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background and continuous suction are currently available. The Weck-
Cell (Alcon Surgical, Fort Worth, TX) microsponge is very useful to
absorb excess fluid or blood from the anastomotic site (Fig. 22.5A).
Fine instruments like the keratotomy knife and angled microscissor
are useful for arteriotomies (Fig. 22.5B). Frequent irrigation of the
anastomotic site using heparinized saline with an angled ophthalmic
needle and a 3 mL syringe is useful to dilate the vessels, wash out clots
and better visualize the anastomosis (Fig. 22.5C). After completing
the anastomosis, a Doppler should be used to listen for a good tripha­
sic flow distal to the anastomosis on the arterial side and an aug­
mented venous rush on the proximal venous side of the anastomosis.
An oxygen analysis system (Oxygen-to-see, LEA-Medizintechnik
adventitia and the straight scissors to cut suture. The needle holder
likewise should be spring-loaded. The instruments should be main­
tained in excellent condition for optimal use and should be kept in a
special protective case for each individual instrument.
The microsutures are usually made from either polypropylene or
nylon and are affixed onto an atraumatic needle. The black color of
nylon may make it easier to visualize suture in the operative field. The
needle should have a taper point and 38 of a circle in design. For
vessels 0.5–1 mm in diameter, either ETHICON (Somerville, NJ)
needles (BV 75–3 and BV 100–4) or Sherwood–Davis & Geck (St
Louis, MO) needles (TE 70 and TE 100) should be used. For vessels
that are from 1 to 3 mm in diameter, a needle with a diameter of from
100 to 140 µm should be considered (ETHICON BV 130–5 or
Sherwood-Davis & Geck TE 143). For vessels above 3 mm in diameter,
standard vascular suture 7–0 and 8–0 in size should work well. Lower
extremity reconstruction may present the additional challenge of anas­
tomosing heavily atherosclerosed vessels. For vessels walls that have
calcium plaques, special hardened black needles (ETHICON VISI-
black laser drilled taper BV 1 needle) that are used in cardiac surgery
can be very useful.
Microvascular clamps (Fig. 22.4) are used to hold the vessels in
close proximity, as they are being anastomosed to one another during
an end-to-end anastomosis. They should be small, lightweight and
atraumatic, and should vary in size, so that they can match the size
of the vessels being repaired. The closing pressure should be anywhere
from 15 to 30 mmHg for smaller arteries and veins. Higher clamping
pressures are required for larger vessels.
Another accessory that is helpful in performing microsurgery is a
small piece of bright yellow colored background material placed
beneath the anastomotic site. This makes it easier to highlight the
needle or suture from the surrounding field. Micro-suctions should
be used to keep blood out of the field. A very small tip is necessary
to avoid accidentally aspirating the vessels and tearing apart a freshly
sutured anastomosis. Prefabricated mats that provide adequate
Figure 22.4  Microvascular clamps come in various sizes appropriate to
the size of the vessel being anastomosed. Double clamps are used to
approximate two vessel ends when performing the microanastomosis.
Figure 22.5  Useful adjuncts in microsurgery include: (A) a microsuction tip and Weck-Cell (Alcon Surgical, Ft Worth, TX) microsponges used to keep
blood from the field; (B) an 11° keratotomy knife and angled microscissor for arteriotomies; (C) 3 mL syringes with angled ophthalmic #25 irrigation
needles used to dilate veins and irrigate out clot.
A
B
C

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
sutures. The platelets disappear over the next 24–72 h as a pseudo-
endothelium forms over the anastomosis. The pseudo-endothelium is
replaced by new endothelium between the 1st and 2nd week after the
anastomosis.36 The critical time during which anastomotic thrombosis
occurs is in the first 3–5 days when the platelets and pseudo-
endothelium cover the anastomotic junction.37
The endothelium regenerates by migration of surrounding cells. If,
however, more layers than just the endothelium have been damaged,
then myoendothelial cells migrate to the site and differentiate into
endothelial cells. The remainder of the vessel wall, including the
elastic and muscular elements, does not regenerate as well as the
endothelium34 and the subsequent repair leaves a thickened area of
collagen deposition at the anastomotic site.38
Damaging the vessel wall during dissection or anastomosis leads to
increased exposure of subendothelial structures and increases the
chance of thrombosis. This points out how critical excellent surgical
technique is to minimize endothelial damage and decrease the likeli­
hood of thrombosis of the anastomotic site. The less the vessels to be
anastomosed are dissected from their surrounding bed, the less chance
there is for endothelial damage. Side branches should either be tied
off or coagulated with bipolar coagulation at least 1 mm from the
main vessel so that the intraluminal endothelium is not damaged. The
vessels should be kept moist because desiccation leads to endothelial
cell damage. Prolonged vasospasm (>2 h) should be avoided because
it also leads to endothelial cell loss. Flat vessel clips with closing pres­
sures of <30 mmHg should be used to hold the vessels in place during
the anastomosis for as short a time as necessary.39
Vessels are damaged during an anastomosis when the suture needle
pierces their wall. The smaller the needle used and the straighter the
path through the vessel, the less damage to the subendothelium and
endothelium. The sutures should be tied with just enough strength to
approximate the vessels without causing leakage. Too tight a closure
leads to endothelial slough. Too loose a closure leads to anastomotic
leakage, predisposing the area to coagulation. Excessive trauma from
repeated needle punctures, manipulation of the endothelium with
dilators, and excessive tension on the suture line, all lead to possible
endothelial slough and subsequent thrombosis.
Analysis of microvascular anastomotic failure shows that in addi­
tion to poor technique, an anastomosis performed within the zone of
injury in trauma cases is an additional risk factor.40 Benacquista and
colleagues41 reviewed a series of failed free flaps in the lower extremi­
ties and found that trauma patients had a failure rate of 11%, while
GmbH, Gießen, Germany) allows for monitoring of blood flow, flow
velocity, hemoglobin concentration, and oxygen saturation.11 Simi­
larly, Optical Diffusion Imaging and Spectroscopy (ODIS) technology
enables non-invasive, direct, real-time measurement of local tissue
oxygen saturation and may be used to supplement postoperative
monitoring12 (Vioptix, Fremont, CA). The use of these devices allows
for assessment of flap viability following vessel anastomosis. For more
information on the techniques of microsurgery, Bernard O’Brien’s
book on microsurgical technique is very helpful.13
HISTORY OF MICROSURGERY
The first successful clinical microsurgical case was performed when
Malt and McKhann14 successfully replanted an amputated arm at the
Massachusetts General Hospital. Surgeons successfully replanted a
hand at wrist level.15 Kleinert and Kastan16 described the technique of
small vessel anastomosis in reattaching severed fingers. Magnifying
loops instead of the microscope were used, and the use of vein grafts
to avoid tension was stressed. The first successful replantation of an
amputated thumb was performed by Komatsu and Tamai.17 Buncke
and Schultz18 then went on to show the feasibility of replanting the
ear of a rabbit and in performing a toe to thumb transfer in a monkey.19
After studying with Buncke, Cobbett20 then went on to perform a suc­
cessful toe to hand transfer.
Nakayama21 reported on the successful jejunal transfer for cervical
esophageal reconstruction in 19 patients with 1-year follow-up. The
vessels were from 3 to 4 mm in size and microsurgical technique was
not used. Krizek et al.22 were successful in transferring groin-free flaps
in a dog model with a >90% success rate without microsurgical tech­
nique. Strauch and Murray were the first to successfully transfer a flap
using microsurgery when they transferred rat-groin flaps to the neck
(1 mm vessels).23 Antia and Buch24 reported on a free epigastric flap
of skin and fat that they transferred to the face to fill a cheek soft tissue
deficit. McLean and Buncke25 performed an omental free flap to cover
a denuded scalp that survived for 3 weeks. Daniel and Taylor26 and,
later, O’Brien and Macleod27 each successfully transferred a cutaneous
groin flap to a lower extremity wound. Over the next 30 years, micro­
surgery exploded with a wide array of flaps being described with
greater success rates.8,9,28–32 O’Brien33 reviewed the changes that
occurred during microsurgery in the 1970s and 1980s, and in the
1990s, Khouri and colleagues34 prospectively looked at the top micro­
surgical centers in the world and was able to establish a baseline
of current microsurgical practice, though an ideal protocol is still
controversial.
BASIC SCIENCE CONCEPTS
In order to perform successful microsurgery, the surgeon has to know
the physiology of arteries and veins and understand the mechanisms
that cause vessel injury and enable or inhibit repair and regeneration.
The surgeon has to be familiar with the manifestations of vasospasm,
the physiology of thrombosis, and how both can be manipulated
pharmacologically. The surgeon has to be aware of how ischemia and
hypoxia affect revascularized tissue.
Injury to the vessel wall leads to exposure of the subendothelium
(Fig. 22.6). This promotes platelet aggregation, the first step in throm­
bosis. Exposed collagen present within the vessel media and adventitia
is the stimulant for platelet aggregation.35 After an anastomosis of two
vessels with resultant intima-to-intima contact, a layer of platelets
covers the anastomotic site. Platelets show little affinity for the exposed
Figure 22.6  Damage to the vessel wall caused by external and surgical
trauma.
(From: O’Brien, B.M., Morrison, W.A., Gumely, G.J., 1990. Principles and techniques
of microvascular surgery. In: McCarthy, J.G. (Ed.), Plastic Surgery. WB Saunders,
Philadelphia, pp. 423.)
Intraluminal valves, clots,
flaps, tears
Separation of medial
and intimal walls
Branches near
anastomosis
Friable walls

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in clinical situations where a high degree of probability for possible
occlusion exists (e.g. digital replant, vein graft use).
TECHNICAL FACTORS
In microsurgery, vascular anastomoses are best performed with eight
simple sutures44 (Fig. 22.8) using a technique that is an adaptation of
Carrel’s triangulation method.45 Fewer stitches lead to excessive bleed­
ing and thrombus formation. A greater number of stitches lead to
endothelial damage and thrombus formation. The suture needle
should go through the vessel perpendicular to the vessel wall rather
than tangentially to minimize the amount of tissue damage. The
surgeon should minimize the amount of perforation of the vessel wall
by the suture needle, and blind stabs or feeling the endothelium with
the needle tip before going through should be avoided. Continuous
suture versus simple interrupted suture technique when performing
the microanastomosis remains an ongoing debate in microsurgery.
Some groups have achieved better results with simple interrupted
sutures,46 while others have had equal or better patency rates with the
continuous suture technique.47 The chief advantage of continuous
suture technique is that it cuts the time of the anastomosis in half.
The chief disadvantage is that the suture may become caught in the
clamp and break, requiring redoing the anastomosis. If an anastomo­
sis has to be repeated, both vessel edges should be trimmed back to
undamaged vessel wall because the distal ends have already been
perforated with previous sutures and, if included, are at increased risk
for thrombus formation. There is also a danger of purse-stringing and
thereby narrowing the anastomotic site when doing the venous anas­
tomosis in a continuous fashion.
Also popular is the sleeve technique where one vessel end is slid
into the other vessel (Fig. 22.9). It is held in place by a through-and-
through stitch of the outer wall that captures the adventitia or wall of
the telescoping vessel. This first was tried by Laretson48 and refined by
Duminy.49 While the technique causes less intimal damage and pro­
motes endothelialization more rapidly, most groups have found that
the patency rate is lower than that of interrupted sutures.50
There is debate regarding whether the microvascular anastomosis
should be performed in an end-to-end or end-to-side fashion (Fig.
22.10). Many reports show higher success rates with the end-to-side
technique.51–53 Acland54 has hypothesized that the reason for increased
patency is caused by higher flow rates. It is clear that when performing
microsurgery around the foot and ankle, an end-to-side anastomosis
to the artery is preferable to an end-to-end anastomosis because it
does not sacrifice one of the principal arteries feeding the foot. End-
to-side anastomoses, however, are technically more difficult. This is
especially true if the recipient vessel wall is sclerotic, as is often the
case in diabetic and renal-failure patients. When performing an end-
to-side anastomosis, it is best to make a long arteriotomy and angle
the arterial anastomosis at about a 45° angle from the main artery,
which has been shown to be superior to angles of 90° and 135°.55
With venous repairs, an end-to-end anastomosis is preferable if the
respective diameters are similar. If the recipient vein is much larger
than the donor vein (i.e. saphenous vein), then an end-to-side anas­
tomosis should be considered.
Anastomoses may also be stapled together. This concept was intro­
duced by Androsov56 and refined by Nakayama et al.57 Currently, the
MCA automatic coupling device (Medical Company Alliance, Bir­
mingham, AL) is used in the USA (Fig. 22.11) and works by bringing
the vessel through a plastic ring with metal spikes. The vessel end is
then everted over those spikes. The same is done to the other vessel
end. Both rings are then locked together bringing the endothelium of
one vessel in complete contact with the endothelium of the other
non-trauma patients had a failure rate of 6.7%. When dealing with
irradiated vessels, the endothelium has a tendency to easily separate
from the underlying media. The needle should always be placed from
inside out (i.e. from endothelium toward the adventitia) to prevent
this separation from occurring. Another important reason for occlu­
sion is external compression of the anastomotic site by a hematoma,
drain or dressing (Fig. 22.7). Veins are far more at risk for this than
arteries.
After the anastomosis has been completed, vasospasm may occur.
This may be treated by removing the adventitia close to the anasto­
motic edge. More effective and less traumatic techniques include the
placement of 20% Xylocaine (Astra, Westborough, MA) on the spas­
modic vessel.42 Other adjuncts include the use of warm solutions at
the site of anastomosis. Third, and more important, is to make sure
that there are no side branch vessels that were inadvertently left untied
on either side of the vascular anastomosis. These are potent causes of
severe vasospasm. Any suspected opening should be sutured with 9–0
or 10–0 suture.
Thrombosis is felt to be at the center of failed anastomoses. As
platelets adhere to exposed subendothelial tissue, they trigger the
coagulation cascade. Fibrinogen changes to fibrin and forms a web
that traps more platelets. The cycle repeats itself as more and more
platelets aggregate until the vessel is occluded. The microsurgery lit­
erature is replete with studies attempting to manipulate the coagula­
tion cascade in order to minimize the chances for occlusion. Heparin
and tissue plasminogen activator have been used topically while
heparin, aspirin and dextran have been used systemically in attempts
to minimize the risk for thrombosis. Davis43 reviewed the protocols
in 73 centers and found that there was no difference in the microvas­
cular patency rates between those centers that did and did not use
anticoagulation. Khouri28 found the same result when he surveyed the
free flap results of the top microsurgical centers. For limb replantation,
the overall success rate was lower with anticoagulation than without
anticoagulation.41 Therefore, the following conclusions about antico­
agulation are currently considered reasonable. Anticoagulation or
antifibrinolytic therapy is not warranted if the mechanical and vascu­
lar factors are optimal (i.e. during elective free flap transfer). When
thrombosis does occur in the perioperative period, flap re-exploration,
and treatment with fibrinolytic therapy (urokinase, streptokinase,
tissue plasminogen activator) followed by subsequent anticoagulation
is prudent. Anticoagulation or fibrinolytic therapy could be indicated
Figure 22.7  External sources can lead to occlusion of the vessel lumen.
The problem is compounded if the vessel lies on top of an unyielding
structure such as bone.
(From: O’Brien, B.M., Morrison, W.A., Gumely, G.J., 1990. Principles and techniques
of microvascular surgery. In: McCarthy, J.G. (Ed.), Plastic Surgery. WB Saunders,
Philadelphia, pp. 423.)
Swelling
Bone
Hematoma
Tight wound
closure
Blood vessel

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 22.9  Sleeve anastomosis. (A) One stitch goes through the outside
wall and grasps the edge of the other vessel wall; (B) Two stitches hold
the invaginated vessel in place; (C) Additional outside stitches that do not
go through the endothelium can be used for further tacking.
(From: O’Brien. B.M., Morrison, W.A., Gumely, G.J., 1990. Principles and techniques
of microvascular surgery. In: McCarthy, J.G. (Ed.), Plastic Surgery. WB Saunders,
Philadelphia, pp. 423.)
A
B
C
Figure 22.10  Intraoperative view on an end-to-end anastomosis.
Figure 22.8  The initial two stitches are placed at opposite ends of the
vessel anastomosis 180° apart. (A) Three stitches are placed on the
anterior side of the vessel anastomosis. (B) The anastomosis is flipped.
(C) The three stitches on the posterior side are placed for a total of eight
stitches. (From: O’Brien, B.M., Morrison, W.A., Gumely, G.J., 1990. Principles and
techniques of microvascular surgery. In: McCarthy, J.G. (Ed.), Plastic Surgery. WB
Saunders, Philadelphia, pp. 423.)
A
B
1
2
3
C

