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2 Anatomy oftheHand andFoot
a
c
b
d
Fig. 2.63 Arteries of medial foot. (a–c) Origin, course, branches, and
anastomosis of arteries of medial foot; (d) Anastomosis of medial perforating branches of foot. (1) Supercial branch of medial plantar
artery. (2) First plantar metatarsal artery; (3) Anterior medial malleolar
Table 2.6 Nutritional vascular data of medial foot (
Initial
diameter
Name Origin vessel
Supercial branch
of medial plantar
artery
Anterior medial
malleolar artery
Medial tarsal artery Dorsalis pedis
Perforator of rst
plantar metatarsal
artery
Medial plantar
artery
Anterior tibial
artery, dorsalis
pedis artery
artery
First planter
metatarsal artery
(mm)
1.1±0.2 5.2±0.1
1.6±0.4 5.2±0.6
1.3±0.3 1.4±0.2
1.1±0.2 3.2±0.2
s )
Length
(cm)
Medial Plantar Artery
After the division from malleolar canal by posterior tibial
artery, through the deep surface of abductor hallucis tendon,
and posterior navicular trochanter, it was divided into the
supercial and deep branches. The supercial branch passes
under abductor hallucis and intertarsal fascia. The deep
branch divides into medial deep branch and lateral deep
branch.
artery; (4) Medial tarsal artery; (5) Deep branch of medial plantar
artery; (6) Abductor hallucis tendon; (7) Anterior tibial tendon; (8)
Perforator; (9) Great saphenous vein
Anterior Medial Malleolar Artery
Originated from anterior tibial artery accounts for 56.7%,
and the origin is 1.5cm above intermalleolar line, at with
intermalleolar line or 1.0cm below the intermalleolar line.
Originated from dorsalis pedis artery accounts for 43.3%.
Medial Tarsal Artery
Starting from the trunk of dorsalis pedis artery, there are one
to three branches, of which, 1 branch accounts for 48%, 2
branch accounts for 46%, and 3 branch accounts for 6%.
Perforator ofFirst Plantar Metatarsal Artery
Oblique backward at the point about 2.3cm proximal to rst
metatarsophalangeal joint, between abductor hallucis tendon
and rst metatarsal bone.
Anastomosed with branches of medial tarsal artery, anterior medial malleolar artery, and medial plantar artery
branches at the upper margin of abductor hallucis.
Dissociation oftheFlap
The blood supply of medial foot skin is multi-source, and
there are multiple groups of vascular pedicles to be chosen.
2.4 Anatomy ofFinger Reconstruction by Transplantation ofFoot Flaps
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61
Axial points of aps are: Near the midpoint of intermalleolar line, where anterior medial malleolar artery originates;
2cm below the tip of medial malleolar is the supercial outlet of the supercial branch of medial plantar artery; 2cm on
the proximal side of the rst metatarsophalangeal joint is the
supercial outlet of the perforating branch of rst metatarsal
artery. The pulsing point of dorsalis pedis artery on the edge
of anterior tibial tendon is the issuing point of medial tarsal
artery.
The axes of aps are: The anterior and posterior edges of
anterior tibial tendon are used to determine the axis of medial
tarsal artery and anterior medial malleolar artery. The upper
margin of abductor hallucis is used to determine the axes of
supercial branch of medial plantar artery and the perforating branch of rst plantar metatarsal artery.
The ap area: The blood vessel axis is taken as the ap
axis, and the ap is extended 2–3cm to both sides as the
design width. Flap range: Anterior to 2cm proximal to rst
metatarsophalangeal joint, posterior to the vertical line of
medial malleolar tip, lower to the edge of medial plantar
non-weight-bearing zone, upper to the medial margin of
extensor hallucis longus tendon.
Dissociation of the ap: According to the design of the
ap, rst cut the lower edge of the ap to deep fascia, turn
the ap up to the perforating position, and adjust the ap
design appropriately. The ap should be pulled back to its
original position, and deep fascia would be temporarily
sutured to subcutaneous tissue for several stitches to prevent
the separation of the fascia from damaging the cutaneous
vessels, then the other edges of the ap would be incised.
Dissociation is also performed under deep fascia to the perforating position until the entire ap is dissociated except for
the pedicle. An incision is made from the axial point to the
wound surface, and the skin could be suitably separated subcutaneously on both sides, and the ap would be transferred
to the recipient site. The donor site could be covered by skin
graft.
