- Email: [email protected]
Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications
+
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e5
Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications A. Russo a, G. Delia a,*, V. Casoli b, M.R. Colonna a, F. Stagno d’Alcontres a a Plastic Reconstructive and Aesthetic Surgery Unit, University of Messina, Policlinico ‘G. Martino’, Via Consolare Valeria 1, 98125 Messina, Italy b Plastic and Burn Unit Fx Michelet Center, Bordeaux Segalen University, Bordeaux, France
Received 2 September 2013; accepted 17 December 2013
KEYWORDS Adipofascial flap; Dorsalis pedis artery perforator; Perforator flap; Dorsal foot reconstruction
Summary Defects of the dorsum of the foot can be challenging to reconstruct, none more so than the dorsum of the toe. The reverse Dorsalis Pedis Adipofascial Perforator (DPAP) flap is one possible reconstructive option for defects in this region. The aim of this study was to first demonstrate the anatomy of this flap, particularly the consistency of the perforators arising from the dorsalis pedis artery. Second, we present a clinical series based on this flap to demonstrate how it can be used. For the anatomical studies, 22 fresh cadaveric lower extremities were dissected, and injection studies were used to delineate the vascular territories. The presence of the distal perforator, distance to the first metatarso-phalangeal joint and diameter of each perforator were recorded. The cadaveric studies confirmed the presence of distal perforators to the first metatarso-phalangeal joint in 100% of limbs examined. The clinical study demonstrated the feasibility of the use of the adipofascial turn-over perforator flap for dorsal foot reconstruction. These anatomic findings provide an alternative method of reconstruction of great toe defects using the reverse DPAP flap. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Background and aim * Corresponding author. Plastic Reconstructive and Aesthetic Surgery Unit, A.O.U. Policlinico ‘G. Martino’, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy. Tel.: þ39 3289215256; fax: þ39 090 221 3727. E-mail addresses: [email protected], [email protected] (G. Delia).
Defects of the dorsum of the foot are challenging problems in reconstructive surgery. These defects may present through a variety of different clinical scenarios, for example, trauma, tumours, burns and diabetes mellitus to name a few. The more distal the defect, the harder to reconstruct with local soft tissue options, as skin laxity and
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.019
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
+
MODEL
2 mobility are limited. For these reasons, reconstruction of defects of the great toe and the first metatarsal joint can frequently become compromised. Lai et al. (1991) reported the use of an adipofascial turn-over flap for resurfacing dorsal defects of the foot in combination with splitthickness skin grafting. With distal dorsal foot defects, local adipofascial flaps can be a good surgical option for the surgeon for several reasons. First, the donor tissue has similar characteristics to the recipient tissue and second, there is reliable vascular anatomy, therefore providing better functional and aesthetic results. We present a cadaveric study to confirm the anatomy of the distal Dorsalis Pedis Adipofascial Perforator (DPAP). In addition, we present a clinical series that demonstrates how this perforator can be reliably used to raise an adiposfascial turnover flap which can ultimately reconstruct defects of the dorsum of the great toe and first metatarsal joint.
Materials and methods Anatomical study This study was performed at the Laboratory of Anatomy of Bordeaux 2 University, France. A total of 22 fresh cadaveric lower limbs were included in this anatomical study (six males and five females). The femoral artery of each lower limb was cannulated and injected with 200 cc of white latex. Systematic dissection was performed under loupe magnification (2.5) to study the location of distal perforator of dorsalis pedis artery. The parameters recorded included the presence of distal perforator artery, the distance from the first metatarso-phalangeal joint to the most distal perforator and the diameter of each perforator. (Figure 1)
Surgical technique For the study, set anatomical landmarks were used to facilitate flap harvest. These were the proximal lower border of the extensor retinaculum and the first distal metatarso-phalangeal joint. A lazy S-incision was made, and skin flaps were elevated to expose the subcutaneous tissue. The superficial peroneal nerve was identified and
Figure 1 Anatomical study: identification of Dorsalis Pedis Adipofascial Perforators and peroneal nerve sparing.
