Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 386e393

Versatility of the pedicled peroneal arteryperforator flaps for soft-tissue coverage of the lowerleg and foot defects*

Ting-Chen Lu, Cheng-Hung Lin*, Chih-Hung Lin, Yu-Te Lin, Ruei-Feng Chen,Fu-Chan Wei

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and ChangGung University, 5, Fu-Hsing St. Kuei-Shan, Taoyuan, Taiwan

Received 19 January 2010; accepted 7 May 2010

KEYWORDSPedicled perforatorflap;Leg and footreconstruction;Peroneal artery;Propeller flap

* Part of the work was presented inJanuary 2009.* Corresponding author. Tel.: þ886E-mail address: lukechlin@gmail.c

1748-6815/$-seefrontmatterª2010Bridoi:10.1016/j.bjps.2010.05.004

Summary Even a small defect in the lower leg and foot with exposure of bones or tendonscan result in an intractable wound, which may require a microsurgical tissue transfer. Withthe concept of the perforator flap, a pedicled peroneal artery perforator flap can be usedfor coverage of this difficult region. Between August 2001 and August 2008, 18 pedicled pero-neal artery perforator flaps were performed in 18 patients. The fasciocutaneous flaps wereemployed to cover defects in the pretibial area (nZ 6), Achilles’ tendon and/or hindfoot(nZ 7) and lateral malleolar area (nZ 5). The pedicled peroneal artery perforator flaps areclassified into five types: propeller flap (nZ 11), peninsular flap (nZ 4), advancement flap(nZ 2), proximally based island flap (nZ 1) and distally based island flap (nZ 0). The sizeof the flaps ranged from 7.5 � 3 cm2 to 20 � 8 cm2. The selected perforator depended onthe defect location, ranging from 4.5 to 18 cm above the tip of the lateral malleolus. Postop-erative venous congestion was encountered in four propeller flaps and one proximally basedisland flap. Venous congestion subsided within days without complications, except one whichneeded further reconstruction with skin grafts. In conclusion, the peroneal artery perforatorsare predictable and reliable for the design of a perforated-based flap. Elevation of the flap canbe performed easily in the supine or prone position, depending on the defect location.Different designs of this perforator-based flap can repair a variety of leg and foot defects.ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Annual Scientific Meeting of American Society of Reconstructive Microsurgery, Maui, Hawaii, on 11

3 3281200x2946; fax: þ886 3 3289582.om (C.-H. Lin).

tishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Versatility of the pedicled peroneal artery perforator flaps 387

It remains a challenge to provide satisfactory coverage fordefects of the lower leg and foot with exposed tendons orbones. Due to the paucity of local cutaneous and muscleflaps in this difficult area, even a small defect that resultsfrom trauma or a non-traumatic lesion, such as skin cancer,traditionally requires free-flap transfer. In 1981, Pontenfirst proposed that local fasciocutaneous flaps could offeran excellent alternative for soft-tissue defects of the legs.1

Thereafter, many flaps were developed, such as proximallyor distally based fasciocutaneous flaps, sural artery flaps2e4

and muscle flaps with skin graft coverage.5 The concept ofperforator-based flaps described in the early 1990sprovided a better way to cover a lower extremity defect.6

An anatomical study of the fibula osteoseptocutaneousflap showed that the peroneal artery perforator flap wasmore adaptable because it supplies a wider area and hasa constant supply of arterial blood.7,8

Although free-tissue transfer plays an important role inlimb salvage, a better understanding of local flap design hasprovided an easier and more cost-effective approach forsoft-tissue coverage of the injured lower extremity. Thepurpose of this article is to present our experience in usingthe pedicled peroneal artery perforator flaps for leg andfoot defects, and to provide a classification scheme of thisversatile flap.

