dorsal metatarsal artery and deep peroneal nerve.
When the perforating branch of the dorsalis pedis is reached, all three vessels at the junction, the proximal
feeding dorsalis pedis, the perforating branch, and the first dorsal metatarsal artery, are identified before the
perforating branch is ligated and divided. Again, the tie on the proximal (flap) end is left long and used to elevate
the flap; the flap is thus lifted on its artery rather than away from it.
Flap dissection is continued proximally, dissecting the dorsalis pedis artery and the deep peroneal nerve from the
underlying tarsal bones and preserving the maximum amount of soft tissue available between the extensor
hallucis longus and extensor digitorum longus tendons. As the arcuate and tarsal branches of the dorsalis pedis
artery are encountered, they are dissected to the point where they pass beneath the extensor tendons before
being divided to ensure the maximum number of connecting vessels between the dorsalis pedis artery and the
flap. The extensor hallucis brevis muscle belly is divided where it passes beneath the second toe extensor
digitorum longus tendon, leaving its tendon and distal muscle in the flap.
If the flap is to be left attached by a skin pedicle, a saphenous vein, or the superficial peroneal nerve, these are
dissected at the proximal end of the flap. If the flap is to be elevated as an island, these structures are divided as
encountered. It may be necessary to incise the lower portion of the extensor retinaculum for adequate
mobilization of the dorsalis pedis pedicle proximal to the flap.

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When flap delay is indicated, the distal dissection is carried proximally until the perforating branch of the dorsalis
pedis can be ligated and divided and from medially and laterally to the margins of the extensor hallucis longus
and extensor digitorum longus tendons, leaving the tissue between the tendons undissected and a portion of the
proximal skin intact. Final elevation of the flap is scheduled for 1 week later. This interval is adequate for the
delay phenomenon but permits easy finger dissection of the previously elevated portions of the flap before
significant fibrous tissue forms in the wound.
If the flap is elevated as an island, I prefer to divide the skin between the pedicle and the defect to be covered
rather than passing the flap beneath the skin bridge. If necessary, this incision can be left unsutured and grafted
with the donor defect.
Before grafting the donor defect of the dorsum of the foot, any rents in the paratenon must be closed carefully to
cover all exposed tendon. The remaining portion of the extensor hallucis brevis muscle belly may be helpful for
tendon coverage (Figs. 548.5 and 548.6).
SUMMARY
The dorsalis pedis flap should be considered as a random subcutaneous flap resting on an underlying axial
artery. It has been very useful for difficult coverage problems of the foot and ankle area but has been used
more often as a free flap because of its thinness; the presence of two sensory nerves for reinnervation; and
because extensor tendons, metatarsi, and toes can be transferred with it.
FIGURE 548.5 A: Muffler burn of medial malleolus and ankle in a motorcyclist. The bone of the medial
malleolus was burned. He had a palpable dorsalis pedis pulse, and the posterior tibial pulse was identified
by Doppler examination. B: One week after flap delay and grafting of defect margins. C,D: Appearance 9 ½
years after coverage with a dorsalis pedis flap.

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FIGURE 548.6 A: In 1971, prior to the first free flap transfer, this 55-year-old woman was the first patient to
undergo dorsalis pedis flap elevation. She had a medial ankle ulcer recurrent after multiple previous skin
graftings, a contralateral AK amputation, and an ipsilateral elbow flexion contracture. B: The dorsalis pedis
flap was elevated as an island and transferred primarily. There was some marginal flap loss, primarily the
skin from the lateral aspect of the foot, but this area was skin-grafted. (Continued)
FIGURE 548.6 (Continued) C,D: Appearance 14 years later, with no further ulcerations.
References
1. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap. Plast Reconstr Surg 1975;55:177.
2. Gilbert A. Composite tissue transfers from the foot: Anatomic basis and surgical technique. In: Daniller A,
Strauch B, eds. Symposium on microsurgery. St. Louis: Mosby, 1976. Chap. 25.
3. May JW Jr, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977;2:387.
4. Man D, Acland R. The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plast
Reconstr Surg 1980;65:419.

