The proximal lateral lower leg perforator flap revisited: Anatomical study and clinical applications

THE PROXIMAL LATERAL LOWER LEG PERFORATOR FLAPREVISITED: ANATOMICAL STUDY AND CLINICAL APPLICATIONS

JIUNN-TAT LEE, MD,1,2 PEIR-RONG CHEN, MD,2,3 HONDA HSU, MBChB,2,4* MENG-SI WU, MD,1 LI-FU CHENG, MD,1,2

CHIEH-CHI HUANG, MD,2,4 and SOU-HSIN CHIEN, MD2,5

Background: The proximal lateral lower leg flap is a flap suited for the reconstruction of small and thin defects. The purpose of this studywas to map the position and consistency of the perforator vessels and to review its reliability and technical considerations clinically. Meth-ods: The location, number, and size of perforator vessels in the proximal third of the lateral lower leg were investigated in 20 fresh frozencadaveric lower limbs. This was analyzed together with 22 clinical cases. Results: Cadaveric dissection showed that there were 1–2 per-forators in the proximal third of the lateral lower leg and these perforator vessels were found to be 63% septocutaneous and 37% muscu-locutaneous. The source vessel of the perforators was variable. Clinically the recipient site consisted of the head and neck in 8 cases, thefoot and ankle region in 13 cases, and 1 case in the hand. The mean thickness of this flap was 5.8 6 0.8 mm. Vascular pedicle lengthranged from 5 to 8.5 cm. The mean diameter of flap artery was 1.3 6 0.3 mm. One flap failure was seen due to arterial thrombosis. Theoverall flap survival rate was 95%. Conclusions: The proximal lateral lower leg flap has the advantages of being thin and pliable, quick toharvest with no major arteries sacrificed. There is minimal donor site morbidity and primary closure of the donor site is possible in themajority of cases. VC 2014 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2014.

Numerous intraoral defects and complicated wounds

with bone or tendon exposure at the hand or the ankle

and foot region often require reconstruction with a rela-

tively thin flap. This is still a challenge to reconstructive

surgeons. The difficulty that arises is not the ability to

provide a soft tissue cover but rather in providing a cos-

metically acceptable cover with minimal donor site mor-

bidity. The ideal flap should be thin, pliable, easy to

harvest, with a reliable blood supply and a vascular pedi-

cle of reasonable length and diameter.

The peroneal flap, which was introduced by Yoshi-

mura et al. in 1984,1 is ideal for the reconstruction of

such thin defects. This flap can be harvested with the fib-

ular bone as an osteocutaneous flap or with fibula bone

and soleus muscle as an osteomyocutaneous flap.2 It is

usually designed in the middle and the distal thirds of

the lower leg. The peroneal artery, which is used as its

pedicle, is sacrificed. Yajima et al.3 reported using the

proximal lateral leg flap based on skin perforators as its

pedicle, thus preserving the peroneal artery. However,

prior studies found that the perforator vessel in this area

always penetrated the soleus muscle and there are

conflicting studies reporting that the perforators in the

proximal lateral lower leg are predominantly musculocu-

taneous in type. At present, there is a lack of detailed

anatomical study with regard the location, characteristics

of the perforator vessels, and properties of the proximal

lateral lower leg flap. The purpose of this study was to

map the position and consistency of the perforator ves-

sels and to review its reliability and technical considera-

tions clinically.

MATERIALS AND METHODS

Cadaveric Dissection

Twenty proximal lateral lower legs were dissected in

ten fresh frozen cadavers at the Tzu Chi University Med-

ical Simulation Center. Latex injection technique was

used to facilitate identification of the vessels. The popli-

teal vessel was dissected out and flushed with hepari-

nized warm saline (10 U/mL) followed by 20 mL of

colored latex (Ward’s, Rochester, NY). The cadaver was

refrigerated at 4�C for 24 hours for the latex to solidify.

