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Background: Local flaps remain a valuable reconstructive tool as a means for limb salvage for patients with advanced arterial disease. Our single-center, retrospective cohort study aims to compare the outcomes of different patterns of blood flow affected by vascular disease to pedicles in local flap reconstruction of the foot and ankle., Methods: A retrospective review of 92 patients and 103 flaps was performed. On angiograms, pattern of blood flow to the flap pedicle was determined to be direct inline flow (DF) or indirect flow (IF). Patterns of IF were either by arterial-arterial connections (AC) or unnamed randomized collaterals (RC). Primary outcomes were immediate flap success and limb salvage. Comparative analyses were performed using the χ2 and Fisher tests for categorical variables., Results: Among all flaps, 73.8% (n = 76/103) had DF and 26.2% (n = 27/103) had IF. Both groups experienced similar rates of immediate flap success (DF = 97.3% vs IF = 92.6%, P = 0.281) and limb salvage (DF = 75.% vs IF = 66.7%, P = 0.403). However, the rate of contralateral amputation was significantly higher in the IF group (26.9% vs 5.3%, P = 0.006). When comparing the 3 distinct patterns of blood flow (DF vs AC vs RC), pedicled flaps were more commonly supplied by DF and AC, while random pattern flaps were more commonly supplied by RC (P = 0.042)., Conclusions: Alternative routes of revascularization can maintain local flap viability and achieve similar rates of limb salvage but risks contralateral amputation. We found that pedicled and local muscle flaps require inline blood flow or blood supply by ACs. Meanwhile, random pattern flap can be supported by random collaterals., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The medial plantar artery flap (MPAF) presents both unique value as well as significant challenges. As the plantar foot has specific anatomy, the use of the MPAF to recreate this highly specialized area may provide improvements in durability and rates of limb salvage. The purpose of this study is to establish the anatomic course of the branching patterns of the medial plantar artery (MPA) and provide a foundation for MPA flap nomenclature as it is related to design and elevation. Thirty-seven fresh frozen cadaver feet were used for dissection: 20 right and 17 left sided limbs. Anatomic measurements recorded included: branching pattern of the MPA, bifurcation distance of the superficial branch (SB) and deep branch (DB) from the origin of the MPA, distance from the MPA origin to the anterior colliculus of the medial malleolus, and the distance from the SB and the DB to the navicular tuberosity. The MPA was found to bifurcate into SB and DB in 30 (81%) specimens; 6 (16%) specimens had only a SB, whereas 1 (3%) specimen had only a DB, which had not been previously described. The distance from the anterior colliculus to the MPA was 3.0 cm, MPA to the distal bifurcation was 2.9 cm, and navicular tuberosity to the SB and DB was 2.2 cm and 1.3 cm, respectively. Minimizing the complexity of the dissection with the use of more reliable landmarks and a deeper understanding of the anatomy may reduce complications and allow for more reproducible outcomes when utilizing the MPAF., (Copyright © 2024 the American College of Foot and Ankle Surgeons. All rights reserved.)

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Computed tomography angiography (CTA) has become a widely used imaging modality in vascular surgery. The first web arterial branches of the foot are significant for surgical planning of the donor site for thumb reconstruction., Methods: We retrospectively analysed 30 thumb reconstructions with free second toe/great toe wrap-around flap transfer, performed between January 2016 and January 2019. The mean patient age was 30 (2-45) years. The causes of hand injury were: 20 machine strangulation injuries, 6 heavy weight smash injuries, and 4 crush injuries. Patients with iodine allergy were excluded preoperatively. We evaluated the effectiveness of CTA in visualizing first web arterial branches and compared it with intraoperative findings. Surgical plan for donor sites was prepared based on the classification of the first web arterial branches., Results: The arterial branches of the patients were classified based on CTA findings as follows: (1) fork type: 24 patients (48 feet, 80%); (2) main trunk type: four patients (8 feet, 13.33%); and (3) side branch type: one patient (2 feet, 3.33%). One case of poor vascular continuity and artifacts in CTA underwent thumb reconstruction with free great toe wrap-around flap transfer. Tissue survival was achieved in all reconstructed thumbs. During the follow-up period (average, 12 months), all reconstructed thumbs exhibited good outcomes. The donor sites on the feet of all patients recovered well., Conclusion: CTA allows preoperative assessment of blood supply and planning of donor site. Our results can serve as a reference for surgical planning of the donor site while reducing the occurrence of adverse events., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021. Published by Elsevier Ltd.)

Medial plantar artery-based flaps have great value in healing full-thickness wounds of the foot and ankle. The goal of this study was to identify a common location for the origin of the medial plantar artery. Recognition of this anatomic marker will help improve incision placement and increase the success of preserving the artery when performing the medial plantar artery fasciocutaneous flap. This study examined the location of the origin of the medial plantar artery in 40 fresh cadavers. Results were obtained by dissection and macroscopic analysis to document the distance of the origin of the medial plantar artery from the intercollicular groove of the medial malleolus in centimeters. The mean distance was determined to be 3.2 ± 0.4 cm (range 2.7 to 4.5), with a low standard error of 0.0621. This suggests a high statistical probability that the common origin of the medial plantar artery is found 3.2 cm distal to the intercollicular groove of the medial malleolus in the general population., (Published by Elsevier Inc.)

