Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
A
B
D
E
F
G
H
I
C
Figure 52.13  (A) Radiograph showing bony tumor. (B) Tumor exposed. (C) Long 17 cm right tibial defect in a 15-year-old boy following
segmental tibial resection. (D) Fibula flap harvested. (E) Fibular flap has been placed in an intramedullary fashion into the tibial allograft.
A trough was created on the planned posteromedial aspect of the tibial allograft to accommodate the pedicle and also allow anastomoses
to the posterior tibial vessels. (F) Following bony reconstruction and soft tissue closure. (G) Following skin grafting. (H) Immediate post­
operative radiograph shows hardware placement and securing of the fibula flap with two unicortical screws from each plate. (I) Postopera­
tive AP view of the leg. The tibial allograft has fully healed.
CASE 52.2  Tibia Reconstruction with a Free Fibula Osseus Flap – Capanna
Technique—cont’d

CHAPTER 52 — Fibula Flap
611
A 24-year-old man presented with osteoradionecrosis of the left
proximal tibia. He was treated with chemotherapy and radiation
5 years prior for B cell type lymphoma, and subsequently had
bone grafting and a plate applied to the lateral tibia. However,
he developed pain in the proximal tibia with full weightbearing.
A biopsy showed avascular bone. He subsequently underwent
refixation with an intramedullary nail and an onlay free fibular
flap harvested from the contralateral leg, with anastomoses per-
formed to the posterior tibial vessels. The intramedullary nail
was subsequently removed. At 5 years postoperatively, the radio-
graph shows healing of the osteonecrosis and incorporation of
the vascularized fibula flap into the proximal tibia (Fig. 52.15).
CASE 52.4  Tibia Reconstruction with a Free Fibula Flap
Figure 52.15  (A) Preoperative radiograph of the left knee demonstrates osteoradionecrosis. (B,C) Harvest of the contralateral fibular flap
with a skin paddle. (D) Immediate postoperative radiograph shows fixation with an intramedullary nail and onlay vascularized fibular flap.
(E) A 5-year postoperative radiograph shows incorporation of the fibular flap into the native tibia; the intramedullary nail has been removed.
A
B
C
D
E

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
5. Mardini S, Wei FC, Lin CH, et al. Mandible reconstruction with
vascularized fibula. Semin Plast Surg 2003;17(4):373–82.
6. Irjala H, Kinnunen I, Aitasalo K. Mandibular reconstruction using
free bone flap after preoperative chemoradiation. Eur Arch Oto­
rhinolaryngol 2012;269:1513–18.
7. Sassu P, Acland RD, Salgado CJ, et al. Anatomy and vascularization
of the flexor hallucis longus muscle and its implication in free
fibula flap transfer: an anatomical study. Ann Plast Surg 2010;64(2):
233–7.
8. Innocenti M, Delcroix L, Manfrini M, et al. Vascularized proximal
fibular epiphyseal transfer for distal radial reconstruction. J Bone
Joint Surg Am 2005;87(Suppl. 1, Pt 2):237–46.
9. Capanna R, Bufalini C, Campanacci C. A new technique for recon­
structions of large metadiaphyseal bone defects: a combined graft
(allograft shell plus vascularized fibula). Orthop Traumatol
1993;2:159–77.
10. Salgado CJ, Lin CH, Fuller DA, et al. Foot salvage after loss of the
first and second metatarsal rays with a free fibular osteocutaneous
flap. J Am Podiatr Med Assoc 2011;101(6):531–6.
11. Duymaz A, Karabekmez FE, Vrtiska TJ, et al. Free tissue transfer for
lower extremity reconstruction: a study of the role of computed
angiography in the planning of free tissue transfer in the posttrau­
matic setting. Plast Reconstr Surg 2009;124(2):523–9.
12. Chen W, Zhang F, Chang SM, et al. Microsurgical fibular flap for
treatment of avascular necrosis of the femoral head. J Am Coll Surg
2006;202:324–34.
13. Korompilias AV, Beras AE, Lykissas MG, et al. Femoral head osteo­
necrosis: why choose free vascularized fibula grafting. Microsurgery
2011;31:223–8.
14. Soldado F, Garcia Fontecha C, Haddad S, et al. Treatment of con­
genital pseudarthrosis of the tibia with vascularized fibular perios­
teal transplant. Microsurgery 2012;32:397–400.
15. Bauer AS, Singh AK, Amanatullah D, et al. Free vascularized fibular
transfer with langenskiold procedure for the treatment of congeni­
tal pseudarthrosis of the forearm. Tech Hand Up Extrem Surg
2013;17:144–50.
16. Medrykowski F, Barbary S, Gibert N, et al. Vascularized proximal
fibular epiphyseal transfer: two cases. Orthop Traumatol Surg Res
2012;98:728–32.
17. Eski M, Turegun M, Deveci M, et al. Vertical distraction osteogen­
esis of fibular bone flap in reconstructed mandible. Ann Plast Surg
2006;57:631–6.
18. Hollenbeck ST, Woo S, Ong S, et al. The combined use of the
Ilizarov method and microsurgical techniques for limb salvage.
Ann Plast Surg 2009;62:486–91.
19. Salgado CJ, Rampazzo A, Xu E, et al. Treatment of dyspareunia
by creation of a pseudojoint in rigid bone following total penile
reconstruction with fibular osteocutaneous flap. J Sex Med 2008;5:
2947–50.
20. Papadopulos NA, Schaff J, Biemer E. The use of free prelaminated
and sensate osteofasciocutaneous fibular flap in phalloplasty.
Injury 2008;39(Suppl. 3):S62–7.
21. Jandali S, DIluna ML, Storm PB, et al. Use of the vascularized free
fibula graft with an arteriovenous loop for fusion of cervical and
thoracic spinal defects in previously irradiated pediatric patients.
Plast Reconstr Surg 2011;127:1932–8.
22. Winters HA, Kraak J, Oosterhuis JW, et al. Spinal reconstruction
with free vascularized bone grafts; approaches and selection of
acceptor vessels. Scand J Surg 2013;102:42–8.
23. Sakuraba M, Kimata Y, Iida H, et al. Pelvic ring reconstruction with
the double-barreled vascularized fibular free flap. Plast Reconstr
Surg 2005;116:1340–5.
24. Chang DW, Fortin AJ, Oates SD, et al. Reconstruction of the pelvic
ring with vascularized double-strut fibular flap following internal
hemipelvectomy. Plast Reconstr Surg 2008;121:1993–2000.
Access Figures 52.14 and 52.16, as well as
case examples 3 and 5 and video online at

REFERENCES
1. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A
clinical extension of microvascular techniques. Plast Reconstr Surg
1975;55(5):533–44.
2. Wei FC, Chen HC, Chuang CC, et al. Fibular osteoseptocutaneous
flap: anatomic study and clinical application. Plast Reconstr Surg
1986;78(2):191–200.
3. Hidalgo DA. Fibula free flap: a new method of mandible recon­
struction. Plast Reconstr Surg 1989;84(1):71–9.
4. Wei FC, Seah CS, Tsai YC, et al. Fibula osteoseptocutaneous flap
for reconstruction of composite mandibular defects. Plast Reconstr
Surg 1994;93(2):294–306.
Expert Commentary
Marco Innocenti, MD
The versatility of free fibula transfer further increased with the
introduction in the clinical practice of the proximal fibula
epiphyseal transfer in children. This is the only surgical option
that provides a true epiphysis with an active growth plate,
which may be used in the case of epiphyseal reconstruction
in skeletally immature patients. In fact, other options such as
the iliac crest or the scapula, are based on a transfer of an
apophysis and therefore they cannot provide a consistent
and predictable growth or a suitable articular surface. In
addition, they are lacking an adjoining diaphysis. Conversely,
the proximal fibula provides an excellent articular surface,
which can significantly remodel over the years and a segment
of tubular bone matching in size the radius and the humerus.
The growth rate of the proximal fibula after transfer in a
heterotopic location depends on the age of the child and,
probably, on the new biomechanical environment. The per-
sonal experience on a series of 34 cases confirms the ana-
tomic findings described by Taylor in 1988, and suggests the
use of the anterior tibial artery as a single pedicle able to
supply both the growth plate and the shaft of the fibula. If
the recurrent branch to the epiphysis and the musculoperi-
osteal perforators to the diaphysis are carefully preserved the
anterior tibial artery may actually be the only source vessel
of such a graft. In order to improve the length of the pedicle,
we modified the original technique, choosing a reverse-flow
pedicle that significantly simplifies the procedure.
Donor site morbidity is usually reasonable, provided that
the lateral compartment of the knee is properly stabilized with
a meticulous reinsertion of the lateral collateral ligament,
augmented with a strip of the biceps femoris tendon. The
most common and severe complication is a palsy of the
peroneal nerve due to the anatomic location of the motor
branches for the muscles of the anterior compartment.
However, this palsy is usually reversible with a spontaneous
recovery after some months, and it is an acceptable draw-
back of the procedure when compared with its advantages.

CHAPTER 52 — Fibula Flap 612.e1
The patient is a 52-year-old woman with recurrent myxopapillary
ependymoma in the lumbosacral region, who had previously
undergone an L4 through S2 laminectomy with a subtotal resec-
tion of the tumor. She had received 5000 rads of external beam
radiation therapy. She then underwent a total sacrectomy, L5
vertebrectomy, and partial L4 corpectomy. A pedicled vertical
rectus abdominis myocutaneous flap was used for reconstruction
of a lower lumbar skin defect and 12 days later the pelvic ring
was reconstructed with bilateral free fibular flaps. Grafts of
14 cm were harvested simultaneously from both legs while the
patient was in the prone position. The peroneal vessels were
anastomosed in series (with one being a flow-through flap) to
the right common iliac artery and vein. Both fibulas were placed
into the defect and fixed with screws. Bony union was seen at 6
months on radiographs. A stable reconstruction of the pelvis was
obtained. At 3 months postoperatively, the patient was gradually
allowed to sit and she was able to take steps with orthoses and a
walker after 9 months (Fig. 52.14).
CASE 52.3  Pelvic Ring Reconstruction with Bilateral Free Fibula Osseus Flaps
A
B
C
Figure 52.14  (A) Preoperative abdominal film. (B) Postoperative anterior-posterior pelvic film, showing spinal construct, with vascularized
fibular struts. (C) CT scan showing incorporation of graft at proximal and distal osteotomy sites.

612.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 32-year-old woman was involved in a motor vehicle accident,
during which she suffered a comminuted open left femur frac-
ture. Initial fracture fixation required a lateral gastrocnemius
muscle flap for soft tissue coverage. The patient went on to
develop an infection at the fracture site with subsequent osteo-
myelitis requiring bone resection and placement of an antibiotic
spacer. The resultant bony defect was 9 cm. A vascularized
double-barreled fibular flap was required. The fibula flap vessels
were anastomosed to the femoral vessels with the aid of inter­
positional vein grafts. The flap was monitored postoperatively
with an implantable Doppler probe. Bony union was obtained
in 4 months. The patient began full weightbearing at 6 months
(Fig. 52.16).
CASE 52.5  Femur Defect Reconstructed with Double-Barreled Fibula Osseous
Figure 52.16  (A) Open comminuted femur fracture in a 32-year-old woman complicated by osteomyelitis and failed attempt at bone
grafting. (B) AP radiograph showing disrupted cortex. (C) Close up of graft in place. Graft inserted as intramedullary rod and fixation
obtained with single locked 4.0 mm screw. (D) A 5-month radiograph showing the healed femoral fracture with incorporation of the fibula.
(E) Postoperative view of the patient.
A
B
C
D
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INTRODUCTION
The word glabrous is defined as “smooth, having a surface
without hairs or projections.” Anatomically, glabrous skin is
present on the palms of the hands and volar fingers, as well
as the plantar surface of the feet and toes. Replacing gla­
brous skin on the hand and fingers is best accomplished by
microneurovascular transplantation of similar skin from the
foot, most often from the great toe. A “pseudo-glabrous”
surface can be created with transplantation of muscle and
split-thickness skin graft (STSG) for coverage of large
palmar defects. This pseudo-glabrous surface is relatively
insensate but feels smooth and has the septal qualities of
glabrous skin.
For palmar defects, we prefer muscle and STSG to fascio­
cutaneous flaps. Non-glabrous skin flaps, fasciocutaneous
flaps, or venous flow-through flaps give excellent cover but
do not have the unique septal support of finger and thumb
tips. Certainly, replacing “like with like” is the first choice in
reconstructing a surgical wound, but glabrous donor tissue
is limited and is reserved for smaller defects. For instance,
an entire palm cannot be resurfaced with a glabrous donor
site because of the lack of availability. An exception would
be an unusual case of “spare parts” surgery, where donor
amputated tissue is present that cannot be replanted. Non-
glabrous tissues have drawbacks: these flaps do not have the
density of nerve fibers, and therefore less chance for finger­
tip quality reinnervation; they may be hair-bearing; and
their color match may be inconsistent.
This chapter focuses on the great toe and second toe pulp
neurovascular island flaps and medial plantar instep neuro­
vascular island flaps, which all provide glabrous skin on a
consistent vascular pedicle. The toe pulp flap can be used
to resurface distal digital pulp wounds, while the instep flap
can provide a larger area of tissue approaching the size of
an entire volar finger or a comparable-sized palmar defect.
REGIONAL ANATOMY (see Figs 13.7, 13.8,
13.11, 13.15, 13.16, 13.17 and 13.19)
ARTERIAL ANATOMY OF THE REGION (see
Figs 13.15 and 13.17)
Arterial blood supply to the foot and toes comes from either
the posterior tibial or anterior tibial system. The anterior
tibial artery becomes the dorsalis pedis artery over the
dorsum of the foot under the extensor retinaculum. At the
level of the proximal first metatarsal interosseous space,
the dorsalis pedis bifurcates, sending the first dorsal
Glabrous Skin Flaps
Gregory M. Buncke  |  Rudolf F. Buntic
53 
metatarsal artery along the dorsal aspect of the interspace
between the first and second metatarsal and a second com­
municating branch that travels deep. This branch perfo­
rates the interspace to communicate with the plantar system.
The posterior tibial arterial system enters the foot poste­
rior to the medial malleolus of the tibia in the tarsal tunnel.
This artery then bifurcates into medial and lateral plantar
arteries, with the medial plantar branch further subdividing
into several branches. The lateral plantar branch joins the
plantar system at the level of the base of the metatarsal.
Multiple common digital arteries branch at this level and
travel deep to the metatarsal and eventually join the dorsal
metatarsal arterial system just distal to the transverse meta­
tarsal ligament. At this junction, the artery immediately
bifurcates, sending terminal digital artery branches both
medially and laterally.
At the level of the first cuneiform the medial plantar
artery divides into several branches. The medial branches
communicate with the dorsalis pedis, while perforators
come through the intermuscular septum between the
abductor hallucis and flexor digitorum brevis to supply the
medial plantar perforator flap.
VENOUS ANATOMY OF THE REGION
(Figs 53.1 and 13.19)
Small veins over the dorsum of the great and second toe
coalesce into tributaries that connect to a venous arch on
the dorsum of the foot, the completeness of this arch being
variable. These veins run in the subcutaneous system just
under the dermis and in the fatty tissue above the deep
fascia of the foot, superficial to the extensor tendons. The
venous arch drains into the dominant saphenous system.
Long venous pedicles on any foot flap can be harvested with
the saphenous system for a vein of virtually any length neces­
sary. A second deep venous system of small venae comitantes
accompanies the proper digital arteries to the toes but is
generally too small for microvascular transplantation. If
these veins are traced proximal to the posterior tibial artery
or dorsalis pedis artery, they are larger and can sometimes
be used for microvascular repair. The subcutaneous veins
are, however, much larger and more amenable to microsur­
gical repair in most cases.
The medial plantar perforators are accompanied by
venae comitantes and are able to drain the medial plantar
flap. These vessels are traced back to a large branch of the
medial plantar system to allow for the size necessary for
microsurgical repair. Although they are comparable in
diameter to the medial plantar artery, the medial plantar
comitans vessels are quite thin and more difficult to handle.
Another option for venous drainage is to trace a superficial
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION G  —  LOCAL AND FREE FLAPS IN THE LOWER EXTREMITY

CHAPTER 53 — Glabrous S kin Flaps
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Branches from the medial plantar nerve or saphenous
nerve may course through the medial plantar flap; whereas
these nerves are inconsistent in their supply to the flap and
we have not generally used them, they can potentially inner­
vate the medial plantar flap.
GREAT TOE PULP FLAP AND SECOND
TOE PULP FLAP
FLAP ANATOMY
ARTERIAL SUPPLY OF THE FLAP (Case 1, Fig. 53.4, see
Figs 13.15 and 13.19)
The blood supply to the great toe pulp and second toe pulp
flaps can be either dorsal or plantar dominant, depending
on the patient’s anatomy. The dorsal system is dominant in
60% of cases. The dorsal system is technically simpler to
dissect than the plantar system, although it can sometimes
run deep between the first and second metatarsals, compli­
cating the dissection. The plantar system is slightly more
difficult to expose because it lies deeper and plantar foot
exposure is more tedious with a patient in supine position.
Dominant:  first dorsal metatarsal artery or plantar meta­
tarsal system
Length: first dorsal metatarsal 3 cm (range 3 cm to very
long if traced to the anterior tibial artery); plantar meta­
tarsal 2.5 cm (range 2–3 cm)
Diameter: first dorsal metatarsal 1 mm (range 0.5–3 mm);
plantar metatarsal 1 mm (range 0.5–3 mm)
If the first dorsal metatarsal artery is traced to the anterior
tibial artery, then the surgeon must be certain that the pos­
terior tibial artery can supply circulation to the foot. This
can be done with preoperative angiography or an Allen’s
test of the foot.
The dorsal and plantar arterial systems join just distal to
the transverse metatarsal ligament, in the first web space.
At this point, small digital arteries branch laterally and
medially. The branch going laterally becomes the medial
digital artery of the second toe. The branch going medially
at the first web space becomes the lateral digital artery of
the great toe.
Minor:  first dorsal metatarsal or plantar metatarsal system
When one system is dominant, the other is considered
the minor blood supply.
VENOUS DRAINAGE OF THE FLAP (Fig. 53.1)
Primary:  dorsal venous branches of the great saphenous
vein
Length: 3 cm (range 3 cm to as long as the saphenous vein
can be traced)
Diameter: 3 mm (range 3–6 mm)
Finding adequate venous drainage for the great toe or
second toe neurovascular island flap can be difficult at
times. Venous drainage is more prominent over the dorsum
of the foot and toes.
vein back to the saphenous system or a large branch and
use this thicker-walled system for venous drainage. Either
system is adequate to decompress the arterial inflow.
NERVES IN THE REGION (see Figs 13.7, 13.8, 13.11,
13.15, 13.16 and 13.19)
Sensory nerve supply to the plantar aspect of the foot and
toes comes from the posterior tibial nerve.
The medial side of the foot is supplied by the medial
plantar nerve, one of the branches of the posterior tibial
nerve, the other being the lateral plantar nerve. The medial
plantar nerve supplies sensation to the great toe, second,
third, and medial side of the fourth toe. The plantar digital
nerves lie just plantar to the digital arteries.
Figure 53.1  Cutaneous nerves and superficial veins of the foot.
1. Great saphenous vein; 2. superficial peroneal nerve; 3. medial
dorsal cutaneous nerve; 4. saphenous nerve; 5. intermediate dorsal
cutaneous nerve; 6. sural nerve; 7. extensor retinaculum; 8. lesser
saphenous vein; 9. dorsal cutaneous nerve to the second web space
and dorsum of great toe; 10. dorsal cutaneous nerve to the third web
space; 11. dorsomedial cutaneous nerve to the great toe; 12. dorsal
cutaneous nerve to the fourth web space; 13. deep peroneal nerve;
14. dorsal venous arch; 15. dorsal metatarsal veins.
1
2
3
5
7
6
8
10
12
15
14
13
11
9
4

