Foot reconstruction using a free proximal peroneal artery perforator flap: Anatomical study and clinical application

Free peroneal artery perforator flap for reconstruction of traumatic limb soft tissue defects: A retrospective case series study

BACKGROUND

The free peroneal artery perforator (FPAP) flap is used for soft tissue defects after burns and trauma. However, the use of FPAP flaps to repair limb soft tissue defects for immediate reconstruction was rarely reported previously. Therefore, the purpose of this report is to evaluate free peroneal artery perforator flap to reconstruct traumatic limb soft tissue defects for immediate reconstruction.

PATIENTS AND METHODS

A total of 25 cases of limb soft tissue defects undergoing immediate reconstruction of FPAP flap transfer were retrospectively evaluated from January 2019 to June 2019 in our institute. The locations of defects included the palm (10 cases), finger (5 cases), foot (7 cases), ankle (2 cases) and wrist (1 case). The sizes of defect varied from 3 × 2 cm to 15 × 7 cm (54.1 cm2 in average). Flaps were harvested based on the peroneal perforator vessels, initially marked using hand-held Doppler.

RESULTS

Average size of harvested flap was 9.7 × 6.2 cm (ranging from 3.5 × 2 cm to 16 × 8 cm). All perforators were harvested from the peroneal artery and the arterial diameter ranged from 0.8 to 1.7 mm. The average pedicle length was 3.04 cm (range, 1.85-4.75 cm). Five vascular thrombosis were found including three cases of arterial thrombosis and two cases of venous thrombosis which were successfully salvaged by re-operation and vein graft. Satisfying functional outcome and acceptable appearance were achieved at 6 months or longer after surgery (range, 6-15 months, 12 months in average). All flaps survived at the end-point.

CONCLUSIONS

The FPAP flap is a reliable and thin fasciocutaneous flap, which can be used for repairing limb soft tissue defects. The FPAP flap can be used for covering defects with various appearances, locations, and sizes.

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.

[Application of free peroneal artery chimeric perforator flap in repairing the defect after advanced local lesions resection in parotid gland carcinoma]

OBJECTIVE

To investigate the effectiveness of free peroneal artery chimeric perforator flap in repairing the defect after advanced local lesions resection in parotid gland carcinoma (PGC).

METHODS

Between June 2010 and June 2020, 32 patients with advanced local lesions of PGC were treated with extended radical resection. After that, 17 patients were repaired with the free peroneal artery chimeric perforator flaps (trial group) and another 15 patients were repaired with the pedicled pectoralis major myocutaneous flaps (control group). There was no significant difference in gender, age, disease type, histopathological classification, clinical stage, and pathological stage between groups ( P>0.05). The size of skin flap in trial group ranged from 7 cm×6 cm to 12 cm×8 cm and the size of soleus muscle flap ranged from 5 cm×3 cm to 6 cm×4 cm. The donor sites were repaired with skin grafting. The size of the pedicled pectoralis major myocutaneous flaps in control group ranged from 9 cm×6 cm to 14 cm×7 cm. The donor sites were sutured directly. The operation time, survival rate of flap, and postoperative survival of patients were recorded and compared between groups. At 1 year after operation, the University of Washington quality of life (UW-QOL) questionnaire was used to evaluate the quality of life of patients in the two groups, including appearance, shoulder movement, sociability, masticatory function, speech function, and mood.

RESULTS

The operations completed successfully. The operation time was (6.19±0.72) hours in trial group and (6.41±0.71) hours in control group, showing no significant difference between groups ( t=-0.863, P=0.395). The survival rate of flap in trial group was 94.1% (16/17); and 1 patient suffered from vascular crisis after operation and was replaced with the pedicled pectoralis major myocutaneous flap. The survival rate of flap in control group was 100%. All grafts survived and the incisions healed by first intention in the two groups. All patients were followed up. The follow-up time was 6-60 months (median, 60 months) in trial group and 7-60 months (median, 60 months) in control group. Cumulative survival rates of patients at 1, 3, and 5 years after operation were 94.1%, 64.7%, and 58.8% in trial group, respectively; 86.7%, 66.7%, and 53.3% in control group, respectively. There was no significant difference in the cumulative survival rate between groups ( χ 2=0.090, P=0.762). According to the UW-QOL questionnaire at 1 year after operation, the scores of appearance, shoulder movement, sociability, and mood in trial group were significantly higher than those in control group ( P<0.05); and there was no significant difference in masticatory function and speech function scores between groups ( P>0.05).

CONCLUSION

The peroneal artery perforator has an invariable anatomical relationship. Each perforator emits the muscular branch that nourishes the soleus muscle. Therefore, personalized free peroneal artery chimeric perforator flap can be designed according to the tissue defect, and used to repair the defect after advanced local lesions resection in PGC.

