Peroneal perforator pedicle propeller flap for lower leg soft tissue defect reconstruction: Clinical applications and treatment of venous congestion

Abstract

Objective To describe the characteristics of the perforator vessel in the peroneal artery of the lower leg and to explore the use of perforator pedicle propeller flaps to repair soft tissue defects in the lower leg, heel and foot. Methods This retrospective study enrolled patients with soft tissue defects of the distal lower leg, heel and foot who underwent surgery using peroneal perforator-based propeller flaps. The peroneal artery perforators were identified preoperatively by colour duplex Doppler ultrasound. The flap was designed based on the preoperatively-identified perforator location, with the posterior border of the fibula employed as an axis, and the perforator vessel as the pivot point of rotation. Patients were followed-up to determine the outcomes. Results The study analysed 36 patients (mean age, 39.7 years). The majority of the soft tissue defects were on the heel (20; 55.6%). The donor-site of the flap was closed in 11 patients by direct suturing and skin grafting was undertaken in 25 patients. Postoperative complications included venous congestion (nine patients), which was managed with delayed wound coverage and bleeding therapy. All wounds were eventually cured and the flaps were cosmetically acceptable. Conclusions The peroneal perforator pedicle propeller flap is an appropriate choice to repair soft tissue defects of the distal limbs.

Keywords: Perforator-based propeller flaps; congestion; peroneal artery; soft tissue reconstruction.

Figure 1.

Schematic diagram illustrating the surgical procedure for peroneal artery perforator-based propeller flap isolation. Dissection of the perforator enables rotation and allows sufficient mobility so that a fasciocutaneous flap can be isolated and is then rotated 180° like a ‘propeller’. The opened section caused by the rotated flap being moved away from its point of origin is then closed with direct suturing or skin grafting. (A) The proximal point of the propeller flap; (B) the pivot point of the flap (the position of the peroneal perforator); and (C) the distal point of the wound. The arrows indicate the clockwise or anticlockwise rotation of the flap. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 2.

Surgical procedure for peroneal artery perforator-based propeller flap isolation. Steps 1 to 7 illustrate the procedure of harvesting a peroneal perforator-based propeller flap by an experienced surgeon. Representative images were taken during surgery on the same patient. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 3.

Operation flowchart showing the surgical processes undertaken and the surgical decisions that need to be made during the procedure. An operation flowchart is important in depicting the process and decisions made during surgery and may serve as a reference for surgeons. This illustrates the chain of decision making by an experienced surgeon during the entire course of the surgery and has been used as a standard operating procedure in our hospital.

Figure 4.

Examples of the aesthetics of the postoperative local flap reconstruction in four patients with soft tissue defects of the distal lower leg, heel and foot who were successfully treated using peroneal perforator-based propeller flaps. These images demonstrate successful recovery and the good cosmetic appearance of the soft tissue reconstruction in each of these patients. Each of the patients had no issue with wearing socks or shoes after the operation due to the nicely fitted contours of the flap over the defect. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 5.

Representative images showing venous congestion and tissue necrosis. The colour of the skin patch turns purple due to occlusion of the vein, which is known as venous congestion (a). On some occasions, it may lead to necrosis of the distal part of the flap (b). The colour version of this figure is available at: http://imr.sagepub.com.

Figure 6.

Exposure of the perforator artery during perforator-based propeller flap isolation. The strain placed on the blood vessels following the surgical procedure was examined before rotation (a) and after rotation (b) of the flap. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 7.

Delaying coverage and suturing of the flap due to venous congestion. (a) If the surgeon finds that the flap is too tight to suture during the operation, then the flap may not be completely sutured. (b) After 3–5 days, when the swelling of the flap has reduced, the surgeon can complete the suturing and wound coverage. This helps to avoid the skin tearing. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 8.

Analysis of the flap after the use of bleeding therapy to control venous congestion. (a) A surgical expert made some small incisions at the peripheral area of the flap when postoperative venous congestion occurred in order to release the blood. (b) The flap can be saved as a result of this procedure. The colour version of this figure is available at: http://imr.sagepub.com.