Key Points forApplication
The following points should be noted in clinic: (1)
Preoperative ultrasonographic Doppler should be used to
detect the perforating points, and the characteristics of vascular anastomosis of the ap are dened. Different vascular
pedicles could be selected according to the recipient site, and
the clinical application is exible. (2) The dissociation of the
ap should be performed under deep fascia, especially at the
attachment of anterior tibial tendon, where the blood vessels
intersect, and the blood vessels are closely attached to the
periosteum. The operation should be very careful to prevent
damage to the vascular arch of the upper margin of abductor
hallucis; (3) Carring medial dorsal cutaneous nerve of foot
can not only provide the sensory function of the ap, but also
the abundant vascular plexus around the cutaneous nerve can
signicantly increase the direction of the blood supply of the
ap and expand the length of medial pedis ap. (4) The ap
should not be cut beyond the inside of the head of rst metatarsal bone, so as not to damage the weight bearing point of
plantar pedis; (5) When the ap area is relatively large, anastomosis of medial foot vein of the ap is recommended to
facilitate venous reux, and too tight bandaging should be
avoided after surgery what would block blood circulation.
2.4.5 Lateral Pedis Flap
Lateral pedis ap is located on lateral dorsum of foot, which
with less subcutaneous fat, no bloated, no sliding, and resistance to pressure abrasion. It can be made into sensory ap.
Free transplantation is suitable for repairing the wound surface of hand, and local transfer is suitable for repairing the
wound surface around ankle and forefoot.
Applied Anatomy
The blood supply of lateral foot is multi-source including
lateral calcaneal artery, lateral tarsal artery, anterior lateral
malleolar artery, descending perforator of peroneal artery
and perforator of fth metatarsal artery (Fig. 2.64,
Table2.7).
Lateral Calcaneal Artery
It is the anastomotic branch of posterior tibial artery and the
anastomotic branch of peroneal artery converged at the deep
surface of the Achilles tendon. It descends from the anterior
space of the Achilles tendon, bypasses posterior lateral malleolus, bends forward and upward, goes to the lateral edge of
the ankle joint and the lateral edge of foot, reaches the bottom of fth metatarsal bone at the end, and is anastomotic
with the blood vessels of the lateral part of foot.
Lateral Tarsal Artery
Lateral tarsal artery originates from the dorsalis pedis artery,
slanting through the outer edge of navicular bone, the deep
surface of extensor digitorum brevis, and running close to
the dorsal side of cuboid bone to the bottom of fth metatarsal bone, divided into the anterior branch and the posterior
branch. The connection between the pulsing point of dorsalis
pedis artery 2.6cm below the interankle line and the base of
the fth metatarsal bone is equivalent to the surface projection of lateral tarsal artery. Along the way, lateral tarsal artery
not only gives off musculoskeletal branches, but also gives
off direct cutaneous and musculocutaneous perforating
branches, which enter deep fascia or reach deep fascia
through extensor digitorum brevis and shallow out to subcutaneous layer.
62
χ
± s
2 Anatomy oftheHand andFoot
a
c
b
d
Fig. 2.64 Blood vessels of lateral dorsum of foot. (a) Origin, course, and
anastomosis of blood vessels of lateral dorsum of foot. (b) Cast specimens. (c) Course and branches of lateral plantar artery. (d) Perforator of
fth plantar metatarsal artery. (1) Dorsalis pedis artery. (2) Lateral tarsal
Table 2.7 Nutritional vascular data of lateral foot (
Initial
diameter
Name Origin vessel
Lateral calcaneal
artery
Lateral tarsal artery Dorsalis pedis
Anterior lateral
malleolar artery
Descending
perforator of bular
artery
Perforator of fth
plantar metatarsal
artery
Fibular artery 1.1±0.3 5.2±0.1
artery
Anterior tibial
artery, dorsalis
pedis artery
Perforator of bular
artery
Lateral plantar
artery
(mm)
1.9±0.4 5.2±0.6
1.4±0.3 1.4±0.2
1.9±0.2 3.2±0.2
1.0±0.2 2.6±0.3
)
Length
(cm)
artery. (3) Anterior branch. (4) Posterior branch. (5) Anterior lateral malleolar artery. (6) Descending perforator of bular artery. (7) Lateral calcaneal artery. (8) Perforator of fth plantar metatarsal artery. (9) Fibular
brevis tendon. (10) Extensor digitorum brevis. (11) Lateral plantar artery
Anterior Lateral Malleolar Artery
Most time there is only one, originated from dorsalis pedis
artery; In a few cases, there are two, originated from anterior
tibial artery and dorsalis pedis artery respectively, passing
posterior extensor digitorum longus and third peroneal tendon, distributes on the lateral side of ankle, tarsal sinus and
the beginning of extensor digitorum brevis, and anastomosed
with descending perforator of peroneal artery and lateral tarsal artery.
Descending Perforator ofPeroneal Artery
Terminal branch of peroneal artery punctures out at 5.9cm
above lateral malleolus, passes between extensor digitorum
longus and peroneus brevis, and then divides into the ascending branch and descending branch.