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on the recipient artery should be permitted. Finally, 5000 units of
subcutaneous heparin are given to the patient twice a day postopera­
tively for deep venous thrombosis prophylaxis.
PATIENT FACTORS
The condition of the patient has been linked to the success or lack of
success of microsurgical-free flap transfers. Patients who were once
thought to be at risk for higher failure rates include the elderly, chil­
dren, patients with diabetes, smokers or patients with an irradiated
operative field. A study reviewing the microvascular-free flap experi­
ence at various international centers by Khouri et al.34 shows that the
microsurgical flap transfer in the extremes of age, in smokers, or in
patients with diabetes did not contribute to the failure rate. Irradia­
tion, however, did.
Advanced age has been shown not to affect free tissue transfer by
numerous reports.30,55,58 The wound-healing complications were no
different than those in the normal population. Youth also poses no
added risk.29 Parry and colleagues29 demonstrated this with a 96%
successful free tissue transfer rate in children. Either extreme of age,
therefore, is not a contraindication to performing free tissue transfers.
However, Wettstein et al.59 found that in cases where thrombosis
necessitated flap revision, patient age was significantly higher in
those cases where the flaps eventually failed versus those that were
salvaged. Potparić and Rajacić60 found that older patients had signifi­
cantly worse sensory recovery in both non-innervated and re-innervated
flaps.
Systemic disease has, likewise, not been shown to be a complicating
factor to performing microsurgical free flaps. Because this surgery is
often lengthy and complex, any patient with a cardiac history should
obtain cardiac clearance before undergoing surgery. Diabetes mellitus
is not a contraindication to microsurgical-free tissue transfers. While
Colen et al.61 showed that anastomotic venous thrombosis was accel­
erated by hyperglycemia, this decreased patency was corrected by the
administration of pentoxifylline. Barr and Joyce62 showed that defec­
tive re-endothelialization might contribute to higher anastomotic
failures in diabetic rats. Cooley et al.63,64 showed that diabetes did not
affect patency rates in rats. Clinically, several series have shown no
increased failure rate for elective free flap transfers in patients with
diabetes. Karp et al.65 showed a 95% patency rate in diabetic foot
salvage, though five of the legs went on to below-knee amputations
6–37 months after repair because of recurrent ulceration secondary to
biomechanical abnormalities. Ioshi et al.66 showed a similar patency
rate in free flap transfer in patients with diabetes. They also eventually
lost six out of 20 limbs over the ensuing 22 months despite viable
free flaps. Lai et al.67 had 100% success rate in repairing limbs of
patients with diabetes with microsurgical-free flaps.
Colen68 outlined some of the main principles to ensure successful
free flap transfer in patients with diabetes. He emphasized that the
wound had to be clean and free of infection before performing the
free flap. This took at the minimum 1 week and could take longer.
The revascularization was performed at least 7 days before the transfer,
serving two purposes. It ensured that the revascularization was suc­
cessful and also helped in re-establishing flow around the area of the
wound so that the necessary white blood cells and antibiotics could
be delivered to the wound. It has been reported that performing a
vein bypass directly to a free flap in a dysvascular foot with a non-
revascularized bed has led to flap survival, but loss of the foot. Unless
the bed itself is revascularized, transferring a free flap to it is likely to
be an exercise in futility. Banis et al.69 points out some of the technical
microsurgical adjuncts that are useful in ensuring successful outcomes
in the patient with diabetes.
vessel. The rings come in various diameters ranging from 1 to 4 mm
in size. Veins, because of their thinner walls, tend to evert far more
easily than arteries. The advantage of a stapled anastomosis is that
it is free of intraluminal foreign bodies (i.e. sutures). This advantage
is mitigated by the necessity of having to mobilize the vessels
extensively to bring the vessel through the ring and onto the
spikes. The mobilization of the distal vessel can damage the endothe­
lium. The vessel length sacrificed with the eversion over the spikes
shortens both vessels and can lead to possible tension across the
anastomosis.
Technical factors that are important in foot and ankle microvascular
reconstruction involve avoiding direct pressure over the length of the
pedicle, preventing twisting of the pedicle, using an end-to-side anas­
tomosis to the artery, performing two end-to-end vein anastomoses,
avoiding all tension, using meticulous surgical technique, and obtain­
ing excellent hemostasis. When the free flap anastomosis has a long
pedicle, there is sometimes a problem in covering the pedicle with
adequate tissue. If obtaining a soft tissue closure means placing exces­
sive pressure on the pedicle, then it is best to leave the pedicle exposed.
It is then covered with an unmeshed split-thickness skin graft and
should go on to heal without a problem. To avoid twisting of the
vascular pedicle, the outside surface of the pedicle should simply
be marked with ink so that any inadvertent twist can immediately be
seen. It is also very important to obtain adequate exposure of the
recipient vessels before flap harvest to minimize ischemia time. Veins
should be found and isolated for end-to-end anastomosis. Although
ischemia time should never be an issue, our protocol has been to give
a 4000 unit bolus of heparin 5 min before the harvest of the flap. The
anastomosis itself is irrigated with heparinized saline by 3 mL syringes
and ophthalmic anterior chamber needles. The anastomotic surgical
technique has to be excellent because the recipient artery is often calci­
fied and the endothelium may easily separate. Only inside-out sutures
Figure 22.11  The MCA automatic coupling device (Medical Company
Alliance, Birmingham, AL) with vessel internal diameter sizer. The open
coupling device allows each of the two vessel ends to be brought
through one of the plastic rings and everted over the spikes.

256
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Radiation has been associated with higher failure rates and has
discouraged microvascular surgeons from performing free flap trans­
fers to such fields in the past. Mulholland et al.70 showed that there
was no statistical difference in success rates in irradiated patients in
head and neck surgery. This is despite the fact that irradiation clearly
affects small vessels.71 The vessels show decrease in smoothness and
density, and there is endothelial cell dehiscence with a resultant
extremely fragile intima while the arterial wall is thicker secondary
to vessel-wall fibrosis.72 Arteries are more susceptible than veins to
damage. The damage to those vessels continues long after radiation is
finished. Suggestions to increase patency rates when dealing with
irradiated fields have been made by Guelincks.72 The dissection of
the recipient vessel should be minimized to limit the damage to the
endothelium. Arterial side branches should not be coagulated, but
sutured to minimize the damage to the intima. Smaller needles
(70 µm needles and 10–0 suture) should be used, again, to minimize
the damage to the intima. When performing the anastomosis, the
needle should be passed from inside out rather than from outside in,
to avoid separating the endothelium from the media. The time of
placing the cross-clamp across the vessel should be minimized. The
vessel should be flushed with heparinized saline during the anasto­
mosis. Particularly with radiation damage, the principle of placing
the anastomosis outside of the ‘zone of injury’ should be adhered
to if at all possible, which may require the use of a longer pedicle
or vein grafts.
Finally, the use of tobacco has been thought to be a contraindica­
tion in microsurgery because nicotine is a vasoconstrictor. This has
not been borne out clinically. Rues et al.73 demonstrated no difference
in patency between smokers and non-smokers. They did find a higher
complication in the wound healing at the site of microsurgical flap
transfer. Khouri et al.34 likewise found no effect of smoking on micro­
vascular success. All possible efforts should be made to decrease
smoking to get optimal healing at the wound site.
FREE FLAPS AND FREE FLAP FAILURE
Microsurgery has now become part of the standard of care in address­
ing complex wounds or defects. It has evolved to being able to transfer
tissue successfully for esthetic and functional reasons and has become
more refined. The success rates likewise have increased remarkably.
Khouri et al.34 found that microsurgery was being performed with a
96% success rate internationally and that higher failure rates were
linked to the use of vein grafts and working in irradiated fields. Schus­
terman et al.74 found that the only significant variables were previous
surgery and the need for vein grafts. However Khouri et al.34 found
that whether the anastomosis was performed end-to-end or end-to-
side, whether the vessel was irrigated with or without heparin, and
whether antithrombotic drugs were used or not did not affect the
overall outcome.
The first factor determining success has to do with the experience
of the operating surgeon. There is a remarkable learning curve between
the first 25 cases and those that follow. This has been nicely summa­
rized in Khouri’s28 article on avoiding free flap failure. There is an
increased frequency of free flap failures when they are performed for
traumatic or radiation wounds. It is critical, when planning the place­
ment of the flap, that the anastomosis be performed outside of the
field of injury. The anastomosis can be done with equal success proxi­
mal or distal to the site of injury. Venous thrombosis is the common­
est source of failure. The use of vein grafts is likewise associated with
increased failure rates.55 Most failure rates are caused by technical
factors, including tension or twisting of the pedicle or pressure from
a hematoma or external source.
CHOICES OF FLAPS
Free flaps can consist of any combination including one or more of
the following components: (1) skin; (2) fascia; (3) muscle and/or (4)
bone. Schusterman et al.74 have shown that familiarity with a selected
number of microsurgical-free flaps ensures a higher success rate. In
terms of foot and ankle reconstruction, the choices should be limited
to a few options.
For dorsal foot defects, the most successful microsurgical-free flaps
are those that are composed of skin and fat or of fascia plus skin graft.
They provide a thin cover that is esthetic and contours easily for
normal shoe wear. The harvested skin flaps can also be sensate if
harvested with the sensory nerve that provides sensation to the area
of the flap. They can also include vascularized tendon or bone for
specific reconstructive tasks. Flaps that have proven to be very success­
ful include the radial forearm flap, the lateral arm flap, and the par­
ascapular flap and the anterolateral thigh flap.
The parascapular flap (Fig. 22.12) based on the circumflex scapular
artery is an excellent choice for large defects.75,76 It is insensate,
however, and often needs to be revised at a later date because of its
bulkiness. The other problem with this flap is that the patient has to
be placed in the lateral decubitus position. This may make it difficult
to work simultaneously on the donor and recipient sites or may
require repositioning of the patient during the microvascular anasto­
mosis. Colen et al.77 have described an adaptation of the flap where
only fascia with a thin layer of overlying fat is harvested. It is then skin
grafted to yield an ultimately far thinner flap.
The lateral arm flap (Fig. 22.13) based on the posterior radial recur­
rent vascular pedicle was first described by Katseros et al.78 It is a
sensory flap (lower lateral cutaneous nerve of the arm) with a rela­
tively long vascular pedicle (up to 14 cm). Including the skin overly­
ing the elbow can extend the flap size. When harvested in its extended
size, the resulting donor site leaves a denuded lateral elbow donor
site, which, when skin grafted, can pose both an esthetic and
functional problem. This flap has been used extensively in hand
reconstruction.
The radial forearm flap (Fig. 22.14) is an excellent choice on the
dorsum of the foot.79,80 The advantage of the radial forearm flap is that
it is thin, pliable, and can be harvested with a sensory nerve (the lateral
antebrachial cutaneous nerve). The palmaris longus tendon can also
be used to reconstruct missing extensor tendons on the dorsum of the
foot if necessary. The radial forearm flap is also very useful around the
malleoli. The radial artery with the venous comitantes provides an
excellent vascular pedicle up to 14 cm in length. The flap, if inset
properly at the time of flap transfer, rarely needs tailoring. The donor
site is skin grafted and, apart from the obvious resulting color dispar­
ity, is very manageable.
The anterolateral thigh (ALT) flap is a septocutaneous flap based
upon perforators originating from the descending branch of the lateral
circumflex femoral system.81 Originally described by Song et al.82 and
popularized by Koshima et al.,83,84 the anterior lateral thigh flap is well
accepted and can supply a large amount of subcutaneous fat and skin
on a safe and reliable pedicle with no functional donor site morbidity.
The flap may be raised both sensate with the lateral femoral cutaneous
nerve, and as a flow through flap.85 Thinning of the flap is well toler­
ated even to the level of the subdermal plexus for tailoring to a par­
ticular defect.86 The anatomy and dissection of ALT flaps has been well
established for both head and neck and lower extremity defects.87 This
flap may also be harvested as a composite or chimeric flap with the
tensor fasciae lata to simultaneously reconstruct soft tissue and tendon
defects. The ALT flap has an average pedicle length of 10 cm and an
average vessel diameter greater than 2 mm making it appropriate for
defects of the medial and lateral ankle and dorsum of foot.86 A

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the plantar surface of the foot holds up better under the stress of
ambulation. Muscle flap and a skin graft are currently favored on the
plantar aspect of the foot.88,89 Muscle flaps provide a better blood
supply to the recipient site, making them the better choice for infected
surgical sites.90 If the fasciocutaneous flaps are innervated they could
potentially be more effective on the sole of the foot in non-neuropathic
patients.60,76 Fasciocutaneous flaps are ideal for providing skin cover­
age and tendon movement. A word of caution is due with respect to
the use of the latissimus dorsi flap. While this flap is an attractive
option in many other parts of the body, the functional loss of the latis­
simus dorsi must be taken into account in lower extremity reconstruc­
tions where many of these patients will be crutch or wheelchair
dependent for a prolonged amount of time.
The rectus abdominus muscle flap91 (Fig. 22.15) is very useful
because it is easy to harvest, has an excellent pedicle, and is a thin
broad muscle. If the muscle is stretched over the recipient site, it may
be made even thinner. The donor site morbidity is minimal. The
portable handheld Doppler is used preoperatively to map out cutane­
ous vessels. The skin island of the ALT flap is an ellipse drawn parallel
to the thigh and centered over a line drawn from the anterior superior
iliac spine to the superolateral corner of the patella. A width up to
8 cm may still be closed primarily. Elevation of the flap begins medi­
ally with dissection down to and including the deep fascia of the
thigh. The angiosome may be supplied by either musculocutaneous
or septocutaneous perforators that pass through the vastus lateralis.
ALT flaps are particularly suited for secondary revision surgeries such
as contouring with liposuction.
Muscle flaps are preferred on exposed bone and the plantar aspects
of the foot. Myocutaneous flaps show better resistance against infec­
tion compared to pure skin flaps. This holds especially true in patients
with osteomyelitis. The most frequently harvested muscles include
the rectus abdominus muscle, gracilis muscle, and serratus anterior
muscle. The muscle flap is inset and skin grafted. There is still some
debate whether muscle plus skin graft versus fasciocutaneous flaps on
Figure 22.12  As a child, this patient’s foot was run over, leaving her with a painful, unstable foot (A). (B) Before an ankle fusion could be performed,
adequate soft tissue cover was necessary and a parascapular flap was harvested from her left back. (C,D) The flap vessels were anastomosed to the
anterior tibial artery and vein. The flap was subsequently debulked with liposuction.
A
B
C
D

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Figure 22.13  This patient suffered a rerupture of his Achilles’ tendon and subsequent infection (A), that required removal of the entire lower Achilles’
tendon (B). A lateral arm fasciocutaneous flap with a portion of the triceps tendon was harvested and the flap was connected to the posterior tibial
artery and vein, and the vascularized triceps tendon was used to reconstruct the Achilles’ tendon (C). The patient was able to flex and extend his foot
and resumed playing tennis and skiing at 6 months post-procedure (D,E).
A
B
C
D
E

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muscle. Stockings with at least 30 mmHg should be worn by the
patient. If that is insufficient, the muscle may need debulking. This is
best performed by using a dermatome to shave the muscle down to
the proper height, provided the pedicle inset was on the undersurface
of the muscle. The original skin graft may be preserved and placed
back on the thinned muscle.
Specialized flaps include the omentum and vascularized bone
flaps. The omentum is an excellent flap to use when faced with
extensive long bone osteomyelitis (i.e. tibia) or a degloved foot. It
appears to withstand bacterial challenge extremely effectively by
providing a well-vascularized surface rich in macrophages and
leukocytes. It is extremely malleable and, therefore, very easy to inset
over irregular surfaces. The only disadvantage is that it requires a
laparotomy. For vascular bone flaps, the fibula, based on the peroneal
artery, is clearly the current bone flap of choice. The fibula can be
harvested with a cutaneous paddle if necessary. Because the flap
harvest means the sacrifice of the peroneal artery, it is critical that the
other two arteries to the foot are patent. Consideration should be
given to fixation of the remaining distal fibula to the tibia as recent
reports suggest that ankle instability may occur. Alternate solutions
gracilis muscle92 (Fig. 22.16) is an excellent muscle to use in foot and
ankle reconstruction.93 It should be harvested from the ipsilateral leg.
This limits all reconstruction to a single extremity. The pedicle is
somewhat smaller and shorter than that of the rectus abdominus
muscle. Depending on the location of the defect and the status of the
recipient vessels, its use may be limited. Using the bottom two or three
sections of the serratus anterior muscle94 (Fig. 22.17) is also an excel­
lent option. The pedicle is much longer than that of the above two
muscles and can be up to 18 cm. The nerve may be harvested with it
provided no more than the lower three or four slips of the muscle are
needed as excessive muscle or nerve harvest can lead to a winged
scapula. The serratus muscle provides well-vascularized thin muscle
to cover existing defects.
In muscle free flap transfers, muscle flaps tend to swell, which
makes it more difficult to fit the foot into a shoe. To minimize the
swelling, outflow should be optimized by performing two vein anas­
tomoses (Fig. 22.18). To minimize the profile of the flap, it should be
inset under tension so that it lies flat and at the same height as that
of the surrounding tissue. After the flap has survived and the skin graft
has healed, compression therapy helps in diminishing the bulk of the
Figure 22.14  This patient developed a severe infection and skin slough after a bunionectomy that left her with a scarred dorsal forefoot, hallux
valgus, and dorsiflexed second toe (A). The scarred tissue was excised, her first metatarsal joint fused, and the second toe straightened out. The
residual defect was covered with a radial forearm flap that was anastomosed into the dorsalis pedis artery and vein (B,C).
A
B
C

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 22.15  The gangrenous plantar aspect of a foot of a patient with diabetic renal failure cachexia was debrided (A). The defect was covered with
a rectus abdominus muscle flap anastomosed to the posterior tibial artery and vein. (B,C) The patient healed completely at 3 months.
A
B
C
A
B
Figure 22.16  This patient had traumatic defect of the medial malleolus with exposed tendon (A). The gracilis muscle was chosen to fill the defect (B).

