Surg Radiol Anat DOI 10.1007/s00276-015-1464-1
ORIGINAL ARTICLE
Anatomic basis of the distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels: a cadaveric dissection Zedong Wu1 • Dajiang Song2,3 • Jian Lin4 • Heping Zheng1 Chunlin Hou3 • Lei Li1 • Tianquan Wang1
•
Received: 14 February 2015 / Accepted: 16 March 2015 Ó Springer-Verlag France 2015
Abstract Purpose This study aims to identify a repair procedure for ulcers or defect of the forefoot region. The general distribution and variation of the vascular anatomy of the distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels were investigated. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels of medial plantar vein and medial dorsal cutaneous nerve to flap viability. Experiments were conducted to obtain information for operating procedures and to understand the vascular reliability of the flap. Methods Thirty cadavers were available for this anatomical study after arterial injection. The tuberosity of the fifth metatarsal bone was adopted as the anatomical landmark. Microdissection was conducted under a microscope, and details of the course and distribution of the medial plantar
Z. Wu and D. Song contributed equally to this work. & Heping Zheng [email protected] & Chunlin Hou [email protected] 1
2
Department of Comparative Medicine, General Hospital of People’s Liberation Army Nanjing District, Fujian Medical University, Fuzhou 350108, China Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
3
Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
4
Department of Orthopedics, Xinhua Hospital (Chongming) of Shanghai Jiao Tong University, Shanghai, China
vein and the communication of the medial plantar artery of the hallux with the fascial vascular network surrounding the medial plantar vein were recorded. The flap-raising procedure was performed in a fresh cadaver specimen. Results The medial plantar vein was incorporated by the medial end of the dorsal pedal vein arch and medial dorsal vein of the hallux around the first metatarsal–medial cuneiform joint. It traveled along the medial margin of the foot and drained into the great saphenous vein at the level of the medial malleolar. The outer diameter of the nerve at the intermalleolar line was 3.2 ± 0.5 mm. These nutrifying arteries to the medial plantar vein were present segmentally and mainly came from the medial plantar artery of the hallux, which traveled forward in the fascia between the abductor hallucis tendon and the first metatarsal bone, emerged into the superficial layer 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, and gave off many minute branches. These branches communicated with the fascial vascular network surrounding the medial plantar vein, supplying the fascia and integument of the medial foot. Conclusion Reliable venocutaneous flap with medial plantar vein and nutrient vessel flaps can be raised based solely on the perforator of the medial plantar artery of the hallux. This flap should be considered as a preferential way to reconstruct soft-tissue defects of the forefoot. Keywords Medial plantar artery of the hallux Medial plantar vein Medial plantar cutaneous nerve Forefoot reconstruction
Introduction Soft-tissue reconstruction of the foot often requires flap coverage to preserve exposed structures, such as bone, joint, tendons, and weight-bearing areas. The repairation
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and reconstruction of tissue defects in the forefoot, mostly caused by trauma and inflammation, remain a huge challenge. A variety of reconstructive techniques are available, but the alternatives for flap coverage are limited. The local flaps have proven to still be the best option, although donor-site availability is limited in some cases [8, 9]. Exploring cutaneous perforators of arteries is enhancing the field of microsurgical reconstructive surgery. Even if only a single perforator is available, an arterial cutaneous flap is obtainable and is useful for clinical application. The main advantages of perforator arterial flaps are better accuracy [26], thinness for resurfacing, and minimum donorsite morbidity. The concept of using flaps of nutrient vessels of the cutaneous nerve of the lower limbs was initially reported by Masquelet et al. [18] in 1992. This type of flap, which is sufficient for repairing soft-tissue defects in the distal leg, ankle, and foot, has been widely applied in clinical situations. However, the use of the traditional distally based pedicled flaps of the nutrient vessels of the medial plantar cutaneous nerve is still insufficient in safely raising largesized medial plantar flaps and results in great damage to the donor site, as well as failure to repair soft-tissue defects in the forefoot. In most of the specimens used in our research, the medial dorsal cutaneous nerve is small and only supplies the medial side of the foot proximal to the insertion of the tendon of the tibialis anterior muscle. Therefore, harvesting large or medium-sized distally based medial plantar island flap pedicled with medial plantar cutaneous nerve and its nutrient vessels is dangerous. The distally based medial plantar cutaneous nerve neuro-fasciocutaneous flap with nutrient vessels is considered to be less reliable as a donor site because of distribution limitation of the nutrient vessels of the saphenous nerve. To solve this problem, a systematic study of anatomic theory was conducted on distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels. Thirty-one lower limbs of adult cadavers were studied by means of a microdissection of the arterial network of the medial side of the foot. The study aimed to assess the anatomic basis of the distally based medial plantar island flap. The focus was on the prevalence of the perforator vessels of the medial plantar artery of the hallux and on the vascular connections among the perforator and nutrient vessels of the medial plantar cutaneous nerve and medial plantar vein, which allowed medium-sized distally based medial plantar island flaps to be raised. This study also assessed the necessity of including the medial plantar cutaneous nerve and its
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nutrient vessels within the flap based on the longitudinal skin perforator system or the possibility of excluding the medial plantar artery of the hallux and raising the flap based on a single distal perforator. The vascularization of the medial side of the foot was studied in 31 injected limbs. Based on the anatomic knowledge, a distally based medial plantar island flap is described. The results show that the distally based medial plantar island flap is a reversed-flow flap on the longitudinal perivenous vascular plexuses of the medial plantar vein and its anastomosis with the perforator vessels of the medial plantar artery of the hallux, the superficial branch of medial plantar, first plantar metatarsal, medial tarsal, and dorsal pedal arteries. The flap arc of rotation includes the forefoot plantar and dorsal region, and the first and second toes. The anatomical basis and design of this flap for reconstruction of the forefoot region are presented in this study. Vascular anatomy, indication, and technical points of the surgery, as well as advantages and disadvantages of the flap, are discussed.