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
arterial supply is plantar dominant. If we can hear the signal
distal to the base of the metatarsal and the level of the com­
municating arterial branch, then there will be a usable
dorsal arterial system. An arteriogram of the foot is unneces­
sary in most cases. We use a Doppler examination to assess
the dominance of the vascular system. A good signal on
either the plantar or dorsal side reassures the surgeon that
a viable system will be found on dissection. Arteriography
can be predictive but vasospasm in angiography of the lower
extremities is often present, limiting visualization. Intra-
arterial injection of a dilating agent can be useful. Magnetic
resonance angiography is a newer technique, but distal
vessels of small caliber can be difficult to assess. Our prefer­
ence is the pencil Doppler.
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 53.2 and Cases 53.1,
53.2 and 53.3)
The first metatarsal artery is located between the first and
second metatarsal bones.
FLAP MARKINGS AND GENERAL THOUGHTS ABOUT
FLAP DESIGN (Figs 53.4–53.6)
• The flap is designed as an oval with the long axis along
the midaxial line of the lateral aspect of the great toe.
If the surgeon wishes to use the second toe pulp, creating
a bilobed flap, or if the second toe donor is preferable
for whatever reason, marking of the oval on the medial
second toe can be performed.
• To achieve primary closure of the donor site, the flap
should not be any wider than 2 cm. If primary closure
cannot be completed, a small skin graft can be used, or
healing by secondary intention of the areas that have
excessive tension on closure is an option.
• The oval is usually 3–4 cm long.
• The dorsal side of the oval marking should be designed to
incorporate enough skin between the lateral nail margin
and the incision to get good suture purchase for skin
closure. Incision markings should continue proximally
from the proximal margin of the oval to the web space and
at that level should be extended both dorsally and in a
plantar direction to identify dorsal and plantar arteries.
• One can base a skin flap over the medial side of the second
toe based on the medial digital artery of the second toe
or a larger skin flap from the lateral side of the great toe
based on the medial digital artery of the great toe. The
medial digital artery of the great toe is small and some­
times from a lifetime of walking can be scarred.
• Venous drainage of the dorsum of the foot and toe should
be marked out preoperatively by having the patient hang
the leg over the bed or chair in a dependent position. In
this position, indelible ink should be used to mark veins,
especially looking for veins draining the lateral side of the
great toe.
• When the dorsal system is dominant, the dissection is
simpler. A longer pedicle can be included with the flap,
and a shorter incision is needed on the plantar surface
of the foot which diminishes rehabilitation time.
SPECIAL CONSIDERATIONS
The oval flap can be used to reconstruct a skin/soft tissue
defect in a finger. Taking the flap in combination with nail
Secondary:  venae comitantes of the first dorsal metatarsal
artery and proper digital arteries
Length: 3 cm (range 3–5 cm)
Diameter: 0.5 mm (range 0.25–3 mm)
Although extremely small, these veins can be preserved
and traced to superficial system branches. The superficial
system in continuity with the deep venae comitantes can
then be used for microsurgical repair and drainage. These
veins can be used as the only drainage system if they are
adequate in size for repair and have not been damaged by
dissection.
FLAP INNERVATION (Fig. 53.1 and Figs 13.8, 13.15
and 13.19)
Sensory:  the plantar digital nerve of the great toe supplies
the toe pulp. The plantar digital nerve of the second toe
supplies the second toe.
The plantar nerves lie just plantar to the digital artery.
The skin landmark is just plantar to the midaxial line of the
toe. When dissecting in the interspace between the great
and second toes, the nerve is usually first visualized and the
smaller digital artery can be found slightly dorsal to the
nerve.
FLAP COMPONENTS
The neurovascular island flap from the pulp of the great toe
is a sensory cutaneous flap of glabrous skin. Other compo­
nents can be added by expanding the flap to include nail,
bone, etc. (see Flap modifications, below.)
ADVANTAGES
• Excellent choice to replace glabrous skin loss of the
thumb or fingertips.
• If the flap is designed to be no wider than 2 cm, then the
donor site can be closed primarily. The donor site may
require a skin graft if the harvested flap is larger, thus
prolonging patient recovery considerably.
DISADVANTAGES
• Harvesting this flap can be technically demanding and
inset of the flaps requires microsurgical skills.
• The surgeon often needs to harvest a thick flap in order
to make sure that the artery is incorporated in the flap
dissection. Therefore the flap can often be bulky on the
thumb or finger and may require a second operation to
debulk it.
PREOPERATIVE PREPARATION
In general, we use the ipsilateral toe as the donor toe as this
lines up better when using the ulnar digital artery of the
thumb as a recipient artery. If the patient has had a trau­
matic injury to the foot or toe, then the surgeon should
consider using the contralateral toe.
A Doppler examination of the foot and toe will help
demonstrate whether the toe arterial supply is plantar or
dorsal dominant. We start by identifying the Doppler arte­
rial signal of the dorsalis pedis artery and follow the signal
distally. If the signal disappears at the level of the base of
the metatarsal, then we can often predict that the toe

CHAPTER 53 — Glabrous S kin Flaps
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In order to achieve primary closure, the flap width should
not exceed 2 cm. Using the second toe requires that less
width be harvested, because primary closure is more
difficult.
PATIENT POSITIONING
The patient is positioned supine with an arm table for the
injured arm and hand. A well-padded tourniquet is placed
on the thigh and the upper arm.
ANESTHETIC CONSIDERATIONS
We prefer general anesthesia since we are generally working
in two teams, on both the hand and the foot. A bupivacaine
block is performed at the foot and toe after the flap harvest
or in continuity with phalangeal bone can aid in recon­
struction of complex composite defects. If a secondary soft
tissue defect is present in the hand, this flap can be com­
bined with a dorsalis pedis or even an extensor brevis flap.
However, insetting and folding can be difficult and the
surgeon must be wary of kinking the vascular pedicles to a
chimeric flap.
FLAP DIMENSIONS
Skin Island Dimensions
Length: 3 cm (range 1–4 cm), maximum to close primarily:
4 cm
Width: 1.5 cm (range 1–2.5 cm), maximum to close primar­
ily: 2 cm
Figure 53.2  Anatomic landmarks. (A) Medial view. (B) Lateral view. (C) Dorsal view.
Lateral malleolus
Extensor
digitorum
longus tendons
Fibularis tertius tendon
Tibialis anterior
tendon
Extensor hallucis
longus tendon
Fibularis brevis tendon
Fibularis longus tendon
overlying fibularis
brevis tendon
Medial malleolus
Calcaneus
Flexor retinaculum
Flexor digitorum longus tendon
Tibialis posterior tendon
Flexor hallucis longus tendon
Tibial nerve
Tarsal tunnel
Posterior tibial artery
A
B
C

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
and extend the arterial pedicle with a vein graft between the
recipient artery and the plantar artery of the flap.
Once the plantar artery, vein, and nerve are identified
and dissected proximally, the rest of the incision can be
carried out, both dorsal and plantar around the previous
markings. Dissection of the flap should be carried out
through skin and subcutaneous tissue, identifying the major
branches that go into the skin from the lateral digital artery
supplying the flap. Sometimes the flap needs to be made
quite thick and dissection has to be carried out all the way
down to the distal phalanx of the toe. This can make for a
relatively bulky flap that may be more difficult to inset. Split-
thickness skin grafts are often necessary to adequately close
the recipient site at the thumb and to cover the pedicle.
Often, the flap does not have to be this bulky if we can
identify the small perforators going into the flap from the
digital artery. We can then ligate any other branches that
are deep to the arterial pedicle. This part of the dissection
can be very tedious and time-consuming, but is perhaps the
most critical portion of the dissection.
Once the flap is elevated and isolated on the neurovascu­
lar bundle, then the tourniquet is released. The flap should
become pink with arterial flow within a few minutes.
Once we are sure of adequate perfusion of the toe and
we see good capillary refill and flow out of the vein, we then
ligate the arterial artery, and then the vein, and then divide
the digital nerve.
SPECIAL INSTRUMENTS
Special instrumentation is not required for flap harvest or
inset unless bone is taken to make a composite flap. The
small area of bone and lack of rigidity in the toes make
osteotomes difficult to use and we therefore use a micro
air-oscillating saw. One must be very careful not to injure
the vascular pedicle.
FLAP MODIFICATIONS
• Web space flap
• Toe wrap-around flap
• Combined lateral aspect of great toe flap and medial
aspect of second toe flap
• Combined lateral great toe, web space, and medial second
toe flap.
DONOR SITE CLOSURE AND MANAGEMENT
We close the donor site with absorbable sutures in the space
between the toes since non-absorbable sutures are difficult
to remove in this area. Non-absorbable sutures can be used
in the plantar and dorsal foot. A dry dressing is placed and
no splinting is required. The patient must be non-weight-
bearing on the surgical site for 3 weeks. Special shoes can
be made for bearing of the weight on the heels if the patient
feels they cannot walk on their heel and avoid digital
pressure.
If the donor site is closed under tension and capillary
refill of the toe appears to be affected, i.e. the toe is ischemic
or poorly perfused, sutures are removed until the toe
becomes pink, and a skin graft is placed.
and closure for postoperative pain control. The block is
performed by infiltrating adjacent to the superficial and
deep peroneal branches on the dorsum, at the proximal
plantar wound subcutaneously, and adjacent to the digital
nerves. A block can be performed of the median and ulnar
nerves at the wrist if necessary, but we are very careful not
to inadvertently injure the recipient artery or vein. We have
not performed this procedure under regional block.
TECHNIQUE OF FLAP HARVEST (see Cases 53.1
and 53.3)
With the patient successfully anesthetized, if the recipient
site is in the hand or contralateral foot, two operative teams
work simultaneously, one team at the foot and one at the
recipient site. At the hand, the operative team dissects out
the recipient nerve, artery, and vein. Usually, there are abun­
dant veins on the dorsum of the thumb and hand. The
arterial blood supply usually is the ulnar digital artery; if this
is not available, then the incision is extended proximally to
the dorsal radial artery at the anatomic snuff box. The nerve
should be the ulnar digital nerve of the thumb in recon­
struction of thumb pulp. If this is not available, nerve grafts
or transfer of the radial digital or distal dorsal radial nerve
may be necessary.
At the foot, the second operative team makes the appro­
priate skin markings as described earlier. The first incision
should be near the proximal end of the marked oval flap,
extending proximally to find any small tributaries in the
subcutaneous tissue that may drain from the flap area. In
so doing, if there is inadequate venous drainage in that area,
then the position of the oval may need to be altered to
extend more dorsally. Once the venous tributaries are iden­
tified, then dissection can be carried out more proximally,
identifying the major draining vein. The dissection can be
extended proximally onto the dorsum of the foot if venous
length is necessary. By this time, the surgical team at the
hand should be able to determine the length of vein needed
there. Once the vein has been identified, an incision con­
tinues into the web space and dissection is taken down
through skin and subcutaneous tissue into the web space,
identifying the lateral digital nerve to the great toe. This
usually is on the plantar side of the digital artery. Once the
digital nerve is identified, the artery supplying the toe will
then be identified, and dissection of the artery is carried out
proximally until we find communication between the dorsal
and plantar systems. We also identify the medial digital
artery of the second toe; eventually this branch to the
second toe will be ligated and divided.
Care is taken at this juncture to identify either a plantar-
dominant or a dorsal-dominant arterial system. If there is a
dorsal-dominant system, then dissection is carried out proxi­
mally to whatever length is needed at the hand. As stated
previously, approximately 40% of the time, we are not able
to use the dorsal system, in which case we must carry out our
incision more onto the plantar surface of the foot in between
the first and second metatarsals, and dissect the plantar
artery through this area. Dissection of the plantar digital
artery can be tedious as often it will be encased in firm tissue
at the level of the sesamoid over the metatarsal head. If a
long arterial pedicle is needed and dissection of the plantar
digital artery is difficult, we may just ligate the plantar artery

CHAPTER 53 — Glabrous S kin Flaps
e181
circulation has been established. The wounds are then
closed relatively loosely.
We are liberal with the use of STSG, even over the pedicle.
We use a venous Doppler probe on the outflow vein to
determine if there is an inflow and outflow circuit estab­
lished into the flap. We have seen several of these neurovas­
cular island flaps take a few days to become fully pink. There
may be some arterial venous shunting that takes place early
on after the microvascular anastomosis is completed.
The donor site is closed in layers. Because of the tightness
of the skin closure, the toe will actually look pale for the
first day or so. If the closure is so tight that there is no flow
to the toe, we suggest placing a skin graft and then, at a later
date, approximately 6 months postoperatively, resecting the
skin graft and trying to close the wound secondarily, if the
patient wishes.
Soft tissue defects on the thumb or fingertips, where sen­
sation is important and glabrous skin has been lost, are ideal
for this type of reconstruction. We ensure that the recipient
area is clean and free of debris or any sign of infection. In
cases of tumor resection, reconstruction can be performed
immediately, if it is certain that tumor margins will be free.
If margins are pending, the hand/finger wound can be
addressed and reconstructed when permanent sections
have established clear margins.
Technique
Under tourniquet control, the reconstruction is begun by
finding a suitable recipient artery, usually a digital artery,
princeps pollicis in case of the thumb or a common digital
artery. The artery should be out of the zone of injury and
free from significant trauma. Flow can be checked when the
tourniquet has been released. A vessel that freely squirts
blood from the lumen in a pulsatile fashion is considered
adequate.
The digital nerve is found, preferably outside the scar
bed. It is transected and bulging fascicles are found. The
digital nerve adjacent to the artery is typically used. The
hand is turned over and a dorsal vein on the finger or more
proximally is found outside the zone of injury. The size of
the vein should be compatible with the toe vein or slightly
larger.
When the donor is ready, it is brought into the field and
partially inset. This allows the arterial pedicle, nerve, and
vein to be aligned for repair. After repair under the micro­
scope, the wound is closed. If closure is tight, a skin graft is
used so as not to compromise arterial inflow or venous
drainage.
MEDIAL PLANTAR FLAP
FLAP ANATOMY (Figs 53.1, 53.7, 13.11, 13.15, 13.16,
13.17, 13.19)
ARTERIAL SUPPLY OF THE FLAP (Figs 13.11, 13.15,
13.16, 13.17 and 13.19)
The medial plantar flap is perfused by the perforators of
the medial plantar artery that penetrate the intermuscular
septum between the abductor hallucis and flexor digitorum
brevis to supply the medial plantar skin.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
• Care must be taken immediately after skin incision to
find the small venous tributaries that drain the lateral or
medial aspect of the great toe or second toe, respectively.
• We generally use papaverine liberally over the area, espe­
cially the arterial side, to reduce any segmental spasm. If
spasm is not reversible by papaverine, then we look for
side branches that have not been clipped or tied off.
These may be a source of spasm.
• Care must be taken to include a vein that drains the toe
pulp flap during the initial dissection of the flap.
FLAP USAGE
PEDICLED
A neurovascular island flap from the great toe pulp is almost
always used for reconstruction of lost pulp from the thumb
or fingertips. We have also used this as a pedicled flap for
closure of wounds over the plantar surface of the foot over
the metatarsal head. The arc of rotation can reach both the
first and second plantar metatarsal regions.
If considering this as a donor to a foot wound in a patient
with a chronic non-healing wound, be aware that, if a local
wound cannot heal, it may be that the toe will not heal
either.
FREE FLAP
• Thumb pulp reconstruction: the skin, pulp, artery, vein,
and nerve must be used.
• Finger pulp reconstruction: the skin, pulp, artery, vein,
and nerve must be used.
• Palmar, thenar, or hypothenar defects: the nerve need not
be used if no recipient area nerve is available.
We do not use this flap in the lower extremity, trunk, or
head and neck region.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Toe Pulp for Volar Thumb Reconstruction
At the hand, the operative team dissects out the recipient
nerve, artery, and vein. Usually, there are abundant veins on
the dorsum of the thumb and hand. The arterial blood
supply usually is the ulnar digital artery, but, if this is not
available, then the incision is extended proximally to the
dorsal radial artery at the anatomic snuff box. The nerve
should be the ulnar digital nerve of the thumb in recon­
struction of thumb pulp. If this is not available, nerve grafts
or transfer of the radial digital or distal dorsal radial nerve
may be necessary.
The flap is dissected as described and the flap is then
brought to the recipient field, where it is then inset with
some loose tacking stitches. The artery is then repaired
either end-to-end with the digital artery or end-to-side or
end-to-end with the dorsal radial artery at the anatomic
snuffbox, using the operating room microscope and either
9 or 10-0 nylon.
The vein is then repaired end-to-end to a branch of the
cephalic vein. The digital nerve is usually repaired after

