Leg Perforator Flap Research Articles

Eccentric free muscular perforator flaps in the proximal lateral leg for hand and foot reconstruction.

We aimed to introduce our modifications by using eccentrically located muscular perforators to shorten the distance between the recipient vessels and the flap pedicle for overcoming the "short pedicle" drawback of the proximal lateral leg perforator (PLLP) flap. A retrospective review of 12 cases undergoing free PLLP flap for hand and foot regions reconstruction during 2010 and 2019. The mean age was 43.3 years. Most defects resulted from burn and trauma injuries. The dimensions of defects ranged from 8× 1.5cm2 to 12 × 6.5cm2 . Muscular perforators were designed eccentrically 1-3cm away from the central point of the flap to shorten the distance between the recipient vessels and the pedicle. The flap was designed to be 0.5-1cm larger than the defect. The flap size ranged from 9× 2cm2 to 15 × 6cm2 . All pedicles were long enough to ensure an appropriate anastomosis without tension. The post-operative course in all cases was uneventful. All flaps survived without complications. Primary repair of the donor sites was performed in all patients. Donor leg function was not hampered by flap harvesting. All patients were satisfied with the scar after at least 1 year of follow-up. Based on our experience, selection of the eccentric locations of the musculo-cutaneous perforators were effective methods to overcome the short pedicle length of this flap type. Using our modifications, thin PLLP flaps can be used in foot and hand reconstruction with minimal donor site morbidity and a high success rate.

The suprafascial course of lower leg perforators: An anatomical study.

BackgroundPerforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design.MethodsAn anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported.ResultsDuring suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them.ConclusionsOur study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.

Using the posterior tibial artery and peroneal artery perforator flaps to repair heel wounds: 18 cases report

Objective To investigate the clinical efficacy of using the posterior tibial artery and peroneal artery perforator flaps to repair the heel wounds. Methods From January, 2011 to May, 2018, heel soft tissue defect caused by trauma in 18 cases were treated by posterior tibial artery and peroneal artery perforator flaps respectively. The posterior tibial artery perforator flap was used in 11 cases, and the peroneal artery perforator flap was used in 7 cases. The area of flaps ranged from 5.0 cm×3.0 cm to 11.0 cm×9.0 cm. The length of the vascular pedicle was from 10.0 cm to 16.0 cm. After operation, the patients were followed-up regularly. The time of wound healing, appearance and texture of the flap, and function of ankle joint were observed. Results After the operation, 13 flaps survived uneventfully. The wound achieved primary healing. Partial necrosis occurred in the distal of posterior tibial artery perforator flap in 2 cases, and repaired by skin graft 1 or 2 months later. Marginal necrosis occurred in posterior tibial artery perforator flap in 2 cases and in peroneal artery perforator flap in 1 case. And scar healing occurred in these 3 cases finally. All the 18 patients were followed-up for 3 to 60 months, with an average of 10 months. Fracture healing time was from 3-6 months, with an average of 4 months. Flap was soft with satisfied appearance in 16 cases. Obvious scar formation occurred in 2 cases. There was no obvious scar contracture in donor sites. There was no obvious limitation of the flexion and extension function of the ankle joint in 18 cases. According to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, there was excellent in 16 cases, and good in 2 cases. Conclusion As for the characteristics of the heel wound, it is a simple and practical method to use leg perforator flap to repair. The flap is based on a long vascular pedicle. And the clinical effect is satisfied. Key words: Posterior tibial artery; Peroneal artery; Perforator flap; Heel; Repair

Reconstruction of Diabetic Foot Defects With the Proximal Lateral Leg Perforator Flap