A. Russo et al. preserved. The flap was then raised over the paratenon plane to preserve the vascularisation of the tendon. The proximal perforator branches of the dorsalis pedis artery were sacrificed. The distal perforator artery was then identified, and the distance from the metatarso-phalangeal joint was measured. This most distal perforator was the pivot point of the flap. The venous drainage was maintained by superficial dorsal venous network and the dorsal metatarsal veins and some superficial veins were included in the flap to avoid congestion. The flap was then turned over into the defect.
Results Anatomical results The origin of the perforator branch of the dorsalis pedis artery was found in all limbs at an average distance of 4.0 cm (range 2.8e4.5 cm) proximal to metatarso-phalangeal joint. The average diameter of the main pedicle distal perforator was 0.46 mm (range 0.35e0.96 mm). In 12 out of 22 (54%) cases, a second distal-perforating branch was found to have an average length of 6.0 cm (range 5.0e7.3 cm) with respect to the metatarso-phalangeal joint (Table 1) (Figure 2).
Clinical series Case 1 A 24-year-old Caucasian patient sustained a skin defect with exposure of extensor hallucis longus tendon and Table 1 Anatomical study results: lower limb side, perforators distance from metatarso-phalangeal joint, perforators caliber. Dissected limb
Perforators
L R L R L R L R L R L R L R L R L R L R L R
3.5 cm 3.5 cm 4 cm 4.3 cm 4.5 cm 3.6 cm 4.5 cm 3.5 cm 3 cm 4.5 cm 4.5 cm 3.5 cm 4 cm 4.5 cm 3.5 cm 4 cm 4 cm 2.8 cm 4.3 cm 4 cm 4.5 cm 4.3 cm
Distal perforator
Caliber Proximal perforator 6 cm 6.3 cm 6 cm 6 cm 5 6 7 6
cm cm cm cm
6 cm
6 cm 5.8 cm
7.3 cm
0.50 mm 0.46 mme0.35 mm 0.56 mme0.60 mm 0.47 mm 0.43 mme0.47 mm 0.62 mme0.80 mm 0.90 mm 0. 46 mme0.55 mm 0.45 mme0.40 mm 0.47 mme0.38 mm 0.96 mme0.70 mm 0.52 mm 0.35 mm 0.62 mme0.50 mm 0.82 mm 0.59 mm 0.60 mme0.70 mm 0.54 mme0.42 mm 0.45 mm 0.56 mm 0.64 mme0.70 mm 0.45 mm
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
+
MODEL
DPAP flap for great toe reconstruction
3 10 cm 4 cm and transferred through a subcutaneous tunnel. The donor site was primarily closed and the flap was covered with a split-thickness skin graft. Good aesthetic results at 12-months of follow-up was noted (Figure 4). Case 3 A 67-year-old Caucasian patient presented with a posttraumatic wound located on the dorsal aspect of right great toe. After debridement, a 10 cm 3 cm DPAP flap was performed to cover the skin defect (3 cm 4 cm). At 6month follow-up, the reconstruction was stable with good cosmetic and functional results (Figure 5).
Figure 2 Anatomical diagram: localisation of the perforators in the anatomical study.
metatarso-phalangeal joint of the left foot, following a motorcycle accident. The size of the skin defect was 4 cm 6 cm. After the debridement of the wound, the defect was covered with an adipofascial perforator turnover flap based on the distal perforator of dorsalis pedis, measuring 6 4 cm. A split-thickness skin graft was applied over the flap .The flap donor site was closed primarily. At 17 months follow-up, the reconstruction was stable with a good cosmetic and functional outcome (Figure 3). Case 2 A 67-year-old Caucasian diabetic patient presented with a full-thickness burn at the medial aspect of the first metatarso-phalangeal joint of the left foot. The skin defect measured 2 cm 3 cm. After wound debridement, an adipofascial turn-over flap was raised measuring
Results Flap survival was seen in all patients with no distal necrosis reported. In one patient (case 2), there was wound dehiscence of the donor site with <20% skin necrosis. This was debrided and covered with a split-thickness skin graft. The superficial branches of the peroneal nerve were preserved in all cases.