Introduction: The medial plantar artery (MPA) flap in its anterograde form is considered the gold standard for heel reconstruction. This flap can be also raised distally for the reconstruction of the weight-bearing forefoot. However, terminal branches of the MPA, together with their connection with distal and dorsal systems, can be variable. Our objective was to provide a comprehensive anatomic description that could match all technical possibilities in raising the distally based MPA flap. A systematic review of indication outcomes and complications of the distally based MPA flap is provided., Methods: According to PRISMA criteria, we systematically reviewed previous literature using the MEDLINE database concerning the MPA flap from 1977 to November 2018 using the keywords « Medial plantar flap » OR « Medial Plantar Artery ». Anatomic variations, techniques, indications, outcomes, and complications were analyzed., Results: All different vascular pedicles that may be used for the vascularization of the MPA flap were classified. Apart from the flap with a proximal flow, there may be five anastomotic connections from the superficial MPA to the plantar arterial network. Four dorso-plantar links supply the plantar network thanks to dorsal vascularization. Literature analysis of outcomes showed how the retrograde MPA flap may be unreliable with 14% of venous congestion rate and 9.3% of average flap loss, for a total average flap complication of 18.6%., Conclusion: This review provides the ultimate, clear picture of the complex anastomosis of the forefoot, with direct referral to surgical flap raising techniques, guiding surgeons during challenging reconstructions., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Destruction of digits from trauma results in a much more significant influence on patients' mental state and quality of life than do injuries to other parts. The purpose of this study was to describe a novel modification of medial plantar venous flap for soft tissue defects in the hands and digits., Methods: Nine patients received medial plantar venous flap to resurface soft tissue defects in the hands or digits between January 2015 and February 2017. This flap can be used either in a free-island pattern or in a flow-through pattern through the medial branch of the great saphenous vein. All patient data including preoperative statues and follow-up examinations (flap survival rates, complication rates, total active motion, static 2-point discrimination, and Semme-Weinstein test score) were analyzed., Results: We included 6 men and 3 women, with a mean age of 34.2 years. The medial plantar venous flaps were used for vascularization in 5 patients because of segmental defects of bilateral digit arteries. Eight flaps survived uneventfully in this study. One flap partially failed (20% of the flap area) because of venous congestion. The functional outcomes and sensory restoration were satisfied for all 9 flaps., Conclusions: Compared with the traditional medial plantar flap, the medial plantar venous flap involves a simpler surgical procedure and allows for revascularization of distal areas using the flow-through technique. Furthermore, the medial plantar area presents a sensitive, glabrous skin with proper bulkiness and allows for movement of the underlying structure.

Background:  Peroneus brevis muscle flap is a distinguished, distally based safe flap that can be manipulated to cover small defects in the leg and ankle. For large-sized defects, a more distal, larger flap is required either locally or distantly., Methods:  Forty-two distally based peroneus brevis muscle flaps were elevated in 42 patients (30 males and 12 females) with major lower leg, ankle, and proximal foot defects of 6 to 15 cm in length and 6 to 12 cm in width. Anatomical findings were recorded as number, size, and sources of blood supply, entry sites, the lowermost two arterial supplies, internal distribution of blood supply to the muscle, the relationship between external and internal distribution of the blood vessels, the length of the muscle, the entry site of the main artery, and the splitting of the proximal portion of the peroneus brevis muscle to increase its width to sufficiently cover large defects., Results:  The anatomical findings suggested that the muscle can be safely extended to cover a large defect in the leg, ankle, or proximal foot. In addition, the longitudinal splitting of the muscle increases its width by up to three times, making it an excellent long-surviving flap to cover a large defect., Conclusion:  A distally based peroneus brevis muscle flap has a rich blood supply and safely reaches the proximal foot, with a secure splitting to cover large defects in the leg, ankle, and proximal foot., Competing Interests: None. Disclosure The author has no financial or personal relationships with other people or organizations that could inappropriately influence my work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The pedicled medial plantar (MP) flap is an optimal solution for defects involving the weight-bearing areas of the foot. However, venous congestion is a frequently encountered complication, especially with the reverse-flow variants of the flap, and several strategies have been reported in literature both to prevent and to manage it. In this article, we present the use of a medial plantar flap based distally on the lateral plantar artery with the adjunct of an extra metatarsal perforator from the dorsalis pedis artery as a vascular enhancement to avoid the venous congestion and to improve the overall circulation. This bipedicled flap was successfully advanced to cover a 5 × 3 cm soft-tissue defect located at the level of the first and second metatarsal heads of the right foot resulting from the excision of a squamous cell carcinoma in an 80-year-old male patient with a history of cardiovascular disease. The postoperative course was uneventful. The patient was discharged 7 days after the operation and was able to walk after 6 weeks wearing normal shoes. We believe that preserving plantar metatarsal perforators during the harvesting of an MP flap based distally on the lateral plantar artery may be a precious adjunct as it increases blood supply, especially the venous drainage of the flap., (© 2018 Wiley Periodicals, Inc.)

Background: Detailed investigation of the vasculature of the lateral aspect of the foot has rarely been presented. However, harvesting the flap in this area to cover defects of the foot and hand is highly important. Repair of soft-tissue defects at the forefoot remains a challenge in reconstructive surgery. This study explores the characteristics of the distal-based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone to establish a repair procedure for ulcers or defects in the forefoot region., Methods: This study is divided into two parts: anatomical study and simulated operation. Thirty cadavers were utilized in the anatomical study after arterial injection. The tuberosity of the fifth metatarsal bone was used as the anatomical landmark. The lateral plantar artery perforator of the fifth metatarsal bone was identified through dissection. The perforators were dissected under a microscope. The details of the lateral plantar artery perforators, the distribution of the lateral dorsal cutaneous nerve and lateral plantar vein, the anastomosis in the lateral plantar artery perforator of the fifth metatarsal bone, the nutrient vessels of the lateral dorsal cutaneous nerve and lateral plantar vein, and other arteries of the lateral foot were recorded. The flap-raising procedure was performed on three fresh cadavers., Results: The lateral dorsal cutaneous nerve originated from sural nerve, traveled obliquely downward along the anterior lateral margin of the foot, and accompanied by the lateral plantar vein after bifurcation, and was eventually distributed on the lateral aspect of the foot. The nutrifying arteries to the lateral dorsal cutaneous nerve and lateral plantar vein were present segmentally and mainly originated from the lateral plantar artery perforator of the fifth metatarsal bone. These nitrifying arteries constantly originated from the lateral plantar artery in the area of tuberosity of the fifth metatarsal, ran along the medial side of the fifth metatarsal, traveled between the fifth metatarsal bone and the lateral muscle group (the flexor digitorum brevis and the abductor digiti minimi muscles), pierced the aponeurosis, vascularized the skin of the anterior lateral plantar region, and resulted in many minute branches, which anastomosed with the lateral tarsal artery and fourth dorsal metatarsal artery. The anatomical study showed that (1) the vasculature pattern can roughly be classified into three types and (2) constant anastomoses occurred between the above-mentioned arteries in the lateral-dorsum region of the foot., Conclusion: A reliable large- or medium-sized neuro-venocutaneous flap with lateral dorsal cutaneous nerve, lateral plantar vein, and nutrient vessels can be raised using only the perforator of the lateral plantar artery of the fifth metatarsal bone, which is thin, is in the immediate vicinity of the forefoot, and has a reliable retrograde blood supply. This flap can be considered an alternative means to reconstruct soft-tissue defects of the forefoot.

