Plastic & Reconstructive Surgery:
Reconstructive: Lower Extremity: Original Articles
Perforators of the Lower Leg: Analysis of Perforator Locations and Clinical Application for Pedicled Perforator Flaps
Schaverien, Mark M.R.C.S.; Saint-Cyr, Michel M.D.
From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.
Received for publication August 10, 2007; accepted November 14, 2007.
Michel Saint-Cyr, M.D.; Department of Plastic Surgery; University of Texas Southwestern Medical School; 1801 Inwood Drive; Dallas, Texas 75201; firstname.lastname@example.org
Disclosure: The authors have no financial interests in this research project or in any of the techniques or equipment used in this study, and neither of the authors has any financial relationships, interests, or commercial associations with the products, drugs, or devices mentioned in this article.
Background: Pedicled perforator flaps in the lower leg enable reconstruction of a variety of local defects without microvascular anastomoses and with minimal donor-site morbidity. This study determined the reliable locations of the lower leg perforators.
Methods: Twenty lower limbs harvested from fresh cadavers were used. In 15 specimens, colored latex intra-arterial injections were performed followed by dissection in the suprafascial plane; perforators with a diameter greater than 0.5 mm were located with respect to a line between the tips of the medial and lateral malleoli. In five further specimens, intra-arterial injection of a barium sulfate/gelatin mixture was performed and computed tomographic scans were acquired. Cluster analysis was performed to determine the 5-cm intervals where perforators were most commonly encountered within each septum.
Results: Perforators were located in discrete intermuscular septa. Those arising from the anterior tibial artery were predominantly encountered within three septa, and those of the peroneal and posterior tibial arteries were found within discrete septa. Reliable perforators were found within three distinct 5-cm intervals: at 4 to 9 cm, 13 to 18 cm, and 21 to 26 cm from the intermalleolar line. The anterior tibial artery perforators clustered in the distal and proximal intervals, those of the peroneal artery in the middle interval, and those of the posterior tibial artery in all three intervals.
Conclusions: Reliable perforators from the anterior tibial, posterior tibial, and peroneal arteries can be found in distinct 5-cm intervals within intermuscular septa. This may aid in the design of pedicled perforator flaps of the lower leg.
Application of the pedicled perforator flap concept for the reconstruction of defects of the lower leg has many advantages. The source artery and underlying muscles are preserved, and the need for microvascular anastomoses is avoided. Flap harvest is relatively quick, and the recipient site has similar texture, thickness, pliability, and pigmentation to that which has been lost.1 V-Y or propellor flap designs may enable primary closure, and there is freedom of rotation about the pedicle of up to 180 degrees. These flaps are particularly suitable for complicated defects of the lower third of the leg, which are among the most challenging. Adipofascial flaps may also be raised based on these perforators.2
Many anatomical studies have evaluated the location of the perforators of the arteries of the lower leg,1–25 revealing a variety of locations for the reliable perforators. Although Doppler ultrasound can be used to locate the position of the perforators,2,3 a map of the consistent perforators would be useful for planning reconstructive options. This study uses latex dissection and computed tomographic angiography to determine the sites of reliable perforators from the source arteries of the lower leg.
Twenty lower limbs from fresh cadavers acquired through the Willed Body Program at the University of Texas Southwestern Medical Center were used in this study. In all specimens, the popliteal artery was cannulated, leak points ligated, and irrigation with warmed (37°C) heparinized (10 U/ml) saline performed until the effluent was clear.
In 15 of these specimens, red latex (Ward’s, Rochester, N.Y.) injection was performed until a red cutaneous flush was visualized. The specimens were then left at room temperature for 24 hours to allow the latex to cure. In five of these specimens, the venae comitantes of the posterior tibial artery were also cannulated distal to the medial malleolus and injected with blue latex until extensive filling of the long saphenous venous system could be visualized, followed by preparation as described above.
