RECONSTRUCTIVE Reconstruction of Great Toe Soft-Tissue Defect with the Retrograde-Flow Medial Pedis Island Flap Haijiao Mao, M.D. Zengyuan Shi, M.D. Weigang Yin, Ph.D. Wenwei Dong, M.D. Keith L. Wapner, M.D. Philadelphia, Pa.; and Ningbo, Zhejiang, People’s Republic of China
Background: Several investigators have reported their clinical experience with medial pedis flaps for reconstruction of soft-tissue defects of the distal forefoot. However, they had only a few reports where this flap was used to repair softtissue defects of the great toe. Thus, reconstruction of soft-tissue defects of the great toe remains a challenge in reconstructive surgery. The authors describe the use of the medial pedis island flap to cover this region. Methods: This study was divided into two parts: an anatomic study and clinical application. In the anatomic study, 48 cadaveric feet were injected with latex, and then the main vessels distributed at the medial aspect of the foot were observed. Clinically, retrograde-flow medial pedis island flaps were harvested to cover the soft-tissue defects of the great toe in eight cases. Results: An anatomic study revealed that the arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis were responsible for the blood supply of the medial region of the foot. The diameter of the pedicle was great, and the pedicle was longer than previously reported. In terms of clinical application, all flaps were successful, without any significant complications. Conclusions: Using the arterial circle under the first metatarsophalangeal joint, the medial pedis island flap has a reliable retrograde blood supply. This flap should be considered as a preferential way of reconstructing soft-tissue defects of the great toe. (Plast. Reconstr. Surg. 134: 120e, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
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econstruction of the forefoot region remains a challenging problem, especially for the great toe. Conservative treatment and local flaps are often insufficient to achieve adequate healing. Although several methods are described, including skin grafts and fillet flap,1 reverse anterior tibial flap,2 lateral supramalleolar flap,3 distally based dorsal pedis island flap,4 distally pedicled reverse-flow medial plantar flap,5,6 and medial plantar flap with Y-V pedicle elongation technique,7 these alternatives generally have their difficulties. In response to these shortcomings and to look for other donor sites, many studies8–11 have begun to experiment with new flaps. This study evaluates a retrograde-flow medial pedis flap that has the advantage of being an From the Department of Orthopaedic Surgery, Pennsylvania Hospital, University of Pennsylvania School of Medicine; and the Department of Orthopaedic Surgery, Affiliated Hospital, and the Department of Anatomy, Medical School of Ningbo University. Received for publication May 12, 2013; accepted January 21, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000274
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adjacent tissue flap of the great toe with minimal donor-site problems. This flap has anatomic characteristics that are similar to those of the adjacent tissues of the great toe, which make it an attractive flap for soft-tissue defects of the great toe. The authors designed a retrograde-flow medial pedis flap as a reliable single-stage technique for coverage of great toe defects. We present the results of an anatomic study of lifting and harvesting the flap and our experience with the medial pedis island flap for reconstruction of the great toe in acute and chronic cases based on the blood supply in the medial pedis.
PATIENTS AND METHODS Anatomic Study This study was conducted in collaboration with the Department of Anatomy at the Medical School of Ningbo University. Forty-eight feet from 24 cadavers
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
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Volume 134, Number 1 • Great Toe Soft-Tissue Defects that had been embalmed with formalin were studied. The cadavers, 15 female and seven male cadavers, had no known vascular disease. The popliteal arteries were dissected and latex was injected manually under physiologic pressure with a syringe. The latex was allowed to cure overnight at room temperature. Having the cadaver’s feet abducted, we drew an incision line from the bifurcation of the posterior tibial artery to the tip of the great toe. An incision was made along the border between the sole and the dorsum of the foot. The flap was elevated distally. An incision was made from a location immediately proximal to the weight-bearing area to the plantar septum of the distal plantar area and great toe. Dissection was performed using a dissection microscope, delineating meticulously the transverse artery of the great toe, the tibial proper plantar digital artery of the great toe, the fibular proper plantar digital artery of the great toe, the branches of the first plantar metatarsal artery, and the deep division of the medial plantar artery. After dissection, we measured the external diameters of every artery and observed the anastomoses between them. Anatomic Results In our series of measurements, the external caliber of the transverse artery of the great toe was 1.3 ± 0.3 mm below the flexor hallucis longus tendon located under the interphalangeal joint of the great toe. It usually runs in concert with one vena comitans, but occasionally two venae comitantes. At the tibial region of the phalanx, the transverse artery of the great toe divides into a distal branch and a proximal branch that run to and reach the arterial circle system under the first metatarsophalangeal joint (Fig. 1).
The external caliber of the tibial proper plantar digital artery of the great toe was 1.1 ± 0.2 mm, which was anastomosed with the medial branch of the deep division of the medial plantar artery. The external caliber of the medial branch of the deep division of the medial plantar artery was 0.8 ± 0.2 mm. The fibular proper plantar digital artery of the great toe was the main trunk blood supply for the great toe, and its external caliber was 1.5 ± 0.3 mm. The deep division of the medial plantar artery divided into the medial and lateral branches at 3.8 ± 1.0 cm distal to origin of the medial plantar artery (Fig. 2). The medial branch of the deep division of the medial plantar artery runs between the abductor hallucis and flexor hallucis brevis muscles, and terminates in the arterial circle system under the first metatarsophalangeal joint in concert with one vena comitans. The external caliber was 0.8 ± 0.2 mm. Some subbranches of the medial branch of the deep division of the medial plantar artery were anastomosed with branches of the arterial arch at the superior border of the abductor hallucis, which formed an arterial network on the surface of the abductor hallucis (Figs. 2 and 3). The lateral branch of the deep division of the medial plantar artery runs in the space between the first and second metatarsal bones below the plantar fascia. It generally anastomoses with the distal part of first plantar metatarsal artery in concert with the first common plantar digital nerves. The external caliber was 0.9 ± 0.2 mm. As described above, there was an arterial circle under the first metatarsophalangeal joint that consisted of the transverse artery of the great toe, the tibial proper plantar digital artery of the great
Fig. 1. Arterial circle under the first metatarsophalangeal joint. 1, Transverse artery of the great toe; 2, tibial proper plantar digital artery of the great toe; 3, fibular proper plantar digital artery of the great toe; 4, distal part of the first plantar metatarsal artery; 5, arterial arch at the superior border of the abductor hallucis; and 6, medial branch of the deep division of the medial plantar artery.
