The dorsalis pedis region is supplied by the dorsalis pedis artery and drained by the venous network on the dorsum of the foot. The dorsalis pedis artery courses plantarly at the level of the base of the first and second metatarsal. The first dorsal metatarsal artery originates from the dorsalis pedis at this level. Using the skin over the first and second metatarsals requires the presence of a first dorsal-metatarsal artery. This vessel can be confirmed by Doppler or arteriogram. Our experience with toe transplantation has shown that this vessel may be rudimentary and too small to use in about 60% of cases. If the toe is to be transplanted, the plantar metatarsal artery (deep to the first transverse metatarsal ligament) is included in flap elevation. This plantar artery can be repaired to a second recipient artery to augment the blood supply to the first metatarsal or metatarsophalangeal joint. We do not use the distal dorsalis pedis skin flap alone when the first dorsal-metatarsal artery is not present.

The donor site skin on the foot must be treated meticulously. A skin graft is preferable to skin closure under tension. Constant elevation of the foot for 2 weeks is mandatory. If the second toe or part of the second metatarsal is removed with the flap, removal of the remaining metatarsal shaft should be performed to eliminate the gap in the foot and allow better wound approximation. With attention to detail, problems related to this donor site can be minimized.

Anatomy

VEINS

Dorsal digital veins run along the dorsal side of each toe. At the web space, these unite to form dorsal-metatarsal veins that empty into the dorsal venous arch. This subcutaneous arch overlies the metatarsal bones. The dorsal-digital vein on the medial side of the great toe joins with the dorsal-venous arch on the medial side of the foot vein to form the great saphenous vein. The dorsal-digital vein on the lateral side of the little toe meets the dorsal-venous arch to form the small saphenous vein. While venae comitantes of the dorsalis pedis artery may be used for venous drainage, the superficial venous network provides veins of larger caliber that can be dissected proximally to provide more length.

ARTERIES

The dorsalis pedis artery, a continuation of the anterior tibial artery, lies between

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