Materials and methods Anatomic dissections Thirty-one fresh human lower limbs (17 right, 14 left) were injected with green latex by the femoral artery. Approximately, 50 ml of latex was injected, and the injection was stopped when the small arteries of the toes were revealed to the extent that the branches, distribution, and anastomoses of the small vessels could be clearly seen. Specimens were then kept at 4 °C, and after 48 h the medial side of the foot was dissected. After the injection, the specimens were handled using a common antiseptic technique. Then, the lower legs of the specimens were dissected with the assistance of a magnification loupe (49). With the first metatarsophalangeal joint as the reference point for anatomic measurement, importance was attached to observe the following: (1) the sources, branches, and anastomoses of the nutrient vessels of the medial plantar vein and medial dorsal cutaneous nerve and (2) the vascular communication between the nutrient vessels of the medial plantar vein and medial dorsal cutaneous nerve and the perforator vessels of the medial plantar artery of the hallux. The flap-raising procedure was also performed in a fresh cadaver specimen. The results are presented in the following sections. The external diameter and length of each perforator, as well as the related data, were measured using a Vernier caliper. All data were expressed as mean ± SD.
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The medial plantar vein was 100 % present in the 30 cadaveric feet used in this study. In all specimens, the medial plantar vein appeared from around the first metatarsal–medial cuneiform joint, incorporated by the medial end of the dorsal pedal vein arch and medial dorsal vein of the hallux, then traveled along the medial margin of the foot and drained into the great saphenous vein at the level of the medial malleolar, which contained many tributaries from the medial aspect of the foot (Fig. 1). The outer diameter of the nerve at the intermalleolar line was 3.2 ± 0.5 mm. In all specimens, the medial plantar vein was identified to communicate with the medial end of the dorsal pedal vein arch and the medial dorsal vein of the hallux at the level of the first metatarsal–medial cuneiform joint.
plantar cutaneous nerve are located at the proximal part of the medial foot proximal to the ending of the tibialis anterior muscle. While distal to the tibialis anterior muscle, the medial proximal aspect of the foot is innervated by the medial dorsal cutaneous nerve (Fig. 1a). This pattern was found in 20 foot specimens, accounting for 66.7 % of the included specimens. In pattern 2 (long course), the course of the medial plantar cutaneous nerve lies either anterior or posterior to the medial plantar vein or crosses and overlaps it. This pattern was found in ten foot specimens, accounting for 33.3 % of the included specimens. The outer diameter of the nerve at the intermalleolar line is 1.5 ± 0.4 mm. In all ten specimens, the nerve travels along the medial side of the foot and reaches the level of the first metatarsophalangeal joint. In three specimens, the nerve ends at the hallux. The nerve sends out one to four branches to innervate the medial aspect of the foot (Fig. 1b).
Medial plantar cutaneous nerve
Nutrient vessels of the medial plantar vein
The medial plantar cutaneous nerve originates from the saphenous nerve and reaches the medial side of the foot after passing through the medial malleolar. It comes superficially out of the deep fascia and is mainly in the form of a single stem. It always lies inside the subcutaneous tissue. The medial plantar cutaneous nerve is divided into two types based on its distribution. Two patterns of the distribution of the medial plantar cutaneous nerve were observed in the medial side of the foot. In pattern 1 (short course), the trunk of the medial plantar cutaneous nerve traveled along the medial side of the foot and ramifies into one to three branches 1–3 cm distal to the intermalleolar line. The branches of the medial
The perforators that nourish the medial plantar vein are present segmentally through the vein or along the vein. The arterial perforators originate from the medial plantar artery of the hallux, the first plantar metatarsal artery, the medial tarsal artery, the superficial branch of the medial plantar artery, and the proximal branch of the dorsal pedal artery distal to proximal (Fig. 1).
Fig. 1 Anatomy of the medial plantar cutaneous nerve and medial plantar vein. a Medial plantar cutaneous nerve (short coursed pattern); b medial plantar cutaneous nerve (long coursed pattern); 1 medial plantar vein; 2 medial plantar cutaneous nerve; 3 the medial dorsal
cutaneous nerve; 4 medial plantar artery of the hallux; 5 medial malleolar; 6 perforator of the medial tarsal artery; 7 perforator of the anterior medial malleolar artery
Results Medial plantar vein
First plantar metatarsal artery cutaneous perforator The constant perforators of the first plantar metatarsal artery were found in all 31 specimens. The originating point of the cutaneous perforator branch off the first plantar metatarsal artery was 23.0 ± 2.0 mm proximal to the first metatarsophalangeal joint.
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The perforators of the first plantar metatarsal artery constantly originate from the lateral plantar artery (73.3 %) or share the same pedicle with the medial plantar artery of the hallux (26.7 %), then travel between the space of the abductor hallucis tendon and the first metatarsal bone. The main trunk travels backward obliquely and pierces in the superficial fascia of the medial aspect of the foot and supplies it. Finally, it anastomoses with the medial tarsal, medial anterior malleolar, and medial plantar arteries (Fig. 2a, b). The outer diameter of the perforator at its origin level was 11.6 ± 2.8 mm. The length of the perforators was 32.0 ± 2.0 mm.
