Free tissue transfer of cutaneous or osteocutaneous flaps of the dorsum of the foot is an alternative less frequently used by most reconstructive microsurgeons. Although the flaps from the dorsum of the foot are relatively easy to harvest, the rate of donor site problems is high. The dorsum of the foot can provide thin, sensory cutaneous flaps with or without bone, joint, and tendon.1-9 The major arterial supply, the dorsalis pedis artery, is constant in size; however, its terminal branch, the first dorsal metatarsal artery, is variable in size and location.10-15

Indications

DORSALIS PEDIS SENSORY CUTANEOUS FLAP

The skin supplied by the dorsalis pedis artery is thin and pliable and is also innervated by the superficial peroneal nerve. These features make the dorsalis pedis flap a possible alternative for coverage of recipient areas requiring less bulky flaps, such as the hand, the mandible, or the palate. Other cutaneous flaps such as the groin, deltoid skin, or other musculocutaneous flaps are often too thick and require debulking procedures at a second stage.

The major disadvantage to the dorsalis pedis flap is the donor defect. The donor defect cannot be closed primarily and is therefore closed with a split-thickness skin graft. Even though this split-thickness skin graft is on the dorsum of the foot, a nonweight-bearing area, we have seen problems with breakdown of the donor area and verrucous hyperplasia. Of 10 patients who had sequential dorsalis pedis flaps performed, 4 had prolonged wound healing problems from breakdown of the skin graft over the dorsum of the foot. Because of this, the serratus anterior muscle with a skin graft is now used to cover the palm of the hand and similar-sized areas.

Including the superficial or deep peroneal nerve in the transplant and anastomosing this nerve to a sensory nerve in the recipient area can restore sensation to the transplanted skin flap.

First web space sensory cutaneous flaps are innervated by the deep peroneal nerve. Dorsalis pedis sensory cutaneous flaps are innervated by the superficial peroneal nerve. On occasion, both superficial and deep peroneal nerves are harvested simultaneously.

DORSALIS PEDIS OSTEOCUTANEOUS FLAPS

The dorsalis pedis flap can be harvested with the underlying metatarsal bone or metatarsophalangeal joint.15,16 A ray amputation is performed of the second toe to provide better function of the foot. The thin skin and bone flap can be used to reconstruct defects of the hand and face. Vascularized metatarsal joints do not flex in the same way as metacarpophalangeal joints. Flexion at best is approximately 45 degrees with extension at approximately 70 degrees. Capsuloplasty can be performed to decrease extension and increase flexion.

Technical Considerations

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