Free Peroneal Artery Perforator Flap Research Articles

Clinical effects of free peroneal artery perforator flaps in repairing forefoot skin and soft tissue defect wounds assisted with three-dimensional computed tomography angiography

Objective: To investigate the clinical effects of free peroneal artery perforator flaps in repairing forefoot skin and soft tissue defect wounds assisted with three-dimensional computed tomography angiography (3D-CTA). Methods: A retrospective observational study was conducted. From March 2017 to September 2019, 15 patients with skin and soft tissue defect wounds in the forefoot were treated in the Department of Burn and Plastic Surgery of Yidu Central Hospital of Weifang, including 12 males and 3 females, with age of 18-60 years. The wound area on admission was 3.0 cm×3.0 cm-9.0 cm×8.0 cm. The 3D-CTA examination before operation was performed to select the peroneal artery perforating vessels with appropriate length of vascular pedicle and good blood perfusion. According to the wound area and the perforating vessels of the peroneal artery located by 3D-CTA, the peroneal artery perforator flaps of 3.5 cm×3.5 cm-9.5 cm×8.5 cm carried with lateral sural cutaneous nerve was designed and cut, and the nerve was anastomosed with the nerve of the wound. The wound in the donor site of the flap was directly sutured or covered with medium-thickness skin graft from the thigh. The consistencies of type, diameter, and perforating position of perforating vessel of the peroneal artery detected by 3D-CTA before the operation with those of the actual measurement during operation were observed. The length of time for flap cutting and the survival of the flap after operation were recorded. During follow-up of 12 months after the operation, the patients were instructed to evaluate the foot function according to the Maryland foot function score standard, and the wound healing in the donor area and the occurrence of complications affecting the motor function of limb were observed. Data were statistically analyzed with paired sample t test. Results: The types of peroneal artery perforating vessels in patients measured during the operation were septocutaneous perforator of 12 cases, musculocutaneous perforator of 2 cases, and musculomuscular septal perforator of 1 case, which were consistent with those measured by preoperative 3D-CTA. The diameter of the peroneal artery perforating vessel measured by preoperative 3D-CTA was (1.38±0.17) mm, which was close to (1.40±0.19) mm measured during the operation (t=0.30, P>0.05). The horizontal distance from the starting point of the perforating vessel to the outer edge of the shank was (42±6) mm, and the vertical distance from the starting point of the perforating vessel to the level of the lateral ankle tip was (219±14) mm measured by preoperative 3D-CTA, which were respectively close to (43±6) and (221±15) mm of intraoperative measurement (with t values of 0.46 and 0.38, respectively, P>0.05). The length of time for cutting flap was (31±6) min. All flaps survived post operation without vascular crisis. During follow-up of 12 months after the operation, the foot function was evaluated as excellent in 11 cases, good in 3 cases, and fair in 1 case, the donor site wound healed well, the scar was not noticeable with no contracture, and the motor function of joints was not affected. Conclusions: Free peroneal artery perforator flap is one of the effective methods to reconstruct skin and soft tissue defect wounds in the forefoot, and the risk of surgery can be reduced when the anatomical location of the perforating vessels is confirmed by 3D-CTA.

Clinical application of free peroneal artery perforator flap in soft tissue defect of foot and ankle

