A free dorsalis pedis flap from the other foot combined with a dorsalis pedis pedicle flap from the same foot to close foot ulcers

A FREE DORSALIS PEDIS FLAP FROM THE OTHER FOOT COMBINED WITH A DORSALIS PEDIS PEDICLE FLAP FROM THE SAME FOOT TO CLOSE FOOT ULCERS By HISASHI OHTSUKA,M.D.*, NOBUYUKI SHIOYA, M.D., F.A.C.S.*, EIICHI HOSHI, M.D.t, and YOICW OGINO, M.D.t * Department of Plastic and Reconstructive Surgery, Kitasato University, School of Me&&, Sagamihara,Japan; t Department of Plastic and Reconstructive Surgery, ST Marianna Universit_y, School of Medicine, Kawasaki, Japan THE dorsalis pedis flap has several advantages:

the skin is thin and hairless, a long vascular pedicle with relatively large diameter vessels is available, and a cutaneous nerve supply is also available if needed. It may be used as a free flap or as a local pedicle flap; we have combined both methods in 2 patients. CASE I A Q-year-old man, who had suffered from a basal cell carcinoma on the lateral malleolar area of the left foot for 3 years, was referred to us. Radiation and occlusive dressing therapy with bleomycin ointment had been performed alternately at intervals of about 6 months, during the prior z years but had resulted only in the enlargement of the ulcerated area. He also had a

FIG. I

Cast

I. Preoperative condition.

An area of chronic inflammation therapy surrounds the ulcer.

due to radiation and bleomycm

BRITISH

JOURNAL

OF PLASTIC

SURGERY

A Great saphenous

vein

,Dorsalis

Chrome Subcutaneous

pedis artery

ulcer

Transferred dorsalls pedls

tunr Necrosed

Arterlallzed

Previously

rotation

flap

flap

flap _

grafted

Newly area

area

grafted

I

B FIG.

2.

planning. B. The arterialized dorsalis pedis flap, subcutaneous tunnei, and the anastomosed portions of the recipient and donor vessels are shown.

Case I. A. Preoperative

FREE

DORSALIS

FIG. 3.

PEDIS

Case

FLAP

1. Four

TO

months

CLOSE

FOOT

ULCER

postoperatively.

FIG. 4. Case 2. Preoperative c0ndition. The centre of the exposed arca did not take a skin graft successfully

5

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JOURNAL

/Dorsalis

area

OF PLASTIC

pedis artery

Great saphenous

Subcutaneous

Arterlallzed

FIG. 5.

SURGERY

VCI:I

tunml

flap I*~’

Case 2. Operative procedures. The arterialised dorsalis pedis flap, the subcutaneous vascular routes, the rotated short hallucis muscle, and other details are shown.

tunnel,

the

FREE DORSALIS PEDIS FLAP TO CLOSE FOOT ULC,ER

7

skin grafted area and a necrosed local flap, the results of a procedure performed elsewhere about 3 weeks earlier (Fig. I). A free dorsalis pedis flap from the right foot, combined with an arterialised segmental flap from the recipient foot, was performed by anastomosing the Zeft dorsalis pedis artery and the left great saphenous vein to the right dorsalis pedis artery and the right saphenous vein (Fig. 2). In this case, the dorsal venous network in the flap seemed to be poor, although the diameter of the great saphenous vein was wide and reliable at the site of the anastomosis. Postoperatively, bleeding from the distal margin of the transferred flap was continuous until the 4th day, and a blood transfusion of 3,000 ml was necessary. There were, however, no major problems or complications either at the recipient or donor site from the 5th postoperative day onwards (Fig. 3‘. CASE 2 An IS-year-old girl sustained a severe injury of the dorsal region of the right foot in a bicycle accident. About I month after the injury, a split thickness skin graft was performed. However, the centre of the exposed area did not take the graft successfully (Fig. 4). A free flap transfer, therefore, appeared to be justified. In this case, a free dorsalis pedis flap from the left foot was inset at the recipient site so as to turn the proximal end of the flap distally. An arterialised rectangular flap, including the left dorsalis pedis artery, was rotated to cover the vascular pedicle of the free flap, The short hallucis muscle was also rotated to prevent the anastomosed vessels from protruding into the grafted region. The vessel anastomoses were performed at the sites shown (Fig.5). The postoperative course was entirely uneventful (Fig.6).

FIG. 6.

Case 2. Two and weeks postoperatively,

a 11alf

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JOURNAL

OF PLASTIC

SURGERY

DISCUSSION A dorsalis

pedis

island

pedicle.

However,

extensive

in the recipient

cover

the anastomosed

(Robinson,

1976).

of the body; dorsalis

pedis

flap may

if inelastic, region, vessels

Fortunately,

therefore,

characteristically

fibrotic

be raised

areas, such as scarred

as in the 2 cases presented, because

of the absence

with

a long

tissue or grafted

artery itself is partly

pedis

covered

of a subcutaneous

strip flap may be safely lifted,

with grafted

skin are

some device is necessary tunnel

the dorsalis pedis artery is one of the cutaneous

a local dorsalis

vascular to

route

arteries

even if the

skin.

We wish to express our gratitude to Dr Masahide Ando, Department of Plastic and Reconstructive Surgery, Saku Central Hospital, for referring Case I to us and for his assistance during the operation. REFERENCE ROBINSON, D. W. (1976). flap. BritishJournal

Microsurgical

of Plastic

transfer

Surgery,

of the dorsalis

29, 209.

pedis

neurovascular

island