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The gracilis muscle was harvested (C). This muscle was anastomosed to the anterior tibial artery and vein to cover the large
defect (D).
(Courtesy of M. Venturi, MD.)
C
D
Figure 22.16, Continued 
Figure 22.17  This patient with diabetes suffered midfoot breakdown because of Charcot collapse of the midfoot (A). The wound was aggressively
debrided (B). (C,D) The bottom three slips of the serratus muscle were harvested. The foot has remained completely healed for the last 8 years.
A
B
C
D

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
attempted nerve coaptation, patients with neuropathies or heavy scar­
ring due to chronic wounds may not show improvements in flap
reinnervation when compared to surrounding tissue.60
Depending on the recipient site location, flaps may undergo distinct
histological changes after surgery. Flaps transferred to either weight
bearing or non weight bearing regions of the foot develop a similarity
to the recipient area when compared to the donor region (Fig. 22.20).
Due to hyperplasia of the papillae, transferred tissue shows, on
average, double the thickness of tissue from the donor area at the
that have proven to be extremely successful include using current
adaptations of the Ilizarov technique with tri-cortical pelvic bone
strut grafts. In those instances, the free flap need only consist of soft
tissue components.
With many of the described flaps, a neurorrhaphy may be per­
formed to increase reinnervation efficiency (Fig. 22.19). Outcomes
and overall benefit of this added procedure remain controversial.
Some studies report no difference in flap survival or ulceration rates
between innervated and non-innervated flaps. Regardless of age or
Figure 22.18  This patient presented with a large traumatic medial malleolus wound with exposed hardware and antibiotic cement (A). Note
(B) preoperative markings; (C) elevation of the flap; (D) posterior tibial recipient vessels; (E) following anastomosis with bright red bleeding from
flap; (F) flap inset.
A
B
C
D
E
F

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A
B
C
D
Figure 22.19  This patient presented with a sarcoma of the dorsum of her foot, status
post-resection of soft tissue and tendons with subsequent bracytherapy (A). (B) A radial
forearm free flap with antebrachial cutaneous nerve, and palmaris longus tendon was used to
reconstruct lost extensors. (C) Postoperatively, the patient had complete sensation except over
the fourth toe. (D) Donor site.
dermal-epidermal junction. The papillar and reticular dermal layer
show increased collagen and elastic fibers. Increased angiogenesis
was found in the recipient site, with the exception of a flap transferred
to the heel.95 Within innervated flaps, sensibility tests show that
on average patients detect touch sensation at 6 months, heat sensa­
tion at 18 months, cold at 6 months, and pain at 12 months
post-transplantation.96
WORKING WITH THE VASCULAR,
ORTHOPEDIC AND PODIATRIC SURGEONS
When the patient’s problem involves the expertise of several disci­
plines, it is critical that the entire reconstruction be planned with the
following three ‘rules’ being adhered to. The first prerequisite is that

264
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
(E) Extension and (F) flexion.
E
F
Figure 22.19, Continued 
Figure 22.20  This patient, with a history of a renal transplant and morbid obesity, developed gangrene of the heel (A). (B) Intraoperative markings for
a rectus abdominis flap. (C,D) The patient received excisional debridement and placement of a rectus free flap with skin graft; 1 year postoperatively.
A
B
C
D

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POSTOPERATIVE REGIMEN
The flaps are monitored postoperatively by use of the 9.0 MHz hand-
held Doppler. The nurses and residents are taught what sounds to
listen for, including occluded sounds of an artery or the loss of the
venous augment with compression of the flap. The flap is visualized
to make sure that it has a normal color, and lightly palpated to make
sure that it is warm. The flap is monitored closely the first 24 h (every
15–30 min). The frequency of the monitoring decreases until day
4 or 5, after which no further monitoring is performed. The patient
usually stays in the hospital until the anastomosis has had time to
re-endothelialize (approximately 5 days). Most vascular occlusions
occur within the first 24–48 h. Complications including thrombosis,
hematoma, and flap dehiscence may arise during initial mobilization
of the limb. The patient must be monitored for kinking, torsion,
and pressure, as flap compromise may necessitate timely surgical
intervention.
The patients are kept in a non-weight-bearing position with the leg
splinted with either an external splint or an external fixator. If the flap
is on a weight-bearing surface, the patient remains non-weight-bearing
until the wound has fully healed (4–6 weeks). If the wound is on the
ankle or dorsum of the foot, the patient may be mobilized earlier.
Obviously, if bone fixation is involved, the orthopedist or podiatrist
determines the ultimate non-weight-bearing status. Appropriate shoe
wear is ordered, including anything from gel type orthotics to custom-
made shoes with or without ankle-foot orthoses (AFOs).
REVISING FREE FLAPS
Although all attempts are made to ensure that the free flap is tailored
to be as thin as possible so that it can fit in a normal shoe without
causing excessive sheer or stress, it often remains bulky. One should
wait at least 6 weeks before revising it, but preferably 3–6 months.
Muscle flaps show signs of atrophy over time, which reduces bulk. No
revision should be planned until the flap and the surrounding tissues
have softened which may take between 6 and 12 months. If a flap is
fasciocutaneous in nature, then it may undergo liposuction and one
edge may be trimmed and re-inset. Care should be taken not to
damage the pedicle, although there are reports that the pedicle can be
cut at 6 weeks post-procedure without damaging the flap. If the flap
is a muscle flap, then it is thinned by shaving it with a dermatome
until the desired thickness is attained. The initial skin graft should be
preserved and placed back on the thinned muscle flap. Bleeding is
controlled with topical epinephrine, topical thrombin, or thrombin
glue. Once the bleeding has stopped, the skin graft is placed back on
the now debulked muscle. The wound is then allowed to heal.
FUTURE DIRECTIONS
Just as nearly 40 years ago, the foundations established by vascular
surgery made microsurgery possible, so now microsurgery has ushered
in the potential for composite tissue allo-transplantation (CTA). A
future is not hard to imagine where CTA may become a viable alterna­
tive to prosthetics and a final solution to amputations. The last decade
has seen the use of CTA in facial and upper extremity transplantation.
Zuker et al.98 in 2006 described the first successful CTA reconstruction
in the lower extremity. A normal lower limb in a 3-month-old ischio­
pagus twin who was not going to survive was transplanted to the
appropriate pelvic position, revascularized, and reinnervated to an
the extremity has adequate blood flow. The second is that the wound
is free of infection. The third is adequate bony fixation. Only then
can the surgeon plan the soft tissue components necessary for the
reconstruction.
There is adequate blood flow to the foot for a microsurgical anas­
tomosis if the pulses are palpable or if the Doppler sounds over the
arteries are triphasic.97 When evaluating the foot, care must be taken
to ascertain whether arterial flow is antegrade or retrograde through a
collateral system such as the first metatarsal artery. This is accom­
plished by occluding the posterior tibial artery when evaluating flow
through the dorsalis pedis and vice versa. If after a thorough physical
exam any doubt remains regarding vascular flow, the patient should
undergo an angiogram to assess whether the flow is sufficient for a
successful microvascular anastomosis. If it is inadequate then a vascu­
lar surgeon should be consulted for a bypass. When planning a micro­
vascular anastomosis, it is essential that either the dorsalis pedis or
posterior tibial artery have adequate flow. These arteries are larger in
diameter than the distal peroneal and it is easier to perform an end-
to-side anastomosis. When dealing with medial ankle and plantar
wounds, it is easier to perform the anastomoses to the posterior tibial
artery. When dealing with dorsal foot and anterior ankle wounds,
anastomosing to the anterior tibial artery is simpler. If dealing with a
lateral ankle or heel wound, the anterior tibial or posterior tibial are
both accessible. The posterior tibial is accessible by passing the donor
vessels deep to the Achilles’ tendon in the fat pad just above its inser­
tion. This allows direct and shorter access (average 6 cm) to the pos­
terior tibial vessels.
If the leg has to be revascularized, the angiogram should be reviewed
with the vascular surgeon. The vessel to be revascularized should, if
possible, be the closest to the planned reconstruction. It is most
important that the vascular surgeon understand what is needed for
the soft tissue reconstruction to follow. After vascular bypass, it is safer
to delay the reconstruction for 5–7 days while, after angioplasty, one
may have to wait 3–4 weeks. This delay allows the tissue around the
wound to revascularize, enables bacteriologic control of the wound,
and ensures that the bypass graft remains open. It has been the
authors’ practice, when dealing with infected diabetic foot wounds, to
discharge the patient home with dressing changes or vacuum-assisted
closure (VAC, Kinetic Concepts Inc, San Antonio, TX) therapy and
plan the free flap reconstruction only when there is granulation at the
wound edges.
With respect to optimizing the wound bed so that it can successfully
accept a free flap, a thorough debridement must be performed. No
free flap should be attempted unless the wound bed is clean and free
of infection. It has been both the authors’ and other centers’ experi­
ence that the free flaps that are lost in the setting of an infected wound
generally do so because of venous thrombosis. The authors feel that
the underlying infection contributes to this process. This is why
repeated debridements followed by topical silver-sulfadiazine or use
of the VAC to decrease the bacterial count have been keys to successful
free flap transfer over wounds and ulcers.
Bony stabilization is necessary for a wound to heal and remain
closed. Continuous movement at the wound site inhibits healing and
leads to breakdown. The orthopedist or podiatrist has to decide
whether internal or external fixation is to be used. In a clean setting,
internal fixation with immediate soft tissue coverage is preferred. With
a dirty wound, the application of an external fixator is the safest way
to proceed. The placement of the frame has to be carefully planned
to allow access to the wound for repeated debridements. It also
has to allow access to the recipient vessels and sufficient space to
perform the microsurgical anastomosis. When performing microsur­
gery around a frame, the authors have found that loop magnification,
rather than the operating microscope, gives the surgeon more freedom
with which to perform the anastomosis.

266
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
the team should have a special focus on limb salvage. The more expe­
rienced and knowledgeable the microsurgeon, the better the planning
and the higher the chance of success. Current success rates in large
microsurgical centers exceed 95% free flap survival. Skill in choosing
the appropriate flap and optimizing how it is inset ensure an optimal
esthetic and functional result while minimizing the need for later
revisions. Flap outcomes are subject to certain risk factors. Age,
tobacco, and diabetes do not seem to contribute to flap success rates;
irradiation damage at the recipient site does result in a higher rate of
flap failure. Tobacco users have poorer wound healing at incision sites.
Current efforts should be directed toward the salvage of only those
feet that will be functional, while avoiding limb salvage surgery in
other cases. Considerations of donor site morbidity and recipient site
requirements help in determining the optimal free flap procedure.
Microsurgical salvage should not be undertaken simply because it is
technically feasible. If the physician determines that functional salvage
will not occur within a given number of operations in a specified time
frame, then a below-knee amputation should be considered strongly.
This will allow the patient to recover more quickly and to return to
their daily activities. Adding microsurgical-free flaps to the armamen­
tarium of limb salvage surgeons ensures a much higher salvage rate
in limbs that heretofore posed too large a reconstructive challenge
and, therefore, were amputated.
otherwise healthy sister. Due to compatibility, the transplant did not
require immune suppressive therapy, and the limb has demonstrated
return of muscle and full sensory function.
Advancing knowledge of angiosomes and perfection of perforator
flaps has enabled a myriad of potential free flap donor sites. Any
perforator which supplies the skin throughout the body may be
employed enabling free style flaps where flap harvest is based only on
the preoperative knowledge of Doppler signals present in a specific
region.99 The future trend in flap selection will be to focus on choosing
tissue with appropriate texture, thickness, and pliability to closely
match the requirements of the recipient site while minimizing donor-
site morbidity.
CONCLUSION
Local flaps will always have an important role in lower extremity
reconstruction particularly in patients with comorbidities, which pre­
clude microsurgery. However, microsurgery is an essential component
of the surgeon’s armamentarium in foot and ankle reconstruction. It
requires a multidisciplinary approach between the micro-surgeon and
vascular, podiatric, and orthopedic surgeons. Ideally, each member of
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end-to-side arterial anastomosis and free
flap transfer. Plast Reconstr Surg 64,
673–682.
52. Brennan, M., O’Brien, B.M., 1979. Patency
rates in end-to-side anastomosis in the
rabbit. Br J Plast Surg 32, 2.
53. Bas, L., May, J.W., Handren, J., et al., 1986.
End-to-end versus end-to-side
microvascular anastomosis patency in
experimental venous repair. Plast Reconstr
Surg 77, 442.
54. Acland, R.D., 1986. Discussion of
end-to-end versus end-to-side
microvascular anastomosis patency in
experimental venous repairs by Bas and
others. Plast Reconstr Surg 77, 449.
55. Zhang, L., Moskovitz, M., Piscatelli, S.,
et al., 1995. Hemodynamic study of
different angled end-to-side anastomoses.
Microsurgery 16 (2), 114–117.
56. Androsov, P.I., 1956. A new method of
surgical treatment in blood vessel union.
Arch Surg 73, 902.
57. Nakayama, K., Yamamoto, K., Makino, H.,
1963. A new vascular anastomosing
instrument and its clinical application.
Clin Orthop 29, 123.
58. Shestack, K.C., Johns, N.F., 1991.
Microsurgical free tissue transfer in the
elderly patient. Plast Reconstr Surg 88,
259–263.
59. Wettstein, R., Schurch, R., Banic, A., et al.,
2008. Review of 197 consecutive free flap
reconstructions in the lower extremity.
J Plast Reconstr Aesthet Surg 61 (7),
772–776.
60. Potparic´, Z., Rajacic´, N., 1997. Long-term
results of weight-bearing foot
reconstruction with non-innervated and
reinnervated free flaps. Br J Plast Surg 50
(3), 176–181.
61. Colen, L.B., Stevenson, A.S., Cideroff, V.,
et al., 1997. Microvascular anastomotic
thrombosis in experimental diabetes
mellitus. Plast Reconstr Surg 99, 156.
62. Barr, L.C., Joyce, A.D., 1989. Microvascular
anastomosis in diabetes:
An experimental study. Br J Vasc Surg 4,
50–53.
63. Cooley, B.C., Hanel, D.P., Anderson, R.B.,
et al., 1992. The influence of diabetes on
free flap transfer: I. Flap survival and
microvascular healing. Ann Plast Surg 29,
58–64.
64. Cooley, B.C., Hanel, D.P., Lan, M., et al.,
1992. The influence of diabetes on free
flap transfer: II. The effect of ischemia
on flap survival. Ann Plast Surg 29,
65–69.
65. Karp, N.S., Kasabian, A.K., Seibert, J.W.,
1994. Microvascular free flap salvage of the
diabetic foot: A five-year experience. Plast
Reconstr Surg 94, 834.
66. Ioshi, S.N., Levine, S.L., Pederson, W.C.,
1993. Microsurgical management of
extremity wounds in diabetes with
peripheral vascular disease. Plast Reconstr
Surg 92, 485.
67. Lai, C.S., Lynn, S.D., Yang, C.C., 1991.
Limb salvage of the infected diabetic foot
with microsurgical free muscle transfer.
Annals of Plastic Surgery 26, 212–220.
68. Colen, L.B., 1987. Limb salvage in patients
with severe peripheral vascular disease: the
role of microsurgical free tissue. Tran
Plastic and Reconstructive Surgery 179,
389.
69. Banis Jr., J.C., Richardson, J.D., Derr, J.W.,
et al., 1992. Microsurgical adjuncts in the
salvage of the ischemic and diabetic lower
extremity. Clin Plast Surg 19, 881.
70. Mulholland, S., Boyd, J.B., McCabe, S.,
et al., 1993. Recipient vessels in head
and neck microsurgery: Radiation affects
in vessel access. Plast Reconstr Surg 92,
628.
71. Krag, C., DeRose, G., Lyczakowski, T.,
et al., 1982. Free flaps and irradiated
recipient vessels in experimental study in
rabbits. Br J Plast Surg 35, 328.
72. Guelincks, P.J., 1984. Scanning electron
microscopy for irradiated recipient blood
vessels in head and neck free flaps. Plast
Reconstr Surg 74, 217.
73. Rues III, W.F., Colen, L.B., Stracker, D.J.,
1992. Tobacco smoking and complications
in elective microsurgery. Plast Reconstr
Surg 89, 490.
74. Schusterman, M.A., Miller, M.J., Riess, G.P.,
et al., 1994. A single experience with 380
free flaps for repair of head and neck
cancer defects. Plast Reconstr Surg 93, 472.
75. Nassif, T.M., Vida, L., Bovet, J.L., et al.,
1982. The parascapular flap: a new
cutaneous microsurgical free flap. Plast
Reconstr Surg 69 (4), 591–600.
76. Jin, Y.T., Cao, H.P., Chang, T.S., 1989.
Clinical applications of the free scapular
fascial flap. Ann Plast Surg 23, 170.
77. Colen, L.B., Bessa, G.E., Potparic´, Z., 1998.
Reconstruction of the extremity with
dorsothoracic fascia free flap. Plast
Reconstr Surg 101, 738.
78. Katseros, J., Schusterman, M., Beppu, M.,
1984. The lateral upper arm flap: anatomy
and clinical applications. Ann Plast Surg
12, 489.
79. Suttar, D.S., McGregor, I.A., 1986. The
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reconstruction: the experience of 60
consecutive cases. Plast Reconstr Surg
78, 1.
80. Weinzweig, N., Davis, B.W., 1998. Foot and
ankle reconstruction using the radial
forearm flap: a review of 25 cases. Plast
Reconstr Surg 102, 1999.
81. Kimata, Y., Uchiyama, K., Ebihara, S.,
et al., 1998. Anatomic variations and
technical problems of the anterolateral
thigh flap: a report of 74 cases. Plast
Reconstr Surg 102, 1517.
82. Song, Y.G., Chen, G.Z., Song, Y.L., 1984.
The free thigh flap: a new free flap concept
based on the septocutaneous artery. Br J
Plast Surg 37, 149.
83. Koshima, I., Fukuda, S., Yamamoto, H.,
et al., 1993. Free anterolateral thigh
flaps for reconstruction of head and
neck defects. Plast Reconstr Surg
92, 421.
84. Koshima, I., Yamamoto, H., Hosoda, M.,
et al., 1993. Free combined composite
flaps using the lateral circumflex femoral
system for repair of massive defects of the
head and neck regions: An introduction to
the chimeric flap principle. Plast Reconstr
Surg 92, 411.
85. Ao, M., Nagase, Y., Mae, O., et al., 1997.
Reconstruction of posttraumatic defects of
the foot by flow-through anterolateral or
anteromedial thigh flaps with preservation
of posterior tibial vessels. Ann Plast Surg
38, 598.
86. Kimura, N., Satoh, K., 1996. Consideration
of a thin flap as an entity and clinical
applications of the thin anterolateral thigh
flap. Plast Reconstr Surg 97, 985.
87. Kuo, Y.R., Jeng, S.F., Kuo, M.H., et al.,
2001. Free anterolateral thigh flap for
extremity reconstruction: Clinical
experience and functional assessment of
donor site. Plast Reconstr Surg 107,
1766.
88. May, J.W., Halls, M.J., Simon, S.R., 1985.
Microvascular muscle flaps with skin graft,
reconstruction of extensive defects of the
foot clinical gait and analysis study. Plast
Reconstr Surg 75, 627.
89. High, F., 1985. Free microvascular muscle
flaps with skin graft, reconstruction of
extensive defects of the foot: a clinical gait
and analysis study [Discussion]. Plast
Reconstr Surg 75, 64.
90. Heller, L., Kronowitz, S.J., 2006. Lower
extremity reconstruction J Surg Oncol 94
(6), 479–489.
91. Boyd, J.B., Taylor, G.I., Corlett, R., 1984.
The vascular territories of the superior
epigastric and deep inferior epigastric
systems. Plast Reconstr Surg 73, 1.
92. Harii, K., Ohmori, K., Sekiguchi, J., 1976.
The free musculocutaneous flap. Plast
Reconstr Surg 57, 294.
93. Redett, R.J., Robertson, B.C., Chang, B.,
et al., 2000. Limb salvage of lower-
extremity wounds using free gracilis muscle
reconstruction. Plast Reconstr Surg 106,
1507.
94. Takayanagi, S., Tsukie, T., 1982. Free
serratus anterior muscle and myocutaneous
flaps. Ann Plast Surg 8, 277.
95. Portincasa, A., Armenio, A., Gozzo, G.,
et al., 2008. Morphostructural changes
in transferred fasciocutaneous free
flaps: a preliminary clinical and
immunohistochemical report.
J Plast Reconstr Aesthet Surg 61 (6),
662–668.
96. Kozarski, J.V., 2007. Some biological
characteristics of transferred
free flaps. Microsurgery 27 (5),
360–368.
97. O’Brien, B.M., Morrison, W.A., Gumely,
G.J., 1990. Principles and techniques of
microvascular surgery. In: McCarthy, J.G.
(Ed.), Plastic Surgery. WB Saunders,
Philadelphia, pp. 423.
98. Zuker, R.M., Redett, R., Alman, B., 2006.
First Successful Lower-Extremity
Transplantation: Technique and Functional
Result. J Reconstr Microsurg 22 (4),
239–244.
99. Wei, F.C., Mardini, S., 2004. Free Style
Free Flaps. Plast Reconstr Surg 114 (4),
910–916.

