Dorsalis Pedis Flap

The dorsalis pedis flap has been used as a solution for wound coverage at the medial, anterior, and lateral ankle as an island flap^1-3. The vascular pedicle can be dissected proximally on the anterior tibial artery and allow cover over the heel^4,5 and Achilles tendon.⁶  It can be based on the perforator branch of the dorsalis pedis artery with reversed flow from the posterior tibial artery for distal foot reconstruction.^7-9

The dorsalis pedis flap's more popular use has been as a microvascular transplant for composite tissue reconstruction. It is thin and easily contoured making it popular in reconstructions of the face,^10-12 floor of mouth,^13,14 palate,¹⁵ and hand, ^16,17 areas which would suffer from bulky-nonpliable tissue transplants. It can be harvested on a long reliable dorsalis pedis or anterior tibial pedicle with the greater or lesser saphenous vein. It can be harvested with the deep or superficial peroneal nerve for sensate reconstructions,^18,19 with the second metatarsal, second metatarso-phalangeal joint or second toe for complex reconstruction of the hand,^20-23 and with the dorsal foot extensor system as tendo-cutaneous flap for vascular reconstruction of the extensor digitorum communis tendons.^24-27

Angiography has been recommended in cases in which adequate collateral blood supply to the foot cannot be confirmed. Absence of a patent posterior tibial artery and vascular arch is a strict contraindication to harvest of the dorsalis pedis flap.

In theory, the dorsalis pedis flap offers thin, innervated tissue which can be harvest with a number of other tissues allowing creative single stage reconstructions of many areas. Unfortunately, in practice, donor site morbidity such as delayed healing, infection, tendon exposure, pain, and dorsal foot contracture have limited its widespread use.²⁸

Anatomy

The dorsalis pedis flap is a thin fascio-cutaneous flap supplied by an axial artery. It can be designed to include the majority of the dorsum of the foot usually up to 12 by 12 cm depending on the breadth of the foot. As mentioned above, it can be harvested in combination with other tissues to create an innervated flap, osteocutaneous flap, tendo-cutaneous flap, or musculocutaneous flap.

Arterial Anatomy

The dorsalis pedis artery which is an extension of the anterior tibial artery supplies the flap. The anterior tibial artery lies lateral to the tibialis anterior tendon and medial to the extensor hallucis longus (EHL) tendon at the entrance of the extensor retinaculum or the ankle. It courses under the retinaculum and emerges medial to the EHL tendon as the dorsalis pedis artery. The dorsalis pedis artery branches to form the arcuate artery, lateral, and medial tarsal arteries which supply structures beneath the extensor tendons and are not harvested as part of the flap. The artery branches into the first dorsal metatarsal artery and deep perforating branch at the first intermetataral space. The perforating branch joins the plantar arch. The first dorsal metatarsal artery (FDMA) supplies the first web space, great or second toe. The FDMA can have a variable course above, through, or below the first dorsal interosseous muscle.²⁹ The dorsalis pedis supplies the overlying soft tissue via several tenuous branches along its length. The most important branches are located in the soft tissue that lies between the EHL and EDL tendon to the second toe.³⁰

Venous Anatomy

The superficial veins of the dorsal foot form an arch and drain medially through the greater and laterally through the lesser saphenous systems. These can be diagramed to decide which is most appropriate for an individual reconstruction. If these are inadequate the flap can be effectively drained by the venae associated with the dorsalis pedis artery.

Nerves

Two separate nerves which supply the dorsum of the foot can be utilized with this flap. The superficial peroneal nerve runs down the lateral leg and branches at the level of the extensor retinaculum to provide sensation to the medial and lateral dorsum of the foot. The deep peroneal nerve runs with the dorsalis pedis artery below the extensor retinaculum, under the extensor hallucis brevis tendon and into the first web space.

Dissection

The most difficult aspect of the dorsalis pedis flap harvest is protection of the tenuous perforators between the axial system and the cutaneous paddle. Because of this, care must be taken to define the trough of tissue lying between the EHL and EDL tendons and capture all perforators from the dorsalis pedis artery and branches of the dorsalis pedis artery.

The dimension of the flap should be marked along with the axis of the dorsalis pedis artery and saphenous system. The harvest should proceed under tourniquet control. Care should be taken not to completely exsanguinate the foot so that small perforators can be identified and protected.

Harvest of the flap proceeds from its medial or distal extent. The proximal or distal edge is developed first depending on the surgeon's preference. If begun distally, the first dorsal metacarpal artery should be identified and the dissection plane should be developed under it to capture it in the flap. If begun proximally, the dorsalis pedis artery should be identified with the deep peroneal nerve lateral to the EHL.

Once identified, elevation of the medial aspect of the flap is performed below the fascia and above the peritenon of the extensor tendons. As the dissection approaches the trough of tissue between the EHL and EDL tendons all soft tissue and branches from the dorsalis pedis artery is taken. Again care is taken to define the level of the dorsalis pedis artery so that it is not separated from the cutaneous paddle. Suture can be applied between the fascia and cutaneous paddle to insure that no shearing of the perforators occurs.

Once the dorsalis pedis artery, deep perforating branch, and first dorsal metatarsal arteries are defined care is taken to elevate the lateral aspect of the flap below fascia and above peritenon towards the trough of tissue between the EHL and EDL. Again, the proximal and distal vessels are identified to define the level of dissection. The deep perforating branch is ligated and transected releasing this arterial leash. The extensor hallucis brevis muscle and tendon travel obliquely through this trough of tissue. It is included with this trough of tissue decreasing injury to the perforators in that area. The superficial and deep peroneal nerves can be identified and harvest with additional graft length as needed. The tourniquet is released confirming adequate perfusion to the foot and flap.

