Atlas Phẫu Thuật Vi Phẫu Mạch Máu (Atlas of Microvascular Surgery)

DORSALIS PEDIS SKIN FLAP
379
Figure 8–8
Medial elevation and identi cation of
the vascular bundle.
3. FDMA and deep peroneal n.
6. Extensor hallucis brevis m.
7. Dorsalis pedis a. and v.
8. Greater saphenous v.
9. Deep plantar a.
Figure 8–7
Distal elevation of the ap.
3. FDMA and deep peroneal n.
5. Dorsal venous arch
6. Extensor hallucis brevis m.
Medial Elevation and Identi cation of
the Vascular Bundle (Fig. 8–8)
On the medial side, the ap is raised with the greater
saphenous vein (8) maintained in the ap. Just over the
extensor hallucis longus tendon, the dissection is
deepened close to the lateral edge of the tendon and on
the tarsal bones to identify the dorsalis pedis vascular
bundle (7) from its undersurface. The dissection proceeds
between the vascular bundle and tarsal bones toward
the interspace where the FDMA (3) originates and the
deep plantar artery (9) plunges downward to the
plantar arch. The latter is ligated deep to the takeoff of
the FDMA.
Distal Elevation of the Flap (Fig. 8–7)
Keeping the FDMA (3) and deep peroneal nerve (3)
intact with the ap, the ap is elevated from distal to
proximal above the paratenon of all extensor tendons.
The extensor hallucis brevis tendon (6) is detached, and
this muscle should be included in the ap because it
passes between the dorsalis pedis–FDMA system and
the skin.

380
II.8 LOWER EXTREMITY: ANKLE AND FOOT
Figure 8–9
Proximal dissection.
7. Dorsalis pedis a. and v.
8. Greater saphenous v.
10. Lateral and medial dorsal cutaneous n.
Proximal Dissection (Fig. 8–9)
On the proximal edge of the ap and in the extension
incision, the dorsalis pedis vascular bundle (7) with
deep peroneal nerve is dissected further. Medial and
lateral dorsal cutaneous nerves (10) (branches of the
super cial peroneal nerve), greater saphenous vein (8),
and the medial dorsal vein are identi ed and isolated.
According to the venous pattern on the dorsum of the
foot, a m ore dom inant superficial vein is selected
(usually the greater saphenous vein), and the other
veins are ligated.
The dorsalis pedis neurovascular bundle, cuta-
neous nerves, and selected vein can be dissected for ad-
equate lengths as required at the recipient site.
Completion of Flap Elevation (Fig. 8–10)
The lateral edge of the ap is elevated above the
paratenon of the extensor digitorum longus tendons (2).
As soon as the medial edge of the tendon of the second
toe is reached, the extensor hallucis brevis muscle (6) is
divided, and the lateral tarsal artery with the arcuate ar-
tery is ligated. The muscular branch of the deep peroneal
nerve is separated from its main trunk. Dissection is per-
formed over the periosteum of the tarsal bone. The dor-
salis pedis ap, with the extensor hallucis brevis (6) and
dorsalis pedis vascular bundle (7) kept intact with its un-
dersurface, is isolated on its vascular pedicle.
Figure 8–10
Completion of ap elevation.
1. Extensor hallucis longus tendon
2. Extensor digitorum longus tendons
6. Extensor hallucis brevis m.
7. Dorsalis pedis a. and v.
8. Greater saphenous v.
9. Deep plantar a.
10. Lateral and medial dorsal cutaneous n.

DORSALIS PEDIS OSTEOCUTANEOUS FLAP WITH SECOND METATARSAL
381
DORSALIS PEDIS OSTEOCUTANEOUS
FLAP WITH SECOND METATARSAL
Flap Design (Fig. 8–11)
The skin flap is designed w ith reference to the
dorsalis pedis ap. It should be centralized over the
base of the second m etatarsal bone. This osteocuta-
neous ap provides a second m etatarsal w ith a length
of 7 to 8 cm .
Figure 8–11
Flap design.
1. Dorsalis pedis a. and v. and
greater saphenous v.
2. Deep plantar a.
3. FDMA
4. Extensor hallucis brevis m.
5. Interosseous m.
6. Lesser saphenous v.
7. Deep transverse ligament
8. Second metatarsal bone
9. Proximal phalanx bone
10. Arcuate a.
Medial Elevation of the Flap (Fig. 8–12)
After the FDMA (3) is dissected and ligated at the rst
web space, the ap is elevated medially, above the
paratenon of the extensors digitorum and hallucis longus
tendons, before the rst and second dorsal interosseous
muscles (5) are reached. The extensor hallucis brevis
tendon (4) is detached, and the FDMA is dissected on its
medial side, keeping it (and any musculature that lies
between it and the second metatarsal) in the ap.
Figure 8–12
Medial elevation of the ap.
1. Dorsalis pedis a. and v. and greater
saphenous v.
2. Deep plantar a.
3. FDMA
4. Extensor hallucis brevis m.
5. Interosseous m.
7. Deep transverse ligament

382
II.8 LOWER EXTREMITY: ANKLE AND FOOT
Lateral Elevation of the Flap
(Fig. 8–13)
The lateral side of the ap is elevated with care in
dissecting the lesser saphenous vein (6). The in-
terosseous muscles (5) and deep transverse metatarsal
ligament (7) between the second and third metatarsals
are reached and divided. The origin of the extensor
hallucis brevis (4) is detached, keeping the muscle with
the ap intact.
Figure 8–13
Lateral elevation of the ap.
4. Extensor hallucis brevis m.
5. Interosseous m.
6. Lesser saphenous v.
7. Deep transverse ligament
Disarticulation of the Second
Metatarsal Phalangeal (MTP)
Joint (Fig. 8–14)
The extensor tendons of the second toe are divided, and
the second metatarsophalangeal (MTP) joint is entered.
Deep transverse m etatarsal ligam ents (7) and in-
terosseous m usculatures (5) are transected along
the adjacent borders of the rst and third metatarsals.
The second metatarsal is kept intact with the ap and
the FDMA.
Figure 8–14
Disarticulation of the second metatarso-
phalangeal (MTP) joint.
1. Dorsalis pedis a. and v. and greater saphenous v.
5. Interosseous m.
7. Deep transverse ligament
8. Second metatarsal bone
9. Proximal phalanx bone

