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Summary: Adequate arterial inflow is mandatory for a successful free tissue transfer. Maximizing this inflow appears to be especially important during distal lower extremity reconstruction, where perfusion pressures can be significantly lower than in the trunk or head and neck. In the current study, the authors used color and pulsed-wave Doppler ultrasonography to analyze blood flow volumes in the foot in accordance with the ankle position. Twenty feet of 10 healthy subjects were included in the analyses. All subjects were examined by Doppler ultrasonography at three different ankle angles (dorsiflexion at 90 degrees, relaxed position, and complete plantar flexion). The average flow volumes of the dorsalis pedis artery varied dramatically at the different ankle positions, as follows: dorsiflexion, 19.81 ± 3.88 ml/minute; relaxed position, 11.71 ± 4.72 ml/minute; and plantar flexion, 3.47 ± 1.41 ml/minute. The average flow volume of the posterior tibial artery also varied dramatically at these different ankle positions: dorsiflexion, 9.08 ± 8.25 ml/minute; relaxed position, 14.78 ± 2.45 ml/minute; and plantar flexion, 19.03 ± 5.03 ml/minute. The ankle position dramatically affects the flow velocity in the anterior and posterior tibial vessels, which is an important consideration when performing free tissue transfer reconstruction of the foot. Ankle dorsiflexion would be recommended when using the anterior tibial artery as a recipient vessel, whereas plantar flexion of the ankle would be advised when the posterior tibial artery is used as a recipient vessel., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Summary: The authors present indocyanine green angiography to assess the effects of hyperbaric oxygen therapy and as a potential biomarker to predict healing of chronic wounds. They hypothesize that favorable initial response to hyperbaric oxygen therapy (improved perfusion) would be an early indicator of eventual response to the treatment (wound healing). Two groups were recruited: patients with chronic wounds and unwounded healthy controls. Inclusion criteria included adults with only one active wound of Wagner grade III diabetic foot ulcer or caused by soft-tissue radionecrosis. Patients with chronic wounds underwent 30 to 40 consecutive hyperbaric oxygen therapy sessions, once per day, 5 days per week; controls underwent two consecutive sessions. Indocyanine green angiography was performed before and after the sessions, and perfusion patterns were analyzed. Healing was determined clinically and defined as full skin epithelialization with no clinical evidence of wound drainage. Fourteen chronic-wound patients and 10 controls were enrolled. Unlike unwounded healthy volunteers, a significant increase in indocyanine green angiography perfusion was found in chronic-wound patients immediately after therapy (p < 0.03). Moreover, the authors found that 100 percent of the wounds that demonstrated improved perfusion from session 1 to session 2 went on to heal within 30 days of hyperbaric oxygen therapy completion, compared with none in the subgroup that did not demonstrate improved perfusion (p < 0.01). This study demonstrates a beneficial impact of hyperbaric oxygen therapy on perfusion in chronic wounds by ameliorating hypoxia and improving angiogenesis, and also proposes a potential role for indocyanine green angiography in early identification of those who would benefit the most from hyperbaric oxygen therapy., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: The sympathetic innervation of the hand was demonstrated using formaldehyde staining techniques in the 1990s and provides a basis for both medical (botulinum toxin type A) and surgical (sympathectomy) therapeutic approaches. This research investigates the sympathetic innervation of the human foot using tyrosine hydroxylase immunohistochemistry., Methods: With institutional review board approval, six freshly amputated lower extremities had arterial, venous, and peripheral nerve biopsies obtained at the distal leg, ankle, and forefoot levels. Tibial, peroneal, sural, and saphenous nerves were processed immediately for immunohistochemical staining using an anti-tyrosine hydroxylase antibody, for light and electron microscopy evaluation. Qualitative assessments noted the presence or absence of tyrosine hydroxylase-positive fibers in artery, vein, and peripheral nerve. Within the nerve, location of the tyrosine hydroxylase staining was noted., Results: The presence of tyrosine hydroxylase-positive material was identified in each artery, vein, and nerve examined at each level of the foot and ankle. For the artery, the staining was in the adventitia, and rarely in the media of the vessel wall. There were clear entry points into the artery from the connective tissue. For the vein, the staining was more evenly distributed but to a lesser intensity than in the artery. Within each nerve at the proximal levels, the staining was diffusely throughout the fascicles, with clear sites of fibers leaving the periphery., Conclusions: It is concluded that (1) sympathetic innervation of the foot arrives along each peripheral nerve, (2) the vessels already contain sympathetic innervation at the level of the ankle, and (3) the sympathetic innervation of the foot is extensive.

