Cutaneous perforators of the peroneal artery: Cadaveric study with implications in the design of the osteocutaneous free fibular flap

Fibular free flap with proximal perforator skin paddle due to aberrant anatomy - a case report

BACKGROUND

The fibular free flap is considered one of the most valuable options for mandible reconstruction. A perforator flap has gained widespread acceptance in oral and maxillofacial reconstruction. Typically, the fibula flap is obtained primarily with the distal perforator due to its reliable blood supply, with less attention given to the proximal perforators during the harvesting process. Normally, the distal perforator of the fibula exhibits stability and shows limited anatomical variations. However, there have been reported cases in which the distal perforator is absent. At times, these vascular abnormalities remain undetectable through Doppler examination or preoperative angiography evaluation. Therefore, this case details the experience of encountering the rare event of vascular abnormality in oral cancer surgery.

CASE PRESENTATION

This article reports the case of a patient who presented with a congenital absence of the distal perforator in the peroneal artery, attributed to a vascular abnormality. Additionally, we provide a review of the concept of utilizing the proximal perforator as an alternative approach in the flap harvesting process.

CONCLUSIONS

While the distal perforator of the peroneal artery is typically utilized for fibula free flap procedures, surgeons must remain cognizant of the potential for its absence due to aberrant anatomy. Recognizing an alternative approach in such cases can be pivotal for precise surgical planning and favorable outcomes in oral and maxillofacial reconstruction.

Use of Rare Anatomical Variant of the Free Fibula Flap to Reconstruct the Nasal Septum

The osteocutaneous fibula free flap (FFF)'s skin paddle is commonly vascularized by the septocutaneous (SC) perforators of the peroneal artery that course through the posterior intercrural septum. However, a rare anatomical variant exists in which the skin paddle is vascularized via a separate arterial system to the fibula. We report the case of a 31-year-old man who was planned for osteocutaneous FFF reconstruction of his anterior maxilla and hard palate following resection of nasal septal chondrosarcoma. Intraoperatively, he was found to have a rare anatomical variant: the perforator to the skin paddle arose proximal to the peroneal artery, off the tibioperoneal trunk. This was a fortuitous, rare anatomical variant, as it enabled a double free flap reconstruction from a single donor site-an intraoral fasciocutaneous free flap oriented with its long axis perpendicular to that of an osseous FFF. This particular defect enabled reconstructive freedom beyond that of the standard osteocutaneous free flap, in which the skin paddle orientation is limited by the risk of kinking the septal perforator. This case report summarizes the flap raising technique and the learning points relevant to the osteocutaneous FFF with no SC perforators. The extant literature on this anatomical variant is then summarized. The average estimated rate of FFF with no SC perforators is between 3% and 25%, based on four published studies.

Proximal peroneal perforator flap, cadaveric study, and clinical applications for shallow defect reconstructions

PURPOSE

Peroneal artery perforator offers a versatile range of microvascular tissue transfer methods from local flaps to vascularized osteocutaneous fibula flaps. It is one of the few flaps that can cover shallow defects that require thin and pliable skin paddles, such as in hands and feet (Han et al., 2018). The proximal region of the lower leg offers such flexible and thin flap compared to the middle and distal lower leg (Winters & de Jongh, 1999). However, the anatomy of the proximal peroneal artery perforator is relatively unknown in literature and its proximity to the common peroneal nerve (CPN) has not yet been studied. This study conducted a cadaveric study and put it in application into clinical settings.

METHODS

Twenty lower leg specimens were dissected according to the methods of clinical proximal peroneal artery perforator flap harvest. Perforators arising in the proximal lower leg area of between 20 and 40 percentile of fibular length were inspected. Perforator length, location from fibular head, course, and location of CPN were recorded. Clinical reconstruction cases using the proximal lateral lower leg were analyzed. Six patients between the ages of thirty and seventy were included. Five cases were due to trauma, and one from mass excision, but all required thin and pliable flaps for reconstructions in hands or feet. Flaps were designed concentrical oval shapes, and harvest was done similarly to cadaveric perforator dissection, but perforator dissection was done only up to the required pedicle length. Perforator length, flap size, thickness, and long-term complications were recorded.

RESULTS

Among 20 specimens, a total of 20 perforators were found in 18 cadavers (90%). Two specimens showed no perforators while two specimens showed multiple perforators. The perforators were located at an average of 101 mm from fibular head, with an average length of 55 mm ranging from 20 to 153 mm. The average size of perforator at origin was 2.0 mm, ranging from 1.0 to 3.6 mm. 45% showed septocutaneous course and 55% intramuscular course. Two out of 20 perforators were shown to arise from source vessels other than the peroneal artery. All clinical cases were successful without complications or debulking for contour shaping. Flap sizes ranged from 15 to 40 cm² . Largest flap width was 5 cm, and all donor sites were primarily closed without complications. One year of follow-up showed no complications.