e182
PART 4 — CONVENTIONAL WORKHORSE FLAPS
should be marked out preoperatively by having the patient
hang the leg over the bed or chair in a dependent position
or with a venepuncture-type tourniquet.
FLAP DESIGN
ANATOMIC LANDMARKS (Figs 52.2, 52.3, 53.7C and D)
In Figure 53.7D, the medial cuneiform plantar surface
marks the site of the perforator, right near the midpoint of
the bone. Doppler examination confirms the presence of
the perforator. The plantar edge of the first metatarsal, first
cuneiform, and navicular is palpated and used as the axis of
the flap.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The flap is designed as an oval along this axis, with the
perforator arising about one-third of the distance between
the medial malleolus and the medial aspect of the first
metatarsal head. To achieve primary closure of the donor
site, the flap should not be any wider than 2 cm. The oval
can be up to 7 or 8 cm long. The perforator is identified
with a pencil Doppler and the dorsal-plantar dimension of
the flap is centered on this perforator.
When defects are larger, the medial plantar flap can fill
a recipient area that is too large to fill with a great toe pulp.
SPECIAL CONSIDERATIONS
Defects that result in loss of the palmar surface of the fingers
or hand, if not too large, can be reconstructed with this flap.
Because the flap can be only 2 cm wide, very large defects
cannot be covered, but an entire volar finger or narrow
palm defect is an excellent indication.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
If the flap is to be used in a pedicled fashion to cover local
defects, some changes in flap design are needed. The arte­
rial pedicle length is very short and does not allow signifi­
cant motion in plantar, dorsal, proximal, or distal dimensions,
even with the medial plantar artery traced and transected
distal to the perforator. For this reason, use of the flap as a
rotation flap necessitates designing the oval skin paddle
with the perforator proximally based in the oval for rotation
to proximal defects. Conversely, the perforator can be
placed at the distal oval for rotating the proximal flap tip
into more distal defects.
FLAP DIMENSIONS
Skin Island Dimensions
Length: 7.5 cm (range 7–8 cm), maximum to close primar­
ily: 8 cm
Width: 2 cm (range 1.5–2 cm), maximum to close primarily:
2 cm
Thickness: 1.5 cm (range 1.5–2 cm)
FLAP MARKINGS (Fig. 53.3 and 53.7C)
The flap is marked along the axis of the plantar first meta­
tarsal and first cuneiform. For a free flap it is centered
around the perforators (blue on Fig. 53.3) as found by the
Doppler. It can be marked eccentrically for local rotation
(green and red).
Dominant:  medial plantar perforator from medial plantar
artery
Length: 1 cm (range 1–1.5 cm)
Diameter: 1 mm (range 0.5–1.5 mm)
The perforating branch that supplies this flap arises from
the medial plantar artery at the level of the plantar first
cuneiform and along the axis of an imaginary line running
parallel to the plantar aspect of the first cuneiform and the
plantar first metatarsal.
VENOUS DRAINAGE OF THE FLAP (see Figs 53.1
and 13.19)
Primary:  venae comitantes of the medial plantar artery
Length: 1 cm (range 1–1.5 cm)
These vessels are traced back to a large branch of the
medial plantar system to allow for the size necessary for
microsurgical repair.
Secondary:  superficial vein(s) draining to the saphenous
vein
Length: 2 cm (range 2 cm to very long with the saphenous
system)
Diameter: 1.5 mm (range 1–3 mm)
We prefer this larger system for venous drainage.
FLAP INNERVATION (Fig. 53.1, see Figs 13.11, 13.15,
13.16 and 13.19)
Sensory:  Medial plantar or saphenous branch (if present).
Because this flap does not have a specific well-defined and
consistent nerve supply, it is transplanted without nerve
repair. If a large branch of these nerves is found, it can be
transplanted with the flap.
Motor:  This flap is not harvested with muscle.
FLAP COMPONENTS
The medial plantar perforator flap is a cutaneous flap of
glabrous skin.
ADVANTAGES
The medial plantar flap can be up to 7 cm long and 2 cm
wide, providing a large surface area, larger than that of the
great toe pulp.
DISADVANTAGES
The medial plantar flap closure can be tight if harvested
more than 2 cm wide, making healing of the donor site slow.
The donor area may need a STSG if closure is judged to be
too tight.
PREOPERATIVE PREPARATION
The ipsilateral or contralateral foot can be used, depending
on recipient anatomy and patient or surgeon preference.
Venous drainage of the medial plantar aspect of the foot

CHAPTER 53 — Glabrous S kin Flaps
e183
Once the flap is elevated and isolated, then the tourni­
quet is deflated. The flap should become pink with arterial
flow within a few minutes. We generally use papaverine
liberally over the area, especially the arterial side, to reduce
any segmental spasm.
The flap is allowed to perfuse for approximately 20 min
and then the vessels are ligated and divided. The flap is
brought to the recipient field, where it is then inset with
some loose tacking stitches.
As with the toe pulp flap, we are liberal with the use of
split-thickness skin grafts, even over the pedicle. A venous
Doppler probe or pencil Doppler can be used to monitor
the flap.
The donor site is closed with simple skin sutures. We do
not typically splint the foot, but the patient is required to
keep it elevated and does not bear weight until the skin is
well healed.
FLAP USAGE
PEDICLED
The flap can be used to close small defects around the
medial malleolus, distal medial foot or medial first metatar­
sal head. Calcaneal defects are hard to reach unless the flap
can be traced to the posterior tibial artery.
FREE FLAP
Indications for this flap are volar wounds of the entire finger
or thumb and small palmar defects ≤2 cm wide.
It is not indicated in the head and neck or trunk.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Medial Plantar Free Flap for Reconstruction of
a Hand Defect
The hand defect should be clean and free of infection.
Tumor defects must have clear margins. A two-team setting
is preferred, with the hand recipient area preparation taking
place while the flap is harvested. The defect on the finger
or hand is extended proximally to isolate a proximal artery
and nerve, if one is present in the flap. The artery must be
adjacent to the wound because of the short pedicle length
or vein grafts will be needed. Because venae comitantes
in the hand are quite small, a dorsal hand vein is used
for drainage. For finger defects, this can be from a dorsal
digital vein extended proximally and transposed volarly if
needed. For hand defects, a dorsal hand vein in the radial
or ulnar aspect of the hand will be needed, depending on
the defect.
We partially inset the flap in the hand after harvesting so
that our pedicle orientation and draping is mapped out.
The artery and vein are then repaired under the micro­
scope. Skin grafts are used liberally to avoid tight closure.
POSTOPERATIVE CARE
GENERAL
The hand is splinted and the skin paddle is monitored for
color, capillary refill, and Doppler signal. Close monitoring
of the flap is necessary for the first 5 days. Patients are
PATIENT POSITIONING
The patient is positioned in a supine position with an arm
table for the injured arm and hand. A well-padded tourni­
quet is placed on the thigh and the upper arm so that the
flap and recipient area are both adequately exposed.
ANESTHETIC CONSIDERATIONS
We prefer general anesthesia, since we generally work in two
teams, on both the hand and the foot. A bupivacaine block
is performed at the foot for postoperative pain control. A
block can be performed of the median and ulnar nerves at
the wrist if necessary; however, we are very careful not to
inadvertently injure the recipient artery or vein.
TECHNIQUE OF FLAP HARVEST (see also Case 53.4)
With the patient successfully anesthetized, two operative
teams work simultaneously, one team at the foot and one at
the hand. At the hand, the operative team dissects out the
recipient artery and vein and nerve if nerve coaptation is
planned.
At the foot, the second operative team makes the appro­
priate skin markings as described earlier. The first incision
is made at the plantar aspect of the flap. The fascia over the
abductor hallucis is entered and the flap is raised from
plantar to dorsal. Perforators between the abductor hallucis
and flexor hallucis tendon are identified and preserved.
The abductor hallucis muscle is retracted and the perfora­
tors are followed to their origin on the medial plantar
system. With deep retraction, the medial plantar vessel is
exposed in the intermuscular space. When adequate vessel
length and caliber are gained, the dissection of the donor
arterial system is ended. The superficial venous system can
be traced when the dorsal incision is made. This system can
be traced back to the saphenous vein and a cutaneous nerve
can be incorporated and traced proximally if necessary. A
pedicle length of up to 3 cm can be achieved. We prefer to
use the cutaneous vein for venous drainage because its size
and caliber make microanastomosis straightforward.
Figure 53.3  Flap markings. For a free flap the mark is centered
around the perforators (blue). Flap marked eccentrically for local rota­
tion (green, red).

e184
PART 4 — CONVENTIONAL WORKHORSE FLAPS
UNTOWARD OUTCOMES
GENERAL
Untoward outcomes are uncommon.
THUMB PULP RECONSTRUCTION WITH TOE PULP FLAPS
In some instances, the sensory return to the flap is minimal
or non-existent. In those cases, a clinical decision has to be
made to explore the nerve repair site. If there is a strong
Tinel’s sign at the level of the nerve repair that has not
advanced along the track of the nerve to the flap, then we
can assume there is something wrong with the nerve repair.
At this juncture, the nerve repair site needs to be resected
and a small interpositional nerve graft placed. This usually
occurs because the nerve has been repaired under tension
or a damaged recipient nerve was repaired to the lateral
digital nerve of the flap.
DONOR SITE
At the donor site, there may be problems with wound
healing because of the tight closure and lack of artery blood
supply to that portion of the toe. In such instances, the
wound on the lateral aspect of the toe may heal by second­
ary intention or with a small skin graft. At 6 months postop­
eratively, the skin graft will have contracted and can be
resected and closure again attempted.
LONG-TERM OUTCOMES
The expected nerve recovery is comparable with any nerve
repair. This is very age dependent: young patients usually
regain sensation to 2–3 mm of two-point discrimination,
while patients over the age of 60 may only regain protective
sensation.
CONCLUSIONS
Glabrous skin can be successfully transplanted from the toe
or instep of the foot to the hand or palm to reconstruct
defects of this specialized skin. Sensory return should be
obtained from the microneurorrhaphy. Although these flaps
are technically demanding, the results are worth the effort.
usually hospitalized throughout this time and kept in bed.
We generally use low-molecular-weight dextran as an antico­
agulant (25 mL/h). If poor inflow to the flap is noted, the
patient’s sutures are removed and the pedicle is bathed in
papaverine to try and reverse any spasm. If this does not
improve, then the patient is returned to the operating room
and the arterial and/or venous anastomosis is examined. We
also use fluorescein washout technique to identify inflow
and outflow. Specialized nurses should be trained in evaluat­
ing microsurgical cases to look for capillary refill, turgor,
color, and temperature.
The hand is splinted throughout the first 2–3 weeks to
prevent any kinking of the vascular pedicle. Dressings are
not changed until approximately the 5th postoperative day,
unless they are saturated with blood. The operative splint is
then removed and the hand therapists will design a custom-
made Orthoplast splint for the patient to take home.
DONOR SITE
The donor area is closed with non-absorbable sutures that
are removed after 2 weeks. Tight closure may indicate the
need for skin grafting. The patient is instructed to avoid
weightbearing on this area for 3 weeks and to keep the foot
elevated as much as possible.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
In general, if the flap circulation is maintained for 5 days,
we expect the flap to survive. We have had patients who go
home and unfortunately smoke tobacco and develop prob­
lems with arterial inflow, resulting in lost flaps, replants, etc.
We try to have the patients avoid any vasoconstricting
medications.
DONOR SITE
The donor site can suffer from wound breakdown in smokers
or patients who are not careful. Local wound care is then
undertaken.

CHAPTER 53 — Glabrous S kin Flaps
e185
Figure 53.4  Case 53.1 (A–F).
The vascular anatomy of the neurovascular island flap of the
lateral aspect of the great toe is depicted from the dorsal view
(Fig. 53.4A). The distal phalanx and pulp of the right thumb
have been resurfaced with an abdominal tube after an avulsive
injury. The pad was insensate, floppy, and subject to constant
trauma (Fig. 53.4B). A neurovascular island flap of toe pulp is
designed from the lateral aspect of the large toe, carrying the
digital artery and nerve and a dorsal vein (Fig. 53.4C). The large
island flap from half of the toe is completely isolated on the
neurovascular pedicle (Fig. 53.4D). Figure 53.4E shows the toe
pulp flap ready to be transplanted. The sensory island flap has
been used to resurface the entire volar tactile surface of the
thumb, coapting the digital nerve from the lateral side of the toe
to the ulnar digital nerve of the thumb, re-establishing normal
cortical orientation to the sensory pinch area of the thumb (Fig.
53.4F). Good, solid pulp-to-pulp pinch of normal consistency has
been re-established by replacing the floppy, insensate abdominal
skin with glabrous skin from the toe.
CASE 53.1  Distal Phalanx and Pulp of the Thumb Resurfaced with a Free Great Toe
Pulp Flap
A
Proper digital
artery
Common digital
artery
Common digital
nerve
Neurovascular
island
B
C
D
E
F

e186
PART 4 — CONVENTIONAL WORKHORSE FLAPS
The groin flap coverage of the thumb is floppy, insensate, and
unaesthetic (Fig. 53.5B). A large glabrous skin flap from the
lateral aspect of the great toe extends from the midline to the
nail margin and is mobilized on a dorsal pedicle (Fig. 53.5A).
The lateral plantar nerve innervates the island. The entire
palmar tactile area of the thumb has been replaced with the
physiologically similar tissue from the toe (Fig. 53.5C).
CASE 53.2  Thumb Pulp Defect Reconstructed with a Free Great Toe Pulp Flap
A
B
C
Figure 53.5  Case 53.2 (A–C).

CHAPTER 53 — Glabrous S kin Flaps
e187
This 30-year-old man suffered a traumatic avulsion amputation
of the right thumb. The replantation was successful (Fig. 53.6A),
but sensation did not return since the nerves were avulsed from
the median nerve at the carpal tunnel. To restore sensation, a
great toe pulp neurovascular island flap was selected. The donor
area of the lateral plantar toe was marked with a template made
from a sterile Esmarch bandage (Fig. 53.6B; inset photo). The
template was designed from the thumb recipient area that
required resurfacing. The thumb recipient area was dissected.
Because there was an avulsion injury, there was no ulnar digital
artery for the thumb. The radial digital artery to the index finger
was dissected free and was transposed to supply inflow to the flap
(Fig. 53.6C). The dorsal hand proximal to the thumb was dis-
sected. The upper vessel loop is tagging a draining vein and the
lower vessel loop is tagging a dorsal radial nerve branch (Fig.
53.6D). The dorsal radial nerve branch was used to supply sensa-
tion to the flap, since the initial avulsion amputation caused loss
of digital nerves to the thumb. The toe has a dorsal-dominant
arterial supply and the nerve hook is wrapped around the arte-
rial branch to the second toe to illustrate its course (Fig. 53.6E).
The neurovascular island flap has been dissected free and the
tourniquet deflated. The upper right arrow illustrates the digital
nerve to the flap. The lower Weck sponge sits under the artery
and the upper Weck sponge sits under the draining vein (Fig.
53.6F).
The flap has been removed from the donor area, and the
artery, vein, and nerve and their lengths have been labeled and
placed next to the recipient area (Fig. 53.6G). The dorsal (left)
donor site and plantar (right) donor site are both closed (Fig.
53.6H). The flap has been inset into the thumb and the micro-
surgical repairs have been performed (Fig. 53.6I). After 9 months
the flap is well healed (Fig. 53.6J) and hand range of motion is
excellent. The patient developed light touch sensation to the
flap. The donor site is well healed at 9 months (Fig. 53.6K).
CASE 53.3  Insensate Thumb Pulp Reconstructed with a Free Great Toe Pulp Flap
A
B
C
E
F
G
H
I
J
K
D
Figure 53.6  Case 53.3 (A–K).

e188
PART 4 — CONVENTIONAL WORKHORSE FLAPS
The vascular anatomy of the medial plantar flap and foot is
depicted from the medial view (Fig. 13.17). The medial plantar
perforator is seen arising from the medial plantar artery at the
level of the first cuneiform. A 40-year-old man suffered a crush
injury to his long finger. The volar skin of the proximal and
middle phalanges became necrotic, as did the distal phalanx,
requiring debridement (Fig. 53.7A). After debridement, the
flexor tendons, bone and dorsal soft tissues of the long finger
are intact from the level of the midphalanx proximally. The
wound is clean and a vessel loop is tagging a common digital
artery (Fig. 53.7B). The medial plantar flap is designed on the
axis of the plantar surface of the first metatarsal. A Doppler probe
was used to find the perforator, marked with an ‘X’, adjacent to
the first cuneiform bone (Fig. 53.7C). The plantar incision is
made and the flap is elevated superiorly, off the abductor brevis
muscle. The perforator is visible, coursing over the flexor hallucis
tendon (Fig. 53.7D).
The superior incision is made and the vein draining into the
saphenous system is preserved while the flap is isolated on the
medial plantar perforator (Fig. 53.7E). The flap is isolated on
the arterial pedicle and the venae comitantes. The saphenous
vein branch is also isolated with a saphenous nerve to innervate
the flap (Fig. 53.7F). The flap is inset on the finger. Inflow is
provided by a common digital artery and outflow is established
via a dorsal vein. The digital nerves are repaired to the saphe-
nous nerve branch (Fig. 53.7G). The flap shown at 6 weeks after
surgery (Fig. 53.7H).
CASE 53.4  Volar Middle Finger Defect Reconstructed with a Free Medial Plantar Flap
Figure 53.7  Case 53.4 (A–H).
A
B
C
D
E
F
G
H
Expert Commentary 
Mohammad M. Al-Qattan MBBS
The chapter discusses two flaps (toe pulp and instep flaps) for
hand reconstruction. The hand is a special organ and dictates
that function takes priority over cosmetics.
The toe-pulp free flap is the workhorse of major thumb pulp
defects not only because of its “like with like” replacement but
also because of the expected regain of good sensibility. The
authors have summarized the anatomy and technique well and
gave classic clinical examples.
In the second part of the chapter, the authors describe the
use of instep free flaps in digital reconstruction. This flap is not
commonly used in digital defects because regain of sensibility
is generally poor. Hence, one reasonable indication for using
this flap in hand reconstruction is major first web and palmar
contractures because sensory recovery is not critical. This chapter
on glabrous skin flaps deals with both free and pedicle flaps. The
technique of the instep pedicle flap for heel reconstruction is a
common indication and is often utilized for this purpose. The use
of instep flaps for heel reconstruction should include a branch of
the medial plantar nerve to provide sensibility. In a situation where
the defect includes both the weightbearing heel and the instep
area, the ipsilateral pedicle flap is not available. Here, the contra-
lateral instep free flap can be used for heel reconstruction. Paget
et al. recently studied gait and pressure analysis and demon-
strated a significant donor site morbidity of the instep flap. The
instep flap can also be used as an arterialized venous flap.
Another Glabrous skin flap is the foot web free flap, which is
frequently used for reconstruction of hand webs.

CHAPTER 53 — Glabrous S kin Flaps
e189
FURTHER READING
Buncke HJ. Great toe transplantation. In: Buncke HJ, editor. Microsur­
gical transplantation – an atlas-text. Philadelphia, PA: Lea and
Febiger; 1991.
Buncke HJ, Alpert BS. Neurovascular island and heterotopic transplan­
tation. In: Buncke HJ, editor. Microsurgical transplantation – an
atlas-text. Philadelphia, PA: Lea and Febiger; 1991.
Koshima I, Urushibara K, Inagawa K, et al. Free medial plantar perfora­
tor flaps for the resurfacing of finger and foot defects. Plast Reconstr
Surg 2001;107:1753–8.
Lai CH, Lai CS, Huang SH, et al. Free medial plantar artery perforator
flaps for the resurfacing of thumb defects. Ann Plast Surg 2010;
65(6):535–40.
Sohn WI, Jung SN, Kim SW, et al. Reconstruction of fingertip defects
with great toe pulp grafts. Ann Plast Surg 2012;68(6):579–82.
Siddiqi MA, Hafeez K, Cheema TA, et al. The medial plantar artery
flap: a series of cases over 14 years. J Foot Ankle Surg 2012;51(6):
790–4.
Yang D, Yang JF, Morris SF, et al. Medial plantar artery perforator flap
for soft-tissue reconstruction of the heel. Ann Plast Surg 2011;
67(3):294–8.