Background: Microvascular surgery plays a major role in the reconstructive process of limb salvage. However, microsurgery in the patient with renal disease is still considered a high-risk procedure. Some authors have even recommended immediate amputation because of poor long-term survival in patients with renal failure and lower limb ischemia., Methods: A retrospective review of all patients with end-stage renal disease on hemodialysis who underwent free flap surgery at Dalin Tzu Chi General Hospital was included in the study. Data were collected over a 5-year period, between June of 2005 and June of 2009., Results: A total of 20 patients were included in the study, of which 11 were men and nine were women. The average age of the patients was 63 years. All had a history of diabetes mellitus with peripheral vascular disease. Seven of the 20 patients had undergone prior vascular intervention. The total flap survival rate was 95 percent. Four patients eventually required major limb amputation because of progressive infection at the recipient site. There were no further major limb amputations in these patients during the long-term follow-up. The total limb salvage rate was 80 percent. The average follow-up was 30 months., Conclusions: The authors' present approach shows that the results of limb salvage in this particular group of patients are not as discouraging as previously reported. In the description of patients with renal disease, the authors suggest that they not be described as one entity but that they be divided into subgroups so that this better reflects the risk of surgery and the success of limb salvage.

Background: It is well known that venous drainage of the medial plantar flap is performed by two venous systems: cutaneous veins visible through the skin that drain into the great saphenous vein; and deep veins, namely, accompanying veins of the medial plantar artery. However, there are only a few illustrations of the cutaneous veins of the sole in anatomical textbooks. Further clarification of the cutaneous veins of the sole was considered to be useful information in elevating the medial plantar flap., Methods: Whole-body or local injection with contrast medium was performed in 10 fresh cadavers. The skin and subcutaneous tissue were elevated and radiographed with a soft x-ray system. In an embalmed cadaver, macroscopic observation was performed., Results: In the sole, an intimate venous network was formed by branches of the great saphenous vein, small saphenous vein, and dorsal venous arch. Vascular arrangement of the venous network was not random but characteristic in each region of the sole. In the medial plantar, vessels were arranged toward the anterior margin of the medial malleolus., Conclusion: In planning the medial plantar flap, taking the vascular arrangement into consideration is considered to help the flap to avoid venous congestion and to extend the skin portion.

Background: The aim of this study was to describe the relationship between the deep peroneal nerve and the dorsalis pedis artery to help ensure a safer surgical approach in flap surgery., Methods: The dissection of 36 cadaver lower limbs was undertaken to describe the relationship of the deep peroneal nerve to the dorsalis pedis artery in the anterior tarsal tunnel and on the dorsum of the foot., Results: Four distinct relationships of the deep peroneal nerve to the dorsalis pedis artery were determined. In type 1 (36.1 percent), the artery was medial to the deep peroneal nerve in the tunnel and medial to the medial terminal branch below the tunnel on the dorsum of the foot. In type 2 (25.0 percent), the artery was medial to the deep peroneal nerve in the tunnel and lateral to the medial terminal branch below the tunnel on the dorsum of the foot. In type 3 (30.6 percent), the deep peroneal nerve and the artery were crossing over each other at multiple levels. In type 4 (8.3 percent), no medial terminal branch was observed. The artery was medial to the lateral terminal branch., Conclusions: The dorsalis pedis neurovascular island flap contains both the dorsalis pedis artery and the deep peroneal nerve. Because the design of a neurovascular free flap requires detailed knowledge of the nerve and vascular supply, the data presented here will help surgeons during the surgical approaches to the foot and ankle.

