Keywords
perforator flap - peroneal artery perforator-based flap - finger reconstruction
The peroneal flap as reported by Yoshimura in 1984 is nourished by skin perforator
vessels arising from the peroneal artery and concomitant veins and can be harvested
from the lateral lower leg.[1] The peroneal flap is now called the peroneal artery perforator flap.[2]
[3]
[4] Yoshimura originally described that the vascular pedicle of the peroneal flap was
composed of the peroneal artery and concomitant veins. A disadvantage of the peroneal
flap is that it requires sacrificing the peroneal artery, which is one of the three
main arteries in the lower leg. The recent development of perforator flaps has dramatically
changed soft tissue reconstructive surgery. The use of perforator flaps enables surgeons
to minimize donor-site morbidity by preserving important tissues, including the muscle
and the major vessels.[5]
[6]
[7] The peroneal artery perforator-based flap, which utilizes only perforator vessels
for the vascular pedicle, is minimally disruptive to the donor site because there
is no need to sacrifice any major arteries of the lower leg. Although the peroneal
artery perforator-based flap has been widely used as a pedicled propeller flap for
soft tissue reconstruction in the lower extremity,[8]
[9] free peroneal artery perforator-based flap transfer has been rarely reported.[10] In this article, we report on the utility of the free peroneal artery perforator-based
flap for soft tissue reconstruction of the finger.
Methods
Between 2000 and 2016, twelve patients who had soft tissue defects of the finger underwent
reconstruction with a free peroneal artery perforator-based flap. There were 10 men
and 2 women, and their ages at the time of the surgery ranged from 19 to 60 years
(mean of 48 years). The soft tissue defects were caused by trauma in all cases and
were located on the dorsal and/or lateral sides of the fingers. Six cases involved
the index finger, four the middle finger, two the ring finger, and one the little
finger. The size of the skin defects ranged from 4 × 2 to 7 × 3 cm. Before harvesting
the free peroneal artery perforator-based flap, the location of the perforator vessels
arising from the peroneal artery was plotted using a Doppler flowmeter. There were
often multiple (two to five) points in the distal and middle third of the lateral
lower leg along the posterior margin of the fibula. The flap was designed to include
these points. The first incision was made along the posterior border of the flap.
The skin perforator vessels that passed through the muscle septum between the soleus
and peroneal muscles were easily located. After confirming the perforator vessels,
the flap was elevated anteriorly. The dissection of the perforator vessels was then
performed toward the peroneal artery and concomitant veins with ligation of the muscular
and fibular branches. The free peroneal artery perforator-based flap was elevated
to ligate the perforator vessels at the bifurcation from the peroneal vessels. The
size of the flaps ranged from 5 × 2 to 8 × 3 cm. The length of the vascular pedicles
ranged from 4 to 5 cm. The artery and vein of the perforator vessels were anastomosed
in the finger to the digital artery and subcutaneous vein, respectively.
Results
All flaps survived completely. The donor site in the lower leg was closed primarily
in all cases. There have been no donor-site problems. Secondary defatting of the grafted
flap was performed in 6 of the 12 cases at 3 to 5 months after the flap surgery. In
other cases, thinning of the flap was performed when the flap was transferred. All
the patients were satisfied with their results.
Case Reports
Case 1
A 48-year-old woman had a skin defect on the radial side of the left ring finger caused
by a heat press injury ([Fig. 1A]). An 8 × 3 cm peroneal artery perforator-based flap was harvested from the right
lower leg to cover the skin defect ([Fig. 1B]). The thinning of the flap was performed before ligation of the vascular pedicle.
The length of the vascular pedicle was 5 cm. The donor site was closed primarily ([Fig. 1C]). The perforator artery was anastomosed to the digital artery, and the vein was
anastomosed to the subcutaneous vein in the finger. The flap survived completely and
adapted well in appearance ([Fig. 1D]).