Patients and methods

Between August 2001 and August 2008, 18 patients withdefects over the lower leg and foot were covered using thepedicled peroneal artery perforator flaps in Chang GungMemorial Hospital. There were seven females and 11 males.The average age of the patients was 50.5 years, rangingfrom 4 to 82 years. Among the patients, four patients hadthe co-morbidity of diabetes mellitus. The defects were

Table 1 Clinical details

Case no. Gender Age(years)

Cause of defect Wound l

1 M 66 Crush injury Achilles’2 M 60 Crush injury Lateral m3 F 43 Contact thermal burn Achilles’4 F 53 Crush injury Pretibial5 F 57 Crush injury Pretibial6 M 73 Traffic accident Pretibial7 F 51 Crush injury Achilles’8 F 26 Traffic accident Pretibial9 F 35 Falling injury Lateral m10 M 82 Crush injury Achilles’

Hind foo11 M 74 Melanoma Lateral m12 F 16 Traffic accident Lateral m13 M 60 Contact thermal burn Achilles’14 M 42 Traffic accident Pretibial15 M 59 Traffic accident Achilles’16 M 75 Crush injury Lateral m17 M 33 Traffic accident Pretibial18 M 4 Cutting injury Achilles’

M, male; F, female; L, left; R, right; DM, diabetes mellitus; COPD, ch

located at the pretibial area (nZ 6), Achilles’ tendon and/or hindfoot (nZ 7) and lateral malleolar area (nZ 5).Almost all defects were secondary to trauma, except onepatient whose defect resulted from the excision of mela-noma. The size of defects ranged from 3� 3 cm2 to8� 8 cm2. Routine arteriograms were not performed priorto the use of these flaps, but were carried out in twopatients. Case 4 was a patient with poorly controlled dia-betes mellitus, who has been bedridden for a long time,while case 11 was a 74-year-old patient in whom an arte-riogram was carried out due to his more advanced age(Table 1).

We classified pedicled peroneal artery perforator flapsinto five types: (A) propeller flap, (B) peninsular flap, (C)advancement flap, (D) proximally based island flap and (E)distally based island flap (Figure 1). There were 11 propellerflaps, four peninsular flaps, two advancement flaps and oneproximally based island flap included in this series.

Choice of flaps and surgical techniques

The choice of flap depends on the defect location and size.Among the five types of pedicled peroneal artery flaps, thepeninsular flap (Type B) is often the flap of choice due tothe lower risk of venous congestion and preservation of theperoneal artery. Furthermore, there is seldom a need tocarry out microsurgical dissection of the perforators,resulting in a shorter operating time. The peninsular flap ismost suitable when the rotation arc to reach the defect isless than 90�. For smaller defects located at the lateral legor posterior calf, advancement flaps (Type C) can be used ifthe distance of advancement is less than 4 cm, and also ifthe surrounding tissues are healthy and reliable. Propellerflaps (Type A) possess the advantages of versatility in designand also a greater freedom of movement, allowing more

ocation DefectsSize (cm2)

Comorbidities Arteriogram

tendon, L 4� 3 e e

alleolus, L 6� 4 e e

tendon, L 8� 6 e e

area, R 5� 5 DM Yesarea, L 7� 4.5 DM e

area, L 4� 3 e e

tendon, L 6� 6 Hypertension e

area, L 5� 5 e e

alleolus, L 8� 6 e e

tendon;t, R

4� 2.5 DM e

alleolus, R 4� 3 e Yesalleolus, R 6� 6 e e

tendon, R 8� 8 e e

area, L 3� 3 Hypertension e

tendon, L 4� 3 DM; Hypertension e

alleolus, R 8� 5 COPD e

area, R 8� 5 e e

tendon, R 6� 4 e e

ronic obstructive pulmonary disease.