DORSALIS PEDIS OSTEOCUTANEOUS FLAP WITH SECOND METATARSAL
383
Proximal Dissection of the
Neurovascular Structures
(Fig. 8–15)
Proxim ally, the dorsalis pedis vascular bundle (1),
greater and lesser saphenous veins, medial dorsal vein,
and branches of the super cial peroneal nerve are
dissected as already described. The proximal part of the
ap is raised, including the extensor longus tendon of
the second toe and extensor hallucis brevis muscles in
the ap. If possible, the arcuate artery and the second
dorsal m etatarsal artery can also be preserved in the
ap.
The dissection then proceeds to the base of the
second metatarsal. Tracing the dorsalis pedis artery (1)
and the FDMA, the deep plantar artery (2) is identi ed
and ligated deep to the takeoff of the FDMA.
Figure 8–15
Proximal dissection of
the neurovascular structures.
1. Dorsalis pedis a. and v. and
greater saphenous v.
2. Deep plantar a.
7. Deep transverse ligament
8. Second metatarsal bone
9. Proximal phalanx bone

Figure 8–16
Disarticulation of the second TMT joint and ap
completion.
1. Dorsalis pedis a. and v. and greater saphenous v.
3. FDMA
5. Interosseous m.
8. Second metatarsal bone
10. Arcuate a.
Disarticulation of the Second
Tarsometatarsal (TMT) Joint and Flap
Completion (Fig. 8–16)
Preserving the dorsalis pedis– rst dorsal m etatarsal
arterial system (1,3), the capsule of the joints between
the second metatarsal and the cuneiforms and adjacent
m etatarsals are transected. Then the dorsalis pedis
osteocutaneous ap, with the second metatarsal bone,
is isolated.
Donor Site Closure
Using heavy wire or nonabsorbable sutures, the heads
of the rst and third metatarsals are approximated and
the second toe is am putated. The extensor hallucis
longus tendon and the extensor digitorum longus ten-
dons to the third to fth toes are elevated from the
m etatarsals; they are approxim ated with heavy
absorbable sutures to cover the residual defect of the
second metatarsal. Any rents in the paratenon should
be repaired with ne absorbable sutures. The defect
bed is then grafted with split-thickness skin, and a tie-
over dressing is applied.
384
II.8 LOWER EXTREMITY: ANKLE AND FOOT

DORSALIS PEDIS TENDINOCUTANEOUS FLAP WITH EXTENSOR TENDONS
385
DORSALIS PEDIS TENDINOCUTANEOUS
FLAP WITH EXTENSOR TENDONS
The extensor digitorum longus tendons are nourished
by the superior and inferior lateral tarsal arteries and
the direct cutaneous branches of the dorsalis pedis
artery.
Flap Design (Fig. 8–17)
The ap is designed as described previously. There are
four tendons of the extensor digitorum longus avail-
able. If needed, the tendon of the extensor hallucis
brevis can also be used, but it m ay be too sm all and
short.
Figure 8–17
Flap design.
1. Dorsalis pedis a. and greater saphenous v.
2. FDMA and deep plantar a.
3. Extensor hallucis brevis m.
4. Interosseous m.
5. Extensor digitorum brevis m.
6. Extensor digitorum longus tendons
Medial Elevation of the Flap with the
Vascular Bundle (Fig. 8–18)
The dorsalis pedis– rst dorsal m etatarsal arterial
system is dissected at the rst web and on the medial
side of the ap, and the neurovascular pedicles are
isolated at the proxim al border of the ap in a fashion
similar to the dorsalis pedis skin ap.
Figure 8–18
Medial elevation of the ap with the
vascular bundle.
1. Dorsalis pedis a. and greater saphenous v.
2. FDMA and deep plantar a.
3. Extensor hallucis brevis m.
4. Interosseous m.

Figure 8–19
Lateral elevation of the ap with the tendons.
3. Extensor hallucis brevis m.
5. Extensor digitorum brevis m.
6. Extensor digitorum longus tendons
Lateral Elevation of the Flap with the
Tendons (Fig. 8–19)
The distal and proxim al ends of the tendons (6) are
divided. The dissection proceeds between the tendons
and the extensor digitorum brevis (5) or the periosteum
of the metatarsals.
Preserving the extensor digitorum brevis on the
foot, the extensor hallucis brevis (3) is detached and
kept intact with the ap. The lateral tarsal arteries are
ligated just at the medial border of the extensor digito-
rum brevis of the second toe.
386
II.8 LOWER EXTREMITY: ANKLE AND FOOT

Figure 8–20
Completion of the ap with the tendons.
1. Dorsalis pedis a. and greater saphenous v.
5. Extensor digitorum brevis m.
6. Extensor digitorum longus tendons
Completion of the Flap with the
Tendons (Fig. 8–20)
The dorsalis pedis tendinocutaneous ap is isolated on
its neurovascular pedicles (1).
DORSALIS PEDIS TENDINOCUTANEOUS FLAP WITH EXTENSOR TENDONS
387

5. Extensor retinaculum
6. Extensor hallucis longus tendon
7. Extensor digitorum longus tendons
8. Lateral branch of the deep peroneal n.
Figure 8–21
Anatomy of the extensor digitorum brevis ap.
1. Dorsalis pedis a.
2. Lateral tarsal a.
3. Extensor digitorum brevis m.
4. Extensor hallucis brevis m.
EXTENSOR DIGITORUM BREVIS FLAP
Anatomy (Fig. 8–21)
The origin of the muscle is the superolateral surface of
the calcaneus and the interosseous talocalcaneal
ligam ent. Its insertion is usually in the form of four
digitations. The rst, the extensor hallucis brevis, is to
the lateral aspect of the extensor hallucis longus
tendon, and the other three digitations are to the lateral
aspect of the extensor digitorum longus tendons to the
second, third, and fourth toes.
The shape is thin, rectangular, and trapezoid, and
the size of the muscle belly is 4.5 cm in width and 6.0 cm
in length. Taken with the tendons, the total length can
reach 13 cm .
The muscle functions, through the tendons of the
extensor digitorum and hallucis longus, to aid in extension
of the big, second, third, and fourth toes.
Blood Supply
There are usually two lateral tarsal arteries (2) that
originate from the dorsalis pedis artery (1), 1 and 3 cm
below the lower edge of the extensor retinaculum (5).
Usually, the superior artery, with a diameter of 1.8 mm,
is the dominant vessel. Passing between the muscle and
the tarsal bone, it branches to the undersurface of each
digitation of the muscle.
Innervation
The lateral branch of the deep peroneal nerve (8)
accompanies the superior lateral tarsal artery to supply
each digitation. (For the anatomy of the dorsalis pedis
artery and the deep peroneal nerve in detail, see the
section on the dorsalis pedis ap.)
388
II.8 LOWER EXTREMITY: ANKLE AND FOOT

