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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.
PLATE I-2
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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