2.5 Cutaneous (Perforator) Flaps ofToe
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63
Perforator ofFifth Plantar Metatarsal Artery
It is a relatively constant branch of lateral plantar artery. After
the origin of lateral plantar artery, it extends outwards to the
inner margin of the fth metatarsal bone, and then extends
outwards at the transition of the bottom and the shaft of fth
metatarsal bone, anastomosed with lateral tarsal artery and
fourth dorsal metatarsal artery in lateral dorsal foot region.
There are abundant anastomoses between the above origin
arteries in the ap. Important anastomoses are: (1) Descending
perforator of peroneal artery descends anterolateral to lateral
malleolus, anastomoses to anterior lateral malleolar artery at a
distance of 1.0–2.0cm above the tip of lateral malleolus; (2)
Anterior branch of lateral tarsal artery runs outward along the
anterior edge of peroneal brevis tendon, reaching an average
of 1.0–3.0cm posterior to the trochanter of fth metatarsal,
anastomoses to perforator of fth plantar metatarsal artery; (3)
Posterior branch of lateral tarsal artery penetrates the deep surface of peroneal brevis tendon and is anastomosed with the
terminal branch of lateral tarsal artery (Table2.7).
There are two groups of venous reux in the ap: deep
and supercial, and the two groups communicate with each
other. In the deep group, there are accompanying veins; In
the supercial group, there are supercial dorsal veins of
foot that emerge into small saphenous veins. The sensory
nerve of the ap is lateral dorsal cutaneous nerve of foot.
Dissociation oftheFlap
Lateral foot skin blood supply is also multi-source, there are
also multiple groups of vascular pedicles to be chosen.
Axial points of aps are: Near the midpoint of the interankle line is the place where medial anterior malleolar artery
originates; 2 cm below the tip of medial malleolus is the
point where supercial branch of medial plantar artery perforates; 2cm proximal to rst metatarsophalangeal joint is the
supercial origin of perforator of rst metatarsophalangeal
artery. The pulsing point of dorsalis pedis artery on the edge
of the anterior tibial tendon is the issuing point of medial
tarsal artery.
Axial points of aps are: Axial points of aps are: Near
the midpoint of intermalleolar line, where anterior medial
malleolar artery originates; 2 cm below the tip of medial
malleolar is the supercial outlet of the supercial branch of
medial plantar artery; 2 cm on the proximal side of rst
metatarsophalangeal joint is the supercial outlet of the perforating branch of rst metatarsal artery. The pulsing point of
dorsalis pedis artery on the edge of anterior tibial tendon is
the issuing point of medial tarsal artery.
The axes of aps are: The anterior and posterior edges of
anterior tibial tendon are used to determine the axis of medial
tarsal artery and anterior medial malleolar artery. The upper
margin of abductor hallucis is used to determine the axes of
supercial branch of medial plantar artery and the perforating branch of rst plantar metatarsal artery.
The ap area: The blood vessel axis is taken as the ap
axis, and the ap is extended 2–3cm to both sides as the
design width. Flap range: Anterior to 2cm proximal to rst
metatarsophalangeal joint, posterior to the vertical line of
medial malleolar tip, lower to the edge of medial plantar
non-weight-bearing zone, upper to the medial margin of
extensor hallucis longus tendon.
Dissociation of the ap: According to the design of the
ap, rst cut the lower edge of the ap to deep fascia, turn
the ap up to the perforating position, and adjust the ap
design appropriately. The ap should be pulled back to its
original position, and deep fascia would be temporarily
sutured to subcutaneous tissue for several stitches to prevent
the separation of the fascia from damaging the cutaneous
vessels, then the other edges of the ap would be incised.
Dissociation is also performed under deep fascia to the perforating position until the entire ap is dissociated except for
the pedicle. An incision is made from the axial point to the
wound surface, and the skin could be suitably separated subcutaneously on both sides, and the ap would be transferred
to the recipient site. The donor site could be covered by skin
graft.
Key Points forApplication
The following points should be noted in clinic: When disassociating the lateral tarsal artery, peripheral tissue with a
width of 0.5cm should be carried to protect the accompanying vein from injury. If only to dissociate the ap, the anterior
lateral malleolar artery and lateral tarsal artery should not be
dissociated at the same time, so as not to affect the blood
supply of extensor digitorum brevis. The lateral dorsal cutaneous nerve of foot is divided into two branches at the lower
margin of lateral malleolus, the medial branch should be preserved during surgery.
2.5 Cutaneous (Perforator) Flaps ofToe
Cutaneous (perforator) aps of toe refer to the minor island
ap supplied by proper plantar digitorum artery and dorsal
digitorum artery. In theory, one to ve toes can be used as
donor sites of the ap. However, great toe is the most popular
donor site of the ap in clinic, followed by the second toe,
and the other 3 toes are less used in clinical practice.