Figure 1 (A) propeller flap: The skin island is based on a perforator. This perforator serves as the pivot point for the flap that canbe rotated up to 180 degrees. (B) peninsular flap: The flap, with a dominant blood supply from the perforator, retains the randomsupply from the base. (C) advancement flap: The skin island can be advanced with greater mobility based on one or two perfo-rators. (D) proximally based island flap: The vascular pedicle of the flap includes the peroneal vessels and their perforators to theskin paddle. When the peroneal vessels are ligated distally to the defect, the flap can be raised as proximally based. (E) distallybased island flap: When the peroneal vessels are ligated proximally to the defect, the flap can be raised as distally based. x:location of a perforator.

388 T.-C. Lu et al.

flexibility in insetting. The rotation arc can reach up to180�, allowing it to be applied to most defects in anydirection, as well as larger defects. The main drawback ofthe propeller flap is the higher risk of venous congestionand the longer operating time needed to dissect out theperforator to permit flap rotation. Finally, proximally (TypeD) or distally based (Type E) island flaps are employed whenthere is a need to cover more distant defects. By includingthe peroneal artery, the flap can be raised as a pedicle-flap

Table 2 Results of flap transfers

Case no. Type of flaps Flap size(cm2)

Distance between theperforator and the tip othe lateral malleolus (cm

1 Peninsular 10� 5 52 Propeller 15� 8 83 Peninsular 15� 6 124 Propeller 14� 5 125 Propeller 13� 5 96 Proximally

based island6� 5 6

7 Propeller 16� 6 108 Propeller 18� 6 109 Propeller 20� 6 610 Propeller 7.5� 3 4.511 Propeller 13� 3.5 1212 Propeller 20� 8 6.5

13 Propeller 20� 8 1514 Peninsular 13� 3 17.515 Advancement 8� 5 1216 Propeller 13� 5 617 Peninsular 18� 5 1818 Advancement 12� 5 7

STSG, split thickness skin graft; FTSG, full thickness skin graft.

unit to reach as far as the knee or distal thigh in proximallybased flaps, or the dorsum of the footeankle joint indistally based flaps. These flaps offer valuable alternativesto the use of free-tissue transfers in patients who areunable to undergo long surgery due to various co-morbid-ities. In addition, the robust nature of the peroneal pedicleensures the reliability of this flap and also allows a largerskin paddle to be harvested. The main disadvantagesinclude the need to sacrifice the peroneal artery and

f)

Donorsite

Complications Secondaryprocedure

Outcome

STSG e e HealedSTSG e e HealedSTSG e e HealedSTSG e e HealedClosure e e HealedSTSG Venous congestion e Healed

FTSG Venous congestion STSG HealedFTSG e e HealedSTSG Venous congestion e HealedSTSG e e HealedSTSG e e HealedFTSG Flap tip congestion Delayed

closureHealed

STSG Venous congestion e HealedSTSG e e HealedClosure e e HealedSTSG e e HealedSTSG e e HealedSTSG e e Healed

Versatility of the pedicled peroneal artery perforator flaps 389

a certain level of experience in dissecting out the peronealartery from the inner surface of the fibula.

Preoperative planning routinely begins with identifica-tion of the perforators using a hand-held Doppler machine.The number of perforators usually averaged more than fourper leg, and were predominately distributed in the middlethird of the leg. According to previous anatomical studies9

and our own experience involving the fibula osteoseptocu-taneous flap or pedicled peroneal artery perforator flaps,the incidence of finding no suitable perforators in the lowerleg around the peroneal region is extremely low. However,care is still taken when harvesting the flap and the flapshould only be islanded when an adequate perforator isidentified. In the event that no perforators are found,either due to an extensive zone of injury, or if the locatedperforators are surrounded by scarred tissues, then theoption of free-tissue transfer should be considered.