Background: Ian Taylor introduced the angiosome concept, separating the body into distinct three-dimensional blocks of tissue fed by source arteries. Understanding the angiosomes of the foot and ankle and the interaction among their source arteries is clinically useful in surgery of the foot and ankle, especially in the presence of peripheral vascular disease., Methods: In 50 cadaver dissections of the lower extremity, arteries were injected with methyl methacrylate in different colors and dissected. Preoperatively, each reconstructive patient's vascular anatomy was routinely analyzed using a Doppler instrument and the results were evaluated., Results: There are six angiosomes of the foot and ankle originating from the three main arteries and their branches to the foot and ankle. The three branches of the posterior tibial artery each supply distinct portions of the plantar foot. The two branches of the peroneal artery supply the anterolateral portion of the ankle and rear foot. The anterior tibial artery supplies the anterior ankle, and its continuation, the dorsalis pedis artery, supplies the dorsum of the foot. Blood flow to the foot and ankle is redundant, because the three major arteries feeding the foot have multiple arterial-arterial connections. By selectively performing a Doppler examination of these connections, it is possible to quickly map the existing vascular tree and the direction of flow., Conclusions: Detailed knowledge of the vascular anatomy of the foot and ankle allows the plastic surgeon to plan vascularly sound reconstructions, the foot and ankle surgeon to design safe exposures of the underlying skeleton, and the vascular surgeon to choose the most effective revascularization for a given wound.

Background: Toe-to-hand transfer is an accepted procedure for reconstruction of thumbs and fingers. Although the vascular anatomy of the toe has been well studied, its symmetry on both feet has not previously been reported., Methods: A retrospective review of 85 cases of simultaneous bilateral toe-to-hand transfers, performed between 1984 and 2002, was carried out. All of the pedicles were dissected in a retrograde fashion., Results: A symmetric vascular pedicle anatomy was found in 78.8 percent of the patients, whereas 21.2 percent of the patients had an asymmetric vascular pattern., Conclusions: This result cautions surgeons about the possibility of vascular pedicle asymmetry between two feet in bilateral toe harvest. It proves once more the advantage of a retrograde pedicle dissection technique, which allows for a safe and straightforward toe harvest regardless of the vascular pedicle course variations.

A foot avulsion case, with the dismembered body part submerged in sea water for 1 hour, is presented. This report is unique in that it is the first to document the reattachment of a body part that had been submerged in sea water. It was not known how salt-water exposure would affect wound management. Differences in osmolarity and bacterial flora between the sea water and foot tissues have not caused any problems, and the patient has not suffered any vascular or infectious complications after replantation. Neurotization of the plantar surface by the tibial nerve, which was stripped off during amputation and replaced in its original traces, was the most critical part of convalescence. After management of such an interesting case, we conclude that exposure to sea water of the dismembered part should not be a contraindication for replantation surgery.

A retrograde approach to dissection of the vascular pedicle in toe-to-hand transfer is presented, along with a simplified view of the vascular anatomy of the first web space. This approach has several advantages. First, the dominant vascular supply to the toe is elucidated early in the procedure, allowing for less unnecessary dissection of an inadequate pedicle. This also eliminates the need for preoperative arteriography. Furthermore, in cases where a lengthy pedicle is not required, retrograde dissection dispenses with harvest of a proximal vessel, which will not be needed for the transfer, and destructive dissection of the foot can be minimized.

Gangrene of an extremity secondary to a congenital constriction band may result from in utero or postnatal vascular compromise. Often ths process is completed in utero following spontaneous resolution of the vascular insufficiency, resulting in a healed wound by fetal repair and regeneration or in amputation of the distal part. When this process is progressive as a result of worsening lymphaticovenous and/or arterial obstruction with associated soft-tissue necrosis, salvage of the distal part can be accomplished by immediate decompression to evacuate the lymphedema fluid, staged band excision, Z-plasty closure, and topical antimicrobial therapy of the open wound. A revised classification of constriction-ring syndrome incorporating the "intermediate" stage (3B) of severe lymphaticovenous compromise with soft-tissue loss is introduced.

