Peroneal Artery “Terminal” Perforator Pedicled Flap for Surrounding Soft Tissue Defects: A Retrospective Cohort Study

Background: Soft tissue defects of the lower leg and foot are complicated injuries with numerous causes including trauma, ulcers, and Gout. Widespread treatment of these defects has been effectively applied with perforator flaps of the peroneal artery and posterior tibial artery. Objectives: 1. Construct a map of the perforators of the peroneal artery and posterior tibial artery using a handheld Doppler ultrasound. 2. Evaluate the clinical outcome of perforator flaps to cover soft tissue defects in the lower leg and foot. Materials and method: Cross-sectional study of 34 volunteers with no previous history of vascular diseases and the prospective study of 31 patients with soft tissue defects treated with peroneal artery perforator flap and posterior tibial artery perforator flap. Results: There are, on average, 4.7 peroneal perforating arteries. From the lateral malleolus to the fibula’s head, the percentage of perforating arteries in the 2/10 and 6/10 segments is 85.3% and 97%, respectively. In the 2-3/10 segment, 94.1% have perforator arteries. There are, on average, 3.3 posterior tibial artery perforators. From the medial malleolus to the medial tibial plateau, it was found that 100% of volunteers had perforating arteries in the 3-4/10 segments and 61.7% in the 5/10 segment. Evaluation of postoperative results in 31 patients: 77.49% showed the right flap. The most common complications were edge necrosis (12.9%), partial necrosis (6.44%), and infection (3.23%). The donor sites showed good survival in 96.4% of patients, while partial necrosis resulted in 3.6%. A follow-up examination revealed that 90.32% of flaps had a good result, 9.68% had an average result, and no poor results were shown. 100% of donor sites had good results. Conclusion: An average of 4.7 perforators of the peroneal artery is detected by handheld Doppler ultrasound. Also, there are 1-2 relatively constant perforators in segments 2/10 and 5-6/10 from the lateral malleolus. On average, there are 3.3 perforators of the posterior tibial artery, primarily in the 3-4/10 and 5/10 segments proximally from the medial malleolus. 90.32% of the flap had good results. Key words: Perforator flap, Soft tissue defect, Lower leg, Foot, Reconstruction.

Objective To investigate the clinical effect of relaying reversed peroneal artery perforator flaps in repairing skin and soft tissue defects at ankle and donor site. Methods A retrospective case series study was conducted on the clinical data of 23 cases of skin and soft tissue defects at ankle and donor site from September 2015 to May 2017. There were 16 males and seven females, with an average age of 35 years (range, 18-69 years). The soft tissue defects of ankle ranged from 4.0 cm×4.0 cm to 11.0 cm×7.0 cm. The distal perforator flap of the peroneal artery was firstly cut and used to repair the soft tissue defect of the ankle. The proximal perforator flap of the peroneal artery was used to repair the first donor site, and the second donor site was directly sutured at stage I. The perforator flap area ranges of the distal and the proximal perforator of the peroneal artery were 6.0 cm×5.0 cm to 14.0 cm×8.0 cm and 7.5 cm×4.0 cm to 14.0 cm×5.0 cm, respectively. The shape of recipient area and donor area were observed. The clinical effects were evaluated by American Orthopedic Foot and Ankle Association (AOFAS) score and Weber two-point discrimination test. Results All patients were followed up for 6-19 months (mean, 12 months). One case had partial necrosis of distal skin of ankle flap after operation and recovered 2 weeks after dressing change. All the other flaps survived smoothly in the first stage. The first donor site had no sunken area or rupture. Some linear scar remained at the second donor site, which did not affect the overall appearance. The flaps were smooth in appearance, good in texture, and close to normal color. The AOFAS score of the foot was 95-98 points, and the distance of two-point discrimination of flaps ranged from 8 to 10 mm. Conclusions The relaying reversed peroneal artery perforator flap has abundant blood supply, and the operation site is located at the lateral crural region, without sacrificing the main artery. It can improve the appearance and function of the first donor area while repairing the soft tissue defect of the ankle. Key words: Soft tissue injuries; Surgical flaps; Peroneal artery perforator

