A.

B. Once the surgeon has determined the location of the first metatarsal vessel, the dissection proceeds along the medial margin of the flap. The web space should be opened widely with a distracting instrument so that the vessels on the medial side of the second metatarsal bone can be well visualized and preserved. Transecting the transmetatarsal ligament between the first and second metatarsal heads will enhance this exposure. A cuff of intrinsic muscle must be carried with the osteocutaneous transplant to preserve the blood supply to the bone. Aesthetically, it is better to discard the distal toe than to leave a flail digit if the phalanges are not going to be included in the osteocutaneous flap. Occasionally the proximal phalanx can be of value in temporomandibular joint reconstruction. The saphenous vein is dissected out, preserving branches entering the medial edge of the flap, as a secondary venous outlet if needed.

C. The osteocutaneous flap has been separated from the distal toe and the second metatarsal shaft has been transected far proximally. Paratendon on the extensor hallucus longus and lateral toes is carefully preserved because they sustain a skin graft when the wound is closed.

PLATE V-5

A. The dorsalis pedis metatarsal bone flap has been completely mobilized on the proximal neurovascular pedicle of the dorsalis pedis artery and greater saphenous vein. The metatarsal shaft is cut as far proximal as possible to preserve perforators from the first metatarsal.

PLATE V-6

A. The first metatarsal osteocutaneous flap is to be used for total nasal reconstruction.

B. Outline of the flap onto the second toe is seen. The dorsalis pedis artery and greater saphenous vein are dissected far proximally to gain an extremely long vascular pedicle.

C. Osteotomies are made to create an L-shaped dorsal strut.

PLATE V-7

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