The fibula was marked out and divided into three

equal lengths. An incision was made over the anterior

border of the fibula. The flap was elevated from the sub-

fascial layer progressing posteriorly to the posterior sep-

tum. In each case, the dissection was performed from the

popliteal fossa till one-third of the total length of the fib-

ula. After confirming the presence of the perforator ves-

sels, they were dissected till the source artery. Only

arterial perforators with diameters greater than 0.3 mm in

size (measured at penetration through the deep fascia)

were included in the study. They were recorded as either

septocutaneous or musculocutaneous perforators (Figs. 1a

and 1b). The number, diameter, length of the pedicle,

1Division of Plastic Surgery, Buddhist Tzu Chi General Hospital, Hualien,Taiwan2School of Medicine, Tzu Chi University, Hualien, Taiwan3Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Hualien,Taiwan4Division of Plastic Surgery, Buddhist Dalin Tzu Chi Hospital, Tzu Chi Univer-sity, Dalin, Taiwan5Division of Plastic Surgery, Buddhist Taichung Tzu Chi Hospital, Taichung,Taiwan

*Correspondence to: Honda Hsu, Division of Plastic Surgery, Buddhist DalinTzu Chi Hospital, Tzu Chi University, Dalin, Taiwan.E-mail: [email protected]

Received 21 October 2013; Revision accepted 26 March 2014; Accepted 3April 2014

Published online 00 Month 2014 in Wiley Online Library(wileyonlinelibrary.com). DOI: 10.1002/micr.22264

� 2014 Wiley Periodicals, Inc.

and distance of the perforator from the fibula head were

also noted.

Patients

Twenty-two patients from March 2005 to March

2011 with various defects were reconstructed with the

proximal lateral lower leg flap. The patient’s charts were

reviewed. There were 13 males and 9 females with a

mean age of 52 years. The recipient site consisted of the

head and neck in 8 cases, the foot and ankle region in

13 cases, and 1 case in the hand. The etiology of the tis-

sue defects include: trauma (n 5 5), chronic ulcer (n 5 5),

oral cancer (n 5 5), pressure sore (n 5 3), burn (n 5 2),

hemangioma (n 5 1), and osteoradionecrosis (n 5 1). Flap

thickness, pedicle length, and diameter of the vascular

pedicle as well as the distance of the pedicle from the

fibula head were recorded. The complication rates and

flap failure rates were noted.

Surgical Procedure

The surgical procedure has been described in previ-

ous literature.3 We describe it with some important modi-

fications. The procedure was performed with the patient

in the supine position with the hip and knee flexed. The

contour of the fibula was marked out and divided into

three equal parts. The location of perforator vessels was

identified preoperatively using a handheld Doppler flow-

meter. There were usually one or two points near the dis-

tal portion of the proximal third of the lateral lower leg

along the posterior margin of the fibula (Fig. 2). The out-

line of the flap was then designed to include the marked

out points. The tourniquet was not used as this allowed

us to visualize the perforator, as well as its pulsatile

strength, with greater clarity. The skin was incised ante-

rior to the posterior septum and the flap elevated subfas-

cially. After confirming the presence of the perforator

vessels, the flap was elevated from the posterior border.

The perforator vessel was then dissected intramuscularly

with ligation of the muscular branches if it was found to

be traversing the soleus muscle. If a septocutaneous per-

forator was found, then the dissection was straightfor-

ward (Fig. 3). When multiple perforators were present,

the larger perforator or the septocutaneous perforator was

chosen. The soleus muscle was then detached from the

fibula, and the bifurcation of the perforator vessels from

the main artery was located. The flap was elevated after

ligating the perforator vessels at their bifurcation. The

flap was insetted to the defect with microsurgical anasto-

mosis using 10-0 nylon. The donor site was closed pri-

marily when the width of the flap was less than 6 cm.

RESULTS

Anatomical Observations

The results of cadaveric dissection are summarized in

Table 1. The fibula length ranged from 31 to 39 cm.

A sizable perforator (arterial diameter> 0.3 mm) can

always be found within a 3-cm radius from the junction

of the proximal and middle third of the fibula bone. The

distance of this perforator from the fibular head was

7–10 cm (mean 8.4 6 1.8 cm). In 20% of the cases, a

further perforator can be found within the proximal third

Figure 1. (a) Anatomical specimen showing the presence of a mus-

culocutaneous perforator vessel. Intra-muscular dissection was per-

formed to track the perforator to the main trunk. (b) An anatomical

specimen clearly depicting the presence of a septocutaneous per-

forator vessel. [Color figure can be viewed in the online issue,

which is available at wileyonlinelibrary.com.]

Figure 2. The contour of the fibula was marked out. The presence

and the location of the perforator could easily be detected with a

handheld Doppler flowmeter. The perforators were usually located

along the posterior margin of the fibula, near the distal portion of

the proximal third of the lateral lower leg. [Color figure can be

viewed in the online issue, which is available at

wileyonlinelibrary.com.]