To investigate clinical application of the free peroneal artery perforator flap in soft tissue defect of foot and ankle. The clinical data of 18 patients with soft tissue defects of foot and ankle who were repaired with free peroneal artery perforator flaps between March 2019 and March 2020 were retrospectively analyzed. Among them, there were 11 males and 7 females; the age ranged from 21 to 58 years, with an average age of 45 years. The defect was located in the ankle in 2 cases, in the hindfoot in 4 cases, in the midfoot in 5 cases, and in the forefoot in 7 cases. The causes of injury included 11 cases of traffic accident, 4 cases of machine injuries, 3 cases of infection and necrosis after internal fixation. The time from injury to flap repair was 12-48 days, with an average of 24 days. The range of wound was 3 cm×3 cm to 15 cm×8 cm, and the range of skin flap was 4 cm×3 cm to 16 cm×9 cm. The flap harvesting time, operation time, intraoperative blood loss, and complications were recorded; the flap survival and patient satisfaction were observed during follow-up; and the American Orthopaedic Foot and Ankle Society (AOFAS) foot function score was used to evaluate the foot function. The flap harvesting time was 15-33 minutes (mean, 22 minutes); the operation time was 120-160 minutes (mean, 150 minutes); the intraoperative blood loss was 90-180 mL (mean, 120 mL). There were 3 cases of vascular crisis after operation, including 2 cases of arterial crisis, which survived after vascular exploration and vein graft repair; 1 case of venous crisis, partial necrosis of the skin flap, and skin grafting to cover the wound after repeated debridement. The remaining 15 skin flaps survived completely. All patients were followed up 6 months. The skin flaps were in good shape without obvious bloat. According to the AOFAS foot function score, 5 cases were excellent, 10 cases were good, and 3 cases were fair. The excellent and good rate was 83.3%. The free peroneal artery perforator flap is easy to harvest, the shape and size of the flap are easy to design, and it does not damage the main blood vessels of the limb. The appearance and function of the limbs are satisfactory after operation. It can be widely used in the repair of soft tissue defects of the foot and ankle.

The Microvascular Peroneal Artery Perforator Flap as a "Lifeboat" for Pedicled Flaps.

Background:Pedicled perforator flaps have expanded reconstructive options in extremity reconstruction. Despite preoperative mapping, intraoperative findings may require microvascular tissue transfer when no adequate perforators can be found. The free peroneal artery perforator flap may serve as a reliable back-up plan in small defects.Methods:In 16 patients with small soft tissue defects on the upper and lower extremities, perforator-based propeller flaps were planned. The handheld Doppler device was used to localize potential perforators for a propeller flap in close proximity to the defect. Perforators of the proximal peroneal artery were also marked to allow conversion to microvascular tissue transfer.Results:In 6 cases, no adequate perforators were found intraoperatively. In 4 patients, the peroneal artery perforator flap was harvested and transferred. The pedicle length did not exceed 4 cm. No flap loss occurred.Conclusions:When no adequate perforator capable of nourishing a propeller flap can be found intraoperatively, the free peroneal artery flap is a good option to reconstruct small soft tissue defects in the distal extremities. The short vascular pedicle is less ideal in cases with a large zone of injury requiring a more distant site of anastomosis or when recipient vessels are located in deeper tissue planes.

Clinical application of the free superficial peroneal artery perforator flap under color doppler ultrasound localization for repair of hand and foot wounds

目的 探讨彩超定位下游离腓浅动脉穿支皮瓣修复手足部中小创面的可行性及临床效果。 方法 自2015年8月至2017年11月，我们在彩超定位下游离腓浅动脉穿支皮瓣修复手足部中小创面18例，术中吻合腓浅动脉的穿支血管，未切取腓浅动脉主干，其中修复趾创面2例、足背创面2例、拇指创面5例、示指创面4例、手掌部创面4例、中指创面1例。创面缺损面积为2.0 cm×2.5 cm~3.5 cm×9.0 cm，皮瓣切取面积为2.5 cm×3.0 cm~4.0 cm×10.0 cm。 结果 本组18例皮瓣全部存活，未发生血管危象。术后随访时间为6~12个月，平均8个月，皮瓣色泽、质地优良，弹性良好，外形饱满，均未行二次皮瓣修整，术后6个月恢复保护性感觉，功能恢复良好。小腿供区16例直接缝合，2例植皮修复，无明显瘢痕增生，外形良好，功能无影响。 结论 彩超定位下游离腓浅动脉穿支皮瓣修复手足部中小创面，具有定位准确、操作简便等优点，术后临床效果较满意，是一种较好的修复方法。

Application of lower leg perforator flap for repair of the soft tissue defects in the donor site of toe transplantation

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

Hallux-nail flap with distal phalanx combined with iliac bone for reconstruction of thumb with III degree defect