Objective To report operative techniques and clinical results of free sural cutaneoadipofascial flap containing the neurovascular axis based on a dominant peroneal perforating artery (DPPA, with a caliber≥0.8 mm) and its concomitant veins for reconstruction of dorsal forefoot soft tissue defects. Methods The flap was applied in 32 cases with middle to large soft tissue defects in the dorsal forefoot from Aug. 2009 to Dec. 2014. DPPAs arising from the posterolateral intermuscular septum was located and assessed preoperatively with color Doppler flow image and computed tomography angiography. According to the location, size, and shape of the defects, one of these DPPAs was chosen for flap planning. The flap was harvested from the posterolateral aspect of the leg. The neighboring neurovascular axis (one or more of that of the sural nerve, the medial cutaneous nerve, the lateral cutaneous nerve of calf and the sural communicating nerve) was included to ensure vascular supply. According to skin laxity of the donor site, the width of the full harvesting part which should be able to cover the region of the recipient site where pressure and friction force were prominent while wearing shores was decided; the rest was harvested as an adipofascial flap (without skin) to get enough size. After transfer to recipient site, the flap was revascularized by anastomosing the perforating artery and its venae comitantes with appropriate recipient vessels, and reinnervated (antegrade or retrograded methods). Skin grafting was performed on the adipofascial surface of the flap primarily or secondarily. The defects in donor site of the leg was closed directly. Results All flaps (ranged from 7.5 cm×5.0 cm to 23.0 cm×13.0 cm) were transplanted successfully, and no vascular or donor site problems occurred. All primary skin grafts (19 cases) was partially lost, but only 2 of them need a second grafting. Adipose necrosis occurred in 4 of 13 cases receiving secondary grafting but only needed wound care before surgery. Following up for 11-26 months showed both satisfactory functional and cosmetic results without problems of shoe wearing. Flap sensibility restored at least to the degree of S3. Conclusions The cutaneoadipofascial flap combines the advantages of perforator, neurocutaneous axis, free and adipofascial flaps leaving only suture scar in the donor leg, and is a satisfactory method for free-style and acute coverage of dorsal forefoot defects. Key words: Perforator flap; Peroneal artery fibular artery; Fascio-cutaneous flap; Dorsum of foot

Objective To investigate the clinical results of free super-thin peroneal artery perforator flap containing neurovascular axis in reconstruction of hand or foot soft tissue defects. Methods A retrospective case series study was made on 23 cases of hand or foot soft tissue defects admitted from January 2006 to March 2013. There were 16 males and 7 females, with a mean age of 33 years (range, 17-51 years). Wounds were located in dorsal hand (n=12), dorsal pedis or amputated forefoot (n=8), greater thenar (n=2) and index finger (n=1) respectively. Defects ranged in size from 5.0 cm×3.5 cm to 11.5 cm×7.5 cm. Flap elevating was performed underneath the deep fascia and the perforator supplying the flap was dissected thoroughly, ligated and cut at the location arose from the peroneal artery. Most of the deep fascia except stripe shaped areas along the main blood supply chains was moved sharply and the fat underlying thinned primarily to the subdermal vascular network. After transferred to the recipient site, the flaps were revascularized by anastomosis of the perforating artery and its venae comitantes to appropriate recipient vessels. A total of 15 cases received innervated flap reconstruction. Flap vascularity and cosmetic results were recorded. Hand function was evaluated with the standard set up by the hand surgery branch of Chinese Medical Association. For foot reconstruction, shoe wearing status, gait, pressure-sore, flap sensibility, donor site appearance and complications were evaluated. Results All flaps were transplanted successfully with satisfactory cosmetic results, except that one flap used to cover dorsal ring finger defect left slightly bulky appearance. Mean duration of follow-up was 19 months (range, 11-26 months). For hand reconstruction, the functional results were excellent in 6 cases and good in 9 cases. Repairing of foot defects with the flaps caused no problem of shoe wearing and no sore occurred. Normal gait was acquired except two cases of partially amputated foot. If innervated, flap sensibility was restored at least to the degree of S3. Protective sensation and touch-pressure sensation were restored in eight non-innervated cases, and two of them were recovered to the degree of S3. There was only suture or small grafting scars on the donor leg and partially sensibility loss of lateral foot without functional defects in 13 cases. Conclusion Free super-thin peroneal artery perforator flap containing neurovascular axis is an easy and reliable technique that can attain satisfactory results for accurate coverage of hand or foot soft tissue defects. Key words: Surgical flaps; Hand injuries; Foot

Propeller perforator flaps for coverage of soft tissue defects in the middle and distal lower extremities