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Plastic and Reconstructive Surgery • July 2014
Fig. 2. Blood supply of the medial flap. 1, Posterior tibial artery; 2, medial plantar artery; 3, lateral plantar artery; 4, superficial division of the medial plantar artery; 5, deep division of the medial plantar artery; 6, medial branch of the deep division of the medial plantar artery; 7, lateral branch of the deep division of the medial plantar artery; 8, tibial proper plantar digital artery of the great toe; 9, fibular proper plantar digital artery of the great toe; 10, distal part of the first plantar metatarsal artery; 11, transverse artery of the great toe; 12, arterial network on the surface of the abductor hallucis; and 13, arterial arch at the superior border of the abductor hallucis.
toe, the fibular proper plantar digital artery of the great toe, and the distal part of the first plantar metatarsal artery. This arterial circle under the first metatarsophalangeal joint and arterial network on the surface of the abductor hallucis are responsible for the blood supply of the flap of the medial pedis.
branch of the deep division of the medial plantar artery. The dissection surface is the surface of the abductor hallucis muscle and the plantar fascia. The operations were performed from August of 2006 to December of 2010. All of our patients underwent the same procedures and surgery as described below.
Clinical Application Based on our anatomic findings described above, we designed the medial pedis flap for reconstruction of skin defects of the great toe in eight patients. The rotation point of this flap is the middle shaft of the proximal phalange of the great toe. The blood supply of the flap is from the transverse artery of the great toe and the tibial proper plantar digital artery to the medial
Surgical Technique Preoperatively, patients underwent Doppler imaging of the medial plantar area to identify the location of the medial branch of the deep division of the medial plantar artery and to determine that the transverse artery of the great toe was not injured. The size of the flap was determined based on the size of the recipient site. The vascular territory of this flap is the medial aspect of the foot.
Fig. 3. Formation of the arterial network on the surface of the abductor hallucis. 1, Arterial arch at the superior border of the abductor hallucis; 2, arterial network on the surface of the abductor hallucis; 3, medial branch of the deep division of the medial plantar artery.
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Volume 134, Number 1 • Great Toe Soft-Tissue Defects Under tourniquet control, the recipient site was marked, with the intention of cutting back to healthy skin if possible. This exact size was then marked on the medial aspect of the foot, with the pedicle in the midline and the dimension ranging up to 0.5 cm larger than the defect size. The incision line was drawn and the flap was elevated so that the vascular axis could be positioned centrally on the medial flap. The flap was started from proximal to the middle shaft of the proximal phalange of the great toe. Dissection was then performed at the plane between the abductor hallucis and deeper fascia. Extending the dissection upward, when reaching the upper margin of the abductor hallucis, part of its epimysium was included in the flap to ensure the inclusion of the arterial network on the surface of the abductor hallucis. The tibial proper plantar digital artery of the great toe that was anastomosed with the medial branch of the deep division of the medial plantar artery was easily isolated at the insertion location of the abductor hallucis and flexor hallucis brevis muscles. To rotate the pedicle of the flap, the anastomosis location should be ligated, which will open the arterial circle under the first metatarsophalangeal joint. We can then see the tibial proper plantar digital artery of the great toe, including the medial branch of the deep division of the medial plantar artery in the pedicle of the flap. The vascular supply to the flap was checked
following deflation of the tourniquet. The flap was then raised in a subfascial plane, keeping the medial plantar nerve in this flap. The flap was raised on its neurovascular pedicle, including surrounding fat, until the distally located pivot point of the flap was reached. This ensured that the flap could easily reach the defect (Fig. 4). The donor site was skin grafted with splitthickness skin from the abdomen. Of note, this arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis responsible for the blood supply of the skin penetrate the fascia near its medial margin, distributing to the subcutaneous area around the medial skin. Therefore, the blood supply to the medial aspect of the foot has multiple origins and has a reliable retrograde blood supply. Postoperatively, the foot was immobilized in neutral position with a cast for 2 weeks. The cast was opened at the donor site and all sutures were removed at 2 weeks. Case Report A 25-year-old man was involved in a motorcycle accident and sustained crush injury of the right foot. He had an extensive deep skin defect over the great toe and exposure of the distal phalanx. He underwent multiple débridements and sequestrectomy for necrotic bone and was left with a 2 × 2-cm soft-tissue defect over the great toe. Strong palpable pulsations of the tibialis posterior artery were discerned before surgery. We elected to close it with good-quality skin using a retrograde-flow medial pedis island flap based on the transverse artery of the great toe. A 2.5 × 2.5-cm
Fig. 4. Schematic diagram of blood flow to the medial pedis flap after elevation. 1, Posterior tibial artery; 2, medial plantar artery; 3, lateral plantar artery; 4, superficial division of the medial plantar artery; 5, deep division of the medial plantar artery; 6, medial branch of the deep division of the medial plantar artery; 7, lateral branch of the deep division of the medial plantar artery; 8, tibial proper plantar digital artery of the great toe; 9, fibula proper plantar digital artery of the great toe; 10, distal part of first plantar metatarsal artery; and 11, transverse artery of the great toe.
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Plastic and Reconstructive Surgery • July 2014 medial pedis island flap was designed. The flap was harvested according to the technique mentioned previously and transposed to cover the defect under a pneumatic tourniquet. After ligature of the branch of intersection between the tibial proper plantar digital artery and the medial branch of the deep division of the medial plantar artery, the flap could be raised and transferred to cover the defect completely. The tourniquet was deflated and the vascularization of the flap was noted. The donor site was covered using a split-thickness skin graft. All of the stitches were removed on postoperative day 14. The patient received regular physical therapy, and full recovery ensued with no limitation of dorsiflexion and flexion of the great toe after 1 month (Fig. 5).
Clinical Results Patient demographic data, the cause of the soft-tissue defect, the presence or absence of sensation of the foot, the size and location of the lesion, complications, and follow-up were recorded. During this period, eight reverse medial pedis island flaps were carried out successfully. All eight cases involved exposed tendon and bone, and serial débridement was carried out until all necrotic tissue was removed before application of the flaps. In all eight cases, the flap transferred to the great toe area survived and had adapted well to the area. The flap had sufficient bulkiness and a satisfactory skin color match. The size of the flaps ranged between 2.5 × 2.5 cm and 5.5 × 7. 5 cm. At the donor site, a split-thickness skin graft was
performed in all eight cases. No revision or overgrafting was performed. At the end of 2 weeks, gradual weight bearing was resumed. At the end of 2 months, the patients wore footwear and required no assistance for ambulation. The mean duration of patient follow-up was 16 months (range, 12 to 24 months). The mean static two-point discrimination was 17.7 mm (range,11 to 20 mm). During the follow-up period, none of the flaps demonstrated necrosis, scar contracture, or hindrance of walking and shoe wear. The patients demonstrated no gait disturbance or cold intolerance as a result of the operative procedure.
