VERSATILITY OF THE PERONEAL ARTERY PERFORATOR FLAPS

FOR SOFT-TISSUE COVERAGE OF THE LOWER LEG AND FOOT

DEFECTS

Authors: Le Hong Phuc a, Ho Xuan Truong b ,Le Nguyen Phuong b

a. PhD, Vice-dean of Department of Orthopedic and Thoracic Surgery, HUMPH
b. President Doctor, Department of Orthopedic and Thoracic Surgery, HUMPH

Abstract

Background: The limited soft tissue coverage along with the bone structures located
close to the skin makes soft tissue lesions in the lower leg area easily expose the
structures. Soft tissue defects related to this area almost always require flap conversion.
Among them, the peroneal artery perforator branch flap is a form of use with high
flexibility as well as good management.
Objectives: This study aims to evaluate the effectiveness of peroneal artery perforator in
patients had defects in lower leg and foot.
Subjects and Methods: In this study, we performed prospective and descriptive research
in 35 patients who underwent lower-extremity defect reconstruction using peroneal artery
perforator flaps from September 2017 to January 2024.
Result: All 31 cases survived. Necrosis occurred in 5 case, all of which healed with
dressing change and STSG. There were 11 case had smoke history, 7 cases of which
encountered to wound dehiscence
Conclusion: Peroneal artery perforator flaps are utilized by different methods, which
enhance the outcome.

Author of research Intructor

Ho Xuan Truong PhD. Le Hong Phuc

 VERSATILITY OF THE PERONEAL ARTERY PERFORATOR FLAPS
FOR SOFT-TISSUE COVERAGE OF THE LOWER LEG AND FOOT
DEFECTS

Authors: Le Hong Phuc a, Ho Xuan Truong b ,Le Nguyen Phuong b

a. PhD, Vice-dean of Department of Orthopedic and Thoracic Surgery, HUMPH
b. President Doctor, Department of Orthopedic and Thoracic Surgery, HUMPH

I. INTRODUCTION

Soft tissue defects in the extremities, especially soft tissue defects in the lower legs, are
very common, accounting for 37.7% in total body soft tissue defects [6]. Along with the
advancement of Reconstruction surgery, various options are invented to deal with defects
such as skin grafting, local flaps, cross leg flaps … However, the drawbacks of these
methods are small size flap, long time-to-treatment, incomplete coverage of anatomical
layers leads to declined weight-bearing function, bad scars and construction. Nowadays,
medical science and technology has thrived, especially in Doppler ultrasound, people
increasingly understand the anatomical characteristics of the perforator system, the
distribution and supply of blood to nourish structures and soft tissue. Consequently, more
and more perforator flaps are being discovered and applied, helping to overcome the
limitations of old methods and speed up the healing process. A perforator flap consists of
skin, subcutaneous fat which is nourished by the perforators, which rises through muscle
and intramuscular septa .This flap has merit is that they are safe, flexible, reliable and
slight morbidity to the donor site. The peroneal artery perforator flap has become one of
the available and flexible options which are applied by many surgeons to achieve
effective treatment [7]. Compared with the traditional flap or workhorse flap ( such as
anterolateral thigh flap ), the peroneal artery perforator diminishes bleeding, maintains
muscle function, has numerous flap designs and promotes the mobility of the flap.
In this study, we present the experience in 31 patients with the peroneal artery perforator
flap through different methods such as advancement, rotation or transposition.

II. Methods
Between September 2017 and January 2024, a prospective analysis was performed in 35
patients who had lower extremity defect coverage using PAP flap in the Orthopedic
Department, Hue University of Medicine and Pharmacy Hospital. Statistics features
consist of gender, age, etiology, position, size of the defect, size of the flap,
comorbidities, flap design and dissection and follow up.