2.5.1 Great Toe Flap
Great toe can design nail skin ap and toe pulp ap. Nail skin
ap was reported by Morrison (1980) and Chen Zhongwei
(1982) in China, which has become a mature and classic surgical method for repairing nail defects and nger reconstruction after nearly 40 years of clinical application and
64
2 Anatomy oftheHand andFoot
a
Fig. 2.65 Vascular distribution of great toe. (a) Course, branches, and
distribution of rst dorsal metatarsal artery. (b) Course, branches, and
distribution of rst plantar metatarsal artery. (1) First dorsal metatarsal
artery. (2) Fibular dorsal digitorum artery of great toe. (3) Tibial dorsal
improvement. Since it was rst reported by Foucher etal.
(1980) to repair the defect of half thumb, toe pulp ap has
been further systematically studied by many scholars on its
anatomy and clinic, and now it has become an ideal donor
site for repairing the defect of nger.
Applied Anatomy
The blood supply of nail skin ap mainly consists of two
branches that are bular dorsal digitorum artery of great toe
and bular proper plantar digitorum artery of great toe
(Figs.2.64 and 2.65). Fibular dorsal digitorum artery of great
toe is a branch of rst dorsal metatarsal artery, which originates from the distal end of rst metatarsal space near toe
web, and then enters the bular subcutaneous of great toe
with an outer diameter of 0.6 mm. Fibular proper plantar
digitorum artery of great toe with different origins has a constant course and an outer diameter of 1.1mm, which is the
main blood-supplying artery of the bular side of great toe.
There are extensive trafc and anastomosis between the two
arteries. Nail ap artery adopts “dorsalis pedis artery → rst
dorsal metatarsal artery → bular dorsal digitorum artery” or
“dorsalis pedis artery → deep plantar branch → rst plantar
metatarsal artery → bular proper plantar digitorum artery”
or one of the distal arteries in the above two sets of blood
supply systems. The vein is “dorsal digitorum vein of great
toe → dorsal metatarsal vein → dorsal foot vein network
(arch)→ great saphenous vein”. The nerve is bular plantar
digitorum nerve→half of common plantar nerve of toe and
deep peroneal nerve on the dorsal side.
b
digitorum artery of second toe. (4) Fibular proper plantar digitorum
artery of great toe. (5) Tibial proper plantar digitorum artery of second
toe. (6) First plantar metatarsal artery
Surgical Method
The range of nail skin ap of great toe should be designed
and cut in the ipsilateral according to the size of the thumb
defect. The lingual ap containing neurovascular bundle
with a width of 1.4–1.7cm should be retained. First, an “S”
incision is made from rst toe web to dorsum of foot, and the
ap is lifted between deep fascia and the supercial layer of
extensor tendon. When it comes to the bular side of great
toe and the bottom of the distal phalangeal bone, begins to
dissociate the plantar side. When dissociating the plantar
side, sticking to the surface of exor digitorum longus tendon of great toe. After dissociating to the peroneal side of
great toe, turned to the dorsal side by sticking to the phalanx
from the inside to the outside, and the nail and nail bed
should be lifted to the peroneal side together. Finally, cut off
the soft tissue connected to the peroneal side of phalanx. Pay
attention that a nourishing artery given off by bular plantar
digitorum artery of great toe at the midpoint of the proximal
phalangeal, which should be ligated and severed. At this
point, the nail skin ap is dissociated totally and connected
to the donor foot only through the vascular pedicle.
Key Points forApplication
The following points should be noted in clinic: (1) When carrying the distal phalange of great toe, the ap should be lifted
and thinned, and the phalange should be split longitudinally
before suturing. Otherwise, the tension of the ap would be
too large, which is easy to cause necrosis of the edge of the
ap. (2) Inactivation of skin transferred at donor site is com-
2.5 Cutaneous (Perforator) Flaps ofToe
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mon, improper treatment, easy to fester, and the wound is
difcult to heal. Poor basal blood supply is the main reason.
