Case 1
Clinical Presentation
A 54-year-old White male had a long history of complex congenital deformity of his right foot. He had several previous orthopedic procedures but unfortunately the hardware became infected. He underwent hardware removal by the orthopedic foot and ankle service, which left an open wound with scar tissue in the lateral foot, measuring 7 × 3.5 cm. The plastic surgery service was asked to provide soft tissue coverage for this open wound with the exposed underlying bone in his right lateral foot right after the orthopedic debridement ( Fig. 51.1 ).
Operative Plan and Special Considerations for Reconstruction
A lateral foot wound can be reconstructed with a dorsalis pedis artery flap, elevated either as an island skin flap or as a rotation skin flap. The flap is a type B fasciocutaneous flap and receives blood supply primarily from the dorsalis pedis artery. It is thin, reliable, and mobile and can reach the lateral foot without difficulty. The usual size of the flap is 10 × 8 cm, but it can be designed larger. The sensate flap can also be made by incorporating a branch of the superficial peroneal nerve. A skin graft would be needed to close the flap’s donor site. The posterior tibial artery should be evaluated for its patency in order to ensure the foot could still receive an adequate blood supply once the dorsalis pedis artery has been scarified.
Operative Procedures
Under general anesthesia, with the patient in the supine position, the plastic surgery part of the procedure started after the orthopedic part of the procedure had been completed by the orthopedic foot and ankle service. A large dorsalis pedis artery flap was designed as a rotation flap to cover the right lateral foot wound. Because of the medial foot incision made by the primary service, such an incision was incorporated in the flap design as a large rotational flap with a back cut if needed ( Fig. 51.2 ).
The dorsalis pedis artery was mapped with a handheld Doppler and then marked ( Fig. 51.3 ). Under tourniquet control, the skin incision was made through the subcutaneous tissue down to the fascia. The suprafascial dissection was performed and the flap was elevated sharply with a knife. The distal end of the dorsalis pedis artery was identified and divided with hemoclips near the distal skin edge of the flap. A large dorsal vein was also divided during the flap elevation. The flap dissection was done in a retrograde fashion. After completing the adequate flap dissection, the tourniquet was released. The flap appeared to be well perfused and the dorsalis pedis artery was included within the flap ( Fig. 51.4 ). The flap was rotated into the right lateral foot wound and the excess flap tissue was excised ( Fig. 51.5 ). A drain was inserted under the flap within the right lateral foot wound.
The flap inset was performed next. The flap closure was done with interrupted 3-0 Monocryl sutures in a half-buried horizontal mattress fashion. The flap donor area, measuring 15 × 5 cm, was closed with a skin graft. The split-thickness skin graft was harvested from the right lateral thigh with a dermatome, placed as a sheet graft over the dorsal foot donor site, and secured to the adjacent wound edge and flap with multiple skin staples ( Fig. 51.6 A and B). An occlusive dressing was applied to secure the skin graft. At the end of the procedure, a plantar splint was used to immobilize the ankle.
Follow-Up Results
The patient did well postoperatively without any issues related to the dorsalis pedis artery flap for the lateral foot wound coverage. He was discharged from hospital on postoperative day 5. The right lateral foot wound healed uneventfully ( Fig. 51.7 A and B). He was followed by the plastic surgery service for routine postoperative care and by the orthopedic foot and ankle service for orthopedic care.
Final Outcome
During further follow-up, the right lateral foot wound after the flap reconstruction healed well with good contour and minimal scarring and no wound breakdown, recurrent infection, or contour issues. The flap donor site after skin grafting also healed well ( Fig. 51.8 A and B). He has resumed his weight-bearing status and has returned to his normal activities as instructed.
Pearls for Success
The dorsalis pedis artery flap can be used to cover a dorsal foot wound either as an island flap or as a rotation flap. The flap is based on the dorsalis pedis artery and has relatively limited arc as a rotation flap. If a larger rotation flap is designed, it should include a back cut of the flap to increase the flap’s arc of rotation. The donor site can be closed with a skin graft and its long-term outcome appears to be quite good. Care should be taken not to injure the pedicle vessel during the flap elevation. Suprafascial flap dissection can be performed so that a skin graft can be placed on the fascia for an optimal donor site wound closure. The flap is thin and reliable and can be considered as an excellent choice for a dorsal foot wound closure.
Case 2
Clinical Presentation
A 46-year-old White male sustained a crushing injury to his right foot. He was initially operated on by the orthopedic foot and ankle service and multiple toe fractures were stabilized and the portion of the soft tissue wound was approximated. This had left a large dorsal foot wound, measuring 17 × 10 cm, with the exposed multiple extensor tendons. The plastic surgery service was consulted for soft tissue reconstruction of this large dorsal foot wound. His necrotic toes would be amputated during the definitive soft tissue wound coverage ( Fig. 51.9 ).