DISCUSSION Skin defects of the great toe are usually seen after trauma or because of vascular or neuropathic diseases. Most of the body weight is transferred to the ground during the “toe-off” phase and thus faster pace running requires greater range of motion at this joint. Therefore, especially in young and active patients, amputation of the great toe should be avoided to prevent problems such as gait disturbance and running disability. Because of the demands on the forefoot, soft-tissue reconstruction of the great toe requires flap coverage to resurface exposed tendon, bone, and
Fig. 5. (Above, left) A 25-year-old man had a crush injury of the great toe. (Above, right) A 2 × 2-cm softtissue defect located at the great toe with exposure of the distal phalanx after débridement. (Below, left) The flap was elevated based on the retrograde flow of the medial pedis flap. (Below, right) At 1-year follow-up after surgery, the flap was healed, with good contour match with surrounding skin and no areas of breakdown.
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Volume 134, Number 1 • Great Toe Soft-Tissue Defects joints. Recovery of soft-tissue defects in this area has proved difficult. Conservative treatment and skin grafting are often insufficient if conservation of the phalanx and of some length of the great toe is to be achieved. For reconstruction of hallux soft-tissue defects, many flap choices are described in the literature, such as the cross-toe flap,12,13 the homodigital reverse pedicled island flap,14,15 the retrograde flow medial plantar island flap,9 the reversed dorsal metatarsal artery flap,16,17 the second toe plantar flag flap,18 and the pedicled heterodigital artery flap.19 Each method has its own advantages and disadvantages from the viewpoint of healing time, recurrence of ulceration, morbidity, difficulty, reliability, duration of the operation, tissue compliance, and other aspects. A cross-toe flap raised from the mid and proximal phalangeal plantar surface of the second toe is not long enough to reach the tip of the hallux. The homodigital reverse pedicle island flap and the pedicled heterodigital artery flap are suitable for reconstructing the small tip defects of the great toe but are not adequate for reconstruction of large tip defects. Reverse dorsal metatarsal artery island flaps have been described to reconstruct small soft-tissue defects of the dorsal foot, web spaces, and toes.20 However, the arc of rotation of these flaps is limited and the flap cannot reach the distal plantar forefoot, especially the tip of the toe. Among local flap alternatives, the toe fillet flap is commonly used.1 This flap can be used for reconstruction of minor defects but necessitates amputation of the great toe. This may not be acceptable for all patients. A toe partial fillet flap using tissues from the lateral side of the great toe without amputation has been described.21 The vascular basis of this is the digital neurovascular bundle. It provides a small amount of tissue and has a restricted arc of rotation. V-Y advancement of forefoot skin based on vertical perforating vessels is another reconstructive method.22 The minimal elasticity of sole skin limits the ability of this technique to cover a large distal defect. Web space neurovascular island flaps and distally based dorsalis pedis flaps can be used as options for plantar forefoot reconstruction.4 These flaps are limited, as they do not provide durable plantar skin and fascia for weight-bearing areas. The distant pedicled flaps, cross-foot,23 and cross-leg24 flaps require a prolonged immobilization and hospitalization period. The tissue transferred is generally nonglabrous skin. A microvascular
free flap is a sensible alternative. This technique allows for the transfer of good-quality tissue but involves long surgical procedures and requires a team trained in microsurgery. As a result, the most commonly used flap is the reverse-flow medial plantar artery island flap.10,25 Studies have been conducted with respect to the anatomy of the medial plantar vessels and their clinical applications.25,26 The medial plantar island flap requires sacrificing a main vessel and partial disruption of the plantar aponeurosis, which protects the foot from shearing stress. Although the modified medial plantar perforator flap does not require sacrificing a main vessel, the pedicle is too short to repair the defect of the great toe. Bertelli and Duarte27 reported use of the plantar marginal septum cutaneous island flap to reconstruct the forefoot. The vessel pedicle was the superficial branch of the medial division of the medial plantar artery, which was a branch of the medial plantar artery and was not the main vessel. However, the limit of its rotation point was 1 cm proximal to the neck of the first metatarsal. No clinical cases of repairing skin defects of the great toe with this technique have been reported. Most of these modifications were designed to extend the anterior reach of the flap to reconstruct the distal plantar defect, and there are few reports where this was used to resurface the great toe.7,28 Compared with the aforementioned flaps, the retrograde-flow medial pedis island flap seems to be a more ideal reconstructive choice. As described above, anatomic studies have shown in great detail that the blood supplying the flap is provided by the medial plantar artery system. There was an arterial circle under the first metatarsophalangeal joint consisting of the transverse artery of the great toe, the tibial proper plantar digital artery of the great toe, the fibular proper plantar digital artery of the great toe, and the distal part of the first plantar metatarsal artery. This arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis are responsible for the blood supply of the medial area. When the flap is harvested containing the vein and nerve, the retrograde blood supplied by the transverse artery of the great toe can reach a long distance through both the arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis. We opened the arterial circle during the operation so that the pedicle could be lengthened, making it possible to cover the tip of the toe. The most distal pivot point of
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Plastic and Reconstructive Surgery • July 2014 the flap can be located at the middle shaft of the proximal phalanx. With regard to the territory of this flap, the dorsal and plantar borders should not extend across the midline of the dorsal foot and the medial margin of the sole, respectively. In addition, the anterior and posterior borders should not extend across the perpendicular lines through the tip of the medial malleolus and the middle shaft of the proximal phalanx, respectively. The medial pedis island flap based on the transverse artery of the great toe possesses numerous advantages. First, the rotation point of this flap was moved forward at the middle shaft of the proximal phalanx. The pedicle can be freed up with enough length that we can repair any skin defect of the distal forefoot, including lateral forefoot, with this technique. Second, the skin of this anatomic unit is very attractive because it is outside the weight-bearing zone and has the same cutaneous characteristics as the plantar sole. Third, after the flap is harvested, the raw surface can be easily resurfaced by a skin graft. Fourth, only a single-stage procedure is required, and there is no need to sacrifice a major vessel (e.g., posterior tibial artery, dorsalis pedis artery, or medial plantar artery). Even if the dorsalis pedis artery is of doubtful quality after trauma, we can still use this flap to repair the skin defect. Widely undermining the incision edges of plantar skin in which the pedicle is placed may help to prevent compression of the pedicle. There is no vascular compromise of the foot, and the posterior tibial, dorsalis pedis, and medial plantar arteries are left intact. Fifth, elevation of the flap is easy and quick, it avoids medial plantar artery dissection, and there is minimal donor-site morbidity. Sixth, the other advantage of the flap is the possibility of performing a flap capable of sensitivity by anastomosing the branch of the medial plantar nerve with the nerve of the wound bed. Finally, the good color and texture match with toe skin and the concealed location of the donor site are also advantages of this procedure. An inherent disadvantage to these types of reverse-flow flaps is the risk of venous congestion. The possibility of inadequate retrograde venous return because of the incompetent vein valves can be assumed to be the most important shortcoming of this flap. In cases in which venous perfusion appears to be inadequate, venous drainage can be augmented by anastomosis of the branch of the great saphenous with a vein of the wound bed. We encountered this problem during repair
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of a large skin defect of the distal lateral foot in one case, where part of the flap was necrosed. After this experience, we advise that the use of an anastomosis vein should be performed routinely to overcome venous congestion when performing a large-area flap to repair skin defects of the distal forefoot. Based on the aforementioned advantages and disadvantages, the retrograde-flow medial pedis island flap is an appropriate option in large reconstruction of the distal forefoot, producing satisfactory outcomes, especially for the great toe.