Traditional incision techniques for midfoot amputation might not provide immediate soft tissue coverage of the underlying metatarsal and tarsal bones in the presence of a large plantar soft tissue defect. Patients undergoing transmetatarsal and Lisfranc amputation frequently have compromised plantar tissue in association with neuropathic ulcers, forefoot gangrene, and infection, necessitating wide resection as a part of the amputation procedure. Open amputation will routinely be performed under these circumstances, although secondary healing could be compromised owing to residual bone exposure. Alternatively, the surgeon might elect to perform a more proximal lower extremity amputation, which will allow better soft tissue coverage but compromises function of the lower extremity. A third option for this challenging situation is to modify the plantar flap incision design to incorporate a medial or lateral plantar artery angiosome-based rotational flap, which will provide immediate coverage of the forefoot and midfoot soft tissue defects without excessive shortening of the bone structure. A plantar medial soft tissue defect is treated with the lateral plantar artery angiosome flap, and a plantar lateral defect is treated with the medial plantar artery angiosome flap. Medial and lateral flaps can be combined to cover a central plantar wound defect. Incorporating large rotational flaps requires knowledge of the applicable angiosome anatomy and specific modifications to incision planning and dissection techniques to ensure adequate soft tissue coverage and preservation of the blood supply to the flap. A series of 4 cases with an average follow-up duration of 5.75 years is presented to demonstrate our patient selection criteria, flap design principles, dissection pearls, and surgical staging protocol., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study aims to explore the characteristics of the formation and topography of lateral plantar artery perforators to identify a repair procedure for defects in the forefoot region., Methods: Thirty-three cadavers were available for this anatomical study. The tuberosity of the fifth metatarsal bone was adopted as the anatomical landmark. The details of the lateral plantar artery perforators and the anastomosis between the lateral plantar artery perforators and other arteries of lateral foot were recorded., Results: The perforators from the base and head of the fifth metatarsal bone constantly originate from the lateral plantar artery in the area of tuberosity of the fifth metatarsal, run along the medial side of the fifth metatarsal, then travel between the fifth metatarsal bone and lateral muscle group, pierce the aponeurosis, vascularize the skin of the anterior lateral plantar region, and finally anastomose with the lateral tarsal artery and the fourth dorsal metatarsal artery. At the point of origin, the mean sizes of the perforator of the fifth metatarsal base and head were 1.3 ± 0.2 and 0.9 ± 0.3 mm (mean ± SEM), respectively. The pedicle lengths were 2.6 ± 0.3 and 3.8 ± 0.5 cm, indicating the possibility of a free perforator flap., Conclusion: The lateral plantar artery perforators are presented constant. The forefoot region can be repaired by the reverse perforator flap harvested pedicled with either the lateral plantar artery perforator from the base or head of the fifth metatarsal bone.

The aim of this study was to represent the dorsalis pedis (DP) flap on sectioned images and surface models using Visible Korean for medical education and clinical training in the field of maxillofacial reconstructive surgery. Serially sectioned images of the foot were obtained from a cadaver. The important structures in the sectioned images were outlined and stacked to create a surface model. The PDF file (53 MB) of the assembled models is accessible for free download on the Department of Anatomy at Ajou University School of Medicine Web site (http://anatomy.co.kr). In this file, the significant anatomic structures of the DP flap can be inspected in the sectioned images. All surface models and stereoscopic structures of the DP flap are described in real time. We hope that these state-of-the-art sectioned images, outlined images, and surface models will help students and trainees gain a better understanding of the DP flap anatomy.

Background: Plantar skin has similar histologic features to the palmar area and appears to be the ideal tissue for reconstruction of the palmar region. In this study, an anatomic examination was performed to determine the superficial venous architecture of the instep area, and the use of arterialized venous instep flaps for palmar contracture release was assessed., Methods: The anatomical study was performed on 12 fresh cadaver feet. The arterialized venous instep flap, including the skin, subcutaneous tissue and superficial venous plexus, was harvested. To determine the venous structure, dissection (n = 6) and injection-corrosion (n = 6) techniques were used. In the clinical study, nine arterialized venous instep flaps were used for palmar contracture release. All flaps were harvested above the deep fascia and included skin, subcutaneous fat, and the superficial venous plexus. At the plantar site of the flap, two or three veins, one of which was used, were dissected for a sufficient length for the arterial anastomosis. The saphenous vein was used for the venous anastomosis., Results: Dissection and injection-corrosion techniques revealed that the flap had 7-12 and 4-6 veins at its plantar and superior edges, respectively, with numerous anastomoses and interconnections between the veins. The flap dimensions were between 3 × 5 cm and 4 × 6 cm. All flaps survived, with two partial flap necrosis that healed with spontaneous epithelization. No debulking procedures were undertaken and all flaps adapted well to the recipient site., Conclusions: The arterialized venous instep flap is a good alternative to reconstruct palmar contractures by adding similar tissue that is thin and pliable with minimal donor site morbidity., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: The methods of repairing defects in fingers, volar skin of the palm and soft tissue were investigated., Methods: From 2010 to the present, we examined 12 cases in which medial plantar skin flaps were used to repair defects in the fingers and palm. According to skin and soft tissue defects in the fingers and palm, a flap was designed using the medial plantar artery as the vessel pedicle. The flap was dissected and isolated between the abductor hallucis and flexor digitorum brevis, and transplanted to the hand. We then observed the skin colour, skin texture and tactile sensitivity of the hand, as well as the shape and function of the foot., Results: Follow-up for 3-28 months showed that the flaps survived in all 12 cases, with soft skin, healthy appearance, colour consistent with the palm skin and no pigmentation. The two-point discrimination was 5-7 mm. The donor foot functioned well, and the scar at the donor site was slight and had an aesthetic appearance., Conclusion: The free medial plantar flap is an ideal flap for repairing soft tissue defects in the palm.