It should be noted that the ap should not be cut too deep,
and the exor and extensor tendons must be left with external fascia tissue. The neurovascular bundles in the retained
lingual ap should not be damaged. When the rst plantar
metatarsal artery belongs to Gillert III type, you’d better only
cut the distal segment of it, in other words, the continuity of
tibial proper artery of great toe, medial plantar artery and
rst plantar artery at the x-type vascular anastomosis should
be preserved to ensure the blood supply to the tibial side of
great toe. (3) In addition to covering the distal phalangeal
bone surface, the tibial lingual neurovascular bundle ap
retained on great toe should be kept on the plantar side as far
as possible, which could be widened and expanded after surgery due to the function and contracture of surrounding tissue. (4) In order to reconstruct the shape of thumb, the tissue
amount of nail skin ap, especially the distal segment, should
be reduced as far as possible. The pedicle in the ap should
be cut only on its deep surface, and both sides of the pedicle,
especially the pulp of the distal phalanx, could be thinned,
and the distal phalanx could be split longitudinally. (5) When
the blood supply of great toe wound is poor, the dorsal second toe adjacent pedicled ap is an alternative to repair the
plantar wound of great toe. (6) When the thumb distal segment or part of the defect is transplanted with nail skin ap
of great toe, the “toe-to-hand” vascular anastomosis is usually adopted. The blood vessels in the recipient site can be
dissected rst, and the donor site can be cut out according to
the required length after understanding the recipient site.
2.5.2 Second Toe Flap
The nail skin ap of second toe was reported by Khouri
(1992), which is mainly used for the treatment of degloving
injury of ngers. Due to its size limitation, the advantage of
it alone in repairing degloving injury of whole ngers is not
obvious, and it can be remedied by combined with other
aps. Lateral toe ap was rst reported by Buncke (1979).
Free transplantation is used to repair nger wounds, and the
follow-up results proved satisfactory.
65
Fig. 2.66 Distribution of the nutrient branches of second toe. (1) First
dorsal metatarsal artery. (2) Tibial dorsal digitorum artery of second
toe. (3) Tibial plantar proper digitorum artery of second toe
diameter of 1.0mm. There are anastomoses in the supercial
fascia between dorsal digitorum arteries of both sides,
between proper plantar digitorum arteries and between dorsal digitorum artery and proper plantar digitorum artery, and
two to three artery arches are usually formed on dorsum of
toe. Proper plantar digitorum arteries form vascular network
on toe pulp.
Surgical Method
According to the location and size of the recipient site, the
ap should be designed on the inner or outer bular side of
the toe with proper plantar digitorum artery as the axis. The
operation should be performed under tourniquet. The skin
and subcutaneous tissue should be cut into at the metatarsal
space on the plantar side. First, plantar digitorum arteries and
veins, and proper plantar digitorum and metatarsal nerves
should be dissociated at toe web. Then the ap should be cut
according to the design line, sharply cut from distal to proximal. Once the ap could be completely lifted, it should be
dissociated proximally along the plantar neurovascular bundle of the toe till the desired length. Transfer the ap to the
recipient site. The donor site could be repaired with full
thickness or medium-thickness skin graft.
Applied Anatomy
The arteries of second toe are divided into dorsal digitorum
artery and proper plantar digitorum artery (Fig.2.66). Dorsal
digitorum artery is divided into tibial and bular artery which
are given off by rst dorsal digitorum artery and second dorsal metatarsal artery respectively at toe web. Dorsal digitorum artery is smaller, and the tibial is thicker than the bular
one, with an average diameter of 0.6 mm. Proper plantar
digitorum artery is also divided into the tibial and bular one.
The tibial is thicker than the bular one, with an average
Key Points forApplication
The following points should be noted in clinic: (1) The donor
toe ap should not exceed half of the toe pulp; (2) When dissociating the neurovascular bundle, it is better to retain some
surrounding adipose tissue to ensure the blood supply of the
skin island and avoid damage to plantar digitorum artery; (3)
When passing through the subcutaneous tunnel, the blood
vessel is prevented from torsion and compression. If the tension of the skin ap is high after the tunnel, the skin should
be cut open for transfer; (4) When the ap is dissociated, a
66
thin layer of tissue should be reserved on the surface of joint
capsule and tendon sheath to facilitate skin graft at the donor
site.
2.5.3 Extensor Digitorum BrevisFlap
Extensor digitorum brevis ap is a composite ap that is pedicled with lateral tarsal artery and dorsalis pedis artery and
contains extensor digitorum brevis and part of the skin on dorsum of foot. It is suitable for soft tissue defects of intrinsic
muscle of hand, especially thenar, hand, ankle, and heel.
Applied Anatomy
Morphology ofExtensor Digitorum Brevis
Extensor digitorum brevis lies in front of tarsal sinus, starting
from the upper and lateral sides of the anterior calcaneus and
from the cruciate ligament of the calf. After the muscle bundle
starts, the at thin muscle belly is inclined forward to form
four thin tendons. The medial one inserts at the base of the
proximal phalanx of great toe and is extensor brevis of great
toe. The remaining three tendons insert on second to fourth
toe, are extensor digitorum brevis. Extensor digitorum brevis
runs on the deep surface of extensor digitorum longus tendon
from the lateral proximal dorsum of foot to the distal tibial
side. The blood supply and nerves are shown in Fig.2.67.
