Anatomical study and colour Doppler assessment of the skin perforators of the anterior tibial artery and possible clinical applications

Abstract

Traumatic or trophic defects of the soft tissue of the lower leg are quite often very difficult to manage, especially in the distal third of the leg. Fasciocutaneous flaps are a relatively simple option for covering small- and medium-sized defects of the lower leg. The aim of this study is to investigate the distribution of septocutaneous perforators of the anterior tibial artery and their possible clinical applications. An anatomical study was performed on 50 fresh adult cadaveric lower extremities. Using coloured contrast materials, the location of septocutaneous perforators, originating from the anterior tibial artery, were mapped. These findings were then compared with colour Doppler imaging (CDI) data in 20 living volunteers. The septocutaneous perforators of the anterior tibial artery follow a reproducible pattern all over the lower leg (septa I, II and III). In the distal segment, we found relatively few perforators. There was a marginal difference between cadaveric and CDI data for perforators with diameter >or=1mm. The average number of anterior tibial artery septocutaneous perforators in anatomical dissections was 6.6+/-2.4, while CDI revealed 8.2+/-3.2 perforators in living volunteers (P=0.053). In five areas of the lower leg, there is a >50% chance that a septocutaneous perforator with diameter >or=1mm is coming off the anterior tibial artery. Anatomical dissections for a cutaneous territory 5 cm above the lateral maleollus, and 10 cm in width, revealed 6.1+/-2.2 septocutaneous perforators (range 4 to 12). CDI, paired with knowledge of anatomical details, is a reliable tool for preoperative identification of septocutaneous perforators of 1mm or larger outer diameter, thus providing critical information for planning and harvesting safe fasciocutaneous flaps of the lower leg. Additionally, according to our anatomical study, a new transverse fasciocutaneous flap (Type B according to the Nahai-Mathes classification), located over the distal anterolateral third of the lower leg and based on perforators of the anterior tibial artery, may be successfully used for covering selected defects of the distal third of the lower leg.