The dorsal foot skin island flap pedicled on the plantar vasculature as a reconstructive entity is described. Two successful cases of resurfacing of the distal end of the foot with a dorsal foot island flap pedicled on the proximal communicating vessels and the distal communicating vessels, respectively, are reported, and this type of reconstructive procedure is proposed as an addition to existing procedures for reconstructing the distal end of the foot.

This study reviews 21 microvascular free flaps to the diabetic foot in 19 patients over a 65-month period. All flaps were either to the plantar surface of the foot or to cover exposed Achilles tendon. Twenty of the flaps survived. The operations required a long, costly hospitalization with frequent recipient- and donor-site complications. All patients eventually ambulated on their flaps. Five patients came to proximal amputation from 6 to 37 months after surgery. Only one amputation was for flap breakdown.

Between 1980 and 1989, 46 free-tissue transfers (32 skin flaps, 14 muscle flaps) were performed in 44 patients for foot reconstruction. Patient age averaged 25.8 years (range 2 to 74 years). Length of follow-up averaged 43 months. Flap survival rate was 96 percent. Debulking was done in 16 skin and 8 muscle flaps. The ulceration rate in 25 patients with weight-bearing flaps was 32 versus 11 percent in 19 patients with non-weight-bearing flaps. Time before ambulation averaged 6.4 months following weight-bearing reconstruction and 4.5 months following non-weight-bearing reconstruction. All patients with either abnormal foot-mat diagrams or major gait abnormalities had significant underlying radiologic foot abnormalities or nerve injuries. We conclude that both skin and muscle free flaps frequently need secondary debulking procedures to improve function. The ulceration rate tends to be higher in weight-bearing flaps than in non-weight-bearing flaps. Underlying bony architecture and nerve function affected weight-bearing patterns and gait more than type of wound coverage.

Plastic surgeons are frequently called upon to evaluate wounds in diabetic patients with compromised vascular inflow. Although a few authors have reported success in coverage of such wounds with microsurgical techniques, enthusiasm for this procedure has remained low due to concerns about flap viability, occlusion of flow to the distal limb, and the usually poor systemic status of such patients. We report here on our experience with 19 diabetic patients with peripheral vascular disease and a nonhealing wound of the lower extremity treated over the last 4 years with microvascular tissue transfer. Two patients (10.5 percent) suffered anastomotic difficulties and there was one flap loss (5 percent). Major morbidity rates were acceptable, with only one perioperative death (5 percent) and three cases of nonfatal major systemic difficulties in the immediate postoperative period (16 percent). Despite the importation of well-vascularized tissue, local morbidity at the recipient site was seen in nine patients (47 percent). The overall limb salvage rate was 72 percent during the period of follow-up, which averaged 22 months. Despite this loss of five limbs, all but three of the patients eventually returned to ambulation. The overall death rate in our series was only 2/19 (10.5 percent) over the period of follow-up. Although further work needs to be done in this difficult group of patients to ascertain the long-term benefit (especially relative to the cost/benefit ratio), we feel that this series confirms the safety and short-term efficacy of microsurgical treatment of such individuals.

An anatomic study (30 fresh specimens dissected) and clinical experience (5 patients) have shown the reliability of a fasciocutaneous flap raised from the medial side of the foot. The artery that supplies the flap is issued from the medial plantar artery. The arch of rotation allows one to cover some specific areas, such as the medial malleolus, posterior aspect of the heel, and distal insertion of Achilles tendon.

The dorsalis pedis free flap is an excellent reconstructive tool for thin remote mucosal defects, for heel and hand defects where innervation is critical, and as an osteocutaneous flap with unique application to mandibular and floor of mouth reconstruction. The major criticism with this flap is related to its uncertain vascularity and the donor defect. We have found in our series of 45 cases that the vascular anatomy is exceedingly reliable. Problems with the donor defects are all related to technique. With care in flap elevation and foot closure, which we describe in detail, an acceptable donor site with minimal complications can be achieved. The clinical applications of this flap are illustrated by three case reports. Our experience with the donor site has not been problem-free. However, we do believe that with meticulous technique primary healing will occur without functional disability and with minimal cosmetic deformity.