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| 23 |
CHAPTER CONTENTS
Introduction
269
Vascular anatomy of the leg
270
Arterial–arterial connections
271
Local muscle flaps of the distal one-third of the leg
271
The soleus muscle flap
272
The peroneus brevis muscle flap
272
The extensor digitorum longus and peroneus
tertius muscle flaps
274
The extensor hallucis longus muscle flap
275
Tibialis anterior muscle flap
275
Abductor digiti minimi muscle flap
275
Abductor hallucis brevis muscle flap
276
Flexor digitorum brevis muscle flap
277
Flexor digiti minimi and opponens digiti minimi
muscle flaps
277
Extensor digitorum brevis muscle flap
279
Doppler techniques in muscle dissection
280
Conclusion
285
INTRODUCTION
Soft tissue defects of the distal lower extremity are notoriously difficult
wounds to treat. This area of the leg has a thin integument, relatively
superficial tendons and a paucity of soft tissue. For these reasons,
injuries often expose vital structures and leave the plastic surgeon with
a difficult decision regarding appropriate wound management. Over
the last several decades, microsurgical free-flap techniques looked to
supplant pedicled muscle flaps for coverage of foot and ankle defects.
However, recent studies indicate that local flap options have seen
resurgence in popularity, concurrent with a better understanding of
lower leg vascular anatomy and improved wound care technology.1
Pedicled flaps afford the surgeon a reliable and relatively straightfor­
ward reconstructive option for patients with osteomyelitis or those
who may not tolerate a larger operation.2,3 The usefulness of a muscle
flap to cover exposed tendon and bone is not only from its ability to
physically cover the defect, but also from its ability to introduce a new
vascular bed to potentiate wound healing. Once the surgeon becomes
comfortable in performing the anatomic dissection, harvesting and
insetting, the pedicled muscle flap can be performed rapidly and with
a high success rate.4
Historically, muscle flaps in the lower extremity were first described
at the end of the Second World War.5 Nevertheless, nearly two decades
passed before Ralph Ger6 pioneered the use of the soleus and flexor
digitorum longus (FDL) muscle flaps to cover venous stasis ulcers and
unstable fracture sites. Throughout the ensuing decade, he delineated
the various lower leg flaps including the tibialis anterior, abductor
hallucis longus (AHL), peroneus brevis, and peroneus tertius.6–11 Fur­
thermore, he described specific indications for a given flap, common
complications including partial flap loss, limited mobility, inadequate
reach, and loss of function, and he demonstrated that these flaps
promote healing by increasing vascularity and improving skin graft
take. Finally, Ger went on to describe the use of the intrinsic muscles
of the foot (abductor hallucis brevis, abductor digiti minimi, flexor
digitorum brevis) in salvaging the heel, hindfoot and ankle. His con­
tributions laid the groundwork for our current understanding of the
utility of these flaps.
In the early 1980s, Mathes and Nahai12 developed a classification
system to describe muscle flaps based on their blood supply. Each
muscle in the body falls into one of five possible categories (Fig. 23.1).
By understanding the nature of these vascular supply patterns, it is
possible to deduce whether a given flap is likely to cover a specific
defect. Type I flaps have one dominant pedicle on which they may be
raised safely. In the lower limb, the gastrocnemius provides the only
example of a Type I muscle. Type II flaps contain a dominant pedicle
and one or more minor pedicles. When raised, the muscle survives
based on the single dominant supply. Abductor digiti minimi, abduc­
tor hallucis, flexor digiti minimi, flexor hallucis brevis, flexor digito­
rum brevis and soleus are examples of Type II muscles in the leg and
foot. Type III muscles have two dominant arteries, each of which can
support the muscle alone. There are no Type III muscles in the leg.
Type IV muscles contain segmental pedicles which enter along the
length of the muscle to supply a small region immediately adjacent
to their entry point. It is generally safe to divide a few (2–4) of these
©2012 Elsevier Ltd.
The use of local muscle flaps in foot
and ankle reconstruction
Christopher E. Attinger, Mark W. Clemens, Ivica Ducic, Mark M. Levin, Charles Zelen
Chapter
23

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
dorsalis pedis. It gives off minor pedicles to the tibialis anterior, exten­
sor hallucis longus, and the extensor digitorum longus (Type 4). It
also sends small perforators between the tibia and tibialis anterior and
between tibialis anterior and extensor digitorum longus to feed the
overlying skin. These smaller vessels decrease in caliber as one moves
distally down the leg.15 Recent cadaveric cluster analysis of perforators
off the anterior tibial artery was performed by Schaverien who dem­
onstrated that there are two 5 cm intervals along the leg from where
septal perforators >0.5 mm were most likely to emerge.16 The inter­
vals, referenced from a point between the medial and lateral malleoli
(intermalleolar line), occur between 4–9 cm and 21–26 cm proximal
to the line and provide the surgeon with a more reliable point of
attack when planning to raise perforator flaps. A total of 23% of per­
forators are found within the septum between the tibia and tibialis
anterior (distance to anterior tibial artery 3.7 ± 1.3 cm); 93% of lower
legs had a perforator within this septum. A total of 29% of perforators
could be found in the septum between the extensor digitorum longus
and peroneus longus between 21 and 26 cm proximal to the inter­
malleolar line (distance to anterior tibial artery 2.6 ± 1.5 cm).
Anastomotic connections between the anterior tibial artery and the
posterior tibial artery or peroneal artery only occur through the micro­
vasculature of the periosteum and integument in this area. For this
reason, the anterior compartment is particularly susceptible to vascu­
lar compromise when raising flaps that require dividing the anterior
tibial artery.
The tibioperoneal trunk begins at the inferior border of the popli­
teus, travels a short distance and splits into the posterior tibial and
the peroneal artery. These arteries course distally giving off perforators
and smaller muscular branches to the superficial and deep posterior
and lateral compartments of the leg.17 Perforators off the posterior
tibial artery emerge mainly between flexor digitorum longus and
soleus18 and consistently occur at three intervals between 4–9 cm
(Zone I), 13–18 cm (Zone II) and 21–26 cm (Zone III) from the
intermalleolar line. In zone I, one to four septocutaneous perforators
may be found with an average diameter 1.3 mm. Musculocutaneous
perforators number between one and six with an average diameter of
0.8 mm. Zone II, on average has one to three septocutaneous perfora­
tors (average, 1.2 mm) and two to five musculocutaneous perforators
(average, 0.6 mm). Zone III, has between zero and two septocutane­
ous perforators (average, 0.8 mm), and zero to three musculocutane­
ous perforators (average, 0.4 mm). Septocutaneous perforators are
more likely to be accompanied by one or two concomitant veins.
Peroneal perforators emerge proximally through the soleus or per­
oneus longus and distally through the flexor hallucis longus and
peroneus brevis and tend to cluster in a single group 13–18 cm from
the intermalleolar line.19 The average number of peroneal cutaneous
perforators is 4.8 (range: 3–7) per leg.20 Cutaneous perforators may
be either musculocutaneous (34%) or septocutaneous (66%). The
musculocutaneous perforators are mostly in the upper two-thirds of
the lower leg. Septocutaneous perforators are predominantly in the
lower two-thirds of the leg. Cutaneous perforators at the posterior
border of the fibula had an average diameter of 0.6 mm (range: 0.3–
1.5 mm). It is important to note that the blood supply of the proximal
fibula epiphysis and fibula head are not in the vascular territory of the
peroneal artery.21
The superficial posterior compartment contains three muscles (pop­
liteus, gastrocnemius (two heads) and the tibialis posterior) and four
smaller angiosomes supplied by the medial and lateral sural, posterior
tibial, and peroneal arteries. Each sural artery supplies one head of
the gastrocnemius and overlying skin. The raphe between the two
muscles effectively isolates blood supply to the medial and lateral
gastrocnemius muscle. The soleus, on the other hand, has a dominant
pedicle from the proximal posterior tibial artery and minor pedicles
from the peroneal (laterally) and the posterior tibial artery medially.
Figure 23.1  The five anatomic patterns of blood supply to the muscles
of the body: Type I, a single vascular pedicle; Type II, a dominant vascular
pedicle and several more distal minor pedicles; Type III, two dominant
vascular pedicles; Type IV, segmental minor pedicles; Type V, one
dominant pedicle at one end and minor pedicles at the other end.
(Reproduced with permission from: Daniel, R.K., Kerrigan, C.L.,1990. Principles
and physiology of skin flap surgery. In: McCarthy, J.G. (Ed.) Plastic Surgery. WB
Saunders, Philadelphia, pp. 283.)
Type I
Type II
Type III
Type IV
Type V
minor pedicles, but dividing more results in death of the distal muscle.
Delaying the muscle harvest by serially tying off the pedicles has
proven to be unrewarding as well. Most of the muscles in the leg,
including extensor hallucis longus, flexor hallucis longus, and tibialis
anterior are Type IV. Unfortunately, this severely limits the amount of
well-vascularized muscle available for harvest. Type V muscles have
one dominant pedicle at the origin and several secondary segmental
pedicles at the insertion. These muscles may survive if supply to
either end is cut. The vastus lateralis muscle is an example of the type
5 muscle.
Fortunately, the six intrinsic muscles of the foot (extensor digitorum
brevis, abductor digiti minimi, abductor hallucis, flexor digitorum
brevis and flexor digiti minimi) that are used as pedicled flaps are all
Type II, allowing for a wide arc of rotation. As in the leg however,
these muscles also lose bulk distally. Nevertheless, they are still useful
tools for repairing foot and ankle wounds.13
VASCULAR ANATOMY OF THE LEG
Using pedicled muscle flaps or perforator flaps to effectively cover
wounds of the distal tibia requires a detailed knowledge of relevant
vascular anatomy and an appreciation for angiosomes in the leg, as
elucidated by Ian Taylor.14 Angiosomes refer to the three dimensional
vascular territories supplied by an artery, whereas the Mathes classifi­
cation focuses on the size, number, and anatomic configuration of
vascular pedicles to individual muscles. In 1998, Taylor divided the
lower leg into four primary angiosomes supplied by the popliteal,
anterior tibial, posterior tibial, and peroneal arteries, respectively. The
vascular territory of each vessel as it pertains to raising various muscle
flaps will be reviewed.
The anterior tibial angiosome is comprised of the anterior compart­
ment and its muscles: the tibialis anterior, extensor hallucis longus,
extensor digitorum longus and peroneus tertius. As the popliteal artery
descends through the popliteal fossa, it gives off the anterior tibial
artery along the inferior border of the popliteus. The anterior tibial
artery initially gives off minor pedicles to the peroneus longus and
brevis. It then traverses the interosseous membrane and descends
along its anterior surface between the tibialis anterior and extensor
digitorum longus to end near the tibiotalar joint by becoming the

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The use of local muscle flaps in foot and ankle reconstruction
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| 23 |
ankle, the surgeon can determine both the presence of flow from the
source artery and determine which artery is predominately supplying
a given muscle flap.22
The peroneal artery communicates with the anterior tibial artery via
the anterior perforating branch and the lateral malleolar branch, and
the peroneal and posterior tibial arteries share three transverse com­
municating branches. The anterior tibial and posterior tibial arteries
communicate directly distal to Lisfranc’s joint, where the dorsalis
pedis artery enters into the proximal first interspace to join directly
with the lateral plantar artery. The peroneal artery communicates dis­
tally with the posterior tibial artery via one to three transverse com­
municating branches that are located within the fat pad deep to the
Achilles tendon. These branches are located 5–7 cm above the ankle
joint, at the ankle joint, and just above the insertion of the Achilles
tendon.
As we have previously shown, the importance of evaluating the
patency of the distal connection between the anterior and posterior
tibial arteries cannot be emphasized enough. If that connection
is critical to supplying either the dorsal or plantar surface of the
foot because of existing obstruction of one of the two arteries, damag­
ing that connection while harvesting a flap can lead to flap loss
and gangrene on the portion of the foot that was dependent on ret­
rograde flow.
LOCAL MUSCLE FLAPS OF THE DISTAL
ONE-THIRD OF THE LEG
Pedicled flaps utilizing the soleus, peroneus brevis, extensor digitorum
longus (EDL), and peroneus tertius were elegantly described by
Hughes and Mahoney, but there are several caveats one should con­
sider before using them (Fig. 23.2).23
1. Muscles lying within the original zone of trauma have up to a
40% risk of necrosis24,25
2. With distally based flaps, muscle function may be preserved if
the muscle belly is freed from the tendon but the tendon itself
remains intact
3. For proximally based flaps, any tendon remaining in place after
muscle harvest should be sewn to the most similar-acting
muscle remaining in the leg compartment as feasibly possible
in order to preserve function
4. MRI is the test of choice to determine whether a muscle has
enough distal bulk before undertaking the harvest
5. The anterior compartment is fed solely by the anterior
tibial artery. Therefore, only the distal portion can safely
be raised without threatening other structures in the
angiosome.
For longer flaps, some surgeons perform a delay procedure 7–10
days before the definitive operation by tying off two or three perfora­
tors. This allows choke vessels between neighboring angiosomes
within and around the muscle to open and deliver blood to ischemic
portions therein. In our experience, this has led to disappointing
results with resulting distal muscle necrosis. A muscle may be har­
vested along with one of the principle arteries of the leg in either
an anterograde or retrograde fashion. In so doing, the muscle is
raised with as many minor pedicles as necessary to preserve viability
and bulk (Fig. 23.3). It is critical to ensure that there is enough col­
lateral flow between the remaining two principle arteries so that the
foot is not placed at risk. Therefore, sacrifice of a major artery to
harvest a flap should be avoided in the elderly or atherosclerotic
patient while it remains a viable alternative in younger, healthier
individuals.
These perforators fill the overlying posterior skin and the boundary of
each angiosome is the posterior central raphe.
The deep posterior compartment is supplied by the same vessels as
the superficial compartment and contains the flexor digitorum longus,
flexor hallucis longus and tibialis posterior muscles. Of note, the
tibialis posterior muscle lies within three angiosomes: proximally the
anterior tibial artery, and distally on the medial aspect the posterior
tibial artery and laterally the peroneal artery. Therefore, tibialis poste­
rior muscle also provides an important anastomosis between the
major arteries of the leg.
In the foot, the posterior tibial artery gives off the posterior medial
malleolar branch at the medial malleolus. The posterior medial malle­
olar branch joins the anterior medial malleolar branch from the dor­
salis pedis artery, giving rise to an important interconnection between
the posterior tibial artery and the anterior tibial artery, and this system
supplies the medial malleolar area. At the same level, the medial
calcaneal artery branches off the posterior tibial artery inferiorly and
arborize into multiple branches that travel in a coronal direction to
supply the heel. The posterior tibial artery then enters the calcaneal
canal underneath the flexor retinaculum and bifurcates into the
medial and lateral plantar arteries at the level of the transverse septum,
between the abductor hallucis longus and the flexor digitorum brevis
muscles.
The medial plantar artery gives off two main branches, the superfi­
cial and deep branches. The superficial branch of the medial plantar
artery travels obliquely up to the navicular-cuneiform joint, then
along the superior border of the cuneiform and the first metatarsal
bone before descending to the medial plantar aspect of the distal
metatarsal. Interconnections with the anterior tibial tree exist, as cuta­
neous branches connect proximally with medial cutaneous branches
from the dorsalis pedis artery and distally with branches of the first
dorsal metatarsal artery. The artery then extends plantarly and later­
ally, where it joins with the deep branch of the medial plantar artery
and the first plantar metatarsal artery (a branch of the lateral plantar
artery). The deep branch of the medial plantar artery travels deep and
along the medial intramuscular septum between the abductor hallucis
muscle and the flexor digitorum brevis. It provides the dominant
pedicle to the abductor and flexor hallucis brevis muscle as well as
minor pedicles to the abductor and flexor hallucis muscle and the
flexor digitorum brevis muscle. Perforating branches supply the
medial sole of the foot. At the neck of the first metatarsal, it passes
underneath the flexor tendons and anastomoses with the first plantar
metatarsal artery and/or the distal lateral plantar artery.
The lateral plantar artery enters the middle compartment of the
foot, where it travels obliquely between the flexor digitorum brevis
muscle and the quadratus plantar muscle toward the base of the fifth
metatarsal. It provides the dominant pedicle to the flexor digitorum
brevis muscle, abductor and flexor digitorum minimi muscle as well
as minor pedicles to all three muscles. It then travels distal to the
proximal fifth metatarsal underneath the flexor digiti minimi muscle,
turns medially, forming the deep plantar arch, and crosses the proxi­
mal (two, three, and four) metatarsals. It finally anastomoses directly
with the dorsalis pedis artery in the proximal first interspace. This
direct anastomosis between the dorsal and plantar circulation helps
ensure that if either the dorsalis pedis or lateral plantar artery become
occluded, flow is maintained to the entire foot.
ARTERIAL–ARTERIAL CONNECTIONS
Arterial–arterial connections allow for uninterrupted blood flow to
the entire foot despite the occlusion of one or more arteries. By under­
standing the location of these arterial connections in the foot and