Surgical technique
Preoperative assessment: Prepare the patient comprehensively both physically and
mentally, conduct comprehensive examinations and assessment tests to detect
contraindications, diseases that are at risk of causing embolism, especially patients who
smoke have to quit smoking before and after surgery. Besides, that is crucial to ensure
there is no acute infection in defect. A Doppler probe was used preoperatively to identify
the peroneal artery perforators; therefore surgeon might design flap that fit for the size
and shape of the defect
Surgery equipments: Handheld Dopller probe, microsurgery equipments, magnifying
glass
Procedures:
Firstly, the edge of the defect would be vigorously debrided and size of the defect also
would be reidentified. Flap design and orientations around the site perforators ensured
appropriate length and width so that the flap could be harvested. The skin is incised
according to the design, the perforator vessel dissection is always performed from one
edge of the skin flap. Avoid making skin incisions around the flap until the perforating
vessels are identified that accommodate the requirements for size and length of the
vascular pedicle. Subsequently, check the flap perfusion through opening the tourniquet
(if any) and wait 3-5 minutes to see the perfusion of the flap, shown by bleeding and
changing the blood from white to pink gradually spreading from the pedicle to the flap,
the island of skin bulging. The raised flap movement might be advancement, rotation or
transposition, depending on initial design. In some cases, split thickness skin grafting
(STSG) was required to cover the defect with the PAP flap. The donor sites almost were
directly closed, the STSG might be implemented in a small number of cases. Over-tight
bandaging was avoided to minimize the perfusion and vein embarrassment. A window
was opened in the dressing to observe the condition of the flap. In the post-operation,
patients would be admitted to local and systemic antibiotic therapy as well as
anticoagulation treatment, sedative and anti-inflammatory therapy.

Case study
Case 1
A 59-year-old male had a soft tissue defect at the heel due to chronic infection. After
clear debridement, surgeons designed a PAP flap measuring roughly 13 cm x 7 cm,
which was advanced to cover the defect at the heel. The donor site was directly closed.
The flap survived completely and the 3 months follow-up result was satisfied.
 a
b

c d e
Fig. 1: a. A defect with exposed calcaneus in the heel. b. PAP flap design.
c. post-operative observation. d. 2 weeks after operation e. Follow-up 6 months

Case 2
A 63-year-old female patient suffered a defect measuring 8 x 5 (cm) due to a burn
wound located in the dorsum of the foot. After debridement, a PAP flap was designed
and transferred to the defect. The donor site was covered by STSG ( split thickness skin
graft. The flap completely survived and the patient was satisfied with the appearance and
functon of this site.
 a
b
c

d e

Fig. 2 a. Defect in the dorsum of the foot b. PAP flap design c. Postoperative
appearance d. Follow-up at 3 months e. Follow-up at 6 months

III. Result:
Between September 2017 and January 2024, 31 patients suffered reconstruction in lower
leg and foot by using PAP flap. Details of these patients are performed in Table 1.
Gender ratios in this list do not have a significant difference with the percent of male and
female taking up 58.1% and 41.9% in turn. The size of flaps ranged from 5x3 cm2 to
15x7 cm2. In this study, three kinds of flap movement were applied, rotation flap was
used in 18 cases, which comprised the majority with 58.1%; the remaining types of
movement are advancement and transposition accounting for 29% (9 cases) and 12.9% (4
cases), respectively. Regarding our series, almost all cases had good perfusion in the
postoperative flap with 24 cases having good colour and positive capillary test. Whereas,
in the rest of cases, superficial necrosis was observed in 2 cases ( 6.4%), at the time of 5
days after operation. Fortunately, all the patients were successfully treated and no flaps
were failed.
 Table 1. Patient Summary
Patient Sex/ Etiolog Location Dimension Comorbidit Type of flap Complicati Secondary
Age y of defect of flap ies movement ons procedure
(yrs)
1 M/ Trauma Foot 9x5 None Rotation None
10
2 M/22 Infected Lower 8x6 Arteriopath Rotation None
wound leg y
3 M/66 Trauma Ankle 12x6 DM Transpositio None
n
4 M/54 Trauma Ankle 10x2 None Rotation None
5 M/82 Infected Ankle 15x5 None Rotation Superficial
wound necrosis
6 M/55 Chronic Ankle 10x3 None Rotation None
ulcer
7 M/63 Chronic Foot 7x3 None Rotation None
ulcer
8 M57 Trauma Ankle 9x4 None Advanceme None
nt
9 M/50 Infected Heel 10x5 None Advanceme None
wound nt
10 M/49 Trauma Ankle 11x5 None Advanceme None
nt
11 F/87 Chronic Ankle 7x4 DM Rotation None
ulcer
12 M/56 Trauma Ankle 9x5 None Rotation None
13 F/55 Trauma 10x4 DM Rotation None
14 F/66 Infected Foot 11x4 DM Rotation None
wound
15 M/58 Trauma Heel 8x3 None Rotation None
16 F/15 Trauma Ankle 10x4 None Advanceme None
nt
17 F/63 Infected Foot 12x6 DM Rotation None
 wound
18 F/40 Trauma Heel 6x4 None Rotation None
19 M/49 Trauma Heel 15x5 None Rotation None
20 M/54 Infected Heel 14x5 None Advanceme None
wound nt
21 F/16 Infected Foot 13x6 None Transpositio None
wound n
22 F/17 Trauma Foot 13x4 None Rotation None