Objective To explore the clinical effect of using hallux-nail flap with the distal part of phalanx combined with iliac bone for reconstruction of thumb with III degree defect. Methods From June, 2011 to June, 2016, 7 patients with thumb III degree defect were treated with the hallux-nail flaps with distal phalanx combined with iliac bone to reconstruct thumbs. According to the thumb defect indexing method reported by Cheng Guoliang, the type 1 of thumb III degree defect was 4 cases, and the type 2 of III degree defect was 3 cases. The donor site was covered with skin grafting in 1 case, free superficial iliac artery graft in 5 cases and free peroneal artery perforator flap in 1 case. All patients kept the number and length of donor toes. Regular follow-up was performed after operation to observe the function, shape, feeling of finger reconstruction, the survival condition of flaps or skin graft in donor site, etc. It was also observed if the pain by walking actually exists in the long-term effect. Results All of the reconstructed thumbs survived. One patient suffered the necrotic in the donor site repaired by superficial iliac artery flap, which was successfully covered with the skin graft. All patients were followed-up from 3 months to 18 months (mean, 8 months). The reconstructed thumb with smooth nail had fine textile and good elasticity, good flexion and extension function of the palm, fingers and the metacarpophalangeal joint. The donor sites recovered with fine texture, and there were no difficulties in walking and running and no complaint about the pain and discomfort. According to the Trial Criteria of Upper Limb Functional Evaluation of Chinese Medical Association Hand Surgery Society, 5 cases resulted in excellent, and 2 cases resulted in good. Conclusion The hallux-nail flap with the distal phalanx combined with iliac bone is an excellent option to reconstruct thumb with III degree defect with the outcome of good function and appearance. The trauma of the donor site is small and the number and length of the toes are remained. The clinical effect is good. Key words: Thumb defect; Hallux-nail flap; Reconstruction; Microsurgery

Free Style Proximal Peroneal Artery Perforator (PPAP) Flap: An Alternative to the Radial Forearm Flap for Head and Neck Reconstruction

Free Style Proximal Peroneal Artery Perforator (PPAP) Flap: An Alternative to the Radial Forearm Flap for Head and Neck Reconstruction

Free super-thin peroneal artery perforator flap containing neurovascular axis for coverage of hand or foot tissue defects

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

Minimally invasive soft tissue reconstruction with free peroneal artery perforator flap

<p> </p><p><span style="font-family: Times New Roman;"> The development of a concept of perforator flap has dramatically changed the soft tissue reconstructive surgery. The surgery with perforator flaps enables to minimize donor-site morbidity by preserving important tissues including the muscle and the major vessel. The peroneal artery perforator flap is one of perforator flaps that can be harvested from the lower leg. The peroneal artery perforator flap has been widely used as a local flap for soft tissue reconstruction in the lower extremity; however, the free peroneal artery perforator flap transfer has been little reported. Utilities of the free peroneal artery perforator flap for soft tissue reconstruction of the extremities are reported, and minimally invasive flap surgery with perforator flaps is reviewed.</span></p><p> </p>

Repair of forefoot soft tissue defects with free peroneal artery perforator flap in elderly patients

Objective To investigate the surgical methods and clinical effect of repairing forefoot soft tissue defects with free peroneal artery perforator flap in elderly patients. Methods From June, 2011 to April, 2015, 17 cases of forefoot soft tissue defects repaired with free peroneal artery perforator flap in elderly patients. There were 10 cases of male and female in 7 cases with an average age of 65.8 years old ranging from 60 to 74 years. Causes of injury : traffic accident in 7 cases, heavy crushing in 9 cases, electrical burns in 1 case. Injury part: 6 cases on the left side and 11 cases on the right side. Metatarsus and phalanges fracture in 9 cases, tendon injury in 5 cases. Defect area: 3.0 cm × 4.0 cm-6.3 cm × 11.2 cm. Results All flaps survived. All wounds were primary healing. Skin graft survived for the foot flap donor site, and no complicated with infection. All patients were followed up from 8 to 36 months with an average of 17.6 months. The appearance of flaps were good, slight bloated. The texture and color of the flaps were close to the recipient site. Flap feel were good. Accortling to (AOFAS) criteria system, the AOFAS score of last follow-up was (77.5±13.2). Excellent in 6 cases, good in 9 cases, fair in 2 cases. VAS score was (2.6±0.4). Conclusion The free peroneal artery perforator flap with the advantages of vascular anatomy constant, blood supply is reliable, thickness moderate, etc. It is a useful clinical method to repair forefoot soft tissue defects in elderly patients. Key words: Peroneal artery perforator flap; Soft tissue defect; Forefoot; Transplantation; Elderly patients