CONCLUSIONS An anatomic study using cadavers showed that the diameter of the pedicle was great and the length of the pedicle was greater than previously reported. Designing the pedicle using the transverse artery of the great toe, a retrogradeflow medial pedis island flap provides an attractive and useful alternative for reconstruction of the great toe in acute and chronic cases. Using the arterial circle under the first metatarsophalangeal joint, the flap can be used not only in great toe reconstruction but also in the reconstruction of any skin defect of the distal forefoot. This option is useful and practical for small- to medium-sized defects of the forefoot area. Donor sites showed satisfactory outcomes, without any complications. Haijiao Mao, M.D. Department of Orthopedics The Affiliated Hospital Medical School of Ningbo University Zhejiang 315020, People’s Republic of China [email protected] Zengyuan Shi, M.D. Department of Orthopaedic Surgery The Affiliated Hospital Medical School of Ningbo University Zhejiang 315020, People's Republic of China [email protected]
ACKNOWLEDGMENTS
This project was supported by Ningbo social development projects grant 2011C50007 and Ningbo medical science and technology projects grant 2010A08. REFERENCES 1. Emmett AJ. The filleted toe flap. Br J Plast Surg. 1976;29:19–21. 2. Wee JT. Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibial flap: Preliminary report of a new fasciocutaneous flap. Br J Plast Surg. 1986;39:327–337.
Volume 134, Number 1 • Great Toe Soft-Tissue Defects 3. Masquelet AC, Beveridge J, Romana C, Gerber C. The lateral supramalleolar flap. Plast Reconstr Surg. 1988;81:74–81. 4. Ishikawa K, Isshiki N, Suzuki S, Shimamura S. Distally based dorsalis pedis island flap for coverage of the distal portion of the foot. Br J Plast Surg. 1987;40:521–525. 5. Amarante JA, Martins AF, Reis J. A distally based median plantar flap. Ann Plast Surg. 1978;20:468–470. 6. Torii S, Namiki Y, Mori R. Reverse-flow island flap: Clinical report and venous drainage. Plast Reconstr Surg. 1987;79:600–609. 7. Salon A, Pouliquen JC. Reconstruction of the great toe in a child using the Y-V pedicle elongation technique for a medial plantar flap. Br J Plast Surg. 1999;52:146–148. 8. Pallua N, Di Benedetto G, Berger A. Forefoot reconstruction by reversed island flaps in diabetic patients. Plast Reconstr Surg. 2000;106:823–827. 9. Butler CE, Chevray P. Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and webspace defects. Ann Plast Surg. 2002;49:196–201. 10. Coruh A. Distally based perforator medial plantar flap: A new flap for reconstruction of plantar forefoot defects. Ann Plast Surg. 2004;53:404–408. 11. Miyoshi T, Kura H, Usui M, Okamura K, Ishii S, Yamashita T. A retrograde medial plantar flap with the common plantar digital artery to the second toe. Plast Reconstr Surg. 2005;115:1445–1447. 12. Hamilton RB, O’Brien BM, Morrison WA. The cross toe flap. Br J Plast Surg. 1979;32:213–216. 13. Hait G. Cross-toe flap. Plast Reconstr Surg. 1982;70:94–95. 14. Niranjan NS, Vanstralen P. Homodigital reverse pedicle island flap for reconstruction of the great toe. Br J Plast Surg. 2000;53:499–502. 15. Demirtas Y, Ayhan S, Latifoglu O, Atabay K, Celebi C. Homodigital reverse flow island flap for reconstruction of neuropathic great toe ulcers in diabetic patients. Br J Plast Surg. 2005;58:717–719. 16. Cheng MH, Ulusal BG, Wei FC. Reverse first dorsal metatarsal artery flap for reconstruction of traumatic defects of dorsal great toe. J Trauma 2006;60:1138–1141.
17. Balakrishnan C, Chang YJ, Balakrishnan A, Careaga D. Reversed dorsal metatarsal artery flap for reconstruction of a soft tissue defect of the big toe. Can J Plast Surg. 2009;17:e11–e12. 18. Sawabe K, Ishiko T, Miyata A, Takemoto S, Shigeyoshi N. Resurfacing of the donor defect with a second toe plantar flag flap after free first toe pulp flap. Scand J Plast Reconstr Surg Hand Surg. 2004;38:306–309. 19. Sahin C, Karagoz H, Sever C, Kulahci Y, Ulkur E. Reconstruction of the great toe tip defect with a pedicled heterodigital artery flap. Aesthetic Plast Surg. 2013;37:421–423. 20. Sakai S. A distally based island first dorsal metatarsal artery flap for the coverage of a distal plantar defect. Br J Plast Surg. 1993;46:480–482. 21. Granick MS, Newton ED, Futrell JW, Hurwitz D. The plantar digital web space island flap for reconstruction of the distal sole. Ann Plast Surg. 1987;19:68–74. 22. Colen LB, Replogle SL, Mathes SJ. The V-Y plantar flap for reconstruction of the forefoot. Plast Reconstr Surg. 1988;81:220–228. 23. Taylor GA, Hopson WL. The cross-foot flap. Plast Reconstr Surg. 1975;55:677–681. 24. Morris AM, Buchan AC. The place of the cross-leg flap in reconstructive surgery of the lower leg and foot: A review of 165 cases. Br J Plast Surg. 1978;31:138–142. 25. Acikel C, Celikoz B, Yuksel F, Ergun O. Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle. Ann Plast Surg. 2003;50:498–503. 26. Ulkür E, Açikel C, Karagöz H, Celiköz B. Refinements of medial plantar flap used for covering nonweightbearing ankle and posterior heel defects requiring thin flaps. Ann Plast Surg. 2005;55:371–373. 27. Bertelli JA, Duarte HE. The plantar marginal septum cutaneous island flap: A new flap in forefoot reconstruction. Plast Reconstr Surg. 1997;99:1390–1395. 28. Uygur F, Duman H, Ulkür E, Noyan N, Celiköz B. Reconstruction of distal forefoot burn defect with retrograde medial plantar flap. Burns 2008;34:262–267.
