CT Angiographic Study of the Proximal Leg Peroneal Perforator, and its Application in the Design of Chimeric Flaps for Complex Oromandibular Defects

Introduction: Complex oro-mandibular defects require reconstructing different tissue components, each being at a different spatial relation to the other. Designing tissue components based on multiple perforators of the peroneal vascular system allow three dimensional spatial orientation, reducing the use of multiple donor sites.

Aims: Study of the anatomy of the proximal leg peroneal perforator (PLPP), and its application in designing multiple flaps, in reconstructing full thickness oromandibular defects.

Methodology and Material: a) Thirty CT angiograms of normal lower limbs were studied, documenting the vessel of origin, site and course, of the PLPP.

b) Twelve patients with full thickness defects following excision for oral carcinoma, were reconstructed using double paddle chimeric fibular osteocutaneous flap using both proximal and distal peroneal perforators.

Results: CT angiograms demonstrated the proximal perforator in all cases, arising, average 7 cm from fibular head, originating from a) Peroneal vessels (65%), b) Tibio-peroneal trunk 25%, and c) Popliteal -10%.

The PLPP were also identified in all operated patients, and traced retrogradely till their origin. Perforator dissection was performed under magnification, ex vivo, separating the flap into multiple tissue components.

The PLPP required a separate anastomosis where it arose from the tibioperoneal trunk or popliteal (4/12), while in those arising from the peroneal (8/12)-a single anastomosis of the peroneal vessels sufficed to perfuse all components.

Conclusions: The authors describe a classification system based on the anatomy of the proximal peroneal perforator, and describe its applicability combined with distal perforator based composite fibular osteocutaneous flap in addressing complex oro mandibular defects