2 Anatomy oftheHand andFoot
Blood Supply ofExtensor Digitorum Brevis
Anterior lateral malleolar artery originates near the lateral
wall of inferior extensor retinaculum from dorsalis pe artery.
The initial external diameter of this artery is 0.4mm. It runs
along the deep surface of extensor digitorum longus tendon
and extensor digitorum brevis and sends out small branches
along the way. One to two lateral tarsal arteries are issued
from dorsalis pedis artery at the cervical junction of talus
bone, and the external diameter of the starting part is 1.5mm
which runs along tarsometatarsal joint on the deep surface of
extensor digitorum longus tendon and extensor digitorum
brevis, and are divided into anterolateral and posterior lateral
branches. The anterolateral branch is terminal branch, terminating at fth metatarsal bone. The posterior lateral branch
anastomoses with anterior lateral malleolar artery to form
lateral foot arch (Fig.2.53). The length of lateral tarsal artery
is 6cm, and it gives off muscular and cutaneous branches in
the following three locations: (1) At the beginning, giving off
cutaneous branch to the dorsal skin of foot; (2) On the deep
surface of extensor digitorum brevis gives off muscular and
musculocutaneous perforating branches; (3) At the lateral
edge of muscle abdomen of extensor digitorum brevis and
the proximal cuboid nodules gives off cutaneous branches.
Fig. 2.67 Blood supply and nerves of extensor digitorum brevis. (1)
Extensor digitorum brevis. (2) Extensor digitorum brevis of great toe.
(3) Extensor digitorum brevis tendon. (4) Dorsalis pedis artery. (5)
Head of talus. (6) Lateral tarsal artery. (7) Deep peroneal nerve. (8)
Nerves of extensor digitorum brevis
Nerves ofExtensor Digitorum Brevis
Deep peroneal nerve divides into medial and lateral
branches in the anterior malleolus, and the medial branch is
sensory branch, which innervates the skin sensation of rst
toe web and its vicinity. The lateral branch is muscular
branch, which is further divided into extensor brevis branch
and extensor digitorum brevis branch. Together with lateral
tarsal artery, the extensor big forum brevis branch extends
outward to the deep surface of extensor digitorum brevis,
and gives off muscular branch to supply extensor digitorum
brevis.
2.5 Cutaneous (Perforator) Flaps ofToe
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67
Surgical Methods
The line from the midpoint of anterior ankle striatum to
cuboid bone is used as the axis of the ap, and the dorsolateral musculocutaneous ap is designed according to the
recipient site. The medial edge of the ap is rst cut open,
the initial part of lateral tarsal artery and the muscular
branch of deep peroneal nerve are found in the proximal
segment of dorsalis pedis artery, and dissociates proximally until the appropriate length. The distal edge of the
ap is cut open and extensor digitorum brevis tendon
would be exposed and cut. The lateral edge of the ap is
cut open, and the origin of the cutaneous branch of lateral
tarsl artery could be dissociated near the cuboid nodule
and included in the ap. Extensor digitorum longus tendon
and extensor digitorum brevis would be exposed after cutting open the medial edge of the ap, then extensor digitorum longus tendon should be pulled to the tibial side, and
the initial part of extensor digitorum brevis is cut off.
Dissociation under deep fascia of extensor digitorum brevis, lateral tarsal artery, the ap, extensor digitorum brevis
and the muscular branch of deep peroneal nerve should be
pulled to tibial dorsum of foot. Dorsalis foot artery or lateral tarsal artery is selected as the pedicle according to the
condition of the recipient site. If dorsalis pedis artery is
selected as the pedicle, the musculocutaneous ap should
be passed from inferior extensor digitorum longus to the
tibial side of extensor digitorum longus tendon, and dorsalis pedis artery should be dissociated proximally to an
appropriate length. Extensor digitorum brevis of great toe
can be left in the foot or it can be cut with extensor digitorum brevis. There is extensor digitoeum brevis between
the supercial vein and the deep vein, and the accompanying vein attached to lateral tarsal artery serves as the return
vein of the local ap. During the free ap transplantation,
the accompanying vein and small saphenous vein or its
subordinate branches are used as the return veins of the
ap, which should be paid attention to when the lateral and
proximal edges of the ap are cut. The muscular branches
of deep peroneal nerve accompany lateral tarsal artery.
When dissociating lateral tarsal artery, attention should be
paid to protect the muscular branches and dissociate them
together. The sensory nerve of ap is lateral dorsal cutaneous nerve. When dissociating the proximal edge of the
ap, we should pay attention to nd it and dissociate the
appropriate length to the proximal end. According to the
condition of the recipient site, lateral tarsal artery or dorsalis pedis artery is cut off, small saphenous vein (or its
branch), and lateral dorsal cutaneous nerve of foot is cut
off. When the ap size is small, the donor site can be
sutured directly, otherwise, it should be covered by skin
graft.