The foot was positioned in neutral and a line was drawn to connect the tips of the medial and lateral malleoli parallel to the floor, in addition to a line around the popliteal crease parallel with the floor. Incisions were made along these lines and were connected over the medial surface of the tibia. Flap elevation was performed in the suprafascial plane, and each perforator encountered with an internal diameter greater than or equal to 0.5 mm was tagged, its distance from the point of entry through the fascia to the intermalleolar line measured, its internal diameter measured using electronic calipers, and the distance between the source artery and entry point through the fascia measured. The length of the lower leg was measured from the intermalleolar line to the popliteal crease. For the sural arteries, the distance from the popliteal crease was measured, and the distance from the raphe, and measurements were recorded as coordinates. In the five specimens where the venae comitantes of the posterior tibial artery had been injected with latex, the number of venae comitantes for each perforator was recorded.
In an additional five specimens, the popliteal artery was injected with a barium sulfate/gelatin mixture (barium sulfate, 40 g; normal saline, 100 ml; powdered gelatin, 3 g). These were then refrigerated at 4°C to allow the gelatin to set. Helical scans were obtained using a GE Lightspeed 16-slice scanner (General Electric, Milwaukee, Wis.) set to obtain 0.625-mm slices using a 1-second rotation time, and three-dimensional reconstructions were performed using a computed tomography workstation.
The distance of the perforators from the intermalleolar line measured in line with the septa was recorded to the nearest centimeter. The number of specimens in which perforators occurred within each centimeter interval was calculated, and the 5-cm interval in which perforators were found in the most specimens was chosen.
Perforators were seen emerging from the crural fascia in four longitudinal rows within the intermuscular septa that border the compartments of the lower leg and the tibia. The anterior tibial artery perforators were found predominantly between the tibia and tibialis anterior and between the extensor digitorum longus and the peroneus longus within distinct intermuscular septa. There was one septum within which perforators from the posterior tibial artery coursed and one within which the peroneal artery perforators were found. Approximately twice as many perforators were found originating from the anterior tibial artery as were found from the posterior tibial or peroneal arteries, although they were also generally found to have the smallest diameters. Perforators from the anterior tibial, posterior tibial, and peroneal arteries were found to predominate within three 5-cm intervals: at 4 to 9 cm, 13 to 18 cm, and 21 to 26 cm from the intermalleolar line. The lengths of the lower leg from the intermalleolar line to the popliteal crease were found to follow a normal distribution, and the median length was 35 cm (range, 34 to 41 cm).
Anterior Tibial Artery Perforators
The proximal perforators were found to be the largest, emerging predominantly between the tibia and tibialis anterior muscle and within the anterior peroneal septum between the extensor digitorum longus and the peroneus longus within the intermuscular septa, and also between the tibialis anterior and extensor digitorum longus. The crural fascia was continuous with the periosteum over the medial surface of the tibia, and perforators adjacent to the tibia were enveloped with the periosteal layers, with a network of anastomoses with the posterior tibial artery perforators found over the tibial surface. The superficial peroneal nerve was accompanied by long branches of perforators from the anterior peroneal septum. The perforators became smaller distally, where they were found between the tendons of the muscles of the anterior compartment (Fig. 1).
Cluster analysis of all of the perforators with diameter greater than or equal to 0.5 mm originating from the anterior tibial artery revealed that a cluster occurred distally between 4 and 9 cm proximal to the intermalleolar line, between the tibia and tibialis anterior, and between the tibialis anterior and extensor digitorum longus (Table 1). Twenty-two percent of all of the perforators from the anterior tibial artery were found within this septum (Fig. 2). Evaluation of only the perforators within the septum between the tibia and tibialis anterior revealed the same cluster, with 23 percent of perforators found within this septum, with a mean distance to the artery of 3.7 ± 1.3 cm. Ninety-three percent of lower legs studied had a perforator within this septum. In the septum between the extensor digitorum longus and peroneus longus, 29 percent of perforators were found between 21 and 26 cm proximal to the intermalleolar line, with a mean distance to the artery of 2.6 ± 1.5 cm (Table 2). Eighty percent of specimens had a perforator within this septum (Figs. 1 through 3).