5. Caffee H, Hoefflin S. The extended dorsalis pedis flap. Plast Reconstr Surg 1979;64:807.
6. Ishikawa K, Isshiki N, Suzuki S, Shimamura S. Distally based dorsalis pedis island flap for coverage of the
distal portion of the foot. Br J Plast Surg 1987;40:521.

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Chapter 549
Dorsalis Pedis Myofascial Flap
T. I. A. ISMAIL
EDITORIAL COMMENT
This is a brilliant modification of the dorsalis pedis flap. Very similar to the radial forearm fascial flap, the
dorsalis pedis can be used with fascia alone. This militates against many of the skin problems that were
associated with the dorsalis pedis flap. The flap can be used either as a pedicle flap, as described by
Ismail, or as a free flap.
The dorsalis pedis myofascial flap, composed of the deep fascia of the dorsum of the foot and underlying
extensor digitorum brevis muscle, is a reliable and safe local flap with minimal donor-site morbidity.
INDICATIONS
Defects in the lower half of the leg and malleolar region are difficult and common problems facing the plastic
surgeon.
Several flaps have been described (1, 2, 3, 4, 5, 6, 7) for their management. The dorsalis pedis myofascial
flap has many advantages. The donor site can be closed primarily without skin grafting. This is a very safe
and well-vascularized flap.
It is used to supply coverage for small- and moderately-sized defects over both the medial and lateral
malleoli. The flap can be carried up to cover defects in the lower half of the leg. It can also potentially be
used as a free flap to supply thin coverage over areas such as the dorsum of the hand. In addition, the flap
can be used to cover the Achilles tendon, either by direct rotation, or by passage through a hole in the
interosseous membrane. The extensor tendons of the toes may be included, to supply vascularized tendon
grafts.
The flap is contraindicated when either anterior or posterior tibial arterial pulsations are not palpable. Such
a situation will limit its use in some traumatic defects with damage to either vessel.
ANATOMY
The flap consists of the deep fascia of the dorsum of the foot, with a thin layer of fat over it, and the extensor
digitorum brevis muscle on its undersurface. It is supplied by the dorsalis pedis artery and drained by its venae
comitantes. It extends from the web space up to the extensor retinaculum. The extensor digitorum brevis muscle
is not an essential part of the flap, but its inclusion is believed to augment flap vascularity and to facilitate the
dissection and elevation of the dorsalis pedis artery.
FLAP DESIGN AND DIMENSIONS
Patency of the anterior tibial and posterior tibial vessels is mandatory for flap harvesting. The skin incision starts
between both malleoli and descends to the base of the second toe. Proximal extension of the incision into the leg
may be needed if the flap is to be carried to the lower half of the leg. The flap surface area can oblige defects of

80 cm2 or more, and its size can be increased, if the deep fascia and extensor digitorum brevis muscle are
spread in a bilobed manner (Fig. 549.1).
FIGURE 549.1 Illustration of flap anatomy and extent.
FIGURE 549.2 Defect of the lateral malleolus and lower leg, with exposed ankle joint.
OPERATIVE TECHNIQUE
A bloodless field using a tourniquet is essential. The skin is undermined medially and laterally in the subdermal
plane, preserving one lobule of fat on its undersurface. The skin is reflected medially and laterally 0.5 cm beyond
the flap margins. The desired amount of deep fascia on the dorsum of the foot is elevated with the dorsalis pedis
artery and its venae comitantes, after its ligation at the base of the first metatarsal space.
The flap is elevated from distal to proximal, ligating the deep and side branches of the dorsalis pedis artery. The
extensor digitorum brevis muscle is commonly included on the undersurface of the deep fascia. If the flap is to be
carried to the lower leg, the extensor retinaculum must be cut and the dorsalis pedis artery (now the anterior
tibial artery) is mobilized for a suitable distance, indicated by the site of the defect. Now, the flap is passed
through a subcutaneous tunnel to the malleolar defect, or rotated into the leg defect.
The flap is spread over the defect and covered by a split-thickness skin graft. The donor site on the dorsum of
the foot is closed primarily with a small suction drain.