Figure 8–22
Incisions.
1. Dorsalis pedis a. and v.
2. Lateral tarsal a., v., and n.
3. Extensor hallucis brevis m.
4. Extensor digitorum brevis m.
5. Extensor hallucis longus tendon
6. Extensor digitorum longus tendon
Incisions (Fig. 8–22)
The incision is S-shaped and is made from the midline
between the medial and lateral malleoli, curving
smoothly laterally. It ends on the rst interosseous
metatarsal space. Some accessory incisions may be
needed. Distally, four small transverse incisions at the
metatarsal phalangeal joints of the medial four toes serve
to divide the insertion of the muscle. Proximally, a longi-
tudinal incision, anterior to the lateral malleolus, serves
to detach the origin of the muscle.
EXTENSOR DIGITORUM BREVIS FLAP
389
The extensor digitorum brevis is a thin, at, small-sized
muscle. It is expendable when the extensor digitorum
longus is left intact on the donor foot.
Although the dorsalis pedis artery is som ew hat
variable, the lateral tarsal artery and branch of the
deep peroneal nerve quite constantly supply the
m uscle. The neurovascular pedicle can always reach a
desirable length when dissection proceeds proxim ally
on the anterior tibial artery. Diam eters of the pedicle
vessels are dependably adequate for m icrovascular
anastom osis.
The m uscle ap can be transferred to the face for
treatm ent of facial palsy, and the myocutaneous ap
has been reported in reconstruction of intrinsic muscle
with skin defect in hand injuries. However, the myocu-
taneous ap is not generally used clinically because of
the extensive soft-tissue loss that results in the wide
exposure of bone surface and extensor tendons and in
subsequent problem s with wound healing. A m uscle
island ap can be used for coverage of soft-tissue loss
around the ankle, including the Achilles tendon, and on
the lower third of the leg.
COMMENT AND INSIGHTS

Figure 8–23
Exposure of the neurovascular pedicle.
1. Dorsalis pedis a. and v.
2. Lateral tarsal a., v., and n.
3. Extensor hallucis brevis m.
4. Extensor digitorum brevis mm.
5. Extensor hallucis longus tendon
6. Extensor digitorum longus tendons
Exposure of the Neurovascular
Pedicle (Fig. 8–23)
The extensor digitorum longus tendons (6) are
dissected off the underlying extensor digitorum and
hallucis brevis muscles (4,3). The dorsalis pedis vessels
(1) are identi ed at the upper m edial border of the
extensor hallucis brevis (3) and dissected distally. The
dorsalis pedis vessel is ligated distal to the muscle.
The extensor retinaculum is divided, and the lateral
tarsal neurovascular bundle (2) is then identi ed, with
the nerve branch separated from the main trunk of the
deep peroneal nerve. The muscle, with the neurovascular
bundle, is elevated from the tarsal bones.
390
II.8 LOWER EXTREMITY: ANKLE AND FOOT

Figure 8–24
Detachment of muscle insertions and origin.
3. Extensor hallucis brevis m.
4. Extensor digitorum brevis m.
5. Extensor hallucis longus tendon
6. Extensor digitorum longus tendon
Detachment of Muscle Insertions and
Origin (Fig. 8–24)
Through distal and proximal incisions, muscle insertions
and origin are detached.
EXTENSOR DIGITORUM BREVIS FLAP
391

Figure 8–25
Completion of the muscle ap.
1. Dorsalis pedis a. and v.
2. Lateral tarsal a., v., and n.
3. Extensor hallucis brevis m.
4. Extensor digitorum brevis m.
5. Extensor hallucis longus tendon
6. Extensor digitorum longus tendon
Completion of the Muscle Flap
(Fig. 8–25)
The extensor digitorum (and hallucis) brevis (4,3) muscle
ap is raised from the dorsum of the foot on the dorsalis
pedis vascular pedicle and deep peroneal nerve (1).
392
II.8 LOWER EXTREMITY: ANKLE AND FOOT

Figure 8–26
Applicable anatomy for the medial plantar ap.
1. Posterior tibial a.
2. Medial plantar a.
3. Lateral plantar a.
4. Abductor hallucis m.
5. Flexor digitorum brevis m.
6. Abductor digiti minimi m.
7. Plantar fascia
MEDIAL PLANTAR FLAP
Anatomy (Fig. 8–26)
The non–weight-bearing region of the sole lies between
the heel and the metatarsal heads. A medial plantar ap
can be raised on either the m edial or lateral plantar
arteries (2,3), or both, based ultimately on the posterior
tibial artery.
The posterior tibial artery (1) divides into the
medial and lateral plantar arteries under the origin of
the abductor hallucis (4). The medial plantar artery (2),
as a smaller terminal branch, runs between the abduc-
tor hallucis (4) and exor digitorum brevis (5). At the
base of the rst m etatarsal bone, it passes along the
medial side of the big toe and anastomoses there with
the FPMA. The lateral plantar artery (3), as a larger
terminal branch, travels medially to laterally obliquely
under the proximal third of the exor digitorum brevis
(5), where it supplies this m uscle. It then continues
distally between the exor digitorum brevis (5) and
abductor digiti minimi (6) to join the deep plantar arch.
MEDIAL PLANTAR FLAP
393
Innervation
The medial plantar nerve, the larger terminal division
of the tibial nerve, accom panies the m edial plantar
artery. Its cutaneous branches supply the medial two
thirds of the sole. The lateral plantar nerve passes
obliquely forward, accom panying the lateral plantar
artery. Its cutaneous branches supply the lateral third of
the sole.
The cutaneous neurovascular branches supplying
this area are given off from both m edial and lateral
plantar neurovascular bundles in the clefts between the
abductor hallucis, exor digitorum brevis, and abductor
digiti minimi. They curve around the m edial and lateral
edges of the plantar fascia to the skin.

Figure 8–27
Flap design.
1. Medial plantar a. and n.
2. Abductor hallucis brevis m.
3. Flexor digitorum brevis m.
4. Plantar fascia
5. Posterior tibial a. and n.
6. Lateral plantar a. and n.
Harvesting Technique
Flap Design (Fig. 8–27)
In designing the ap, the m edial or lateral plantar
artery is selected as a vascular pedicle, according to the
required ap size and location; for a large ap, both
arteries m ay be included. Usually, the medial plantar
artery is chosen and designed as the ap axis. The
region of the sole between the heel and the metatarsal
heads, except for the lateral border overlying the fth
m etatarsal, is the territory of the ap, providing a
maxim um area of 10
10 cm.
394
II.8 LOWER EXTREMITY: ANKLE AND FOOT
This instep skin ap has a special anatomic structure and
properties; the skin is thinner but hornier. Subcutaneous
tissue is dense because of the many brous septa that
bind the skin to the plantar fascia. Flap location is in a
non–weight-bearing area, and the healed defect with skin
graft does not usually affect walking and weight bearing.
Because this skin ap is durable and sensitive, the
donor site is ideal for reconstruction of skin defects in a
weight-bearing area, such as on the heel and sole of the
foot, or for reconstruction of defects of the palmar skin,
even with palmar fascia. Heel defects can ordinarily be
covered by an island. If both the instep and heel are lost,
or either the posterior or anterior tibial artery is absent,
a revascularized free ap from the contralateral foot is
indicated.
The exor digitorum brevis muscle can be included
in the ap, but a m uscle ap is not always suitable for
reconstruction of a defect in a weight-bearing area.
COMMENT AND INSIGHTS