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Background: Several investigators have reported their clinical experience with medial pedis flaps for reconstruction of soft-tissue defects of the distal forefoot. However, they had only a few reports where this flap was used to repair softtissue defects of the great toe. Thus, reconstruction of soft-tissue defects of the great toe remains a challenge in reconstructive surgery. The authors describe the use of the medial pedis island flap to cover this region. Methods: This study was divided into two parts: an anatomic study and clinical application. In the anatomic study, 48 cadaveric feet were injected with latex, and then the main vessels distributed at the medial aspect of the foot were observed. Clinically, retrograde-flow medial pedis island flaps were harvested to cover the soft-tissue defects of the great toe in eight cases. Results: An anatomic study revealed that the arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis were responsible for the blood supply of the medial region of the foot. The diameter of the pedicle was great, and the pedicle was longer than previously reported. In terms of clinical application, all flaps were successful, without any significant complications. Conclusions: Using the arterial circle under the first metatarsophalangeal joint, the medial pedis island flap has a reliable retrograde blood supply. This flap should be considered as a preferential way of reconstructing soft-tissue defects of the great toe. (Plast. Reconstr. Surg. 134: 120e, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
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econstruction of the forefoot region remains a challenging problem, especially for the great toe. Conservative treatment and local flaps are often insufficient to achieve adequate healing. Although several methods are described, including skin grafts and fillet flap,1 reverse anterior tibial flap,2 lateral supramalleolar flap,3 distally based dorsal pedis island flap,4 distally pedicled reverse-flow medial plantar flap,5,6 and medial plantar flap with Y-V pedicle elongation technique,7 these alternatives generally have their difficulties. In response to these shortcomings and to look for other donor sites, many studies8–11 have begun to experiment with new flaps. This study evaluates a retrograde-flow medial pedis flap that has the advantage of being an From the Department of Orthopaedic Surgery, Pennsylvania Hospital, University of Pennsylvania School of Medicine; and the Department of Orthopaedic Surgery, Affiliated Hospital, and the Department of Anatomy, Medical School of Ningbo University. Received for publication May 12, 2013; accepted January 21, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000274
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adjacent tissue flap of the great toe with minimal donor-site problems. This flap has anatomic characteristics that are similar to those of the adjacent tissues of the great toe, which make it an attractive flap for soft-tissue defects of the great toe. The authors designed a retrograde-flow medial pedis flap as a reliable single-stage technique for coverage of great toe defects. We present the results of an anatomic study of lifting and harvesting the flap and our experience with the medial pedis island flap for reconstruction of the great toe in acute and chronic cases based on the blood supply in the medial pedis.
PATIENTS AND METHODS Anatomic Study This study was conducted in collaboration with the Department of Anatomy at the Medical School of Ningbo University. Forty-eight feet from 24 cadavers
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
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Volume 134, Number 1 • Great Toe Soft-Tissue Defects that had been embalmed with formalin were studied. The cadavers, 15 female and seven male cadavers, had no known vascular disease. The popliteal arteries were dissected and latex was injected manually under physiologic pressure with a syringe. The latex was allowed to cure overnight at room temperature. Having the cadaver’s feet abducted, we drew an incision line from the bifurcation of the posterior tibial artery to the tip of the great toe. An incision was made along the border between the sole and the dorsum of the foot. The flap was elevated distally. An incision was made from a location immediately proximal to the weight-bearing area to the plantar septum of the distal plantar area and great toe. Dissection was performed using a dissection microscope, delineating meticulously the transverse artery of the great toe, the tibial proper plantar digital artery of the great toe, the fibular proper plantar digital artery of the great toe, the branches of the first plantar metatarsal artery, and the deep division of the medial plantar artery. After dissection, we measured the external diameters of every artery and observed the anastomoses between them. Anatomic Results In our series of measurements, the external caliber of the transverse artery of the great toe was 1.3 ± 0.3 mm below the flexor hallucis longus tendon located under the interphalangeal joint of the great toe. It usually runs in concert with one vena comitans, but occasionally two venae comitantes. At the tibial region of the phalanx, the transverse artery of the great toe divides into a distal branch and a proximal branch that run to and reach the arterial circle system under the first metatarsophalangeal joint (Fig. 1).
The external caliber of the tibial proper plantar digital artery of the great toe was 1.1 ± 0.2 mm, which was anastomosed with the medial branch of the deep division of the medial plantar artery. The external caliber of the medial branch of the deep division of the medial plantar artery was 0.8 ± 0.2 mm. The fibular proper plantar digital artery of the great toe was the main trunk blood supply for the great toe, and its external caliber was 1.5 ± 0.3 mm. The deep division of the medial plantar artery divided into the medial and lateral branches at 3.8 ± 1.0 cm distal to origin of the medial plantar artery (Fig. 2). The medial branch of the deep division of the medial plantar artery runs between the abductor hallucis and flexor hallucis brevis muscles, and terminates in the arterial circle system under the first metatarsophalangeal joint in concert with one vena comitans. The external caliber was 0.8 ± 0.2 mm. Some subbranches of the medial branch of the deep division of the medial plantar artery were anastomosed with branches of the arterial arch at the superior border of the abductor hallucis, which formed an arterial network on the surface of the abductor hallucis (Figs. 2 and 3). The lateral branch of the deep division of the medial plantar artery runs in the space between the first and second metatarsal bones below the plantar fascia. It generally anastomoses with the distal part of first plantar metatarsal artery in concert with the first common plantar digital nerves. The external caliber was 0.9 ± 0.2 mm. As described above, there was an arterial circle under the first metatarsophalangeal joint that consisted of the transverse artery of the great toe, the tibial proper plantar digital artery of the great
Fig. 1. Arterial circle under the first metatarsophalangeal joint. 1, Transverse artery of the great toe; 2, tibial proper plantar digital artery of the great toe; 3, fibular proper plantar digital artery of the great toe; 4, distal part of the first plantar metatarsal artery; 5, arterial arch at the superior border of the abductor hallucis; and 6, medial branch of the deep division of the medial plantar artery.