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FIGURE 549.3 Dorsalis pedis myofascial flap on its way to cover exposed cartilage at the lateral malleolus.
FIGURE 549.4 Flap and extensor digitorum brevis muscle are spread in a bilobed fashion to cover the defect.
CLINICAL RESULTS
Currently, the flap has been used in 20 cases without a single failure (Figs. 549.2, 549.3, 549.4, 549.5).
Minimal complications may occur, such as delayed healing of the donor site, widening of the scar,
hypopigmentation of the donor site, and hypothesia of the dorsum of the foot. Such complications have
been well-tolerated by patients.
FIGURE 549.5 Full take of the skin graft over the flap and primary healing of the donor site.
SUMMARY

The dorsalis pedis myofascial flap, consisting of the deep fascia of the dorsum of the foot with the extensor
digitorum brevis muscle, is a simple, safe, and reliable local flap. It is used to cover defects over both
malleoli and the lower half of the leg, with minimal donor-site morbidity.
References
1. Ismail TIA. The dorsalis pedis myofascial flap. Plast Reconstr Surg 1990;86:573.
2. Morrison WA, Shen TY. Anterior tibial artery flap: anatomy and case report. Br J Plast Surg 1987;40:230.
3. Landi A, Soragni O, Monteleone, M. The extensor digitorum brevis muscle island flap for soft-tissue loss
around the ankle. Plast Reconstr Surg 1985; 75:892.
4. Townsend PLG. An inferiorly based soleus muscle flap. Br J Plast Surg 1979;31:210.
5. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg
1981;34:215.
6. Donski PK, Fogdestam I. Distally based fasciocutaneous flaps from the sural region. Scand J Plast
Reconstr Surg 1983;17:191.
7. Amarante J, Costa H, Reis J, Soares R. A new distally based fasciocutaneous flap of the leg. Br J Plast
Surg 1986;39:338.

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Chapter 550
The Dorsal Metatarsal Artery Perforator Flap
SAMUEL HO
CHONG JIN YEO
EDITORIAL COMMENT
Unless bone or tendon is exposed, there is no need to resort to this elegant procedure.
INDICATIONS
The dorsal metatarsal artery perforator (DMtAP) flap is a thin, pliable flap. For successful use of this flap,
patient and wound selection is of paramount importance. Indications include wounds on the distal foot
dorsum, toes, and web spaces not amenable to skin grafting or where skin grafting would result in
unacceptable postoperative morbidity of web space contracture or recurrent foot dorsum hyperkeratosis
and ulceration.
The ideal indication for this flap is a small soft-tissue defect on the dorsum of a metatarsal head or proximal
interphalangeal joint. It could also be utilized to resurface the donor defect after a toe pulp transfer or a first
web flap transfer, to reduce donor site morbidity. Certainly, this flap should be undertaken with caution in
patients with previous foot trauma or severe peripheral vascular disease.
ANATOMY
The vascular anatomy is fairly consistent, allowing for rapid harvest of the flap in most patients. There are two to
five cutaneous perforators arising from each dorsal metatarsal artery (DMtA), with the most distal cutaneous
perforator having a caliber size of 0.5 to 0.7 mm (1, 2). This distal perforator can be consistently found between
the heads of the metatarsals (Fig. 550.1), lying distal to the juncturae of the extensor tendons. Distal
anastomosis between the dorsal metatarsal arteries and the plantar arterial systems is always present, allowing
for retrograde flow (1). The flap is most reliably based on the first DMtA, which is present in almost all cases, and
has the largest vessel caliber. This is also the most consistently described pedicle in the literature (1, 3). The
anatomical variations of the flap mainly involve the second to fourth DMtAs, which may be absent in increasing
frequency as the arch extends laterally: 5% for second, 7.5% for third, and 17.5% for fourth (4). The vessel
caliber of the perforators also decreases as one proceeds laterally. In 75% of patients, the artery lies superficial
to the interosseous muscle, while the remaining can be found within the muscle. The intramuscular course of the
artery is always within the superficial (dorsal) third of the muscle, requiring minimal dissection for identification
(2).
FLAP DESIGN AND DIMENSIONS
A flap size of up to 2 cm wide and 8 cm long is designed based on the most distal cutaneous perforator, most
reliably from the first DMtA (5) (Fig. 550.2). In order to achieve primary closure of the donor site, we recommend
designing a flap
width of 1 to 1.5 cm, with a smaller width for the more lateral flaps. The arc of rotation of this flap reaches tissue

