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Medial and Lateral Malleolar Perforator Flaps for Repair of Defects Around the Ankle

Koshima, Isao MD; Itoh, Seiko MD; Nanba, Yuzaburo MD; Tsutsui, Tetsuya MD; Takahashi, Yoshio MD

Original Articles

Reconstruction for defects around the ankle continues to be challenging. Repairs have been effected with the dorsalis pedis flap, the medial plantar flap, and with reverse-flow island flaps using the anterior and posterior tibial systems and the peroneal system. However, sacrifice of the major vessels of the lower leg and wide and long scars at the donor site are disadvantages of these flaps. To overcome these disadvantages, the authors developed island lateral and medial malleolar flaps with the perforators located close to the ankle. These flaps are easy to elevate, involve a short operating time, require no sacrifice of major vessels or muscles of the lower legs, and the use of these adipofascial flaps makes donor scars more acceptable. Malleolar perforator flaps are suitable for the repair of small ankle defects.

Reconstruction of ankle defects continues to be challenging. Defects around the ankle joint are often accompanied by exposure of the extensor tendons, tibia, fibula, and Achilles tendon. Hallock 1 indicated that even a small defect in this region may justify the need for a microsurgical tissue transfer to achieve coverage, because bone and extrinsic foot tendons are exposed easily. Therefore, these areas are often affected by chronic ulceration. These defects are very difficult to resurface using random flaps because the skin vascular territory of the random flap is limited in this region. As a result, pedicled flaps, such as the dorsalis pedis island flap, 2 the medial plantar island flap, 3 the extensor digitorum brevis muscle flap, 4 the reversed soleus muscle flap, 5 and free flaps 6 have been used. So far, many authors have documented the detailed anatomy of the vascular supply of the fasciocutaneous flap with the fascial plexus, and have indicated the importance of the cutaneous perforators instead of the fascial plexus in these flaps. 7–11 Therefore, perforator flaps excluding the fascial plexus have been developed in the extremities. In the ankle region, several perforator flaps, including the lateral calcaneal flap, 12 the lateral supramalleolar flap, 13 the reverse peroneal flap, 14–16 the reverse anterior tibial flap, 17,18 the reverse posterior tibial flap, 19–24 and the reverse sural flap 25–28 have been reported. In addition to these flaps, we developed new perforator flaps-the medial and lateral malleolar flaps-which are nourished by unknown, small pedicled perforators around the malleolar processus. We present the usefulness of the medial and lateral malleolar perforator flaps for repair of defects around the ankle joint.

Ten patients with intractable ankle and heel defects were repaired using island medial and lateral malleolar flaps with two distal flap losses and no amputations. Injection cadaver studies demonstrated consistent perforating arteries around the malleoli from all three major leg vessels.

From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Dentistry, Okayama University, Japan.

Received December 20, 2002, and accepted for publication, after revision, April 1, 2003.

Reprints: Isao Koshima, MD, Plastic and Reconstructive Surgery, Graduate School of Medicine and Dentistry, Okayama University, 2-5-1, Shikata, Okayama City, 700–8558 Japan. Tel and Fax: +81-86-235-7212,

Supported in part by grants from the Scientific Councils of the Japanese Ministry of Education (grant no. C2-10671693) and the Japanese Health, Welfare, and Labor Ministry (grant no. H12-17).

Presented in part at the 34th annual meeting of the Japanese Society of Plastic and Reconstructive Surgery, Matsumoto City, Japan, April 1991; and at the first (Gent, Belgium, June 1997), second (New Orleans, LA, November 1998), and third (Munich, Germany, November 1999) international courses of perforator flaps.

© 2003 Lippincott Williams & Wilkins, Inc.