Keypoints forApplication
The following points should be noted in clinic: (1) Extensor
digitorum brevis is located on the lateral side of the deep
surface of extensor digitorum longus tendon of great toe,
which is obvious and can be used as a marker to identify
extensor digitorum brevis tendon; (2) The proximal branch
of lateral tarsal artery is the main vascular pedicle of extensor
digitorum brevis and must be protected; (3)The outer diameter of lateral tarsal artery is small and dorsalis pedis artery
is often intercepted as the vascular bundle for transplantation; (4) The extensor digitorum brevis branch of deep peroneal nerve disposes at the intermalleolus line and runs
forward and outwards, accompanying with the proximal
branch of lateral tarsal artery, and enters the muscle on the
deep surface of the muscle. In the preparation of muscle ap,
if a long nerve is needed, it can be dissociated retrograde
along extensor digitorum brevis to get enough length; (5)
The course of dorlis peids artery is relatively constant,
located on the lateral side of extensor longus tendon of great
toe. When peroneal artery perforator replaces dorlis peids
artery, changes may occur, which should be paid attention to.
2.5.4 Abductor Hallucis Flap
Abductor hallucis ap is a composite ap with medial plantar skin and abductor hallucis pedicled with medial plantar
artery and nerve. It is mostly used to repair the intrinsic muscles of hand, especially the thenar, and reconstruct the opponens function of thumb. Abductor hallucis transplantation
does not necessarily have to take skin, but because thenar
injury cases are often with poor local skin conditions, the
skin will be relatively decient after transplantation, so it is
generally muscle and skin transplanted together.
Applied Anatomy
Morphology ofAbductor Hallucis
Abductor hallucis is located in the supercial layer of medial
plantar, starting from the medial process of calcaneal tuberosity, the lower margin of bifurcate ligament and scaphoid
trochanter, and advancing longitudinally along the medial
margin of the plantar, and merging with the medial head of
exor brevis in the middle of rst metatarsal bone to form a
at tendon and terminating at the medial base of the proximal phalangeal bone.
Blood Supply ofAbductor Hallucis
Medial plantar and lateral plantar arteries are given off by
posterior tibial artery after it runs out of bifurcated ligament.
Medial and lateral plantar arteries pass the deep surface of
68
2 Anatomy oftheHand andFoot
a
b
Fig. 2.68 Abductor halluces myocutaneous ap. (a) Morphology of
abductor halluces and medial plantar artery. (b) Simulated operation.
(1) Abductor hallucis. (2) Calcaneus tuberosity. (3) Flexor hallucis bre-
abductor hallucis and give off branches to it. Then lateral
plantar artery and vein pass laterally from the deep surface of
exor digitorum brevis, and medial plantar artery and vein
pass to the space between abductor hallucis and exor digitorum brevis. Medial plantar artery is further divided into
deep and supercial branches near medial plantar septum
(Fig.2.68). The deep branch rst goes to the deep surface of
medial extensor hallucis, sends out the muscular branch and
the anastomotic branch with medial tarsal artery, bends forward and laterally, enters the deep plantar, and anastomoses
with lateral plantar artery. The supercial branch enters the
medial plantar sputum and gives out one to three cutaneous
branches, and then divides into the medial branch and the
internal supercial arch branch.
There are two groups of venous reux of the ap. The
deep group is accompanying vein of medial plantar artery,
while the supercial group is the branch of medial dorsal
venous arch.
vis. (4) Proximal phalangeal bone of great toe. (5) Medial plantar artery.
(6) Posterior tibial artery. (7) Lateral plantar artery. (8) Medial plantar
nerve. (9) Posterior tibial vein
Nerves ofAbductor Hallucis
Medial plantar nerve travels with medial plantar artery. It
originates from tibial nerve at the deep surface of the proximal abductor hallucis, and enters medial plantar septum
along with medial plantar artery, giving off multiple cutaneous branches along the way. The nerve supplying abductor
hallucis originates from medial plantar nerve deep at the
beginning of abductor hallucis. The cutaneous sensory
nerves on the surface of abductor hallucis come from the
branches of medial plantar nerve, saphenous nerve, and tibial
nerve.