the perforators were small. The outer diameter of the perforator was 0.5 ± 0.2 cm. The length of the perforators was 22.0 ± 2.0 mm. Anastomosis of the medial plantar artery of the hallux and the nutrient vessels of the medial plantar vein
The medial plantar artery of the hallux was found in all 31 specimens. The originating point of the artery branch off directly or indirectly from the first plantar metatarsal artery was 2.2 ± 0.2 cm proximal to the first metatarsophalangeal joint (Fig. 2). It courses along the medial side of the hallux and finally anastomoses with the transverse artery of hallux. The outer diameter of the perforator at its origin level was 1.0 ± 0.2 cm. However, in 10 specimens (33.3 %),
After the aponeurosis is pierced, the medial plantar artery of the hallux inconsistently sends out three to five branches in the superficial fascia. Vascular anastomotic arch has two types. In type 1, the perforator of the medial plantar artery of the hallux communicates with the segmental nutrifying arteries to the medial plantar vein. When the nutrifying arteries approach the vein, they divide into T-shaped branches, which either enter the vein or travel beside the vein in opposite directions, communicating with one another and forming prominent longitudinal perivenous vascular plexuses. In type 2, the perforators of the anterior medial malleolar artery, the proximal branch of the dorsal pedal artery, and the medial tarsal artery anastomose with the perforators of the medial plantar artery of the hallux, forming a vascular anastomotic network, which is located between
Fig. 2 Illustration of the communicating vascular branches between the medial plantar artery of the hallux and the medial plantar vein in a cadaveric foot. a The perforator vessels originates solely; b the perforator vessels issued off from the medial plantar artery of the hallux; c, d the anastomosis of the medial plantar artery of the hallux and the nutrient vessels of the medial plantar vein; 1 the first plantar
metatarsal artery; 2 the perforator vessels; 3 the medial plantar artery of the hallux; 4 the first metatarsal bone; 5 the superficial branch of the medial plantar artery; 6 vascular anastomotic network; 7 the medial plantar vein; 8 the perforator vessels of the medial tarsal artery; 9 the perforator vessels of the dorsal pedal artery; 10 the medial plantar cutaneous nerve; 11 the medial dorsal cutaneous nerve
Medial plantar artery of the hallux
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the deep fascia of the medial aspect of the foot and the surface of the abductor hallucis (Fig. 2). Simulation flap raising The pivot point involves the perforators of the base or the head of the fifth metatarsal. The central axis of the skin island is the interconnection of the perforator and the most prominent point of the medial malleolus. The medial plantar vein is contained in the flap. The distal flap border is the first metatarsophalangeal joint, and the proximal margin is the most prominent point of the medial malleolus (Fig. 3). The width of the skin paddle is based on whether the donor site could be closed directly. However, an extended flap can also be harvested by including skin from the dorsum of the foot. Exsanguination of the limb is avoided before applying the tourniquet to aid visualization of this small vascular pedicle. A full-thickness incision of the inferior edge flap is performed. Once the abductor hallucis tendon is reached, the flap is carefully undermined, until the superior edge of the muscle is reached. The medial plantar vein is included in the flap to ensure the inclusion of the vascular anastomotic arch. Subsequently, the perforators are found and kept intact. In proceeding with the dissection toward the pedicle in a subfascial plane without breaching the periosteum of the tarsal and metatarsal bones, the paratendons of the tibialis anterior muscle and the extensor hallucis longus muscle, if they are within the range of the flap, can guarantee the fullest inclusion of the vascular network into the flap and, at the same time, a good bed for the skin graft to take. When the pedicle is reached, its upper edge is incised first. The flap design can be adapted accordingly, and the dissection is meticulously performed superficially close to the periosteum of the first metatarsal bone toward
the upper margin of the abductor hallucis. The small perforator vessels of the medial plantar artery of the hallux include the perforator in an adipofascial tissue of the pedicle, with a width of approximately 2.5 cm. The medial plantar vein in the flap is cut both proximally and distally; the medial plantar cutaneous nerve is cut proximally. The dissection continues in the distal direction on the subfascial plane, and the dissection is discontinued just before the pivot point. The flap is completely isolated, and it remains attached by the perforating vessels alone. The pedicle is raised with a generous cuff of subcutaneous fibrofatty tissue without skeletonization (Fig. 3). The next incision is made on the skin bridge between the pivot point and the defect, and the flap is then transposed by 180° to the defect. The vascular supply to the flap is checked following the deflation of the tourniquet, and hemostasis is achieved with bipolar cautery. The donor site is closed directly or patched by a split-thickness skin graft.
Discussion Soft-tissue reconstruction of the foot often requires flap coverage to preserve exposed structures, such as bones, joints, tendons, and weight-bearing areas. Recently, reconstruction of skin losses in the foot has been largely improved by the introduction of the new cutaneous island flaps. However, forefoot coverage remains a challenge because the alternatives for flap coverage are limited [6, 13, 17, 21, 24]. Given that the soft-tissue coverage of the foot is notoriously thin, even slight to medium trauma often leads to exposure of the tendon, bone, and joint, which cannot be repaired with a skin graft under most conditions. Almost all donor sites in the human body for commonly used free
Fig. 3 a Flap design; b the perforator vessels are found; c flap raising; d flap isolation; e visualization of the perforator vessels; f flap rotation
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flaps provide bulky tissue, which requires a second-stage debulking procedure. Free flaps are also technically demanding and time-consuming and cannot be easily popularized in small medical facilities with poor medical conditions. Consequently, they are better reserved for the coverage of large defects when pedicled transferred flaps are no longer competent. Ample reports, either in anatomy or in clinical application, exist in the literature about using pedicled transferred flaps from the leg, dorsal foot, and medial plantar foot for reconstruction of soft-tissue defects of the foot [16, 20, 22, 23]. The medial aspect of the foot with thinness of integument similar to that of the dorsal foot, also being in the immediate vicinity of the dorsal foot, is undoubtedly an ideal flap donor site for coverage of the dorsal foot. Given the thinness of the soft tissue in this area, it is perhaps the optimal donor site for free flaps, especially when covering small- to medium-sized defects of the hand [10–12, 14]. Anatomic studies concerning the vascular supply of the medial aspect of the foot were performed to provide plastic surgeons with a new alternative for forefoot reconstruction [4, 7]. The distally based medial plantar cutaneous nerve neuro-fasciocutaneous flap is described in these studies, and its use has been reported [1–3, 5]. In 1998, Nakajima et al. reported that cutaneous veins were accompanied by nutrient arteries that contained cutaneous branches to nourish the skin. Nakajima et al. [19] proposed the concept of venoneuroadipofascial pedicled fasciocutaneous flaps, which have dual blood supply from both the nutrient arteries of the cutaneous nerves and veins. Since then, neurocutaneous, or neurovenofasciocutaneous, flaps, especially in the extremities, have been widely employed to cover soft-tissue defects because of their reliable blood supply and easy dissection. A cutaneous perforator is defined as any vessel that perforates through the outer layer of the deep fascia to supply the overlying subcutaneous fat and skin. Cutaneous perforators, whether arterial or venous, large or small, are derived ultimately from, or return to, an underlying source or segmental vessels that usually course parallel to the bony skeleton [25]. Our preliminary research showed detailed descriptions concerning the vasculature of the medial aspect of the foot (i.e., the anatomical basis for harvest of flaps from the vasculature) [27]. We have reported our research about the anatomical basis of the reverse lateral plantar artery perforator flap design [15]. This paper reports about the anatomical basis of the reverse lateral plantar artery perforator flap design. However, the anatomical basis of the medium-sized distal pedicled medial plantar flap has never been reported. A thorough anatomical review of the vasculature at the medial aspect of the foot was conducted in this study.