Introduction: Perforator propeller flap is a suitable option to cover soft tissue defects in the distal leg and ankle which preserves the main vascular arteries of the lower extremity and muscle function. The aim of this study is to evaluate the use of perforator propeller flaps for coverage of soft tissue defects around the distal leg and ankle.
 Methods: This prospective study was donebetween December 2018 to November 2019in the Department of Burn & Plastic Surgery of National Institute of Traumatology and Orthopedic Rehabilitation ( NITOR), Dhaka. Total 32 patients with small to medium sized soft tissue defect over distal leg and ankle underwent reconstruction with perforator propeller flaps. Sixteen patients had defect over tendo achilles area, 6 had defect over lateral malleolus,7 over medial malleolus and medial aspect of distal third leg and only 3 had defect in front of ankle. Average Flap length and width were 12.72 (+4.19) & 5.63 (+1.78) cm respectively. Flap rotation was measured 180 degrees in 84.37% of the cases. The propeller flaps were based on a single perforator and it was observed from the posterior tibial artery in 62.5% and peroneal artery in 37.5% of the cases.
 Results: 81.25% of the flaps completely survived. Total flap loss was observed in one case (3%) while partial flap loss occurred in 6.2% cases. Marginal flap necrosis and epidermolysis were observed in 6.2% and 3% cases respectively.
 Conclusions: Propeller flapshavereliable vascular pedicle as well as greater freedom in design and arc of rotation that extend the possibility ofreconstructing difficult wounds with local tissues and minimal donor-site morbidity.
 J Bangladesh Coll Phys Surg 2021; 39(2): 87-93

The peroneal artery perforator flap and its modifications have been widely used for coverage of soft tissue defects of ankle and foot in the past decade. In this article, we report on a series of upper knee, ankle, and foot reconstructions with a proximally or distally based extended peroneal artery perforator (EPAP) flap supplied by distinct perforating branches off the proximal or distal peroneal artery. Total pedicle length obtained ranged from 6 to 12 cm. Twelve patients with soft tissue defects of the lower extremity underwent reconstruction using the EPAP flap. The flaps were designed with the sizes from 10 x 6 cm to 25 x 15 cm. All 12 flaps survived completely without complications. Our experience demonstrates that the EPAP flap is reliable and versatile and can provide a large amount of soft tissue for coverage of defects in the leg anywhere from knee to forefoot obviating the need for free tissue transplantation.

Background: Coverage of soft tissue defects around the knee is a reconstructive challenge. The superior lateral genicular artery perforator (SLGAp) flap provides an excellent alternative to muscle and musclocutaneous flaps with less morbidity, for coverage of these defects, especially when the gastrocnemius muscle flap is not available. The vascular basis of this flap, SLGA perforators, have consistent and reliable anatomy.Aim of The Study: This study is a retrospective analysis of our clinical experience with the superior lateral genicular artery perforator flap for coverage of soft tissue defects of the kneePatients and methods: This study was done at The Department of Plastic and Reconstructive Surgery, Menofia University Hospitals, from January 2017 to November 2018, with follow up period of 12 months. It included 7 patients, 6 males, and 1 female, with their age ranged from 19 to 46 years. The around-knee defects were due to different etiologies, 1 patient due to shotgun, 1 patient with post-burn contracture of the lateral popliteal fossa, and 5 patients with traffic accidents. The defects were reconstructed by the superior lateral genicular artery perforator (SLGAp) flap.Results: all flaps survived, except in 2 cases, 1 case managed conservatively and healed well, and in the second, the necrotic part was debrided and skin grafted. The donor site was closed primarily in 2 cases and skin grafted in 5 cases. Skin graft take was perfect, except in 3 cases with minor patches of graft loss and healed spontaneously. Infection around the defect site occurred in 2 cases and managed conservatively. The flap provided stable and durable coverage with minimal donor site morbidity and no functional loss.Conclusion: The superior lateral genicular artery perforator flap is a versatile option for reconstruction of soft tissue defects around the knee or popliteal fossa. The anatomy of the flap perforators is consistent and reliable. The flap is thin, pliable and provides stable coverage with adequate match of the surroundings. Donor site morbidity is minimal with no functional loss.Key Words: Superior lateral genicular artery_ Knee defects_ perforator flap.

