Descending branch of the perforating branch of the peroneal artery perforator-based island flap for reconstruction of the lateral malleolus with minimal invasion

Empirical Evidence on the Reliability of Lateral Supramalleolar Flap over Reverse Sural Flap for Local Soft Tissue Coverage of Dorsum of the Foot and Ankle Defects

Background Soft tissue coverage of the distal foot and ankle region has been an area of debate due to the paucity of local flap options. To provide empirical evidence on the reliability of an underreported local alternative for foot and ankle defects, we aim to compare the lateral supramalleolar flap (LSMF) to the reverse sural flap (RSF).

Methods During 2016–2019, 48 patients were divided randomly into two equal groups, LSMF and RSF groups respectively. The patients' demographic, surgical, and clinical outcome details were recorded and analyzed.

Results Flap necrosis was found in five patients in the group treated with RSF and none in the LSMF group. The mean total number of stages in RSF group was significantly higher than in LSMF group (p < 0.05). The mean operative time for patients in LSMF group was 85.8 ± 18.5 and 54.2 ± 11.2 in RSF group (p < 0.05). Five patients in the RSF group needed additional procedures following flap complications. Nine patients in the LSMF group reported satisfaction outcomes to be “excellent,” five patients reported “good” whereas, in the RSF group, 14 patients reported “excellent,” 5 reported “good,” 3 reported “fair,” and 2 reported “poor” outcomes. Compared to the RSF (46.4 ± 4.3) group, the LSMF group had significantly better foot function indices (34.03 ± 3.9).

Conclusion The lateral supramalleolar flap for foot and ankle defects offers better results, reduced complications as well a lesser number of stages and secondary procedures over the traditionally used reverse sural flap.

Clinical Study of the Lateral Supramalleolar Flap in the Soft Tissue Reconstruction around the Ankle Region

Objective  The purpose of this study is to present the efficiency of the lateral supramalleolar flap which is a very useful and yet underutilized in the soft tissue reconstruction of the regions extending from the distal leg, ankle, and foot.

Methods  Over a period of 3 years, 20 flaps were used in the reconstruction of soft tissue defects in the region extending from the distal leg, ankle, and foot. The location of the defects, the etiology, possible alternative flaps, outcome, and the complications were studied and presented.

Results  The follow-up period of the cases was from 1 month to 18 months after surgery. Seventeen flaps survived and three were lost. All the three lost flaps were those used over the tendocalcaneal region. The lost flaps were later replaced with split skin graft after the wound was debrided and was later covered with granulation tissue.

Conclusion  The lateral supramalleolar flap is a very useful flap in the regional soft tissue reconstruction around the ankle except in the tendocalcaneal region.

Peroneal perforator pedicle propeller flap for lower leg soft tissue defect reconstruction: Clinical applications and treatment of venous congestion

Objective To describe the characteristics of the perforator vessel in the peroneal artery of the lower leg and to explore the use of perforator pedicle propeller flaps to repair soft tissue defects in the lower leg, heel and foot. Methods This retrospective study enrolled patients with soft tissue defects of the distal lower leg, heel and foot who underwent surgery using peroneal perforator-based propeller flaps. The peroneal artery perforators were identified preoperatively by colour duplex Doppler ultrasound. The flap was designed based on the preoperatively-identified perforator location, with the posterior border of the fibula employed as an axis, and the perforator vessel as the pivot point of rotation. Patients were followed-up to determine the outcomes. Results The study analysed 36 patients (mean age, 39.7 years). The majority of the soft tissue defects were on the heel (20; 55.6%). The donor-site of the flap was closed in 11 patients by direct suturing and skin grafting was undertaken in 25 patients. Postoperative complications included venous congestion (nine patients), which was managed with delayed wound coverage and bleeding therapy. All wounds were eventually cured and the flaps were cosmetically acceptable. Conclusions The peroneal perforator pedicle propeller flap is an appropriate choice to repair soft tissue defects of the distal limbs.

Redefining the Vascular Classifications of the Lateral Supramalleolar Flap

BACKGROUND

The blood supply of the lateral supramalleolar flap (LSMF) generally comes from the perforating branch of the peroneal artery. However, the cutaneous branch may also receive blood from the anterior tibial artery. The main objective of the present study was to clarify the vascular anatomy of the LSMF.

METHODS

Anatomical dissections were performed on 28 perfused fresh cadaver legs. The cutaneous branches of LSMF were identified, and the anatomic relationship between the cutaneous branches and the peroneal and anterior tibial arteries was analyzed.

RESULTS

The vascular supply for LSMF was divided into 2 main types. A collateral inferolateral branch from the anterior tibial artery anastomosed with the perforating branch of the peroneal artery around the inferior tibiofibular angle, and the main cutaneous branch of the flap arose from this arterial anastomosis in 20 of 28 limbs (71.4%). The collateral inferolateral branch was absent or very small in the other 8 of 28 dissections (28.6%), and the cutaneous branches solely arose from the perforating branch of the peroneal artery. The anastomosis of the descending branch of the peroneal artery and anterior lateral malleolar artery was always (100%) found around the tibiotalar joint.