In patients with diabetic foot ulcers requiring flap reconstruction, the choice of local flaps is limited by the lack of adequate tissue available. Free flaps are often bulky, presenting footwear difficulty due to poor contouring. Here, we present our experience of using the proximal lateral leg perforator flap in the reconstruction of thin diabetic foot ulcers. This is a retrospective study of 17 patients with diabetic foot ulcers reconstructed with the proximal lateral leg perforator flap during January 2013 and December 2015. Nine patients had varying degrees of peripheral arterial disease. The perforator was located 7 to 14 cm (mean, 9.7 cm) from the fibula head. The pedicle length ranged from 5 to 9 cm (mean, 6.9 cm). The arterial diameter of the pedicle measured 0.8 to 1.9 mm (mean, 1.4 mm). There was 1 total flap failure. One other flap complicated by venous thrombosis was successfully salvaged. All donor sites were closed primarily without morbidities. All the wounds were stable without recurrent ulceration during a mean follow-up time of 12 months. The thin, pliable proximal lateral leg perforator flap is an option for the reconstruction of small to moderate diabetic foot defects especially when it is located over the dorsal foot or the ankle. The flap is simple and quick to harvest without sacrificing a major artery. Although it is limited by the short length and the small diameter of the pedicle, for experienced microsurgeons, the success rate is high.

A Review of Pedicled Perforator Flaps for Reconstruction of the Soft Tissue Defects of the Leg and Foot.

Lower extremity soft tissue defects frequently result from high-energy trauma or oncological resection. The lack of suitable muscle flap options for the distal leg and foot makes defects in these locations especially challenging to reconstruct and free tissue transfer is commonly used. Another option that has become more popular in the past two decades are pedicled perforator flaps. Based on a thorough literature review and the authors’ experience on leg perforator flaps for over a decade, this article presents a historical review, the anatomical basis of common perforator flaps of the leg and foot, patient selection, wound selection, perforator selection, flap design, surgical techniques, refinements, and postoperative care. A review of the clinical outcomes and complications of these flaps was also performed and was noted to be comparable to the outcomes of free tissue transfer with significantly lower total flap failure rate. It is hoped that this review will assist surgeons in the formulation of a comprehensive step-by-step guide in performing pedicled perforator flap reconstruction of the lower extremity.

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

Clinial application of free posterlateral leg perforator flap in the reconstruction of soft tissue defects at oral and maxillofacial region

Objective To investigate the outcome of free posterolateral leg perforator flap in the reconstruction of soft tissue defects of oral and maxillofacial area. Methods From February, 2014 to August, 2016, 16 patients were performed defect reconstruction following oral cancer ablation with free posterolateral leg perforator flap including 3 cases of sequamous cell carcinoma of the tongue, 6 cases of carcinoma of the buccal mucosa, 7 cases of sequamouse cell carcinoma of the floor of mouth. The flap ranged from 5.0 cm×3.0 cm to 13.0 cm ×9.0 cm in size, and were adjected to the soft tissue defects of oral and maxillofacial area. The outcome of reconstruction was evaluated by considering the facial appearance, the swallowing and the speach function, the ranges of mouth opening and patient prognosis. Results All 15 transplanted flaps survived well and only 1 survived after disposing in time, because of vascular crisis. The donor sites were closed directly without donor-site morbidity. All patients were satisfactory with their facial appearance, the ranges of mouth opening and swallowing and speech function. Conclusion The free posterolateral leg perforator was an ideal free tissue for repairing functionally oral and maxillofacial defects, sinceit including some beneficial characteristic such as constant blood vessel, flexible and divese design, abundant and position-latent donor site tissues, small operation loss, flexible preparation and loss of major vascular nerves. Key words: Oral cancer; Tissue defects of oral and maxillofacial; Posterolateral leg perforator flap; Rconstruction

Lateral lower leg perforator flaps: an anatomical study to localize and classify lateral lower leg perforators.