Fig. 1 Case 1 (A) There was a skin defect on the radial side of the ring finger. (B) An 8 × 3 cm peroneal artery perforator-based flap with a 5-cm vascular pedicle was
harvested. (C) The donor site was closed primarily. (D) At 1 month postoperatively, the flap survived uneventfully.
Case 2
A 38-year-old man had a skin defect on the radial side of the left middle finger caused
by a crush injury ([Fig. 2A]). A 5 × 2 cm-peroneal artery perforator-based flap was harvested from the right
lower leg ([Fig. 2B]), and the length of vascular pedicle was 4 cm. The donor site was closed primarily.
The perforator artery was anastomosed to the digital artery, and the vein was anastomosed
to the subcutaneous vein in the finger. The flap survived completely ([Fig. 2C]). Secondary defatting was performed at 3 months after the flap surgery, and the
flap adapted well in appearance ([Fig. 2D]).
Fig. 2 Case 2 (A) There was a skin defect on the radial side of the middle finger. (B) A 5 × 2 cm peroneal artery perforator-based flap with a 4-cm vascular pedicle was
harvested. (C) At 3 months postoperatively, the grafted flap was bulky. (D) After secondary defatting, the flap adapted well and survived.
Discussion
The concept of the perforator flap developed after the first report of a deep inferior
epigastric artery perforator flap by Koshima and Soeda in 1989.[5] It had been believed that vascularity of the skin flap depended on the underlying
rectus abdominis muscle, but Koshima and Soeda proved that the skin flap could be
nourished by just a single perforator vessel without going underneath the muscle.
A variety of perforator flaps have since been developed from various sites of the
body.[6]
[7]
[8] The most important feature of perforator flaps is that these are minimally invasive
to the donor site. Perforator flaps can preserve not only the underlying muscle but
also the main arteries in the extremities. In 1991, the concept of the perforator-based
propeller flap was introduced by Hyakusoku and colleagues.[11] Perforator-based propeller flaps are versatile local island flaps based on a single
dissected perforator vessel and designed to rotate up to 180 degrees to cover adjacent
skin defects. The peroneal artery perforator-based propeller flap has been widely
used for soft tissue reconstruction in the lower extremity.[8]
[9]
A free perforator-based flap, sometimes called a free true perforator flap,[12] has been only rarely reported because the small diameter of the perforator vessels
makes vascular anastomosis difficult at the recipient site.[10] According to previous anatomical studies,[13]
[14]
[15] the average diameter of the perforator vessels arising from the peroneal artery
is approximately 1 mm. The diameter of the perforator vessels is suitable for end-to-end
anastomosis to the digital artery and subcutaneous veins in the finger. The mean length
of the perforators from the peroneal artery was approximately 5 cm, which is adequate
for the vascular pedicle of the flap in finger reconstruction. The other advantages
of the free peroneal artery perforator-based flap for finger soft tissue reconstruction
include the following: the flap is flexible and can be thinned to match the texture
of the finger, elevation of the flap is easy when the septocutaneous perforator is
dissected, and the donor site can be closed primarily with less than 3 cm in width.
However, there are a few disadvantages of the free peroneal artery perforator-based
flap for finger soft tissue reconstruction. The skin of the flap may be hairy in men.
If the patient dislikes hairy skin on the reconstructed finger, hair removal may be
necessary. The flap may be bulky in obese individuals. Primary thinning of the flap
is possible if the patient and surgeon want to avoid secondary defatting. However,
careful thinning must be performed because damage to the subcutaneous vascular plexus
may cause flap necrosis. Secondary defatting is a safe and reliable procedure. The
skin of the lateral lower leg is soft and flexible, which is not suitable as the graft
for the palmar side of the finger. Finally, the free peroneal artery perforator-based
flap cannot restore sensation. For these reasons, a free peroneal artery perforator-based
flap should be applied to defects on the dorsal and/or lateral sides of the finger.
Conclusion
The peroneal artery perforator-based flap is minimally disruptive to the donor site
and is suitable for soft tissue reconstruction of the finger in cases with soft tissue
defects on the dorsal and/or lateral sides of the finger.