Figure 8–28
Distal elevation of the ap.
1. Medial plantar a. and n.
2. Abductor hallucis brevis m.
3. Flexor digitorum brevis m.
4. Plantar fascia
Distal Elevation of the Flap (Fig. 8–28)
The distal edge of the ap is incised and the plantar
fascia (4) is transversely divided. The m edial plantar
neurovascular bundle (1) is identi ed in the cleft
between the abductor hallucis and exor digitorum
brevis (2,3), and the vessels are divided. After the
vessels are separated from the medial plantar nerve (1)
and kept intact with the ap, the ap is raised at the
level between the plantar fascia (4) and the exor
digitorum brevis m uscle (3), from distal to proxim al.
Attention should be paid to the cutaneous branches
from the nerve to the ap, carefully peeling them off
interfascicularly, and leaving the nerve trunk in the foot.
MEDIAL PLANTAR FLAP
395

Figure 8–29
Exposure of the neurovascular bundle.
1. Medial plantar a. and n.
2. Abductor hallucis brevis m.
5. Posterior tibial a. and n.
6. Lateral plantar a. and n.
Exposure of the Neurovascular Bundle
(Fig. 8–29)
Tracing the m edial plantar neurovascular bundle (1)
proximally, dissection proceeds to expose its bifurca-
tion with the lateral plantar neurovascular bundle (6),
whereas the abductor hallucis m uscle (2) is usually
partially divided.
396
II.8 LOWER EXTREMITY: ANKLE AND FOOT

Figure 8–30
Completion of the ap with the
medial plantar vessels.
1. Medial plantar a. and n.
2. Abductor hallucis brevis m.
5. Posterior tibial a. and n.
6. Lateral plantar a. and n.
Completion of the Flap with the Medial
Plantar Vessels (Fig. 8–30)
The ap is com pleted by a circum ferential incision,
with the plantar fascia included in the ap. If a longer
and larger vascular pedicle is required, the dorsalis
pedis artery should be palpated for con rmation before
ligation of the lateral plantar vessels (6) and division of
the posterior tibial vessels (5).
MEDIAL PLANTAR FLAP
397

Figure 8–31
Completion of the ap with both the
medial and lateral plantar vessels.
1. Medial plantar a. and n.
2. Abductor hallucis brevis m.
3. Flexor digitorum brevis m.
5. Posterior tibial a. and n.
6. Lateral plantar a. and n.
Completion of the Flap with Both the Medial
and Lateral Plantar Vessels (Fig. 8–31)
If the lateral plantar vessels (6) and cutaneous nerves
are required for the ap, the exor digitorum brevis (3)
is divided proxim ally and the vascular branches to the
muscle are ligated.
398
II.8 LOWER EXTREMITY: ANKLE AND FOOT

Figure 8–32
Arterial anatomy for free toe and toe tissue transfers.
1. Dorsalis pedis a.
7. Lateral plantar a.
2. FDMA
8. Medial plantar a.
3. Deep plantar a.
9. Plantar arch
4. Distal perforating a.
10. FPMA
5. Dorsal digital arteries (DDA)
11. Plantar digital arteries (PDA)
6. Posterior tibial a.
FREE TOE AND TOE TISSUE TRANSFERS
Arterial Anatomy (Fig. 8–32)
There are two arterial system s to supply the big and
second toes, dorsal and plantar.
Dorsal Arterial System
The dorsalis pedis– rst dorsal m etatarsal arterial
system (1,2) and its variations are described in the
section on the dorsalis pedis ap.
The FDMA (2) courses at varying levels in relation
to the interosseous m uscle and gives off branches to
the muscle, joints, and metatarsals. However, between
the heads of the rst and second metatarsals, it more
constantly lies super cially over the deep transverse
ligament. It then divides into two dorsal digital arteries
(DDAs) (5) that run on adjacent sides of the big and
second toes.
Plantar Arterial System
The rst plantar metatarsal artery (FPMA) (10) issues
from the junction between the plantar arch (9) and the
deep plantar artery (3). The former is a continuation of
the lateral plantar artery (7), and the latter is the com-
m unicating branch of the dorsalis pedis artery (1). In its
course, the artery communicates with the medial plan-
tar artery (8) between the bone and the exor tendons,
after which it passes under the deep transverse liga-
m ent and divides into two plantar digital arteries
(PDAs) (11) that supply the adjacent sides of the toes.
Communication between the Two Systems
Between the dorsal and plantar arterial systems, there
are two com m unications in the interspace between
the rst and second m etatarsals. Proxim ally, the deep
plantar artery (3) serves as com m unication between
the dorsalis pedis artery and the plantar arch (9) (the
continuation of the lateral plantar artery). Distally,
there is the distal perforating artery (4) just distal to
the deep transverse m etatarsal ligam ent. It joins the
dorsal and plantar metatarsal arteries (2,10) near their
bifurcation.
FREE TOE AND TOE TISSUE TRANSFERS
399

Figure 8–33
Variations of the distal perforating artery (see text for details).
Variations of the Distal Perforating Artery
(Fig. 8–33)
A. The distal perforating artery arises from the FDMA
and divides into two PDAs. The FPMA joins into one
of two PDAs (in 46.5% of cases).
B. The distal perforating artery com municates between
the bifurcations of the FDMA and the FPMA (in 24.0%
of cases).
C. The FPMA divides into two PDAs, and the distal per-
forating artery then joins into one of the two PDAs
(in 14.5% of cases).
D. After the bifurcations of the FDMA and FPMA, com-
munications occur between the DDA and PDA, but
there is no apparent distal perforating branch in the
web space.
E. There is no apparent com m unication between the
FDMA and FPMA, and between the DDA and PDA.
Measurements of the Arterial System of the Donor Area
Origin from Web
Diameter (mm)
Edge (cm)
Vessel
Range
Average
Range
Average
FDMA
0.6 – 2.4
1.3
6.0 – 8.5
7.4
FPMA
0.6 – 3.0
1.5
DDA of big and
0.3 – 1.5
0.7
1.6 – 3.8
2.4
second toes
PDA of big and
0.4 – 2.0
0.9
1.5 – 3.5
2.3
second toes
Distal perforating a.
0.5 – 2.0
1.1
1.6 – 3.8
2.4
Asssessments of the FDMA
Type
Diameter (mm)
Incidence(%)
Larger
More than 1.5
26
Median
1.0 – 1.5
50
Narrow
Less than 1.0
19
Absent
—
5
400
II.8 LOWER EXTREMITY: ANKLE AND FOOT