613
Toe Flaps and Toe
Transplantation
Chih-Hung Lin  |  Paolo Sassu
54 
Figure 54.1  Toe flap.
Second toe
Arcurate artery
Dorsal
metatarsal
arteries
Dorsal
interosseus
muscles
Common
digital
branches of
superficial
fibular nerve
Extensor
digitorum
longus
tendons
Extensor hallucis
longus tendon
Dorsal nerves
Plantar nerves
Extensor tendon
Flexor tendon
Cut ends from
medial branch
of deep fibular
(peroneal) nerve
Extensor hallucis
brevis
Dorsalis pedis
artery
Lateral tarsal
artery
Anterior tibial
artery
Deep fibular
(peroneal) nerve
Branches of
superficial
fibular nerve
Lateral dorsal
cutaneous nerve
Medial tarsal
artery
First dorsal
metatarsal artery
INTRODUCTION
It is thanks to the illustrious Austrian surgeon, Carl Nicola­
doni that the foot began to be considered as a precious
warehouse for all requirements of thumb and digital recon­
struction. In his three papers (1897, 1900, 1903), he
described the use of pedicled toe transplantation as a valid
option for reconstruction of missing digits, rather than sac­
rificing viable tissue in an already injured hand. The obvious
inconvenience of attaching the hand to the foot for several
weeks limited the popularity of this technique. Between the
1960s and 1970s, encouraged by the advent of the microsur­
gical era, brilliant surgeons such as Harry Buncke, Yang
Dongyue, and John Cobbett illustrated experimentally, and
applied clinically, the first microsurgical toe transplanta­
tions. Subsequently, the functional and aesthetic innova­
tions by Morrison with the wrap-around toe, Wei with the
trimmed great toe transfer, and many others rendered this
procedure a safe and reliable first choice in the reconstruc­
tive ladder of hand trauma.
FLAP ANATOMY (see Figure 54.1, Figs 13.7,
13.8, 13.11, 13.15, 13.17, 13.19)
The metatarsophalangeal (MTP) joint of the great and
lesser toes has a wider range of motion in extension than
flexion. The interphalangeal (IP) joint of the great toe
allows a slight extension of about 12° and a wider flexion of
about 46°, whereas the proximal and distal interphalangeal
joints of the lesser toes do not allow for any extension.
The principal function of the toes has been described as
the capacity to oppose efficiently against the ground reac­
tion force in the late stance phase of the gait cycle. In this
part of the gait cycle, in fact, the metatarsophalangeal joints
of the toes are passively led to 70–90° of dorsiflexion, as a
consequence of the forward progression of the body while
walking. The toes oppose such movement by means of a
passive and active mechanism. The former is related to the
plantar aponeurosis and the latter to the extrinsic and
intrinsic musculature. The plantar aponeurosis extends
from the os calcis to the base of the first phalanx of the toes,
as well as the sesamoid bones. Its main function is related
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION G  —  LOCAL AND FREE FLAPS IN THE LOWER EXTREMITY

614
PART 4 — CONVENTIONAL WORKHORSE FLAPS
ISOLATED THIRD TOE, COMBINED THIRD AND
FOURTH TOE FLAPS
Dominant:  second plantar metatarsal artery
The dorsal metatarsal arteries arise in 86% of cases from
the arcuate artery, which is a lateral branch of the dorsalis
pedis artery. The arcuate artery is absent in more than 40%
of cases. Its absence does not preclude the transfer.
Minor:  second dorsal and third plantar or dorsal metatar­
sal arteries
The vessel is selected according to the intraoperative find­
ings and the surgical plan.
VENOUS DRAINAGE OF THE FLAP
(see Fig. 13.19)
Primary:  the dorsal superficial venous arch and its medial
continuation into the great saphenous vein represent the
primary venous drainage in most variations of toe flaps.
Secondary:  venae comitantes of the FDMA and FPMA
present a much smaller caliber than the great saphenous
vein and they are rarely employed.
Nonetheless, they offer a valuable alternative in the post­
operative treatment of venous engorgement.
FLAP INNERVATION (see Figure 54.1, Figs 13.8,
13.11, 13.15, 13.19)
Sensory:  plantar digital nerves are of fundamental impor­
tance in the recovery of pulp sensation.
They must be harvested in great toe, second toe, isolated
third toe, and combined second and third, and third and
fourth toe transfers. Branches of the superficial peroneal
nerve are included in combined toe transfer and isolated
third toe transfer. In great and second toe transfers, these
branches are not necessarily included since the first web
space is supplied mainly by the deep peroneal nerve.
The deep peroneal nerve is distributed to the first web
space. Either the medial or lateral branch should always be
included in great toe (both trimmed and wrap-around) and
second toe transfers.
Even in the absence of valuable sensory branches of the
radial nerve in the recipient hand, we still include the dorsal
sensory branches from the donor foot and coapt them to
the proper digital nerves available in the donor finger.
FLAP COMPONENTS
A wide variety of combinations give the opportunity to plan
a custom-made transfer that best adapts to specific situa­
tions. The most utilized flaps are the great toe, which allows
the whole great toe transfers, the trimmed toe technique,
and the wrap-around technique; the second toe, which
allows the whole or extended second toe transfers, the wrap-
around second toe, and vascularized joint transfers from
either the metatarsophalangeal or proximal interphalan­
geal joint; the third toe transfer; combined second–third
and third–fourth toe transfers; and the neurosensory free
flaps, which include pulp transfer and first web flap. These
to the windlass effect mostly present under the first and
second metatarsal rays, where this fibrous band guarantees
the maintenance of the medial longitudinal arch of the foot.
The intrinsic musculature inserts on the base of the first
phalanx of the toes and, in the great toe, on the sesamoid
bones. They participate in providing a good foothold by
active pressure against the ground. The extrinsic muscula­
ture of the toes is represented by the flexor and extensor
hallucis longus and flexor and extensor digitorum longus
of the lesser toes. These muscles work in synergy with both
ankle plantar- and dorsiflexors, balancing the forward pro­
gression of the tibia, especially in running and jogging.
Harvesting of the great or lesser toes implies the interrup­
tion of one or more of these anatomic structures, which can
lead to flattening of the foot, modification of the pressure
distribution beneath the foot during the gait, and conse­
quent callus formation under the remaining metatarsal
heads.
ARTERIAL SUPPLY OF THE FLAP (see Figure 54.1,
Figs 13.7, 13.15, 13.17)
Toe transfer can be based on the dorsal arterial system,
mainly provided by the dorsalis pedis artery and its terminal
branches, or on the plantar arterial system formed by the
plantar metatarsal arteries.
GREAT TOE, SECOND TOE, AND COMBINED
SECOND AND THIRD TOE FLAPS
Dominant:  first dorsal metatarsal artery (FDMA)
Length: 5 cm (range 4–6 cm)
Diameter: 1.3 mm (range 0.6–2.4 mm)
In about 70% of cases, the FDMA is bigger than the first
plantar metatarsal artery (FPMA). The dissection of the
FDMA, whether lying superficial or in the context of the
interosseous muscle, is usually straightforward. An increased
vascular diameter can be obtained by proceeding directly
into the larger dorsalis pedis artery.
The proper plantar digital arteries are the effective blood
source to the great toe, second toe, and combined second
and third toe transfer. Their origin is the distal perforating
artery, which connects the FDMA and FPMA distally.
Minor:  first plantar metatarsal artery (FPMA)
Length: 5 cm (range 4–6 cm)
Diameter: 1.5 mm (range 0.6–3.0 mm)
If the FDMA is absent, or of a small caliber, the FPMA is
the second choice. Because of its course in the deep com­
partments of the foot, the dissection usually proceeds until
the midshaft of the first metatarsal bone. If necessary, an
increased length can be obtained by vein graft. In about
20% of cases this artery is dissected as a dominant vascular
source since the FDMA is absent or of inadequate caliber.
Despite the dominance of the FDMA or the FPMA, the
plantar proper digital arteries are the effective vascular
source for great toe, second toe, and combined second and
third toe transfers. In 10% of cases, the FDMA and FPMA
have a similar diameter, in which case the former is used as
a dominant pedicle since it is easier to dissect.

CHAPTER 54 — Toe Flaps and Toe Transplantation
615
and FPMA can be evaluated with the same method, but not
much information is provided related to their exact course
in the context of the interosseous muscles. Angiographic
assessment of the vascular tree of the foot is not routinely
necessary, unless congenital pathologies, previous traumas,
or arteriosclerosis would suggest a likely unreliability of the
arterial system. Direct visualization of the arterial system by
retrograde dissection from the first web space is an invalu­
able method to appreciate the exact vascular pattern,
whether dorsal or plantar dominant.
RECIPIENT SITE
In trauma cases, the loss of tissue is preferably covered
before the transfer by a pedicled groin flap or free flap.
Local flaps should be avoided in order to spare tissue from
a hand already traumatized. Plastic models, particularly in
proximal thumb reconstruction, can be of great help in
order to assess the best length to be harvested and the loca­
tion that would yield the best outcome and the greatest
functional use for the patient (Fig. 54.3). Tinel’s sign facili­
tates the localization of recipient nerve stumps that, particu­
larly in avulsion amputation, might be unpredictable.
DONOR SITE
Some authors have stressed the importance of strict control
of the temperature in the donor foot before the transfer,
noticing that values <32°C may predispose to vasospasm.
Dimensions of the defect and the exact size of the toe(s)
flaps are composed of one or all tissues involved, including
bone, skin, tendon, joints, nerves, and fat.
PREOPERATIVE PREPARATION
Several possibilities have been developed over the years,
with many different kinds of toe flaps available. Appropriate
indication is mandatory in order to achieve the best results
in terms of function and cosmesis. In Figure 54.2, some
guidelines are presented.
Besides the conventional care given to patients undergo­
ing microsurgical procedures, below are some critical points
relevant to candidates for toe transfer.
AGE
Toe-to-hand transplantation can be safely performed in
patients as young as 1 year old. Young children have a sur­
prising capability of accepting and incorporating a new
finger better than adults. Patients as old as 60 years, and
nonsmokers who have optimal general conditions, can
safely undergo such procedures but the low chance of nerve
regeneration and the probability of atherosclerotic change
in the arterial tree represent risk factors for failure.
VASCULAR PATTERN
Doppler examination is a useful tool in localizing the pres­
ence and position of the dorsalis pedis artery. The FDMA
Figure 54.2  Guidelines in toe transfer. Thumb reconstruction. Amputation at IP level (black): pulp transfer; great toe wrap-around flap. Ampu­
tation between the IP joint and the first metacarpal neck level (gray): great toe; trimmed toe transfer. Proximal amputation (brown): Tsai’s
technique; bone graft and great toe transfer; extended second toe transfer. Digital reconstruction. Wide volar skin defect (yellow): first web
flap. Single-digit amputation or avulsion injury at or distal to the PIP joint (green): single second or third toe transfer; second toe wrap-around
flap. Multiple digit amputation. Distal to the MP joint (blue): double toe transfer; split combined toe transfer. At or proximal to the MP joint
(pink): combined toe transfer.
Thenar eminence
Combined toe transfer
Double toe transfer
Split combined toe transfer
Single second or third toe transfer
Second toe wrap-around flap
First web flap
Pulp transfer
Great toe wrap-around flap
Great toe transfer
Trimmed toe
Twisted-toe transfer
Bone graft and great toe transfer
Extended second toe transfer
Tendon of flexor carpi radialis
Hypothenar eminence
Proximal skin crease of the wrist
Tendon of palmaris longus

616
PART 4 — CONVENTIONAL WORKHORSE FLAPS
• Amputations at or proximal to the MCP joint with pres­
ervation of the thenar musculature can still achieve excel­
lent results, but might necessitate the use of a conventional
bone graft in order to restore adequate length to the
transfer. In case of loss of the thenar muscles, we perform
primary opponensplasty during the transfer. Amputations
at the base of the first metacarpal or involving the carpo­
metacarpal (CMC) joint of the thumb require a different
approach by either an extended second toe transfer or
pollicization.
ADVANTAGES
• In thumb reconstruction, the great toe provides a wider
pulpar and nail surface than the lesser toes, conferring
excellent restoration of pinch and grasp power.
• Wide range of motion of the metatarsophalangeal joint
(Fig. 54.4) if needed; however, removing this joint will
increase morbidity at the donor site.
DISADVANTAGES
• The cosmetic appearance of the foot is often considered
disabling by the patient.
• Even though 1 cm of the proximal phalanx of the first
ray is usually left in situ, patients may notice a decrease
in push-off and manifest different degrees of impairment
in running or walking on unstable terrain.
• Circumferential diameter and nail width are often clearly
bigger than those of the thumb, making the aesthetic
result less pleasant.
FLAP DESIGN
Soft tissue deficiency at the recipient site should be managed
in advance by either a pedicled groin flap or a free flap,
limiting the dimensions of skin flaps from the donor foot.
Regardless of the level of thumb amputation, we routinely
perform an osteotomy of the great toe, preserving 1 cm of
the base of the first phalanx. If more length is required, a
conventional bone graft is harvested from the hip. The
length of the necessary vessels, nerves, and tendons is indi­
cated while exploring the recipient site, so that unnecessary
dissection of the foot is avoided.
ANATOMIC LANDMARKS (Fig. 54.5)
The metatarsophalangeal and interphalangeal joints of the
great toe are identified and outlined with a marking pen.
By dangling the leg, the superficial venous system becomes
visible and the transverse dorsal arch and proximal com­
munication with the great saphenous vein are marked. The
dorsalis pedis artery is also marked. If difficulty occurs in
visualizing the venous system, a venous tourniquet may be
inflated. The extensor hallucis longus, the underlying first
metatarsal, and the second metatarsal are identified along
their entire course. The artery runs between the first and
second metatarsal bones and lateral to the extensor hallucis
longus tendon. A line connecting the palpable dorsalis
pedis artery to the midpoint of the web space marks the axis
of the artery. The terminal branches of the superficial pero­
neal nerve run subcutaneously along the corresponding
intermetatarsal space, parallel to the long extensor tendons.
The deep peroneal nerve is located medial to the dorsalis
pedis artery. In the midfoot, it courses between the extensor
have to be carefully examined in order to select the appro­
priate transfer. Discrepancies in the appearance of fingers
and toes can be corrected in thumb reconstruction by a
trimmed toe or wrap-around technique, as well as a second
toe wrap-around flap indicated in avulsion injuries of the
fingers. Fungal infections in the toes do not constitute a
contraindication to toe transfer since it has been noticed
that modification of the local environment leads to a spon­
taneous resolution of the infection itself.
ANESTHETIC CONSIDERATIONS
All patients in our department undergo general anesthesia.
In addition, axillary plexus blockade is used both intra- and
postoperatively for prevention of pain and vasospasm by
providing sympathectomy and induction of continuous
analgesia. Other centers use epidural and brachial plexus
blocks rather than general anesthesia.
PATIENT POSITIONING
The patient is placed supine on the operating table with a
tourniquet on the proximal thigh. The flap can be har­
vested with the hip in a neutral position and the knee in full
extension. The operator sits beside the operating table
facing the dorsal aspect of the foot, while the assistant divari­
cates the web space depending on the transfer. For the
plantar dissection the operator changes position and faces
the plantar surface of the foot.
GREAT TOE TRANSFER
See Case 54.3.
INDICATIONS
• The best results are obtained for amputations through
the first phalanx of the thumb. In such cases, the mobility
of all three joints of the first ray is restored (see Case
54.3).
Figure 54.3  A splint custom-made prior to surgery is of great help
in planning the correct length and adequate position of the transfer.

CHAPTER 54 — Toe Flaps and Toe Transplantation
617
Figure 54.4  (A,B) The metatarsophalangeal joint of the great toe has
a wide range of motion in extension; on the contrary, the metacarpo­
phalangeal joint of the thumb moves mostly in flexion. (C) Oblique
osteotomy of the first metatarsal avoids hyperextension of the meta­
tarsophalangeal joint of the transferred great toe.
C
60˚
Foot (metatarsophalangeal joint)
20˚
A
Hand (metacarpophalangeal joint)
90˚
B
Hand
Foot
hallucis longus, which lies medial, and the inner part of the
extensor hallucis brevis, which lies lateral. In the forefoot,
the deep peroneal nerve, crossed by the medial portion of
the extensor hallucis brevis, pierces the deep fascia and
becomes superficial, running between the extensor hallucis
brevis tendon laterally, and the long extensor of the second
toe medially.
GENERAL THOUGHTS ABOUT FLAP DESIGN
A wide skin flap on the first web space or on the dorsal
surface of the foot might be considered, but the increase in
donor site morbidity makes this extension undesirable. The
osteotomy can be planned at the base of the first phalanx,
at or proximal to the metatarsophalangeal joint. Routinely,
we preserve the base of the first phalanx in order to main­
tain the distal insertion of the plantar aponeurosis and part
of the intrinsic musculature, so preserving the windlass
mechanism and the stability of the medial longitudinal arch
of the foot. If osteotomy at the metatarsophalangeal joint is
planned, it should be performed oblique, dorsal-proximal
to volar-distal, for two purposes:
1. Preservation of part of the head of the first phalanx, so
that the distal insertion of the intrinsic musculature as
well as the sesamoid-phalangeal ligaments can be reat­
tached to the distal stump of the first metatarsal, limiting
instability of the medial longitudinal arch.
2. Since the metatarsophalangeal joint has a wider range of
motion in extension than flexion, prevention of hyper­
extension of the transferred great toe will be achieved by
pinning the new metacarpophalangeal joint in neutral
position (Fig. 54.4).
SPECIAL CONSIDERATIONS
As a general rule, the donor site is selected so as to best favor
the position of the vascular anastomosis. In thumb recon­
struction, the position of the pedicle and the slight lateral
angulation of the interphalangeal joint make the ipsilateral
great toe the first choice. At the same time, the left great toe
can be considered a better option, particularly since drivers
might prefer to spare the right foot. Crossing over the tendons
by a vascular pedicle of adequate length is a valuable option
that does not compromise the blood supply to the toe.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
A pedicled great toe flap may be used only in areas that lack
microsurgical facilities. The design of the flap is similar but
a longer vascular pedicle is dissected proximally in order to
facilitate transposition to the recipient site.
FLAP DIMENSIONS
Generally, the great toe is slightly longer than the thumb
and its overall circumference wider, as the width of its nail.
As mentioned above, the great toe flap can be harvested
distal, at or proximal to the metatarsophalangeal joint. The
former is our preferred choice. The skin territory can be
limited to a small V-shaped flap on the dorsal and volar
surfaces of the foot, or can include the whole first web space
and a wide skin flap such as the dorsalis pedis flap.
FLAP MARKINGS (Fig. 54.5A,B)
The midpoint between the great and second toe is marked
at the first web space. Medially, a point in line with the
osteotomy site is marked and a V-shaped flap is drawn proxi­
mally on the dorsal surface of the foot. The length of the
V-shaped flap ranges usually between 0.5 and 1.5 cm, allow­
ing primary closure of the donor site. A wider skin flap with
the inclusion of either the first web space or the dorsalis
pedis flap can be harvested with the great toe, but increased
donor site morbidity must be taken into account. A similar