Peroneal Artery Perforators
These perforators were found to emerge through the posterior peroneal septum. Proximally they were found to emerge through the soleus or peroneus longus muscles, whereas distally they were found to emerge between the flexor hallucis longus and the peroneus brevis (Fig. 1). Perforators originating from the posterior tibial artery were occasionally found to emerge through this septum. Perforators were found to predominate in the middle third of the fibula, and a cluster was found 13 to 18 cm proximal to the lateral malleolus, where 28 percent of the total number of perforators were found (Table 3). Ninety-three percent of lower legs studies had a perforator within this cluster (Figs. 2 and 3). Distally, branches of perforators from the peroneal and posterior tibial arteries were found to course over the surface of the tendo Achilles.
Posterior Tibial Artery Perforators
The posterior tibial artery perforators were consistently found to be the largest of the lower leg, particularly in the middle third of the leg, and were found between the flexor digitorum longus and the soleus (Fig. 1). Two venae comitantes accompanied each perforator. In the proximal two-thirds these ran bridged between the venae comitantes of the posterior tibial artery and the long saphenous vein, and in the distal third these were found only to arise from the venae comitantes of the posterior tibial artery. Three consistent clusters were found: at 4 to 9 cm, at 13 to 18 cm, and at 21 to 26 cm from the intermalleolar line (Table 4). Each cluster contained 23 percent of the perforators from the artery. Within each of these intervals, a perforator was found in 80 percent of lower legs studied (Figs. 2 and 3).
Medial and Lateral Sural Artery Perforators
The medial sural artery consistently provided one or two large perforators (Table 5) (Fig. 4). One of these was usually found with the medial sural cutaneous nerve and short saphenous vein. Lateral sural artery perforators were inconsistent in location and absent in several dissections.
This study has found that the perforators of the lower leg occur predominantly within four intermuscular septa. Moreover, when the perforators clusters were analyzed to 5-cm intervals, three distinct clusters emerged.
The perforators of the lower leg emerged through the deep fascia in four longitudinal rows adjacent to the intermuscular septa. Cluster analysis revealed that the perforators occurred in three 5-cm intervals from the intermalleolar line. These intervals were 4 to 9 cm, 13 to 18 cm, and 21 to 26 cm proximal to the intermalleolar line (Fig. 1). In the 4- to 9-cm interval, perforators from both the anterior and posterior tibial arteries could be found; in the 13- to 18-cm interval, constant perforators from the peroneal and posterior tibial arteries were found; and from 21- to 26-cm, perforators from the anterior tibial and posterior tibial arteries were clustered. The posterior tibial artery perforators were found to be consistently the largest and easiest to dissect, and were accompanied by two venae comitantes in all specimens. Perforators with the largest caliber from this source artery were found in the proximal two-thirds, and perforators were occasionally found in the peroneal septum, as has been reported previously.13
Although there have been several anatomical studies of the perforators of the lower leg, predominantly those of the posterior tibial artery, there has generally been disagreement regarding the locations of reliable perforators within these specimens. There has also been incongruity regarding the landmarks used for locating these perforators, leading to difficulty in comparing results from separate studies. The different perforator mapping techniques used have included angiography, dissection, dissection following latex injection, and different cutoffs for perforator diameter.
This study has found that the peroneal artery perforators predominate in the 13- to 18-cm interval, supporting previous findings of the predominance of perforators in the middle third of the fibula.18 These perforators were found to be the most difficult to dissect to their source artery, and the location of the perforator cluster reduces the clinical use of this flap as a pedicled perforator flap.