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Fig. 2. Blood supply of the medial flap. 1, Posterior tibial artery; 2, medial plantar artery; 3, lateral plantar artery; 4, superficial division of the medial plantar artery; 5, deep division of the medial plantar artery; 6, medial branch of the deep division of the medial plantar artery; 7, lateral branch of the deep division of the medial plantar artery; 8, tibial proper plantar digital artery of the great toe; 9, fibular proper plantar digital artery of the great toe; 10, distal part of the first plantar metatarsal artery; 11, transverse artery of the great toe; 12, arterial network on the surface of the abductor hallucis; and 13, arterial arch at the superior border of the abductor hallucis.
toe, the fibular proper plantar digital artery of the great toe, and the distal part of the first plantar metatarsal artery. This arterial circle under the first metatarsophalangeal joint and arterial network on the surface of the abductor hallucis are responsible for the blood supply of the flap of the medial pedis.
branch of the deep division of the medial plantar artery. The dissection surface is the surface of the abductor hallucis muscle and the plantar fascia. The operations were performed from August of 2006 to December of 2010. All of our patients underwent the same procedures and surgery as described below.
Clinical Application Based on our anatomic findings described above, we designed the medial pedis flap for reconstruction of skin defects of the great toe in eight patients. The rotation point of this flap is the middle shaft of the proximal phalange of the great toe. The blood supply of the flap is from the transverse artery of the great toe and the tibial proper plantar digital artery to the medial
Surgical Technique Preoperatively, patients underwent Doppler imaging of the medial plantar area to identify the location of the medial branch of the deep division of the medial plantar artery and to determine that the transverse artery of the great toe was not injured. The size of the flap was determined based on the size of the recipient site. The vascular territory of this flap is the medial aspect of the foot.
Fig. 3. Formation of the arterial network on the surface of the abductor hallucis. 1, Arterial arch at the superior border of the abductor hallucis; 2, arterial network on the surface of the abductor hallucis; 3, medial branch of the deep division of the medial plantar artery.
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Volume 134, Number 1 • Great Toe Soft-Tissue Defects Under tourniquet control, the recipient site was marked, with the intention of cutting back to healthy skin if possible. This exact size was then marked on the medial aspect of the foot, with the pedicle in the midline and the dimension ranging up to 0.5 cm larger than the defect size. The incision line was drawn and the flap was elevated so that the vascular axis could be positioned centrally on the medial flap. The flap was started from proximal to the middle shaft of the proximal phalange of the great toe. Dissection was then performed at the plane between the abductor hallucis and deeper fascia. Extending the dissection upward, when reaching the upper margin of the abductor hallucis, part of its epimysium was included in the flap to ensure the inclusion of the arterial network on the surface of the abductor hallucis. The tibial proper plantar digital artery of the great toe that was anastomosed with the medial branch of the deep division of the medial plantar artery was easily isolated at the insertion location of the abductor hallucis and flexor hallucis brevis muscles. To rotate the pedicle of the flap, the anastomosis location should be ligated, which will open the arterial circle under the first metatarsophalangeal joint. We can then see the tibial proper plantar digital artery of the great toe, including the medial branch of the deep division of the medial plantar artery in the pedicle of the flap. The vascular supply to the flap was checked
following deflation of the tourniquet. The flap was then raised in a subfascial plane, keeping the medial plantar nerve in this flap. The flap was raised on its neurovascular pedicle, including surrounding fat, until the distally located pivot point of the flap was reached. This ensured that the flap could easily reach the defect (Fig. 4). The donor site was skin grafted with splitthickness skin from the abdomen. Of note, this arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis responsible for the blood supply of the skin penetrate the fascia near its medial margin, distributing to the subcutaneous area around the medial skin. Therefore, the blood supply to the medial aspect of the foot has multiple origins and has a reliable retrograde blood supply. Postoperatively, the foot was immobilized in neutral position with a cast for 2 weeks. The cast was opened at the donor site and all sutures were removed at 2 weeks. Case Report A 25-year-old man was involved in a motorcycle accident and sustained crush injury of the right foot. He had an extensive deep skin defect over the great toe and exposure of the distal phalanx. He underwent multiple débridements and sequestrectomy for necrotic bone and was left with a 2 × 2-cm soft-tissue defect over the great toe. Strong palpable pulsations of the tibialis posterior artery were discerned before surgery. We elected to close it with good-quality skin using a retrograde-flow medial pedis island flap based on the transverse artery of the great toe. A 2.5 × 2.5-cm
Fig. 4. Schematic diagram of blood flow to the medial pedis flap after elevation. 1, Posterior tibial artery; 2, medial plantar artery; 3, lateral plantar artery; 4, superficial division of the medial plantar artery; 5, deep division of the medial plantar artery; 6, medial branch of the deep division of the medial plantar artery; 7, lateral branch of the deep division of the medial plantar artery; 8, tibial proper plantar digital artery of the great toe; 9, fibula proper plantar digital artery of the great toe; 10, distal part of first plantar metatarsal artery; and 11, transverse artery of the great toe.
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Plastic and Reconstructive Surgery • July 2014 medial pedis island flap was designed. The flap was harvested according to the technique mentioned previously and transposed to cover the defect under a pneumatic tourniquet. After ligature of the branch of intersection between the tibial proper plantar digital artery and the medial branch of the deep division of the medial plantar artery, the flap could be raised and transferred to cover the defect completely. The tourniquet was deflated and the vascularization of the flap was noted. The donor site was covered using a split-thickness skin graft. All of the stitches were removed on postoperative day 14. The patient received regular physical therapy, and full recovery ensued with no limitation of dorsiflexion and flexion of the great toe after 1 month (Fig. 5).
Clinical Results Patient demographic data, the cause of the soft-tissue defect, the presence or absence of sensation of the foot, the size and location of the lesion, complications, and follow-up were recorded. During this period, eight reverse medial pedis island flaps were carried out successfully. All eight cases involved exposed tendon and bone, and serial débridement was carried out until all necrotic tissue was removed before application of the flaps. In all eight cases, the flap transferred to the great toe area survived and had adapted well to the area. The flap had sufficient bulkiness and a satisfactory skin color match. The size of the flaps ranged between 2.5 × 2.5 cm and 5.5 × 7. 5 cm. At the donor site, a split-thickness skin graft was
performed in all eight cases. No revision or overgrafting was performed. At the end of 2 weeks, gradual weight bearing was resumed. At the end of 2 months, the patients wore footwear and required no assistance for ambulation. The mean duration of patient follow-up was 16 months (range, 12 to 24 months). The mean static two-point discrimination was 17.7 mm (range,11 to 20 mm). During the follow-up period, none of the flaps demonstrated necrosis, scar contracture, or hindrance of walking and shoe wear. The patients demonstrated no gait disturbance or cold intolerance as a result of the operative procedure.