Clinical application of free peroneal artery perforator flap transplantation for forefoot defects reparation

Objective To analyze features of the lateral leg peroneal artery perforator free flap,and study the clinical application of free peroneal artery perforator flap transplantation for repairing forefoot defects.Methods Retrospectively analyzed 9 patients with forefoot defects which had been repaired with free lateral leg peroneal artery perforator flap transplantation.In this group,the skin and soft tissue defects size were 4.5 cm ×4.0 cm-13.5 cm × 6.5 cm,Focused on analyzing the features of forefoot skin and soft tissue defects,the design and harvesting of lateral leg peroneal artery perforator flap,and vascular anastomosis and vessel matching,meanwhile,follow-up the survival condition and appearance of the flap,the function of foot and ankle after operation.Results In the 9 cases,the larger myocutaneous perforator arising from peroneal artery,accompanying 2 vena comitans,were found slightly above the midpoint of the line between fibula head and lateral malleolus in lateral leg.The flaps transfered to repair forefoot defects,artery end-end anastomosis:in 5 cases cutaneous branch of peroneal artery to dorsal artery of foot,in 4 cases by cutaneous branch of peroneal artery to dorsal metatarsal artery;vein end-end anastomosis:in 1 case 2 accompanying veins of peroneal artery cutaneous branch to 2 accompanying veins of dorsal artery of foot,in 5 cases 1 accompanying vein of peroneal artery cutaneous branch to 1 accompanying vein of dorsal artery of foot or metatarsal,in 3 cases 1 accompanying vein of peroneal artery cutaneous branch to 1 accompanying vein of dorsal artery of foot or metatarsal,simultaneously,the another accompanying vein of peroneal artery cutaneous branch to 1 dorsal superficial vein of the foot.All the 9 flaps survived,and no vessel articulo happened.The venous return of flaps had no significant difference between repairing 1 vein and 2 veins in gross appearance.All wounds healed in one-period.Followed-up 2-6 months postoperative,1 patient was performed flap reshaping due to flap fat and clumsy at 5 months postoperative,others,the skin texture and appearance of the flaps were good and satisfactive.Conclusion Free transplantation of the lateral leg peroneal artery perforator flap broke away from the bondage of pedicled flap,had more freedom in flap design,and effectively controlled the trauma of donor and recipient site.The flap have the merits,blood vessel anatomy is relatively stable,blood supply is reliable,harvesting is simple,skin texture is similar to the forefoot and the effect is better,operation of the donor and recipient sites can accomplish under a identical anaesthesia and tourniquet.Thus,the lateral leg peroneal artery perforator free flap is an effective metheod in reparation of the forefoot defects. Key words: Forefoot; Peroneal artery perforator flap; Transplantation

Free superficial peroneal artery perforator flap free transplantation for wound coverage in the hand

Objective To investigate the clinical outcomes of repairing wound in the hand with free superficial peroneal artery perforator flap transplantation.Methods From March 2008 to March 2012,9 cases of wound in the hand were treated with free superficial peroneal artery perforator flap transplantation.There were 4 cases of volar defects,1 case of first web space wound,1 case of lateral finger defect and 3 cases of dorsal defects.The size of the wounds ranged from 3.0 cm× 4.5 cm to 5.0 cm × 10.0 cm.The perforator flap vascular pedicle was anastomosed to the radial artery and cephalic vein of the recipient area in 4 cases,to the proper digital artery and superficial vein in 4 cases,and to the ulnar artery and basilic vein in 1 case.The donor site was closed directly in 5 cases and covered with skin graft in 4 cases.Results All of the 9 flaps survived completely.No vascular crisis occurred.Postoperative follow-up ranged from 3 to 12 months.The appearance and function of the repaired sites were satisfactory.Conclusion Free superficial peroneal artery perforator flap transfer for coverage of wound in the hand can lead to satisfactory clinical results.It is an effective method that is worth wide clinical application. Key words: Transplantation; Microsurgery; Superficial peroneal artery; Perforator flap; Wound