Either an anterior or posterior incision can be employeddepending on the location of the defect and patient posi-tion (prone vs. supine). Usually, the perforator has to bedissected for several centimetres to allow easier rotation oradvancement. If proximally or distally based island flapswere chosen, then the peroneal artery should be dissectedout to permit a greater degree of movement. In certaininstances, a vascularised muscle graft can be harvested

Figure 2 Case 13. (A) Diagram of the flap design. (B) A chronicperforators (blue dots) were identified along the posterior margin of(C) A major perforator was found through the posterior approachtransfer.

together with the skin paddle for dead space filling, asdemonstrated in case 15. The donor defects can be closedeither primarily or with the use of skin grafts, depending onthe size of the defect.

Postoperative care mainly focussed on the managementof venous congestion, especially in the use of propeller flaps.If mild venous congestion was encountered, massaging theflap from theperipheralmargins to the centre can sometimesrelieve the problem. An over-tight closuremay sometimes bethe cause of the problem, in which case releasing of a fewsutures and delayed closure may be helpful. In our experi-ence, the postoperative care of these local flaps is easier andless time consuming than the care of free-tissue transfers,without the need to transfer patients to a microsurgicalintensive care unit. Patients also generally ambulate and aredischarged earlier.

Results

The size of the flaps ranged from 7.5� 3 to 20� 8 cm2. Theselected perforator depended on the defect location, rangingfrom 4.5 to 18 cm above the tip of the lateral malleolus. Thedonor site could be closed primarily in two cases, includingone propeller flap and one advancement flap. Split thickness

ulcer at right lower leg with Achilles’ tendon exposure. Twothe fibula with the assistance of hand-held Doppler ultrasound.(arrow). (D) Nice contour at 2.5 months after a propeller flap

390 T.-C. Lu et al.

skin grafts (STSGs) were used in 13 cases, and full thicknessskin grafts were used in three for donor-site coverage. Post-operative venous congestion occurred in four propeller flapsand one proximally based island flap. Venous congestionsubsided within days after removal of some stitches withoutcomplications, except partial loss in one propeller flap,whichneeded further reconstructionwithskingrafts.Novascular re-exploration was performed (Table 2).

Case reports

Case no. 13 (Figure 2)

A 60-year-old male, who suffered from a motorcycle acci-dent half-a-year ago resulting in a thermal contact burn atthe right lower leg, presented with a chronic ulcer withAchilles’ tendon exposure. On examination, an 8� 8 cm2

wound was located posteriorly at the lower third of theright leg. Because of the location of the defect, the oper-ation was performed in the prone position. After Achilles’tendon tenolysis, a 20� 8 cm2 pedicled peroneal arteryperforator flap, based on one perforator 15 cm proximal tothe tip of the lateral malleolus, was raised. The propellerflap was rotated 160� to cover the posterior leg defect. Thedonor-site defect was covered by an STSG. Mild venouscongestion occurred after the operation, but subsided

Figure 3 Case 14. (A) Diagram of the flap design. (B) Left prepeninsular flap was based on one perforator emerging from its base

spontaneously within 2 days. Nice contour of right lower legwas achieved at 2.5-months follow-up.

Case no. 14 (Figure 3)

A 42-year-old male, who was involved in a car accident,presented to the emergency room with left haemothorax,pelvic fracture and bilateral tibiaefibula open fractures.Initially, the patient was treated for his pelvic and bilateraltibiaefibula open fractures. Three weeks later, he wastransferred to our service for management of the leftpretibial defect. There was a 3� 3 cm2 wound with expo-sure of the tibia fracture site. The leg was swollen withmultiple suture lines. Only the lateral leg was spared. A13� 3 cm2 pedicled peroneal artery perforator flap wasdesigned in the peninsular style to cover the pretibialdefect via the subcutaneous tunnel. The flap was based onone perforator emerging from its base. The rotation arc was80�. STSG was used for the donor-site defect coverage. Thepostoperative course was uneventful. A smooth contour ofleft leg was achieved at 5-months follow-up.

Case no. 15 (Figure 4)

A 59-year-old male patient with diabetes mellitus sufferedfrom contusion of the left posterior ankle during

tibial defect with exposure of the tibia fracture site. (C) A(arrow). (D) Smooth contour of left leg at 5-month follow-up.