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The traditional approach to the repair of wounds in the forefoot incorporates a distally based pedicled flap with the nutrient vessels of the medial plantar cutaneous nerve and is often inadequate in meeting the demands for an extensive repair and healing. The results revealed that in 66.7 % of the included specimens, the branches of the medial plantar cutaneous nerve located at the proximal part of the medial foot proximal to the ending of the tibialis anterior muscle are limited; whereas distal to the tibialis anterior muscle, the medial proximal aspect of the foot is innervated by the medial dorsal cutaneous nerve. Therefore, this study shows that the nutrient vessels of the medial plantar vein provide an abundant blood supply, with an obvious longitudinal distribution and a homogeneous origin, which promote forefoot tissue healing and repair. Constant perforators 2.3 ± 0.2 mm proximal to the first metatarsophalangeal joint were found in all 31 specimens. Raising the venocutaneous flap with medial plantar vein and nutrient vessels based on the vascular anastomotic arch of the medial plantar artery of the hallux and the segmental nutrifying arteries to the medial plantar vein is a safe choice. Some concerns during the dissection of the flap should be addressed 1.
2.
3.
4. 5.
6.
7. 8.
The piercing point of the arterial perforators should be detected by a Doppler ultrasound examination before the operation. The medial plantar vein and its nutrient vessels should be used as the central axis for the distal pedicle. Damage to the medial plantar vein and its nutrient vessels must be avoided or it may result in ischemia of the flap. The perforator on which the flap is based is a tiny perforator, and even a minimal amount of extra traction on the flap can lead to spasm of the perforator. The perforator must always be kept moist by perfusing it with lignocaine solution. The flap must be circumferentially dissected of all the fibrous strands to prevent kinking the perforator. However, a rim of fat must be left surrounding the perforator. The ligation of the great saphenous vein stem located far from the rotation point of the distal pedicle can prevent venous blood from flowing back into the flap. The skin of the exposed tunnel should be moisturized. The flap inset must be conducted without tension to avoid traction injury to the perforator. Compression of the pedicle vessels should be prevented in the transfer of the compound flap to the wound surface.
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9.
10.
11. 12.
Using a recipient sensory nerve, cutaneous sensation can be restored with neurorrhaphy to the sensory nerve of the flap. The first two sutures are placed by the side of the perforator before suturing the distal end to prevent traction to the perforator. Delicate dissection must always be performed under tourniquet control and loupe magnification. The donor site is initially quite deep, but the contour can fill in with time considering the contracture of the site.
The anatomic findings in this study show that a distally based venocutaneous flap based on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels can be safely raised. This phenomenon is found in all specimens. Acknowledgments This research was supported by the Fujian Provincial Natural Science Foundation (No. 2012J01410). Conflict of interest
None.
References 1. Amarante J, Martins A, Reis J (1988) A distally based median plantar flap. Ann Plast Surg 20:468–470 2. Bach AD, Leffler M, Kneser U, Kopp J, Horch RE (2007) The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg 58:397–404 3. Bhandari PS, Sobti C (1999) Reverse flow instep island flap. Plast Reconstr Surg 103:1986–1989 4. Butler CE, Chevray P (2002) Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and webspace defects. Ann Plast Surg 49:196–201 5. Cavadas PC (1997) Reversed saphenous neurocutaneous island flap: clinical experience. Plast Reconstr Surg 99:1940–1946 6. Earley MJ, Milner RH (1989) A distally based first web flap in the foot. Br J Plast Surg 42:507–511 7. Gabrielli C, Olave E, Mandiola E, Rodrigues CF, Prates JC (2001) The deep plantar arch in humans: constitution and topography. Surg Radiol Anat SRA 23:253–258 8. Hayashi A, Maruyama Y (1993) Reverse first dorsal metatarsal artery flap for reconstruction of the distal foot. Ann Plast Surg 31:117–122 9. Ishikawa K, Isshiki N, Suzuki S, Shimamura S (1987) Distally based dorsalis pedis island flap for coverage of the distal portion of the foot. Br J Plast Surg 40:521–525
10. Koshima I, Nanba Y, Tsutsui T, Takahashi Y (2003) Medial plantar perforator flaps with supermicrosurgery. Clin Plast Surg 30:447–455 (vii) 11. Koshima I, Narushima M, Mihara M et al (2007) Island medial plantar artery perforator flap for reconstruction of plantar defects. Ann Plast Surg 59:558–562 12. Koshima I, Urushibara K, Inagawa K, Hamasaki T, Moriguchi T (2001) Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg 107:1753–1758 13. Kurata S, Hashimoto H, Terashi H, Honda T, Takayasu S (1992) Reconstruction of the distal foot dorsum with a distally based extensor digitorum brevis muscle flap. Ann Plast Surg 29:76–79 14. Lai CH, Lai CS, Huang SH, Lin SD, Chang KP (2010) Free medial plantar artery perforator flaps for the resurfacing of thumb defects. Ann Plast Surg 65:535–540 15. Li L, Song D, Zheng H et al (2015) Anatomical basis of the reverse lateral plantar artery perforator flap design. Surg Radiol Anat. 23 Jan 2015 (Epub ahead of print) 16. Masquelet AC, Beveridge J, Romana C, Gerber C (1988) The lateral supramalleolar flap. Plast Reconstr Surg 81:74–81 17. Masquelet AC, Romana MC (1990) The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg 85:765–772 18. Masquelet AC, Romana MC, Wolf G (1992) Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 89:1115–1121 19. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T (1998) Accompanying arteries of the cutaneous veins and cutaneous nerves in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr Surg 102:779–791 20. Ruan HJ, Cai PH, Schleich AR, Fan CY, Chai YM (2010) The extended peroneal artery perforator flap for lower extremity reconstruction. Ann Plast Surg 64:451–457 21. Sakai S (1993) A distally based island first dorsal metatarsal artery flap for the coverage of a distal plantar defect. Br J Plast Surg 46:480–482 22. Samson MC, Morris SF, Tweed AE (1998) Dorsalis pedis flap donor site: acceptable or not? Plast Reconstr Surg 102:1549–1554 23. Shanahan RE, Gingrass RP (1979) Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg 64:295–298 24. Smith AA, Arons JA, Reyes R, Hegstad SJ (1995) Distal foot coverage with a reverse dorsalis pedis flap. Ann Plast Surg 34:191–196 25. Taylor GI (2003) The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 30:331–342 26. Wei FC, Jain V, Suominen S, Chen HC (2001) Confusion among perforator flaps: what is a true perforator flap? Plast Reconstr Surg 107:874–876 27. Zhuang YH, Zheng HP, Lin SQ, Xu DC (2011) Vasculature at the medial aspect of the foot and clinical application of flaps based on it for forefoot reconstruction. Plast Reconstr Surg 127:1967–1978
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ORIGINAL ARTICLE
