Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 1:
Great Toe Transplantation
  D. Dorsal view of the same structures, with the rich venous arcade over the bases of the toes. The short extensor to the great toe is shown crossing the first metatarsal space, covering the dorsalis pedis artery and its venae comitantes. This muscle should be cut early in the dissection to facilitate the identification of the artery and its penetrating branch in the first metatarsal space. This muscle can be cut long and used in the hand to anastomose to the short extensor or be brought around to the palmar surface to strengthen opposition of the transplanted toe.


A. The lateral incision of the skin island has been carried well back on the dorsal medial aspect of the foot, exposing the large saphenous vein. The short extensor has been cut, and the underlying dorsalis pedis artery and its venae comitantes have been mobilized from the dorsum of the foot distally into the toe. The proximal communicator at the base of the first metatarsal space is seen with a branch from the saphenous vein joining it. This communicating branch between the saphenous vein and the venae comitantes of the dorsalis pedis artery is a consistent anatomic finding and can often be used to locate this point of penetration of the artery.

B. The same structures are rotated laterally, more clearly showing the communicating vein between the two systems. The long extensor tendon has been mobilized well back on the dorsum of the foot and provides an almost unlimited length of tendon. The deep peroneal nerve can be seen running with the dorsalis pedis artery and its venae comitantes, usually down its medial side. It branches out over the distal portion of the web space and into the dorsum of the first and second toes. This nerve is carried with the A-V pedicle and can be anastomosed to the branch of the superficial radial nerve in the hand, thus increasing the quality of sensation in the dorsum of the transplant. Proximal segments of the deep peroneal nerve may also be used for nerve grafts if a short segment is needed in the hand.


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