Versatility of the pedicled peroneal artery perforator flaps 391

a motorcycle accident. The patient presented to ourhospital 1 week after the accident. The wound appearedinfected with Achilles’ tendon exposure, and a fracture ofleft lateral malleolus was found. After debridement, a deadspace under the Achilles’ tendon was noted and requiredobliteration. A peroneal artery perforator includinga muscular branch to the soleus muscle was identified.Subsequently, a fasciocutaneous flap based on this perfo-rator was elevated and covered the defect in theadvancement style. A piece of the soleus based on the samepedicle was included and inserted into the dead space. Thedonor-site defect was approximated with the shoelacesuture, and healed without the need of a skin graft. At 10-months follow-up, a smooth contour of the left ankle wasachieved without recurrent abscess.

Discussion

Successful soft-tissue coverage is often a decisive proce-dure for limb salvage in patients with lower leg and footdefects. Although a free flap can provide sufficient tissuefor reconstruction, not all patients are suitable candidatesfor free-tissue transfer because of existing co-morbidities.Furthermore, the appearance after initial free-tissuetransfer is often bulky. The use of a local cutaneous flap is

Figure 4 Case 15. (A) Diagram of the flap design. (B) An infectedflap was harvested in a chimeric fashion, which included not onlyneous flap, but also one muscular branch to supply a piece of therecurrent abscess at 10-month follow-up.

limited because the neighbouring tissue is usually involvedand massive oedema formation prevents adequate mobi-lisation. Regional muscle or myocutaneous flaps are asso-ciated with aesthetic and functional deficits, and they maynot reliably reach the lower leg and foot defects. With theadvent of perforator-based flaps, an alternative is availablefor soft-tissue coverage of the lower leg and foot defects.Pedicled perforator flaps have a reliable blood supply,spare the major vessels and muscles, avoid microvascularanastomosis and can provide a wealth of thin fasciocuta-neous tissue for lower leg and foot reconstruction.

The lateral leg, which is mainly perfused by a number ofbranches from the peroneal artery, is one of the mostsuitable areas for harvesting perforator flaps.7 In addition,the prevalence of vascular abnormalities in the leg hasbeen studied, and the peroneal artery is least likely to haveatherosclerosis.10 Therefore, it is crucial to use pedicledperoneal artery perforator flaps in the elderly, especiallypatients with diabetes. The vasculature of the peronealartery has been well described. The average number of theperforators is more than four per leg.11 The peroneal arteryperforators are distributed predominately in the middlethird of the leg,11e20 and the perforators over the lowertwo-thirds of leg are mostly of the septocutaneous type.17

Furthermore, Wei et al. noted that septocutaneous perfo-rators near the junction between the middle and lower

wound at left lower leg with Achilles’ tendon exposure. (C) Theone septocutaneous perforator (arrow) to supply a fasciocuta-soleus muscle. (D) Smooth contour of left lower leg without

Table 3 Comparison among five types of pedicled peroneal artery perforator flaps

Type of flap Propellerflap

Peninsularflap

Advancementflap

Proximallybased island flap

Distally basedisland flap

Covered defect size þþ þþ þ þþþ þþþMicrosurgical dissection of the perforator þþ þ þþ þþþ þþþOperation time þþ þ þþ þþþ þþþFreedom of insetting þþ þ þþ þþþ þþþPreservation of peroneal vessels þ þ þ � �Venous congestion þþ þ þ þ þþþ

392 T.-C. Lu et al.

thirds of the fibula can supply a skin paddle about 22e25 cmlong and 10e14 cm wide.8,9 In this series, the largest flapwas 20� 8 cm2. These characteristics make the pedicledperoneal artery perforator flap predictable and reliable forsoft-tissue coverage of the lower leg and foot defects, andless technically demanding than a flap with musculocuta-neous perforators.