Eccentric free muscular perforator flaps in the proximal lateral leg for hand and foot reconstruction

BACKGROUND

We aimed to introduce our modifications by using eccentrically located muscular perforators to shorten the distance between the recipient vessels and the flap pedicle for overcoming the "short pedicle" drawback of the proximal lateral leg perforator (PLLP) flap.

PATIENTS AND METHODS

A retrospective review of 12 cases undergoing free PLLP flap for hand and foot regions reconstruction during 2010 and 2019. The mean age was 43.3 years. Most defects resulted from burn and trauma injuries. The dimensions of defects ranged from 8 × 1.5 cm² to 12 × 6.5 cm² . Muscular perforators were designed eccentrically 1-3 cm away from the central point of the flap to shorten the distance between the recipient vessels and the pedicle. The flap was designed to be 0.5-1 cm larger than the defect.

RESULTS

The flap size ranged from 9 × 2 cm² to 15 × 6 cm² . All pedicles were long enough to ensure an appropriate anastomosis without tension. The post-operative course in all cases was uneventful. All flaps survived without complications. Primary repair of the donor sites was performed in all patients. Donor leg function was not hampered by flap harvesting. All patients were satisfied with the scar after at least 1 year of follow-up.

CONCLUSION

Based on our experience, selection of the eccentric locations of the musculo-cutaneous perforators were effective methods to overcome the short pedicle length of this flap type. Using our modifications, thin PLLP flaps can be used in foot and hand reconstruction with minimal donor site morbidity and a high success rate.

Orthoplastic Management of Open Midfoot Injuries: Is Functional Limb Salvage Possible?

High energy open midfoot injuries are uncommon but devastating injuries. A combination of complex fracture dislocations and soft tissue injury patterns render reconstruction challenging. The aim of this study was to assess the surgical and patient reported outcomes following orthoplastic management of open midfoot injuries in a Major Trauma Center. A retrospective review of all open midfoot fractures admitted to our unit between January 2015 and December 2016 was undertaken. Demographics, operative details, complications, additional surgeries, and patient reported outcomes in the form of EQ-5D and Enneking scores were collected. Fifteen patients were identified (13 male, mean age 39.2 years). One patient underwent amputation at initial debridement and 8 required additional debridement. Of these 8 patients, 3 had an amputation during their index admission. In the limb salvage group (11 patients), definitive soft tissue cover involved free flaps in 6 patients, split skin graft in 3 patients, and delayed primary closure in 2 patients. Definitive orthopedic treatment was internal fixation in 8 and external fixation in 3 patients. Two patients required a Masquelet procedure for bone loss. One patient had a toe amputation and 1 had a below knee amputation for deep infection. The median EQ-5D score was 66 (interquartile range 43), and the median Enneking score was 20.5 (interquartile range 9). Limb salvage following open midfoot fractures is technically possible in most cases, however this often involves multiple procedures and the outcomes are variable and difficult to predict. Patients should be carefully counseled, and amputation considered in all such cases.

[Effect of double-leaf perforator free flap posterolateral calf peroneal artery on reconstruction of oropharyngeal anatomy after ablation of advanced oropharyngeal carcinoma]

OBJECTIVE

To evaluate the effect of using free double- leaf perforator flap posterolateral calf peroneal artery in anatomical reconstruction of the oropharyngeal structure after ablation of advanced oropharyngeal carcinoma.

METHODS

Twenty-six patients with oropharyngeal defects after ablation of oropharyngeal malignancies were recruited, including 12 with carcinoma in the tongue base, 5 in the latenral pharyngeal wall and 9 in the soft palate. Between July, 2016 and July, 2018, the patients underwent surgeries for reconstruction of the oropharyngeal defects using flaps. The areas of tissue defects repaired by double-leaf perforator flaps ranged from 40.5 to 72.5 cm2. Reconstruction was performed for oropharyngeal defects in the soft palate, pterygopalate, parapharyngeal, pterygo- mandibular, and tongue base tissues. The patients' outcomes including mouth opening, functions of deglutition, linguistic function, restoration of palatopharyngeal anatomical structure and postoperative survival were evaluated, and their quality of life was assessed using FACT-H&N scale (Chinese Edition).

RESULTS

All the 26 patients with transplantation of the free flaps survived. Six months after the operation, the oropharyngeal function and anatomical structure of the patients were basically restored. The questionnaire survey showed that the patients' physical, social/family, emotional and functional conditions, the total score of the core scale, items scores for the head and neck, and the total score of the scale all improved significantly after the operation compared with those before the operation (P < 0.05).

CONCLUSIONS

The free peroneal artery bilobate perforator flap in the posterolateral crus, which seldom has anatomical variations of the blood vessels, allows flexible design and contains rich tissue volume to facilitate defect repair with different approaches and ranges. The application of this flap, which is an ideal perforator flap for reconstruction of the oropharyngeal structure and function, can improve the quality of life of patients following operations for advanced oropharyngeal cancer.