CONCLUSIONS

In addition to the perforating branch of the peroneal artery, the LSMF may also receive blood from the anterior tibial artery through the collateral inferolateral branch. New modified proximally based flaps could be designed, and caution is warranted for these variations when a distally based flap is performed.

Anatomical study of anterior supramalleolar artery and its potential application to design a bi-foliate fasciocutaneous flap

Purpose:

A further understanding of the anterior supramalleolar artery (ASMA) and its potential applications in reconstructive surgery.

Materials and Methods:

A total of 24 fresh lower limbs from fresh cadavers were injected with red latex for dissection. The type of origin, course, diameter of the pedicle, and the distance between the origin of the ASMA from the anterior tibial artery to the extensor retinaculum (O-R) were recorded. Bi-foliate fasciocutaneous flaps were harvested using the branches of the ASMA.

Results:

We found four types of origin of the ASMA, and we have accordingly classified them into four types. 10 of them were type A, 7 were type B, 6 were type C and 1 was type D. The mean O-R (origin of ASMA to retinaculum) distance was 2.0 ± 0.8 cm. The diameter of the medial branch (D1), the diameter of the lateral branch (D2), and the diameter of artery stem (D3) (only in type A) were 1.0 ± 0.2 mm, 0.8 ± 0.3 mm, 1.1 ± 0.2 mm, respectively. The mean pedicle length of the lateral flap (L1) and medial flap (L2) were 5.1 ± 1.0 cm and 3.7 ± 0.6 cm, respectively.

Conclusions:

The ASMA exists constantly with four different types of origin. Its sizable diameter and lengthy pedicle make it suitable for bi-foliate fasciocutaneous flap transfer.

Reconstruction of the lateral malleolus and calcaneus region using free thoracodorsal artery perforator flaps

Reconstruction of the lateral malleolus or calcaneus region is challenging because of poor vascularity, minimal presence of soft tissue, and difficulties with flap positioning during and after the operation. In many cases, local flaps are limited in terms of size, durability, and vascularity. Free tissue transfer can be useful for complicated wounds. We report here on the results of the reconstruction in this region using free thoracodorsal artery perforator flaps. Between October 2010 and October 2013, 16 cases of lateral malleolus or calcaneus defects were reconstructed using free thoracodorsal artery perforator flaps. The defects varied from 2 × 5 cm(2) to 12 × 16 cm(2), and the flaps from 3 × 5 cm(2) to 10 × 15 cm(2). Two cases were reconstructed using chimeric-pattern flaps. Only the superficial adipose layers were harvested for all the flaps, without further thinning or debulking process. Five cases with complications occurred, including three cases of partial necrosis of the flap and two cases of venous congestion caused by thrombosis and compression of the venous pedicle, and one flap was totally lost. The mean follow-up duration was 11.8 months. All the patients were able to wear shoes. All but one were able to walk. The thoracodorsal artery perforator flap can be made super-thin, allowing patients to wear shoes, and it can be harvested in a chimeric-pattern for complex defects. Therefore, it may represent a viable alternative choice for the reconstruction of the lateral malleolus and calcaneus region.

Versatility of the Perforator-Based Adipose, Adipofascial, and Fasciocutaneous Flaps in Reconstruction of Distal Leg and Foot Defects

Reconstruction of the distal leg, ankle, and foot is challenging, and local perforator flaps have emerged as valuable options. The aim of the present study was to evaluate the outcomes of local perforator flaps in the distal lower extremity. A total of 14 local perforator flaps were used in 12 patients (9 males [75%] and 3 females [25%], aged 19 to 83 years). The etiologies included 7 motor vehicle accidents (50%), 2 acute burns (14.29%), 2 chronic wounds (14.29%), 1 postburn contracture (7.14%), 1 gunshot wound (7.14%), and 1 malignancy (7.14%). The defects were localized to the mid-leg in 3 cases (21.43%), ankle in 4 (28.57%), calcaneus in 4 (28.57%), and foot in 3 (21.43%). A peroneal artery perforator flap (11 sites [78.57%]) or a posterior tibial artery perforator flap (3 sites [21.43%]) was used. Of the 14 flaps, 8 (57.14%) were fasciocutaneous, 4 (28.57%) were adipofascial, and 2 (14.29%) were adipose. The flap transfers were rotational in 9 cases (64.29%), flipped in 2 (14.29%), propeller in 2 (14.29%), and transcrural in 1 (7.14%). The flap dimensions ranged from 8 cm × 5 cm to 22 cm × 5 cm. Finally, 12 flaps (85.71%) remained viable, 1 (7.14%) had partially sloughed, and 1 (7.14%) had completely died owing to a hypercoagulable state. Overall, 13 flaps (92.86%) had good outcomes after a median follow-up period of 19 (range 12 to 37) months. Perforator flaps in the lower extremity are versatile in terms of size, design, composition, and axis of rotation. They are reliable and safe when used to reconstruct local defects.