618
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Now that the superficial venous system and the extensor
hallucis longus have been prepared, the dissection proceeds
from the first web space distal to proximal in a retrograde
fashion in order to isolate the FDMA previously identified.
Collateral branches are ligated and the dissection proceeds
proximally up to the dorsalis pedis artery, depending on the
length needed. The deep peroneal nerve is usually identi­
fied while dissecting the FDMA in the forefoot. Its medial
branch to the lateral surface of the great toe is followed up
to 5–7 cm and divided by intraneural dissection so as to save
the lateral branch to the medial surface of the second toe.
If the plantar system is dominant, there is no need for
deep dorsal dissection and the artery is followed plantarly
in a retrograde manner.
PLANTAR DISSECTION
A triangular flap of 0.5–4 cm in height, with the base in the
web space, is raised. If the arterial plantar system is domi­
nant, the first plantar metatarsal artery is dissected in a
retrograde fashion to the middle portion of the metatarsal
shaft. Further dissection might be too disruptive to the foot
and the use of a vein graft is advised if a longer pedicle
length is required. Most of the fatty pad under the skin is
excised and the proper digital nerves on both sides are
isolated and harvested as long as needed. Intrafascicular
dissection of the first common digital nerve enables the
neural fascicles of the second toe to be saved. The flexor
hallucis longus is dissected out from its sheath, pulled out,
and cut at a proper length. Rarely an additional transverse
incision under the medial plantar arch of the foot is needed
in order to harvest a longer tendon. After elevating the
tendons and the proper digital nerves, the artery and
vein are protected, and the soft tissue and the periosteum
V-shaped flap is marked on the plantar surface with its
proximal apex slightly shifted between the first and second
metatarsal heads in order to avoid any scar beneath the
weightbearing areas.
TECHNIQUE OF FLAP HARVEST
A similar sequence in procedure can be applied to all kinds
of toe transfers. The dissection is performed under tourni­
quet control avoiding the use of an Esmarch band.
DORSAL DISSECTION
A V-shaped flap on the dorsum of the foot is elevated while
taking care to preserve the superficial venous system. The
incision starts from the midpoint between the first and
second toes. At the first web space, all the soft tissues are
carefully excised in order to obtain a clear vision of the
dominant arterial system (Fig. 54.6). If the first dorsal meta­
tarsal artery has a greater or equal caliber compared with
the first plantar metatarsal artery, the dissection proceeds
dorsally in a retrograde fashion, prolonging the skin inci­
sion proximally in a lazy S up to the dorsalis pedis artery.
Once the dominant arterial pattern has been assessed, a
superficial vein of adequate caliber is selected and followed
proximally through the dorsal venous arch up to the great
saphenous vein on the medial surface of the midfoot. At this
level, the dissection is concentrated on the vein, avoiding
excessive thinning of the skin, which may lead to skin necro­
sis of that area. Once the vein has been isolated for the
necessary length, the extensor hallucis longus is identified,
dissected, and divided at the required length. Branches of
the superficial peroneal nerve can be clearly visible during
this step and spared.
Figure 54.5  (A) A V-shaped skin flap is marked on the dorsal surface. (B) A V-shaped flap on the plantar surface. The incision is extended
between the first and second metatarsal heads, avoiding scar formation on the weightbearing areas is marked. FDMA, first dorsal metatarsal
artery.
A
FDMA and
proper digital
arteries
Extensor
hallucis brevis
Proximal extent
of incision
Superficial vein
Incision area
Extensor hallucis
longus
B

CHAPTER 54 — Toe Flaps and Toe Transplantation
619
FLAP DESIGN (Fig. 54.8)
The diameter of the contralateral intact thumb is measured
at three levels: the nail eponychium; the interphalangeal
joint; and the middle of the first phalanx. The width of the
nail is measured as well. The values obtained are marked on
the nondominant great toe, so as to create a medial skin
flap, tapered on the tip of the toe. This represents the excess
tissue, which usually measures 0.8–1.5 mm and is left in situ
to allow free tension closure of the donor foot.
ANATOMIC LANDMARKS
See great toe transfer, Figs 54.5 and 54.8.
surrounding the osteotomy site are gently elevated so that
the toe can be autonomized by osteotomy, preserving 1 cm
of the proximal phalanx (Fig. 54.7). Warm wet dressings are
placed over and around the flap and the tourniquet is
released. The toe is reperfused for at least 20 min before
transfer.
TRIMMED GREAT TOE TRANSFER (Fig. 54.8)
INDICATIONS
Described by Wei et al. in 1988, the trimmed great toe was
conceived for the purpose of improving the discrepancy in
the appearance between the great toe and the thumb. Indica­
tions are similar to those of great toe transfer when the great
toe shows overall dimensions that are evidently bigger than
the thumb. Performed in children, the trimmed great toe
transfer does not interfere with physiologic growth of the toe.
ADVANTAGES
• Besides the inherent advantages of great toe transplanta­
tion, trimmed great toe transfer offers the best aesthetic
match for thumb restoration.
DISADVANTAGES
• Disadvantages are similar to those mentioned for the
great toe transfer. A slight reduction in mobility of
the interphalangeal joint motion is usually observed with
the trimmed great toe.
Figure 54.6  Retrograde dissection from the first web space allows direct visualization of the main vascular pattern and anatomic variations.
Once the FDMA and the distal perforating branch to the plantar system are exposed, one can choose to proceed with dorsal or plantar dis­
section depending on the vessel’s diameter. Dorsal dissection is easier and straightforward and should be considered as first choice whenever
possible.
Deep transverse
metatarsal ligament
First dorsal
metatarsal artery
Proper digital arteries
Deep plantar artery
Extensor hallucis
longus tendon
Distal perforating
branch
Deep peroneal nerve
Dorsalis pedis artery
Figure 54.7  Great toe flap harvested. One centimeter of the first
phalanx is preserved in order to maintain the attachment of the
plantar aponeurosis and intrinsic muscles in the foot. Red arrow,
FDMA; blue arrow, superficial dorsal vein; yellow arrows, plantar
digital nerves and deep peroneal nerve.

620
PART 4 — CONVENTIONAL WORKHORSE FLAPS
GENERAL THOUGHTS ABOUT FLAP DESIGN
The medial skin flap is preserved in order to provide ade­
quate coverage for the remaining portion of the great toe.
The dorsal and plantar incisions on the foot reflect the same
principles of great toe transfer.
SPECIAL CONSIDERATIONS
Accurate reattachment of the medial collateral ligament
and capsule of the interphalangeal joint of the great toe
avoids instability of the joint itself.
FLAP DIMENSIONS
See Great Toe Transfer.
FLAP MARKINGS (Fig. 54.8)
V-shaped skin flaps are designed on the dorsal and plantar
surface of the first ray as shown for great toe transfer.
The diameter of the intact thumb is reproduced on the
medial surface of the great toe at three levels: the nail
eponychium, the interphalangeal joint, and the middle
of the first phalanx. The discrepancy in circumference
delineates a medial flap that is being tapered at the tip of
the toe.
TECHNIQUE OF FLAP HARVEST (Fig. 54.8)
Dissection of vessels, nerves, and tendons is carried out as
already described for the whole great toe. The medial skin
flap is raised from distal to proximal and the dissection
deepened to the bone. A hemi-circumferential joint flap
composed of the periosteum, the medial collateral
Figure 54.8  Trimmed toe transfer. (A,B) Circumferential measurements of the intact thumb are reproduced on the great toe. The resulting
medial flap represents the excess tissue. (C) A medial joint flap composed of the periosteum, the medial collateral ligament, and the capsule
is elevated plantarly and a longitudinal osteotomy resects part of the bone. (D) The joint and collateral ligament are reconstructed with appro­
priate tension, so as to avoid instability in the interphalangeal joint.
A
B
C
D
ligament, and capsule is elevated in a dorsal to plantar
fashion. By means of an oscillating saw, a longitudinal oste­
otomy removes 4–6 mm at the joint and 2–4 mm at the
proximal and distal phalangeal shaft. After removing the
excess tissue, the joint capsule and the collateral ligament
are repositioned, taking care to tighten sufficiently to avoid
instability of the interphalangeal joint.
WRAP-AROUND TECHNIQUE (Fig. 54.9)
In the original description by Morrison in 1980, the wrap-
around flap was harvested by degloving the great toe,
respecting the dimension of the thumb. The soft tissue
obtained is used to cover a conventional bone graft that
provides stable support. Due to the frequent bone graft
resorption and the instability of the pulp, the original tech­
nique has been modified in order to include part of the
distal phalanx in the flap. This avoids swiveling of the pulp
and beaking of the nail, and prevents bone resorption by a
higher vascular support either proximal or distal to the
conventional bone graft.
INDICATIONS
• Degloving injuries distal to the metacarpophalangeal
joint with skeleton and tendons intact
• Complete amputations at the first phalanx of the thumb.
In this case a longer bone graft is required, which needs
to be shaped in slight flexion at the IP level
• This flap is not indicated in children because of the lack
of growth capacity.

CHAPTER 54 — Toe Flaps and Toe Transplantation
621
performed. In Doi’s method the graft will have a flat shape in
order to replace the volar cortex of the distal phalanx of the
new thumb. The donor site is closed by the remaining medial
skin flap and a second cross-toe flap. We usually cover the
dorsal defect by a conventional skin graft. Others have sug­
gested the use of a lateral forearm free flap, reverse anterior
tibial artery flap, or free peroneal flap.
TWISTED-TOE TECHNIQUE (Fig. 54.10)
Thumb reconstruction with either the great toe or the
second toe might lead to unsatisfactory results due to several
anatomic differences, including a certain aesthetic morbid­
ity after the transfer of the great toe. This has given the
impulse to several authors such as Tsai, Foucher, and Iglesias
to develop the twisted-toe technique which combines the
transfer of part of the great and second toe assembled
together so as the new thumb has a better match to the
uninjured side in terms of width and general appearance.
Furthermore, thanks to new technical refinements by
Kempny (see Further Reading), the appropriate combina­
tion of the remnant parts of the great and second toe in the
foot, leaves a better cosmetic result in the donor site. The
surgical technique is demanding (Fig. 54.10).
SECOND TOE TRANSFER (Fig. 54.11)
INDICATIONS
Second toe transfer is the first choice in finger reconstruc­
tion (Fig. 54.11). It is also advisable in thumb reconstruction
for patients who do not accept the loss of the great toe or
in children in whom the great toe is preferably spared.
ADVANTAGES
• The wrap-around flap produces an optimal aesthetic and
functional restoration of the thumb, with minimal loss in
length of the great toe.
DISADVANTAGES
• The wrap-around flap does not restore joint mobility;
therefore, for complete amputations between the MP and
IP joints, great toe or trimmed toe transfers are more
appropriate.
• When part of the distal phalanx is not included, bone
resorption, beaking of the nail, and instability of the pulp
can be troublesome for the patient.
• The bone graft can fracture if overstressed in the first 6
months, and patients should be advised to avoid trauma
of the new thumb during that period.
TECHNIQUE OF FLAP HARVEST (Fig. 54.9)
Circumferential measurements of the intact thumb as well as
of the nail are traced on the nondominant great toe.
A longitudinal skin flap will result on the medial side of the
toe, which will taper to the tip of the distal phalanx
(Fig. 54.9A). The soft tissues are raised off in an avascular
plane above the tendon sheath in a medial to lateral direc­
tion. During the plantar dissection both plantar digital
nerves are identified and included in the transplant
(Fig. 54.9B). Osteotomy of the distal phalanx can be carried
out either transversely, as our preferred choice, or, as
described by Doi, longitudinally, elevating the nail with the
underlying periosteum and the dorsal cortex as a unique
block, preserving the plantar cortex at the donor site.
In either case a conventional bone graft is harvested and
appropriately shaped depending on the type of osteotomy
Figure 54.9  Wrap-around technique. (A) The width of the intact thumb is reproduced on the great toe and the resulting skin flap tapers to
the tip of the toe. (B) A portion of the distal phalanx is included with the flap in order to improve stability and avoid bone resorption and beaking
of the nail.
A
B
First dorsal
metatarsal artery
Portion of distal
phalanx included
in the flap
Superficial vein
Plantar digital
nerves
Extensor hallucis
longus tendon
Portion of distal
phalanx remaining
on the great toe

622
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 54.10  Twisted-toe transfer: the great and second toes are assembled combining different bony and nail components in order to obtain
a better match in the new thumb as well as improved cosmesis in the foot. In the description by Kempny, the nail from the great toe is shaped
appropriately and matched with the thumb’s nail, supported by including part of the distal phalanx. The latter is fixed to the second toe by
means of a K-wire whether the nail from the second toe is used to reconstruct the nail in the new great toe. Red, bony components; gray, nail
component.
Tsai’s method
Foucher’s method
Iglesias’ method
Kempny’s method
Figure 54.11  (A,B) A 25-year-old man, with amputation of his index finger at P1. (C,D) Notice good flexion and extension of the transferred
second toe, even though this level of amputation leads to a less satisfactory range of motion when compared with amputations distal to the
proximal interphalangeal joint.
A
B
C
D
A

CHAPTER 54 — Toe Flaps and Toe Transplantation
623
artery. The terminal branches of the superficial and deep
peroneal nerves are located as described in great toe
transfer.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Our preference is to use triangular flaps in order to help
interdigitate the skin during the inset.
SPECIAL CONSIDERATIONS
In single-digit reconstruction the toe is selected in the
ipsilateral foot. This allows maintenance of the vascular
pedicle in a favorable position for anastomosis in the
recipient site. A wide skin flap on the first web space or on
the dorsal surface of the foot might be considered, but the
increase in donor site morbidity makes this extension
undesirable.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
A pedicled second toe flap for hand reconstruction has
recently been reported from Pakistan but this may only be
considered in areas that lack microsurgical facilities. The
flap should be based on the dorsalis pedis artery, which is
harvested with a dorsalis pedis flap, allowing coverage of
both the recipient site and vascular pedicle. The transfer is
fixed in the recipient site with maximal flexion of the hip
and knee joints. Division of the vessels is performed after 2
weeks and complete autonomization after 3 weeks.
FLAP DIMENSIONS
The second toe is usually much shorter than any finger, and
its circumference at the middle phalanx is thin and presents
a marked bulbous appearance at the tip. Aesthetic refine­
ments to overcome these differences will be discussed later
in more detail. The second toe can be harvested at the
metatarsophalangeal joint by disarticulation or by osteot­
omy at the midshaft of the second metatarsal bone. In the
latter case it is prudent, during dissection of the vascular
pedicle, to maintain the connections between the first meta­
tarsal artery (whether dorsal or plantar) and the second
metatarsal bone by preserving part of the interosseous
muscle. It is our routine to harvest a dorsal skin flap of
4–5 cm in length, with a width corresponding to the dis­
tance between the midpoint of the first web space and that
of the second web space. At the plantar side, the length of
the skin island does not pass the midpoint between two
adjacent metatarsal heads, except in extended second toe
transfers where its dimensions can reach up to 4–5 cm.
Other authors have described greater dimensions but the
surgeon must be aware of possible tension in wound closure
or the need for a skin graft to cover the surgical wound, with
an increase in donor site morbidity.
FLAP MARKINGS (Fig. 54.12)
A point 1–2 mm fibular to the midpoint of the first web
space is marked. Then a point 1–2 mm tibial to the mid­
point of the second web space is marked. This allows for a
more aesthetically pleasing closure of the donor site and
avoids the appearance of a wide web space after donor site
closure. A V-shaped skin flap is marked, with the tip of the
V being centered over the second metatarsal at 0.5–4 cm
ADVANTAGES
• Cosmetic and functional results on the donor foot are
superior to great toe transfer.
DISADVANTAGES
• The second toe has a tendency to claw, even though
we have often pinned the DIP joint. Furthermore, it is
usually thin, and endowed with a bulky square-shaped
pulp, and so offers less expectation in terms of function
and cosmetic appearance for thumb reconstruction.
FLAP DESIGN (Fig. 54.12)
Disarticulation of the second toe at the metacarpophalan­
geal joint is more suitable for amputations distal to the
proximal interphalangeal (PIP) joint, whereas inclusion of
the second metatarsal bone can be utilized for more proxi­
mal amputations. In the latter circumstance the harvest of
the second metatarsal reduces tension in closure of the
donor site, so a slightly wider skin flap can be included in
the flap if needed.
ANATOMIC LANDMARKS (Fig. 54.12)
The metatarsophalangeal and interphalangeal joints of the
second toe are identified and outlined with a marking pen.
The dorsalis pedis artery and the superficial venous system
are identified as in great toe transfer. The extensor com­
munis tendon to the second toe, the underlying second
metatarsal, the extensor hallucis longus, and the first meta­
tarsal are identified along their entire course. The first
dorsal metatarsal artery runs between the first and second
metatarsal bones and lateral to the extensor hallucis longus
tendon. A line connecting the palpable dorsalis pedis artery
to the midpoint of the web space marks the axis of the
Figure 54.12  The midpoint between the first and second toe is
visualized. A V-shaped skin flap is marked, starting 1–2 mm medially
toward the great toe and laterally towards the third toe in order to
provide a more aesthetic closure. FDMA, first dorsal metatarsal
artery.
Proximal
extent
of incision
Superficial
vein
Incision area
FDMA and
proper digital
arteries
Extensor
digitorum
longus

