We had the great pleasure of reading the extremely interesting article by Schmidt and Giessler entitled “The Muscular and the New Osteomuscular Composite Peroneus Brevis Flap: Experiences from 109 Cases.”1 We congratulate the authors for the exhaustive and complete description of their experience concerning the use of this flap for restoration of small to medium defects around the ankle, foot, and distal lower leg.1 We would like to take the opportunity to further discuss indications and advantages of the reverse-flow peroneus brevis flap from our experience.2
Since its first clinical application by Eren et al.,3 the distally based peroneus muscle flap has been indicated as a convincing alternative in small to moderate defect coverage of the distal third of the lower limb. Although there has been some criticism,4 its versatility and its advantages have been confirmed by numerous investigations.2,5–10 Primary tension-free closure of the donor site results in a cosmetically acceptable scar over the lateral aspect of the leg2,3; with its arc of rotation, it allows coverage of more anterior defects of the ankle, the Achilles tendon, the heel area, and the lateral and medial malleolus areas.1–3,7,10 Because of its vascular supply, the reverse-flow peroneus brevis muscle flap represents a better choice when dealing with soft-tissue and bone infections rather than other local fasciocutaneous flaps1,2,10; moreover, its reliability is not grossly influenced by associated comorbidities that are expected in both old and posttraumatic patients.2,10
The article by Schmidt and Giessler1 offers a further advantage by describing the osteomuscular variant of this flap obtained by raising the peroneus brevis flap with a semicircular lateral fibula vascularized segment firmly attached to the muscle origin. In its composite form, it allows for optimal and complete restorations of a bone-deficient recipient site either to achieve full reconstruction of a defect or to add stability and volume to a hollowed-out recipient bone.1 Moreover, because harvesting this flap is associated with very low donor-site morbidity, the German authors suggest its use as a free flap, proposing more investigations to prove the feasibility of the microsurgical peroneus brevis muscle.1
In our experience,2 we adopted the distally based peroneus brevis flap, as we believe it offers many advantages compared with other reconstructive options. Although the size of the flap makes it suitable only for small or moderate sized defects, it is a quick and safe reconstructive surgical procedure that allows reliable soft-tissue coverage of bone and tendons and preservation of major arteries of the leg. In particular, we have studied the effect of raising this flap on plantar flexion and foot eversion.2 By assigning clinical demerit points according to the Weber demerit score and giving a clinical grade according to the Olerud-Molander Ankle Score in which subjective parameters such as pain, stiffness, and swelling and the functions of stair climbing, running, jumping, squatting, and work or activities of daily life were scored, we compared preoperative and postoperative ankle function and stability.2 Neither score was observed to be worsened, because no differences have been found between presurgical and postsurgical reconstruction procedures. Thus, the successful healing of all defects obtained with the peroneus brevis flap and the absence of functional impairment of the ankle lead to a very high rate of patient satisfaction with the outcomes. The resolution of major complaints of the patients, mainly pain and stiffness, was perceived as was the negligible morbidity because of the preservation of ankle functionality (plantar flexion and foot eversion) ensured by the preservation of the peroneus longus muscle.
Because of its almost constant vascularity, the distally based peroneus muscle flap is a useful option for moderate size defects in the distal third of the lower leg, and is often preferable to the use of free flaps. Coverage of defects of the ankle, the Achilles tendon, heel, and lateral and medial malleolus areas is allowed by its arc of rotation. Its versatility is attributable to its simple and quick elevation and its easy transposition within the wound without further dissection. Ankle instability is avoided by preservation of the peroneus longus.
Fulvio Lorenzetti, M.D., Ph.D.
Plastic and Reconstructive Surgery Unit
Tommaso Agostini, M.D.
Burn Center Unit
Marcello Pantaloni, M.D.
Davide Lazzeri, M.D.
Plastic and Reconstructive Surgery Unit
Hospital of Pisa
The authors have no financial interest to declare in relation to the content of this communication.
1. Schmidt AB, Giessler GA. The muscular and the new osteomuscular composite peroneus brevis flap: Experiences from 109 cases. Plast Reconstr Surg
2. Lorenzetti F, Lazzeri D, Bonini L, et al. Distally based peroneus brevis muscle flap in reconstructive surgery of the lower leg: Postoperative ankle function and stability evaluation. J Plast Reconstr Aesthet Surg
3. Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus brevis muscle flap: A new flap for the lower leg. Plast Reconstr Surg
4. Barr ST, Rowley JM, O'Neill PJ, et al. How reliable is the distally based peroneus brevis muscle flap? Plast Reconstr Surg
5. Saydam M, Yilmaz S, Seven E. Distal peroneus brevis muscle flap. Plast Reconstr Surg
6. McHenry TP, Early JS, Schacherer TG. Peroneus brevis rotation flap: Anatomic considerations and clinical experience. J Trauma
7. Koski EA, Kuokkanen HO, Tukiainen EJ. Distally-based peroneus brevis muscle flap: A successful way of reconstructing lateral soft tissue defects of the ankle. Scand J Plast Reconstr Surg Hand Surg
8. Yang YL, Lin TM, Lee SS, Chang KP, Lai CS. The distally pedicled peroneus brevis muscle flap anatomic studies and clinical applications. J Foot Ankle Surg
9. Fansa H, Frerichs O, Schneider W. Distally pedicled peroneus brevis muscle flap for defect coverage on the lower leg (in German). Unfallchirurg
10. Bach AD, Leffler M, Kneser U, Kopp J, Horch RE. The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg
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