The suprafascial course of lower leg perforators: An anatomical study

Abstract

Background: Perforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design.

Methods: An anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported.

Results: During suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them.

Conclusions: Our study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.

Keywords: Arteries; Lower extremity; Perforator flaps.

Fig. 1.. Single non-branching perforators

Intraoperative photos of single perforators. (A) A classic single perforator flap, with a single vessel emerging from the fascia and entering the flap. (B, C) Flaps with more than one perforator (2 and 3, respectively). A normal vascular course is observed in these photos.

Fig. 2.. Suprafascial branching perforators

This figure illustrates the vascular branching patterns encountered in our series. (A) The 2-in-1 “λ” pattern; at the base are two close perforators, just above the fascia; at the apex, the two perforators converge in a single common branch, entering the flap. (B) The 3-in-1 “reverse ψ” pattern; three different perforators converge in a single branch. (C) The 1-in-2 “Y” pattern; in contrast to (A) and (B), here a single perforator diverges into two smaller branches. This is considered to be a normal anatomical configuration.

Fig. 3.. Anatomical schematic of perforator courses

This schematic shows a simplified portrayal of the relevant anatomy, designating the three planes through which the perforators run. The same anatomical configurations are presented as in Fig. 2.