British Journal of Plastic Surgery (1996), 49, 170-173 0 1996 The British Association of Plastic Surgeons

The dorsal metatarsal V-Y advancement flap for dorsal foot reconstruction

K. Onishi and Y. Maruyama

Department of Plastic and Reconstructive Surgery, Toho University Hospital, Tokyo, Japan

SUMMAR Y. Two cases of dorsal foot reconstruction using dorsal metatarsal V-Y advancement flaps based on dorsal metatarsal vessels are presented. The flap is useful for the repair of small to moderate sized dorsal foot defects.

The advent of the proximally based dorsal metatarsal flap and later the distally based dorsal metatarsal flap supplied by plantar vessels led to a new approach to distal foot reconstruction. An important factor to consider in repair of a soft tissue defect with a flap is the flap donor site. The V-Y advancement flap has the advantages of excellent colour and texture match- ing and primary donor site closure. We have used the metatarsal flap with V-Y advancement to repair

dorsal foot defects and obtained satisfactory results in two cases.

Case reports

Case 1

A 64-year-old man was referred to our hospital with Bowen’s disease on the lateral part of the dorsum of his

Fig. 1

Figure l-(A) Design of the dorsal metatarsal V-Y advancement flap based on the 3rd and 4th dorsal metatarsal vessels. (B) The flap elevated. (C) The flap transferred to the defect, and the donor site closed with V-Y advancement. (D) One year and 10 months after the operation, satisfactory result of reconstruction and no signs of tumour recurrence.

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Dorsal metatarsal V-Y advancement flaps 171

left foot. The tumour was excised with a 1 cm margin. It was planned to repair the resulting defect using a proximally based dorsal metatarsal V-Y advancement flap based on the 3rd and 4th dorsal metatarsal vessels (Fig. 1A). The blood supply from the arcuate artery and from the 3rd and 4th deep plantar branches was preserved when elevating the flap. The flap was rotated as well as advanced to facilitate movement of the flap into the defect. The flap was elevated and transferred to cover the defect, and the donor site was closed primarily in a V-Y fashion (Fig. lB,

C). The flap survived completely without any partial necrosis. One year and 10 months after the operation, there were no signs of recurrence and the result of the flap reconstruction is satisfactory (Fig. 1D).

Case 2

A 41-year-old man had a soft tissue defect on the lateral part of the dorsum of his left foot due to a traffic accident (Fig. 2A). A transversely designed dorsal metatarsal V-Y

Fig. 2

Figure 2-(A) Skin defect of the dorsum of the distal foot. (B) Design of the flap. (C) The distally based dorsal metatarsal flap based on the first dorsal metatarsal vessels transferred to the defect with V-Y advancement. (D) Postoperative view 3 months after the operation.

172 British Journal of Plastic Surgery

metatarsal region :

proximally or distally based flap

proximal defect :

proximally based flap

Fig. 3

distal defect :

distally based flap

Figure 3-Flap designs for defects at different sites.

advancement flap, distally based on the first dorsal meta- tarsal vessels, was elevated and transferred to the defect, and the donor site was closed primarily in a V-Y fashion (Fig. 2B, C). The flap survived completely and he had an uneventful postoperative course (Fig. 2D).

Discussion

Repair of the leg and foot is challenging for plastic surgeons. Especially when the defects are located more distally, the donor sites for flaps become more limited. Reverse flow flaps taken from the lower leg and free flaps are not suitable, and it is often difficult to select ideal reconstructive procedures.

In 1989, Earley and Milner’ described a distally based first web flap, supplied by branches of the dorsal and plantar metatarsal arteries and their distal communicating branches, for resurfacing defects on the dorsum of the foot. In 1992, Yoshitake et al.’ reported on the dorsal metatarsal flap. Hayashi and Maruyama,3 and Sakai4 reported on the repair of the distal foot and toe by the reverse dorsal metatarsal flap, stressing its usefulness. The first dorsal meta- tarsal artery is connected with the dorsalis pedis artery and therefore the reverse first dorsal metatarsal flap can be extended and elevated to the centre of the dorsal foot by including the dorsalis pedis artery. By elevation of this extended reverse first dorsal metatarsal flap, the arc of rotation can reach from the distal one-half of the dorsum to the distal one- third of the sole.3 However, with these extended flaps the dorsalis pedis artery, an important artery for the foot, must be divided proximally.

In contrast, dorsal metatarsal flaps can be elevated based not only on the first but also the 2nd to 4th dorsal metatarsal vessels. The dorsal metatarsal vessels have branches communicating with the plantar and digital vascular system. This means variations of the dorsal metatarsal flap are possible, similar to the dorsal metacarpal flaps of the hand.5m12

We repaired dorsal foot defects using dorsal meta- tarsal flaps with V-Y advancement without dividing the dorsalis pedis artery. The V-Y advancement flap has the advantage of an excellent colour and texture because of the proximity of the donor and recipient sites, and the donor site can be closed primarily without requiring a skin graft.i3 The flap can be prepared at any site on the metatarsal region and a large flap can be elevated safely by including more than one dorsal metatarsal artery. The flap can also be elevated with a proximal or distal base. Unlike the dorsum of the hand, the dorsum of the distal foot does not have much skin available for flaps. Relatively long, oblique flaps moved by rotation in addition to the V-Y advancement are preferred, in order to facilitate movement of the flap and ensure easy pri- mary closure of the donor site. In general, both proximally and distally based flaps can be used for defects in the metatarsal region. The procedure is easier when proximally based flaps are used for cases with defects at sites proximal to the centre of the metatarsal bone, and distally based flaps are used for cases with defects at sites distal to the centre of the metatarsal bone (Fig. 3). With this in mind, a proxi- mally based flap was used in Case 1. Both proximally and distally based flaps were applicable for the defect in the metatarsal region in Case 2. A distally based flap, relatively obliquely orientated, was selected for Case 2 since the dorsum of the proximal foot had more skin available for a flap. In conclusion, the advancement flap is useful for the repair of small and moderate sized dorsal foot defects.

References 1. Earley MJ, Milner RH. A distally based first web flap in the

foot. Br J Plast Surg 1989; 42: 507-l 1. 2. Yoshitake M, Maruyama Y, Hayashi A. The dorsal metatarsal

flap. Jpn J Plast Reconstr Surg 1992; 35: 261-7. 3. Hayashi A, Maruyama Y. Reverse first dorsal metatarsal

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Earley MJ, Milner RH. Dorsal metacarpal flaps. Br J Plast Surg 1987; 40: 333-41.

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12. Onishi K, Maruyama Y, Yoshitake M. Transversely designed dorsal metacarpal V-Y advancement flaps for dorsal hand reconstruction. Br J Plast Surg 1996; 49: 165-169

13. Barron JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast Surg 1965; 18: 51-78.

The Authors

Kiyoshi Onishi MD, Associate Professor Yu Maruyama MD, Professor and Chairman

Department of Plastic and Reconstructive Surgery, Toho University Hospital, 6-l l-l Omorinishi, Ota-ku, Tokyo 143, Japan.

Correspondence to Dr Onishi.

Paper received 21 September 1995. Accepted 8 November 1995, after revision.