Intraadiposal Pedicle Dissection when Performing Free Tissue Transfer: A Means to Address a Short Pedicle

Abstract

A 77-year-old male patient with a diabetic foot ulcer on his right great toe visited the outpatient clinic. As necrosis of the toe had already progressed, the patient underwent toe amputation to prevent extensive gangrene. With the goal of enabling future ambulation, an anterolateral thigh fasciocutaneous free flap was planned to preserve the metatarsal head and to cover the defect. Subfascial dissection was performed when elevating the fasciocutaneous flap, but the sole healthy perforator was in an extremely proximal area and allowed only a 4-cm-long pedicle. The pedicle had to be at least 8 cm long to ensure secure anastomosis to the medial plantar artery. To overcome this unexpected challenge, we pierced the deep fascia near the perforator and dissected the perforator distally within the deep adipose layer. The necessary additional length of the pedicle was obtained through intraadiposal dissection. The flap survived without any complications, and the foot was reconstructed with successful ambulation. This case demonstrates the value of attempting intraadiposal pedicle dissection when the pedicle turns out to be unmanageably short.