FREE TOE AND TOE TISSUE TRANSFERS
401
Because of a resem blance between the forefoot and
hand, this donor area has become extremely useful as a
multiple tissue bank in reconstructive microsurgery of
the hand. There are two arterial systems available for
transplantation. Although there is some variation in the
dorsal system , it is still the primary choice as an arterial
pedicle; it is usually super cial and more easily accessi-
ble, and a fairly long pedicle length can be obtained. The
super cial venous system is usually m ore consistent
and reliable.
If the FDMA is absent or narrow, the follow ing
procedures can be used as alternates: (1) the deep
transverse m etatarsal ligam ent is divided, and the
FPMA and deep plantar arteries are dissected out in
continuity with the dorsalis pedis artery as the vascu-
lar pedicle; (2) the dorsalis pedis–second dorsal
m etatarsal artery can be used as the pedicle for the
second toe; or (3) only the FPMA can be used as the
pedicle.
In the development and re nement of thum b re-
construction, free toe transfer has been a milestone. It
provides a reconstructed thumb with good appearance,
function, sensibility, stability, and cold tolerance. If the
surgical procedures are successful, patient acceptance
is high.
Using microsurgical techniques, the thumb can be
reconstructed with several optional procedures, each
with advantages and disadvantages. The big toe trans-
fer involves two phalanges and a large nail, similar to a
normal thumb, but it is excessively large. Also, loss of
the big toe m ay im pair appearance of the foot to a
certain extent. However, grip strength, using recon-
struction of the thum b with a big toe, is m uch stronger
than with a second toe. This procedure is usually
indicated for a male patient who is engaged in heavy
manual work.
The second toe transfer involves a digit that is
smaller than the big toe, although it has three phalanges.
If the proximal and distal interphalangeal (PIP and DIP)
joints are maintained in varying degrees of exion, the
second toe transfer may have a more pleasing cosmetic
effect. In societies where sandals are standard footwear,
surgeons and patients prefer to sacri ce the second toe,
rather than the big toe, for thumb reconstruction.
Currently, the total number of cases reported for thumb
reconstruction using vascularized second toe is much
larger than that for vascularized big toe.
Contrasted with the disadvantages of size and
appearance of big or second toe transfer for thum b
reconstruction, the wrap-around ap reconstructs a
thumb almost identical in size to the original. This par-
ticular procedure is ideal for function and cosmesis of a
degloved thum b, where skeleton and tendon rem ain
intact. Combined with an iliac bone graft, this proce-
dure is indicated for reconstruction of a thumb loss dis-
tal to the metacarpophalangeal (MCP) joint; however,
no interphalangeal joint is present.
Currently, the modi ed wrap-around, rather than
the original, ap is more commonly applied in thumb
reconstruction. In the original wrap-around ap, there
alm ost always were wound-healing problem s on the
dorsum of the distal phalanx of the toe, as well as
painful hyperkeratosis on the plantar surface of the skin
graft at the donor site. Also, there would frequently be
resorption and fracture of the iliac bone graft, as well as
problems with toenail growth resulting from harvest-
ing dam aged skin m atrix, occurring in the recon-
structed thumb at the recipient site. Usually, the partial
or even whole distal phalanx would be resected and
discarded so that the plantar surface could be covered
properly by an intact medial ap.
With the m odi ed wrap-around ap, the distal
phalanx that would have been discarded is included in
the ap, keeping it intact with the toenail, so that
damage to the nail bed and matrix is avoided. In addi-
tion, the iliac bone graft becom es an interposition
between the distal and proximal phalanx or metacarpal,
thus decreasing the length and degree of resorption of
the graft.
Removing the bulging condyles at the base of the
distal phalanx, the modi ed wrap-around ap can be
tailored to the exact size of the lost thumb.
Neither traditional nor m odi ed wrap-around
aps are applicable for children because there is no
growth plate in the bony components.
Although the rst web skin ap provides a limited
amount of tissue, the glabrous skin texture and excel-
lent recovered sensibility are ideal for skin coverage to
the hand. In addition, following its special shape in the
rst web space and matching the texture and color of
dorsal skin, the ap can be properly applied in recon-
struction of the upper and lower eyelids.
Each toe is com posed of several com ponents,
namely, nail, pulp, bones, joints, epiphysis, and tendons.
COMMENT AND INSIGHTS

To meet the requirements for reconstruction of a recip-
ient site, various techniques have been designed for
selective transfer of parts from the big or second toe, or
both. The procedure can be a single transfer (pulp) or a
combination of composite tissue transfers.
To the present tim e, vascularized joint transfer
reported for autograft has been donated from the PIP
and MTP joints of the second toe, applied for reconstruc-
tion of the PIP and MCP joints of the hand. The PIP joint
of the second toe is preferably applied in adults for both
MCP and PIP reconstruction because of its greater ex-
ion range, lateral stability, size match, and smaller sec-
ondary defect. In children, the PIP joint provides only a
single growth plate. The MTP joint, including both
growth centers, should be used for replacing the hand
402
II.8 LOWER EXTREMITY: ANKLE AND FOOT
joint, so that the reconstructed nger can keep up
growth rate with the adjacent digits.
Because of greater hyperextensibility and less ex-
ion of the MTP joint of the second toe, reverse insetting
into the recipient site is recommended.
The second and third toes can be transferred en bloc
to the hand. Indications for this technique are limited to
special cases, when all ngers have been amputated.
If microsurgically transferred skin aps or toes in
the donor area are used and if vessels and nerves are
successfully anastom osed, recovery of postoperative
sensibility in the hand can be excellent. Surprisingly,
these aps or toes often develop better two-point
discrim ination in the hand than was ever present in
the foot.