2 Lee et al.

Microsurgery DOI 10.1002/micr

of the lower leg. However, there was a wide variation in

the number of perforators seen in both inter- and intra-

cadaver legs. The perforators were found in these 20 legs

to be 63% septocutaneous and 37% musculocutaneous

perforators. The length of the perforators ranged from

4 to 8 cm (mean 5.2 6 1.3 cm). The mean arterial diame-

ter, at its bifurcation from the main trunk, had a range of

range 0.5–1.8 mm (mean 1.0 6 0.3 mm). The source ves-

sel of the perforators arose from peroneal artery (13/24,

54%), tibioperoneal trunk (6/24, 25%), posterior tibial

artery (4/24, 17%), and popliteal artery (1/24, 4%).

Clinical Applications

The flap size ranged from 4 3 3 cm to 11 3 8 cm.

The mean thickness of the flap had a range of 4.5–7 mm

(mean 5.8 6 0.8 mm). The mean diameter of the perfora-

tor artery was 1.3 6 0.3 mm and the mean length of the

vascular pedicle was 6.5 6 1.2 cm. Six flaps had a single

conmitant vein and the other sixteen flaps had two con-

mitant veins. The diameter of the vena comitante ranged

from 0.7 to 2.8 mm (mean 2.0 6 0.8 mm). The mean dis-

tance from the fibula head was 8.6 6 2.1 cm. The mean

time of flap harvesting was 62 minutes (range 42–120

minutes). In 41% of the cases, a septocutaneous perfora-

tor was used and in 59% of the cases a musculocutane-

ous perforator was used (Table 2).

One venous thrombosis developed in a patient with

oral cancer (case 6) and this was successfully salvaged.

One flap developed total necrosis in a patient with diabe-

tes mellitus due to arterial thrombosis and one further

flap developed partial necrosis. The other 20 flaps sur-

vived completely. The flap survival rate was 95%

(21/22). The donor site was closed primarily in 20 cases.

Skin grafts were required in 2 cases. There was no sen-

sory or motor deficit at the donor leg. Apart from the

skin grafted donor legs, cosmesis of the linear scar was

good to excellent (Fig. 4).

CASE REPORTS

Case 1

A 54-year-old female patient sustained an avulsion

injury over her right lower leg and posterior heel with

exposure of the Achilles tendon (Fig. 5a). An 11 3 5 cm

flap was designed on the distal portion of the proximal

third of the right leg (Fig. 5b). The largest perforator,

which was musculocutaneous type and found to penetrate

through the soleus muscle, was used. After intramuscular

dissection of the perforator, the flap was elevated and

transferred to the recipient site. End-to-side anastomosis

of the pedicle artery to posterior tibial artery was per-

formed with 10-0 Nylon sutures. The pedicle veins, of

which there were two, were both anastomosed to the

conmitant veins of posterior tibial artery by end-to-end

fashion (Fig. 5c). The remaining defect was skin grafted.

The donor site was closed primarily. Follow-up at 1 year

showed complete survival of the flap (Fig. 5d).

Case 2

A 56-year-old man with squamous cell carcinoma of

the right buccal area underwent wide excision with a

resultant defect of 8 3 5 cm (Fig. 6a). This was recon-

structed with a proximal lateral lower leg flap designed

over the right lower leg (Fig. 6b). The artery was anasto-

mosed to a branch of the facial artery in end-to-end anas-

tomosis. The pedicle with only one conmitant vein was

anastomosed to a branch of the facial vein also in an

end-to-end anastomosis (Fig. 6c). The flap healed well

and showed good contouring to the buccal surface at

1 year follow up (Fig. 6d).

DISCUSSION

In our center, as well as in others, the radial forearm

flap is still the favored flap for small and thin defects.

However, donor site morbidity and complications remain

a major concern for this workhorse flap.4–6 They often

need to be skin grafted for wound closure. Wound

Table 1. Summary of Pertinent Cadaveric Findings

Number of legs with one perforator 16

Number of legs with two perforators 4

Number of musculocutaneous perforators 9

Number of septocutaneous perforators 15

Distance from fibula head 8.35 6 1.78 cm

Length of pedicle 5.15 6 1.25 cm

Diameter of perforator artery 1.01 6 0.31 mm

Figure 3. Schematic illustration depicting the course of the perfora-

tor vessels. It could pass either straight through the septum as a

septocutaneous perforator or traverse the muscle as a musculocu-

taneous perforator. [Color figure can be viewed in the online issue,

which is available at wileyonlinelibrary.com.]