defects over adjoining metatarsal heads, the web spaces, the dorsum of the proximal interphalangeal joints of
the adjacent toes, and the dorsum of the distal interphalangeal joint of the same toe (6). Islanding the flap based
on the perforator alone can increase the reach of the flap.
FIGURE 550.1 The distal perforator can be consistently found between the heads of the metatarsals, distal to
the juncturae of the extensor tendons.
FIGURE 550.2 Schematic diagram showing a flap design based on the most distal cutaneous perforator, most
reliably from the first DMtA. The various arcs of rotation are shown.
OPERATIVE TECHNIQUE
The skin paddle is circumscribed along the prescribed dimensions over the metatarsal space chosen to
resurface the defect, as marked in Figure 550.3. For primary closure of the donor site, the maximum width is 2
cm (2, 5, 6). The most distal skin perforator is first identified by making an incision on the medial aspect of the
skin paddle. The distal anastomosis to the plantar system is identified just distal to the edge of the
intermetatarsal ligament. Once the distal perforator is identified and judged to be of sufficient caliber, the paddle
is circumscribed and harvest is performed in a subcutaneous plane above the chosen DMtA between the
adjoining metatarsal heads (Fig. 550.4). It is crucial to appreciate the planes in which the vessels run: the vein in
the subcutaneous plane and the artery in the subtendinous plane. The DMtA is clamped proximally and distally
to check for skin paddle vascularity before the remaining two to four proximal cutaneous perforators are ligated

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to allow for a greater arc of rotation. Preservation of the proximal two to four perforators and intramuscular
dissection of the DMtA is neither routinely done nor necessary as it would involve incising the extensor tendons
and their juncturae. Key surgical points include the following: (a) avoid dissecting out the DMtA and (b) include a
cuff of soft tissue around the perforator in order to minimize venous congestion.
FIGURE 550.3 The flap's skin paddle is circumscribed along the prescribed dimensions over the metatarsal
space chosen to resurface the defect.
FIGURE 550.4 Flap harvest is performed in a subcutaneous plane above the chosen DMtA between the
adjoining metatarsal heads. It is vital to preserve the areolar tissue around the pedicle.
CLINICAL RESULTS
Clinical application of the DMtA flap is centered on appropriate patient selection. Figure 550.5 shows a
primarily closed donor site. Figures 550.6 and 550.7 show a typical indication for the use of the DMtA flap,
good flap vascularity after tourniquet release, and excellent donor site aesthetics. The complication rate is
fairly low in our series. The main postoperative concern is flap congestion, which is minimized by keeping
the areolar cuff around the pedicle as shown in Figure 550.4 and leg elevation. Well-healed DMtA flaps
show excellent contour and appearance as seen in Figure 550.8.
SUMMARY
The DMtA flap is a thin, pliable, and well-vascularized flap that is useful in selected patients. It has a
consistent anatomy, which allows for rapid flap harvest and minimal donor site morbidity. This flap should
be undertaken with caution in patients with previous foot trauma and severe peripheral vascular disease.

FIGURE 550.5 Primarily closed donor site. Tension-free inset of the flap is crucial.
FIGURE 550.6 A classic indication for the use of the DMtA flap.
FIGURE 550.7 Close-up showing good flap vascularity up to the distal tip of the flap after tourniquet
release.
FIGURE 550.8 Well-healed DMtA flap showing excellent contour and appearance and excellent donor site
aesthetics.