Discussion The reconstruction of defects of the dorsum of the great toe can be surgically challenging especially if there are exposed tendon and bone. Unfortunately, in many cases, the use of a skin graft is not possible because of lack of paratenon or periosteum. In more challenging cases, the use of a local muscle flap or free flap will give good coverage of the defect. However, these reconstructions are often too bulky, causing functional problems with shoe wear. In addition, the donor-site morbidity should be taken into consideration. The adipofascial turn-over flap is a well-described option available to the surgeon in the reconstruction of the dorsum of the foot and great toe with exposed tendons and joints.1 Our study seeks to further refine this existing technique, extending the
Figure 3 Traumatic exposure of extensor hallucis longus tendon and metatarso-phalangeal joint of the left foot. Reconstruction with DPAP flap.
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
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MODEL
4
Figure 4
A. Russo et al.
Reconstruction with DPAP flap for left first metatarso-phalageal joint exposure after deep burn sequelae on diabetic patient.
Figure 5 Using of Dorsalis Pedis Adipofascial Perforator flap for resurfacing of post traumatic wound on the dorsal side of right big toe.
coverage of this flap. The perforator flap as described in this study allows reconstruction of more distal defects than what has been classically described. The donor tissue has similar anatomical characteristics, provides a good vascular bed for skin grafting and ensures better functional and aesthetic results. The classic surgical technique of skin grafts, local flaps and free flaps can still used if the wound is too near the pivot point of the flap. The microarterial anatomy of the dorsalis pedis artery which mainly supplies the dorsal skin of the foot has been studied by Man and Acland.2 The blood supply of the adipofascial turn-over flap was described by Hamdy,3 who studied the vascular territory of the perforators to harvest an adipofascial turn-over flap sized 13 cm 7 cm. Senyuva4 described a reverse first dorsal metatarsal artery adipofascial flap for the distal foot defects, but Man and Acland showed the possible absence of the first dorsal metatarsal artery (FDMA) in 13% of the cases. Our anatomical studies confirmed the constant presence of a perforator distal branch of the dorsalis pedis artery in 100% of cadaver dissection, an average of 4 cm proximal to the metatarsophalangeal joint. This supports the potential use of the distal perforator branch for reconstruction of distal foot and great toe defects. Donor-site morbidity is another important factor restricting the flap alternatives.10,11 The dermal plexus ensures the survival of the skin flaps that are raised during flap harvest. The key point to note during harvest of this flap is the dissection over the paratenon plane. This minimises damage to the skin flaps and decreases the possible ischaemic compromise, which can lead to skin edge necrosis. Donor-site complications, such as marginal necrosis, widened scar, hypopigmentation and hypoesthesia of the dorsum of the foot after dorsalis pedis myofascial flaps5 were noted.
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
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MODEL
DPAP flap for great toe reconstruction Delia et al. described distally based perforator adipofascial flap for fingertip reconstruction. The same concept of the use of distal perforator of dorsalis pedis artery was used to find the pivot point of this adipofascial flap for the resurfacing of great toe.6e9 The DPAP flap for the coverage of the great toe and first metatarso-phalangeal joint provides these advantages: (1) easy and rapid procedure (<1 h of surgical procedure time); (2) minimal donor-site morbidity; (3) no bulky reconstruction; (4) no sacrifice of principal arteries of the foot; (5) there is only a single scar on the donor site and (6) it heals with good aesthetic results. However, the use of this flap is limited in patients with poor vascular conditions.
Conclusion Based on the anatomical studies and the clinical cases, the DPAP flap appears to be a safe, rapid and simple procedure for the resurfacing of great toe and first metatarsophalangeal joint.
Conflict of interest We, Antonio Russo, Vincent Casoli, Michele Rosario Colonna, Francesco Stagno d’Alcontres and Gabriele Delia, have submitted for publication in Journal of Plastic, Reconstructive & Aesthetic Surgerymanuscript entitled: The Dorsalis Pedis Adipofascial Perforator (DPAP) flap for big toe reconstruction: anatomical study and clinical applications. We, hereby certify, that: No financial support or benefits have been received by me or any co-author, by any member of my (our) immediate family or any individual or entity with whom or with which I (we) have a relationship from any commercial source which is related directly or indirectly to the scientific work which is reported in the article except as described below. I (we) understand an example of such a financial interest would be consulting relationship or stock interest in any business entity that is included in the subject matter of the
5 manuscript or that which sells a product relating to the subject matter of the manuscript.