624
PART 4 — CONVENTIONAL WORKHORSE FLAPS
proximal to the metatarsophalangeal joint. Plantarly, a
similar V flap is marked with the apex directed longitudi­
nally in the non-weightbearing area that lies between the
metatarsal heads.
TECHNIQUE OF FLAP HARVEST
From the midpoint of the first and second web space, a
V-shaped skin flap is elevated, with appropriate care in pre­
serving the underlying venous network. The incision is
extended proximally in a lazy S shape and one or two veins
are selected and dissected to the required length and caliber.
The extensor digitorum longus of the second toe is isolated
depending on the recipient site, and the extensor hallucis
brevis is divided. At the first web space the lateral digital
artery of the great toe and the medial digital artery of the
second toe are visualized and dissected 1 cm proximally.
Then the first dorsal and plantar metatarsal arteries can be
identified and dissected in a retrograde fashion, depending
on the dominant pattern. In the plantar surface a V-shaped
skin flap is elevated and the underlying fatty tissue is
excised (Fig. 54.13A,B). If the FPMA is dominant, this is
followed up to the middle of the metatarsal shaft. The use
of a vein graft avoids the need for further and more damag­
ing dissection in the foot. Then the flexor tendon can be
identified, pulled out, and cut proximally, followed by isola­
tion of proper digital nerves. While protecting the artery
and vein, all the remaining soft tissues are raised off the
bone for a few millimeters at the base of the proximal
phalanx and the toe is autonomized (Fig. 54.13C). The
circulation is then verified and the flap is allowed to perfuse
for 15–20 min.
IMPROVING THE COSMESIS OF THE SECOND TOE
The second toe has a bulbous tip, a thin proximal and
middle phalanx, and a short nail, so as its appearance might
be considered unpleasant by the patients, particularly
when used to replace the thumb. Wei and Yim proposed
a simple method to reduce the circumference of the third
phalanx, applicable for both the second and the great
toe, by means of the longitudinal excision of an elliptical
Figure 54.13  Second toe transfer. (A) Artery and vein are dissected to reach adequate length. Branches of the superficial peroneal nerve are
visualized and included in the transfer during dorsal dissection. (B) Defatting of the triangular plantar flap is important for better cosmesis and
ease of inset. (C) A, first dorsal metatarsal artery – dorsalis pedis artery; V, superficial dorsal vein; ET, extensor digitorum longus; FT, flexor
digitorum longus; N, plantar digital nerve; DPN, deep peroneal nerve.
A
B
C
portion of the central pulp of the toe. Neither hypersen­
sitivity nor painful scarring was noted in the follow-up of
their patients. Further development was described by Zhao
and colleagues, who proposed three different steps: (1) use
of a key-hole vascularized flap from the fibular side of the
great toe, inserted volarly in the second toe. This improves
the sense of fullness at the first and second phalanx. (2)
Removal of 2 mm of the eponychial fold in order to obtain
the appearance of a longer nail. (3) Excision of two small
elliptical skin corners of the pulp. This procedure might
lengthen the total surgical time of about 2–3 h, taken
mainly by the elevation of the key-hole flap from the great
toe (Fig. 54.14A,B).
SECOND TOE WRAP-AROUND
INDICATIONS
Degloving injuries or hemi-circumferential loss of the
fingers distal to the proximal portion of the middle phalanx
where the skeleton, tendons, and the distal interphalangeal
(DIP) joint are intact.
TECHNIQUE OF FLAP HARVEST
Either the right or left second toe is selected, depending on
which finger is being reconstructed. Since one side of the
toe is incised longitudinally as in the great toe wrap-around
flap, scars must be avoided over the radial side of the index
and middle fingers and ulnar side of the ring and small
fingers. A circumferential skin incision is made on the
second toe, depending on the level of reconstruction, taking
care to preserve one superficial vein of good caliber. A lon­
gitudinal incision is carried out on the nondominant side
of the toe up to the distal interphalangeal joint. The skin,
the subcutaneous tissue, and the superficial venous network
are then elevated in an avascular plan above the paratenon
of the flexor and extensor tendons. The flap always includes
the distal phalanx, which is disarticulated at the DIP
joint. The surgical dissection of either the FDMA or the

CHAPTER 54 — Toe Flaps and Toe Transplantation
625
COMBINED TOE TRANSFERS (Fig. 54.15)
See Case 54.4.
SECOND AND THIRD TOE TRANSFER
(Figs 54.15, 54.20)
INDICATIONS
Combined second and third toe transfer is the first choice
when two adjacent digits need to be reconstructed at or
proximal to the metacarpophalangeal joint. A typical indica­
tion is in metacarpal hand, either type I or type II.
THIRD AND FOURTH TOE TRANSFER
INDICATIONS
As for combined second and third toe transfer. Selection of
the third and fourth combined toe transfer is made when
the great toe is utilized to restore thumb function and the
second toe needs to be preserved for gait balance; an
extended second toe is needed to reconstruct a proximal
amputation of the thumb; or there is any injury or deformity
that renders the second toe unsuitable.
FLAP DESIGN (Fig. 54.20)
Combined toe transfer can be autonomized by either disarticu­
lation at the metatarsophalangeal joint or osteotomy. If the
digits are amputated at the metacarpophalangeal level, disar­
ticulation is the preferred method. If the amputation level is
more proximal, osteotomy at the metatarsal shaft is indicated.
FPMA, depending on the dominant pattern, is similar to
that described for conventional second toe transfer. Skele­
tonization of the artery and veins is time-consuming but
indispensable during the inset. Disarticulation of the
remaining bone structure at the metatarsophalangeal joint
is suggested.
THIRD TOE TRANSFER
INDICATIONS
Primary indications for isolated third toe transfer occur in
three circumstances:
• The great toe has been transferred. In such situations, the
second toe is spared to maintain a better gait balance.
• The second toe has already been harvested or is unsuit­
able due to previous trauma or deformity.
• The size of the third toe is a better match for finger
reconstruction than that of the second toe.
TECHNIQUE OF FLAP HARVEST
The surgical dissection is similar to that described for second
toe transfer. Selection of the arterial pedicle takes into
consideration anatomic variations and reconstructive plan­
ning. In our experience, the second dorsal metatarsal
artery is normally used. If, intraoperatively, this artery is
found to have the same or better caliber than the plantar
one, the dissection proceeds dorsal since it is much easier.
If the second toe has been used already or is going to be
harvested, the first choice is the third plantar metatarsal
artery.
Figure 54.14  (A,B) Kempny’s description for improving the cosmesis of the second toe in thumb reconstruction. (A) Excision of the two
corners of the toe’s pulp, and elevation of a vascularized key-hole flap from the fibular side of the great toe. The flap is then inserted volarly
in the second toe in order to give a sense of fullness in the proximal and middle phalanx. (B) The excision of 2 mm of the eponychial fold can
give the appearance of a longer nail in the new finger. Further excision is not advisable since the nail matrix could be damaged.
A
B

626
PART 4 — CONVENTIONAL WORKHORSE FLAPS
• The length of the combined transfer should be in
harmony with the tip of the small finger. If another intact
finger is much longer, the result is unpleasant and func­
tionally unsatisfactory (Fig. 54.15).
• The long finger always occupies a central position whether
radial (index and middle) or ulnar (ring and small)
digital reconstruction has been planned. Therefore, in
combined toe transfer, either the ipsilateral or the con­
tralateral foot is selected in order to respect this
principle.
SPECIAL CONSIDERATIONS
For amputations of adjacent fingers distal to the meta­
carpophalangeal joint, combined toe transfer creates an
unpleasant palmate appearance of the web space, so
multiple toe transfer is better indicated. In such cases, we
have successfully used split second and third toe transfer.
We harvest the combined second and third toe, pre­serv­
ing one artery to the second toe (most likely the FDMA)
and one artery to the third toe (most likely the second
plantar metatarsal artery) and two veins, one for each toe.
Once harvested, the toes are split and transferred
independently.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
There is no indication for pedicled transfer of combined
toes.
ANATOMIC LANDMARKS
The metatarsophalangeal joints of the selected combined
toes are isolated by palpation and marked with a marking
pen. The superficial venous system and the dorsalis pedis
artery are marked. The arcuate artery is absent in 40% of
cases and its palpation in the midfoot is usually difficult. The
use of a Doppler probe for its localization might be helpful.
The extensor communis tendons, the underlying metatarsal
bones, the extensor hallucis longus, and the first metatarsal
are identified along their entire course. In combined second
and third toe transfer the artery runs between the first and
second metatarsal bones and lateral to the extensor hallucis
longus tendon. A line connecting the palpable dorsalis
pedis artery to the midpoint of the first web space marks the
axis of the first dorsal metatarsal artery. As a general rule,
the arterial dissection begins at the first web space (second
web space in combined third and fourth toe transfer) and
the dominant artery, whether dorsal or plantar, is followed
in a retrograde fashion along the corresponding intermeta­
tarsal space. The terminal branches of the medial and inter­
mediate dorsal cutaneous nerves (terminal branches of the
superficial peroneal nerve) run subcutaneously along the
first, second, and third intermetatarsal spaces, parallel to
the long extensor tendons.
GENERAL THOUGHTS ABOUT FLAP DESIGN
In order to achieve good functional and aesthetic results,
some basic rules have to be kept in mind:
Figure 54.15  Combined toe transfers must re-create a harmonious digital cascade. The tip of the small finger is the reference in reconstruc­
tive planning.
Combined second
and third toe
Correct
Incorrect
Combined second
and third toe

CHAPTER 54 — Toe Flaps and Toe Transplantation
627
• Tendency toward flexion of the PIP joint of the trans­
ferred toe
• Limited mobility in flexion of the MTP joint with
the necessity to rotate the transfer 180° at the recipient
site
TECHNIQUE OF FLAP HARVEST
PIP JOINT TRANSFER
A small skin flap is drawn on the dorsal surface of the PIP
joint as a monitor for the transfer. The dissection begins at
the first web space and proceeds in a retrograde fashion
along the FDMA or the FPMA, depending on which is domi­
nant. The medial digital artery, which is the main supply to
the transfer, is traced distally, preserving the articular branch
to the PIP joint, and ligated at the DIP level. If the second
toe is being preserved, the lateral digital artery is identified
and the articular branch to the PIP joint ligated. This vessel,
left intact, will provide the vascular supply to the remaining
portion of the second toe. The extensor tendon is cut proxi­
mal and distal to the joint, with as much length as needed.
Autonomization of the transfer is performed by disarticula­
tion at the DIP joint and osteotomy at the first phalanx. If
the toe is being preserved, the remaining gap can be filled
by a conventional bone graft, sometimes taken from the
recipient finger. In our experience, preservation of the
second toe has led to discomfort in walking and running,
so in the preoperative discussion with the patient we suggest
proximal disarticulation of the toe. As proposed by Ellis and
Tsai, a better skin flap for coverage can be harvested from
the dorsal surface of the great toe. In this case both the
lateral digital artery of the great toe and the medial digital
artery of the second toe are included in the transfer.
MTP JOINT TRANSFER
The MTP joint has a higher excursion in extension than in
flexion; therefore, 180° of rotation during the transfer is
recommended. When a dorsal skin flap is included, this is
harvested eccentrically in respect to the long axis of the
joint, which allows maintenance of skin coverage on the
dorsal surface of the joint. Dissection starts at the first web
space, where the first metatarsal artery, whether dorsal or
plantar dominant, is isolated and traced proximally. The
vessel is then followed distally along the medial digital
artery, which gives an articular branch to the MTP joint. The
lateral digital artery of the toe can be ligated, unless the toe
is being preserved. Osteotomy sites and extensor tendon
length are selected depending on the donor site require­
ment (see Case 54.1).
NEUROSENSORY FREE FLAPS (See also Chapter 53 –
Glabrous skin flaps)
The skin of the first web space of the foot is highly inner­
vated and is composed mostly of glabrous skin. It is utilized
for the coverage of volar defects in adjacent fingers or
release of finger web space contracture. The sensory inner­
vation comes from the deep peroneal nerve. The first web
flap can be extended to the tip of the great or second toe,
including part of the corresponding pulp. The FDMA is
the dominant vascular supply. Its absence does not preclude
harvest of the flap, which is then based on the plantar system
(Fig. 54.16).
FLAP DIMENSIONS
The length of the dorsal skin island is usually 2–3 cm and
its width corresponds to the distance between the midpoint
of the first (or second) web space and the third (or fourth)
web space. The plantar skin flap has a similar width and its
apex falls between two adjacent metatarsal heads. A wider
skin flap either leads to tension in wound closure or may
require the use of a skin graft.
FLAP MARKINGS
Adequate closure of the foot wound is essential in limiting
donor site morbidity, and therefore the skin incisions differ
slightly from single toe transfer. The midpoint of the first and
third (in combined second and third toe transfer) or second
and fourth (in combined third and fourth toe transfer) web
spaces is traced with a marking pen. A point 1–2 mm closer
to the toe flap rather than at the midpoint is marked and a
triangular skin flap is drawn on the dorsal surface of the foot
with its apex at a proximal distance of 2–4 cm. A similar tri­
angular flap is raised on the plantar surface with its apex
falling between the two corresponding metatarsal heads.
TECHNIQUE OF FLAP HARVEST
The surgical dissection follows the principles described
above. Incision at the first (in combined second and third toe
transfer) or second web space (in combined third and
fourth toe transfer) allows dissection of the arterial system in
a retrograde fashion on either the dorsal or plantar surface,
depending on which system is dominant. Both toes
are satisfactorily supplied by one artery and one vein. If,
intraoperatively, vascular refill seems to be insufficient, a
second arterial anastomosis is performed. Disarticulation
at the metatarsophalangeal joint or transverse osteotomy
at the metatarsal shaft is managed in relation to the recipi­
ent site.
VASCULARIZED JOINT TRANSFER
See also Case 54.1.
INDICATIONS
• Fingers: traumatic or nontraumatic destruction of the MP
and/or PIP joint when either prosthetic replacement or
fusion is contraindicated
• Thumb: MP reconstruction by vascularized joint transfer
for young adults, particularly for those who have suffered
severe injuries with destruction of both MP and PIP joints
• Congenital or traumatic loss of the MP or PIP joint in
children who can benefit from potential growth of the
transferred joint
ADVANTAGES
• Stability, durability, and potential growth in children
DISADVANTAGES
• Limited range of motion

628
PART 4 — CONVENTIONAL WORKHORSE FLAPS
increased length can be reached by vein graft. This limits
the donor site morbidity.
• Intrafascicular dissection of the nerve under micro­
scopic visualization is performed in order to preserve
sensation at the donor site while achieving the maximum
length of nerve possible to the flap. At this stage, the
nerve should be divided at a level proximal to the head
of the metatarsal bone in order to avoid the possibility of
neuroma formation that may cause symptoms in the foot.
• Debulking of the adipofibrous tissue under the plantar skin:
at the plantar surface of the metatarsophalangeal level of
each toe, a thick layer of fibroadipose tissue covers the
bone structures, providing adequate support during
push-off. This tissue is too bulky when transferred to the
recipient site and needs to be excised during foot
dissection.
• Prevention of claw deformity in lesser toe transfer: we usually
suture the extensor digitorum communis tightly and
insert a longitudinal K-wire through the distal and proxi­
mal interphalangeal joints of the toe. A week later, the
K-wire is partially pulled out in order to free the PIP joint
and allow rehabilitation. The wire can be completely
removed at 4 weeks and is followed by a nighttime exten­
sion splint for a year following surgery. As mentioned
above, even using a K-wire, some claw deformity of the
second toe is to be expected.
GENERAL CONSIDERATIONS AT
THE RECIPIENT SITE
MULTIPLE-DIGIT AMPUTATION
Hand reconstruction in mutilating injuries should aim to
provide a basic tripod pinch that offers the possibility of
achieving precise as well as power grip, throwing, and club­
bing potentials. These qualities require three main features:
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
• After release of the leg tourniquet, the toe is monitored for a
few minutes to make sure that it pinks up. If the toe
remains white, the systolic blood pressure is checked and
maintained above 100 mmHg. The room must be kept
warm, and the dressings are removed to make sure that
there is no compression. The pedicle position and the
presence of possible kinking are assessed. The toe is mon­
itored for a period of 10–20 min and, if flow is still not
apparent, the vascular anatomy of the toe is inspected
under microscopic visualization to ensure that the
anatomy is good and to assess the presence of vascular
spasm. Adventitiectomy is performed if spasm is appar­
ent. If the toe still does not pink up and the vascular
anatomy has a good assessment, we recommend transfer
of the toe and evaluation of the vascular supply once the
inset has been completed.
• Retrograde dissection of the arterial pedicle facilitates the
surgical approach, giving more self-confidence for any
anatomic variation, since the course of the nourishing
vessel is directly visualized and followed-up to an ade­
quate length. Furthermore, it avoids the need for preop­
erative angiograms of the donor foot.
• Skeletonization of vessels and nerves is time-consuming, but
makes an enormous contribution when these structures
come to be tunneled in the hand, avoiding excessive
bulkiness and allowing primary closure of the recipient
site.
• Primary adventitiectomy, especially of the artery, may
prevent the frequent tendency toward arterial spasm
and is partly achieved as part of the skeletonization
process.
• In the donor foot, dissection of the plantar artery should be
confined to the distal half of the metatarsal shaft, and
Figure 54.16  First web flap. Distal dissection must include the lateral digital artery of the great toe and the medial digital artery of the second
toe, which are nourished by either the FDMA or FPMA, depending on the dominant pattern.
Proper digital artery
to the first toe
Proper digital artery
to the second toe
1st dorsal
metatarsal artery
Deep peroneal nerve

