Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 5:
Dorsalis Pedis

Plate V-1

A. Anatomy. Relationships of tendons, nerves, and blood vessels are shown. Skin territory can be extended distally to include the first web space on the superficial first metatarsal vessels.


A, B. An incision is made along the medial margin of the proposed flap and the large veins draining in this region of the skin are identified and dissected proximally.

C. Dissection of the flap and its arterial pedicle may begin at the proximal end or the distal end of the flap. The surgeon must keep all the septocutaneous connections between the arteries and the skin intact. If the dissection is begun distally, the first dorsal metatarsal vessel is ligated and divided unless the tissue from the first web space is to be included. One must be careful not to disturb proximal branches in this area that enter the flap because these perforators are critical to flap perfusion. The flap is elevated deep to the fascia, leaving peritenon intact. Stitches should be placed between the deep fascia and the skin to avoid skin-flap shearing.

D. The extensor hallucis brevis is usually included in the flap to keep it in the proper plane. Peritenon must be left on the extensor digitorum communis, extensor hallucis longus, and remaining extensor brevis. Both the deep peroneal running with the artery and the superficial peroneal nerves in the superficial plane can be easily harvested with the flap.


E. The flap is now elevated with arteries, veins, nerves, and extensor hallucis brevis included in the flap.

F. The entire flap is now elevated. The arterial venous pedicle is intact. The tourniquet is now released to confirm adequate flow to the flap before transplantation. Branches of the saphenous vein and proximal veins over the central dorsum of the foot should be tied long for venous anastomoses if needed.


A. Anatomy of second metatarsal osteocutaneous flap. Dorsalis pedis flap including second metatarsal bone. The anatomy of the flap is the same as that of the sensory cutaneous dorsalis pedis flap except that the circulation to the first web space is critical. Whether the first metatarsal artery is dorsal- or volar-dominant, it must be incorporated to vascularize the second metatarsal bone. It may continue as a superficial branch of the dorsalis pedis on or under the fascia of the interosseous muscle, travel in the muscle, or come back up in a V fashion from the proximal communicating branch of the dorsalis pedis to the deep plantar system (see inset).


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