Anatomic basis of the distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels: a cadaveric dissection Zedong Wu1 • Dajiang Song2,3 • Jian Lin4 • Heping Zheng1 Chunlin Hou3 • Lei Li1 • Tianquan Wang1
•
Received: 14 February 2015 / Accepted: 16 March 2015 Ó Springer-Verlag France 2015
Abstract Purpose This study aims to identify a repair procedure for ulcers or defect of the forefoot region. The general distribution and variation of the vascular anatomy of the distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels were investigated. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels of medial plantar vein and medial dorsal cutaneous nerve to flap viability. Experiments were conducted to obtain information for operating procedures and to understand the vascular reliability of the flap. Methods Thirty cadavers were available for this anatomical study after arterial injection. The tuberosity of the fifth metatarsal bone was adopted as the anatomical landmark. Microdissection was conducted under a microscope, and details of the course and distribution of the medial plantar
Z. Wu and D. Song contributed equally to this work. & Heping Zheng [email protected] & Chunlin Hou [email protected] 1
2
Department of Comparative Medicine, General Hospital of People’s Liberation Army Nanjing District, Fujian Medical University, Fuzhou 350108, China Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China
3
Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
4
Department of Orthopedics, Xinhua Hospital (Chongming) of Shanghai Jiao Tong University, Shanghai, China
vein and the communication of the medial plantar artery of the hallux with the fascial vascular network surrounding the medial plantar vein were recorded. The flap-raising procedure was performed in a fresh cadaver specimen. Results The medial plantar vein was incorporated by the medial end of the dorsal pedal vein arch and medial dorsal vein of the hallux around the first metatarsal–medial cuneiform joint. It traveled along the medial margin of the foot and drained into the great saphenous vein at the level of the medial malleolar. The outer diameter of the nerve at the intermalleolar line was 3.2 ± 0.5 mm. These nutrifying arteries to the medial plantar vein were present segmentally and mainly came from the medial plantar artery of the hallux, which traveled forward in the fascia between the abductor hallucis tendon and the first metatarsal bone, emerged into the superficial layer 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, and gave off many minute branches. These branches communicated with the fascial vascular network surrounding the medial plantar vein, supplying the fascia and integument of the medial foot. Conclusion Reliable venocutaneous flap with medial plantar vein and nutrient vessel flaps can be raised based solely on the perforator of the medial plantar artery of the hallux. This flap should be considered as a preferential way to reconstruct soft-tissue defects of the forefoot. Keywords Medial plantar artery of the hallux Medial plantar vein Medial plantar cutaneous nerve Forefoot reconstruction
Introduction Soft-tissue reconstruction of the foot often requires flap coverage to preserve exposed structures, such as bone, joint, tendons, and weight-bearing areas. The repairation
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and reconstruction of tissue defects in the forefoot, mostly caused by trauma and inflammation, remain a huge challenge. A variety of reconstructive techniques are available, but the alternatives for flap coverage are limited. The local flaps have proven to still be the best option, although donor-site availability is limited in some cases [8, 9]. Exploring cutaneous perforators of arteries is enhancing the field of microsurgical reconstructive surgery. Even if only a single perforator is available, an arterial cutaneous flap is obtainable and is useful for clinical application. The main advantages of perforator arterial flaps are better accuracy [26], thinness for resurfacing, and minimum donorsite morbidity. The concept of using flaps of nutrient vessels of the cutaneous nerve of the lower limbs was initially reported by Masquelet et al. [18] in 1992. This type of flap, which is sufficient for repairing soft-tissue defects in the distal leg, ankle, and foot, has been widely applied in clinical situations. However, the use of the traditional distally based pedicled flaps of the nutrient vessels of the medial plantar cutaneous nerve is still insufficient in safely raising largesized medial plantar flaps and results in great damage to the donor site, as well as failure to repair soft-tissue defects in the forefoot. In most of the specimens used in our research, the medial dorsal cutaneous nerve is small and only supplies the medial side of the foot proximal to the insertion of the tendon of the tibialis anterior muscle. Therefore, harvesting large or medium-sized distally based medial plantar island flap pedicled with medial plantar cutaneous nerve and its nutrient vessels is dangerous. The distally based medial plantar cutaneous nerve neuro-fasciocutaneous flap with nutrient vessels is considered to be less reliable as a donor site because of distribution limitation of the nutrient vessels of the saphenous nerve. To solve this problem, a systematic study of anatomic theory was conducted on distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels. Thirty-one lower limbs of adult cadavers were studied by means of a microdissection of the arterial network of the medial side of the foot. The study aimed to assess the anatomic basis of the distally based medial plantar island flap. The focus was on the prevalence of the perforator vessels of the medial plantar artery of the hallux and on the vascular connections among the perforator and nutrient vessels of the medial plantar cutaneous nerve and medial plantar vein, which allowed medium-sized distally based medial plantar island flaps to be raised. This study also assessed the necessity of including the medial plantar cutaneous nerve and its
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nutrient vessels within the flap based on the longitudinal skin perforator system or the possibility of excluding the medial plantar artery of the hallux and raising the flap based on a single distal perforator. The vascularization of the medial side of the foot was studied in 31 injected limbs. Based on the anatomic knowledge, a distally based medial plantar island flap is described. The results show that the distally based medial plantar island flap is a reversed-flow flap on the longitudinal perivenous vascular plexuses of the medial plantar vein and its anastomosis with the perforator vessels of the medial plantar artery of the hallux, the superficial branch of medial plantar, first plantar metatarsal, medial tarsal, and dorsal pedal arteries. The flap arc of rotation includes the forefoot plantar and dorsal region, and the first and second toes. The anatomical basis and design of this flap for reconstruction of the forefoot region are presented in this study. Vascular anatomy, indication, and technical points of the surgery, as well as advantages and disadvantages of the flap, are discussed.
