Leg perforators and leg length: An anatomic study focusing on topography and angiogenesis

Anatomic study of septocutaneous system of the human fetuses' lower leg: peroneal artery

The septocutaneous system of the lower leg perforating blood vessels consists of a vascular basis of fasciocutaneous flaps. This system is of particular importance when designing distally based fasciocutaneous flaps that are the 'workhorse' in reconstructing the distal third of the lower leg and foot. The aim of this study was to provide a comprehensive, clear and conclusive overview of the lower-leg septocutaneous system of skin blood supply in fetal age. Dissection was conducted on 20 fetuses of both sexes and gestational age from 20 to 28 weeks. The focus was on the vascular anatomy of peroneal artery and its septocutaneous (fasciocutaneous) perforating arterial vessels. Cluster analysis was applied to the obtained data. A total of 212 perforating arterial vessels were identified for peroneal artery. The average number of perforating arterial vessels was 5.32 (ranging from 4 to 7). Based on cluster analysis, perforating blood vessels were more likely to be found at certain lower-leg levels ('safe levels of finding perforators'). The presence of septocutaneous system of perforating blood vessels and reliability of their localization even in the fetal period allows for the application of these findings in the lower leg reconstructions in children of early age.

Perforators of the fibular artery and suprafascial network

INTRODUCTION

Soft tissue defect on lower limb can result in an intractable wound. Surgeons resort in flaps to cover these injuries. Including fascia as in the case of a fasciocutaneous flap increases survey of the flap. Rising a perforator flap avoids to sacrifice a major vessel whence the nourishing perforator artery is born. We wanted to explore suprafascial distribution of the fibular skin perforator arteries supposing possible to find out a vascular axis composed of anastomoses of the fibular perforator vessels.

MATERIALS AND METHODS

Systematic observation was carried out on ten injected legs about the fibular perforator distribution, and especially their suprafascial course.

RESULTS

Dissection allowed us to raise in all specimens a large fasciocutaneous paddle including a fine arteriolar vessel connecting fibular perforators. Perforators were isolated along from the leg and we found suprafascial arteriole connecting all perforators from the fibular head to the lateral malleolus. There were a total number of 126 perforators for 10 legs. The mean length of the fibula was 32.9 cm. No perforator was located at more than 2 cm from fibular posterior border. Proximal perforators were closer to posterior fibular side than distal perforators. We found that fibular perforators clustered in the middle and upper third of the leg.

CONCLUSION

This study proves the real existence of a microvascular suprafascial axis formed by fibular perforator anastomoses and stretching over the entire length of the fibula, from the fibular head to the distal tip of the lateral malleolus. This suprafascial vascular axis could be an anatomical basis for a fasciocutaneous fibular flap.

Redefining Vascular Anatomy of Posterior Tibial Artery Perforators: A Cadaveric Study and Review of the Literature

INTRODUCTION

Perforator flaps whether in a free or pedicled form are essential in leg reconstruction, requiring meticulous dissection based on a detailed understanding of vascular topographic anatomy. Numerous investigators have addressed this issue. However, the directionality of their fascial exit has not been greatly discussed in the literature. Subfascial course of the perforating vessel is a crucial determinant for optimal perforator selection especially when the propeller perforator flap option is considered, because an angulated fascial penetration would eventually result in perforator kinking which would additionally compromise vascular patency. The aim of the current study was to investigate the vascular anatomy of posterior tibial artery evaluating a wide range of parameters, including perforators' subfascial directionality, to precisely determine constant reliable perforator sites, in relation to surface landmarks on the medial aspect of the lower leg.

MATERIAL AND METHODS

Dissections in 30 lower legs from 25 fresh cadavers were performed. The lower leg was divided into 3 equal vascular zones. Measurements were taken in reference to anatomical landmarks. Perforator clusters to 5-cm intervals from medial malleolus were recorded and analyzed. Vessels with external diameter less than 0.5 mm were excluded. Data regarding the number, distribution, type, external diameter, length from posterior tibial artery, distance, and subfascial directionality were collected and treated.

RESULTS

A total of 155 perforators were identified (average number, 5 per leg; average diameter, 1.0 mm). Septocutaneous (127/155) perforators predominated, followed by musculocutaneous (19/155) and septomusculocutaneous (9/155). Most was concentrated in the middle (73/155) and distal (64/155) tertile. There were no septomusculocutaneous perforators at the distal third of the leg, whereas septocutaneous perforators were encountered into all vascular tertiles. An average of 2 comitant veins accompanied each perforator. Length and diameter related to the perforators' location. There was a significant association between perforator length and type. Cluster analysis revealed that reliable perforators were identified within the 21 to 25, 26 to 30, and 16 to 20 cm intervals.

CONCLUSIONS

Clinically optimal perforators for the first time were precisely located in relation to subfascial directionality, vascular diameter, and length from the source artery. Continuous improving details of vascular anatomy will further evolve perforator flaps' applications.

Can we consider standard microsurgical anastomosis on the posterior tibial perforator network? An anatomical study

PURPOSE

The main vessels in an injured leg can be spared with perforator-to-perforator anastomosis. However, supermicrosurgery is not a routine procedure for all plastic surgeons. Our objective was to establish if the diameter of the perforators of the leg could allow anastomosis with standard microsurgical procedures.

METHODS

Twenty lower legs harvested from ten fresh cadavers were dissected. Arterial and venous vessels were injected with colored latex. The limbs were then dissected in a suprafascial plane. All the perforating arteries of a diameter >0.8 mm were located and their external diameter, the number and external diameter of the venae comitantes were reported.

RESULTS

We found at least three tibial posterior artery perforators with diameters >0.8 mm per leg with a mean external diameter of 1.1 mm and one vena comitans in almost all cases (96 %). The vena comitans was usually bigger than the perforating artery with a mean diameter of 1.6 mm. After statistical analysis, we were able to locate two main perforator clusters: at the junctions of the upper two-thirds of the leg and of the lower two-thirds of the leg.

CONCLUSION

The low-morbidity concept of perforator-to-perforator anastomosis can apply to posterior tibial artery perforators without using supermicrosurgical techniques. This is of high interest for open leg fractures where main vessels could be injured. We hope that the results of our study will incite surgeons to consider sparing of main vessels for coverage of open leg fractures whether surgical teams master supermicrosurgery or not.