Proximal Lateral Lower Leg Perforator Flap Revisited 3


Tab

le2.

Patient

Dem

ogra

phic

s

Case

Age/

Sex

Defe

ct

Location

Fla

pS

ize

(cm

)

Patient

Weig

ht

(kg)

Fla

p

Thic

kness

(mm

)

Septo

/

Musc

ulo

-

cuta

neous

Dis

tance

from

fibula

r

Fib

ula

rhead

Head

(cm

)

Pedic

le

Length

(cm

)

Art

ery

Dia

mete

r

(mm

)

Fla

p

Surv

ival

Com

plic

atio

ns

174/M

Late

ralF

oot

73

468

5M

c8

61.5

Yes

Nil

265/F

Left

Heel

83

554

6M

c7

71.2

Yes

Nil

370/F

Left

Ankle

63

370

5M

c9

71.4

Yes

Nil

425/F

Dors

alF

oot

63

346

6M

c7

50.8

Yes

Nil

554/F

Rig

ht

Ankle

11

35

50

7M

c7

71.4

Yes

Nil

647/M

Tongue

Base

73

475

6M

c7

81.4

Yes

Venous

thro

mbosis

762/F

Mouth

Flo

or

73

450

6M

c8

60.8

Yes

Nil

820/F

Scalp

43

447

7M

c7

8.5

1.5

Yes

Nil

942/M

Left

Face

11

38

75

5S

86

1.5

Yes

Part

ialw

ound

dehescence

10

15/F

Left

Thum

b6

35

45

7S

85

1.0

Yes

Nil

11

53/M

Left

Ankle

43

370

5.5

S9

71.4

Yes

Nil

12

51/M

Left

Ankle

73

473

6S

78

1.6

Yes

Nil

13

68/F

Left

Foot

63

453

6.5

S10

71.5

Yes

Nil

14

49/M

Left

Mandib

le13

35.5

73

6M

c15

81.4

Yes

Nil

15

64/M

Rig

ht

Heel

11

35

71

5.5

S8

51.5

Yes

Nil

16

49/M

Dors

alF

oot

93

770

4.5

S7

70.8

Yes

Part

ialflap

necro

sis

17

55/M

Pla

nta

rfo

ot

93

569

5M

c11

51.4

No

Art

erialth

rom

bosis

with

flap

failu

re

18

54/M

Left

Buccal

73

468

5S

13

51.5

Yes

Nil

19

66/F

Left

Buccal

93

351

7M

c7

61.5

Yes

Nil

20

56/M

Rig

ht

Bucca

l8

35

70

5.5

Mc

88

1.6

Yes

Nil

21

65/M

Rig

ht

Foot

53

468

5M

c10

71.2

Yes

Nil

22

42/M

Rig

ht

Ankle

12

34

68

5S

95

1.5

Yes

Nil

M5

Male

male

,F

5F

em

ale

fem

ale

,M

c5

Musculo

cuta

ne

ousm

usculo

cuta

neous,

S5

Septo

cuta

neoussep

tocuta

neous.

4 Lee et al.


complications include partial loss of the skin graft, expo-

sure of tendons, and delays in wound healing. Long-term

morbidities include reduced range of motion of the wrist,

reduced pinch and grip strength, loss of superficial radial

nerve sensation, and cold intolerance.4–6 Cosmesis

remains a major problem, especially in the Asian popula-

tion. Hyperpigmentation and hypertrophic scar is com-

monly seen in this population group.

The introduction of perforator flaps has gradually

gained widespread acceptance amongst the reconstructive

surgeons. The anterolateral thigh perforator flap is the

most commonly used perforator flap for various kinds of

defects. It functions well when a larger and thicker flap

is required.7–9 However, it is usually too bulky in some

female and obese patients and hence primary thinning of

the flap or secondary debulking are required. Some stud-

ies have shown that these flaps can be thinned till a

thickness of 3–5 mm.10,11 But in our experience and

others, this is technically demanding and runs the risk of

damaging the subdermal plexus, resulting in flap ische-

mia and partial flap necrosis.12,13 A number of other per-

forator flaps had been described, but thin perforator flaps

for the reconstruction of small and thin defects are still

uncommon.

