Versatility of the Perforator Based Adipose, Adipofascial and fasciocutaneous flaps in Reconstruction of the Distal Leg and Foot Defects

Introduction: The use of pedicled perforator flaps in the lower extremity has opened a new era and decreased the need for free flaps. Main advantages are repair of like with like tissue, a shorter and simpler operation and no need for microsurgical anastomosis, as well as cost efficiency. The presence of multiple perforator alternatives around the distal leg creates versatility of design and choice of flaps that are applicable to defects of various locations and sizes. We present our experience with various perforator flaps, etiologies, defect locations and designs. We have applied several modifications to increase the versatility, ease of use and decrease the donor area complications.

Methodology and Material: Fourteen local perforator flaps were performed on 12 patients (9 male, 3 female, age range 19 to 83) with defects involving the distal leg, ankle and foot. The etiologies were 7 motor vehicle accident, 2 acute burn, 2 chronic wound, 1 postburn contracture, 1 gunshot wound and 1 malignancy. The locations of the defects were 3 mid-leg, 4 peri-ankle, 4 calcaneal, and 3 foot. Depending on the location of the defect either a peroneal artery perforator flap (11patients) or a posterior tibial artery perforator flap (3 patients) were chosen. Perforators were identified using a handheld Doppler. Eight flaps were fasciocutaneous, 4 were adipofascial and 2 were adipose. The flap transfer technique was 9 rotation, 2 flip, 2 propeller and 1 transcrural. Flap dimensions ranged from 8x5cm to 22x5cm.

Results: Twelve flaps had full viability, one had partial necrosis of distal 20% (due to malposition of the ankle) and one had complete necrosis (due to undiagnosed hereditary hypercoagulable syndrome). None of the patients had donor site complications. The age, etiology, flap transfer technique or tissue components of the flap did not change the outcome. Overall there was 93% good outcome determined by complete closure of the exposed structures and return to functionality.

Conclusions: Perforator flaps from the lower extremity can be very reliable in reconstructing local defects. They can be versatile in terms of size, design, composition and axis of rotation. When appropriate principles are applied, they are safe, faster and cost efficient alternatives to microsurgical reconstruction.