272
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
THE SOLEUS MUSCLE FLAP
The soleus muscle is a type II muscle that can cover large defects
(average 26 cm2) in the mid and distal third of the leg. Its musculo­
tendinous junction26 averages 6.0 ± 1.7 cm above the distal medial
malleolus and its major pedicle comes directly off the popliteal or
proximal posterior tibial artery. Numerous (4–10) minor pedicles are
based off the posterior tibial and peroneal arteries. As previously
stated, the dense intramuscular vascular network created by three
adjoining angiosomes provides a vital anastomosis between arteries
in the leg and affords the soleus excellent blood supply when raised
as a flap. When the inferior four to five pedicles on either side are
divided and the distal aspect of the muscle is dissected off the Achilles
tendon, 18–20 cm of bulky muscle can be freed and rotated either
medially or laterally. The distally rotated muscle covers tissue as far
down to an average of 6.6 cm above the medial malleolus.
Soleus dissection may be quite tedious, particularly if one attempts
to preserve other structures. The soleus is best approached via a medial
or lateral incision overlying the border of the posterior compartment
in order to preserve the saphenous or sural neurovascular bundles,
respectively. The plane between the gastrocnemius and soleus can be
Figure 23.2  (A) Shown are the distances of the maximal possible reach of the muscles as measured from the tip of the medial malleolus. (B) The leg
muscles in this cadaver specimen are dissected to the full length of the muscles and are swung over to cover the medial malleolus. (C) Note that the
distal muscle with or without tendon is narrow and has limited reach. The reach is also limited when trying to cover the lateral malleolus, restricting
the usefulness of these flaps in foot and ankle reconstruction. EDL (extensor digitorum longus); EHL (extensor hallucis longus).
(Reproduced with permission from: Attinger, C.E.,1995. Soft tissue coverage for lower extremity trauma. Orthop Clin North Am 26, 316–317.)
Extensor
hallucis
longus 2.0cm
Flexor
digitorum
longus 6.1cm
Soleus 6.6cm
Extensor digitorum
longus and peroneus
tertius 2.1cm
Peroneus
brevis 2.1cm
A
B
C
bluntly dissected at mid-calf. More distally, the two muscles must be
surgically separated as they join to form a common Achilles tendon.
The soleus is then dissected from the deeper posterior tibial and pero­
neal perforators coming through the deep posterior fascia. Only those
perforators that need to be ligated for adequate mobilization are tied
off (Fig. 23.4). Alternatively, one may harvest the medial or lateral half
of the distal soleus for smaller defects. The hemi-soleus muscle flap27
(medial or lateral lower half) can be freed to leave the remaining
portion of muscle as a functional ankle flexor. The hemi-soleus works
very well for smaller anterior tibial defects. A reverse soleus muscle
flap28 based on the distal perforators has also been described. Its dis­
section leads to donor-site complications and its marginal blood
supply can lead to distal muscle loss.26 The reverse soleus flap is not
recommended.
THE PERONEUS BREVIS MUSCLE FLAP
The peroneus brevis (PB), a type IV muscle, can be used to cover rela­
tively small distal defects (average 15.6 cm2). The muscle lies in the
lateral compartment with a musculotendinous junction averaging

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0.85 cm above the distal medial malleolus. It is a type IV muscle with
the anterior tibial artery providing minor pedicles proximally and
the peroneal artery providing several others (average 4) distally.12 The
muscle can be dissected 11–15 cm and rotated anteriorly to cover
the distal tibia down to an average 4 cm above the distal medial
Figure 23.3  (A) This patient developed osteomyelitis after an open ankle fracture had been reduced and internally fixated by plates and screws.
(B) The wound was debrided, the hardware removed and the ankle fused and placed in an external fixator. (C) The tibialis anterior muscle was
elevated on the distal one-third of the anterior tibial artery. Excellent retrograde flow from the posterior tibial artery by way of the lateral plantar and
dorsalis pedis arteries made this procedure possible. Because the ankle was fused, the anterior tibial muscle was expendable. The remaining anterior
compartment muscles continued to receive blood from the antegrade flow of the remaining proximal two-thirds of the anterior tibial artery. (D) The
muscle was rotated downwards to cover the defect and skin grafted. (E) The healed wound is shown with the fixator in place. (F) With the fixator
removed.
A
B
C
D
E
F
malleolus. This muscle is best approached by way of an incision along
the posterior border of the distal fibula. When the proximal tendon
is harvested with the flap, the remaining distal portion should be
tenodesed to the peroneus longus tendon so that the PB function is
not totally lost.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
of 10 small pedicles from the anterior tibial artery. By ligating the
distal three to five pedicles and dissecting proximally for 10–12 cm,
the muscles can be mobilized to cover defects down to an average
2.1 cm above the distal medial malleolus. This flap is also described
as a musculocutaneous flap29 when harvested with the overlying skin.
The distal EDL can be harvested with the distal anterior tibial artery.
This maneuver preserves distal minor pedicles and assures better
blood flow to the distal muscle. The reverse EDL provides substantial
muscle bulk that can be safely rotated to easily cover any medium-size
ankle defect. Before harvesting the flap, the clinician must ensure that
there is good antegrade flow down the anterior tibial artery and
THE EXTENSOR DIGITORUM LONGUS AND
PERONEUS TERTIUS MUSCLE FLAPS
The EDL and peroneus tertius are type IV muscles and presented
together because their proximal bellies and blood supply are often
intimately conjoined. Typically, they are used to cover distal tibial
defects up to 18.7 cm2. The musculotendinous junction for the EDL
and peroneal tertius extend to an average of 0.65 cm above the distal
medial malleolus. They are both type IV muscles receiving an average
Figure 23.4  (A) This patient had venous stasis disease and superficial osteomyelitis of the distal tibia. (B) The wound was debrided and the soleus
muscle was harvested. (C) It was rotated into position to cover the existing defect. (D) The muscle was skin grafted. The flap healed uneventfully.
A
B
C
D

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advantage is that it leaves minimal donor-site morbidity because the
incision to harvest the muscle is along the glabrous junction, i.e. the
boundary between two adjoining angiosomes and can be closed pri­
marily. The muscle’s chief disadvantage is that it can be quite small,
especially distally where bulk is usually needed.
The blood supply32 from the lateral plantar artery enters the muscle
medially near its origin along the lateral tuberosity of the calcaneus.
The muscle slowly tapers out to a tendon from the base of the fifth
metatarsal to its insertion into the lateral proximal phalanx of the fifth
digit. The bulk of the muscle is located proximal to the proximal
aspect of the fifth metatarsal.
The ADM can be dissected via a lateral incision at the glabrous
junction between the dorsum and sole of the foot (Fig. 23.9). An
retrograde flow along the dorsalis pedis from the posterior tibial
artery. Once the muscle is rotated in place, the EDL tendon distal
to the harvested muscle is cut. It is then tenodesed to the exten­
sor hallucis longus (EHL) so that the EDL’s function is not
totally lost.
THE EXTENSOR HALLUCIS
LONGUS MUSCLE FLAP
The EHL, a type IV muscle, can cover defects averaging 14.4 cm2 over
the most distal tibia. Its musculotendinous junction lays an average
of 0.7 cm above the medial malleolus, and has an average of nine
minor pedicles off the anterior tibial artery. By ligating the bottom
two or three minor pedicles, one can dissect the muscle proximally
for 10 cm and cover defects down to an average 2 cm above the distal
medial malleolus. This muscle is best approached by an incision over
the medial portion of the anterior compartment.
The distal EHL can be harvested with the distal anterior tibial artery
to preserve the distal minor pedicles and create a reverse EHL flap.
This flap provides substantial muscle bulk, which is safely rotated to
easily cover any medium-size ankle defect. Before harvesting the flap,
the clinician must ensure there is good antegrade flow down the
anterior tibial artery and retrograde flow along the dorsalis pedis from
the posterior tibial artery. Once the muscle is rotated in place, the EHL
tendon distal to the harvest site is cut and tenodesed to the EDL. This
ensures that the EHL’s function is not totally lost and the patient does
not suffer from a plantar flexed hallux.
TIBIALIS ANTERIOR MUSCLE FLAP
The tibialis anterior muscle has a segmental Type IV blood supply.
This thick bulky muscle is an attractive option for local flap recon­
struction. However, its role as the chief dorsiflexor of the foot limits
its use to partial muscle harvest while leaving the tendons intact.30 It
can be harvested with the tendon only if the ankle is fused. The muscle
originates from the lateral condyle of the tibia and the interosseous
membrane and inserts into the medial cuneiform and base of the first
metatarsal. The muscle overlaps and is supplied by the anterior tibial
artery and the deep peroneal nerve. Portions of the muscle may be
sagittally split, and rotated for middle third tibial wound coverage
without functional loss.31 In select cases of ankle fusion, transposition
of the entire muscle is possible. As such, it can distally be harvested
with the distal anterior tibial artery and rotated to cover the distal tibia
and ankle. Again, one has to make sure there is good retrograde flow
to the anterior tibial artery.
ABDUCTOR DIGITI MINIMI
MUSCLE FLAP
The ADM is a type II muscle harvested to fill defects of the lateral ankle
joint, calcaneus, lateral midfoot or lateral plantar heel (Fig. 23.5). It
is especially useful for poorly healing incisions after calcaneal fracture
repairs (Fig. 23.6). The flap may even survive in the non-compliant
patient with calcaneal osteomyelitis (Fig. 23.7), and is durable under
continual abuse (Fig. 23.8). It can also be used in combination
with the AHB muscle for larger defects of the plantar heel. Its chief
Figure 23.5  The abductor digiti minimi (ADM) muscle flap receives its
chief blood supply proximally off the lateral plantar artery, while the
minor branches come off more distally.
(Reproduced with permission from: Attinger, C.E., 2000. Plastic surgery techniques
for foot and ankle surgery. In: Myerson, M. (Ed.), Foot and Ankle Disorders. WB
Saunders, Philadelphia, pp. 1–1151.)
Abductor digiti
minimi muscle
Posterior tibial
artery
Medial plantar
artery
Lateral incision site
Lateral plantar artery

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
distally. Loss of the AHB may make the foot more prone to develop
a hallux valgus. When harvesting, it may be useful to fix the proximal
portion of the cut distal AHB tendon to the metatarsal head with
anchors.
The muscle arises from the medial calcaneal tubercle (MCT), travels
distally becoming tendinous proximal to the first MTP joint, and
inserts on the medial proximal phalanx of the hallux. The dominant
pedicle comes proximally off the medial plantar artery while minor
pedicles off the deep medial plantar artery are more distal. As long as
the major pedicle3 is undisturbed, the minor pedicles can be ligated
without jeopardizing the muscle’s viability. Distally, AHB is some­
times fused with flexor hallucis brevis and should be carefully freed
during the dissection.
A surgical approach through an incision at the glabrous junction
allows AHB to be easily detached from its distal tendinous junction.
After placing a stitch in the freed end of the muscle, AHB is dissected
proximally from its distal aspect off of the flexor hallucis brevis (Fig.
23.12). During the dissection, intraoperative Doppler is helpful to
locate minor pedicles for ligation while ensuring that the dominant
pedicle is preserved. If added mobility is desired, the muscle can be
freed from its proximal origin. After harvest, the donor site is closed
primarily (Fig. 23.13).
incision is made down to muscle to expose the distal ADM tendon.
The tendon is cut and a suture is placed in the distal end of the freed
muscle to allow manipulation with minimal trauma. Doppler is used
to locate proximal and distal perforators and the dissection then pro­
ceeds from distal to proximal. Any intervening minor perforators are
safely tied off while the major proximal pedicle is left intact. If a wider
rotation arc is required, the muscle’s origin may be detached as well.
ADM is then rotated posteriorly into the soft tissue or bony defect
without discernible functional loss. The muscle is then skin grafted
while the donor site is closed primarily.
ABDUCTOR HALLUCIS BREVIS
MUSCLE FLAP
The AHB is a type II muscle useful for reconstructing medial malleolar,
calcaneal, medial midfoot, and plantar heel defects (Figs. 23.10 and
23.11). It can be used in conjunction with the ADM for added bulk
when filling heel defects. The chief advantage of this flap is minimal
donor site morbidity, while the major disadvantage is the lack of bulk
Figure 23.6  This patient had a reduction of his calcaneal fracture. (A) The inferior portion of the incision sloughed and the hardware was exposed.
(B) The ADM was harvested and rotated in to cover the exposed hardware. (C) The flap is shown at 2 weeks out and (D) when completely
healed.
A
B
C
D

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identified and preserved. Distal minor pedicles are tied off. If addi­
tional purchase is needed, the muscle can be freed up from the proxi­
mal calcaneal attachment. The muscle is then rotated in or flipped
backwards to fill the proximal heel defect and the donor site is closed
primarily (Fig. 23.15).
FLEXOR DIGITI MINIMI AND OPPONENS
DIGITI MINIMI MUSCLE FLAPS
These muscles are type II intrinsic muscles of the foot and have
recently34 been described for lateral midfoot and forefoot soft tissue
coverage. This is a sensory myocutaneous flap, which leaves minimal
donor site morbidity and is easy to dissect out. These features make
it a very attractive option for reconstructing small lateral midfoot
defects. It is especially useful over proximal fifth metatarsal defects
(Fig. 23.16).
FDM has its origin at the fibrous sheath of the peroneus longus,
base of the fifth metatarsal, crest of the cuboid, and the plantar apone­
urosis (Fig. 23.17). It inserts at the fibrous plate of the fifth metatarsal
phalangeal joint. The opponens digiti minimi has the same origin,
but inserts on the lateral border of the distal fifth metatarsal. There is
FLEXOR DIGITORUM BREVIS MUSCLE FLAP
The FDB33 is a type II muscle that was developed in the 1980s as a
muscle flap and was a tremendous breakthrough in heel reconstruc­
tion. It provides another alternative for covering proximal heel or
calcaneal defects and the dissection does not disturb the vascular
supply to the sole of the foot (i.e. the perforators on either side of the
plantar fascia remain undisturbed). One drawback however, is that
the muscle is small and thin, and lacks sufficient bulk to serve as the
only barrier between the calcaneus and overlying skin. Its main utility
is in filling dead space for plantar heel defects.
The muscle originates from the medial tubercle of the calcaneus
and the proximal plantar aponeurosis (Fig. 23.14). The muscle belly
extends to the metatarsal-phalangeal joints where four tendons take
off to insert into the middle phalanges. The lateral plantar artery gives
off a dominant proximal pedicle and several distal minor pedicles.
The deep branch of the medial plantar artery also gives off minor
distal pedicles.
A midline incision is made through the plantar fascia to expose the
FDB muscle. Once visualized, FDB is freed from the overlying tissue
and its four tendons are cut distally. The muscle is then lifted off the
quadratus planus muscle and the proximal dominant pedicle is
Figure 23.7  This patient had osteomyelitis of two-thirds of his posterior calcaneus, which was completely removed (A). (B) The defect was filled with
antibiotic impregnated methyl-methacrylate beads. (C) The ADM flap was harvested to cover the beads. When the flap healed (D), the beads were
removed and replaced with bone graft.
A
B
C
D

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
musculocutaneous flap (Fig. 23.18). The flap can also be used as a
reverse island flap. The flap can then be rotated to cover any small
defect of the lateral distal midfoot and proximal forefoot. The clini­
cian, however, has to be sure that there is adequate retrograde blood
flow from the deep metatarsal artery.
some question as to whether the opponens is actually separate from
the FDM since it is present in approximately 50% of cadavers. The
blood supply comes from dominant and minor pedicles off of the
lateral plantar artery. The overlying skin is fed by musculocutaneous
perforators and may be harvested with the muscle to create a
Figure 23.8  (A) This patient with diabetes and renal failure is morbidly obese, non-compliant, and has osteomyelitis of the lateral calcaneus. (B) The
wound was serially debrided and the incision for harvest of the ADM muscle drawn out. (C) The flap was dissected out and the minor pedicles ligated.
(D) The flap was sewn in place but not skin grafted because the patient was totally non-compliant. (E) The muscle epithelialized over the ensuing 3
months, and the patient has remained healed.
A
B
C
D
E