The lateral lower leg is a good donor site for perfora-

tor flaps and a great majority of cutaneous perforators

here originate from the peroneal artery.14,15 The average

number of perforators from the peroneal artery is

4.8 6 1.4 (range 3–8). The peroneal artery nourishes

mainly the middle third to the lower third of the lateral

aspect of the lower leg.14 However, perforators of the

proximal lateral lower leg can originate from several dif-

ferent source arteries, these include: inferior lateral genic-

ulate, popliteal, anterior tibial, tibio-peroneal trunk,

posterior tibial or peroneal artery.3 These cutaneous per-

forators can be classified into musculocutaneous perfora-

tors that penetrate into muscle before reaching the skin

or septocutaneous perforators that traverse through the

septum before reaching the skin. Yajima et al.3 intro-

duced the proximal lateral leg flap. They based the flap

on the cutaneous branches of the major nutrient artery to

the lateral half of the soleus muscle, thereby sparing the

peroneal artery. They further described that there are usu-

ally one or two “points” near the distal portion of the

proximal third of the lower leg where a major nutrient

artery could be found by using a Doppler flowmeter.3 In

2005, Kawamura together with Yajima and others

described in two separate reports the use of this flap and

renamed it “soleus perforator flap,” as they found that

the perforator vessels always pierce the soleus muscle

prior to reaching the skin.16,17

Yoshimura et al.1 initially reported that “the musculo-

cutaneous branch is distributed from the lower part of

the upper third of the lateral side of the lower leg to the

middle third and that the direct cutaneous artery is dis-

tributed from the middle third to the lower third.” In

1990, he performed a further cadaver study, where he

divided the length of the fibula into 10 equal parts.

According to them even though the septocutaneous-type

vessels were found all along the lateral leg except the

proximal 2/10 of the leg, but at the proximal third of lat-

eral lower leg, the musculocutaneous perforators predo-

minated and septocutaneous perforators were rare.11

Chen in 1985 found that the first artery is usually a

direct cutaneous artery and that the others are predomi-

nately musculocutaneous.18 Our findings showed that in

our anatomical dissection (20 legs), 63% of all perfora-

tors in the proximal one-third of the lateral leg were sep-

tocutaneous and clinically (22 legs) showed that 41% of

the flap perforators used were septocutaneous. These per-

forator vessels do not necessarily have to penetrate the

soleus muscle. Wolff et al. used perforator flaps from the

proximal one-half of the lateral lower leg for intraoral

reconstruction. In their earlier studies, they described that

30% of the perforators were septocutaneous.19,20 But in

their latest study in 2012, 70% of the vessels were found

to be septocutaneous and they used the term “peroneal

perforator flap” because in their cases, the perforators all

originated from the peroneal artery.21 In light of the find-

ings that at the proximal lateral lower leg, the perforators

do not always penetrate the soleus muscle, and the perfo-

rator can originate from several different source arteries;

other than the peroneal artery, we would recommend the

Figure 4. Only a fine linear scar was visible at the donor site upon

follow up. [Color figure can be viewed in the online issue, which is

available at wileyonlinelibrary.com.]



Figure 5. (a) The defect over the Achilles tendon was debrided and suitable vessels for anastomosis were identified and prepared for

anastomosis. (b) A proximal lateral lower leg flap with a septocutaneous perforator was elevated. (c) The flap was insetted over the

exposed Achilles tendon defect. (d) One year follow up showed good survival of the flap and good contouring of the area reconstructed.

[Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 6. (a) A 56-year-old male patient with primary squamous cell carcinoma of the right buccal area, after wide excision a 8 3 5 cm

defect remained, with exposure of the mandibular bone. (b) A 8 3 5 cm proximal lateral lower leg flap was designed over the right lower

leg. The perforator was located 8 cm distal to the fibula head. (c) Immediate post-reconstruction photograph showed the flap fitting the

defect well. (d) Post-operative follow up at 1 year showed a small, thin flap with absence of trismus. [Color figure can be viewed in the

online issue, which is available at wileyonlinelibrary.com.]

6 Lee et al.


use of the previous name, the proximal lateral lower leg

flap. This is in accordance to the location of the flap.

The small diameter of pedicle vessels was the main

challenge for anastomosis, but it was not especially diffi-

cult in the hands of an experienced microsurgeon.

Venous thrombosis was seen in 5 of 18 flaps (28 percent)

in Kawamura’s series.16 They commented that the venous

wall of these perforator flaps running through the

muscles were very thin contributing to the high compli-

cation rate. In our series, only one venous thrombosis

developed in case 6. This was successfully salvaged.