23 F/20 Infected Ankle 5x3 None Advanceme None

wound nt
24 F/8 Chronic Heel 10x5 None Rotation Partial
ulcer necrosis
25 M/47 Infected Heel 11x4 None Rotation Partial
wound necrosis
26 M/10 Trauma Foot 7x4 None Rotation Partial
necrosis
27 F/21 Trauma Heel 10x5 None Rotation None
28 F/26 Infected Foot 15x7 None Advanceme None
wound nt
29 M/59 Chronic Foot 10x4 None Transpositio None
ulcer n
30 M/42 Infected Ankle 8x5 None Rotation Superficial
wound necrosis
31 F/74 Infected Heel 12x6 DM Transpositio None
wound n
None

IV. DISCUSSION
Reconstruction of defects in the lower leg and foot region remains argumentative and
challenging issues for surgeons. Variety techniques may become an option for recovering
defects in this area, such as local flaps, distant flap or free flap. However, there were
some demerits of these methods. In particular, local flaps have a significant rate of
failure, free flaps not also need microsurgery facility and expertise but only have a
remarkable donor site morbidity and time-consuming.
The peroneal artery is one of the main arterial trunks of the lower leg and
provides many opportunities to reconstructive surgeons as a basis for flaps. The thin skin
of the dorsum of the foot and ankle is loosely attached to the underlying tendons and
ligaments. Its propensity to trauma, especially in traffic accidents, makes reconstruction
challenging, because the exposed tendon, bone, and ligaments
are not suitable for skin grafting [9]. Perforators flaps from the peroneal artery are now
routinely used for reconstructing such defects
In our study, all 31 cases are pedicled peroneal perforator flap, classified into 3 types:
propeller flaps (n = 18), advancement flap (n = 9), transposition flap (n = 4). The concept
of perforator flaps has progressed with improvement in understanding of flap perfusion
based on different studies of Taylor on angiosomes of the body [1] [2] [3] [4] [5].
Perforator flap is based on a reliable vascular pedicle. Perforator flaps play an important
role in reconstruction of different regions of the body . Perforator flaps may be
transposed, advanced in V-Y manner or rotated depending upon the site of the defect.
Necrosis was witnessed in 5 cases ( including four men and one woman), accounting for
16.1%. Fortunately, all 5 cases survived by implementing methods as dressing change ( 4
cases) or STSG (1 case).
Regards our outcome, smoke history was documented in 11 cases; In there, wound
dehiscence occurred in 7 patients ( 63.6%). We believe that smoking plays a crucial role
in the healing process, therefore, surgeons need to examine the clinic history as well as
comorbidities to assess the potential risks.

About the surgical technique, peroneal vessels can be identified by Doppler studies [6]
but Lin et al [7] suggested direct visualization intraoperatively. We still find it helpful to
use a Doppler probe to locate the perforators, thus surgeons may have precise surface
landmarks preoperatively.

Table 2. Patients occurred necrosis

Patient Gender/ Etiology Smoke Site of Complication Second

No. Age history defect procedure

5 M/82 Infected Yes 15x 5 Superficial Dressing

wound necrosis change

24 F/8 Chronic No 10 x 5 Partial Dressing

ulcer necrosis change
 25 M/47 Infected Yes 11 x 4 Partial Dressing
wound necrosis change

26 M/ 10 Trauma No 7x4 Partial STSG

necrosis

30 M/ 42 Infected No 12 x 6 Superficial Dressing

wound necrosis change

V. CONCLUSION
Peroneal artery perforator becomes a viable option for soft-tissue coverage in lower leg
and foot defects. They are reliable procedures which provide low postoperative
morbidity, short time of treatment, good aesthetic outcome and daily function

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