CONCLUSION

Proximal peroneal artery perforator flap provides a reliable pedicle for a versatile tissue transfer. This study shows that the perforators of the proximal lateral lower leg often arise from vessels other than the peroneal artery, such as the anterior tibial artery or popliteal artery, as had been previously reported (Winters & de Jongh, 1999). Although the source vessel varies, perforator anatomy is at a safe distance from CPN. This variation of source vessels suggests a change in nomenclature to "proximal peroneal perforator flap." The clinical applications of this flap showed that it can be effectively used for reconstructions of shallow defects, such as in the hands and feet without secondary procedures for debulking.

Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects-Anatomical Study and Clinical Application

The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases-anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm² (mean 28.2 ± 23.8 [range 6-120] cm²) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.

Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap

INTRODUCTION

Achilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue.

METHODS

7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel.

RESULTS

The size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage.

CONCLUSION

Distally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.

Reconstruction of composite oral and maxillofacial defects by free flaps based on a new classification

Reconstruction of composite oral and maxillofacial defects using free flaps is challenging. The key to such delicate reconstruction lies in the evaluation of the defect. However, few reports have described the clinical classification of these difficult defects. In this study, we proposed a classification method and developed different reconstructive solutions using free flap techniques according to this classification. This classification method was established based on two parameters (the elements and distribution of the missing tissues). Among the 17 patients with composite oral and maxillofacial defects included in this study, 8 patients presented with type A defects, one patient presented with a type B defect, and the other 8 patients presented with type C defects. No type D defects were observed in this study. Three types of free flaps were used to reconstruct the respective types of composite defects. Perforator-based ALT flaps were used to reconstruct Type A defects. Branch-based ALT flaps were used to reconstruct Type B defects. For Type C defects, two reconstructive solutions were used, including a well-designed fibular flap and a perforator-based ALT flap with or without a metal plate for bony reconstruction. All flaps survived after surgery. This classification system may help select and design specific free flaps for reconstructing composite oral and maxillofacial defects.

Evaluation of Anatomic Variations of Fibula Free Flap in Human Fresh Cadavers

BACKGROUND

Reconstruction of the head and neck defects is still one of the most challenging surgeries for the surgeons. This study investigated on anatomic variations of fibula free flap in human fresh cadavers.

METHODS

Twenty fibula free flaps harvested from 10 fresh human corpses were enrolled. The number and type of skin perforators and their origin were recorded during the flap harvesting. After the completion of flap harvesting, the length of vascular pedicle and diameter of the artery and vein at the origin, the fibula length, the distance of the head of fibula to the site of peroneal artery bifurcation and harvesting time were also recorded.

RESULTS

The fibula free flaps were performed on 2 women and 8 men with the mean age of 35.6 years. The average number of perforators per flap was 1.7, most of which were musculocutaneous (35.29%) from soleus muscle. The mean fibula length was 33.1 (range: 31-35) cm. The mean distance of the head of fibula to the site of peroneal artery bifurcation from the tibialis posterior trunk was 5.76 (range: 4.5-6.5) cm. The mean length of the pedicle flap was 11.15 (range: 10-13) cm. The mean diameters of the peroneal artery and vein at the origin were 2.83 and 51.5 mm, respectively.

CONCLUSION

Although the fibula osteocutaneous flap is a reliable choice for maxillofacial reconstruction, flap harvesting is fairly difficult. Accordingly, surgeons must be aware of anatomical variations of the flap and have a suitable case selection to minimize the risk of surgical complications.

Pedicled Peroneal Artery Perforator Flap for Knee Defect Reconstruction: Case Presentation and Literature Discussion

There have been very limited data on the use of pedicled peroneal artery perforator flaps in knee soft-tissue reconstruction, especially for anterior and medial defects. Here, we present a case of proximally based peroneal artery perforator flap for knee soft-tissue reconstruction in a defect that included lateral, anterior, and medial surfaces of the knee presenting the technical challenges associated with this flap. A 15-year-old girl presented with extruded knee implant after osteosarcoma resection of femur. The defect involved the whole knee with the anterior and mostly the lateral knee surfaces. Her medical condition precluded the use of free tissue transfer. During her previous surgery, gastrocnemius muscles were detached with injured vascular pedicled and posterior tibial artery. Successful single-stage coverage was achieved using a large proximally based pedicled peroneal artery perforator flap. There are only few reports that described the use of peroneal artery flaps for knee soft-tissue coverage. The reach of a proximally based flap can be increased when it is raised on a distal perforator or when peroneal artery has a proximal takeoff. Furthermore, removing the fibula can facilitate the dissection and the reach of the flap till the most medial aspect of the knee. Pedicled peroneal artery perforator flap provides superior soft-tissue coverage with limited morbidity for knee soft-tissue reconstruction; however, flap reach is usually affected by anatomic variation. Preoperative planning can help to determine the reach of the flap and ease the dissection.