References 1. Lai CS, Lin SD, Yang CC, Chou CK. Adipofascial turn-over flap for reconstruction of the dorsum of the foot. Br J Plast Surg 1991 Apr;44(3):170e4. 2. Man D, Acland RD. The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plast Reconstr Surg 1980;65:419e23. 3. Hamdy A, El-Khatib HA. Adipofascialturn-over flap based on perforators of the dorsalis pedis for resurfacing forefoot defects: an anatomic and clinical approach. PlastReconstr Surg 1998 Aug;102(2):393e7. discussion 398e9. 4. Senyuva C, Yucel A, Fassio E, Cetinkale O, Goga D. Reverse first dorsal metatarsal artery adipofascial flap. Ann Plast Surg 1996 Feb;36(2):158e61. 5. Ismail TIA. The dorsalis pedis myofascial flap. Plast Reconstr Surg 1990 Sep;86(3):573e6. 6. Delia G, Campolo MF, Risitano G, Manasseri B, d’Alcontres FS, Colonna MR. Homodigital dorsal adipofascial reverse flap: clinical applications. Plast Reconstr Surg 2011 Jun;127(6): 162ee3e. 7. Sarhadi NS, Quaba AA. Experience with the adipofascial turnover flap. Br J Plast Surg 1993 Jun;46(4):307e13. 8. Ishikawa K, Isshiki N, Suzuki S. Distally based dorsalis pedis Island flap for coverage of distal portion of the foot. Br J Plast Surg 1987;40:521e5. 9. Delia G, Casoli V, Sommario M, Risitano G, D’Alcontres FS, Colonna MR. Homodigital dorsal adipofascial reverse flap: anatomical study of distal perforators and key points for safe dissection. J Hand Surg Eur Vol 2010 Jul;35(6): 454e8. 10. Cigna E, Maruccia M, Sorvillo V, Parisi P, Palumbo F, Onesti MG. The use of negative pressure therapy and hyaluronic acid for the management of post-traumatic lower limb injury. Int Wound J 2013 Oct;10(5):534e8. 11. Ribuffo D, Chiummariello S, Cigna E, Scuderi N. Salvage of a free flap after late total thrombosis of the flap and revascularisation. Scand J Plast Reconstr Surg Hand Surg 2004;38(1): 50e2.
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e5
Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications A. Russo a, G. Delia a,*, V. Casoli b, M.R. Colonna a, F. Stagno d’Alcontres a a Plastic Reconstructive and Aesthetic Surgery Unit, University of Messina, Policlinico ‘G. Martino’, Via Consolare Valeria 1, 98125 Messina, Italy b Plastic and Burn Unit Fx Michelet Center, Bordeaux Segalen University, Bordeaux, France
Received 2 September 2013; accepted 17 December 2013
KEYWORDS Adipofascial flap; Dorsalis pedis artery perforator; Perforator flap; Dorsal foot reconstruction
Summary Defects of the dorsum of the foot can be challenging to reconstruct, none more so than the dorsum of the toe. The reverse Dorsalis Pedis Adipofascial Perforator (DPAP) flap is one possible reconstructive option for defects in this region. The aim of this study was to first demonstrate the anatomy of this flap, particularly the consistency of the perforators arising from the dorsalis pedis artery. Second, we present a clinical series based on this flap to demonstrate how it can be used. For the anatomical studies, 22 fresh cadaveric lower extremities were dissected, and injection studies were used to delineate the vascular territories. The presence of the distal perforator, distance to the first metatarso-phalangeal joint and diameter of each perforator were recorded. The cadaveric studies confirmed the presence of distal perforators to the first metatarso-phalangeal joint in 100% of limbs examined. The clinical study demonstrated the feasibility of the use of the adipofascial turn-over perforator flap for dorsal foot reconstruction. These anatomic findings provide an alternative method of reconstruction of great toe defects using the reverse DPAP flap. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Background and aim * Corresponding author. Plastic Reconstructive and Aesthetic Surgery Unit, A.O.U. Policlinico ‘G. Martino’, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy. Tel.: þ39 3289215256; fax: þ39 090 221 3727. E-mail addresses: [email protected], [email protected] (G. Delia).