There was one total flap failure due to arterial thrombosis

with a flap success rate of 95%. This is comparable to

the use of radial forearm flap or anterolateral thigh flap.

We also noticed that due to the small size of the vessels

they tend to undergo vessel spasm during dissection. If

this does occur, one should give the vessel some time,

flush with Lidocaine or Prostagladin E1, and wait for the

spasm to pass.

The donor site of proximal lateral lower leg flap can

usually be closed primarily when the width of this flap

was less than 6 cm. Only a linear scar is seen. We usu-

ally perform a pinch test to determine whether the donor

site can be closed primarily. When compared to the

“peroneal perforator flap” located at distal lower leg in

Kawamura’s study,16 the proximal lateral leg lower flap

has the advantage of being located in a region where the

surrounding skin is looser. This permits a slightly larger

flap to be harvested while still allowing for primary clo-

sure of the donor site. The proximal lateral lower leg

flap also has a longer pedicle than the “peroneal perfora-

tor flap” that was described by Kawamura et al.16

Some surgeons recommend the use of computed

tomographic angiography22,23 or magnetic resonance

angiography24 for flaps with variable anatomy such as

anterolateral thigh flap, deep inferior epigastric perforator

flap, and fibula osteocutaneous flap. However, we found

this unnecessary with this flap, because the vascular anat-

omy of this flap is simple and the skin at proximal lateral

lower leg is thin; even if the perforator was a musculocu-

taneous type, the intramuscular course was short. In all

our cases, 1–2 perforator vessels could easily be located

using Doppler flowmeter preoperatively. The location of

the perforator always lies on the posterior margin of the

fibula bone about 7–15 cm distal to proximal end of fib-

ula. We always made the anterior incision first. This was

different to a previous surgical technique described. We

found that by making the anterior incision first, it was

easier to locate the septocutaneous perforator. Patients

with peripheral artery occlusive disease are excluded

from the use of this flap. However, patients with diabetes

mellitus and old age d not preclude the use of this flap.

We used this flap in five diabetic patients and in four

patients aged greater than 65 years. The only flap failure

in our series was found in a diabetic patient. Although

the flap perfusion was intact during elevation, severe ath-

erosclerosis was noted in the recipient artery during anas-

tomosis. Postoperative arterial thrombosis was considered

to be the primary cause of flap failure. One should still

be cautious of the possibility of poor quality of recipient

vessels, leading to a higher complication rate and ulti-

mately total flap failure as seen in this case.

In head and neck reconstruction, the anterolateral

thigh flap and the radial forearm flap have become the

workhorse flaps at our center. Anterolateral thigh flaps

are often used when a larger flap with bulk is required.

The radial forearm flap is utilized mainly for small and

thin defects. In this series, we used the proximal lateral

lower leg perforator flap in eight selected patients taking

advantage of the minimal donor site morbidities associ-

ated with this flap. All the flaps in our eight patients sur-

vived well. Due to the short pedicle of this flap, we

chose the lingual artery and the facial artery as their

donor vessels. Numerous veins can be used at this area.

In our opinion, we would not recommend the use of this

flap as the first choice for patients who had undergone

previous surgery or radiotherapy. One would encounter

difficulties with anastomosis when considering the small

vessel caliber and short pedicle. We suggest that this flap

can be used for reconstruction of small defects in

selected cases as an alternative to the radial forearm flap.

CONCLUSION

The proximal lateral lower leg flap provides a thin

and pliable flap, which has constant anatomical structures

and blood supply. Our anatomical study shows that a

sizeable perforator can always be found within a 3-cm

radius from the junction of the proximal and middle third

of the fibula bone and these perforator vessels are 63%

septocutaneous and 37% musculocutaneous. Clinically,

the harvesting of this flap does not require any major

arteries to be sacrificed. There is minimal donor site mor-

bidity with primary closure possible if the width of the

flap did not exceed 6 cm. However, this flap demands

mature microsurgical skills due to small vessels with a

short pedicle. This flap is a useful option in selected

patients with small to medium soft-tissue defects.

REFERENCES

1. Yoshimura M, Imura S, Shimamura K, Yamauchi S, Nomura S. Per-oneal flap for reconstruction in the extremity: preliminary report.Plast ReconstrSurg 1984;74:402–409.

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The proximal lateral lower leg perforator flap revisited: Anatomical study and clinical applications