CHAPTER 54 — Toe Flaps and Toe Transplantation
629
case. If unfeasible, arthrodesis of the CMC joint offers a
good alternative providing a stable first ray placed in ade­
quate pronated position.
SINGLE-DIGIT AMPUTATION
Reconstruction consists of a lesser toe transplantation,
which offers an excellent margin of recovery when the inser­
tion of the flexor digitorum superficialis is intact. In ampu­
tations to the PIP joint, functional results are inferior since
the transferred toe is unlikely to restore optimal range of
motion at the new PIP joints.
METACARPAL HAND
This condition derives from the loss of all fingers at a level
proximal to the middle of the proximal phalanx, with or
without involvement of the thumb. Every effort is employed
in restoring tripod prehension, which requires at least
two reconstructed fingers that can efficiently oppose a stable
and sensate thumb. In type I the thumb is intact or damaged
at the IP joint, which is considered the minimal functional
length with which acceptable pinch is still possible. In
accordance with patient wishes, the ring and small fingers
are reconstructed to restore strong grasp, whereas the
middle and index fingers can better restore the finest tripod
pinch. If amputation is at or proximal to the metacarpopha­
langeal joint, combined toe transfer is the best choice.
If amputation is distal to the metacarpophalangeal joint, two
single toe transfers offer a better cosmetic and functional
result. In type II the thumb is lost at different levels
proximal to the IP joint (see Case 54.4). In such circum­
stances, besides the transfer of lesser toes for digital recon­
struction the great toe is utilized to replace the amputated
thumb. In bilateral metacarpal hand, 3–5 toes might be
required.
FLAP USAGE
TYPICAL INDICATIONS FOR USE OF THIS FLAP
• Great toe, trimmed great toe: complete amputation
between the MP and IP joints of the thumb
• Great toe wrap-around flap: degloving injuries of the
thumb distal to the MP joint
• Second toe transfer: amputations distal to PIP joint with
intact FDS
• Third toe transfer: same as the second toe when this is
not available or needs to be spared
• Combined second and third toe transfer: in metacarpal
hand for amputation at or proximal to the MP joint of
adjacent fingers
• Combined third and fourth toe transfer: same as second
and third toe when the second toe is not available or
needs to be spared
ATYPICAL INDICATIONS FOR USE OF THIS FLAP
• Great toe, trimmed great toe: amputations at the base of
the first metacarpal. In such cases a longer conventional
bone graft shaped with 30° of flexion and primary oppo­
nensplasty are required.
• Great toe wrap-around flap: amputations proximal to the
metacarpophalangeal joint. A longer conventional bone
graft is harvested and shaped with 30° and 15° of flexion
at the MP and IP joints, respectively. The graft must have
a stable radial component, the thumb; an ulnar component
represented by one or two digits; and a functional opposi­
tion. Having many different options in flap selection, it
becomes evident that the choice strictly depends on what is
left in the injured hand and the length of each single com­
ponent. It is mandatory to make every effort to respect a
harmonious digital cascade while planning a reconstructive
procedure so that the position and the length of the trans­
ferred toes are being fully integrated in the remaining parts
of the hand. For instance, if the index and long fingers are
intact it would be cosmetically and functionally unpleasant
to transfer one or two toes in the III or V position at the
MCP joint level.
Radial Component Reconstruction: The Thumb
Adequate length, opposition, stability, and sensibility are the
main requirements that must be considered in thumb
reconstruction. Each of these has different priorities,
depending on several factors: level of amputation, domi­
nant hand, patient’s age, job, daily life activities, and
personal requests. Amputations at the distal third level
are usually well-tolerated and do not necessarily need a
reconstruction. Amputations proximal to the distal third
can benefit from neurosensory flaps or a modified wrap-
around flap. The main goal in this case is restoration of a
sensate stable glabrous skin rather than full length. The
whole great toe or trimmed toe is the best choice for ampu­
tations around the metacarpophalangeal joint. Proximal
amputations, with loss of the thenar musculature, are chal­
lenging and require an extended second toe transfer or a
bone graft fixed in arthrodesis to a great toe transfer. Alter­
natively, as nicely shown by Adani et al., the first metacarpal
is lengthened by an external fixator on top of which, after
an average of 3 months, a mini wrap-around flap is trans­
ferred. In children, thumb reconstruction is better provided
by second toe transfer in order to avoid sacrifice of the great
toe.
Ulnar Component Reconstruction
In general, a single digit that opposes to the thumb, as in
a bi-digital hand, hardly allows one to perform all the
common tasks required for daily living. On the contrary, the
more sophisticated tripod pinch offers better grip and
strength in grasping an object, and more stability in holding
a pencil or using a key. As discussed for metacarpal hand
injuries, the position of the transferred toes depends on the
patient’s requests, whether a fine and precise (II–III
position) or a more powerful grip (IV and V positions) is
considered.
Opposition Reconstruction
Precision grip and power grip are the two essential features
gained during evolution by the human hand. They greatly
depend on the ability of the first ray to adapt, by means of
the opposition, to a certain object. This relies mainly on the
thenar musculature and the CMC joint, secondly on the
MCP and IP joints.
When the thenar muscles are injured, it is vital to perform
a proper opponensplasty and, if necessary, abductorplasty at
the time of reconstruction. Harvesting the extensor digito­
rum brevis together with the second toe can facilitate such
transfer, using different motors depending on the clinical

630
PART 4 — CONVENTIONAL WORKHORSE FLAPS
intensive care unit for the first 5 days where specialized
nurses can constantly monitor the transplant. We usually
administer dextran 40 (low-molecular-weight) in a continu­
ous infusion (25 mL/h) for 4–5 days. Assessment of skin
color, temperature, and capillary refill allows accurate moni­
toring of the transfer. Portable Doppler ultrasound aids in
verifying the patency of the vascular pedicle. Prophylactic
antibiotics such as cephalosporins are used in elective cases,
combined with gentamicin if further coverage is required.
Discharge is possible after 2 weeks when the rehabilitation
protocol has been set up.
MOTOR AND SENSORY REHABILITATION
For the first 4 postoperative days the patient receives psy­
chologic support and efforts are addressed exclusively to
assessing and maintaining vascular support to the transfer.
Subsequently, physical therapy is started and focused par­
ticularly on motor function.
• Day 4 to week 4: during the first 2 weeks, the wrist is kept
in neutral position and the transferred toe(s) at heart
level. From the second week, shoulder and elbow joints
can be gently mobilized, reaching a full range of motion.
If any rotational deformity is present, it should be cor­
rected at this stage. From the third week, a light Tubigrip
is employed, leaving the fingertips uncovered, and the
patient is instructed to apply gentle pressure in order to
control edema. A 15° passive motion can be sustained at
each joint of the transfer several times a day, alternated
by a splint in functional position.
• Week 5–6: at this stage, tendon healing can be expected
as well as good stability of the bone. Active range-of-motion
exercise is encouraged with the use of a dynamic splint.
Furthermore, blocking the PIP and MP joints consecutively,
each flexor as well as the extensor tendons are mobilized
separately. Massage is suggested to reduce scar formation.
• Week 7–8: muscle-strengthening exercises are encour­
aged, providing multiple tasks that reproduce daily life
activities with a full range of motion.
• Week 8 on: at this stage the program focuses on improv­
ing coordination and muscle strength. A nighttime splint
in extension is suggested to prevent flexion deformity at
the PIP joint.
Sensory reeducation is started as soon as the patient is
able to perceive 30 cps vibrations from a tuning fork with
the reconstructed finger. The program follows the same
principles traced by Dellon in the recovery of replanted
fingers and is based on training the patient to distinguish
materials that differ in texture, shape, and size. Once
instructed, the patient can continue with a home program.
OUTCOMES
EXPECTED OUTCOMES
The main goal in any reconstruction, whether in single- or
multiple-digit amputation or metacarpal hand, is the
an internal rotation of 45° to allow adequate opposition
to the other fingers.
• Multiple toe transfer: amputations at the wrist level can
be dealt with, as described by Vilkki, by transferring the
great toe and two adjacent toes in order to provide a
tripod pinch.
RECIPIENT SITE PREPARATION AND
FLAP INSET
The initial care of a traumatized hand is a fundamental step
when reconstruction by toe transfer is planned. All non-
viable tissue must be properly removed, avoiding, at the
same time, excessive shortening of the tendons and nerves.
All efforts should be made to maintain the full length of the
bony structures, which can be covered by a pedicle groin
flap. Adequate replacement of the soft tissue defect avoids
the need for wide dissection on the donor foot and facili­
tates the restoration of the first web space.
Two teams work simultaneously during the reconstruc­
tion. The recipient site is approached by a cruciform
incision so as to create four skin flaps that are of great
help when covering the neurovascular bundles of the trans­
ferred toe(s). The length of bones, tendons, and nerves is
measured as well as the distance to valuable recipient vessels.
The radial artery at the snuff box and a superficial vein
on the dorsum of the hand usually guarantee a reliable
vascular anastomosis and a good blood inflow/outflow. The
common digital arteries as well as the proper digital artery
can be selected in distal reconstruction. Bone fixation
is achieved by two parallel intraosseous wires, which lead to
a stable but not rigid fixation, allowing for secondary
corrective maneuvers by the physiotherapist to reach a
perfect alignment.
SECONDARY PROCEDURES TO
OPTIMIZE OUTCOMES
• Flexor tendon tenolysis (6.8%): the most common sec­
ondary procedure, producing satisfactory results
• Arthrodesis (3.0%): particularly at the DIP joint for cor­
rection of clawing deformity
• Web space deepening (3.0%): previous reconstructions
with pedicled groin flap are excellent in offering ade­
quate coverage in toe-to-hand transfer, but they often
require deepening of the web space in order to provide
better mobility
• Less frequently, tendon graft, tenorrhaphy or tendon
transfer, corrective osteotomy, and closure of the web
space are performed to improve function of the trans­
ferred toe(s).
POSTOPERATIVE CARE
The operated hand is protected in a soft dressing and ele­
vated at heart level in order to favor a good venous return
but avoid an extreme antigravity position. No splint is
applied. We transfer the patient to the microsurgical

CHAPTER 54 — Toe Flaps and Toe Transplantation
631
transfers were performed in 206 patients with a success rate
of 99.6% (Table 54.1). Arterial vasospasm is the most
common complication and occurs predominantly in the
first 3 postoperative days. Several factors should be carefully
supervised: room temperature, blood pressure, hydration,
and patient anxiety. If spasm occurs, it is advisable to remove
some of the skin sutures, place the hand in a dependent
position, use a warming lamp to maintain the temperature
above 35°C, and instill lidocaine 2% or papaverine (30 mg/
ml). If the spasm is persistent, consider systemic intravenous
infusion of prostaglandin E1 or continuous axillary blockade
with bupivacaine. If there is no resolution, re-exploration
provides a chance of success by removal of a possible hema­
toma, adventitiectomy, or vascular reanastomosis. When the
local arterial condition is critical it might be useful to find
a new recipient artery. The digital artery from an adjacent
finger can be dissected along its course and rerouted as a
recipient vessel. An Allen test of the neighboring finger is
mandatory.
Venous thrombosis is less frequent than arterial spasm. It
is generally a consequence of kinking of the pedicle, incor­
rect closure with tension around the vessel, or hematoma
formation after tunnelization. Re-exploration leads in
almost 80% of cases to success and should be carried out
without hesitation if there is no recovery within an hour.
However, an overall 3.5% failure rate has been reported. As
a last resort in cases of vascular failure, a tubed groin flap
can be raised in order to provide coverage to a transferred
toe that has been appropriately de-epithelialized and so
treated as a composite graft.
LONG-TERM OUTCOMES
Many factors play a role in functional outcome, such as type
of injury, recipient site preparation, accuracy in insetting
the transfer, and postoperative rehabilitation.
Thumb reconstruction depends mostly on preservation
of the thenar musculature and CMC joint. When these com­
ponents are preserved, great toe transfer achieves optimal
results, with grip strength and key pinch close or equal
to the normal side. The best functional result is reached
restoration of stable, sensate opposable digits that permits
the most fluent ability of prehension.
UNTOWARD OUTCOMES
DONOR SITE
Wound healing complications have been reported in up to
20% of patients after the harvest of the great toe. Skin
necrosis is related to excessive tension of the skin over
the osteotomy site; lack of adequate padding around weight­
bearing areas, such as the volar surface of the great toe in
wrap-around flaps; extensive undermining during dissec­
tion, especially on the dorsum of the foot; and poor surgical
technique. Care should be taken in planning a surgical inci­
sion that allows tension-free closure of the foot. Protection
of the plantar skin graft in the wrap-around technique with
a soft pad while walking is suggested up to 3 months. Late
complications are related, especially to gait imbalance after
great toe transplantation or scissor deformity in combined
toe transfer. In the majority of cases, patients do not have
problems in walking but demonstrate a decrease in push-off
and fatigue in those activities that require an efficient grip
strength and rapid change of direction. Therefore, football
players, climbers, and dancers should be advised of a pos­
sible decrease in their performance. Jogging and running
might be better tolerated with the use of shoe fillers.
RECIPIENT SITE
Toe-to-hand transfer is a safe procedure. In a recent review
of our series between 1991 and 2011, a total of 252 toe
Table 54.1  Microvascular toe flaps performed in
our center between 1991 and 2011
Toe-flap types
Number of
patients
Number of
flaps
Combined 2nd and 3rd toes
25
25
Double 2nd toes, or separated
2nd and 3rd toes
42
86a
Three toe transfersb
35
35
Two toe transfersc
2
4
2nd toe transfer
26
26
2nd toe to thumb
5
5
Total great toe to thumb
23
23
Trimmed great toe to thumb
18
18
Great toe wrap-around to
thumb
5
5
Vascularized joint transfer
25
25
206
252
aOne patient had four toe-transfer after 2–5th finger loss.
bThree toe transfer: either great toe-to-thumb and combined 2nd
and 3rd toe to fingers, or great toe-to-thumb and two toes to
fingers.
cTwo toe transfer: left big toe and right 2nd toe transfer.
Table 54.2  Key pinch and active motion in
different types of toe flaps
Great toe
transfer
2nd toe
Trimmed
great toe
Total
great toe
Great toe
wrap-
around
Number  
of cases
5
18
23a
5
IPJ active
ROM
22°
13°
31°
48°
Key pinch
power
1.8 kg
2.1 kg
3.3 kg
4.6 kg
aExcluding total great toe combined with toe(s) to fingers. IPJ,
interphalangeal joint; ROM, range of motion.

632
PART 4 — CONVENTIONAL WORKHORSE FLAPS
with total great toe transfer. Even though the trimmed toe
technique might have a better cosmesis, violation of the
IP joint during preparation leads to an average of 13° of
ROM compared with 31° of total great toe transfer. Further­
more, in accordance to different authors, key pinch is stron­
ger with the transfer of the great toe than the second toe
(Table 54.2). Two-point discrimination is usually <10 mm
after 2 years.
Isolated finger reconstruction varies with different levels
of amputation. The best results are usually achieved in
reconstruction at the middle phalanx. In such conditions,
the PIP joint can reach a mean range of active motion of
95° and the MP joint of about 80–90°. Reconstructions at
the proximal phalanx are less satisfactory and usually offer
an active range of motion of 60–70° at the PIP joint and 20–30°
at the MP joint. Transfers at or proximal to the MP joint
can provide an active range of motion of 25–35° at the toe
PIP joint, and 30–40° at the toe MP joint. Regardless of the
type of reconstruction, active range of motion at the DIP
joint is generally 10–20°. In most cases, 2PD is <10 mm within
2 years after reconstruction. The younger the patient, the
more satisfactory the final result. Children can reach 2PD
comparable with the normal side. Furthermore, growth
plate potential in pediatric toe-to-hand transfer is preserved,
with possible reduction where multiple longitudinal K-wires
are used.
The main goal in reconstruction of a metacarpal hand is
the restoration of stable, sensate, opposable digits, rather
than restoration of full range of motion, which the patient
is unlikely to recover. If adequate trouble is taken to match
the length of the restored digits and thumb, results are
very satisfactory. 2PD in combined toe transfers averages
7 mm.
In vascularized joint transfer, toe PIP joint to finger PIP
joint transfer leads to an average active range of motion of
about 26.7°. Toe PIP joint to finger MP joint transfer results
in about 35°. Toe MP joint to finger MP joint transfer leads
to an average of 29.9°.
CONCLUSIONS
The toes and the dorsal surface of the foot are the only
composite tissues that can mimic with great similarity the
features of the fingers. Technical advancements in micro­
surgical skill and aesthetic refinements in the procedure
make toe flap transfers an ideal first choice in the recon­
structive planning of a mutilated hand.

CHAPTER 54 — Toe Flaps and Toe Transplantation
633
A 33-year-old woman suffered from an open fracture at the
proximal interphalangeal (PIP) joint level of the III finger, right
dominant hand. A subsequent osteomyelitis was treated with
antibiotic and surgical debridement, resulting eventually
in ankylosis (Fig. 54.17A–D). Preoperatively, she had 10° hyper-
extension deformity and no flexion. A vascularized PIP joint
transfer from the contralateral second toe was planned. Osteo-
synthesis was performed with K-wire and cerclage. One artery
and one vein were anastomosed. Very good functional restora-
tion was achieved 10 weeks after surgery (Fig. 54.17E–H).
CASE 54.1  Vascularized PIP Joint Transfer for Reconstruction of a PIP Joint
Figure 54.17  (A–H) Second proximal interphalangeal joint transfer for restoration of the PIP joint of the long finger.
A
B
C
E
F
D
G
H

634
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 42-year-old man suffered from high-voltage 3rd-degree electric
burn on both hands. After several surgical debridements, his
right dominant hand resulted in amputation of the V finger and
the third phalanx of the second and third fingers. Moreover, the
entire volar skin surface of the thumb as well as the III and IV
fingers was lost (Fig 54.18A,B). The thumb was reconstructed
with a hemipulp neurosensory free flap, while the volar surface
of the fingers was replaced with a pedicled groin flap. The
patient regained a good tripod pinch and grasp capability, being
able to go back to his previous job (Fig. 54.18C–H).
CASE 54.2  Vascularized Hemipulp Transfer for Reconstruction of a Thumb Defect
Figure 54.18  (A–H) Hemipulp transfer for thumb reconstruction in a 3rd-degree burn patient.
A
D
G
H
E
F
B
C

CHAPTER 54 — Toe Flaps and Toe Transplantation
635
Expert Commentaries 
David T.W. Chiu, MD, FACS, FAAP, Wenhai Sun, MD
The characteristic nail complex, the articulating joints, and the
stable glabrous finger pad, so emblematic of Homo sapiens
digit, can only be appropriated and transplanted as a vascular-
ized composite tissue unit. The only readily available autoge-
nous donor site is the toe. Partial toe transfer, vascularized joint
transplantation, and toe pad, along with the vascularized and
neural pedicle as a vascularized flap have become indispens-
able surgical techniques in hand reconstruction. When a sig-
nificant portion of a thumb or finger is lost, unless an incidental
finger part happens to be available, the foot again is the only
reservoir for replacement parts.
The history of the development of toe-to-hand transfer, as
detailed by the authorship in this venerable chapter, is indeed
a manifesto of an irrepressible pursuit of excellence and innova-
tive brilliance of pioneers in our field. Meaningful assessment
of the reconstructive results requires balanced consideration of
(1) the form and function of the reconstructed digits and hand;
and (2) morbidity and residual deformity of the donor site. A
great deal of effort has been devoted to rebuilding a thumb or
finger that looks like a normal digit. Minimizing the bulkiness of
the big toe, wrapped-around technique was invented. To refine
shape and stability of the nail complex, trimmed-toe technique
was utilized for thumb reconstruction. Appropriating a big toe
left a large defect at the donor foot, a deformity that is generally
ill accepted. On the other hand, using a second toe as donor,
the left donor site morbidity and deformity are minimal. Yet the
construct is so slender and small that it is not comparable to a
normal thumb in shape and form. Combining the soft tissue
envelope of the big toe and skeletal of the second toe, as
advocated in the twist flap approach, and the combined com-
posite flap of various types produced a good-looking, albeit
after a stiff thumb has left a relatively deformed recombinant
big toe with a minuscule nail.
Reconstruction of the fingers presents a unique challenge:
restoration of the cascade of the hand. If all fingers are missing,
replacing the whole complement of fingers with two double toe
transfer restores the number of fingers which that are similar in
length, thus an acceptable cascade. However, if only the central
fingers are missing, a short construct would produce a dis-
torted cascade and would be ill-received. Reconstructing a
finger with a composite flap technique utilizes a vascularized
PIP joint and a big toe wrapped around flap can produce a
finger of normal length with the PIP joint as the appropriate
interval, but sacrificing the distal interphalangeal articulation. It
takes two toes to create one finger. Moreover, a long plantar
scar often ensues; the residue big toe also bears significant
deformity. The challenge remains; the pursuit of excellence
continues!
Fu-Chan Wei, MD, FACS
Toe-to-hand transfer is the only procedure that allows “like with
like” reconstruction of the amputated digits with minimal donor
site morbidity and no complications. The functional and aes-
thetic outcomes are superior to those achieved by prosthesis,
and the lack of immunosuppressants, as well, qualifies it as an
absolute indication for reconstruction of multiple finger and/or
thumb amputation and an appealing alternative for more proxi-
mal amputations.
Toe-to-hand transfer has evolved over time since its first
introduction to reach the “state-of-the-art.” From great or
second toe transfer to combined second and third or third and
fourth toe transfer, any toe can be transplanted with high
success rate (98%). It also evolved from whole to partial toe
transfer, including the vascularized nail complex, the vascular-
ized PIP or MP joint and pulp neurosensory flaps, increasing
the versatility of the reconstruction. Cosmesis has significantly
benefited from key procedures such as trimmed great toe, pulp
plasty, and components of aesthetic transfer such as partial
vascularized nail transfer.
The refinements in the technique have not been possible
without revolutionizing the concepts of toe-to-hand surgery,
drawing on accumulated knowledge and experience, which has
broadened, as a result, the indications to include (1) the most
rewarding distal single digit amputation and (2) thenar muscle
group injury, and alleviated the concerns regarding the ana-
tomic variations at the first web space through the retrograde
dissection strategy, established the safety of primary recon-
struction and pediatric toe-to-hand transfer, and provided reli-
able and trusted contingency plans for intraoperative hardship
such as spasm, exploration, and failure.
Metacarpal hand and metacarpal-like hand defects have also
benefited from toe-to-hand transplantation, especially in the
younger population and the unilateral defect patient group, in
whom allotransplantation is debatable. In these patients, tripod,
pulp-to-pulp or pulp-to-side pinch can be achieved with good
functional gain.
However, aside from innovations and refinements in toe-to-
hand surgery, the importance of planning, thoughtful consider-
ation at the time of replantation, tissue preservation approach,
patient selection and education, and vigorous sensory and
motor rehabilitation, lay the foundation for equally rewarding
surgery to the patients and the surgeon and cannot be further
emphasized.
Access Figures 54.19–21, as well as case
examples 54.3–54.5 and further reading online
at