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artery. If the patient has retrograde blood flow along the dorsalis pedis,
the flap’s reach can be increased by including this artery with the flap.
Healing of the donor site can sometimes be a problem because the
perforators to the overlying skin on either side of the incision are
sacrificed during the flap harvest.
The EDB originates along the lateral talocalcaneal ligament and the
lateral surface of the calcaneus, and terminates at the level of Lisfranc’s
joint (Fig. 23.20). Its main pedicle arises from the lateral tarsal artery,
which tends to tether the flap, thereby limiting its reach. If the proxi­
mal dorsalis pedis is harvested with the EDB muscle, the flap easily
reaches either malleolus as well as the lower anterior tibia. This
maneuver unfortunately requires ligating the dorsalis pedis distal to
the tarsal artery and should only be done if retrograde flow from the
lateral plantar artery to the distal dorsalis pedis and first dorsal
EXTENSOR DIGITORUM BREVIS
MUSCLE FLAP
The EDB35 is a thin 4.5 × 6 cm type II muscle which, when pedicled,
provides excellent coverage of small defects of the ankle, sinus tarsus,
and lower tibia (Fig. 23.19). Its reach, however, is limited by the tarsal
A
B
Figure 23.9  (A) Anatomic dissection of the ADM. (B) The incision and
exposure were along the glabrous junction between the dorsal and
plantar aspect of the lateral foot. (C) The flap was elevated with its
proximal dominant pedicle carefully preserved.
C
Figure 23.10  The abductor hallucis brevis (AHB) muscle. The proximal
pedicle is at the takeoff of the medial plantar artery. The more distal
minor pedicles come off the more distal deep medial plantar artery.
(Reproduced with permission from: Attinger, C.E., 2000. Plastic surgery techniques
for foot and ankle surgery. In: Myerson, M. (Ed.), Foot and Ankle Disorders. WB
Saunders, Philadelphia, pp. 1–1151.)
Abductor
hallicus brevis
Posterior tibial
artery
Medial plantar
artery
Medial incision site
Lateral plantar artery

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DOPPLER TECHNIQUES
IN MUSCLE DISSECTION
When planning to use a muscle flap, a careful Doppler examination
of the foot and ankle is important. When planning a pedicled flap in
a patient with an intact vascular tree, the dissection should be straight­
forward. It is still useful to use the Doppler device to map out the
vascular anatomy to ensure that the dominant pedicle of the planned
flap is open. After locating the artery with the Doppler, the direction
of flow can be evaluated by applying selective occlusion with finger
pressure above and below the area being studied.14 The initial charac­
ter of the Doppler signal helps to evaluate the quality of flow present
in the artery. Triphasic flow indicates normal arterial flow. Biphasic
flow indicates mildly compromised flow. Monophasic flow indicates
metatarsal artery exists. If there is retrograde flow, a reverse island flap
can be created by tying off the dorsalis pedis proximal to the lateral
tarsal artery. In this capacity, the muscle can be used for more distal
dorsal defects.
The dissection is performed by making a curvilinear incision over
the lateral dorsal forefoot under tourniquet. The EDL and EHL tendons
are retracted laterally and medially, respectively, to expose the underly­
ing muscle. The EDB tendons are cut distally and tacked together to
prevent an intramuscular tear during harvest that may split the muscle
belly. The muscle is carefully elevated to avoid damaging the lateral
tarsal artery and the origin is detached. For additional length, the
dorsalis pedis is ligated just distal to the lateral tarsal artery and then
freed as far proximally as necessary for the muscle to reach the defect
without tension. The muscle is then inset into the defect and covered
with a skin graft. The donor site is closed primarily.
A
B
C
D
Figure 23.11  (A) This patient suffered a talus fracture that became severely infected after reduction of the fracture. (B) The ankle was debrided and
the tibia was docked to residual healthy bone. (C,D) The AHB muscle was harvested and (E) inset into the defect.

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E
F
(F) The flap was skin grafted and healed uneventfully.
Figure 23.11, Continued 
Figure 23.12  (A) Anatomic dissection of the abductor hallucis brevis (AHB). The incision and exposure were along the glabrous junction between the
dorsal and plantar aspect of the medial foot. (B) The flap was elevated from distal to proximal and the minor pedicles were ligated. (C) The flap was
elevated with its dominant pedicle carefully preserved. (D) The reach of the muscle increased when the muscle’s origin was detached.
A
B
C
D

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 23.13  (A) This patient had a non-healing wound of the medial malleolus and Achilles’ tendon for 18 months. The wound was serially
débrided. (B) The muscle was fully dissected out with the dominant pedicle left intact. (C) The flap was sewn into position, filing in the defect.
(D) The wound was allowed to heal after a skin graft had been placed on the wound.
A
B
C
D
Figure 23.14  (A) The location of the flexor digitorum brevis (FDB) muscle was drawn on the plantar surface of this cadaver foot. (B) A midline incision
was used to expose the muscle. The flexor tendons were cut proximally and the muscle was flipped backwards to cover heel defects. (C) The dominant
pedicle was off the proximal lateral plantar artery in this specimen with the retracted abductor hallucis brevis (AHB) muscle.
A
B
C

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Figure 23.15  (A) This patient had recurrent osteomyelitis of the plantar calcaneus. (B) The planned muscle flap was outlined. (C) The ulcer was
debrided, a partial calcanectomy performed, and the flap harvested. (D) The flexor digitorum brevis (FDB) muscle was inset. (E) The defect was closed
over a Penrose drain. The patient was kept non-weight-bearing for 6 weeks, and the wound healed.
A
B
C
D
E
arterial compromise, unless the patient suffers from sympathetic neu­
ropathy (a common complication of diabetes) and the distal vessels
have lost their tone. A blunt, short, monophasic spitting sound indi­
cates complete distal occlusion with no runoff.
When dissecting out type II muscle flaps, use of the Doppler is criti­
cal in ensuring that only the minor pedicles are ligated and that the
dominant pedicle is preserved. Whenever there is a question as to
whether the pedicle to be ligated is dominant or not, either a vascular
microclamp is placed on the pedicle under consideration, or gentle
compression of the pedicle with a vascular forcep, and the muscle is
mapped with the Doppler device. If the arterial signal does not change,
the pedicle can be safely ligated. If the signal decreases significantly,
further careful dissection is needed to determine whether ligation is
appropriate. If the signal disappears altogether, the pedicle is most
likely the dominant pedicle and has to be preserved.
When trying to extend the range of a given flap by sacrificing one
of the major arteries to the foot (e.g. retrograde extensor hallucis
muscle flap harvested with the distal portion of anterior tibial artery),
it is critical to ensure that there is antegrade flow in the proximal
anterior tibial artery and adequate retrograde flow from either the

284
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 23.16  Ulcer with osteomyelitis of the proximal fifth metatarsal in a renal failure patient with congestive heart failure and peripheral vascular
disease (A). The muscle was harvested after the abductor digiti minimi (ADM) was retracted (B). The muscle was rotated up to cover the debrided
proximal metatarsal (C). The muscle was inset (D) and skin grafted. The patient 2 weeks after surgery with the wound healing (E). He went on to heal
and live for an additional 6 months using his foot.
A
B
C
D
E
peroneal artery via the lateral malleolar artery or from the posterior
tibial artery via the lateral plantar artery and dorsalis pedis artery.
Other flaps whose range can be extended by taking the flap with the
main artery and ligating the other main branches include the medial
plantar flap, the abductor hallucis muscle flap, the extensor digitorum
brevis muscle flap, and the supramalleolar flap. Because the sacrifice
of a major artery to the foot can lead to complications when the
patient later develops peripheral artery disease, serious consideration
should be given to using a free flap with an end-to-side arterial anas­
tomosis instead.
Doppler examination becomes all the more critical when dealing
with the vascularly compromised foot. One has to make sure that
there is inflow to the planned flap and that the dissection of the flap
will not interrupt critical flow to the rest of foot. For example, if the
dorsum of the foot depends on the posterior tibial artery via the
medial plantar artery flow, the medial plantar flap is not an option. If

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Figure 23.17  The flexor digiti minimi (FDM) and opponens digiti minimi
muscle receive their blood supply from the superficial fifth plantar
metatarsal artery.
(Reproduced with permission from: Attinger, C.E., 2000. Plastic surgery techniques
for foot and ankle surgery. In: Myerson, M. (Ed.), Foot and Ankle Disorders. WB
Saunders, Philadelphia, pp. 1–1151.)
Flexor digiti minimi
and Opponens digiti
minimi muscles
Posterior tibial
artery
Medial plantar
artery
Deep arterial
plantar arch
Common digital
arteries
Lateral plantar
artery
Fibular plantar
superficial
artery
A
B
Figure 23.18  (A) The outline of the flexor digiti minimi (FDM) and
(B) overlying skin with its blood supply off of the fibular plantar
superficial artery. (C) The proximal reach of the muscle is shown.
C
the anterior tibial artery is providing flow to the plantar foot via the
dorsalis pedis artery, the dorsalis pedis flap cannot be used. When
planning an incision to harvest a muscle flap, one has to be sure that
there is inflow on either side of the incision. Using the angiosome
boundaries for exposure is usually safe and should minimize vascular
compromise, because the dissection usually does not sacrifice key
arterial–arterial connections. Examples of incisions that are usually
safe include those along the glabrous junction medially for the abduc­
tor hallucis muscle, along the glabrous junction laterally for the
abductor digiti minimi muscle, and along the center of the plantar
midfoot for the flexor digitorum muscle flap.
When coordinating a reconstruction with a foot and ankle surgeon,
make sure that the skeletal exposure does not compromise a flap that
you may be planning to use to close the resulting defect. If an Ilizarov
frame is used, make sure the fine wires are not going though the flap
that you are planning to use later. Often speared is the abductor hal­
lucis or abductor digiti minimi flap. Coordination of pin placement
is critical around the ankle so that muscle flaps can be adequately
mobilized.
CONCLUSION
Utilizing pedicled muscle flaps to reconstruct distal-third of the leg,
ankle and forefoot defects affords the experienced surgeon a reliable,
safe and rapid alternative to micro-surgical free-flap repair. By giving

286
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 23.19  This patient with diabetes suffered trauma to his anterior ankle and had a non-healing wound over the anterior tibia tendon (A). The
tendon was debrided and skin grafted. The distal portion of the skin graft failed to take (B) and an extensor digitorum brevis (EDB) flap was planned
(C). The EDB muscle could be rotated into the defect on the tarsal artery (D). The muscle was skin grafted (E). The healed wound (F).
A
B
C
D
E
F
special attention to vascular anatomy and meticulous dissection, these
flaps help to decrease in-hospital time for patients, lower donor site
morbidity, and with appropriate tenodesis, minimize functional loss.
Pedicled flaps should seriously be considered when treating patients
with defects of exposed joints, bone or tendon. As long as the vital
structures are covered by the muscle, the rest of the defect may be
skin grafted.
Gaining the necessary clinical competency and confidence to
perform these operations often requires familiarity by doing anatomic
dissections in the laboratory. The anatomic dissection would be per­
formed with magnification loupes and with Doppler guidance. Vascu­
lopathic patients, a paucity of distal muscle bulk, and functional loss
after harvest are all factors to consider before choosing a pedicled
muscle flap as a solution to the problem. Using microsurgical

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Figure 23.20  The extensor digitorum brevis (EDB) muscle with its arterial supply coming
from the proximal tarsal artery (A). The relationship between the tarsal artery and the
EDB muscle is shown in this injected specimen (B). The EDB flap was drawn out on the
dorsum of this cadaver foot (C). The flap here was elevated on the lateral tarsal artery
(D). To increase the flap’s reach, the dorsalis pedis artery proximal or distal to the tarsal
artery takeoff can be cut depending on whether the flap has to go proximally or distally
and whether there is adequate retrograde flow.
(Reproduced with permission from: Attinger, C.E., 2000. Plastic surgery techniques for foot and ankle
surgery. In: Myerson, M. (Ed.), Foot and Ankle Disorders. WB Saunders, Philadelphia, pp. 1–1151.)
Extensor
hallicus
brevis muscle
Extensor
digitorum
brevis muscle
Dorsalis pedis
artery
Lateral tarsal
artery
Skin incision
Extensor
retinaculum
A
B
C
D

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technique to harvest flaps and avoiding excessive tension or torsion
on the pedicle during inset are keys to success. Doppler verification
of both arterial inflow and venous outflow is essential at the end of
the case.
The importance of anastomotic connections in the leg cannot be
overemphasized, particularly when attempting to raise flaps based off
the distal anterior tibial artery. The entire anterior compartment is a
single angiosome whose survival depends on this artery. Harvesting
distal pedicled flaps based off anterior tibial supply may provide
much-needed muscle bulk, but adequate antegrade flow to the proxi­
mal anterior compartment must be verified.
The use of pedicled muscle flaps should be in the armamentarium
of the reconstructive surgeon in lower extremity salvage. These muscles
can be very useful in covering vital structures. Their use demands both
excellent anatomic knowledge of the muscle and blood supply. Their
use can solve complex problems in an elegant fashion.
REFERENCES
1. Parrett, B.M., Matros, E., Pribaz, J.J., et al.,
2006. Lower extremity trauma: Trends
in the management of soft-tissue
reconstruction of open tibia-fibula
fractures. Plast Reconstr Surg 117,
1315.
2. Pers, M., Medgyesi, S., 1973. Pedicle
muscle flaps and their applications in
the surgery of repair. Br J Plast Surg 26,
313.
3. McCraw, J.B., 1979. Selection of alternative
local flaps in the leg and foot. Clin Plast
Surg 6 (2), 227–246.
4. Attinger, C.E., Ducic, I., Cooper, P., et al.,
2002. The role of intrinsic muscle flaps
of the foot for bone coverage in foot and
ankle defects in diabetic and non-diabetic
patients. Plast Reconstr Surg 110,
1047–1054.
5. Stark. W.J., 1946. The use of pedicled
muscle flaps in the surgical treatment
of chronic osteomyelitis resulting from
compound fracture. J Bone Joint Surg
28, 343.
6. Ger, R., 1966. The operative treatment
of advanced stasis ulcer: a preliminary
communication. Am J Surg 111, 659.
7. Ger, R., 1968. The management of pretibial
skin loss. Surgery 63, 757.
8. Ger, R., 1970. Operative treatment of
advanced stasis ulcer disease using muscle
transposition: A follow up study. Am J Surg
120, 376.
9. Ger, R., 1971. The techniques of muscle
transposition and the operative treatment
of traumatic and ulcerative lesions.
J Trauma 2, 502.
10. Ger, R., 1976. The management of chronic
ulcers of the dorsum of the foot by muscle
transposition and free skin grafting. Br J
Plast Surg 29, 199.
11. Ger, R., 1976. The surgical management of
ulcer of the heel. Surg Gynecol Obstet 140,
909.
12. Mathes, S.J., Nahai, F., 1979. Clinical atlas
of muscle and musculocutaneous flaps.
Mosby, St Louis, MO.
13. Quaba, O., Quaba, A., 2006. Pedicled
perforator flaps for the lower limb. Semin
Plast Surg 20, 103.
14. Taylor, I., Pan, W.R., 1998. Angiosomes
of the leg, anatomic study and clinical
applications. Plast Reconstr Surg 102,
599.
15. Panagiotopoulos, K., Soucacos, P.N.,
Korres, D.S., et al., 2009. Anatomical study
and colour Doppler assessment of the skin
perforators of the anterior tibial artery and
possible clinical applications. J Plast
Reconstr Aesthet Surg 62 (11), 1524–1529.
16. Schaverien, M., 2008. Perforators of the
lower leg: analysis of perforator locations
and clinical application for pedicled
perforator flaps. Plast Reconstr Surg 122
(1), 161.
17. Wu, W.C., Chang, Y.P., So,Y.C., et al., 1993.
The anatomic basis and clinical
applications of flaps based on the posterior
tibial vessels. Br J Plast Surg 46, 470.
18. Ozdemir, R., Kocer, U., Sahin, B., et al.,
2006. Examination of the skin perforators
of the posterior tibial artery on the leg and
the ankle region and their clinical use.
Plast Reconstr Surg 117, 1619.
19. Ozalp, T., Masquelet, A.C., Begue, T.C.,
2006. Septocutaneous perforators of the
peroneal artery relative to the fibula:
Anatomical basis of the use of pedicled
fasciocutaneous flap. Surg Radiol Anat
28, 54.
20. Heitmann, C., Khan, F.N., Levin, L.S.,
2003. Vasculature of the peroneal artery:
An anatomic study focused on the
perforator vessels. J Reconstr Microsurg 19,
157.
21. Mozaffarian, K., Lascombes, P., Dautel, G.,
2009. Vascular basis of free transfer of
proximal epiphysis and diaphysis of fibula:
an anatomical study. Arch Orthop Trauma
Surg 129 (2), 183–187.
22. Attinger, C.E., Evans, K.K., Bulan, E.,
et al., 2006. Angiosomes of the foot and
ankle and clinical implications for limb
salvage: reconstruction, incisions, and
revascularization. Plast Reconstr Surg 117,
261S–293S.
23. Hughes, L.A., Mahoney, J.L., 1993.
Anatomic basis of local muscle flaps in the
distal third of the leg. Plast Reconstr Surg
92, 1144.
24. Riley, Jr., W.B., Cotlar, S.W., Long, J.K.,
1980. The injury-compromised
gastrocnemius musculocutaneous flap:
lessons and limits. Plast Surg Forum 3,
136.
25. Neale, H.W., Stern, P.J., Kreilein, J.G., et al.,
1983. Complications of muscle flap
transposition for traumatic defect of the
leg. Plast Reconstr Surg 72, 512.
26. Tobin, G.R., 1985. Hemisoleus and
reversed hemisoleus flaps. Plast Reconstr
Surg 76 (1), 87–96.
27. Tobin, G.R., Moberg, A.W., Adcock, R.,
et al., 1981. Hemi-soleus flaps. Plast
Surg Forum 4, 126.
28. Townsend, P.L.G., 1978. An inferiorly
based soleus muscle flap. Br J Plast Surg
31, 210.
29. Bloch, R.J., Cordero, L.M., Psillakis, J.M.,
1990. Combined extensor digitorum
longus and peroneus longus
musculocutaneous flap. In: Strauch, B.,
Vasconez, L.O., Hall-Findlay, E.J. (Eds.),
Grabb’s Encyclopedia of Flaps. Little,
Brown & Co, Boston, p. 1745.
30. Ebraheim, N.A., Madsen, T.D., Humpherys,
B., 2003. The tibialis anterior used as a
local muscle flap over the tibia after soft
tissue loss. J Traum Inj Infec Crit Care 55
(5), 959–961.
31. Hallock, G.G., 2002. Sagittal split tibialis
anterior muscle flap. Ann Plast Surg 49,
39.
32. Mathes, S.J., McCraw, J.B., Vasconez, L.O.,
1974. Muscle transposition flaps for
coverage of lower extremity defects:
anatomic consideration. Surg Clin North
Am 54, 1337.
33. Hartrampf, Jr., C.R., Scheflan, M., Bostwick,
III., J., 1980. The flexor digitorum brevis
muscle island pedicle flap, a new
dimension in heel reconstruction. Plast
Reconstr Surg 66, 264.
34. Papp, C.T., Hasenohrl, C., 1990. Small toe
muscles for defect coverage. Plast Reconstr
Surg 86, 941.
35. Leitner, D.W., Gordon, L., Buncke, H.J.,
1985. The extensor digitorum brevis as a
muscle island flap. Plast Reconstr Surg 767,
777.