DISCUSSION Skin defects of the great toe are usually seen after trauma or because of vascular or neuropathic diseases. Most of the body weight is transferred to the ground during the “toe-off” phase and thus faster pace running requires greater range of motion at this joint. Therefore, especially in young and active patients, amputation of the great toe should be avoided to prevent problems such as gait disturbance and running disability. Because of the demands on the forefoot, soft-tissue reconstruction of the great toe requires flap coverage to resurface exposed tendon, bone, and
Fig. 5. (Above, left) A 25-year-old man had a crush injury of the great toe. (Above, right) A 2 × 2-cm softtissue defect located at the great toe with exposure of the distal phalanx after débridement. (Below, left) The flap was elevated based on the retrograde flow of the medial pedis flap. (Below, right) At 1-year follow-up after surgery, the flap was healed, with good contour match with surrounding skin and no areas of breakdown.
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Volume 134, Number 1 • Great Toe Soft-Tissue Defects joints. Recovery of soft-tissue defects in this area has proved difficult. Conservative treatment and skin grafting are often insufficient if conservation of the phalanx and of some length of the great toe is to be achieved. For reconstruction of hallux soft-tissue defects, many flap choices are described in the literature, such as the cross-toe flap,12,13 the homodigital reverse pedicled island flap,14,15 the retrograde flow medial plantar island flap,9 the reversed dorsal metatarsal artery flap,16,17 the second toe plantar flag flap,18 and the pedicled heterodigital artery flap.19 Each method has its own advantages and disadvantages from the viewpoint of healing time, recurrence of ulceration, morbidity, difficulty, reliability, duration of the operation, tissue compliance, and other aspects. A cross-toe flap raised from the mid and proximal phalangeal plantar surface of the second toe is not long enough to reach the tip of the hallux. The homodigital reverse pedicle island flap and the pedicled heterodigital artery flap are suitable for reconstructing the small tip defects of the great toe but are not adequate for reconstruction of large tip defects. Reverse dorsal metatarsal artery island flaps have been described to reconstruct small soft-tissue defects of the dorsal foot, web spaces, and toes.20 However, the arc of rotation of these flaps is limited and the flap cannot reach the distal plantar forefoot, especially the tip of the toe. Among local flap alternatives, the toe fillet flap is commonly used.1 This flap can be used for reconstruction of minor defects but necessitates amputation of the great toe. This may not be acceptable for all patients. A toe partial fillet flap using tissues from the lateral side of the great toe without amputation has been described.21 The vascular basis of this is the digital neurovascular bundle. It provides a small amount of tissue and has a restricted arc of rotation. V-Y advancement of forefoot skin based on vertical perforating vessels is another reconstructive method.22 The minimal elasticity of sole skin limits the ability of this technique to cover a large distal defect. Web space neurovascular island flaps and distally based dorsalis pedis flaps can be used as options for plantar forefoot reconstruction.4 These flaps are limited, as they do not provide durable plantar skin and fascia for weight-bearing areas. The distant pedicled flaps, cross-foot,23 and cross-leg24 flaps require a prolonged immobilization and hospitalization period. The tissue transferred is generally nonglabrous skin. A microvascular
free flap is a sensible alternative. This technique allows for the transfer of good-quality tissue but involves long surgical procedures and requires a team trained in microsurgery. As a result, the most commonly used flap is the reverse-flow medial plantar artery island flap.10,25 Studies have been conducted with respect to the anatomy of the medial plantar vessels and their clinical applications.25,26 The medial plantar island flap requires sacrificing a main vessel and partial disruption of the plantar aponeurosis, which protects the foot from shearing stress. Although the modified medial plantar perforator flap does not require sacrificing a main vessel, the pedicle is too short to repair the defect of the great toe. Bertelli and Duarte27 reported use of the plantar marginal septum cutaneous island flap to reconstruct the forefoot. The vessel pedicle was the superficial branch of the medial division of the medial plantar artery, which was a branch of the medial plantar artery and was not the main vessel. However, the limit of its rotation point was 1 cm proximal to the neck of the first metatarsal. No clinical cases of repairing skin defects of the great toe with this technique have been reported. Most of these modifications were designed to extend the anterior reach of the flap to reconstruct the distal plantar defect, and there are few reports where this was used to resurface the great toe.7,28 Compared with the aforementioned flaps, the retrograde-flow medial pedis island flap seems to be a more ideal reconstructive choice. As described above, anatomic studies have shown in great detail that the blood supplying the flap is provided by the medial plantar artery system. There was an arterial circle under the first metatarsophalangeal joint consisting of the transverse artery of the great toe, the tibial proper plantar digital artery of the great toe, the fibular proper plantar digital artery of the great toe, and the distal part of the first plantar metatarsal artery. This arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis are responsible for the blood supply of the medial area. When the flap is harvested containing the vein and nerve, the retrograde blood supplied by the transverse artery of the great toe can reach a long distance through both the arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis. We opened the arterial circle during the operation so that the pedicle could be lengthened, making it possible to cover the tip of the toe. The most distal pivot point of
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Plastic and Reconstructive Surgery • July 2014 the flap can be located at the middle shaft of the proximal phalanx. With regard to the territory of this flap, the dorsal and plantar borders should not extend across the midline of the dorsal foot and the medial margin of the sole, respectively. In addition, the anterior and posterior borders should not extend across the perpendicular lines through the tip of the medial malleolus and the middle shaft of the proximal phalanx, respectively. The medial pedis island flap based on the transverse artery of the great toe possesses numerous advantages. First, the rotation point of this flap was moved forward at the middle shaft of the proximal phalanx. The pedicle can be freed up with enough length that we can repair any skin defect of the distal forefoot, including lateral forefoot, with this technique. Second, the skin of this anatomic unit is very attractive because it is outside the weight-bearing zone and has the same cutaneous characteristics as the plantar sole. Third, after the flap is harvested, the raw surface can be easily resurfaced by a skin graft. Fourth, only a single-stage procedure is required, and there is no need to sacrifice a major vessel (e.g., posterior tibial artery, dorsalis pedis artery, or medial plantar artery). Even if the dorsalis pedis artery is of doubtful quality after trauma, we can still use this flap to repair the skin defect. Widely undermining the incision edges of plantar skin in which the pedicle is placed may help to prevent compression of the pedicle. There is no vascular compromise of the foot, and the posterior tibial, dorsalis pedis, and medial plantar arteries are left intact. Fifth, elevation of the flap is easy and quick, it avoids medial plantar artery dissection, and there is minimal donor-site morbidity. Sixth, the other advantage of the flap is the possibility of performing a flap capable of sensitivity by anastomosing the branch of the medial plantar nerve with the nerve of the wound bed. Finally, the good color and texture match with toe skin and the concealed location of the donor site are also advantages of this procedure. An inherent disadvantage to these types of reverse-flow flaps is the risk of venous congestion. The possibility of inadequate retrograde venous return because of the incompetent vein valves can be assumed to be the most important shortcoming of this flap. In cases in which venous perfusion appears to be inadequate, venous drainage can be augmented by anastomosis of the branch of the great saphenous with a vein of the wound bed. We encountered this problem during repair
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of a large skin defect of the distal lateral foot in one case, where part of the flap was necrosed. After this experience, we advise that the use of an anastomosis vein should be performed routinely to overcome venous congestion when performing a large-area flap to repair skin defects of the distal forefoot. Based on the aforementioned advantages and disadvantages, the retrograde-flow medial pedis island flap is an appropriate option in large reconstruction of the distal forefoot, producing satisfactory outcomes, especially for the great toe.