This study was undertaken to clarify the microanatomic details of the cutaneous branches of the dorsalis pedis artery. The microarterial anatomy of the dorsalis pedis flap area and its clinical implications are described.

Conventional nerve grafts in complex digital injuries often yield poor results, particularly when placed in traumatized or avascular beds. Vascularized nerve grafts offer an option; experimental evidence suggests superior axonal regeneration across scarred beds with vascularized nerve grafts. We previously described a vascularized graft based on the dorsalis pedis artery--deep peroneal nerve "system." Reluctance to sacrifice this major artery, combined with the recent description by Townsend and Taylor and Gu, et al, of "reversed venous" arterialized nerve grafts, spurred us on to investigate the deep peroneal nerve--dorsalis pedis venae comitantes system. Fourteen neurovenous grafts were used in scarred or poorly vascularized beds for digital nerve reconstruction in 10 patients over a 4-year period. Graft length averaged 4.4 cm; interval from injury was 1 to 17 months. Sensory parameters of return included average static two-point discrimination of 8.3 mm, moving two-point discrimination of 5.8 mm, and median Semmes-Weinstein monofilament appreciation of 2.83. Two patients received three vascularized grafts and three conventional grafts for adjacent nerve injuries in the same digit, serving as internal controls. In these patients, the vascularized nerve grafts returned mean static two-point discrimination values of 9.3 mm and moving two-point discrimination values of 6.7 mm. The conventional nerve grafts averaged static two-point discrimination of 14.3 mm and moving two-point discrimination values of 10.3 mm. These differences imply enhanced axonal regeneration through vascularized nerve grafts. These data suggest that the reversed neurovenous graft may be the procedure of choice in secondary reconstruction of digital nerves across scarred beds or following injuries with poor soft-tissue vascularity, especially in those patients with cold intolerance.

The nutrient flap is a new concept of the role of the flap. It has three functions: (1) it provides supplementary blood flow to ischemic zones, (2) it assists venous drainage in regions of venous insufficiency, and (3) it induces the formation of a capillary network. Its skin covering role is only accessory. We have applied this principle to osteitis, pseudoarthrosis, and arteriosclerosis. The nutrient flap constitutes a new type of treatment for stage IV arteriosclerosis of the lower limbs when classical revascularization techniques cannot be performed and when high amputation is indicated. Four clinical cases and the surgical techniques used are described. The flap, usually raised from the latissimus dorsi, is anastomosed to the popliteal artery by means of an inverted saphenous vein graft. It is applied to the distal extremity of the limb after excision of the necrotic tissues. The nutrient flap preserves weight-bearing by maintaining the heel.

Safe planes exist for plantar incisions that minimize the possibility of subcutaneous nerve injury and are therefore useful in flap design. Nerve branch orientation in the plantar subcutaneous tissue is specific and guides dissection so as to avoid producing anesthesia in weight-bearing areas. An extensive proximal plantar subcutaneous plexus exists that permits elevation of plantar flaps in a superficial plane. This is due to the major contribution that the dorsal circulation makes to the skin of the plantar surface. The blood supply to the non-weight-bearing midsole area is not from the medial plantar artery exclusively. This is a watershed area with important lateral plantar artery and dorsalis pedis artery contributions as well. It is not necessary or desirable to base plantar flaps on a myocutaneous or fasciocutaneous supply with its required deep dissection. Local plantar flaps can be designed to include sensation and abundant blood supply without the need for "subfascial" dissection. Subcutaneous sensory plantar flaps designed in accordance with these principles promise a more ideal solution for the treatment of plantar defects.

Twenty-two reverse-flow island flaps were transferred. These included peroneal, forearm, anterior tibial, and temporal flaps. Sixteen of 22 flaps survived completely. We encountered partial necrosis in 4 flaps and total necrosis in only 2 flaps. We credit this success to the reliability and availability of the peroneal, forearm, and temporal flaps; but we do not encourage use of the anterior tibial flap. The flaps that survived well did not show any signs of venous congestion. The advantage of the reverse-flow island flap is that it can be transferred from a proximal to a distal location. Using cadavers and fresh amputated limbs, studies on venous drainage of the reverse-flow island flap were performed. The venae comitantes had numerous venous valves and communicating branches, but more than sufficient reflux of the venous blood occurred through the valves at pressures of 90 to 105 cmH2O. We believe that the venous drainage of the reverse-flow island flap occurs as a result of reflux actions at the valve, communicating branches between the venae comitantes, and bypass vessels around the valves.

