a 50-year - old man presented to the authors institution with a chronic plantar ulceration to the right foot . the patient reported that the wound had resulted from a large hyperkeratotic lesion that had opened nearly two years previously . the wound persisted with intermittent drainage despite professional local wound care . worsening size , drainage , and pain caused the patient to seek further care in our emergency department . although his past medical history included diabetes mellitus and hypertension , he admitted to non - compliance with his medications . his social history was significant for 30 pack - years of smoking and occasional alcohol use . examination of the foot demonstrated palpable arterial pulses and brisk capillary refill to the digits ; however , there was profound loss of protective sensation via semmes - weinstein 10-g monofilament testing . the partial - thickness ulceration located at the plantar aspect of the right first metatarsal head measured 2.22.00.5 cm and had a granular base without purulence , probing to bone or cellulitis . despite mild periwound edema , the remaining skin to the foot was supple and warm to touch . range of motion to the joints and manual muscle testing of both lower extremities showed no deficits . a review of three standard radiographic views of the foot revealed only mild degenerative changes to the hallux proximal phalanx and first metatarsal head . laboratory analysis including complete blood cell count , serum chemistry , erythrocyte sedimentation rate , and c - reactive protein were within normal limits . based on the patient 's history of uncontrolled diabetes and heavy smoking , non - invasive vascular testing was performed to evaluate perfusion to the right lower extremity . results showed triphasic arterial waveforms , ankle - brachial index of 1.11 , and toe - brachial index of 0.68 , indicating no evidence of macrovascular occlusive disease . owing to the chronicity of the wound and failure of previous conservative care , the authors decided that a digital artery pedicle flap could provide adequate coverage of the plantar wound . after administration of a weight - based first - generation cephalosporin antibiotic and induction of general anesthesia , a pneumatic thigh tourniquet was secured to the right lower extremity . the procedure began with full - thickness excision of the ulceration to the subcutaneous level to remove all non - viable tissue . deep soft tissue cultures were obtained , and the wound was irrigated with copious amounts of sterile saline . a sterile doppler probe was utilized to identify the digital vascular pedicle at the lateral aspect of the hallux and this was marked with a surgical marker . the recipient wound was marked and the corresponding identical size and shape was marked at the donor site to incorporate the neurovascular pedicle . the thigh tourniquet was then inflated to 325 mmhg to enhance visualization , and the full thickness pedicle flap was raised under loupe magnification . the tourniquet was deflated and the flap was carefully secured in place using simple interrupted non - absorbable sutures . the medial arch of the ipsilateral foot was subsequently prepared for harvesting of the stsg by local subcutaneous infiltration of 1% lidocaine with epinephrine . a 0.018-inch thick by 1-inch wide stsg was harvested using an electric powered dermatome and the graft was meshed in a 1:1.5 ratio . the graft was placed at the lateral aspect of the hallux to cover the donor site of the pedicle flap and secured with skin staples under minimal tension , followed by a small bolster dressing consisting of a sterile sponge and non - adherent gauze . topical thrombin was applied to the skin graft donor site and this area was dressed with povidone - iodine soaked non - adherent gauze . the foot was then loosely dressed with gauze to allow access to the pedicle flap for close monitoring every 2 h while the patient was in the hospital ( fig . intra - operative picture of the right plantar forefoot wound ( a ) followed by a full thickness ulceration excision and a reverse flow digital artery pedicle flap for closure ( b ) . intra - operative picture showing the viability of the pedicle flap and harvesting of the stsg ( c ) for the donor site at the lateral aspect of the hallux ( d ) . clinical pictures showing the healed pedicle flap ( e ) and donor sites ( f ) at 9 weeks postoperatively . long - term clinical outcomes at 26 weeks postoperatively ( g , h ) . the patient was discharged from the hospital 2 days later with instructions for strict non - weight bearing to the right foot with crutches , and a 2-week course of culture - specific oral antibiotics . one week after surgery , the flap was intact and well perfused at