Figure 8–35
Incision at the plantar aspect.
Figure 8–34
Incision at the dorsal aspect.
1. Dorsalis pedis a., greater saphenous v.,
deep peroneal n.
2. FDMA
3. Extensor hallucis brevis m.
4. Extensor hallucis longus tendon
5. Deep transverse metatarsal ligament
6. PDA and n.
7. Flexor hallucis tendon
8. Dorsal metatarsal v.
9. Deep plantar a.
10. Interosseous m.
FREE BIG TOE TRANSFER
Incision at the Dorsal and Plantar
Aspects (Figs. 8–34, 8–35)
The ipsilateral big toe is commonly used in reconstruc-
tion of the thumb.
A curvilinear incision is made on the dorsum of the
foot between the dorsalis pedis artery and the greater
saphenous vein, down to the rst web. There, the
incision is turned circum ferentially around the big toe
at about the MTP joint level.
The procedure should be performed under tourni-
quet application, without exsanguination, to allow the
vessels to be more visible.
FREE BIG TOE TRANSFER
403

Figure 8–36
Dissection of the super cial veins.
1. Dorsalis pedis a., greater saphenous v., deep
peroneal n.
3. Extensor hallucis brevis m.
4. Extensor hallucis longus tendon
8. Dorsal metatarsal v.
Dissection of the Super cial Veins
(Fig. 8–36)
The dorsal metatarsal veins (8) that drain the big toe,
the dorsal venous arch, and the greater saphenous vein
(1) are dissected. After the branches to the second toe
and the com m unicating branch to the deep vein are
ligated, this super cial venous system is isolated.
404
II.8 LOWER EXTREMITY: ANKLE AND FOOT

Figure 8–37
Identi cation of the vascular pedicle.
1. Dorsalis pedis a., greater sapheneus v., deep peroneal n.
2. FDMA
3. Extensor hallucis brevis m.
4. Extensor hallucis longus tendon
9. Deep plantar a.
Identi cation of the Vascular Pedicle
(Fig. 8–37)
Then the extensor hallucis brevis tendon (3) is identi-
ed at the lateral side of the extensor hallucis longus
tendon (4). The extensor hallucis brevis tendon is
divided, and this muscle is turned proximally to expose
the dorsalis pedis vessels (1) and the deep peroneal
nerve (1). The vessels are dissected and traced to
identify the FDMA (2) at the proximal end of the rst
intermetatarsal space.
If the FDMA is super cial and adequate in caliber
(more than 1 mm), the dissection proceeds to the rst
web space.
FREE BIG TOE TRANSFER
405

Figure 8–38
Dissection of the FDMA.
1. Dorsalis pedis a., greater saphenous
v., deep peroneal n.
2. FDMA
9. Deep plantar a.
10. Interosseous m.
Dissection of the FDMA
(Fig. 8–38)
If there is no adequate super cial FDMA or if it takes off
deeply from the deep plantar artery (9) or the FPMA,
the dissection turns toward the rst web space,
between the heads of the rst and second metatarsals,
where the FDMA usually lies quite super cially over the
deep transverse metatarsal ligam ent. Then, dividing the
interosseous m uscle (10), the dissection proceeds
proximally to isolate the artery (2).
406
II.8 LOWER EXTREMITY: ANKLE AND FOOT

Figure 8–39
Further dissection of the vascular
pedicle.
1. Dorsalis pedis a., greater saphenous v., deep
peroneal n.
2. FDMA
3. Extensor hallucis brevis m.
4. Extensor hallucis longus tendon
5. Deep transverse metatarsal ligament
9. Deep plantar a.
Further Dissection of the Vascular
Pedicle (Fig. 8–39)
After isolating the dorsalis pedis artery (1) and the
FDMA (2), the deep plantar artery (9) is carefully ligated
distal to the takeoff of the FDMA (2). The extensor
tendon (4) of the big toe is divided as proxim ally as
possible.
The vessels supplying the second toe should be lig-
ated, and the deep transverse metatarsal ligament (5)
on the lateral side of the MTP joint of the big toe is care-
fully divided.
FREE BIG TOE TRANSFER
407

Figure 8–41
Disarticulation of the MTP joint and
completion of the harvesting.
1. Dorsalis pedis a., greater saphenous v., deep peroneal n.
4. Extensor hallucis longus tendon
6. PDA and n.
7. Flexor hallucis tendon
Figure 8–40
Dissection on the plantar side.
5. Deep transverse metatarsal ligament
6. PDA and n.
7. Flexor hallucis tendon
Disarticulation of the MTP Joint and
Completion of the Harvesting
(Fig. 8–41)
The MTP joint is disarticulated and, after releasing the
tourniquet, its circulation is assessed. The big toe is now
ready for transfer.
Dissection on the Plantar Side
(Fig. 8–40)
Through a longitudinal incision on the plantar aspect,
the lateral and m edial plantar digital nerves (6) and
exor hallucis longus tendon (7) are exposed and
dissected for an adequate length and then divided.
408
II.8 LOWER EXTREMITY: ANKLE AND FOOT

FREE SECOND TOE TRANSFER
409
FREE SECOND TOE TRANSFER
Incision (Figs. 8–42, 8–43)
It is suggested that the contralateral second toe be
selected in reconstructions of the thumb, especially if
there is a contracture of the rst web on the hand that
needs release.
A curvilinear incision is m ade between the greater
saphenous vein and the dorsalis pedis artery from the
ankle to the head or neck of the second m etatarsal.
There the incision forks toward the rst and second
webs and then merges at the plantar aspect of the MTP
joint. To m eet recipient-site requirem ents, a dorsalis
pedis ap or rst web space ap can be com bined with
a second toe transfer.
The procedure should be performed under tourni-
quet application to allow the vessels to be more visible
without exsanguination.
Figure 8–42
Incision on the dorsal aspect.
1. Greater saphenous v.
7. FDMA
2. Extensor hallucis brevis m.
8. Interosseous m.
3. Extensor hallucis longus tendon
9. Extensor tendons
4. Dorsal metatarsal v.
10. Deep transverse metatarsal ligament
5. Dorsalis pedis a. and deep peroneal n.
11. Flexor tendon
6. Deep plantar a.
12. PDA and n.
Figure 8–43
Incision on the plantar aspect.

Figure 8–44
Dissection of the super cial veins.
1. Greater saphenous v.
2. Extensor hallucis brevis m.
3. Extensor hallucis longus tendon
4. Dorsal metatarsal v.
9. Extensor tendons
Dissection of the Super cial Veins
(Fig. 8–44)
The dorsal m etatarsal veins (4) that drain the second
toe, the dorsal venous arch, and the greater saphenous
vein (1) are dissected. After the branches to the
adjacent toes and the com m unicating branch to the
deep vein are ligated, this super cial venous system is
isolated.
410
II.8 LOWER EXTREMITY: ANKLE AND FOOT

FREE SECOND TOE TRANSFER
411
Identi cation of the Arterial System
(Fig. 8–45)
Then the extensor hallucis brevis tendon (2) is identi ed
at the lateral side of the extensor hallucis longus tendon.
The extensor hallucis brevis tendon is divided, and this
muscle is turned proximally to expose the dorsalis pedis
vessels (5) and the deep peroneal nerve (5). The vessels
are dissected and traced to identify the FDMA (7) at the
proximal end of the rst intermetatarsal space.
If the FDMA is super cial and adequate in caliber
(more than 1 mm), the dissection proceeds to the rst
web space.
Figure 8–45
Identi cation of the arterial system.
2. Extensor hallucis brevis m.
5. Dorsalis pedis a. and deep peroneal n.
6. Deep plantar a.
7. FDMA
9. Extensor tendons