Background: Soft tissue defects of the hands require coverage with soft, pliable full-thickness skin. The posterior interosseous artery (PIA) flap fulfils all these requirements and also has significant advantages over other flaps; it is a single-stage procedure that does not sacrifice major vascular axis of the hand. However, the dissection can be challenging and requires meticulous skill. The objective of the study was to evaluate the reverse PIA flap for coverage of hand soft tissue defects in terms of its safety, reliability, comfort, function and aesthetic appearance.Methods: Over a period of 3 years, patients with soft tissue defects over the dorsum of the hand and first web space were observed. A standard PIA flap was raised using loupe magnification under general or brachial anesthesia. The size and location of the defect were noted along with the size and success of the flap.Results: Twelve patients, including nine males and three females, were taken up for this procedure. All the flaps survived completely except one with marginal necrosis not requiring a secondary procedure. All patients were quite satisfied with the procedure and went on to resume their work within a month or two.Conclusion: PIA flap is a safe, reliable option with great versatility for coverage of hand defects, especially over the dorsum. A well-planned flap surgery done under loupe magnification affords excellent results. The entire treatment also requires a shorter hospital stay and allows the patient to return to work quickly.

To investigate the anatomy of anterior and posterior terminal perforators of the peroneal artery and its clinical applications. Six lower limb specimens were obtained from 3 fresh cadavers. The anterior and posterior terminal perforators and the perforator of terminal peroneal artery were exposed under surgical microscope, and the distances from the beginning of each perforator branch to the lateral malleolus tip and the external diameter of each perforator were measured. With these anatomical knowledge and contrast-enhanced ultrasound (CEUS) guidance, the pedicle flaps with above-mentioned perforators were rationally selected and precisely designed for 18 patients with skin defects in the ankle and foot region between October 2016 and December 2018. Among the patients, there were 14 males and 4 females, aged 28-62 years, with an average age of 40 years. The area of wound ranged from 4 cm×3 cm to 13 cm×10 cm and the area of skin flap ranged from 5 cm×4 cm to 14 cm×10 cm. The anterior peroneal artery terminal perforator flap were applied in 13 cases and the posterior peroneal artery terminal perforator flap in 5 cases. The donor sites were closed directly in 7 cases and repaired with full thickness skin graft in 11 cases. The distance from the beginning of the anterior terminal perforator to the lateral malleolus tip was (5.1±0.5) cm, the external diameter of the anterior terminal perforator was (1.51±0.05) mm. The distance from the beginning of the posterior terminal perforator to the lateral malleolus tip was (4.9±0.9) cm, the external diameter was (1.78±0.17) mm; the distance from the beginning of the perforator of terminal peroneal artery to the lateral malleolus tip was (1.7±0.7) cm, the external diameter was (0.58±0.12) mm. Clinical application results: The edge of the flap was dark in 2 cases after operation and healed after surgical dressing, and 1 case of wound infection healed gradually after debridement. The other flaps survived and healed by first intention. Three patients underwent plastic surgery at 3 months after operation due to flap swelling. All patients were followed up 3-18 months. During the follow-up period, the flaps had good texture and appearance, and partial recovery of sensation. All cases were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) score at last follow-up. The results were excellent in 9 cases, good in 6 cases, fair in 2 cases, and poor in 1 case, with the excellent and good rate of 83.3%. Further classification of peroneal artery perforators in the lateral malleolus region can improve clinical understanding and be helpful to selection and application of perforator flaps in the lateral malleolus.

Objective To explore the clinical effects of lower leg perforator flap in the treatment of the soft tissue defects in the donor site of toe transplantation. Methods From December 2015 to December 2016, 15 cases of thumb or finger defects were reconstructed by the transplantation of big toe nail flap, the fibula side flap of great toe and second toe wrap-around flap. Simultaneously, the free peroneal artery perforator flap or posterior tibial artery perforator flap was used to repair the soft tissue defects in donor site of toe transplantation. Results All the reconstructed fingers and thumbs survived. All the flaps used to cover donor site of the foot survived. The follow-up time ranged from 1 to 18 months with an average of 8.6 months. The donor site of toe transplantation recovered well without influence on wearing shoes and walking. According to the Maryland foot function scoring system issued by Sanders et al, the results were rated as excellent in 14 cases and good in 1 case. Conclusion Lower leg perforator flap for repair of the soft tissue defects in the donor site of toe transplantation can not only reconstruct the good appearance and function of thumbs and fingers, but also can restore the integrity of donor foot. The function and appearance of the foot are well recovered. Key words: Surgical flaps; Treatment outcome; Soft tissue defects; Toe donor site