A neurovascular free flap from the first web space of the foot was used successfully in two patients for replacement of glabrous skin of the hand and fingers. The potential advantages of this flap are that (1) it may be used to replace large defects of glabrous skin, (2) it provides a rich vascular supply to the periphery of the hand, and (3) the sensation achieved approaches the normal for the intact glabrous skin of the hand.

Normal skin blood flow was measured by the xenon 133 clearance method at different anatomic sites of the body and the following results were obtained. First, the skin blood flow of the face and anterior chest was significantly greater than that of the deltoid region (P less than 0.01). The skin blood flow of the dorsal side of the hand and foot was significantly lower than that of the deltoid region (P less than 0.01). A tendency was observed for the skin blood flow to decrease gradually from the upper part of the body to the lower part of the body. For example, the ratio of the highest value at the face to the lowest value at the dorsal side of the foot was about 2.5:1, indicating a remarkable difference among the various sites of the body. The skin blood flow at the dorsum of the hand was significantly higher by about 25.4 percent than that of the foot (P less than 0.01). Second, the skin blood flow at the left side of the deltoid region was higher by about 5 percent than that of the right side (P less than 0.01). Bilateral comparison of the skin blood flow at the dorsal side of the hand and foot showed that the values were almost the same on the left and right.

A sensory flap, based on the medial plantar artery and incorporating the cutaneous branches of the medial plantar nerve, is described for the coverage of heel defects.

Many defects of the head and neck can be readily repaired with a free dorsalis pedis flap, and we report success with these flaps in 9 of 12 cases. A precise knowledge of the anatomy of the arterial supply of the flap is necessary. Preoperative arteriography is recommended if the dorsalis pedis artery is not easily palpable, or if an anomalous distribution of the artery along the dorsum of the foot is sus pected. However, the transfer of the flap should be delayed for two weeks after preoperative arteriography is performed. The one-stage soft tissue reconstruction with a free dorsalis pedis flap has been associated with minimal morbidity and good acceptance by patients. A delay procedure for the flap seems to enhance the chances of complete survival which is so necessary in the repair of intraoral and pharyngeal defects. Careful attention to details and close monitoring of the flap will minimize morbidity. In case of an early failure of a flap, a secondary reconstruction by a different flap can be done in the first 48 to 72 hours. Early postoperative radiotherapy has been well tolerated over these free flaps.

The use of free flaps to repair defects of the leg or foot is a viable alternative to cross-leg flaps because (1) the total time of immobilization and hospitalization is less, (2) the total number of general anesthetics is less, and (3) the morbidity and cost are less. Increased experience will enhance the survival statistics for free flaps, making their use the method of choice for the reconstruction of defects in the distal part of the lower extremity.

Closure of plantar defects with local rotation flaps was studied in 10 patients with 11 plantar defects. Ages ranged from 15 to 66 years, and the average defect was 3.0 X 3.6 cm. Two patients were diabetics. Etiology was variable and included trauma, tumors, and breakdown in patients with anesthetic plantar surfaces. Plantar flaps were designed superficial to the plantar fascia based on the proximal plantar subcutaneous plexus blood supply. Sensation was provided by including the medial calcaneal nerve territory within the flap and by performing a limited intraneural dissection of the medial and lateral plantar nerves. Flaps were medially based, although laterally based designs are also possible when sensation is absent. The follow-up period averaged 20.8 months. Patients with normal sensation preoperatively had full sensation postoperatively and were able to bear weight on the flap without limitation. There was minor breakdown in one patient with incomplete sensation. One patient developed a hematoma. Sensate plantar flaps can be designed superficial to the plantar fascia. These flaps are durable and allow normal weight-bearing on the reconstructed surface.