Surgical Methods
The rotation axis of the ap is located at the intersection of
the anterior margin of medial malleolus and the medial margin of the plantar. The abductor hallucis is used as the axis
line. The ap should be designed in the non-weight-bearing
area of the medial plantar, and the proximal incision line is
2.5 Cutaneous (Perforator) Flaps ofToe
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marked along the vascular direction. First, a distal ap incision is made to look for medial plantar vessels in the space
between abductor hallucis and exor digitorum brevis on the
distal side of the ap. The medial plantar vessels are cut off
on the distal side of the ap, and the vessels are used as a
guide to separate from far to near in the deep surface of the
muscle, and the muscle is lifted together with the supercial
skin. Proximal incisions are made to dissociate proximally,
and the starting point of the muscle is cut off to form an
island musculocutaneous ap. Be careful not to damage the
medial plantar vessels located deep in the muscle. The origination of medial plantar artery and vein are cut off also do
the nerve branches after the proximal separation of the
appropriate length, and the sensory branches of the ap are
marked with silk threads, and the musculocutaneous ap is
transplanted to the recipient site. The muscular branches of
abductor hallucis ap should be sutured to the thenar muscular branches of the recipient site or other adjacent muscular
branches, and the sensory branches should be sutured to the
adjacent sensory nerves.
Keypoints forApplication
The following points should be noted in clinic: (1) The nerve
of abductor hallucis comes from medial plantar nerve, which
is closely accompanied by medial plantar artery trunk or its
supercial branches, and the motor branch of the proximal
end of the muscle should be protected; (2) The length of the
nerve pedicle can be cut as needed. When the pedicle is dissociated to the beginning of medial plantar artery, the length
of the pedicle can reach more than 8.5cm. If a retrograde
sharp split is made along the bifurcation of medial plantar
nerve, a longer nerve pedicle can be cut; (3) In the design of
muscular (cutaneous) ap, the ap in the non-weight-bearing
area of the medial plantar could be cut, and the size of the
cutaneous ap could be larger than that of the muscular ap.
2.5.5 Extensor Digitorum Myocutaneous
Flap
Flexor digitorum brevis myocutaneous ap pedicled with
lateral plantar artery is located in the non-weight-bearing
area of the plantar between metatarsal bone and the heel. It
could be widely cut and used to repair chronic ulcers, chronic
osteomyelitis, uncured sinus tract, and unstable scar of the
heel. Free transplantation is used to reconstruct the function
of thenar and soft tissue defect of hand.
Applied Anatomy
Morphology ofFlexor Digitorum Brevis
The exor digitorum brevis belongs to the middle group of
plantar muscle, which is covered by the middle band of plantar aponeurosis. The muscle abdomen is spindle-shaped,
starting from the plantar fascia and the medial process of calcaneus, with four tendons ending at the middle phalanges of
second to the fth toes. The morphology of exor digitorum
brevis tendon is similar to exor digitorum supercialis tendon of hand.
Vassculars ofFlexor Digitorum Brevis
Blood supply to exor digitorum brevis comes from lateral
plantar artery and medial plantar artery (Fig.2.69). Medial
plantar artery passes between exor digitorum brevis and
abductor hallucis and gives out branches along the way to
exor digitorum brevis. Lateral plantar artery follows the
nerve along the line between exor digitorum brevis and
abductor minimi and branches along the way to exor digitorum brevis. The above vessels are usually divided into
4–12 muscular branches with an outer diameter of 0.4–
0.5mm. Most of them enter the muscle from the medial and
lateral parts of the proximal half of the muscle and anastomose to each other in the muscle. Along the way muscular
branches supply exor digitorum brevis and its surface skin.
Nerves ofFlexor Digitorum Brevis
Flexor digitorum brevis is innervated by the muscle branches
of lateral plantar nerve, most of which enter the muscle at the
junction of proximal and middle one-third of the muscle.
Surgical Methods
The intersecting point of the anterior margin of medial malleolus and the medial margin of the plantar is the axis point
of the ap rotation. A straight line between the point and
fourth and fth metatarsal bones is used as the longitudinal
axis of the ap design, and the ap should be designed in the
non-weight-bearing area in the mid-plantar. A longitudinal
incision is made posterior to medial malleolus, the skin and
supporting ligaments are incised to locate the posterior tibial
vessels and nerves. The incision is advanced to the anterior
and lower part of medial malleolus to connect with the
medial incision from which the ap is planned to be removed.
The medial and proximal incisions are made to cut off the
attachment of plantar fascia and exor digitorum brevis on
calcaneus. After the myocutaneous ap is opened, medial
plantar artery and lateral plantar nerve are cut off and ligated
the branches from medial plantar artery to exor digitorum
brevis but protect the branches from lateral plantar artery. If
the branches from medial plantar artery to are thick and
numerous that should be retained and the branches from lateral plantar artery can be cut. The medial plantar incision is
extended forward to the front plantar transverse incision. The
plantar fascia and exor digitorum brevis tendons should be
cut open, and the distal ends of the severed tendons are
sutured and xed on the respective accompanying exor
digitorum longus tendons. The skin and plantar fascia of the
incision on the lateral plantar is cut open, and exor digitorum brevis should be temporarily sutured on the skin to pre-
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