A large flap territory can be raised on a single perforator from the posterior tibial artery.11 This is because of its extensive communications with the vascular territories of the other source arteries of the lower leg,8 including the saphenous artery.2 Previous studies have revealed that a flap of up to 19 × 13 cm can be harvested clinically,10 and Quaba and Quaba1 have reported extending the flap to within 10 cm of the popliteal skin crease, with drainage through the venae comitantes only. The saphenous nerve can be included if required,10 as can the saphenous vein if there is a question of inadequate venous drainage. The posterior tibial artery perforators have the largest diameter in the proximal two-thirds of the tibia.7,11 Here the perforators were noted to be predominantly septocutaneous, which is in agreement with other studies.7 The flap provides local coverage for wounds of the heel and ankle, where few good options exist,1,9,22 and can also be safely harvested as an adipofascial flap.2 The posterior tibial artery, which is the dominant source of blood supply to the foot, is preserved. Transient ankle edema has been reported following harvest of this artery,23 and vascular insufficiency may occur following its harvest.8,10 This study has found that the perforators of the posterior tibial artery were accompanied by two venae comitantes, which is in agreement with other studies6,12 (Fig. 5).
Pedicled perforator flap harvest does not necessitate exposure of the posterior tibial artery or skeletonization of the perforator,1 reducing the risk of damage to the perforator and delicate venae comitantes. In a large clinical series, significant flap necrosis necessitating an alternative reconstruction occurred in only 7.5 percent of cases,1 and the flap has demonstrated reliability for coverage of open fractures of the distal third of the tibia in combination with reamed intramedullary nailing. The posterior tibial artery perforators are also amenable to location using Doppler.2,3 Of interest, we combined our results with those of a study of 20 lower legs by Hung et al.,11 which used a similar methodology, and found the cluster intervals to remain the same.
A variety of methods have previously been used to evaluate the perforator locations within the lower limb. Koshima et al.10 measured the locations of the posterior tibial artery perforators by using stereoscopic angiography and divided the leg into five equal parts, each 7 cm in length. Wu et al.7 examined the locations of the perforators of the posterior tibial artery and divided the leg into zones of 7 cm in length. Ozdemir et al.3 divided the lower leg into three equal zones. Whetzel et al.4 divided the leg into tenths to map the location of the perforators and their vascular territories. This study uses actual measurements rather that percentage lengths or dividing the leg into intervals to provide a reliable and simple tool for perforator flap planning in the lower leg. A small 5-cm exploratory incision can be made through which the perforator can be identified, allowing freedom in flap design without committing to a larger incision. An acoustic Doppler probe can also be used to confirm the location of perforators within these intervals.
Of the perforator intervals, the most clinically useful are those harvested from the posterior tibial artery. The distal perforators in particular can be used for coverage of defects of the heel, medial malleolus, Achilles tendon, and distal two-thirds of the tibia (Fig. 6). The largest perforators were found in the middle third in this study. The location of the reliable peroneal artery perforators limits their use clinically, and the dissection to the source artery was found to be the most technically difficult. The anterior tibial artery perforators within the distal cluster can be used for coverage of defects over the lateral malleolus (Fig. 7). The proximal cluster within the anterior peroneal septum, however, provides large perforators that may be used for coverage of proximal tibial defects. This study supports findings of large reliable perforators from the medial sural artery, particularly proximally, that can be used for tibial coverage.
Reliable perforators from the anterior tibial, posterior tibial, and peroneal arteries can be found in 5-cm intervals within distinct intermuscular septa. This may aid in the design of pedicled perforator flaps for reconstruction of defects of the lower leg.
The authors would like to thank Alexandra Hernandez, M.A., of Gory Details Illustration for the artwork provided in this article.
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Future Meetings of the American Society of Plastic Surgeons
The following are the planned sites and dates for future annual meetings of the American Society of Plastic Surgeons:
2008 Chicago, Ill. October 31 to November 4
2009 Seattle, Wash. October 23 to 28
2010 Toronto, Canada October 1 to 6
2011 Denver, Colo. September 23 to 28
2012 Washington, D.C.November 1 to 7
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©2008American Society of Plastic Surgeons
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