Defects of the dorsum of the foot are challenging problems in reconstructive surgery. These defects may present through a variety of different clinical scenarios, for example, trauma, tumours, burns and diabetes mellitus to name a few. The more distal the defect, the harder to reconstruct with local soft tissue options, as skin laxity and
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.019
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
+
MODEL
2 mobility are limited. For these reasons, reconstruction of defects of the great toe and the first metatarsal joint can frequently become compromised. Lai et al. (1991) reported the use of an adipofascial turn-over flap for resurfacing dorsal defects of the foot in combination with splitthickness skin grafting. With distal dorsal foot defects, local adipofascial flaps can be a good surgical option for the surgeon for several reasons. First, the donor tissue has similar characteristics to the recipient tissue and second, there is reliable vascular anatomy, therefore providing better functional and aesthetic results. We present a cadaveric study to confirm the anatomy of the distal Dorsalis Pedis Adipofascial Perforator (DPAP). In addition, we present a clinical series that demonstrates how this perforator can be reliably used to raise an adiposfascial turnover flap which can ultimately reconstruct defects of the dorsum of the great toe and first metatarsal joint.
Materials and methods Anatomical study This study was performed at the Laboratory of Anatomy of Bordeaux 2 University, France. A total of 22 fresh cadaveric lower limbs were included in this anatomical study (six males and five females). The femoral artery of each lower limb was cannulated and injected with 200 cc of white latex. Systematic dissection was performed under loupe magnification (2.5) to study the location of distal perforator of dorsalis pedis artery. The parameters recorded included the presence of distal perforator artery, the distance from the first metatarso-phalangeal joint to the most distal perforator and the diameter of each perforator. (Figure 1)
Surgical technique For the study, set anatomical landmarks were used to facilitate flap harvest. These were the proximal lower border of the extensor retinaculum and the first distal metatarso-phalangeal joint. A lazy S-incision was made, and skin flaps were elevated to expose the subcutaneous tissue. The superficial peroneal nerve was identified and
Figure 1 Anatomical study: identification of Dorsalis Pedis Adipofascial Perforators and peroneal nerve sparing.
A. Russo et al. preserved. The flap was then raised over the paratenon plane to preserve the vascularisation of the tendon. The proximal perforator branches of the dorsalis pedis artery were sacrificed. The distal perforator artery was then identified, and the distance from the metatarso-phalangeal joint was measured. This most distal perforator was the pivot point of the flap. The venous drainage was maintained by superficial dorsal venous network and the dorsal metatarsal veins and some superficial veins were included in the flap to avoid congestion. The flap was then turned over into the defect.
Results Anatomical results The origin of the perforator branch of the dorsalis pedis artery was found in all limbs at an average distance of 4.0 cm (range 2.8e4.5 cm) proximal to metatarso-phalangeal joint. The average diameter of the main pedicle distal perforator was 0.46 mm (range 0.35e0.96 mm). In 12 out of 22 (54%) cases, a second distal-perforating branch was found to have an average length of 6.0 cm (range 5.0e7.3 cm) with respect to the metatarso-phalangeal joint (Table 1) (Figure 2).
Clinical series Case 1 A 24-year-old Caucasian patient sustained a skin defect with exposure of extensor hallucis longus tendon and Table 1 Anatomical study results: lower limb side, perforators distance from metatarso-phalangeal joint, perforators caliber. Dissected limb
Perforators
L R L R L R L R L R L R L R L R L R L R L R
3.5 cm 3.5 cm 4 cm 4.3 cm 4.5 cm 3.6 cm 4.5 cm 3.5 cm 3 cm 4.5 cm 4.5 cm 3.5 cm 4 cm 4.5 cm 3.5 cm 4 cm 4 cm 2.8 cm 4.3 cm 4 cm 4.5 cm 4.3 cm
Distal perforator
Caliber Proximal perforator 6 cm 6.3 cm 6 cm 6 cm 5 6 7 6
cm cm cm cm
6 cm
6 cm 5.8 cm
7.3 cm
0.50 mm 0.46 mme0.35 mm 0.56 mme0.60 mm 0.47 mm 0.43 mme0.47 mm 0.62 mme0.80 mm 0.90 mm 0. 46 mme0.55 mm 0.45 mme0.40 mm 0.47 mme0.38 mm 0.96 mme0.70 mm 0.52 mm 0.35 mm 0.62 mme0.50 mm 0.82 mm 0.59 mm 0.60 mme0.70 mm 0.54 mme0.42 mm 0.45 mm 0.56 mm 0.64 mme0.70 mm 0.45 mm
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
+
MODEL
DPAP flap for great toe reconstruction
3 10 cm 4 cm and transferred through a subcutaneous tunnel. The donor site was primarily closed and the flap was covered with a split-thickness skin graft. Good aesthetic results at 12-months of follow-up was noted (Figure 4). Case 3 A 67-year-old Caucasian patient presented with a posttraumatic wound located on the dorsal aspect of right great toe. After debridement, a 10 cm 3 cm DPAP flap was performed to cover the skin defect (3 cm 4 cm). At 6month follow-up, the reconstruction was stable with good cosmetic and functional results (Figure 5).
