The ipsilateral second toe is most frequently used because its first dorsal metatarsal artery is directly aligned with the dorsal-radial artery. The anatomy of the vascular pedicle, whether it is a plantar- or dorsal-dominant system, may be assessed preoperatively with Doppler or angiograms. This information is particularly helpful in planning the dissection of a foot. The operation is performed under tourniquet control.

Technical Considerations

The dissection of the proximal interphalangeal joint is carried out through a lazy-S incision over the dorsalis pedis and first dorsal metatarsal system. An ellipse of skin dorsal to the joint is maintained, as is the soft tissue surrounding the neurovascular pedicle. Preservation of this cuff of tissue helps to support a skin graft if the available cutaneous flap coverage at the hand is insufficient.

As the dissection proceeds distally, division of the interosseous muscle, along with ligation and division of the communicating branches to the plantar system, is performed. The vascular structures are dissected in such a way as to maintain them on the fibular side toward the second toe. This prevents inadvertent transection of the branches to the second toe and the second metatarsal. At the level of the transmetatarsal ligament, the H-branching between great and second toe, as well as those between the dorsal and plantar system, are identified. The pedicle and branches to the second toe are preserved and those to the great toe and plantar system are ligated and divided.

The toe joint and the proximal and middle phalanx are dissected from the surrounding skin and soft tissues with preservation of the pedicle, dorsal skin island, and the extensor and flexor tendons. The tendons are resected with preservation of the sheaths and osteotomies of the phalanges made at the appropriate levels (often the phalanges are disarticulated from the MT and DIP joints first). The joint with its dorsal skin paddle is thus tethered only by its pedicle. The tourniquet is released and the viability at the joint flap is assessed.

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