Objective: To investigate the effect of reverse saphenous nerve neurocutaneous flaps for skin defects of forefoot., Methods: In the anatomic study, 50 cadaveric feet were injected with red latex and the anastomosis, distribution and external diameters of medialtarsal artery, medial anterior malleolus artery, medial plantar artery, the superficial branch of the medial basal hallucal artery and saphenousnerve nutritional vessels were observed. Based on anatomic research results, we designed the reverse saphenous nerve neurocutaneous flaps for repairing skin defects of forefoot., Results: The blood supply of reverse saphenous nerve neurocutaneous flaps were based on the vasoganglion, which consist of arterial arch at the superior border of abductor hallucis and arterial network on the surface of abductor hallucis around the saphenous nerve and medial pedis flap. From Oct. 2006 to Oct. 2011, the reverse saphenous nerve neurocutaneous flaps were used to repair skin defects of forefoot in 11 cases. The flap size ranged from 2.5 cm x 3.5 cm to 7.5 cm x 8.5 cm. The wounds at donor site were covered with full-thickness skin graft. All flaps survived completely with no ulcer at the donor site. 11 cases were followed up for 6 to 18 months( mean, 10 months). The skin color and texture were satisfactory. The patients could walk very well., Conclusions: It is reliable to repair the skin defects of forefoot with reverse saphenous nerve neurocutaneous flaps. It is easily performed with less morbidity. This flap should be considered as a preferential way to reconstruct skin defects of forefoot.

Reconstruction of complex defects of the distal portion of the foot remains a challenging problem for plastic surgeons. A traumatic case is presented where reconstruction of a complex plantar defect of the hallux was achieved using a distally-based osteocutaneous metatarsal artery flap based on the second dorsal metatarsal artery. Local flap repair is a viable reconstructive option for complex defects of the plantar surface of the forefoot., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Because of its outstanding texture, bulkiness, pliability and sensory recovery, the medialis pedis is an excellent alternative in the reconstruction of complex volar skin defects of the digits in selected patients. However, the surgical flap anatomy related with the medial plantar artery is still somewhat confusing to the point that the different journal articles and anatomy textbooks and atlases use different terminology and are, to some extent, misleading and/or incomplete. The authors report a clinical series of 15 medialis pedis free flaps in the reconstruction of skin defects of the fingers and evaluate their indications in free flap reconstruction of the skin defects of the digits. A review is made of the most relevant journal articles, anatomy textbooks, and atlases that describe the anatomy of the medial plantar artery with a special emphasis on the cutaneous branches that nourish the medialis pedis flap.

Objective: To investigate the vascular supply of intrinsic muscles of foot and anatomic basis for muscular flap design., Methods: A radiopaque injectate (lead oxide-gelatin mixtures, 26 ml/kg) was injected into 10 fresh cadavers. The dissected regions were photographed and each intrinsic muscles on the foot was removed and radiographed. The number, type, diameter of vascular branches of muscles and their distributions were observed. The area of the vascular territory supplied by each source vessel was calculated using Scion Image for Windows software., Results: There were significant architectural differences among the intrinsic muscles. The muscles length varied from 22.5mm to 116.2mm [average, (66.1 +/- 23.2)mm]. The measured fiber length were relatively consistent, ranging from 14.2 mm to 27.5 mm [average, (20.2 +/- 4.5)mm]. There are 63 vascular branches into the 23 foot muscles, each muscle having average branches of 3.2 +/- 0.8. The average diameter of branches, the length and width of each vascular territorial area is (0.8 +/- 0.3) mm, (2.2 +/- 0.8) cm, and (0.9 +/- 0.4) cm, respectively. Other findings included that some muscles were not present in some cadavers., Conclusions: The blood supply of intrinsic muscles of foot is abundant with different diameter and distributions of branches. There is an anatomic basis for muscular or musculoosseous flap design. There are 7 intrinsic muscles with large and reliable vascular supply which can be chosen as muscular flaps.

Objective: To investigate the feasibility and effectiveness of free popi iteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein for the repair of wound on the foot and ankle by anatomical observation and clinical application., Methods: Latex was poured into the blood vessels of 8 cadavers, then perforator vessel of posterolateral upper calf was dissected, and the popl iteal artery cutaneous branch flap was designed with a pedicle of 2.5 cm in length; the lateral tarsal artery of the foot was dissected, could be freed to 6 cm in length; the diameter of these vessels was measured, and the number of the accompanying veins was counted. Between March 2010 and January 2013, 13 cases of foot and ankle wounds were repaired with popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein. The size of flaps ranged from 6.0 cm x 4.0 cm to 7.5 cm x 5.5 cm. There were 11 males and 2 females, aged from 41 to 65 years (mean, 47.3 years). The causes of injury included traffic accident in 8 cases, crushing in 4 cases, and twist by machine in 1 case. The size of wounds, ranged from 5.0 cm x 3.5 cm to 7.0 cm x 5.0 cm. The donor sites were sutured directly., Results: According to anatomical observation, the popliteal artery cutaneous branch flap was designed by using the lateral popliteal artery perforator for shaft. The vessel of the pedicle perforator flaps from the popliteal artery cutaneous branch flap matched well with the lateral tarsal artery., Clinical Results: vascular crisis occurred in 2 flaps, which survived after symptomatic treatment; the other flaps survived, with primary healing of wound and incision at donor site. The patients were all followed up 5-18 months (mean, 11 months). The flap had normal color and good elasticity. Second stage operation was performed to make the flap thinner in 3 female patients because of bulky flaps. The remaining patients had no obvious fat flap. According to American Orthopaedic Foot and Ankle Society (AOFAS) score for evaluation of the ankle function at 6 months after operation, the results were excellent in 7 cases, good in 5 cases, and fair in 1 case, with an excellent and good rate of 92.3%., Conclusion: Free popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein for the repair of wound on the foot and ankle is simple and effective. The donor site is hidden.