References
1. Alagoz MS, Orbay H, Uysal AC, et al. Vascular anatomy of the metatarsal bones and the interosseous
muscles of the foot. J Plast Reconstr Aesthet Surg 2009;62:1227-1232.
2. Yeo CJ, Sebastin SJ, Ho SY, et al. The dorsal metatarsal artery perforator flap. Ann Plast Surg
2014;73(4):441-444.
3. Hou Z, Zou J, Wang Z, et al. Anatomical classification of the first dorsal metatarsal artery and its clinical
application. Plast Reconstr Surg 2013;132(6):1028e-1039e.
4. Huber JF. The arterial network supplying the dorsum of the foot. Anat Rec 1941;80:373-391.
5. Cheng MH, Ulusal BG, Wei FC. Reverse first dorsal metatarsal artery flap for reconstruction of traumatic
defects of dorsal great toe. J Trauma 2006;60:1138-1141.
6. Hayashi A, Maruyama Y. Reverse first dorsal metatarsal artery flap for reconstruction of the distal foot.
Ann Plast Surg 1993;31:117-122.

Chapter 551
Medialis Pedis Flap
A. C. MASQUELET
M. C. ROMAÑA
EDITORIAL COMMENT
This is an extremely clever series of flaps based on the medial plantar artery. Dissection is not easy but
learning to utilize this flap is well worth the effort. Its versatility is considerable.
The medialis pedis flap is a fasciocutaneous flap raised on the medial aspect of the foot. Initially developed as an
island pedicled flap for coverage of elective areas of the foot (1, 2), it also has been used as a free flap for
resurfacing restricted areas of the foot, and skin defects of the hand and digits (3).
INDICATIONS
For certain indications, no other flap is better: use of the dorsalis pedis implies a heavy arterial sacrifice; the
medial plantar flap is not pliable enough; and the lateral supramalleolar flap is too thick and too big. We
think that the free flap should be reserved for areas where a sensory flap is not mandatory; it also can be
very useful in the hand for large defects, when other conventional flaps, because of their bulk, are not
suitable. The flap has restricted, but elective, indications on the foot: it can be used to cover the tip of the
medial malleolus and the area of insertion of the Achilles tendon; defects of the medial aspect of the heel
(calcaneum) may also be easily covered by this flap. The length and caliber of the vessels allow its
application as a free flap, and it can be oriented specifically for tissue repairs in the hands and fingers (3).
Among its advantages, the medialis pedis flap is very thin, compared to other free or local flaps raised from
the foot. Unlike many conventional free and pedicled flaps, it can be used for small-sized defects. It also
provides a good color and texture match for finger repairs. The thinness of the flap allows good recovery of
protective sensation, although the flap is not sensory.
A principal disadvantage is that a skin graft is usually required for donor-site closure.
ANATOMY (FIG. 551.1)
The flap is supplied by a constant and reliable cutaneous artery arising from the medial plantar artery (1). At the
level of the plantar vault, the medial plantar artery divides into a superficial and a deep branch. The superficial
branch emerges from the septum between the abductor hallucis and flexor digitorum brevis muscles. It gives off 2
to 4 cutaneous branches destined for the plantar arch and constitutes the arterial axis of the medial plantar flap.
The deep branch has not been well explored. It arises from the medial plantar artery near its origin, and also
divides into two branches—a lateral branch that penetrates into the sole of the foot and anastomoses with the
deep plantar arch; and a medial branch that is of interest for the flap under discussion. This branch follows the
medial aspect of the bones of the foot, to reach the base of the first metatarsal and to anastomose with the first
plantar metatarsal artery. The medial branch crosses the terminal part of the tibialis posterior tendon, on which it
lies just behind the tuberosity of the navicular bone. It then takes an oblique course parallel to the medial aspect
of