Materials and methods Anatomic dissections Thirty-one fresh human lower limbs (17 right, 14 left) were injected with green latex by the femoral artery. Approximately, 50 ml of latex was injected, and the injection was stopped when the small arteries of the toes were revealed to the extent that the branches, distribution, and anastomoses of the small vessels could be clearly seen. Specimens were then kept at 4 °C, and after 48 h the medial side of the foot was dissected. After the injection, the specimens were handled using a common antiseptic technique. Then, the lower legs of the specimens were dissected with the assistance of a magnification loupe (49). With the first metatarsophalangeal joint as the reference point for anatomic measurement, importance was attached to observe the following: (1) the sources, branches, and anastomoses of the nutrient vessels of the medial plantar vein and medial dorsal cutaneous nerve and (2) the vascular communication between the nutrient vessels of the medial plantar vein and medial dorsal cutaneous nerve and the perforator vessels of the medial plantar artery of the hallux. The flap-raising procedure was also performed in a fresh cadaver specimen. The results are presented in the following sections. The external diameter and length of each perforator, as well as the related data, were measured using a Vernier caliper. All data were expressed as mean ± SD.
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The medial plantar vein was 100 % present in the 30 cadaveric feet used in this study. In all specimens, the medial plantar vein appeared from around the first metatarsal–medial cuneiform joint, incorporated by the medial end of the dorsal pedal vein arch and medial dorsal vein of the hallux, then traveled along the medial margin of the foot and drained into the great saphenous vein at the level of the medial malleolar, which contained many tributaries from the medial aspect of the foot (Fig. 1). The outer diameter of the nerve at the intermalleolar line was 3.2 ± 0.5 mm. In all specimens, the medial plantar vein was identified to communicate with the medial end of the dorsal pedal vein arch and the medial dorsal vein of the hallux at the level of the first metatarsal–medial cuneiform joint.
plantar cutaneous nerve are located at the proximal part of the medial foot proximal to the ending of the tibialis anterior muscle. While distal to the tibialis anterior muscle, the medial proximal aspect of the foot is innervated by the medial dorsal cutaneous nerve (Fig. 1a). This pattern was found in 20 foot specimens, accounting for 66.7 % of the included specimens. In pattern 2 (long course), the course of the medial plantar cutaneous nerve lies either anterior or posterior to the medial plantar vein or crosses and overlaps it. This pattern was found in ten foot specimens, accounting for 33.3 % of the included specimens. The outer diameter of the nerve at the intermalleolar line is 1.5 ± 0.4 mm. In all ten specimens, the nerve travels along the medial side of the foot and reaches the level of the first metatarsophalangeal joint. In three specimens, the nerve ends at the hallux. The nerve sends out one to four branches to innervate the medial aspect of the foot (Fig. 1b).
Medial plantar cutaneous nerve
Nutrient vessels of the medial plantar vein
The medial plantar cutaneous nerve originates from the saphenous nerve and reaches the medial side of the foot after passing through the medial malleolar. It comes superficially out of the deep fascia and is mainly in the form of a single stem. It always lies inside the subcutaneous tissue. The medial plantar cutaneous nerve is divided into two types based on its distribution. Two patterns of the distribution of the medial plantar cutaneous nerve were observed in the medial side of the foot. In pattern 1 (short course), the trunk of the medial plantar cutaneous nerve traveled along the medial side of the foot and ramifies into one to three branches 1–3 cm distal to the intermalleolar line. The branches of the medial
The perforators that nourish the medial plantar vein are present segmentally through the vein or along the vein. The arterial perforators originate from the medial plantar artery of the hallux, the first plantar metatarsal artery, the medial tarsal artery, the superficial branch of the medial plantar artery, and the proximal branch of the dorsal pedal artery distal to proximal (Fig. 1).
Fig. 1 Anatomy of the medial plantar cutaneous nerve and medial plantar vein. a Medial plantar cutaneous nerve (short coursed pattern); b medial plantar cutaneous nerve (long coursed pattern); 1 medial plantar vein; 2 medial plantar cutaneous nerve; 3 the medial dorsal
cutaneous nerve; 4 medial plantar artery of the hallux; 5 medial malleolar; 6 perforator of the medial tarsal artery; 7 perforator of the anterior medial malleolar artery
Results Medial plantar vein
First plantar metatarsal artery cutaneous perforator The constant perforators of the first plantar metatarsal artery were found in all 31 specimens. The originating point of the cutaneous perforator branch off the first plantar metatarsal artery was 23.0 ± 2.0 mm proximal to the first metatarsophalangeal joint.
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The perforators of the first plantar metatarsal artery constantly originate from the lateral plantar artery (73.3 %) or share the same pedicle with the medial plantar artery of the hallux (26.7 %), then travel between the space of the abductor hallucis tendon and the first metatarsal bone. The main trunk travels backward obliquely and pierces in the superficial fascia of the medial aspect of the foot and supplies it. Finally, it anastomoses with the medial tarsal, medial anterior malleolar, and medial plantar arteries (Fig. 2a, b). The outer diameter of the perforator at its origin level was 11.6 ± 2.8 mm. The length of the perforators was 32.0 ± 2.0 mm.