The anterolateral thigh flap has been used for coverage of defects in the foot and ankle for years. Conventional extended anterolateral thigh flaps do not undergo thinning procedures, which limit their application. Here, a clinical series of 24 patients is reported in which extended anterolateral thigh flaps were used for posttraumatic foot and ankle reconstruction. Of the 24 flaps, 14 were simple extended anterolateral thigh fasciocutaneous flaps and 10 were thinned extended anterolateral thigh flaps. One artery and two veins, including a superficial vein and an accompanying vein, were anastomosed to vascularize each flap. Follow-up of the 24 patients ranged from 10 months to 4 years postoperatively. All 24 flaps survived successfully, except one case that had partial flap necrosis distally due to excessive thinning. The cutaneous flap territory ranged from 250 cm(2) to 400 cm(2) (mean, 297 cm(2)). Only one patient received a debulking procedure. No ulceration occurred in any of the flaps due to contact with the shoe. The extended anterolateral thigh flap is a good alternative for extensive soft tissue defects of the foot and ankle. This study also supports the high reliability and excellent vascular supply of moderate thinned extended ALT flaps.

There were presented the anatomical substantiation, surgical technique of the flap mobilization, the methods for the flaps survival capacity enhancing, as well as the first experience of plasty, using fasciocutaneous flaps of the ankle on a distal nutrating pedicle with a double axial blood supply. The flaps were successfully used for the treatment of durably nonhealing wounds of the foot and the ankle in 23 patients.

Coverage of the weightbearing heel poses a unique technical challenge to the reconstructive surgeon. In the present study, we share our clinical experience with the use of the medial plantar artery-based flap for coverage of tissue defects around the heel. Eighteen medial plantar artery flaps performed from January 1996 to December 2009 were included. All the procedures were performed by 2 surgeons at Aga Khan University and Hospital (Karachi, Pakistan) and Bahawal Victoria Hospital (Bahawalpur, Pakistan). Of the 18 patients, 16 were male and 2 were female. The indications were traumatic loss of the heel pad in 13, pressure sores in 2, and unstable plantar scars in 3. All the flaps were raised as sensate fasciocutaneous pedicled flaps based on the medial plantar artery. All the flaps healed uneventfully without major complications. The donor site was covered with a split-thickness skin graft, and we had partial graft loss in 1 case. The sensate flaps had slightly inferior protective sensation compared with the normal side. From our results, we suggest that the medial plantar artery flap is a good addition to the existing armamentarium. It provides tissue to the plantar skin with a similar texture and an intact protective sensation. The technique is easier to master compared with free microvascular flaps and has less risk of any functional donor site morbidity., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Through-and-through facial defects can be the result of malignancy, malformations, or trauma and pose a challenge for reconstructive surgeons. An ideal reconstruction of such defects should restore both lining and external skin defects at the same time. In this report, we describe the use of combined anterior tibial flap and dorsalis pedis flap to reconstruct complex facial defects. Six patients who presented with through-and-through facial defects were included. The cause of defects were trauma, radiotherapy, or flap necrosis, and defect locations were the buccal (3 patients), oral region (2 patients), and frontal (1 patient). The outer defects were between 5 × 6 cm and 13 × 9 cm, whereas the inner defects were between 3 × 3 cm and 5 × 6 cm. The anterior tibial flaps that were used to cover the outer defects ranged from 5 × 8 cm to 10 × 15 cm, and the dorsalis pedis flaps that were used to reconstruct the lining ranged from 3 × 4 cm to 6 × 8 cm. Donor sites were covered with skin grafts. No flap failure was evident, and a good aesthetic outcome was obtained in all cases. In 1 patient, the skin graft on the dorsal pedis presented partial necrosis and ultimately healed by dressing change. Compared with other techniques, the combined anterior tibial flap and dorsalis pedis flap possesses the potential benefits of being thin and pliable and having reliable vascularity. It brings a new alternative method for complex facial defect reconstruction.

The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Retinoblastoma is a common malignant intraocular tumor in childhood, and most patients require enucleation or exenteration even with irradiation. Severe anophthalmic orbits and atresic eye sockets are not rare. We conducted a retrospective study to evaluate the results of surgical management of reconstruction of severe anophthalmic orbits and atresic eye sockets with vascular anastomosed free dorsalis pedis flap transplantation. There were 5 patients (5 eyes) who underwent reconstructive surgery of severe anophthalmic orbits and atresic eye sockets after enucleation and irradiation of retinoblastoma in our hospital during the 3 years. All patients had enucleation and irradiation immediately after the retinoblastoma was diagnosed and had never worn artificial eyes because of the atresic eye sockets. Vascular anastomosed free dorsalis pedis flaps, whose dimensions were typically 6.5 × 5.5 cm(2), were transplanted to reconstruct the severe anophthalmic orbits and atresic eye sockets. The donor sites were covered by free abdominal skin flaps. All the vascular anastomosed free dorsalis pedis flaps were valid after more than 6 months of follow-up. And then all the 5 patients underwent secondary autogenous dermal fat implantation to augment the supraorbital area depression. After the 2-stage reconstruction surgery, the dimensions of the eye sockets were adequate, and all patients were able to wear their prosthesis and had a satisfactory cosmetic result. Implantation of alloplastic materials is not recommended because of insufficient blood supply of the irradiated orbital area.

