Posterior Tibial System Research Articles

Avoiding second donor site and the second set of neck vessels in a case of absent peroneal skin perforators

This report describes the procedure of a case in which the skin paddle of the free fibula flap derived its supply solely from a soleal musculocutaneous perforator originating from the posterior tibial system. In contrast, the osteo-muscular component was supplied by the peroneal vascular system. We harvested the skin paddle with its vascular supply from the posterior tibial artery separately, and the osteo-muscular fibula was harvested with its supply from peroneal vessels. In this way, we avoided violation of the second donor site for the skin paddle. In addition, we used the distal end of peroneal vessels to salvage our skin paddle instead of sacrificing another set of neck vessels for anastomosis. This technique may also be utilised in cases where the neck vessels may not be available due to previous surgeries, radiation therapy, or decision by the surgery team to not sacrifice two sets of neck vessels for anastomosis.

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.

Preoperative Magnetic Resonance Angiography Detection of Septocutaneous Perforators in Fibula Free Flap Transfer

To investigate whether preoperative magnetic resonance angiography (MRA) is predictive of surgical findings in fibula free flap surgery for head and neck reconstruction. Retrospective review (April 2004 until September 2009) of 123 patients who underwent preoperative MRA as part of surgical planning for fibula free flap tissue transfer for head and neck reconstruction. Each MRA was reviewed by a board-certified radiologist masked to the intraoperative findings and to the number of septocutaneous perforators documented. Operative notes were reviewed and the number of septocutaneous perforators found during the operation was recorded. A κ interrater agreement statistic was calculated to compare these values. Two vascular anomalies found during the operation were undetected by MRA. Analysis of the entire cohort demonstrated that agreement between the number of perforators documented on MRA and the number found intraoperatively approached zero (unweighted κ = -0.088, P = .04). The agreement between the 2 values was 17.9% and the average percentage correctly classified was 10.9%. Contrary to previous reports, preoperative MRA does not accurately predict the presence and/or number of skin perforators found intraoperatively for a fibula free flap operation. The surgeon should not be dissuaded from planning a fibula free flap operation if skin perforators appear unfavorable on preoperative MRA because intraoperative observation is definitive. The surgeon should prepare for anomalous cases in which perforators may arise from the posterior tibial system. Further investigation is needed to achieve more accurate imaging modalities for evaluating septocutaneous perforators prior to free fibula flap transfer.