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CHAPTER CONTENTS
Introduction
289
Anatomy of the nail
289
Pathologic anatomy
290
Nail trauma
290
Diagnosis of nail and periungual conditions
291
Techniques of nail and periungual biopsy
292
Shave biopsy of soft tissues
292
Nail bed and plate biopsy
292
Nail matrix biopsy
294
Surgical nail procedures
296
Local anesthesia toe block
296
Soft tissue procedures
297
Soft tissue lateral wedge resection
297
Soft tissue correction of malaligned toenail
297
Distal skin plasty for clubbing deformity
297
Partial and total nail avulsions
297
Partial matrixectomy
298
Total matrixectomy
298
Zadik procedure
298
Terminal Syme operation
298
Postoperative care
300
Conclusion
302
INTRODUCTION
The toenail and the tissues surrounding the nails can frequently be
damaged or distorted and in need of surgical correction. Since the nail
is hard and does not desquamate, many of the conditions involving
the nails become more difficult to treat either with medications or by
surgical means. Toenail surgery is delicate and the procedures should
be carefully planned. A thorough knowledge of the properties of the
nail and the surrounding soft tissue structures increases the effective­
ness of the treatment programs and enables the surgeon to provide
better cosmetic results.
ANATOMY OF THE NAIL
The nail consists of a nail plate and its surrounding supporting tissues
(Fig. 24.1). Nail growth appears to be continuous with very little
change in the overall rate. Toenails extend distally approximately
0.03–0.05 mm a day. The thickness of the toenail is between 0.05 and
1.0 mm. The toenail is set on the dorsal surface of the distal end of
the toes in grooves that are referred to as the lateral, medial, distal and
proximal nail grooves that are covered by corresponding lateral,
medial, distal and proximal nail folds (Fig. 24.2). The nail plate itself
appears translucent in areas where it is not attached to the underlying
nail bed. The areas that are adherent to the underlying vascular
nail bed appear pink as the result of the transmission of color from
this area.
Many digits will display a white semicircular lunula at the proximal
end of the nail plate, which is the topographical marker of the nail
matrix. The lunula represents the junction points between the nail
matrix and the nail bed. The nail matrix, which synthesizes the
nail plate substance, extends proximally under the nail fold to a depth
of about 5–10 mm. Overlapping the matrix of the nail is the proximal
nail fold, the stratum corneum of which is prolonged distally as a thin
cuticular fold, the eponychium. The region underlying the free edge
of the nail plate distal to the nail bed and proximal to the epidermis
of the tip of the digit is the hyponychium. Below the nail lies the
germinative zone that, together with the subjacent corium, forms
the nail bed.
Circulation to the nail is supplied by two arterial arches derived
from the two digital arteries. The digital arteries course laterally on the
digits and give off multiple small dorsal branches into the pulp space
of the distal phalanx. These dorsal branches in turn divide to form
the distal and proximal arches. An additional branch leaves the digital
artery at the midportion of the middle phalanx and does not enter
the pulp space but courses over the distal interphalangeal joint
©2012 Elsevier Ltd.
Nail and periungual reconstruction
G. Dock Dockery
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deformation of the distal nail bed. As the new nail begins to grow
out, it approaches the end of the toe only to meet this soft tissue
wall, which tends to bulge the soft tissues upward around the distal
part of the new nail (Fig. 24.4), creating an ingrown or clubbed nail
(Fig. 24.5).
PATHOLOGIC ANATOMY
Changes in the toenails may be caused by disease, trauma, infection,
biomechanical abnormalities, hereditary or genetic factors and the
effects of aging. Toenails offer little or no benefit, with the possible
exception of protection to the dorsal toes; however, they represent a
large number of complaints in patients with foot problems. Diseases
and disorders of the nails may be classified into divisions according
to maladies peculiar to the nails themselves; onychodystrophies, nail
manifestations of dermatitis, nail manifestations of systemic disease,
and congenital conditions of the nails. The diseases themselves can
be grouped into different classifications according to the most
common types, which include infection, psoriasis, contact dermatitis,
eczematous dermatitis, hypovitaminosis, tumor, trauma, and general
disease.
NAIL TRAUMA
Direct damage to the nail plate and nail bed will result in pathological
changes of the nail. Injury to the nail matrix will cause defects ranging
from grooves, pits, and ridges to frank abnormalities of the new
growing nail. Trauma may also result in the complete loss of the nail
by avulsion, and if the nail root is concurrently damaged, a thicker,
discolored nail may be the result. Injury to the underlying distal
phalanx may also cause irreparable osseous change that will result in
deformity of the outgrowing nail. One of those deformities is the
subungual exostosis that is believed to be secondary to trauma to the
dorsal toe area (Fig. 24.6). The osseous configuration of the distal
phalanx may be responsible for ingrown toenails, whether it be a
dorsal spur of the tip of the phalanx or the upward sweep of the
phalanx. The distal pulp of the digit, as well as the nail, may be
changed because of the exostosis formation or, in more pronounced
cases, the resultant condition is a pincer nail (Fig. 24.7). The underly­
ing subungual exostosis may result directly in onychocryptosis. In
many of these cases, the moderate growing exostosis becomes painful
as it enlarges and surgical intervention is warranted.
space. This serves the proximal matrix and provides the corollary
circulation.
The hallux receives its innervation from four nerves: a digital branch
of the deep peroneal that supplies the lateral dorsal area, the medial
dorsal cutaneous nerve, the lateral common digital nerve from the
medial plantar nerve that supplies the lateral plantar area, and the
medial common digital nerve from the medial plantar nerve that sup­
plies the medial plantar area of the hallux.
Because of the orientation of the matrix cells in a forward position
and of pressure exerted by the posterior nail fold, the nail will grow
forward and flat rather than up. If a portion of the nail matrix is
rearranged because of injury or surgery, or if it is grafted on the
skin away from the nail fold, it will produce a nail that will project
straight up from its surface. This is frequently referred to as a nail
spicule (Fig. 24.3).
If the nail is completely removed, the upward ground pressure
will force the distal nail bed to bend and elevate upward, causing a
Figure 24.1  Schematic appearance of toe with a sagittal section through
the distal phalanx. Notice the close anatomical association of the matrix,
periosteum, and distal attachment of the extensor tendon.
(Reprinted by permission of the publisher from Surgical Anatomy of the Nail Unit,
Ditre, C.M., Howe, N.R., 1992. J Dermatol Surg Oncol 18, 665. Copyright 1992,
Elsevier Science Inc.)
Eponychium
Hyponychium
Keratogenous zone
Matrix
Cuticle
Lunula
Nail bed
Nail plate
Onychodermal
band
Distal nail
groove
Figure 24.2  Illustrative anatomy of the nail depicting the nail folds and grooves.
Nail plate
Proximal nail fold
Lateral nail fold
Lateral nail
groove
Proximal nail
groove
Distal nail fold

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DIAGNOSIS OF NAIL AND
PERIUNGUAL CONDITIONS
The diagnosis of nail and periungual conditions is primarily based on
the clinical evaluation of the nail itself and the associated surrounding
soft tissues. The pathological processes that are responsible for most
nail changes are usually self-evident but may be difficult to diagnose.
The nails can react in relatively few ways so that the same clinical
symptoms and appearances may occur in several different disease
states.
Specimens of the nails and surrounding structures may be taken for
further diagnostic evaluation. Test mediums, such as potassium
hydroxide (KOH), which will dissolve the keratin portions, allowing
microscopic examination of any other element, are very useful in the
diagnosis of fungal and candidal infections of the toenails. Specimens
may also be placed on culture mediums such as the dermatophyte test
medium (DTM) or standard laboratory test media. The periodic-Acid
Schiff reaction (PAS) is a laboratory test whereby, through a series of
oxidation-reduction reactions, polysaccharides, basement membrane
material and mucosubstances are stained bright red. Because many
normally colorless fungi possess carbohydrates within their cell walls
or capsules, PAS reaction is an effective means to allow for their iden­
tification in tissue (cutaneous, nail plate or deep tissues). These tests
help to confirm the diagnosis of fungal infections and are useful in
the overall treatment program.
Removal of a portion of the nail plate, nail bed, nail matrix, proxi­
mal or lateral nail fold, hyponychium, or any combination of these
structures may be necessary to obtain a proper biopsy specimen.
Figure 24.3  Nail spicule. When a small piece of the nail matrix is left
after surgical removal it may produce a spike of nail material that will
grow straight up requiring additional excision.
Figure 24.4  Nail avulsion may allow clubbing or ingrown nail formation.
(A) Normal nail plate maintains shape of distal toe. (B) Avulsion of nail
plate allows the distal nail bed to deform upward, causing hypertrophy
of the nail lip. (C) Resultant deformity of distal toe may result in an
embedded or clubbed nail as the new nail grows out.
A
B
C
Figure 24.5  Clinical illustration of clubbing of distal nail bed and soft
tissue following previous nail avulsion and nail regrowth.
Figure 24.6  Schematic lateral view showing how distal exostosis may
result in onychocryptosis.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
amount of tissue should be removed as necessary for an adequate
specimen. Always try to obtain a specimen from the nail bed rather
than the matrix whenever possible, unless the lesion appears to
emanate from the matrix (as in pigmented streaks). Use circular or
fusiform biopsies of ≤4 mm in most cases. As a general rule, orient
excisions in the matrix transversely and in the nail bed longitudinally.
In all cases, except for the shave biopsy, excise the specimen down to
the phalanx. (See Chapter 13 for additional information on biopsy
techniques.)
Shave biopsy of soft tissues
A shave biopsy is probably the simplest procedure for obtaining a
sample of nail and surrounding tissue for evaluation. Superficial
lesions may be removed from the subungual and periungual areas of
the nails using the shave technique. For lesions on the borders of the
nail unit a slice of the involved tissue is excised from the nail fold
down to the matrix area using a No. 15 surgical blade (Fig. 24.8). The
biopsy site may be allowed to heal in by secondary intention healing
or closed with Steri-Strips or sutures as needed.
Nail bed and plate biopsy
A variety of biopsies may be performed of the nail bed to diagnose
and treat Bowen’s disease, squamous cell carcinoma, melanoma,
glomus tumors or other nail bed conditions. Even though the biopsy
specimen is being taken from the nail bed and not necessarily from
the matrix area, the patient should always be warned about the pos­
sibility of permanent nail dystrophy following the biopsy. The most
common nail bed biopsies include the longitudinal en bloc, punch,
lateral fusiform, horizontal fusiform and longitudinal wedge types.
A nail-plate and nail bed biopsy specimen should be submitted for
routine hematoxylin and eosin (H&E) pathology staining as well as a
periodic-Acid Schiff (PAS) reaction, as both psoriasis and onychomy­
cosis may manifest histologically as hyperkeratosis of the nail bed and
may also show parakeratosis and neutrophils. The PAS reaction will
almost always demonstrate hyphae and spores in the keratinized
portion of the nail bed or the lowest regions of the nail plate when
fungally infected.
Longitudinal nail biopsy
This biopsy technique is sometimes referred to as longitudinal resec­
tion or en bloc, which includes the nail, proximal nail fold, and nail
bed. A No. 15 surgical blade is used in a longitudinal biopsy to make
two parallel incisions from the proximal nail fold to the tip of the toe,
usually in the central portion of the nail (Fig. 24.9). The distance
between these incisions should not exceed 3 mm or severe scarring
may occur. The tip of the surgical blade should glide over the bony
phalanx creating a wedge-shaped section. The shorter ends of the
rectangular specimen are then cut, and the entire section is carefully
Figure 24.7  Pincer nail formation caused by subungual exostosis of the
distal phalanx. (A) Moderate pincer deformity. (B) Severe pincer deformity.
A
B
Figure 24.8  Shave biopsy. An excised wedge of tissue is taken from the
nail fold down to the matrix area.
Biopsies are helpful in determining the cause of certain types of nail
disorders; however, there is a risk of possibly damaging the nail or
nail bed. Even though biopsy techniques are listed as surgical proce­
dures, they should be thought of strictly as special forms of tests or
diagnostic tools. The primary reasons for performing nail biopsies
are to make a diagnosis, to confirm a suspected condition before
beginning definitive care, to follow the progression of a disease, to
assess the effectiveness of treatment, to understand nail diseases better
(i.e. research), and to discover new or undiagnosed diseases. Relative
contraindications to nail biopsy include diabetes with peripheral vas­
cular disease, untreated infections (bacterial or viral), scleroderma,
generalized peripheral vascular disease, complex regional pain syn­
drome, and various immunocompromised states.
Techniques of nail and periungual biopsy
It is important to use the biopsy procedure that will provide the
highest benefit to risk ratio. The biopsy should be limited to a single
anatomic unit and performed only on the involved tissue that will aid
in making the correct diagnosis. During the biopsy, the smallest

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Nail punch biopsy
The punch biopsy is the most commonly used procedure for obtain­
ing an accurate diagnosis of nail and surrounding tissue conditions
(Fig. 24.11). The author believes that the punch biopsy should be used
more frequently by those who are treating skin and nail diseases on
a regular basis. A 3- or 4-mm new, sterile, disposable punch is used
to bore directly through the nail plate into the nail bed and/or hypo­
nychium area. The matrix site is avoided to prevent distortion of the
outgrowing nail. When the punch reaches the periosteum, it is with­
drawn and a fine, sharp pair of dissecting scissors is used to remove
the specimen. There is generally very little bleeding; however, if
present it may be stopped by applying a small amount of clear Mon­
sel’s hemostatic solution (ferric subsulfate) or Drysol (20% aluminum
chloride hexahydrate) to the site. No suturing is ever needed, and
the biopsy site will granulate in quickly and heal without nail
distortion.
Lateral and horizontal nail biopsy
The lateral nail and tissue biopsy is relatively easy to perform; however,
the amount of tissue obtained and the pathological information
received from the specimen may not be adequate (Fig. 24.12). This
technique may be performed on the distal medial or lateral border of
the toenail and it is still referred to as a lateral nail biopsy. If the
overlying nail plate is partially removed first and a sufficient amount
of the nail bed along with the suspicious lesion is removed, it will
probably be enough material for an adequate biopsy (Fig. 24.13).
The horizontal nail biopsy is slightly more difficult to perform but
may provide more accurate information than the lateral biopsy (Fig.
24.14). In this technique, the nail may be totally avulsed before the
procedure is begun, and the biopsy procedure is performed horizon­
tally in the nail bed. Another approach is to avulse only the proximal
part of the nail to obtain the specimen and to leave the distal portion
of the nail intact. Because the nail plate is usually firmly attached to
dissected free from the underlying phalanx with fine-point surgical
scissors or with the surgical blade. The proximal nail fold and the nail
bed (but not the matrix) should be sutured with fine-gauge suture
material, such as 6–0 Vicryl or surgical plain gut type A, which dissolve
quickly or may be removed in 5–10 days. This technique produces
remarkably little discomfort or deformity and may provide a great deal
of information regarding the nail or nail bed condition. When there
are lesions or tumors on the lateral or medial borders this same tech­
nique may be used (Fig. 24.10).
Figure 24.9  Longitudinal nail biopsy. This en bloc resection is useful in
determining and defining disease processes such as psoriasis and lichen
planus. This has the highest rate of long-term nail dystrophy.
Figure 24.10  Longitudinal nail biopsy. The en bloc resection is useful
with border lesions. (A) Subungual fibromatous lesion. (B) Biopsy wedge
resection. This is closed in a similar fashion as a matrixectomy procedure.
A
B
Figure 24.11  Nail punch biopsy. A 3- or 4-mm new, sterile punch biopsy
tool is used to bore through the nail plate into the nail bed and
hyponychium away from the matrix.
Figure 24.12  Lateral nail biopsy. The technique is easy but may not
provide sufficient materials for a proper biopsy.