CHAPTER 54 — Toe Flaps and Toe Transplantation 635.e1
A 25-year-old man sustained a traumatic amputation of his left
thumb at the base of the first phalanx, while working on a farm
(Fig. 54.19A). The level of amputation represented an ideal
indication for the transfer of the great toe in order to restore an
efficient pinch and grip strength. The left great toe was har-
vested in the acute stage (Fig. 54.19B) and transferred to the
first ray of the hand. Good appearance and mobility were evident
at 1-year follow-up (Fig. 54.19C–E).
Figure 54.19  (A–E) Left great toe-to-thumb transfer for amputation at the MP joint.
B
C
D
E
A
CASE 54.3  Thumb Reconstruction with Great Toe Transfer

635.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 37-year-old man suffered amputations of all his fingers while
thenar muscle function was preserved (Fig. 54.20A,B). Since the
wish of the patient was to insert the combined second and third
toe transfer into an ulnar position and maintain a long finger
centrally, the right great toe and left combined second and third
toes were transferred (Fig. 54.20C,D). Good extension and func-
tional tripod pinch were obtained (Fig. 54.20E,F).
CASE 54.4  Metacarpal Hand Type IIB Reconstructed with Multiple Toe Transfers
Figure 54.20  (A–F) Single-stage multiple toe transfer, metacarpal hand type IIB.
A
B
C
D
E
F

CHAPTER 54 — Toe Flaps and Toe Transplantation 635.e3
Figure 54.21  (A–F) Second metatarsophalangeal joint transfer for restoration of the MP joint of the ring finger.
A
B
C
D
E
F
A 37-year-old man presented with the loss of the fourth metacar-
pal head and the articular cartilage of the base of the first
phalanx of the same finger (Fig. 54.21A). A 2 × 3 cm area of skin
loss was also present in the palm, with disruption of the flexor
tendon (Fig. 54.21B). The second metatarsophalangeal joint of
the left foot was harvested for composite reconstruction (Fig.
54.21C). Fixation was performed by interosseous wire and plate
(Fig. 54.21D). Good functional results in flexion and extension
were achieved, and the aesthetic appearance was satisfactory
(Fig. 54.21E,F).
CASE 54.5  Vascularized MTP Joint Transfer for Reconstruction of an MP Joint Defect

635.e4 PART 4 — CONVENTIONAL WORKHORSE FLAPS
FURTHER READING
Adani R, Corain M, Tarallo L, et al. Alternative method for thumb
reconstruction. Combination of 2 techniques: metacarpal lengthen­
ing and mini wraparound transfer. J Hand Surg 2013;38A:1006–9.
Del Pinal F, Herrero F, Garcia-Bernal FJ, et al. Minimizing
impairment in laborers with finger losses distal to the proximal
interphalangeal joint by second toe transfer. Plast Reconstr Surg
2003;112(4):1000–11.
Del Pinal F, Garcia-Bernal FJ, Thams C, et al. Report on 250 consecutive
toe to finger transplants. Indications, results, failures, and new appli­
cations. Rev Esp Cir Ortop Traumatol 2011;55(4):257–62.
Dellon AL. Sensory recovery in replanted digits and transplanted toes:
a review. J Reconstr Microsurg 1986;2(2):123–9.
Doi K, Hattori Y, Dhawan V. The wrap-around flap in thumb reconstruc­
tion. Tech Hand Up Extrem Surg 2002;6(3):124–32.
El-Gammal TA, Wei FC. Microvascular reconstruction of the distal digits
by partial toe transfer. Hand Clin 1997;24(1):49–55.
Ellis PR, Hanna D, Tsai TM. Vascularized single toe joint transfer to the
hand. J Hand Surg Am 1991;16(1):160–8.
Foucher G, Binhammer P. Plea to save the great toe in total thumb
reconstruction. Microsurgery 1995;16:373–6.
Gilbert A. Vascular anatomy of the first web space of the foot. In: Landi
A, editor. Reconstruction of the thumb. London: Chapman and Hall;
1989. p. 205.
Halbert CF, Wei FC. Neurosensory free flaps. Digits Hand Clin
1997;13(2):251–62.
Iglesias M, Butron P, Serrano A. Thumb reconstruction with extended
twisted toe flap. J Hand Surg Am 1995;20:731–6.
Kempny T, Paroulek J, Marik V, et al. Further developments in the
twisted-toe technique for isolated thumb reconstruction: our method
of choice. Plast Reconstr Surg 2013;131(6):871–9.
Kurt E, Ozturk S, Isik S, et al. Continuous brachial plexus blockade for
digital replantations and toe-to-hand transfers. Ann Plast Surg
2005;54(1):24–7.
Kvernmo HD, Tsai TM. Post-traumatic reconstruction of the hand – a
retrospective review of 87 toe-to-hand transfers compared with an
earlier report. J Hand Surg 2011;36A:1176–81.
Lin CH. Toe-to-thumb reconstruction. Injury 2013;44:361–5.
Lin CH, Tang PL, Lin CH. Second toe extensor digitorum brevis
provides a simultaneous abductorplasty to free vascularized metatar­
sophalangeal joint transfer for posttraumatic thumb composite meta­
carpophalangeal joint defect. J Trauma 2009;66:1374–8.
Lin PY, Sebastin SJ, Ono S, et al. A systematic review of outcomes of
toe-to-thumb transfers for isolated traumatic thumb amputation.
Hand (NY) 2011;6:235–43.
Lister GD, Kalisman M, Tsai TM. Reconstruction of the hand with free
microneurovascular toe-to-hand transfer: experience with 54 toe
transfers. Plast Reconstr Surg 1983;71(3):372–86.
Mardini S, Wei FC. Unilateral and bilateral metacarpal hand injuries:
classification and treatment guidelines. Plast Reconstr Surg
2004;113(6):1756–9.
Morrison WA. Thumb and fingertip reconstruction by composite
microvascular tissue from the toes. Hand Clin 1992;8(3):537–50.
Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with
a free neurovascular wrap-around flap from the big toe. J Hand Surg
1980;5(6):573–83.
Tan BK, Wei FC, Chang KJ, et al. Combined third and fourth toe trans­
plantation. Hand Clin 1999;15(4):589–96.
Tsai TM, Aziz W. Toe-to-thumb transfer: a new technique. Plast Recon­
str Surg 1991;88(1):149–53.
Wei FC. Tissue preservation in hand injury: the first step to toe-to-hand
transplantation. Plast Reconstr Surg 1998;102(7):2497–501.
Wei FC, Chen HC, Chuang CC, et al. Reconstruction of the thumb
with a trimmed-toe transfer technique. Plast Reconstr Surg
1988;82(3):506–15.
Wei FC, Colony LH, Chen HC, et al. Combined second and third toe
transfer. Plast Reconstr Surg 1989;84(4):651–61.
Wei FC, Chen HC, Chuang DCC, et al. Second toe wrap-around flap.
Plast Reconstr Surg 1991;88(5):837–43.
Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb reconstruc­
tion with toe transfer: selection of various techniques. Plast Reconstr
Surg 1994;93(2):345–57.
Wei FC, Silverman RT, Hsu WM. Retrograde dissection of the vascular
pedicle in toe harvest. Plast Reconstr Surg 1995;96(5):1211–14.
Wei FC, Chen HC, Chuang DCC, et al. Aesthetic refinements in toe-to-
hand transfer surgery. Plast Reconstr Surg 1996;98(3):485–90.
Wei FC, El-Gammal T, Lin CH, et al. Metacarpal hand: classification
and guidelines for microsurgical reconstruction with toe transfers.
Plast Reconstr Surg 1997;99(1):122–8.
Wei FC, Coskunfirat OK, Lin CH, et al. Isolated third-toe transfer:
indications, technique, and reliability. Plast Reconstr Surg 2005;
115(5):1314–24.
Yim KK, Wei FC. Secondary procedures to improve function after toe-
to-hand transfers. Br J Plast Surg 1995;48(7):487–91.
Zhao J, Tien HY, Abdullah S, et al. Aesthetic refinements in second
toe-to-thumb transfer surgery. Plast Reconstr Surg 2010;126(6):
2052–9.

636
Medial Femoral Condyle
and Descending Genicular
Artery Perforator Flaps
Matthew Houdek  |  Heinz Bürger  |  Steven L. Moran
55 
INTRODUCTION
Increasing knowledge of the blood supply to the distal
femur has resulted in the development of a variety of com­
posite flaps designed to include bone from the medial
femoral condyle. Flaps from this area can be designed to
include not only bone but also articular cartilage, skin,
muscle, and tendon. The original description of a periosteal
flap from this region was described by Masquelet in 1988
and was based on the descending geniculate artery.1 This
flap was then modified by Doi to include the periosteum
and femoral cortex for the management of scaphoid non-
unions.1–4 Recent publications have shown the medial genic­
ulate arterial system also supplies the surrounding skin,
articular cartilage, muscle, and tendon allowing for the cre­
ation of composite vascularized bone flaps.5–7 This variation
in tissue types, in addition to a relatively small donor site,
has allowed this flap to gain a newfound popularity for the
management of composite bony defects within the extremi­
ties as well as the head and neck as its donor site may
compare favorably with that of the fibula or iliac crest bone
flaps.
FLAP ANATOMY (Figs 55.1, 55.2, see
Figs 13.1, 13.2, 13.4 and 13.19)
The flaps of the medial femoral condyle (MFC) are based
on the geniculate arterial system, which is a branch of the
femoral artery and is located medially in the thigh and knee.
ARTERIAL ANATOMY OF THE FLAP
(Figs 55.1 and 55.2, see Figs 13.2 and 13.4)
The anatomy of the MFC flap has been studied extensively
and most recently by Yamamoto and Iorio and colleagues.7,8
The bone flap is located over the medial femoral condyle
and is bound by three borders, the posterior border of the
femur, anteriorly by the medial patellar facet, and distally
by the medial collateral ligament. The flap is supplied by
two sources: the descending genicular artery (DGA) and the
superomedial genicular artery (SGA). The DGA originates
Figure 55.1  Medial Femoral Condyle and Descending Genicular
Artery Perforator Flaps.
Superficial femoral artery
Superomedial
genicular artery
Medial
femoral
condyle
Descending
genicular artery
(DGA)
Popliteal
artery
Medial
metaphyseal
periosteal
artery
Transverse
branch of DGA
Longitudinal
branch
of DGA
Saphenous
branch of DGA
Distal cutaneous
branch of DGA
Medial
collateral
ligament
Saphenous
nerve
Infrapatellar
branch of
saphenous
nerve
Patellar
ligament
Vastus
medialis
Semi-
tendinosus
Semi-
membranosus
Gracilis
Sartorius
(retracted)
Adductor magnus
tendon
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION G  —  LOCAL AND FREE FLAPS IN THE LOWER EXTREMITY

CHAPTER 55 — Medial Femoral Condyle and De scending Ge nicular Artery Perforator Flaps
637
cartilage on the superior femoral condyle. The muscular
branch supplies the vastus medialis muscle and the saphe­
nous branch supplies the subcutaneous tissue and overlying
skin.9
Yamamoto and colleagues studied the arterial anatomy to
the medal femoral condyle in 19 cadavers. They discovered
from the femoral artery just distal to the adductor hiatus. It
lies deep or lateral to the adductor magnus tendon along
the posterior aspect of the medial intermuscular septum.
The DGA typically has three branches, including an articu­
lar branch, a muscular branch, and a saphenous branch.
The articular branch feeds the periosteum and the articular
Figure 55.2  (A) Schematic of the anatomy of the descending genicular artery (DGA) and superomedial genicular arterial system. The DGA
has perforators to the bone (via the osteoarticular branch), skin (via the saphenous branch), and the muscle. The superomedial genicular branch
has a shorter pedicle length and smaller internal diameter than the DGA but is more consistently identified during dissection. (B) Arterial anatomy
of the medial femoral condyle flap with particular attention to the harvest of osteoarticular tissue to be used for scaphoid reconstruction.
Medial collateral ligament
Descending genicular artery
Descending genicular artery
Superiomedial genicular artery
Adductor magnus tendon
Femoral
harvest site
Excised
bone
Scaphoid after
resection of nonunion
Shadow image of
scaphoid is drawn
overlying the MFT
to demonstrate
the orientation of
the cartilage harvest
employed to re-create
the scaphoid
proximal pole
Nonunion
A
B

638
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Articular Branch of the DGA
Distance from the medial knee joint line: 12.5 cm
(10–17.5 cm)
Diameter: 1.2 mm (0.5–1.8 mm)
Length: 11.4 cm (6.5–14 cm)
Saphenous Branch of the DGA
Distance from the medial knee joint line: 13 cm (9–17.5 cm)
Diameter: 1.3 mm (0.4–2 mm)
Length: 13.7 cm (10.5–16 cm)
ARTERIAL SUPPLY OF PERIOSTEUM
UPPER TRANSVERSE ARTERY (UTA)
Distance from the medial knee joint line: 7.2 cm (5.4–
8.9 cm)
Diameter: 0.55 mm (0.38–0.70 mm)
BRANCHES OF THE UTA
Middle Descending Branch
Distance from the UTA takeoff of the descending genicular
artery: 2.7 cm (1.4–7 cm)
Diameter: 0.28 mm (0.21–0.29 mm)
Anterior Descending Branch
Distance from the UTA takeoff of the descending genicular
artery: 0.96 cm (0.3–1.6 cm)
Diameter: 0.33 mm (0.18–0.41 mm)
CENTRAL LONGITUDINAL ARTERY (CLA)
Length from the UTA takeoff of the descending genicular
artery: 3.4 cm (1.7–5.3 cm)
Diameter: 0.49 mm (0.31–0.67 mm)
BRANCHES OF THE CLA
Anterior Branch
Distance from the CLA origin of the descending genicular
artery: 1.98 cm (0.4–4.1 cm)
Posterior Branch
Distance from the CLA origin of the descending genicular
artery: 2.59 cm (0.8–4.65 cm)
ANGIOSOME OF THE SKIN PADDLE
Descending Geniculate Artery Distal
Cutaneous Branch
Angiosome area: 70 cm2
Saphenous Branch
Angiosome area: 361 cm2
the DGA was present in 89% of the specimens with the
artery originating on average 13.7 cm from the articular
surface of the knee. At its origin the vessel had an average
internal diameter of 1.5 mm (range 1–2 mm). An osteoar­
ticular branch was present in 89% of specimens branching
from the DGA approximately 11.3 cm (range 5.5–15 cm)
from the knee joint and this branch had an average internal
diameter of 1.1 mm (range 0.63–1.5 mm); 79% of speci­
mens had an identifiable saphenous branch, which travels
with the saphenous nerve and perfuses the overlying
skin.7
The SGA originates from the proximal portion of the
popliteal artery. In Yamamoto’s anatomic study, this vessel
was present in 100% of the specimens with the origin of the
vessel just 5.2 cm from the articular surface. The vessel has
an average internal diameter of 0.78 mm at its origin and
ranged in diameter at 0.38–1.4 mm. The vessel crosses from
behind the adductor magnus tendon to anastomose with
the osteoarticular branch of the DGA contributing to the
perforating vessels over the condyle. The superior medial
genicular artery was the dominant vessel supplying the
medial femoral condyle in two of the specimens in Yama­
moto’s study (Fig. 55.2).7
Additional pertinent anatomic points about the flap
include:
• The preferred vascular supply to the flap is the DGA, as
it has a longer pedicle length (between 5 and 10 cm), and
larger internal diameter than the SGA, facilitating micro­
vascular anastomosis.
• The DGA divides into three arteries: the muscular branch,
the articular branch, and the saphenous branch.
• The articular branch divides into the upper transverse
artery (UTA) and the central longitudinal artery (CLA):
• The UTA gives off four branches: ascending, posterior
descending, middle descending, and anterior descend­
ing branches
• The CLA divides into the posterior (arcuate) and ante­
rior branch.
• The middle branch of the UTA and the anterior branch
of the CLA anastomose to form the main anastomotic
arch of the medial femoral condyle.
Dominant:  descending geniculate artery (DGA)
Distance from the medial knee joint line: 15.4 cm
(11.3–20.8 cm)
Diameter: 1.5 mm (1–2 mm)
Length: 1.2 cm (0.3–3 cm)
The descending geniculate artery is absent or diminutive
in 10–15%.7,8
Secondary:  superior medial geniculate artery (SMGA)
Distance from the medial knee joint line: 7.5 cm (4.7–9 cm)
Diameter: 0.75 mm (0.29–1.3 mm)
Muscular Branch of the DGA
Distance from the medial knee joint line: 12 cm (8–18 cm)
Diameter: 1.4 mm (0.5–3 mm)
Length: 6.3 cm (5–7 cm)