Anatomical Basis And Clinical Application Of The First Metatarsal Proximal Perforator-based Neurocutaneous Vascular Flap

Objective:(1)To explore the anatomical characteristics of mediate dorsal pedal cutaneous nerve and its nutritional vessels to provide anatomical basis of the perforator pedicle flap based on the medial dorsal pedal neurocutaneous vessels for repairing the forefoot soft-tissue defects.(2)To investigate the therapeutic effects of the perforator pedicled flap based on the medial dorsal pedal neurocutaneous vessels for repairing the forefoot soft-tissue defects so as to provide the evidence for clinical application.Method:(1)Microscopic anatomy: The following contents were investigated in 30 adult feet specimens perfused with red latex:(1)The course,branches and distribution of the medial dorsal pedal cutaneous nerve.(2)The origin,course,branches and distribution of the nutrient vessels of the medial dorsal pedal neurocutaneous vessels.Mimic operation was performed on another fresh specimen.Macro-micro-anatomy and mimic surgery images were taken by a digital camera.The data were collected and analyzed.(2)Clinical application: From 2017 to 2018,the perforator-based medial dorsal pedal neurocutaneous vascular flaps were designed on the lateral dorsum of the foot for restoring 6 cases of forefoot soft tissue defects.The flap size ranged from 6.0cm×4.9cm to 3.0cm×2.1cm.The clinical data and images were collected,and the patients were followed up and assessed regularly after the operation.Result:(1)Microscopic anatomy:(1)The mediate dorsal pedal cutaneous nerve mainly arose from the medial branch of the superficial peroneal nerve and proceeded forward for a distance of(2.5±0.4)cm over the surface of the inferior extensor retinaculum,and then divided into the mediate dorsal branch,the 1st and 2nd dorsal metatarsal branch which distributed in part of the dorsal pedal and digital skin.(2)The medial dorsal pedal neurocutaneous vessels were multiple segmental and polyphyletic,which mainly included the dorsalis pedis artery proximal perforator,the first metatarsal proximal perforator,the tibial proper plantar digital artery of the great toe,and the perforater of the second toe web artery.The first metatarsal proximal perforator had a closest relationship with the surgical method,which puncturing through the deep fascia constantly at the point 1~2 cm proximal to the first plantar gap,and the anatomical plane is higher than that of both the perforator of the toe web artery and the tibial proper plantar digital artery of the great toe.The first metatarsal proximal perforator sent out lots of branches,which closely anastomosed with adjacent perforators and other medial dorsal pedal neurocutaneous vessels.(3)Mimic surgery showed that the first metatarsal proximal perforator pedicled flap could meet the forefoot soft-tissue defect repair well.(2)Clinical application: All flaps survived completely and the wounds healed at the first stage.After a follow-up of 3 to 12 months,the flaps turned out excellent in texture,coherent in color and fine in appearance,and the patients were satisfied with both the functions and the appearances.Conclusion:(1)The first metatarsal proximal perforator was constant in puncturing point and high in anatomical plane to ensure a reliable blood supply,so that the first metatarsal proximal perforator-based medial dorsal pedal neurocutaneous vascular flap could be transferred to repair the soft-tissue defects of forefoot.(2)The first metatarsal proximal perforator-based neurocutaneous vascular flap has an abundant blood supply,and the surgical procedure is simple and safe,therefore,this flap provides a new choice for the reconstruction of forefoot soft-tissue defects.