CONCLUSIONS An anatomic study using cadavers showed that the diameter of the pedicle was great and the length of the pedicle was greater than previously reported. Designing the pedicle using the transverse artery of the great toe, a retrogradeflow medial pedis island flap provides an attractive and useful alternative for reconstruction of the great toe in acute and chronic cases. Using the arterial circle under the first metatarsophalangeal joint, the flap can be used not only in great toe reconstruction but also in the reconstruction of any skin defect of the distal forefoot. This option is useful and practical for small- to medium-sized defects of the forefoot area. Donor sites showed satisfactory outcomes, without any complications. Haijiao Mao, M.D. Department of Orthopedics The Affiliated Hospital Medical School of Ningbo University Zhejiang 315020, People’s Republic of China [email protected] Zengyuan Shi, M.D. Department of Orthopaedic Surgery The Affiliated Hospital Medical School of Ningbo University Zhejiang 315020, People's Republic of China [email protected]
ACKNOWLEDGMENTS
This project was supported by Ningbo social development projects grant 2011C50007 and Ningbo medical science and technology projects grant 2010A08. REFERENCES 1. Emmett AJ. The filleted toe flap. Br J Plast Surg. 1976;29:19–21. 2. Wee JT. Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibial flap: Preliminary report of a new fasciocutaneous flap. Br J Plast Surg. 1986;39:327–337.
Volume 134, Number 1 • Great Toe Soft-Tissue Defects 3. Masquelet AC, Beveridge J, Romana C, Gerber C. The lateral supramalleolar flap. Plast Reconstr Surg. 1988;81:74–81. 4. Ishikawa K, Isshiki N, Suzuki S, Shimamura S. Distally based dorsalis pedis island flap for coverage of the distal portion of the foot. Br J Plast Surg. 1987;40:521–525. 5. Amarante JA, Martins AF, Reis J. A distally based median plantar flap. Ann Plast Surg. 1978;20:468–470. 6. Torii S, Namiki Y, Mori R. Reverse-flow island flap: Clinical report and venous drainage. Plast Reconstr Surg. 1987;79:600–609. 7. Salon A, Pouliquen JC. Reconstruction of the great toe in a child using the Y-V pedicle elongation technique for a medial plantar flap. Br J Plast Surg. 1999;52:146–148. 8. Pallua N, Di Benedetto G, Berger A. Forefoot reconstruction by reversed island flaps in diabetic patients. Plast Reconstr Surg. 2000;106:823–827. 9. Butler CE, Chevray P. Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and webspace defects. Ann Plast Surg. 2002;49:196–201. 10. Coruh A. Distally based perforator medial plantar flap: A new flap for reconstruction of plantar forefoot defects. Ann Plast Surg. 2004;53:404–408. 11. Miyoshi T, Kura H, Usui M, Okamura K, Ishii S, Yamashita T. A retrograde medial plantar flap with the common plantar digital artery to the second toe. Plast Reconstr Surg. 2005;115:1445–1447. 12. Hamilton RB, O’Brien BM, Morrison WA. The cross toe flap. Br J Plast Surg. 1979;32:213–216. 13. Hait G. Cross-toe flap. Plast Reconstr Surg. 1982;70:94–95. 14. Niranjan NS, Vanstralen P. Homodigital reverse pedicle island flap for reconstruction of the great toe. Br J Plast Surg. 2000;53:499–502. 15. Demirtas Y, Ayhan S, Latifoglu O, Atabay K, Celebi C. Homodigital reverse flow island flap for reconstruction of neuropathic great toe ulcers in diabetic patients. Br J Plast Surg. 2005;58:717–719. 16. Cheng MH, Ulusal BG, Wei FC. Reverse first dorsal metatarsal artery flap for reconstruction of traumatic defects of dorsal great toe. J Trauma 2006;60:1138–1141.
17. Balakrishnan C, Chang YJ, Balakrishnan A, Careaga D. Reversed dorsal metatarsal artery flap for reconstruction of a soft tissue defect of the big toe. Can J Plast Surg. 2009;17:e11–e12. 18. Sawabe K, Ishiko T, Miyata A, Takemoto S, Shigeyoshi N. Resurfacing of the donor defect with a second toe plantar flag flap after free first toe pulp flap. Scand J Plast Reconstr Surg Hand Surg. 2004;38:306–309. 19. Sahin C, Karagoz H, Sever C, Kulahci Y, Ulkur E. Reconstruction of the great toe tip defect with a pedicled heterodigital artery flap. Aesthetic Plast Surg. 2013;37:421–423. 20. Sakai S. A distally based island first dorsal metatarsal artery flap for the coverage of a distal plantar defect. Br J Plast Surg. 1993;46:480–482. 21. Granick MS, Newton ED, Futrell JW, Hurwitz D. The plantar digital web space island flap for reconstruction of the distal sole. Ann Plast Surg. 1987;19:68–74. 22. Colen LB, Replogle SL, Mathes SJ. The V-Y plantar flap for reconstruction of the forefoot. Plast Reconstr Surg. 1988;81:220–228. 23. Taylor GA, Hopson WL. The cross-foot flap. Plast Reconstr Surg. 1975;55:677–681. 24. Morris AM, Buchan AC. The place of the cross-leg flap in reconstructive surgery of the lower leg and foot: A review of 165 cases. Br J Plast Surg. 1978;31:138–142. 25. Acikel C, Celikoz B, Yuksel F, Ergun O. Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle. Ann Plast Surg. 2003;50:498–503. 26. Ulkür E, Açikel C, Karagöz H, Celiköz B. Refinements of medial plantar flap used for covering nonweightbearing ankle and posterior heel defects requiring thin flaps. Ann Plast Surg. 2005;55:371–373. 27. Bertelli JA, Duarte HE. The plantar marginal septum cutaneous island flap: A new flap in forefoot reconstruction. Plast Reconstr Surg. 1997;99:1390–1395. 28. Uygur F, Duman H, Ulkür E, Noyan N, Celiköz B. Reconstruction of distal forefoot burn defect with retrograde medial plantar flap. Burns 2008;34:262–267.
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