**Region:** Lower Extremity # Dorsalis Pedis Flap ## Anatomy - Pedicle: dorsalis pedis artery (continuation of the anterior tibial artery; gives branches to the arcuate and terminates at the 1st dorsal metatarsal artery). Venae comitantes of the dorsalis pedis and/or the greater saphenous vein provide venous outflow. The pedicle can be mobilized proximally to the anterior tibial artery for additional length. - Course: dorsalis pedis runs on the dorsum of the foot between the tendons of extensor digitorum longus (EDL, lateral) and extensor hallucis longus (EHL, medial), deep to the extensor hallucis brevis (EHBr). The artery is palpable/Dopplable from the first web space to the distal edge of the extensor retinaculum. - Perforator / venous pattern: surface flap supplied directly by dorsalis pedis and its distal branches (including the 1st dorsal metatarsal); superficial venous drainage (medial superficial vein → greater saphenous) should be identified and preserved when possible. - Nerves: skin over the dorsum is supplied chiefly by the superficial peroneal (fibular) nerve; the deep peroneal nerve lies lateral to the dorsalis pedis artery and may be left in situ or included in the flap when a sensate component is desired. - Included tissues: skin, subcutaneous tissue and deep fascia; flap may be harvested with extensor hallucis brevis muscle, extensor tendons, second metatarsal bone, or metatarsophalangeal joint to create composite osteocutaneous or tendocutaneous flaps. A purely fascial dorsalis pedis flap is also possible. - Size/thickness/arc of rotation: in an adult the dorsalis pedis pedicle or free flap area can be approximately 9 × 12 cm (mark artery from first web to retinaculum as guide). Can be used as a proximally based pedicled flap for lateral/medial malleoli, distal leg and ankle or as a free flap for dorsal hand, palate, head and neck defects. - Common variants/anomalies: dorsalis pedis artery arises from the anterior tibial artery in most patients but may originate from the peroneal artery in a substantive minority (~40% reported). Verify dual blood supply preoperatively if planning to ligate or mobilize inflow. ## Dissection Steps 1. Positioning, markings, landmarks. - Position: supine with foot accessible. Place a tourniquet proximal to the ankle (tourniquet above ankle). - Mark defect and design flap 10–20% larger than the defect to allow for contraction and inset. - Palpate/Doppler the dorsalis pedis artery from the first web space to the distal edge of the extensor retinaculum; mark the vessel course and surface borders of the planned flap (preoperative angiogram recommended when vascular anatomy or perfusion is uncertain). 2. Plane (suprafascial/subfascial), perforator identification (handheld/IO Doppler). - Incise skin and deep fascia—raise the flap in a subfascial plane, preserving paratenon over extensor tendons. - Identify and include the superficial venous draining system on the medial border. - Locate and ligate the first dorsal metatarsal artery distally early if harvesting a free flap (step used to mobilize the flap proximally). 3. Pedicle dissection: exposure, control, division; transfer/inset; perfusion checks. - Elevation sequence: elevate flap distally → proximally, keeping paratenon intact on the tendons and preserving the vascular pedicle. - Anatomic relationships during dissection: - Medial border: overlies EHL and medial dorsal vein. - Lateral border: lies lateral to EDL. - Artery: between EDL (lateral) and EHL (medial), deep to EHBr. - Include EHBr if desired by dividing EHBr tendon where it inserts laterally into EHL; inclusion provides a small muscle cuff. - Suture fascial layer to skin at the borders to prevent shear and protect the vascular supply. - To increase pedicle length cut the extensor retinaculum and continue proximal dissection toward the ankle/ anterior tibial origin as required. - When used as a free flap: once adequate pedicle length is reached, temporarily occlude the anterior tibial inflow with an Ackland clamp to confirm foot perfusion prior to definitive ligation of the anterior tibial origin; only ligate if foot perfusion is adequate. - Verify flap perfusion intraoperatively (visual, bleeding edges, Doppler of pedicle). - Transfer/inset: rotate/transpose flap to recipient site as planned (pedicled rotation or free microvascular inset). 4. Donor-site closure techniques. - Primary closure is rarely possible for moderate to large flaps; donor site classically at risk for breakdown if closed under tension. - Recommended staged reconstruction: apply a dermal substitute (examples used clinically: Integra, MatriDerm, Alloderm) as a first stage to reconstruct donor bed, followed by a thin split-thickness skin graft (STSG) once neodermis has integrated. This staged approach reduces risk of graft failure and wound breakdown. - Keep donor site elevated for approximately 2 weeks postoperatively to reduce edema and encourage graft take. ## Indications and Contraindications - Indications: - Thin, pliable coverage required for dorsal hand reconstruction, dorsal digits, or intraoral/palatal resurfacing. - Reconstruction of lower leg/ankle and malleolar soft-tissue defects when used as a proximally based pedicle flap. - Composite reconstruction when tendon, joint or bone is required (can include extensor tendons or second metatarsal for osteocutaneous transfer). - When a thin gliding surface is needed (e.g., tendon coverage on the hand). - Ideal when recipient vessels and foot perfusion permit harvest with ligation/mobilization of the anterior tibial origin. - Typical adult flap planning region: surface area in the dorsum approximating 9 × 12 cm (use Doppler/angiogram to confirm safe limits). - Contraindications (relative/absolute): - Absent dorsalis pedis pulse / inadequate