Despite increasing use of lateral lower leg perforator flaps, comprehensive anatomical data are still lacking. The aim of this article was to comprehensively document the pattern of usable lateral lower leg perforators. Systematic mapping of 16 cadaver leg perforators in a well-defined area was performed to elucidate location, course, length, diameter, and origin. Overall, 197 perforators were found in 16 lateral lower legs. The mean number of perforators per leg with a diameter ≥ 0.3 mm was 13.4 ± 3.6. Most perforators were found in the distal third (39.0%), followed by the middle third (32.0%), and proximal third (29.0%). A musculocutaneous course was found in 26.9% of the perforators, whereas 73.1% revealed a septocutaneous course. Most septocutaneous perforators (50.0%) were found in the distal third and most musculocutaneous perforators (58.5%) in the proximal third (P < 0.001). The majority of perforators originated from the anterior tibial artery (53.0%), followed by the peroneal artery (41.6%), and the popliteal artery (5.1%). Popliteal artery perforators (1.64 mm) were significantly larger than anterior tibial artery (0.91 mm) and peroneal artery perforators (1.02 mm; P < 0.001). These results may facilitate tissue transfer around the lateral lower leg.

Using lower leg perforator flaps to repair soft tissue defect on ankle

Objective To explore the application value of the lower leg perforator flaps in repairing soft tissue defect on ankle.Methods From January 2007 to December 2012,62 cases of soft tissue defect on ankles have been repaired.The defects were combined with tendon and/or bone exposure for all the cases,among them 7 cases were exposure or sinus tract after achilles tendon rupture surgery,8 cases with ankle or intertarsal joint defect and exposure,24 cases with distal tibia fracture,or medial malleolus fracture,or lateral malleolus fracture,or calcaneus fracture,11 cases with different level of infection.Fifteen cases were primarily repair,and 47 cases were secondly repair or extended phase.The cases were repaired by applying different types retrograde transferred perforator pedicle flaps of lower legs,with 10 cases of posterior tibial artery perforator flaps on the medial malleolus,12 cases of front top flaps of com peroneal artery on external ankle,40 cases of back top flaps of peroneal artery on external ankle.The sizes of the flap ranged from 4.0 cm ×5.5 cm to 9.0 cm × 15.0 cm.Ten cases were applied direct suturing in donor site,and other cases were applied skin grafts to repair the defect.Results Flaps in 56 cases completely survived.Partial necrosis appeared in 3 cases of front top flaps of peroneal artery on external ankle,one perforator flap of posterior tibial artery on the medial malleolus and 2 cases of back top flaps of peroneal artery on external ankle.All these cases recovered after careful dressing changes.Sixty two cases were followed up for 3-12 months.Texture of flaps was soft with good elasticity.All of the donor skin grafts in patients survived.Conclusion Perforator flaps have the advantage of easy operation,little damage to the main blood vessels,high reliability in flap survival,less destroy to donor site.It is important that individualized flap is selected given different position of defect. Key words: Ankle; Perforator flaps ; Lower leg; Soft tissue injury ; Repair

Vascular Anatomy and Clinical Application of Anterolateral Leg Perforator Flaps

There is a dearth of detailed published work on anterolateral leg perforators. The authors fully documented the vascular basis of the anterolateral leg perforator flap and report its use in reconstruction of distal extremities. Anterolateral leg perforators were investigated in 25 fresh cadavers and 10 casts of arteries. Fresh cadavers were injected with a standardized injection of lead oxide for three-dimensional visualization reconstruction using multidetector-row computed tomography and professional software. The origin, course, and distribution of the perforators in the anterolateral leg region were observed. Between March of 2008 and March of 2012, 15 free superficial peroneal artery perforator flaps were used for reconstruction of distal limbs. Flap size varied from 3.5 × 4.0 cm to 11 × 5 cm, with a uniform thickness of 3 mm. There were 7 ± 3.0 perforators in the anterolateral leg. The average external diameter was 0.7 ± 0.2 mm. Each perforator supplied an average area of 33 ± 8.0 cm. Extensive anastomoses were found between the superficial peroneal artery perforators and multiple adjacent source arteries. All cases were repaired successfully without any complications. The clinical results were satisfactory after 3 to 12 months of follow-up. The flaps were considered cosmetically acceptable by both patients and doctors. The anterolateral leg perforator flaps have a consistent, reliable blood supply and good texture. The donor site not only supplies a thin skin flap but also provides the option of harvesting cross-boundary proximally or distally based perforator flaps that could be useful for repairing widespread traumatic soft-tissue defects.

