INTRODUCTION:

Lower extremity reconstruction has evolved along with advances in perforator flap surgery.  Microvascular reconstruction of the extremities has become a standard option, thus attention can be more focused on minimizing morbidity and optimizing aesthetics. The anterolateral thigh (ALT) flap has become well established in lower extremity microvascular reconstruction and has been successfully used over complex wounds.  This laid the groundwork for further perforator fasciocutaneous flap development in distal lower extremity reconstruction.  In the North American population, the use of the ALT flap can be limited due to obesity and its effects on the flap's characteristics, requiring either risky primary thinning or secondary procedures to correct the disproportionately thick flap for use in the distal extremity.  We therefore sought an alternative flap for use in the distal lower extremity that would be a thin flap with good match of recipient and donor skin qualities, allow for primary closure of the donor site, and minimize extension of iatrogenic morbidity by remaining close to the site of injury.

METHODS:

Six proximal peroneal perforator (PPP) flaps were performed for reconstruction of distal lower and upper extremity wounds. Harvest of the flap was from the proximal lateral calf, with the perforator located by Doppler five to fifteen centimeters distal to the fibular head and slightly posterior to the posterior crural septum.  A longitudinal ellipse no more than six centimeters wide was centered over the perforator.  It was then harvested as a free fasciocutaneous flap based on a perforator that passed through the soleus and/or flexor hallucis longus muscles.  The pedicle was 4 - 6 centimeters in length, and the vessels were approximately 0.5 - 1 millimeter in diameter.

RESULTS:

The six proximal peroneal perforator flaps provided excellent skin match for use in the distal lower extremity (five flaps) and hand (one flap) with good contour.  The wounds healed with the use of the PPP flap, and primary closure of the donor site was achieved.

Figure: The proximal peroneal perforator flap is a thin fasciocutaneous flap harvested from the lateral calf for reconstruction of a small wound over an open fracture in the distal leg.

CONCLUSION:

The PPP flap is a useful flap for microvascular reconstruction in the distal extremities.  It provides excellent match of recipient and donor skin qualities, keeps the donor site scar in the same area of the body as the original site of injury (for leg wounds), and can be closed primarily.  In obese patients, this flap remains relatively thin and is a good alternative for smaller wounds. 

REFERENCES:

1.         Hong, J. P., Shin, H. W., Kim, J. J., et al. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg 115: 142-147, 2005.

2.         Wolff, K. D., Kesting, M., Thurmuller, P., et al. The early use of a perforator flap of the lateral lower limb in maxillofacial reconstructive surgery. Int J Oral Maxillofac Surg 35: 602-607, 2006.

3.         Yazar, S., Lin, C. H., Lin, Y. T., et al. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 117: 2468-2475; discussion 2476-2467, 2006.