To investigate the applied anatomy of the superficial peroneal artery perforator flap and report the clinical results of repairing the soft tissue defects with free perforator flaps. 15 fresh cadavers were injected with a modified lead oxide-gelatin mixture for three-dimensional visualization reconstruction using a 16-slice spiral computed tomography scanner and specialized software (Materiaise's interactive medical image control system, MIMICS). The origin, course and distribution of the superficial peroneal artery perforator in the anterolateral leg region were observed. Clinically 6 cases with hand defects and 6 cases with feet defects were treated with free superficial peroneal artery perforator flap transplantation. The defect size ranged from 3.0 cm x 4.5 cm to 5.0 cm x 11.0 cm. The diameter of the superficial peroneal artery is (1.2 +/- 0.3) mm at its origin from the anterior tibial artery 5 cm below the fibula head. It is (5.6 +/- 1.8) cm in length. This artery is truly anastomosed with other perforators to form the chain of superficial peroneal nerve accessory artery. The superficial peroneal artery perforators [outer diameter (0.7 +/- 0.2) mm] with a vein are in the anterolateral leg region, supplying the skin in proximal-middle region. All the 12 cases were treated successfully. The clinical results were satisfactory after 3-12 months of following-up. The superficial peroneal artery perforator flap has constantly, reliable blood supply, and good texture. It is a good option for repairing soft-tissue defect with free transfer.

Objective According to the characteristics of skin defects in ankle and foot select the posterior lateral leg pedide skin flaps supplyed by different blood to repair, providing advice and reference. Methods Between January, 2001 and December, 2015, 163 cases of soft tissue defects at the foot and ankle were treated in our department. ①The sural neurovascular flap was used in 93 cases in ankle and foot defect. ②The sural nerve nutritional vessel flap pediele with the perforating branch of the peroneal artery in 36 cases in ankle and foot defect. ③The sural nerve nutritional vessel flap pediele with the perforating branch of the peroneal artery including sensory reconstruction in 16 cases in heel rejion defect. ④Peroneal artery perforator flap in 10 cases in anterior ankle, lateral malleolus and posterior malleolus defect.⑤The use of the sural fasciocutaneous flap alonged with peroneal artery and perforators in 8 cases in dorsal foot defect. The donor site with skin graft. Results Of the 93 sural neurovascular flaps, 8 had partial loss, which were cured after dressing. All the sural nerve nutritional vessel flaps pediele with the perforating branch of the peroneal artery survived. Sensory grading standard by UK Medical Research Council was used to evaluate the recovery of sensory function on the last follow-up. The sensory function recovery of heel region flaps with reconstruction of the sensory was between S0 and S1. All peroneal artery perforator flaps survived. One of the sural fasciocutaneous flap alonged with peroneal artery and perforators occurred distal epidermis, which were cured after dressing. All patients were followed up 6-50 months (mean 20 months). All patients had recoveryed walking function, and infection wound had no recurrence after surgery. Conclusion According to the location, size, severity and the injury of peripheral vascular, select the most simple, safe, minimal damage flap for the soft tissue defects at the foot and ankle. The right choice and the exact design can improve flap survival rate, and recieve good clinical results. Key words: Foot and ankle; Soft tissue defect; Surgical flap; Repair; Sense reconstruction

The ability to provide thin and pliable soft tissue coverage and the advantageous results of underlying muscle preservation has popularized perforator flaps during the last few years. The thoracodorsal artery perforator (TAP) flap contains only skin and subcutaneous fat, and its blood supply comes from one or two perforator vessels piercing the latissimus dorsi muscle after they originate from the thoracodorsal pedicle. The aim of this study was to report clinical experience with free and pedicled transfer of TAP flaps to various soft tissue defects.

Background: The hand is an intricate part of the body that plays an essential role in social functioning, expression, productivity, and interactions with our environment.Many flap options have been described to address the specific functional and anatomic requirements in soft tissue reconstruction of the hand. The aim of this study isto find the ideal donor tissue for coverage of soft tissue defects of the hand to achieve wound closure and maintain joint and hand function. Patients and methods: A prospective study wasconducted betweenfrom April 2018 and May 2019, on all patients with soft tissue defects of the hand presented to plastic surgery department, Qena faculty of medicine,South Valley University. Results:There were 62 hand injuries in 50 patients with a mean age of 35 years (range, 1- 69 years). The etiologies of the injuries were mostly due to post-traumatic raw areas (86%). In our study we divided cases into 4 main groups, the first group including fingertip injuries, second group proximal to fingertips, third group palm and fourth group dorsum of the hand. The distribution of the hand injuries were 48 fingertips injury, 8 injuries proximal to fingertips, palm injury in one patient and injuries over hand dorsum in 5 patients.The follow up period was ranged 1 to 6 months. Conclusion:An algorithmic approach for coverage of the hand soft tissue defect seems to provide predictable results regarding flaps survival and preservation of finger length.