Even a small defect in the lower leg and foot with exposure of bones or tendons can result in an intractable wound, which may require a microsurgical tissue transfer. With the concept of the perforator flap, a pedicled peroneal artery perforator flap can be used for coverage of this difficult region. Between August 2001 and August 2008, 18 pedicled peroneal artery perforator flaps were performed in 18 patients. The fasciocutaneous flaps were employed to cover defects in the pretibial area (n=6), Achilles' tendon and/or hindfoot (n=7) and lateral malleolar area (n=5). The pedicled peroneal artery perforator flaps are classified into five types: propeller flap (n=11), peninsular flap (n=4), advancement flap (n=2), proximally based island flap (n=1) and distally based island flap (n=0). The size of the flaps ranged from 7.5×3 cm(2) to 20×8 cm(2). The selected perforator depended on the defect location, ranging from 4.5 to 18 cm above the tip of the lateral malleolus. Postoperative venous congestion was encountered in four propeller flaps and one proximally based island flap. Venous congestion subsided within days without complications, except one which needed further reconstruction with skin grafts. In conclusion, the peroneal artery perforators are predictable and reliable for the design of a perforated-based flap. Elevation of the flap can be performed easily in the supine or prone position, depending on the defect location. Different designs of this perforator-based flap can repair a variety of leg and foot defects., (Copyright © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Aim of the Study: The treatment of chronic osteomyelitis with large skin defects at the foot or the ankle is uneasy. In such cases, free muscular flaps are currently advised but they are less reliable in patients with medical diseases. In such difficult cases we have used the distally based soleus island flap, vascularized with retrograde flow on the posterior tibial artery. The technique and the indications of this flap are discussed., Patients and Method: This flap has been used for seven patients with bone infection and skin defects measuring an average of 10 x 7 cm. The preoperative arteriography had to find the whole three arteries at the leg, with a good distal anastomotic arcade. The soleus muscle was raised with the posterior tibial artery, after it was ligated proximally and dissected up to the tarsal tunnel., Results: All of the seven flaps totally survived, except one that a marginal necrosis treated by excision and iterative dissection of the pedicle for a more distal repositioning. No clinical vascular deficiency was found on the legs. At the last review, all the osteomyelitis were cured., Discussion: The soleus island flap, distally vascularized on the posterior tibial artery, is a reliable flap, useful for the coverage of the distal leg, from the ankle to the very distal foot. Harvesting a major artery at the leg should be weighed against the failure of a free flap in high risk patients.

Reconstruction of defects or wounds of the distal third of the leg with exposed bone, tendon, or hardware is challenging. Free tissue transfer has allowed limb salvage in many cases but requires a relatively healthy and stable patient, long operative times, and a significant expense. Small and moderate-size wounds of the distal leg may be better served by the use of local and regional flaps. Due to a better understanding of leg vascular anatomy and angiosomes, as well as more sophisticated and varied flap designs, local and regional flaps have been described and successfully used in distal leg wounds. The goal is choosing the most appropriate flap given the patient's anatomy and wound characteristics. The following review will detail the available local and regional flaps for reconstruction of the distal third of the leg with an emphasis on decision making, anatomy, flap design, and technique.

Objectives: To evaluate the results and complications of combined simultaneous arterial re-vascularisation and free flap transfer in patients with critical limb ischaemia and large soft-tissue defects that would otherwise have required major amputation., Design: Retrospective analysis of all combined procedures performed between 1993 and 2007 with regard to complications and outcome., Materials and Methods: Seventy-eight procedures were performed in 76 patients with a mean age of 60 years (range: 18-80 years). The majority had diabetes (70.5%). Follow-up was obtained from hospital charts and telephone contacts with patients or GPs., Results: The limb-salvage rate was 93% after 1 year, 80% after 3 years and 71% after 5 years. Perioperative complications occurred in 50% of the patients; six out of 78 (7.7%) arterial reconstructions and 13 out of 78 (16.7%) flaps had to be revised during the early postoperative period. However, most flaps could be saved by a secondary procedure resulting in an early failure (amputation) rate of 6%. In-hospital mortality was 3.8%. End-stage renal disease was the only factor predicting limb loss. In total, 65% of the patients survived and were able to walk on their reconstructed limb at 1-year follow-up. Combined survival and limb-salvage rates were 85%, 66% and 51% after 1, 3 and 5 years., Conclusions: Combined arterial re-vascularisation and free flap transfer can be performed safely with acceptable morbidity and mortality and should be considered for every mobile patient with large soft-tissue deficit (>10cm(2)) without end-stage renal disease prior to major amputation.

Objective: To study the clinical application of the neurovascular island flap of the calf supported by perforating branches of peroneal artery for the soft tissue defects of ankle and the foot., Methods: The flaps were used in 27 cases to repair the soft tissue defects of ankle and the lower leg from February 2004 to December 2007. Among them, 21 cases were male and 6 cases were female, ranging in age from 7 months to 64 years, with an average of 31.5 years. There were 7 cases with external malleolus, 5 cases with medial malleolus, 8 cases with dorsum of foot, 7 cases with achilles tendon. The range of soft tissue defects was from 2.5 cm x 3.5 cm to 10 cm x 24 cm and the range of flap was from 3 cm x 4 cm to 12 cm x 26.5 cm., Results: Seven cases were lightly swelling and distension after operation from 3 to 7 days. After 7 days, the swelling subsidised gradually and all flaps survived. In the follow-up for 3-12 months with an average of 5 months, all flaps showed fine appearance without fat and clumsy. The function of donor site was very well., Conclusion: The neurovascular island flap of the calf supported by perforating branches of peroneal artery can provide reliable blood supply, long reversed distance and wide repairing limitation and the proximal end of flap can reach to popliteal fossa. It is a good method to repair the defects of the lower leg and the foot.