Figure 2 Anatomical diagram: localisation of the perforators in the anatomical study.
metatarso-phalangeal joint of the left foot, following a motorcycle accident. The size of the skin defect was 4 cm 6 cm. After the debridement of the wound, the defect was covered with an adipofascial perforator turnover flap based on the distal perforator of dorsalis pedis, measuring 6 4 cm. A split-thickness skin graft was applied over the flap .The flap donor site was closed primarily. At 17 months follow-up, the reconstruction was stable with a good cosmetic and functional outcome (Figure 3). Case 2 A 67-year-old Caucasian diabetic patient presented with a full-thickness burn at the medial aspect of the first metatarso-phalangeal joint of the left foot. The skin defect measured 2 cm 3 cm. After wound debridement, an adipofascial turn-over flap was raised measuring
Results Flap survival was seen in all patients with no distal necrosis reported. In one patient (case 2), there was wound dehiscence of the donor site with <20% skin necrosis. This was debrided and covered with a split-thickness skin graft. The superficial branches of the peroneal nerve were preserved in all cases.
Discussion The reconstruction of defects of the dorsum of the great toe can be surgically challenging especially if there are exposed tendon and bone. Unfortunately, in many cases, the use of a skin graft is not possible because of lack of paratenon or periosteum. In more challenging cases, the use of a local muscle flap or free flap will give good coverage of the defect. However, these reconstructions are often too bulky, causing functional problems with shoe wear. In addition, the donor-site morbidity should be taken into consideration. The adipofascial turn-over flap is a well-described option available to the surgeon in the reconstruction of the dorsum of the foot and great toe with exposed tendons and joints.1 Our study seeks to further refine this existing technique, extending the
Figure 3 Traumatic exposure of extensor hallucis longus tendon and metatarso-phalangeal joint of the left foot. Reconstruction with DPAP flap.
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
+
MODEL
4
Figure 4
A. Russo et al.
Reconstruction with DPAP flap for left first metatarso-phalageal joint exposure after deep burn sequelae on diabetic patient.
Figure 5 Using of Dorsalis Pedis Adipofascial Perforator flap for resurfacing of post traumatic wound on the dorsal side of right big toe.
coverage of this flap. The perforator flap as described in this study allows reconstruction of more distal defects than what has been classically described. The donor tissue has similar anatomical characteristics, provides a good vascular bed for skin grafting and ensures better functional and aesthetic results. The classic surgical technique of skin grafts, local flaps and free flaps can still used if the wound is too near the pivot point of the flap. The microarterial anatomy of the dorsalis pedis artery which mainly supplies the dorsal skin of the foot has been studied by Man and Acland.2 The blood supply of the adipofascial turn-over flap was described by Hamdy,3 who studied the vascular territory of the perforators to harvest an adipofascial turn-over flap sized 13 cm 7 cm. Senyuva4 described a reverse first dorsal metatarsal artery adipofascial flap for the distal foot defects, but Man and Acland showed the possible absence of the first dorsal metatarsal artery (FDMA) in 13% of the cases. Our anatomical studies confirmed the constant presence of a perforator distal branch of the dorsalis pedis artery in 100% of cadaver dissection, an average of 4 cm proximal to the metatarsophalangeal joint. This supports the potential use of the distal perforator branch for reconstruction of distal foot and great toe defects. Donor-site morbidity is another important factor restricting the flap alternatives.10,11 The dermal plexus ensures the survival of the skin flaps that are raised during flap harvest. The key point to note during harvest of this flap is the dissection over the paratenon plane. This minimises damage to the skin flaps and decreases the possible ischaemic compromise, which can lead to skin edge necrosis. Donor-site complications, such as marginal necrosis, widened scar, hypopigmentation and hypoesthesia of the dorsum of the foot after dorsalis pedis myofascial flaps5 were noted.