Figure 8–46
Dissection of the FDMA.
5. Dorsalis pedis a. and deep peroneal n.
6. Deep plantar a.
7. FDMA
8. Interosseous m.
Dissection of the FDMA (Fig. 8–46)
If there is no adequate super cial FDMA or if it takes off
deeply from the deep plantar artery or the FPMA, the
dissection turns toward the rst web space, between
the heads of the rst and second metatarsals, where the
FDMA usually lies quite super cially over the deep
transverse metatarsal ligam ent. Then, dividing the in-
terosseous m uscle (8), the dissection proceeds proxi-
mally to isolate the artery.
412
II.8 LOWER EXTREMITY: ANKLE AND FOOT

FREE SECOND TOE TRANSFER
413
Figure 8–47
Further dissection of the
arterial pedicle.
5. Dorsalis pedis a. and deep peroneal n.
6. Deep plantar a.
7. FDMA
8. Interosseous m.
9. Extensor tendons
10. Deep transverse metatarsal ligament
Further Dissection of the Arterial
Pedicle (Fig. 8–47)
After isolating the dorsalis pedis artery (5) and the
FDMA (7), the deep plantar artery (6) is carefully ligated
distal to the takeoff of the FDMA (7). The extensor
tendons (9) of the second toe are divided as proximally
as possible.
The vessels supplying the big and third toes should
be ligated, and the deep transverse m etatarsal
ligaments (10) on both sides of the second MTP joint are
carefully divided.

Figure 8–48
Dissection on the plantar side.
10. Deep transverse metatarsal ligament
11. Flexor tendon
12. PDA and n.
Dissection on the Plantar Side
(Fig. 8–48)
Plantar dissection is performed to identify the plantar
digital nerves (12) and to separate them from the lateral
and medial plantar digital nerves of the big and third
toes, respectively. The exor longus and exor brevis
(11) are exposed, and all exor tendons and plantar
digital nerves are divided as proxim ally as possible,
usually at the middle sole.
414
II.8 LOWER EXTREMITY: ANKLE AND FOOT

FREE SECOND TOE TRANSFER
415
Figure 8–49
Disarticulation of the MTP joint and
completion of harvesting.
1. Greater saphenous v.
4. Dorsal metatarsal v.
5. Dorsalis pedis a. and deep peroneal n.
7. FDMA
9. Extensor tendons
11. Flexor tendons
12. PDA and n.
Disarticulation of the MTP Joint
and Completion of Harvesting
(Fig. 8–49)
With great attention to protect all the soft tissues from
injury, including the vascular pedicle, nerves, and ten-
dons, the MTP joint is disarticulated. The second toe is
then isolated only on the dorsalis pedis–FDMA (5,7)
and the greater saphenous vein (1). If m etacarpal re-
construction w ith thum b or nger reconstruction is
needed at the same time, the second metatarsal bone is
divided with a Gigli saw at a proper level (instead of
disarticulating it). The distal part of the second
metatarsal should be removed to allow primary donor-
site closure.

Figure 8–51
Flap design on the plantar aspect.
Figure 8–50
Flap design on the dorsal aspect.
1. Dorsalis pedis a., greater saphenous v.
2. Extensor hallucis brevis m.
3. Extensor hallucis longus tendon
4. Common PDA and n.
5. Deep transverse metatarsal ligament
6. Flexor tendons
7. Deep peroneal n.
FIRST WEB SPACE SKIN FLAP
Flap Design (Figs. 8–50, 8–51)
A standard rst web space skin ap is composed of four
parts, each part providing a separate dim ension: the
lateral side of the big toe (5
3 cm), the medial side of
the second toe (4
3 cm), the dorsal aspect of the web
(4 3 cm), and the plantar aspect of the web (3 3 cm).
The total area can reach a size of 7
7 cm, and the ap
can be com bined with a dorsalis pedis ap, the second
toe, or other designs.
416
II.8 LOWER EXTREMITY: ANKLE AND FOOT

FIRST WEB SPACE SKIN FLAP
417
Figure 8–52
Dissection of the venous and arterial
systems.
1. Dorsalis pedis a., greater saphenous v.
2. Extensor hallucis brevis m.
3. Extensor hallucis longus tendon
7. Deep peroneal n.
Dissection of the Venous and Arterial
Systems (Fig. 8–52)
The greater saphenous vein and the dorsalis
pedis–FDMA (1) are dissected out through an incision
on the dorsum of the foot. The deep peroneal nerve (7)
is preserved for inclusion in the ap.

Figure 8–54
Flap elevation.
1. Dorsalis pedis a., greater saphenous v.
2. Extensor hallucis brevis m.
4. Common PDA and n.
5. Deep transverse metatarsal ligament
Dissection on the Plantar Aspect
(Fig. 8–53)
Through the incision on the plantar aspect, the
comm on plantar digital nerve (4) is dissected for som e
length and cut.
418
II.8 LOWER EXTREMITY: ANKLE AND FOOT
Flap Elevation (Fig. 8–54)
The skin ap is dissected away from the fascia of the
two toes and then isolated. The defect is covered with a
split-thickness skin graft.
Figure 8–53
Dissection on the plantar aspect.
4. Common PDA and n.
6. Flexor tendons

WRAP-AROUND FLAP
419
Figure 8–56
Flap design from an oblique-lateral view.
Figure 8–55
Flap design from a dorsal
view.
1. Dorsalis pedis a., deep peroneal n.,
greater saphenous v.
2. Extensor hallucis brevis m.
3. Extensor hallucis longus tendon
4. Common PDA and n.
5. Deep transverse metatarsal
ligament
6. Flexor tendon
7. Medial PDA and n.
8. Distal perforator a.
WRAP-AROUND FLAP
Flap Design (Figs. 8–55, 8–56)
The ipsilateral big toe is selected, and the circumference
and length of the opposite, normal thumb are m eas-
ured. A template is made for m arking the ap on the
donor big toe.
A medial skin bridge, extending around the tip, is
preserved, with its width just the difference between
the circumferences of the thumb and the toe. It usually
m easures 1.0 to 1.5 cm at its base. Because the nail of
the big toe is wider than that of the thumb, the medial
m argin of the ap on the dorsum is placed on the
m edial third of the toenail and its matrix.