collateral perfusion to the foot; harvest that requires ligation of major inflow (anterior tibial) without robust collateral circulation is contraindicated. - Peripheral arterial disease involving anterior tibial / dorsalis pedis or single-vessel foot—obtain angiogram if concern exists. - Local infection or gross soft-tissue compromise of the dorsum that would jeopardize the donor bed or pedicle. - Patient circumstances where donor-site morbidity (risk of breakdown over weight-bearing foot) is unacceptable. ## Postoperative Care - Monitoring schedule/method: - Immediate clinical monitoring of flap color, turgor, capillary refill and bleeding from margins. - Handheld Doppler assessment of the pedicle post-inset is appropriate for early detection of arterial/venous problems (documented intraop use for localization and verification). - When harvested as a free flap, standard microvascular flap monitoring protocols apply (hourly checks in first 24 hours, then spacing according to institutional policy). Use clinical exam ± Doppler. - Perfusion checks intraop: - Temporary Ackland clamp occlusion of anterior tibial inflow before permanent ligation; confirm adequate pedal perfusion prior to division (prevents foot ischemia). - Positioning/warming/immobilization: - Keep donor foot elevated for approximately 2 weeks to reduce edema and protect grafts. - Splinting as required to protect the flap and recipient site; avoid pressure over pedicle or donor graft. - Drains, mobilization, diet/analgesia: - Place small drains in donor site if large dead space (surgeon preference); analgesia and skin graft care per standard protocols. - Early mobilization of the rest of the patient is allowed, but protected weight-bearing or non–weight-bearing on donor foot until graft integration is advised. - Antithrombotic practice: - No specific prophylaxis protocol is specified in the source text for this flap; follow institutional venous thromboembolism prophylaxis and microvascular thrombosis prevention (if free flap) protocols. - Return-to-OR thresholds and time windows: - Any signs of acute vascular compromise (rapidly deteriorating color, no Doppler signal, progressive flap congestion) mandate immediate return to OR for exploration. In microvascular transfers, re-exploration within the first several hours offers the best chance of salvage. ## Complications (rates & management) - Reported frequencies: the dorsalis pedis chapter does not provide explicit numeric complication rates. - Typical complications and management (from source practice points): - Donor-site breakdown / graft loss: the dorsum donor site is at higher risk of wound breakdown; management is staged reconstruction with dermal substitute followed by thin STSG. If breakdown occurs, debridement and repeat grafting or local flap coverage are required. - Foot ischemia after pedicle division/ligature: risk if collateral circulation inadequate. Prevention: preoperative angiogram when anatomy or perfusion is in question; intraoperative temporary occlusion (Ackland clamp) to confirm perfusion before permanent ligation. If ischemia occurs, urgent revascularization or vascular bypass is required. - Tendon/paratenon injury → tendon exposure: preserve paratenon during dissection; if exposure occurs postoperatively, consider local flap coverage or tendon repair. - Neuroma or sensory disturbance: inclusion or transection of superficial/deep peroneal nerves can cause sensory changes or neuroma formation; avoid unnecessary nerve sacrifice; if neuroma develops, excision and targeted nerve repair/neurectomy management may be required. - Partial flap loss or skin graft failure at donor site: treated with debridement and repeat grafting or staged reconstruction. - Management algorithms: - Suspected arterial insufficiency of flap: immediate return to OR for exploration of pedicle (look for kinks, thrombosis); for free flap, perform thrombectomy/flush, revise anastomosis; consider thrombolysis per institutional microvascular protocol. - Venous congestion: if congestion noted early, return to OR for exploration and relieve compressive causes, revise venous anastomosis (free flap) or widen pedicle skin bridge (pedicled flap); temporary leech therapy is a salvage adjunct in selected cases but not specified for this flap in source text. - Donor-site graft failure: local wound care, negative-pressure wound therapy if appropriate, then staged revision with dermal substitute and STSG. ## Key Clinical Pearls - Preoperative mapping: palpate/Doppler the dorsalis pedis artery from the first web to the extensor retinaculum; obtain angiogram when inflow anatomy or single-vessel foot is a concern. - Flap sizing: design the skin paddle 10–20% larger than the defect to allow for contraction and inset. - Tourniquet and exposure: place tourniquet above the ankle; begin dissection distally and proceed proximally to protect paratenon and visualize pedicle. - Tendon/paratenon preservation: keep paratenon intact over extensor tendons to preserve tendon nutrition and decrease tendon exposure risk. - Include EHBr for a muscle cuff if needed; divide EHBr tendon where it inserts laterally into EHL to incorporate the muscle. - Pedicle length: cut the extensor retinaculum and continue dissection proximally toward the anterior tibial origin to gain pedicle length; when planning to ligate anterior tibial inflow, temporarily occlude it (Ackland clamp) and confirm distal foot perfusion before division. - Donor-site strategy: reconstruct donor site in two stages (dermal substitute → thin STSG) to minimize risk of breakdown; keep donor site elevated for approximately 2 weeks. - Anticipate variants: ~40% of patients may have dorsalis pedis originating from the peroneal artery—confirm blood supply preop to avoid unexpected ischemic complications.