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019
+
MODEL
DPAP flap for great toe reconstruction Delia et al. described distally based perforator adipofascial flap for fingertip reconstruction. The same concept of the use of distal perforator of dorsalis pedis artery was used to find the pivot point of this adipofascial flap for the resurfacing of great toe.6e9 The DPAP flap for the coverage of the great toe and first metatarso-phalangeal joint provides these advantages: (1) easy and rapid procedure (<1 h of surgical procedure time); (2) minimal donor-site morbidity; (3) no bulky reconstruction; (4) no sacrifice of principal arteries of the foot; (5) there is only a single scar on the donor site and (6) it heals with good aesthetic results. However, the use of this flap is limited in patients with poor vascular conditions.
Conclusion Based on the anatomical studies and the clinical cases, the DPAP flap appears to be a safe, rapid and simple procedure for the resurfacing of great toe and first metatarsophalangeal joint.
Conflict of interest We, Antonio Russo, Vincent Casoli, Michele Rosario Colonna, Francesco Stagno d’Alcontres and Gabriele Delia, have submitted for publication in Journal of Plastic, Reconstructive & Aesthetic Surgerymanuscript entitled: The Dorsalis Pedis Adipofascial Perforator (DPAP) flap for big toe reconstruction: anatomical study and clinical applications. We, hereby certify, that: No financial support or benefits have been received by me or any co-author, by any member of my (our) immediate family or any individual or entity with whom or with which I (we) have a relationship from any commercial source which is related directly or indirectly to the scientific work which is reported in the article except as described below. I (we) understand an example of such a financial interest would be consulting relationship or stock interest in any business entity that is included in the subject matter of the
5 manuscript or that which sells a product relating to the subject matter of the manuscript.
References 1. Lai CS, Lin SD, Yang CC, Chou CK. Adipofascial turn-over flap for reconstruction of the dorsum of the foot. Br J Plast Surg 1991 Apr;44(3):170e4. 2. Man D, Acland RD. The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plast Reconstr Surg 1980;65:419e23. 3. Hamdy A, El-Khatib HA. Adipofascialturn-over flap based on perforators of the dorsalis pedis for resurfacing forefoot defects: an anatomic and clinical approach. PlastReconstr Surg 1998 Aug;102(2):393e7. discussion 398e9. 4. Senyuva C, Yucel A, Fassio E, Cetinkale O, Goga D. Reverse first dorsal metatarsal artery adipofascial flap. Ann Plast Surg 1996 Feb;36(2):158e61. 5. Ismail TIA. The dorsalis pedis myofascial flap. Plast Reconstr Surg 1990 Sep;86(3):573e6. 6. Delia G, Campolo MF, Risitano G, Manasseri B, d’Alcontres FS, Colonna MR. Homodigital dorsal adipofascial reverse flap: clinical applications. Plast Reconstr Surg 2011 Jun;127(6): 162ee3e. 7. Sarhadi NS, Quaba AA. Experience with the adipofascial turnover flap. Br J Plast Surg 1993 Jun;46(4):307e13. 8. Ishikawa K, Isshiki N, Suzuki S. Distally based dorsalis pedis Island flap for coverage of distal portion of the foot. Br J Plast Surg 1987;40:521e5. 9. Delia G, Casoli V, Sommario M, Risitano G, D’Alcontres FS, Colonna MR. Homodigital dorsal adipofascial reverse flap: anatomical study of distal perforators and key points for safe dissection. J Hand Surg Eur Vol 2010 Jul;35(6): 454e8. 10. Cigna E, Maruccia M, Sorvillo V, Parisi P, Palumbo F, Onesti MG. The use of negative pressure therapy and hyaluronic acid for the management of post-traumatic lower limb injury. Int Wound J 2013 Oct;10(5):534e8. 11. Ribuffo D, Chiummariello S, Cigna E, Scuderi N. Salvage of a free flap after late total thrombosis of the flap and revascularisation. Scand J Plast Reconstr Surg Hand Surg 2004;38(1): 50e2.
Please cite this article in press as: Russo A, et al., Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: Anatomical study and clinical applications, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.019