Repair of forefoot soft tissue defect by free ultra-thin superficial peroneal artery perforator flap

Objective To investigate the clinical effect of free ultra-thin superficial peroneal artery perforator flap for repairing the wound in forefoot.Methods From January 2010 to June 2012,six cases were treated with free ultra-thin superficial peroneal artery perforator flap for repairing the wound in forefoot,including 4 cases of dorsal defect,two cases of wound on the toe.The size of the wound ranged from 3.0 cm × 5.0 cm 5.5 cm × 8.0 cm.Four cases for direct suture,two cases of donor site repairing with skin graft.Results All of 6 cases were repaired successfully and no vascular crisis occurred,and clinical follow ups were performed after 3-12 months,the results was satisfactory.Conclusion It is an effective method of repairing the wound in forefoot by free ultra-thin superficial peroneal artery perforator flap. Key words: Superficial peroneal artery ; Perforator flap; Transplantation ; Forefoot ; Microsurgery

Clinical application of the free superficial peroneal artery perforator flap

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.

Propeller-Lappenplastiken: die Reliabilität der präoperativen, unidirektionalen Dopplersonografie

Propeller flaps represent an elegant and reliable method for soft-tissue reconstruction of the extremities and trunk, obviating the need for free tissue transfer. Preoperative localisation of perforators adjacent to the defect is important regarding the pivot point and length of the flap. Most commonly unidirectional Doppler sonography is used. The reliability of this method regarding propellerflaps has not thoroughly been evaluated. The aim of this study is to assess the positive predictive value of this method for planning propeller flaps. In a total of 68 patients, soft-tissue reconstruction using propeller flaps was planned with unidirectional Doppler sonography. Defects were located on the lower extremity in 48 cases, the buttock area in 15 cases and the trunk in 5 cases. In 12 cases no adequate perforators were located intraoperatively despite a positive Doppler signal. In the lower extremity Doppler produced a false-positive result in 21% of the cases, whereas in the buttock region only 13% false positives result were found. The positive predictive value overall was 82%. When no perforator was located, flap coverage was achieved using the reverse sural artery flap in 6 cases, the free peroneal artery perforator flap in 3 cases, local advancement flaps in 2 cases and skin grafting in 1 case. The reliability of unidirectional Doppler sonography is inadequate for localisation and selection of the dominant perforator when planning propeller flaps. A high rate of false-positive results needs to be anticipated especially distally in the extremities. In 18% of cases an alternative surgical plan was required to achieve soft tissue coverage. We recommend using colour duplex sonography for a more reliable preoperative localisation of perforators.

Reconstruction of soft tissue defects of the Achilles tendon with rotation flaps, pedicled propeller flaps and free perforator flaps

Soft tissue defects exposing the Achilles tendon are challenging. Local perforator flaps represent a valuable option gaining increasing popularity. Despite preoperative planning an adequate perforator cannot always be found intraoperatively. The free peroneal artery perforator flap can serve as a back-up option limiting the donor site morbidity to the same extremity without sacrificing major vessels or nerves. Nine patients with soft tissue defects exposing the Achilles tendon were treated with local perforator flaps, seven were scheduled for 180° propeller flap coverage after Doppler-ultrasound examination. However, in two patients (22%) no adequate perforators were found intraoperatively. As the perforators for the free peroneal artery perforator flap were routinely mapped out, this flap was harvested for microsurgical reconstruction. One patient with a 180° propeller flap developed a partial flap necrosis, another patient developed superficial epidermolysis, both requiring skingrafting. no complications were seen with free tissue transfer. Pedicled perforator flaps as propeller flaps add options to the armamentarium of microsurgeons. Despite thorough preoperative planning the surgeons must be prepared to perform a different method of reconstruction if inadequate vessels are encountered. To limit additional donor site morbidity, local options are preferred. The free peroneal artery perforator flap represents a good option as it matches the original tissue properties closely. The complication rate of propeller flaps in this series is tolerable. Propeller flaps should therefore be considered an alternative but not as a replacement of local fasciocutaneous flaps.