Modified Fillet Toe Flap for Toe Amputation: A Random-pattern Approach beyond the Axial Concept

The fillet toe flap embodies the "spare parts" concept, utilizing tissue from a nonsalvageable toe for local reconstruction; however, its use in ischemic limbs has traditionally been limited by compromised digital arterial inflow. Increasing evidence from studies on angiosomes and perforasomes suggests that collateral and subdermal vascular networks can sustain tissue perfusion under ischemic conditions. Based on these findings, we developed a modified fillet toe flap incorporating a limited plantar releasing incision to enhance flap mobility while preserving the dorsal subdermal vascular plexus, allowing the flap to be conceptualized as a random-pattern pedicled flap. Five patients underwent reconstruction following toe amputation using this technique. One patient had a diabetic neuropathic ulcer, and four had chronic limb-threatening ischemia treated with revascularization. The flap was applied only after improvement in local perfusion was confirmed. The plantar releasing incision enabled three-dimensional unfolding of the flap and facilitated coverage of defects that would be difficult to reconstruct with conventional fillet flaps. No total flap necrosis occurred. Minor complications included partial wound dehiscence and mild distal perfusion disturbance, and no patient required reamputation. During a mean follow-up of 23 months in surviving patients, stable wound coverage was maintained. This modified fillet toe flap extends the conventional axial concept by reinterpreting the fillet flap as a random-pattern technique. When applied in appropriately selected patients after revascularization, it may represent a practical reconstructive option for ischemic or neuropathic forefoot defects while adhering to the spare parts concept.