Figure 8–57
Dissection of neurovascular
pedicle and dorsal elevation of the ap.
1. Dorsalis pedis a., deep peroneal n.,
greater saphenous v.
2. Extensor hallucis brevis m.
3. Extensor hallucis longus tendon
Dissection of Neurovascular Pedicle
and Dorsal Elevation of the Flap
(Fig. 8–57)
The greater saphenous vein, dorsalis pedis–FDMA, and
deep peroneal nerve (1) are dissected out through the
incision on the dorsum of the foot. Branches to the
second toe are ligated. The ap over the dorsum of the
toe is raised medially over the paratenon of the exten-
sor tendon (3), with the dissection below the nail
proceeding subperiosteally to avoid dam age to the
germinal matrix. If necessary, a ne sliver of bone may
be included to further insure integrity.
420
II.8 LOWER EXTREMITY: ANKLE AND FOOT

WRAP-AROUND FLAP
421
Figure 8–59
Completion of ap harvesting.
1. Dorsalis pedis a., deep peroneal n., greater
saphenous v.
4. Common PDA and n.
5. Deep transverse metatarsal ligament
8. Distal perforator a.
Note: For donor-site closure, please refer to the
section on the modi ed wrap-around ap.
Figure 8–58
Plantar dissection and ap elevation.
4. Common PDA and n.
6. Flexor tendon
7. Medial PDA and n.
Plantar Dissection and Flap Elevation
(Fig. 8–58)
The m edial PDA and nerve (7) are preserved on the
plantar aspect for the medial skin ap. The lateral PDA
and nerve (4) are dissected, the artery is ligated, and the
nerve is separated from the nerve of the second toe and
divided to the proper length. Then the plantar part of
the ap is raised toward the rst web, with care taken
to include the lateral plantar digital neurovascular
bundle (4) in the ap.
Completion of Flap Harvesting
(Fig. 8–59)
During dissection in the rst web, attention should be
paid to the distal edge of the deep transverse ligament
(5), so that the distal perforating artery is not injured
and keeps its communication between the dorsal and
plantar arteries. Then the ap is isolated on the dorsalis
pedis–FDMA and greater saphenous vein (1).

Figure 8–61
Flap design shown in an oblique-lateral view.
MODIFIED WRAP-AROUND FLAP
Flap Design (Figs. 8–60, 8–61)
The ipsilateral big toe is selected, and the circumference
and length, as well as the nail width, of the opposite,
normal thumb are m easured. A template is m ade for
marking the ap on the donor big toe.
A medial skin bridge, extending around the tip, is
preserved, with its width just the difference between
the circumferences of the thumb and the toe. It usually
m easures 1.0 to 1.5 cm at its base. Because the nail of
the big toe is wider than that of the thumb, the medial
m argin of the ap on the dorsum is placed on about the
m edial third of the toenail and its matrix to match the
nail width of the normal thumb.
422
II.8 LOWER EXTREMITY: ANKLE AND FOOT
Figure 8–60
Flap design shown in a dorsal view c.
1. Dorsalis pedis a., deep peroneal n., greater
saphenous v.
2. Extensor hallucis brevis m.
3. Extensor hallucis longus tendon
4. Lateral PDA and n.
5. Deep transverse metatarsal ligament
6. Flexor tendon
7. Medial PDA and n.
8. Distal perforating a.

MODIFIED WRAP-AROUND FLAP
423
Figure 8–62
Dissection of the neurovascular
pedicle on the dorsum of the foot.
1. Dorsalis pedis a., deep peroneal n.,
greater saphenous v.
2. Extensor hallucis brevis m.
3. Extensor hallucis longus tendon
Dissection of the Neurovascular
Pedicle on the Dorsum of the
Foot (Fig. 8–62)
The greater saphenous vein, dorsalis pedis–FDMA sys-
tem , and deep peroneal nerve (1) are dissected out
through the incision on the dorsum of the foot.
Branches of the super cial veins and deep peroneal
nerve to the second toe are ligated and divided, except
the arterial branch to the second toe.

Figure 8–63
Plantar dissection.
4. Lateral PDA and n.
6. Flexor tendon
7. Medial PDA and n.
Plantar Dissection (Fig. 8–63)
The dissection is turned to the plantar aspect. The m e-
dial PDA and nerve (7) are preserved for the medial skin
ap. The lateral PDA and nerve (4) are dissected, and
the nerve is separated from the nerve of the second toe
and divided to the proper length. Then the plantar part
of the ap is raised toward the rst web, with care
taken to include the lateral plantar digital neurovascular
bundle (4) in the ap.
After assessm ent that the dorsalis pedis–FDMA
system is capable of blood supply to the big toe, the
lateral PDA is ligated as far as possible proximally.
424
II.8 LOWER EXTREMITY: ANKLE AND FOOT

MODIFIED WRAP-AROUND FLAP
425
Figure 8–64
Dissection in the rst web.
1. Dorsalis pedis a., deep peroneal n., greater
saphenous v.
4. Lateral PDA and n.
5. Deep transverse metatarsal ligament
8. Distal perforating a.
Dissection in the First Web (Fig. 8–64)
During dissection in the rst web, attention should be
paid to the distal edge of the deep transverse ligament
(5), so that the distal perforating artery (8) is not
injured and keeps its com m unication between the
dorsal and plantar arteries (1,4) before ligating the
dorsal and plantar digital arteries to the second toe.

Figure 8–65
Elevation of the medial
ap from the distal phalanx.
1. Dorsalis pedis a., deep peroneal
n., greater saphenous v.
3. Extensor hallucis longus tendon
7. Medial PDA and n.
Elevation of the Medial Flap from the
Distal Phalanx (Fig. 8–65)
The medial excess portion of the toenail with its bed
and germinal matrix is resected. The medial ap of the
toe is elevated from the tip of the distal phalanx proxi-
mally until reaching the middle portion of the proximal
phalanx. Then the skin ap over the dorsum of the
proximal phalanx is raised over the paratenon of the
extensor tendon distally until reaching the interpha-
langeal joint, with care to protect the arterial and
venous system of the wrap-around ap.
426
II.8 LOWER EXTREMITY: ANKLE AND FOOT

MODIFIED WRAP-AROUND FLAP
427
Figure 8–66
Disarticulation of the interphalangeal joint and
completion of ap elevation.
1. Dorsalis pedis a., deep peroneal n., greater saphenous v.
2. Extensor hallucis brevis m.
3. Extensor hallucis longus tendon
4. Lateral PDA and n.
8. Distal perforating a.
Disarticulation of the Interphalangeal
Joint and Completion of Flap
Elevation (Fig. 8–66)
The extensor and exor tendons (3) are divided, and the
interphalangeal joint is disarticulated. At this point, the
m odi ed w rap-around ap, with nail and distal
phalanx intact together, is isolated on the dorsalis
pedis–FDMA and greater saphenous vein (1).