Objective: To explore an anatomical basis and incising scope for the medial plantar artery combined flaps and its feasibility of repairing heel and adjacent vast soft tissue defects., Methods: The origin, branches, course and distribution of the medial plantar artery were studied in 20 legs of adult cadavers. The largest area of healthy adult's medial plantar and medialis pedis scope that could be incised for the combined flap was measured. Ten cases of heel and adjacent vast soft tissue defects were repaired by the combined medial plantar and medialis pedis flaps. Age range 28-60 years old. The areas of flaps were 9 cm x 7 cm - 10 cm x 8 cm. Defects of tendo calcaneus were repaired by the tendon of abductor muscle and plantar fascia in 3 cases with skin grafts on the donor sites., Results: The medial plantar artery gave off deep branch (diameter: 1.5 mm +/- 0.3 mm) and superficial branch (diameter: 1.0 mm +/- 0.2 mm). The length of media plantar artery deep branch was (8.9 +/- 0.2) cm and gave off 3-5 cutaneous branches. The largest area of combined flap was about 10.4 cm x 9.2 cm - 9.1 cm x 8.2 cm. Ten flaps survived completely. Eight flaps were followed up for 1 month to 1.5 years. The color, texture and appearance of flaps were excellent. The flaps of two-point discrimination were not different with opposite medial region. The affected limb exercised freely and had no ulceration on the flap., Conclusions: The combined flap has a reliable blood supply and it can recover good sensation after operation. It is one of ideal flaps to repair heel and adjacent vast soft tissue defects. Its disadvantage is a complicated operation.

The objective of this study was to find out whether a compensatory increase in blood flow to the foot is observed after sacrifice of one of the tibial arteries. Eleven patients who had one of the tibial arteries as the recipient artery of free tissue transfer to their lower extremities were included. The arterial diameter, cross-sectional area, maximum flow velocity, minimum flow velocity, and flow rate were measured by a Doppler ultrasound in the nonrecipient tibial artery and perforating peroneal artery in the operated limb. The same parameters were measured in the anterior and posterior tibial arteries and the perforating peroneal artery in the contralateral limb. The arterial diameter, cross-sectional area, flow velocity, and flow rate were increased significantly in the nonrecipient tibial artery of the operated limb with respect to the same artery on the contralateral limb. The same changes were not demonstrated in the perforating branch of the peroneal artery. Total blood flow to the foot in the operated extremity was not different from that of the nonoperated foot. The results reveal that if a major feeder to the foot is sacrificed, the other tibial artery compensates for it, and resting blood supply to the foot is not altered.

Objective: To investigate the operative method and effect of the reversed sural neurocutaneous flap in repairing soft tissue defects of the anterior foot and the ankle., Methods: From March 1999 to November 2004, 19 cases (17 male, 2 female) of soft tissue defects of the anterior foot and the ankle were repaired with the reversed sural neurocutaneous flaps. The flap sizes range from 18 cm x 9 cm to 30 cm x 18 cm., Results: All flaps survived well, while 1 flap had distal partial necrosis and healed after dressing change. The follow-up from 6 months to 2 years showed that all flaps were satisfactory., Conclusion: Sural neurocutaneous flap is easy to get and to survive. It is an effective method to repair the soft tissue defects of the anterior foot and the ankle.

Background: The medial plantar venous flap is suitable for reconstruction of the palmar surface of the finger. However, it is sometimes difficult to detect and harvest the distal subcutaneous vein of the flap. In such a situation, the communicating vein can be used as a distal vein for the flap. However, the location of these veins is not obvious., Methods: By using 20 feet from 10 cadavers and ultrasound imaging for 40 feet from 20 healthy individuals, we investigated the location of communicating veins., Results: In cadavers, 11 communicating veins (45.8%, n = 24) were located in the area above the abductor hallucis muscle and 12 veins (50%) in the area below it. Ultrasound imaging revealed 15 bifurcations of the communicating veins (31.3%, n = 48) in the upper area and 27 bifurcations in the lower area of the medial plantar region (56.3%)., Conclusion: It was observed that the communicating veins were concentrated in the areas above and below the abductor hallucis muscle.

Objective: To investigate the anatomy of the medial pedis composite flaps with saphenous nerve and tendon and its application in the repair of tendo calcaneus and adjacent defects., Methods: 10 cadavers (20 sides) were observed. The origin, course, size and the distribution of the medial plantar artery were studied. 12 cases with tendo calcaneus and adjacent defects were reconstructed with the medial pedis composite flaps with saphenous nerve. Donor site defects were covered with free skin graft., Results: The medial plantar artery gives off deep branch [diameter (1.5 +/- 0.3) mm] and superficial branch [diameter (1.0 +/- 0.2) mm]. In 18 sides, the deep branches give off the medial branches and lateral branches. While in 2 sides, the superficial branches give off the medial branches and lateral branches with no big branches from the deep branches. There are branches of saphenous nerve and medial dorsal cutaneous nerve in the flap. All the flaps were survived. 8 cases were followed up for one months to one years. Good color, texture and function of the flaps were achieved., Conclusions: The medial pedis composite flaps with saphenous nerve can repair tendo calcaneus and adjacent defects. It is a easy and safe procedure with reliable anatomy and good results.