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the foot. At the level of the distal end of the tibialis posterior tendon, the artery gives off several cutaneous
branches supplying a cutaneous area from the navicular bone to the mid-shaft of the first metatarsal, which
constitutes the territory of the medialis pedis flap.
FIGURE 551.1 Diagram of vascular anatomy. 1, navicular bone; 2, cutaneous branch supplying the medial
aspect of the foot; 3, tubercle of the navicular bone; 4, superficial branch of the medial plantar artery; 5, deep
branch of the medial plantar artery; 6, abductor hallucis muscle; 7, medial plantar artery; 8, lateral plantar artery;
9, posterior tibial artery; 10, tibialis posterior tendon.
Among possible variations, the cutaneous branches sometimes arise from the trunk of the medial plantar artery.
This variation is not important, as a constant landmark is the passage of the cutaneous branch on the tibialis
posterior tendon, just behind the tubercle of the navicular bone. The pedicle of the flap is always dissected up to
the origin of the medial plantar artery.
FLAP DESIGN AND DIMENSIONS
The flap is outlined on the medial border of the foot, including the tuberosity of the navicular bone and the slight
depression that identifies the distal part of the tibialis posterior tendon. The proximal end of the flap can be
extended proximally beneath the medial malleolar; the distal end extends to the mid-shaft of the first metatarsal
bone. Flap size clinically ranges from 2 × 3 cm to 5 × 10 cm.
OPERATIVE TECHNIQUE
Raising the flap is performed under tourniquet. Arteriograms may be mandatory to assess flow-through of the
main distal trunks. Through a retro-malleolar incision, the terminal portion of the tibialis posterior artery is first
exposed just proximal to the posterior edge of the abductor hallucis muscle. The plantar border of the flap is
incised with fascia included (Fig. 551.2). The subcutaneous veins are ligated and severed; they should be
spared for anastomosis at the recipient site, when the flap is used as a free flap. On the dorsal border of the flap,
only the skin is incised, to spare a dorsal hinge of fascia.
The flap is progressively raised and retracted from plantar to dorsal. The dissection in depth is performed close
to the tubercle of the navicular and the tendon of the tibialis posterior bones. Dissection is pursued until the deep
branch plunging under the navicular is seen. Then, the abductor hallucis muscle is retracted (Fig. 551.3) and
detached from the inner border of the foot. The flap remains attached by its dorsal hinge. Retraction of the
abductor hallucis allows exposure of the vascular axis.

FIGURE 551.2 Elevation of the flap; origin of the medial plantar artery is identified. The fascia covering the
abductor hallucis muscle is incised in line with the skin incision. The insertion of the tibialis posterior tendon and
the tubercle of the navicular bone should be included in the design.
FIGURE 551.3 The flap is progressively raised from posterior to anterior. The abductor hallucis muscle is
retracted. The vascular branches are identified. The release of the pedicle implies ligation of the deep and
superficial branches of the medial plantar artery distal to the cutaneous branch supplying the flap.
The superficial branch of the medial plantar artery, the pedicle to the abductor hallucis, and the distal portion of
the deep branch of the medial plantar artery are successively ligated and divided. At last, the dorsal hinge of the
flap is cut, and the pedicle is released as far as the division of the posterior tibial artery. The donor site is
immediately covered with a split-thickness skin graft.
CLINICAL RESULTS
The arc of rotation provided by the medial plantar artery allows coverage of defects of the medial malleolus
and the heel. Division of the lateral plantar pedicle dramatically increases the arc of rotation of the flap. The
flap is mandatory when a thin, supple, and hairless flap is needed. In the foot, the medial aspect of the heel,
the medial malleolar, and the distal insertion of the Achilles tendon are all sites for elective indications (Fig.
551.4). The flap is not indicated in the weight-bearing area and posterior aspect of the heel. The precise
location of the cutaneous branch (just behind the tuberosity of the navicular bone) allows the raising of
small and reliable flaps, very useful for small defects that are otherwise difficult to manage (Fig. 551.5).

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SUMMARY
The medialis pedis flap has restricted, but elective, indications for defects of the foot and for other areas
where a very supple coverage is required.
FIGURE 551.4 Arc of rotation of the flap. Medial aspect of the posterior tuberosity of the calcaneum also
can be covered.
FIGURE 551.5 A: Recurrent ulceration of the medial malleolar area in spina bifida. Note marking of the
vascularization. B: Elevation of the medialis pedis flap. C: Final result.
References
1. Romaña MC. Masquelet AC. Vascularization of the inner border of the foot: surgical applications. Surg
Radiol Anat 1988;11:177.
2. Masquelet AC, Romaña MC. The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg
1990;85:765.

3. Ishikura N, Heshiki T, Tsukada S. The use of a free medialis pedis flap for resurfacing skin defects of the
hand and digits: results in five cases. Plast Reconstr Surg 1995;95:100.

