A.

PLATE V-8

First web space neurovascular flap.

A. This flap depends on the superficial first metatarsal vessels. If they are not obvious on Doppler studies, an arteriogram is indicated. It would be extremely difficult to mobilize this flap on the deep first metatarsal vessels without damaging branches to the skin island. The sensory supply to the dorsal web tissue comes from the deep peroneal nerves, which run with the dorsalis pedis vessels. Sensation to the plantar half of the flap and pulp of the toes comes from the plantar digital nerves. If critical sensation is important, such as in a thumb or finger pinch area, these plantar nerves must be included. The proximal part of the flap, like the dorsalis pedis flap, is innervated by the superficial peroneal nerve.

B. Potential recipient area in the palm of the hand with proximal blood and nerve supply outlined from the ulnar artery and nerve. A template of the expected donor area can be fabricated from the normal right hand and reversed.

C. Flap in place with neurovascular hookup.

Clinical Cases: Dorsalis Pedis Sensory Cutaneous Flap

CASE 1

The patient sustained an avulsive crushing injury to a heel, with loss of soft tissue covering of the heel and a portion of the calcaneus. The area was initially covered with a thin split-thickness skin graft. The heel area was prone to breaking down and was extremely tender.

FIG. 5-01. Initial defect. Medial view.

FIG. 5-02. Posterior view.

FIG. 5-03. Template of skin paddle needed.

FIG. 5-04. The cutaneous flap is marked, with the tourniquet partially elevated to allow marking of several veins.

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