Objectives: Major tissue loss caused by the critical limb ischemia requires improvement of distal perfusion and cover of large tissue defects. We propose a new method, the y-shaped subscapular artery flow-through (Y-SCAFT) muscle flap using the subscapular artery that yields an arterial graft and a free muscle flap sustained by a collateral branch of this artery. This prospective study evaluated the feasibility of this technique and analyzed wound healing, graft patency, and limb salvage., Methods: Between 2002 and 2007, 20 patients, mean age 64 years (range, 55-79 years), were treated with this technique. All presented with critical ischemia and major tissue loss, with exposure of the tendons, bones, or joint, and were candidates for major amputation. Revascularization and cover of tissue loss with the same Y-SCAFT anatomic unit was used for all patients. The distal anastomosis was performed between the distal branch of the Y-SCAFT and the pedal artery in 9, posterior tibial artery in 4, peroneal artery in 1, lateral tarsal artery in 3, and the plantar artery in 3. In four patients, the distal part of the arterial graft, including the anastomosis, was covered with the muscle flap because the tissue loss was nearby. The proximal anastomosis was performed between a leg artery and the arterial graft in 10 patients. A venous graft was necessary in 10 patients to extend the bypass proximally., Results: One patient died during the postoperative period. Duplex control evidenced patency all the Y-SCAFT muscle flaps. Healing was achieved in all patients. Mean follow-up was 31 months (range, 6-58 months). No patients died during follow-up. One patient presented occlusion of the Y-SCAFT muscle flap and underwent amputated. One patient had major amputation despite a patent graft. At 2 years, leg salvage was 85%, patency was 94%, and survival was 94%. At the end of the follow-up, 17 patients (1 death, 2 amputations) had a patent graft, a viable muscle flap, wound healing, and a functional leg., Conclusion: We showed the clinical feasibility of the technique of Y-SCAFT muscle flap, which allows for revascularization and cover of major tissue loss with one anatomic unit. This method is particularly useful in selected cases with poor run-off and large ischemic lesions.

Background: The medial plantar venous flap is ideally suited for reconstruction of injuries to the palmar surface of the finger. However, when the distal veins of such flaps are narrow, harvesting is no longer simple and anastomosis to the digital artery presents a challenge., Methods: Using ultrasound imaging, we investigated the presence or absence of communicating veins in the medial plantar region in 40 feet of 20 healthy individuals. In addition, we performed preoperative ultrasound imaging in 8 patients., Results: The investigation in healthy individuals revealed a mean number of 1.2 communicating veins in the medial plantar region. Communicating veins were confirmed preoperatively in 6 of our 8 patients., Conclusion: Preoperative ultrasound imaging to investigate the course and diameter of subcutaneous veins and communicating veins in the medial plantar region allows the flap design to be determined appropriately and for the surgery to proceed more simply.

The distally based neurocutaneous flaps have been popular for lower leg and foot reconstruction. On the basis of pre-existing anatomic studies and clinical experiences, we designed a reversed superficial peroneal neurocutaneous island flap with the descending branch of the distal peroneal perforator as the pedicle. The flap is supplied through both axial perforator and longitudinal chain-linked vascular plexuses. This modified neurocutaneous island flap, measuring around 5 cm x 4 cm to 12 cm x 13 cm in size, was transferred for coverage of foot soft-tissue defects in 21 cases with a low complication rate. Compared to the original neurocutaneous flap, the rotation point of this flap is more distal and the pedicle is thinner. It could provide good texture and contour matching to the recipient area. In conclusion, the modified neurocutaneous island flap provides a reliable tool for repairing soft-tissue defects of the ankle and foot.

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.

Arteriovenous malformation of the foot is very uncommon, and surgical closure after its treatment with embolization and total excision may be challenging for the foot surgeon, particularly in distally localized lesions. A popular method to cover these difficult wounds is free-tissue transfer, which is a highly demanding procedure. Alternatively, distally based regional flaps have been occasionally reported for clinical use in such distant foot defects. Herein, we present a 36-year-old female patient with a diagnosis of arteriovenous malformation arising in the distal medial plantar and dorsal surfaces of the right foot. After surgical resection of the vascular lesion preceded by a misapplied embolization procedure, an extended lateral supramalleolar flap was successfully transferred to the defect area, covering it completely. Functional and aesthetic outcome was satisfactory after 6 months follow-up. Extended lateral supramalleolar flap is a useful and reliable choice for distal foot reconstructions.

Objective: To explore the better method of repairing the soft tissue defect of the distal foot., Methods: The soft tissue defect in the distal foot of six patients were repaired by the distally based dorsum pedis island flap pedicled with the bust deep artery and(or) the first dorsal metatarsal artery., Results: Six patients were repaired in one stage, the biggest defect was 8 cm x 6 cm, all patients were followed-up 1 to 4 years, the function of foot was evidently improved, the patients were all satisfied with the operative results., Conclusions: The bust deep artery and (or) the first dorsal metatarsal artery, with reliable blood supply, were easily dissected and with good texture. So far this kind of flap is a good choice in repairing the defects of the soft tissue in the distal foot.

Several investigators have reported their clinical experience with medial pedis flaps for reconstruction of soft tissue defects of the hand and digits. In a cadaveric study in 1997, Jayme and Hamilton described the anatomy of the medial branch of the deep division of the medial plantar artery, which is used in the medial pedis flap. However, they had only a few cases where this flap was used. There have been no such anatomic studies in Korea to date. We found the medial pedis flap to be a reliable option for reconstruction of soft tissue defects of the hand and digits, based on an anatomic study with 10 dissected fresh cadavers (20 cases) and analyzing the clinical outcomes in 17 patients. An anatomic study revealed that there were some racial differences in the diameter and length of the vessels. The diameter of vessels in the Korean population is larger than that in whites. Using a thin, flexible medial pedis flap, which has skin and subcutaneous tissue similar to that of the volar aspect of the hand and digits, we harvested and performed the reconstruction on 17 patients with soft tissue defects of the hands and digits. The vessels used for this flap were the medial branch of the deep division of the medial plantar artery and vena comitantes, or subcutaneous veins. The mean size of the flap was 2.82 cm x 4.15 cm. All flaps were successful without any significant complications. The medial pedis flap possesses several advantages: (1) it is very thin in comparison to other standard free flaps; (2) it has 2 draining venous pathways; (3) it provides a good color and texture match for the hand and fingers; (4) it has a satisfactory recovery of protective sensation.