According to the authors’ experiences, the differentindications of these five types of pedicled peroneal arteryperforator flaps with regard to the defect size, ease ofmicrosurgical dissection of the perforator, operation time,freedom of insetting, preservation of the peroneal vesselsand incidence of venous congestion have been summarisedin Table 3. Among the five types of the pedicled peronealartery perforator flaps, we recommend the peninsular flapas the first flap of choice for reconstruction. Based on theperforator-plus concept, the peninsular perforator flap hasnot only dual arterial supply from a perforator plus randomsupply from its base, but also dual venous drainage.21,22

Unlike traditional random flaps, the largest ratio of flapwidth to length in a peninsular perforator flap couldapproach 1:4.5.22 In this series, the largest width-to-lengthratio was 1:4.3 in case 14. The peninsular perforator flap iseasy to elevate without tedious perforator dissection.Although the retained base limits the rotation arc of theskin paddle, it prevents excessive strain on the perforatorvessels, especially the vein. No venous congestion wasexhibited in our cases.

Out of our 18 cases, there were 11 propeller flaps. Apropeller flap has the advantages of versatile design andfreedom of insetting. However, microsurgical expertise isusually needed for the dissection of the perforator. Up to180� rotation, propeller peroneal artery perforator flapscould resurface any small- to moderate-sized defect of thepretibial, lateral malleolar, Achilles’ tendon or dorsal footregion. Even in patients with stage IV peripheral arteryocclusion disease, propeller flaps could achieve excellentresult after revascularisation.23 However, venous compro-mise is usually a major concern for propeller flaps. Wonget al. proposed non-linear finite element simulations toelucidate the determinants of perforator patency inpropeller flaps, and advocated that the selected perforatorshould be approximately 1 mm in diameter and more than30 mm in length.24 According to anatomical studies, theaverage distance of the perforator to the peroneal artery is3.7e5.4 cm,11,12 and the diameter of the perforator vein isaround 0.8 mm.12 Therefore, the peroneal artery perfo-rator is safe for the design of a propeller flap when theperforator is mobilised carefully to obtain longer length forless strain on the vessels.

There are two types of peroneal island flaps. One isproximally based, and the other is distally based. The longpedicle makes it possible to cover defects that range fromslightly proximal to the knee to the foot.25 Sacrificing oneof the main arterial supplies to the foot has been a majorobjection to the use of the peroneal island flap. This type offlap should be avoided in patients who depend mainly onthe peroneal artery for foot circulation.

The concept of perforator-based advancement flap,which was first described by Venkataramakrishnan et al.,26

can be applied in soft-tissue coverage of the lower leg withthe advantages of primary closure of the donor site anda superior cosmetic result. It can also be designed asa sensate flap including a sensory nerve. However, this typeof flap still has the limitation of advancement, and it can onlybeused for small-sized soft tissuedefects in theneighbouringarea.26,27 In our previous case report (case no. 15), the flapwas harvested in a chimaeric fashion, which included notonly one septocutaneous perforator to supply a fasciocuta-neous flap, but also onemuscular branch to supply a piece ofthe soleusmuscle. The vascularisedmuscle graft was used toobliterate the dead space under the Achilles’ tendon.

In conclusion, the peroneal artery perforators arepredictable and reliable for the design of a perforated-based flap. Elevation of the flap can be performed easily inthe supine or prone position, depending on the defectlocation. Different designs of the perforator-based flap canfulfil the need of the leg and foot reconstruction.Furthermore, a nice contour of the foot can be achieved sothat patients may comfortably wear shoes.

Acknowledgement

The authors would like to thank Mr. Timothy W. Ng for hisassistance with the preparation of this article.

Financial disclosure statement

None of the authors has a financial interest in any of theproducts, devices or drugs mentioned in this manuscript.

Conflict of interest

N/A.

Funding

N/A.

Versatility of the pedicled peroneal artery perforator flaps 393

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