the perforators were small. The outer diameter of the perforator was 0.5 ± 0.2 cm. The length of the perforators was 22.0 ± 2.0 mm. Anastomosis of the medial plantar artery of the hallux and the nutrient vessels of the medial plantar vein
The medial plantar artery of the hallux was found in all 31 specimens. The originating point of the artery branch off directly or indirectly from the first plantar metatarsal artery was 2.2 ± 0.2 cm proximal to the first metatarsophalangeal joint (Fig. 2). It courses along the medial side of the hallux and finally anastomoses with the transverse artery of hallux. The outer diameter of the perforator at its origin level was 1.0 ± 0.2 cm. However, in 10 specimens (33.3 %),
After the aponeurosis is pierced, the medial plantar artery of the hallux inconsistently sends out three to five branches in the superficial fascia. Vascular anastomotic arch has two types. In type 1, the perforator of the medial plantar artery of the hallux communicates with the segmental nutrifying arteries to the medial plantar vein. When the nutrifying arteries approach the vein, they divide into T-shaped branches, which either enter the vein or travel beside the vein in opposite directions, communicating with one another and forming prominent longitudinal perivenous vascular plexuses. In type 2, the perforators of the anterior medial malleolar artery, the proximal branch of the dorsal pedal artery, and the medial tarsal artery anastomose with the perforators of the medial plantar artery of the hallux, forming a vascular anastomotic network, which is located between
Fig. 2 Illustration of the communicating vascular branches between the medial plantar artery of the hallux and the medial plantar vein in a cadaveric foot. a The perforator vessels originates solely; b the perforator vessels issued off from the medial plantar artery of the hallux; c, d the anastomosis of the medial plantar artery of the hallux and the nutrient vessels of the medial plantar vein; 1 the first plantar
metatarsal artery; 2 the perforator vessels; 3 the medial plantar artery of the hallux; 4 the first metatarsal bone; 5 the superficial branch of the medial plantar artery; 6 vascular anastomotic network; 7 the medial plantar vein; 8 the perforator vessels of the medial tarsal artery; 9 the perforator vessels of the dorsal pedal artery; 10 the medial plantar cutaneous nerve; 11 the medial dorsal cutaneous nerve
Medial plantar artery of the hallux
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the deep fascia of the medial aspect of the foot and the surface of the abductor hallucis (Fig. 2). Simulation flap raising The pivot point involves the perforators of the base or the head of the fifth metatarsal. The central axis of the skin island is the interconnection of the perforator and the most prominent point of the medial malleolus. The medial plantar vein is contained in the flap. The distal flap border is the first metatarsophalangeal joint, and the proximal margin is the most prominent point of the medial malleolus (Fig. 3). The width of the skin paddle is based on whether the donor site could be closed directly. However, an extended flap can also be harvested by including skin from the dorsum of the foot. Exsanguination of the limb is avoided before applying the tourniquet to aid visualization of this small vascular pedicle. A full-thickness incision of the inferior edge flap is performed. Once the abductor hallucis tendon is reached, the flap is carefully undermined, until the superior edge of the muscle is reached. The medial plantar vein is included in the flap to ensure the inclusion of the vascular anastomotic arch. Subsequently, the perforators are found and kept intact. In proceeding with the dissection toward the pedicle in a subfascial plane without breaching the periosteum of the tarsal and metatarsal bones, the paratendons of the tibialis anterior muscle and the extensor hallucis longus muscle, if they are within the range of the flap, can guarantee the fullest inclusion of the vascular network into the flap and, at the same time, a good bed for the skin graft to take. When the pedicle is reached, its upper edge is incised first. The flap design can be adapted accordingly, and the dissection is meticulously performed superficially close to the periosteum of the first metatarsal bone toward
the upper margin of the abductor hallucis. The small perforator vessels of the medial plantar artery of the hallux include the perforator in an adipofascial tissue of the pedicle, with a width of approximately 2.5 cm. The medial plantar vein in the flap is cut both proximally and distally; the medial plantar cutaneous nerve is cut proximally. The dissection continues in the distal direction on the subfascial plane, and the dissection is discontinued just before the pivot point. The flap is completely isolated, and it remains attached by the perforating vessels alone. The pedicle is raised with a generous cuff of subcutaneous fibrofatty tissue without skeletonization (Fig. 3). The next incision is made on the skin bridge between the pivot point and the defect, and the flap is then transposed by 180° to the defect. The vascular supply to the flap is checked following the deflation of the tourniquet, and hemostasis is achieved with bipolar cautery. The donor site is closed directly or patched by a split-thickness skin graft.
Discussion Soft-tissue reconstruction of the foot often requires flap coverage to preserve exposed structures, such as bones, joints, tendons, and weight-bearing areas. Recently, reconstruction of skin losses in the foot has been largely improved by the introduction of the new cutaneous island flaps. However, forefoot coverage remains a challenge because the alternatives for flap coverage are limited [6, 13, 17, 21, 24]. Given that the soft-tissue coverage of the foot is notoriously thin, even slight to medium trauma often leads to exposure of the tendon, bone, and joint, which cannot be repaired with a skin graft under most conditions. Almost all donor sites in the human body for commonly used free
Fig. 3 a Flap design; b the perforator vessels are found; c flap raising; d flap isolation; e visualization of the perforator vessels; f flap rotation
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flaps provide bulky tissue, which requires a second-stage debulking procedure. Free flaps are also technically demanding and time-consuming and cannot be easily popularized in small medical facilities with poor medical conditions. Consequently, they are better reserved for the coverage of large defects when pedicled transferred flaps are no longer competent. Ample reports, either in anatomy or in clinical application, exist in the literature about using pedicled transferred flaps from the leg, dorsal foot, and medial plantar foot for reconstruction of soft-tissue defects of the foot [16, 20, 22, 23]. The medial aspect of the foot with thinness of integument similar to that of the dorsal foot, also being in the immediate vicinity of the dorsal foot, is undoubtedly an ideal flap donor site for coverage of the dorsal foot. Given the thinness of the soft tissue in this area, it is perhaps the optimal donor site for free flaps, especially when covering small- to medium-sized defects of the hand [10–12, 14]. Anatomic studies concerning the vascular supply of the medial aspect of the foot were performed to provide plastic surgeons with a new alternative for forefoot reconstruction [4, 7]. The distally based medial plantar cutaneous nerve neuro-fasciocutaneous flap is described in these studies, and its use has been reported [1–3, 5]. In 1998, Nakajima et al. reported that cutaneous veins were accompanied by nutrient arteries that contained cutaneous branches to nourish the skin. Nakajima et al. [19] proposed the concept of venoneuroadipofascial pedicled fasciocutaneous flaps, which have dual blood supply from both the nutrient arteries of the cutaneous nerves and veins. Since then, neurocutaneous, or neurovenofasciocutaneous, flaps, especially in the extremities, have been widely employed to cover soft-tissue defects because of their reliable blood supply and easy dissection. A cutaneous perforator is defined as any vessel that perforates through the outer layer of the deep fascia to supply the overlying subcutaneous fat and skin. Cutaneous perforators, whether arterial or venous, large or small, are derived ultimately from, or return to, an underlying source or segmental vessels that usually course parallel to the bony skeleton [25]. Our preliminary research showed detailed descriptions concerning the vasculature of the medial aspect of the foot (i.e., the anatomical basis for harvest of flaps from the vasculature) [27]. We have reported our research about the anatomical basis of the reverse lateral plantar artery perforator flap design [15]. This paper reports about the anatomical basis of the reverse lateral plantar artery perforator flap design. However, the anatomical basis of the medium-sized distal pedicled medial plantar flap has never been reported. A thorough anatomical review of the vasculature at the medial aspect of the foot was conducted in this study.