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Chapter 552
Local Fasciocutaneous Flaps for Dorsal Foot and Ankle Coverage
G. G. HALLOCK
EDITORIAL COMMENT
Although most of these flaps have adequate viability, a good number of them do suffer from necrosis,
particularly the distal end of the flap. This negates the objectives of the reconstructive effort (“Vasconez
principle”).
Undelayed cutaneous flaps from the fascial plexus of the lower leg may be used as a simple means of coverage
for adjacent defects of the dorsal foot and ankle.
INDICATIONS
Substantial defects involving the ankle or dorsum of the foot are usually treated most expeditiously by
microsurgical tissue transfer (1). However, if the resultant morbidity is unacceptable, a source of vascular
inflow or exit is unavailable, or because of patient disagreement, a dorsal foot or ankle fasciocutaneous flap
may be a simpler alternative. Of course, sufficient local tissue must still be available as a donor, and the
multiple perforators of the deep fascia must have remained undisturbed by the original injury or disease.
ANATOMY
The deep fascia of the dorsum of the foot, although not as thick as the crural fascia, nevertheless is a distinct
layer, except at the ankle where it tends to blend with the extensor retinaculum (2). All three major leg arteries
contribute to the confluence of perforators nourishing this deep fascia, which has longitudinally- oriented
perfusion. Periodic direct perforators, ascending and descending malleolar or tarsal branches, and their terminal
vessels are included (Fig. 552.1), as well as collaterals from the proximal plantar subcutaneous plexus of the
sole (3).
Although this confluence of perifascial vessels makes the boundaries of skin territories on the dorsal foot
relatively indistinct, the branches of the posterior tibial vessels dominate in their supply to the posteromedial
ankle and foot. The anterior tibial vessels, the terminating dorsalis pedis, and the first dorsal metatarsal vessels
(4) supply the peroneal to the posterolateral region, and the remaining central portion. Any proximally- based flap
will have the additional advantage of being sensate if a cutaneous nerve branch is included.
FLAP DESIGN AND DIMENSIONS
One boundary of any chosen local dorsal foot or ankle flap will coincide with the defect to be covered (Fig.
552.2). A length:width ratio not exceeding 1.8:1 allows undelayed flap transfer, without risk of necrosis, if the
circulation is otherwise normal (2). Any choice should lie preferentially over the course of one of the major leg
source vessels to ensure that a fascial perforator is captured in the base of the flap. The long flap axis is drawn
parallel to the known longitudinal orientation of the microcirculation. When based proximally, the flap
will be potentially sensate, and a subcutaneous vein can be included to enhance venous outflow.

FIGURE 552.1 Diagram of typical distribution of multiple perforators to the region of the dorsal foot and ankle.
Note contributions from all three major lower-limb source vessels. A proximally-based flap overlying the anterior
tibial-dorsalis pedis axis can be used to cover medial or lateral malleolar defects. It will rely on an interconnecting
network with more proximal fascial perforators (left). A bipedicled flap, shown in a horizontal orientation (right),
captures perforators from two directions (medial and lateral), which otherwise might be sparse over the Achilles
tendon. (Diagram courtesy of Carol Varma, medical illustrator at the Lehigh Valley Hospital, Allentown,
Pennsylvania.)
FIGURE 552.2 A: Following diabetic coma, this male patient developed a full-thickness pressure sore over the
lateral heel. Because of bone exposure after debridement, vascularized coverage was proposed, with a 7 × 4 cm
proximally-based local flap, intended to capture the territory of the lateral calcaneus branches, but without their
specific identification. B: Flap inset without tension. C: Viable flap in the early stage of healing, demonstrating
how the mandatory skin graft at the donor site can have an unaesthetic result.
Since underlying tendons are numerous and easily exposed in any donor site from this region, sometimes a
distally-based flap offers the potential of reduced donor-site morbidity (Fig. 552.3) (5). It must also be noted that
the extensor retinaculum must be kept with the deep fascia at the ankle area, to avoid injuring the fascial plane.
This may not be an option in patients with compromised vascularity and marginal antegrade inflow. In these
cases, a vertical or horizontal bipedicle flap to maximize the number of perforators may be elected at the expense
of less freedom in flap mobility (Fig. 552.3) (6).