Photo Epilation with Intense Pulsed Light for Thinning of Anterior Hairline after Hairline Correction Surgery in East Asians

Background

Thin hairs are critical to achieve natural result in female hairline correction surgery. However, there are few studies on the usefulness of hair thinning by intense pulsed light (IPL) after hairline correction surgery in East Asian females.

Methods

Hair thinning using IPL was performed in 54 women who had complained about thick hairs along the frontal hairline after hairline correction surgery. Patient mean age was 31.2 years old and patients were an average of 2.1 years post-hairline correction surgery. Initial treatment used 10 J, while second and third sessions were conducted with 10 to 15 J according to responsiveness to treatment.

Results

Mean thickness of individual hairs assessed before the procedure was 78.86 µm. The mean number of procedures was 1.6 per patient. Forty of 54 subjects (74%) achieved satisfactory hair thinning with only one procedure from 78.01 to 66.14 µm after treatment. The measured thickness was 66.43 µm at the end of the first year in patients who were satisfied after one procedure. Thirteen cases achieved satisfactory hair thinning after two sessions. Mean thickness was 74.44 µm and 67.51 µm, before and after the second session. One case required a third session with 15J, thinning from 89.00 to 66.50 µm.

Conclusions

Hair thinning by IPL is a very useful method to provide a natural look after hairline correction surgery in East Asians, who have naturally thick hair.

Peroneal Flap: Clinical Application and Cadaveric Study

Background

The goal of this study was to investigate the anatomy of the peroneal artery and its perforators, and to report the clinical results of reconstruction with peroneal artery perforator flaps.

Methods

The authors dissected 4 cadaver legs and investigated the distribution, course, origin, number, type, and length of the perforators. Peroneal artery perforator flap surgery was performed on 29 patients.

Results

We identified 19 perforators in 4 legs. The mean number of perforators was 4.8 per leg, and the mean length was 4.8 cm. Five perforators were found proximally, 9 medially, and 5 distally. We found 12 true septocutaneous perforators and 7 musculocutaneous perforators. Four emerged from the posterior tibia artery, and 15 were from the peroneal artery. The peroneal artery perforator flap was used in 29 patients. Retrograde island peroneal flaps were used in 8 cases, anterograde island peroneal flaps in 5 cases, and free peroneal flaps in 16 cases. The mean age was 59.9 years, and the defect size ranged from 2.0 cm×4.5 cm to 8.0 cm×8.0 cm. All the flaps survived. Five flaps developed partial skin necrosis. In 2 cases, a split-thickness skin graft was performed, and the other 3 cases were treated without any additional procedures.

Conclusions

The peroneal artery perforator flap is a good alternative for the reconstruction of soft tissue defects, with a constant and reliable vascular pedicle, thin and pliable skin, and the possibility of creating a composite tissue flap.

[Harvesting technique of chimeric multiple paddles fibular flap for wide oromandibular defects]

Carcinological head and neck reconstruction still remains a challenge due to the volume and varied tissues needed. Large and wide oromandibular defects require, not just the bone but also soft tissues for the pelvilingual reconstruction and therefore, a second free flap may become necessary in addition to a fibular flap. The option of an unique chimeric flap based on the fibular artery and its branches is less known whereas it offers the advantage of a unique flap with bone, muscle and multiple skin paddles, independent of each other. The aim of this technical note is to present step by step the surgical procedure of this chimeric flap and share this method that avoids a second free flap.

Vascular anatomy of the integument of the lateral lower leg: an anatomical study focused on cutaneous perforators and their clinical importance

BACKGROUND

Certain studies have attempted to investigate the vascular anatomy of the integument of the lateral aspect of the lower leg. However, many issues remain controversial. The aim of this study was to investigate in detail the distribution and characteristics of cutaneous perforators of the lateral aspect of the lower leg.

METHODS

Fifty-two fresh cadaver legs were dissected. The lateral lower leg was divided into five zones, and all cutaneous perforators were identified. Only perforators with a diameter greater than 0.5 mm were dissected further, and the type, location, course, length, and origin of those perforators were recorded.

RESULTS

Three hundred two perforators were dissected. Two hundred twelve were septocutaneous (70.2 percent), 43 were septomusculocutaneous (14.2 percent), and 47 were musculocutaneous (15.6 percent). The majority of perforators (78.1 percent) originated from the peroneal artery. The peroneal artery was the dominant source vessel in all except for the proximal zone. The tibial-peroneal trunk predominated in the proximal zone. High contribution of the posterior tibial artery was noticed in the distal zone. Higher percentages of perforators were recorded in the middle and midproximal zones (26.8 percent and 25.2 percent, respectively). Septocutaneous perforators were present in all five zones, with higher percentages in the middle and middistal zones. Septomusculocutaneous and musculocutaneous perforators were identified in all except for the distal zone.

CONCLUSION

The authors' findings provide information about the cutaneous perforators/perforasomes of the lateral aspect of the lower leg, useful for reliable planning and harvesting of perforator-based flaps in this area.