Perforator Flap from Proximal Lateral Leg for Head and Neck Reconstruction

Perforator flap transfer has the benefits of minimal donor site morbidity and customization in design. This study reports on the proximal lateral leg perforator (PLLP) flap transfer for head and neck reconstruction. From January 2000 through December 2009, 18 patients underwent head and neck reconstruction with the PLLP flap, including 16 males and 2 females ranging in age between 32 and 80 years old. The mean follow-up time was 9.8 months. Mother vessels of PLLP flaps can arise 77.8% (14/18) from the peroneal system, 11.1% (2/18) from the posterior tibial system, or 11.1% (2/18) from the common popliteal system. The skin dimension ranges from 4 cm × 7 cm to 6.5 cm × 18 cm. The mean of the perforator size is 1.96 mm (1.5 mm to 2.3 mm). The mean of the pedicle length is 6.96 cm (4.5 cm to 10 cm). All flaps survived completely except one flap that had partial necrosis. The PLLP flap for head and neck reconstruction offers versatility in design, diverse tissues for composition, a two-team approach, and negligible donor site morbidity, and it spares major vessels. The unpredictable pedicle length and the feasibility for microvascular anastomosis in the perforator level can be adapted with further experience and refining techniques.

Free vascularized leg perforator flap for the wounds of the extremities

Objective To evaluate the locating effects of a portable ultrasound for leg perforator flaps,and the clinical effects of leg perforator flaps for the wounds of the extremities.Methods Since December 2009 to March 2011,thirty-one cases of soft tissue defects of the extremities were treated with free vascularized leg perforator flaps in our center.A portable ultrasound were used for the locating of the perforator arteries of the leg before the operations.These flaps include 24 cases of the fibular artery perforator flaps (4 with simultaneous fibula transfer),three cases of the posterior tibia artery perforator flap,two cases of the medial gastrocnemius artery perforator flap,and 2 cases of the lateral gastrocnemius artery perforator flap.The flap size ranged from 15.0 cm × 8.0 cm to 1.0 cm × 1.5 cm.The caliber diameter of the perforator artery ranged from 0.2 mm to 1.8 mm.The wounds included 21 cases of the hand,five cases of the forearm,and 5 cases of the leg.Results The coincidence rate intraoperatively of the portable ultrasound was 96.8％.All the flaps survived and the wounds healed uneventfully.The donor site of the flaps were either closed directly or closed with partial split-thickness skin graft.Conclusion The portable ultrasound is an effective,reliable and accurate instrument for locating the leg perforator flaps.The leg perforator flaps have the advantages of convenient harvest,satisfactory thickness,less donor site morbidity,and high survival rate. Key words: Leg; Perforator flaps; Transfer; Trauma; Microsurgical operation

Aesthetic reconstruction of lower leg defects using a new anterolateral lower leg perforator flap

Our objective in this study was to report on the successful clinical use of a new perforator flap obtained from the proximal quarter of the anterolateral lower leg. Eight patients had the procedure either as a result of trauma (seven patients) or to treat Marjolin's ulcer (one patient). During the procedure, a line was drawn from the anterior fibular head to the anterior lateral malleolus. Then, using Doppler, a septocutaneous perforator from the fibular head to the proximal quarter point of the line was identified. The subfascial dissection was continued to the detected perforator. Along the perforator in the anterior intermuscular (peroneal) septum, a deep dissection was performed. The perforator was then separated and the flap harvested. The septocutaneous perforator was the perforator of the superficial peroneal nerve accessory artery in three cases, the perforator of the superior lateral peroneal artery in one case, and the perforator originating directly from the anterior tibial artery in four cases. Seven of eight cases were treated successfully. The results obtained were satisfactory, both aesthetically and functionally. This flap is a valuable alternative to the various perforator flaps from the lower leg. This flap has the advantage of being very thin, which makes it suitable for reconstruction of defects in the foot, ankle, pretibial area, and knee. However, one limitation of this procedure is that the diameter of the perforator was approximately 0.6-1.2 mm.

Clinical Applications of Free Soleus and Peroneal Perforator Flaps

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.