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The traditional approach to the repair of wounds in the forefoot incorporates a distally based pedicled flap with the nutrient vessels of the medial plantar cutaneous nerve and is often inadequate in meeting the demands for an extensive repair and healing. The results revealed that in 66.7 % of the included specimens, the branches of the medial plantar cutaneous nerve located at the proximal part of the medial foot proximal to the ending of the tibialis anterior muscle are limited; whereas distal to the tibialis anterior muscle, the medial proximal aspect of the foot is innervated by the medial dorsal cutaneous nerve. Therefore, this study shows that the nutrient vessels of the medial plantar vein provide an abundant blood supply, with an obvious longitudinal distribution and a homogeneous origin, which promote forefoot tissue healing and repair. Constant perforators 2.3 ± 0.2 mm proximal to the first metatarsophalangeal joint were found in all 31 specimens. Raising the venocutaneous flap with medial plantar vein and nutrient vessels based on the vascular anastomotic arch of the medial plantar artery of the hallux and the segmental nutrifying arteries to the medial plantar vein is a safe choice. Some concerns during the dissection of the flap should be addressed 1.
2.
3.
4. 5.
6.
7. 8.
The piercing point of the arterial perforators should be detected by a Doppler ultrasound examination before the operation. The medial plantar vein and its nutrient vessels should be used as the central axis for the distal pedicle. Damage to the medial plantar vein and its nutrient vessels must be avoided or it may result in ischemia of the flap. The perforator on which the flap is based is a tiny perforator, and even a minimal amount of extra traction on the flap can lead to spasm of the perforator. The perforator must always be kept moist by perfusing it with lignocaine solution. The flap must be circumferentially dissected of all the fibrous strands to prevent kinking the perforator. However, a rim of fat must be left surrounding the perforator. The ligation of the great saphenous vein stem located far from the rotation point of the distal pedicle can prevent venous blood from flowing back into the flap. The skin of the exposed tunnel should be moisturized. The flap inset must be conducted without tension to avoid traction injury to the perforator. Compression of the pedicle vessels should be prevented in the transfer of the compound flap to the wound surface.
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9.
10.
11. 12.
Using a recipient sensory nerve, cutaneous sensation can be restored with neurorrhaphy to the sensory nerve of the flap. The first two sutures are placed by the side of the perforator before suturing the distal end to prevent traction to the perforator. Delicate dissection must always be performed under tourniquet control and loupe magnification. The donor site is initially quite deep, but the contour can fill in with time considering the contracture of the site.
The anatomic findings in this study show that a distally based venocutaneous flap based on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels can be safely raised. This phenomenon is found in all specimens. Acknowledgments This research was supported by the Fujian Provincial Natural Science Foundation (No. 2012J01410). Conflict of interest
None.
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10. Koshima I, Nanba Y, Tsutsui T, Takahashi Y (2003) Medial plantar perforator flaps with supermicrosurgery. Clin Plast Surg 30:447–455 (vii) 11. Koshima I, Narushima M, Mihara M et al (2007) Island medial plantar artery perforator flap for reconstruction of plantar defects. Ann Plast Surg 59:558–562 12. Koshima I, Urushibara K, Inagawa K, Hamasaki T, Moriguchi T (2001) Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg 107:1753–1758 13. Kurata S, Hashimoto H, Terashi H, Honda T, Takayasu S (1992) Reconstruction of the distal foot dorsum with a distally based extensor digitorum brevis muscle flap. Ann Plast Surg 29:76–79 14. Lai CH, Lai CS, Huang SH, Lin SD, Chang KP (2010) Free medial plantar artery perforator flaps for the resurfacing of thumb defects. Ann Plast Surg 65:535–540 15. Li L, Song D, Zheng H et al (2015) Anatomical basis of the reverse lateral plantar artery perforator flap design. Surg Radiol Anat. 23 Jan 2015 (Epub ahead of print) 16. Masquelet AC, Beveridge J, Romana C, Gerber C (1988) The lateral supramalleolar flap. Plast Reconstr Surg 81:74–81 17. Masquelet AC, Romana MC (1990) The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg 85:765–772 18. Masquelet AC, Romana MC, Wolf G (1992) Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 89:1115–1121 19. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T (1998) Accompanying arteries of the cutaneous veins and cutaneous nerves in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr Surg 102:779–791 20. Ruan HJ, Cai PH, Schleich AR, Fan CY, Chai YM (2010) The extended peroneal artery perforator flap for lower extremity reconstruction. Ann Plast Surg 64:451–457 21. Sakai S (1993) A distally based island first dorsal metatarsal artery flap for the coverage of a distal plantar defect. Br J Plast Surg 46:480–482 22. Samson MC, Morris SF, Tweed AE (1998) Dorsalis pedis flap donor site: acceptable or not? Plast Reconstr Surg 102:1549–1554 23. Shanahan RE, Gingrass RP (1979) Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg 64:295–298 24. Smith AA, Arons JA, Reyes R, Hegstad SJ (1995) Distal foot coverage with a reverse dorsalis pedis flap. Ann Plast Surg 34:191–196 25. Taylor GI (2003) The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 30:331–342 26. Wei FC, Jain V, Suominen S, Chen HC (2001) Confusion among perforator flaps: what is a true perforator flap? Plast Reconstr Surg 107:874–876 27. Zhuang YH, Zheng HP, Lin SQ, Xu DC (2011) Vasculature at the medial aspect of the foot and clinical application of flaps based on it for forefoot reconstruction. Plast Reconstr Surg 127:1967–1978
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