After hemostasis is achieved all rents in the peritenon should be closed. The donor site can then be skin grafted. The leg is then strictly elevated for two weeks. After that point, compression with an Ace bandage is employed whenever the leg is dependent for an additional two weeks.

Bibliograhpy

1. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap. A Clinical study. Plast Reconstr Surg 1975;55:177-185.

2. Bos GD, Buehler MJ. Lower extremity local flaps. J Am Acad Orthop Surg. 1994;2:342-351.

3. Gibstein LA, Abramson DL, Sampson CE, Pribaz JJ. Musculofascial flaps based on the dorsalis pedis vascular pedicle for coverage of the foot and ankle. Ann Plast Surg 1996;37:152-157.

4. Duncan MJ, Zuker RM, Manktelow RT. Resurfacing weight bearing areas of the heel. The role of the dorsalis pedis innervated free tissue transfer. J Reconstr Microsurg 1985;1:201-208.

5. Gajiwala KJ, Mehta IM, Mahaluxmuvivala SM, Padia RK. A new approach to heel ulcers: dorsalis pedis neurovascular transinterosseous island flap. Br J Plast Surg 1987;40:241-245.

6. Babu V, Chittaranjan S, Abraham G, Korula RJ. Single-staged reconstruction of soft-tissue defects including the Achilles tendon using the dorsalis pedis arterialized flap along with the extensor digitorum brevis as bridge graft.

7. Governa M, Barisoni, D. Distally based dorsalis pedis island flap for a distal lateral electric burn of the big toe. Burns 1996;22:641-643.

8. Karacaoglan N. Distally based dorsalis pedis adipofascial flap. Plast Reconstr Surg 1996;98:752-753.

9. Kamal MS, Azab AS, Talaat HA. Leg repairs with an island flap from the dorsum of the foot, based on the anterior tibial vessels. Plast Reconstr Surg 1979;64:498-504.

10. Thai KN, Billmire DA, Yakuboff KP. Total eyelid reconstruction with free dorsalis pedis flap after deep facial burn. Plast Reconstr Surg 1999;104:1048-1051.

11.  Benmeir P, Neuman A, Wienberg A, Rotem M, Eldad A, Lusthaus S, Kaplan H, Wexler MR. Reconstruction of a completely burned nose be a free dorsalis pedis flap. Br J Plast Surg 1991;44:570-571.

12. Ohmori K, Sekiguchi J, Ohmori S. Total rhinoplasty with a free osteocutaneous flap. Plast Reconstr Surg 1979;63:387-394.

13. Mazzarella LA, Friedlander AH, Leeb DC. Floor of mouth reconstruction with free dorsalis pedis flap. Arch Otolaryngol 1978;104:38-41.

14. Leeb DC, Ben-Hur N, Mazarella L. Reconstruction of the floor of the mouth with a free dorsalis pedis flap. Plast Reconstr Surg 1977;59:379-381.

15. Correa Chem R, Franciosi LF. Dorsalis pedis free flap to close extensive palate fistulae. Microsurgery 1983;4:35-39.

16. McCraw JB. On the transfer of a free dorsalis pedis sensory flap to the hand. Plast Reconstr Surg 1977;59:738-739.

17. Ohmori K, Harii K. Free dorsalis pedis sensory flap to the hand, with microvscular anastomosis. Plast Reconstr Surg 1976;58:546-554.

18. Minami A, Usui M, Katoh H, Ishii S. Thumb reconstruction by free sensory flaps from the foot using microsurgical techniques. J Hand Surg 1984;9B:239-244.

19. Struach B, Greenstein B. Neurovascular flap to the hand. Hand Clin 1985;1:327-333.

20.  Smith PJ, Jones BM. Free vascularized transfer of a metatarsophalangeal joint to the hand. A technical modification. J Hand Surg 1985;10B:109-112.

21. Rose EH, Buncke HJ. Free transfer of a large sensory flap from the first web space and dorsum of the foot including the second toe for reconstruction of a mutilated hand. J Hand Surg 1981;6A:196-201.

22. Chang TS, Wang W, Wu JB. Free transfer of the second toe combined with dorsalis pedis flap using microvascular technique for reconstruction of the thumb and other fingers. Ann Acad Med Singapore 1979;8:404-412.

23. Macionis V. Reversed free osteoarhtrocutaneous dorsalis pedis flap for simultaneous reconstruction of the trapeziometacarpal joint and the first metacarpal bone. Plast Reconstr Surg 1997;99:2066-2070.

24. Desai SS, Chuang DC, Levin LS. Microsurgical reconstruction of the extensor system. Hand Clin 1995;11:471-476.

25. Lee KS, Park SW, Kim HY. Tendocutaneous free flap transfer from the dorsum of

26. Caroli A, Adani R, Castagnetti C, Panacaldi G, Squarzin PB. Dorsalis pedis flap with vascularized extensor tendons for dorsal hand reconstruction. Plast Reconstr Surg 1993;92:1326-1330.

27. Vila-Rovira R, Ferreira BJ, Guinot A. Transfer of vascularized extensor tendons from the foot to the hand with a dorsalis pedis flap. Plast Reconstr Surg 1985;76:421-427.

28. Samson MC, Morris SF, Tweed AE. Dorsalis pedis flap donor site: acceptable or not? Plast Reconstr Surg 1998;102:1549-1554.

29. Steichen JB, Weiss AP. Reconstruction of traumatic absence of the thumb by microvascular free tissue transfer from the foot. Hand Clin 1992;8:17-32.

30. Man D, Acland R. The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plast Reconstr Surg 1980;65:419-430.