Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps

Abstract

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.