294
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
the nail bed, this distal segment will stay in place and thus prevent
the soft tissue from distorting upwards, while the new nail is growing
back in.
In both cases, the procedure is performed with a small scalpel creat­
ing an elliptical or fusiform wedge excision through the nail bed down
to bone. In most cases, it is much better to perform nail bed wedge
biopsy excisions longitudinally rather than transversely or horizon­
tally to decrease nail dystrophy and deformity later on.
Longitudinal wedge biopsy
This fusiform biopsy of the nail bed may be performed through the
nail plate or after a partial or full nail avulsion. In most cases, it is
probably better to only avulse the part of nail necessary to obtain a
good biopsy (Fig. 24.15). Using a small scalpel blade or mini-Beaver
blade an elliptical or fusiform wedge excision is cut through the nail
bed down to bone. In this case the ellipse is oriented longitudinally
and should not exceed 4 mm in width. Care should be taken to avoid
the proximal matrix area during this procedure. As with other biopsy
specimen collection a fine sharp iris scissors is used to free the speci­
men and a 30-gauge needle is used to skewer the specimen for
removal. This prevents crushing of the specimen with tissue forceps
during its removal. The excision site may then be undermined and
closed with fine absorbable or non-absorbable sutures (Fig. 24.16).
Again, if a portion of the nail plate was removed, the patient should
be informed that the remaining nail plate may be shed following the
operation. In most cases, however, the nail plate that remains will be
maintained without problems.
Figure 24.13  Lateral nail biopsy. (A) Suspicious distal medial nail bed lesion. (B) Planned distal biopsy. (C) Partial nail avulsion is performed first
followed by the full-depth nail bed and lesion biopsy.
A
B
C
Figure 24.14  Horizontal nail biopsy. (A) Following total nail avulsion.
(B) Following proximal nail avulsion, leaving the distal nail intact.
A
B
Figure 24.15  Longitudinal nail biopsy. (A) Through nail plate. (B) After
partial nail avulsion.
A
B
Nail matrix biopsy
This procedure is performed to rule out conditions such as pigmented
streaks, tumors of the matrix area, and full-length nail dystrophies.
The matrix biopsies include the punch, fusiform and longitudinal
types (Fig. 24.17). The best way to approach the proximal nail matrix
is to reflect the proximal nail fold. Incisions are made on the medial
and lateral sides of the proximal nail fold region so that a small skin
flap can be retracted proximally with skin hooks or fine-suture retrac­
tors. The nail plate should not be avulsed or disturbed before the
biopsy is performed. Once everything is ready for the biopsy, it may
be necessary to avulse part of the nail for proximal specimen or the
entire nail when a pigmented lesion extends onto the nail bed distally.
It is always best to take the specimen from the distal or central portion
of the matrix rather than the proximal segment, since this reduces the
possibility of nail dystrophy or splitting. The distal matrix may be
distinguished from the adjoining nail bed by its somewhat lighter
color and a softer feel appreciated when probing with a blunt instru­
ment like the Freer elevator.
Matrix punch biopsy
By taking the punch biopsy specimen from within the distal portion
of the matrix area, there is reduced risk of subsequent nail damage. A
3- or 4-mm disposable punch-biopsy tool is usually used to obtain
the specimen rather than a scalpel blade. The punch is used to obtain
a circular specimen with care to avoid injury to the underlying tendon
and bone. Once the specimen has been removed closure of the biopsy

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reduce the risk of permanent damage the excision should not violate
the edge of the lunula. Undermining allows the sides of the fusiform
excision to be smoothly apposed and closed with fine absorbable
sutures.
Longitudinal wedge matrix biopsy
This is the least preferred matrix biopsy type, but in some instances it
may be necessary to take a longitudinal fusiform biopsy of the entire
length of the matrix. This process does increase the risk of deformity
to the nail, especially if the wedge is >3 mm in diameter and extends
site should be attempted. Although only partial closure is usually
achievable, this is preferable to no closure of the matrix.
Transverse fusiform matrix biopsy
This is the preferred biopsy type for matrix evaluation as it gives the
most control of the placement and amount of the excision. The least
amount of matrix is removed to establish a diagnosis or to remove
the suspicious lesion. A transverse elliptical biopsy can be used to
remove all or part of the suspicious lesion. The distal edge of the
fusiform excision should parallel the distal curve of the lunula. To
A
B
C
D
Figure 24.16  Longitudinal nail bed biopsy. (A) Suspicious subungual lesion running from lunula to distal nail. (B) Nail avulsion to expose nail bed. (C)
Using a small surgical blade the lesion is removed with a fusiform wedge to the underlying bone. (D) The excision borders are inspected for any
obvious residual lesion and the edges are gently undermined. (E) The nail bed is then sutured with 6–0 nylon.
E

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
plantar surface), the H-block technique (similar to the two-point
injection but with an infiltration of local anesthetic across the toe
from one side to the other), and the triangular block (a three-point
local block).
All of these procedures, with the exception of the unilateral infiltra­
tion block, have the potential disadvantage of causing complete vas­
cular compression from the injected local anesthetic agent subjecting
increased pressure completely around the digit. However, this compli­
cation is very rare, and, in most cases, relatively small amounts of local
anesthetic agent that is accurately placed will cause the necessary
anesthetic effect without compression. The addition of hyaluronidase
to the local anesthetic agent will greatly facilitate the anesthesia and
prevent the agent from causing too much pressure in one area, because
the mixture will readily spread throughout the subcutaneous tissues.
The use of vasoconstrictors, such as epinephrine, is still somewhat
controversial even though there is no good evidence that this agent
causes any serious untoward effects when used properly. I have used
epinephrine in local toe blocks since 1975 without any complications
or problems noted. However, I still use caution in patients with a
history of diabetes, vasoconstrictive disorders or peripheral vascular
disease.
Toxicity from local anesthetic agents does not seem to be a problem,
particularly during a toe block, but it must be kept in mind that all
anesthetic agents are toxic in varying degrees and the possibility of
toxicity increases with the volume and concentration of the agent. As
proximally into the proximal matrix. It is best to close the defect with
small absorbable 5–0 or 6–0 sutures to try to prevent permanent
longitudinal nail deformity.
If the proximal nail fold has been reflected prior to the biopsy, as
is most often the case, it is closed with Steri-Strip suture tape or
sutured back into place with non-absorbable suture such as 5–0 or
6–0 nylon, along the lines of original incisions. A small piece of
Xeroform petrolatum gauze may be placed between the posterior
nail fold and matrix during healing to prevent adhesion formation. A
mild compression bandage is applied and the sutures are removed in
7–14 days.
SURGICAL NAIL PROCEDURES
The surgical treatment of malaligned, incurvated or ingrown nails, and
hypertrophied or painful nail borders, ranges from simple surgical
nail avulsions, to complex plastic reconstructive lip procedures, to
distal amputations. Even though the use of chemical matrixectomy
and other forms of non-surgical matrix destruction are popular, they
will not be covered in this section of surgical revision. An emphasis
will be placed on those procedures that change the matrix or growth
of the toenail. Since most, if not all, surgical procedures on toenails
are done using local anesthesia, a brief review of the technique will
be covered first.
Local anesthesia toe block
Infiltration of a local anesthetic agent in digital nerve-block fashion
is commonly employed to reduce the discomfort of treatment pro­
vided to the toenail area. Many different local anesthetic agents are
available either with or without epinephrine. Lidocaine hydrochloride
is still the primary agent used. However, mepivacaine hydrochloride
and bupivacaine hydrochloride are used regularly. Procaine hydro­
chloride is seldom used today.
Techniques for infiltration digital blocks vary, but the most com­
monly used method is the two-point block (Fig. 24.18). The two-point
anesthesia toe block involves starting the injection of local on either
the medial or lateral side of the proximal base of the toe. The injection
is carried from the dorsal surface to the plantar surface. The same
method is then used on the opposite side thus effectively numbing
the four main nerve branches to the involved distal toe.
Other injection techniques are utilized and include the unilateral
infiltration block (injection along the involved border of the nail
only), the plantar-V infiltration block (injecting the toe from the
Figure 24.17  Nail matrix biopsy. Reflection of proximal nail fold. (A) Punch biopsy. (B) Transverse fusiform wedge biopsy (preferred). (C) Longitudinal
fusiform wedge biopsy.
A
B
C
Figure 24.18  Common proximal two-point local anesthesia toe block for
surgical procedures around the toenail area. Both the medial and lateral
base of the toe is blocked.

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Soft tissue correction of malaligned toenail
This procedure is reserved for the significantly malaligned toenail,
which is characterized by a lateral deviation of the nail plate with
respect to the longitudinal axis of the distal phalanx (Fig. 24.20). This
condition becomes more serious as the deviated nail begins to receive
trauma from pressure against the shoe or against a small margin of
heaped-up tissue in front of the nail. The nail begins to impinge on
the soft tissue anteriorly and becomes imbedded. An ingrown nail
usually results, and secondary problems such as pain and infection
may follow. Treatment is designed to realign the entire toenail appa­
ratus and does not work well on severely incurvated nails. A crescentic
wedge is created that is carried back proximal to and below the nail
bed and matrix. The crescent has to be larger on the medial aspect
than on the lateral side, and a small triangular excision is performed
at the start of the lateral incision, which will enable the whole nail
apparatus to be swung over the resected area, so it may be realigned
and sutured in the correct position. The best results are achieved when
the malalignment is corrected surgically in the very young patient.
Distal skin plasty for clubbing deformity
Distal clubbing deformity is a potential complication anytime there
has been a loss of the toenail. Predisposing factors for developing
clubbing deformity include hypermobility of the distal pulp of the
toe, a disproportionately long toe and excessive interphalangeal joint
hyperextension. This clubbing deformity can result in localized symp­
toms of pain, swelling, redness and callus formation from pressure
and friction on the distal toe. The soft tissue surgical correction of this
distal clubbing deformity was originally described in the French litera­
ture by Dubois in 1938 but more recently popularized by Bouché in
1995 (Fig. 24.21). The procedure is performed by excising a fusiform
or crescentic wedge of tissue from the distal aspect of the toe. If the
medial and lateral borders are prominent as well, the incision may be
extended proximally along the involved nail border as needed. The
superior incision should be approximately 4–5 mm from the most
superior border of the skin at the distal nail. The extent of the skin
wedge removed depends upon the severity of the distal clubbing
deformity (Fig. 24.22).
Partial and total nail avulsions
The simplest form of surgical nail treatment is nail avulsion, which is
usually performed using local anesthesia. When the patient manifests
an acutely painful nail groove or ingrown nail, the offending border
was stated earlier, the smallest amount of drug necessary to produce
complete anesthesia should be used. Allergic reactions are more rare,
especially with the amide anesthetic agents. (See Chapter 6 for addi­
tional anesthesia information.)
Soft tissue procedures
Soft tissue lateral wedge resection
The most common soft tissue procedure still in use today for the cor­
rection of hypertrophy of the lateral nail fold is a modification of the
DuVries skin plasty. This procedure involves taking a large segment of
tissue from the side of the toe with two semielliptical incisions closed
with suture. This procedure is designed to relieve all the soft tissue
pressure from the toenail margin (Fig. 24.19). It effectively debulks
the side of the toe and is more commonly performed after a chroni­
cally ingrown toenail has been corrected but hypertrophy of the fold
is still present.
Figure 24.19  DuVries plastic reduction of hypertrophied nail fold. A
wedge of the hypertrophied tissue is removed from the side of the toe
and the nail fold and groove are pulled together with suturing of the
margins, thus relieving the pressure on the tissues next to the nail.
Figure 24.20  Soft tissue correction of malaligned toenail. A crescentic wedge resection is carried proximal to and below the nail bed and matrix
staying close to the bone. A small Bürow’s triangle is excised at the start of the incision line. The entire nail unit is then swung over the resection and
realigned and sutured.
(As described by Baran R. Surgery of the nail. Clin Podiatr Med Surg 1986; 3: 357–379.)

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
most cases, a single suture is placed through the mid-point of the cut
nail edge into the revised skin fold to close the tissues in this area as
well. The Winograd is most often thought of in regards to the great
toenail (Fig. 24.27), but it is a useful procedure for all lesser toenail
problems (Fig. 24.28). For patients with severe recurrent ingrown
toenails and chronic hypertrophied nail borders, the Winograd pro­
cedure can provide long-term relief with relatively consistent excellent
cosmetic results (Fig. 24.29). This is still a very popular procedure
today among foot surgeons for the treatment of onychocryptosis and
nail-border deformities. Frost in 1950 developed a modification by
creating a transverse incision at the end of the proximal portion of
the first incision for better visibility of the underlying matrix (Fig.
24.30). Some surgeons believe there is no need to create this corner
flap for fear of delayed healing; however, the author has not seen this
as a complication of the procedure. This procedure, though, does not
resect a wedge of tissue as does the Winograd and, consequently, it is
not as useful in cases where there is a hypertrophied nail border. The
original procedure is described with the use of Steri-Strips or tape for
closure of the incision, but most surgeons are more comfortable using
suture for the final closure.
Total matrixectomy
In some cases, it is necessary to totally remove the entire toenail by
avulsion and destruction of the nail matrix to prevent recurrence. The
two primary techniques to accomplish this (other than the chemical
matrixectomy procedures) are the total Zadik matrixectomy and the
terminal Syme amputation procedure.
Zadik procedure
The purpose of this operation is to remove the total germinal nail
matrix, the nail-forming part of the nail bed and provide adequate
skin cover without shortening the distal phalanx as occurs in the
terminal Syme operation (Fig. 24.31). The procedure consists of an
H-shaped skin incision. The skin over the base of the nail bed proxi­
mal to the lunula border and the germinal matrix is excised, and both
the small distal and longer proximal skin flaps are advanced and
sutured together, without tension, in the original H design (Fig.
24.32). If the distal skin flap is thin or too small, then the proximal
skin flap is sutured to the edge of the distal part of the nail bed. This
procedure is especially useful when dealing with large distal exostoses
and total nail dystrophies.
Terminal Syme operation
The most radical treatment for chronic ingrown or dystrophic toenails
is the terminal resection procedure. This involves the surgical removal
of the entire nail, nail wall and matrix, and underlying distal half of
the distal phalanx, with closure of the defect by a plantar skin flap
fashioned from the end of the toe (Fig. 24.33). The procedure has
acquired the name of Syme because the plantar flap, which is brought
up and over the resected end of the terminal phalanx, is similar to
that used in the Syme amputation through the ankle joint.
This technique may be most useful in dealing with underlying
terminal phalangeal bone lesions with secondary toenail involve­
ment. Conditions such as distal osteomyelitis and chronic non-
healing ulcerations are also acceptable criteria for this procedure (Fig.
24.34). As a general rule, patients appear to be satisfied with the
results of this radical approach and the appearance and function are
acceptable. Even though it is rare, the lesser digits may also be treated
with this procedure (Fig. 24.35). The operation has certain dis­
advantages, such as shortening of the toe, creating a bulbous terminal
stub, potential for sloughing of the flap, and scar formation, as
may simply be cut back to, but not through, the matrix, and the nail
edge removed. If this is the first occurrence of the problem a partial
nail avulsion is the treatment of choice. If the entire nail is involved,
then the total nail avulsion is appropriate (Figs 24.23, 24.24). Mild
compression with simple pressure along the lateral margins of the
digit is usually all that is necessary for hemostasis, but a simple elastic
toe tourniquet may be utilized if needed. Following avulsion, a non-
adherent dressing and topical ointment covered with gauze and mild
self-adherent compression bandage is applied for 2–3 days (Fig.
24.25), followed by the utilization of Epsom salts foot soaks and daily
adhesive bandaid for the next week or two.
A modification of the standard total nail avulsion involves remov­
ing the nail plate by a proximal to distal technique using a small
dental spatula to free up the posterior proximal nail fold. This
approach is especially useful in severe onychodystrophies in which
scarring or distortion of the nail unit components occurs, such as with
chronic mucocutaneous candidiasis or chronic onychomycosis.
Partial matrixectomy
A partial nail avulsion may be combined with removal of a small
segment of the germinal matrix, thereby preventing its regrowth. This
procedure has been popular for many years and has several different
versions or modifications.
One of the early, and still one of the best known, procedures was
developed by Winograd in 1929. The procedure involves splitting and
removing a 14 inch edge of the nail, excising or curetting away the
matrix and nail bed, and removing a strip of the nail fold, creating a
semielliptical wedge down to bone. The margins are then undermined
and the incision closed with non-absorbable sutures (Fig. 24.26). In
Figure 24.21  Distal skin plasty for clubbing deformity. Top: Typical distal
toe clubbing deformity. Middle: Skin wedge is excised full-depth to the
distal phalanx. Bottom: Final reduction of clubbing deformity and suture
placement.

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Figure 24.22  Bouché distal wedge resection. (A) Distal clubbing following a previous total temporary nail avulsion. (B) Intraoperative distal toe wedge
resection. (C) Correction with closure with sutures.
A
B
C
Figure 24.23  Total hallux nail avulsion. (A) After local anesthesia, blunt dissection is performed under the proximal and lateral nail folds with a
fine-tipped hemostat, teeth directed toward the nail plate. (B) Dissection underneath the nail plate, freeing the plate from the nail bed while avoiding
the matrix. (C) Rolling the nail plate off, which should require very little force if the dissection has been accomplished thoroughly.
(Reproduced with permission from: Moschella, S.L., Hurley, H.J. (Eds.), Disorders of the Nails, third ed. WB Saunders, Philadelphia, 1992.)
Nail plate
Nail bed
Matrix
Proximal nail fold
A
B
C