the first postoperative visit in the authors outpatient clinic . at postoperative week 3 , the pedicle flap remained viable and the bolster dressing to the lateral hallux was removed , revealing the incorporated skin graft . all sutures to the foot were removed at this visit as well . at postoperative week 9 , all surgical sites were completely healed and the patient was advanced to full weight bearing in extra depth shoes with custom trilaminar insoles . the patient 's foot remained well - healed and showed no evidence of skin breakdown or other complications during his most recent outpatient visit at 26 weeks postoperatively . among diabetic patients , complications of foot ulcers represent a leading cause of hospitalization and amputation ( 6 ) . several conservative and surgical techniques exist to provide closure of diabetic forefoot wounds , yet failure to restore the area with durable tissue can lead to wound recurrence and risk of infection . the plantar aspect of the forefoot , particularly the submetatarsal areas , is comprised of a thick layer of keratinized epithelium and multiple fibrous septae that firmly anchor the skin to underlying structures ( 7 ) . the composition of the digital artery pedicle flap closely resembles the plantar soft tissue at the forefoot , making it ideal for coverage of these defects . a multidisciplinary approach to patient treatment is important for favorable outcomes in the diabetic population ( 8) . appropriate medical management of comorbidities , eradication of infection , and vascular assessment to determine distal arterial patency should be undertaken prior to any reconstructive foot procedures . digital artery pedicle flaps first gained popularity in reconstructive surgery of the hand ( 9 ) . modifications of the flap have been used for salvage of the foot , particularly at the digits and other forefoot areas ( 1012 ) . reviewed the use of reversed island flaps in 12 diabetic patients ; however , their study was restricted to dorsalis pedis flaps and medial plantar artery flaps ( 13 ) . reported on the digital artery pedicle flap for forefoot wounds in 12 patients , but not all were diabetic ( 4 ) . roukis and zgonis described modifications of the great toe fibular flap for soft tissue and bone reconstruction in the diabetic foot ( 12 ) used the homodigital reverse flow island flap for coverage of four diabetic great toe ulcers with good results ( 14 ) . in this case report , the pedicle flap is based on the lateral plantar digital artery and includes the digital nerve when it is harvested ( 15 ) . coverage of the donor site can be achieved through a stsg or syndactilization to an adjacent toe ( 4 ) . in this case report , the authors harvested a stsg from the medial arch of the foot rather than from the more traditionally used leg or thigh sites . the consistency and appearance of the skin at this part of the foot closely replicates the skin at the lateral aspect of the digit , leading to a more functional and aesthetically pleasing result ( 16 ) . possible complications of digital artery pedicle flaps include incomplete flap take , delayed healing , dehiscence , flap necrosis , venous congestion , hematoma , and infection ( 12 , 14 , 17 ) . careful monitoring of the flap every 1 to 2 h during the patient 's hospital stay can allow for prevention and/or early treatment of complications . strict non - weight - bearing and loose sterile dressings to the flap facilitate incorporation and prevent ischemia . donor site morbidity is usually minimal , but depends on how the area is surgically addressed . the patient in this case report experienced an uneventful postoperative course . by the sixth postoperative month , he had only minimal scar formation to the surgical sites , full mobility of the foot with return to normal activity , and no ulcer recurrence . in carefully selected patients , the authors strongly recommend the reverse flow digital artery pedicle flap as an alternative treatment for recalcitrant diabetic forefoot wounds . this flap allows for restoration of the highly specialized soft tissue at the plantar forefoot . a successful functional outcome can allow the patient to withstand shearing forces encountered during ambulation , even in the setting of peripheral neuropathy , thereby reducing the risk of reulceration and/or amputation the authors have not received any funding or benefits from industry to conduct this study .
digital artery pedicle flap is a useful surgical technique for coverage of plantar foot defects . for diabetic forefoot ulcers that are subject to recurrence despite consistent care 
 , this flap can provide long - term durable closure . 
 the authors provide a case report and overview of this innovative reconstructive procedure .