Optimizing localization accuracy in peroneal artery perforator sequential flap transplantation with digital subtraction angiography and high-frequency ultrasound
DOI:
https://doi.org/10.2340/jphs.v60.42954Keywords:
Peroneal artery perforator sequential flap, Digital subtraction angiography, High-frequency ultrasound, distal lower leg, Wound repairAbstract
The peroneal artery perforator flap is widely used to repair deep defects in the distal lower leg and ankle. However, the success of flap transplantation depends on the accurate location of the peroneal artery perforators, which can be a challenge due to potential vascular damage and anatomical variations. This study utilizes digital subtraction angiography and high-frequency ultrasound to clarify the anatomical features of the peroneal artery and its perforators and accurately locate these perforators, thereby improving preoperative design and clinical outcomes. Peroneal artery perforator sequential flaps were employed to repair the wounds and donor sites, with the second donor site sutured directly. A total of 36 peroneal artery perforators were identified in seven patients, with an average of 5.14 perforators per patient. The majority of these perforators (47.22%) were concentrated in the middle segment of the lower leg. All flaps underwent tension-free primary closure and survived successfully, presenting a smooth appearance, a fine texture, and a color similar to that of the surrounding skin. Only a linear scar was left in the secondary donor site, which did not affect the overall appearance of the limb. This technique can accurately localize peroneal artery perforators, optimize the design of peroneal artery perforator sequential flaps, and facilitate the success of the surgery and postoperative esthetic recovery.
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Altinkaya A, Yazar S, Bengur FB. Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap. Injury. 2021;52(7):1985–1992. https://doi.org/10.1016/j.injury.2021.04.015 DOI: https://doi.org/10.1016/j.injury.2021.04.015
Uricchio M, Gupta S, Jakowenko N, Levito M, Vu N, Doucette J, et al. Computed tomography angiography versus digital subtraction angiography for postclipping aneurysm obliteration detection. Stroke. 2019;50(2):381–388. https://doi.org/10.1161/STROKEAHA.118.023614 DOI: https://doi.org/10.1161/STROKEAHA.118.023614
Aziz MU, Eisenbrey JR, Deganello A, Zahid M, Sharbidre K, Sidhu P, et al. Microvascular flow imaging: a state-of-the-art review of clinical use and promise. Radiology. 2022;305(2):250–264. https://doi.org/10.1148/radiol.213303 DOI: https://doi.org/10.1148/radiol.213303
Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg. 2011;128(1):173–180. https://doi.org/10.1097/PRS.0b013e3182173d3a DOI: https://doi.org/10.1097/PRS.0b013e3182173d3a
Huang Q, Wang Q, Xu Y, Ren C, Lin H, Zhang C, et al. Dual-perforator flap with wide pedicle versus sural neurocutaneous flap with peroneal artery perforator in the treatment of soft tissue defects of foot and ankle. J Foot Ankle Surg. 2023;62(1):150–155. https://doi.org/10.1053/j.jfas.2022.06.003 DOI: https://doi.org/10.1053/j.jfas.2022.06.003
Wang C, Yang W, Zhang F, Lineaweaver WC, Wen G, Chai Y. Superficial peroneal neurocutaneous flap for coverage of donor site defect after the combined transfer of toe and dorsal foot flap. Ann Plast Surg. 2021;86(4):440–443. https://doi.org/10.1097/SAP.0000000000002520 DOI: https://doi.org/10.1097/SAP.0000000000002520
Zhong W, Lu S, Chai Y. Distally based saphenous neurocutaneous perforator flap: a versatile donor site for reconstruction of soft tissue defects of the medial malleolar region. J Foot Ankle Surg. 2016;55(2):391–396. https://doi.org/10.1053/j.jfas.2015.02.002 DOI: https://doi.org/10.1053/j.jfas.2015.02.002
Ciudad P, Kaciulyte J, Torto FL, Vargas MI, Bustamante A, Chen HC, et al. The profunda artery perforator free flap for lower extremity reconstruction. Microsurgery. 2022;42(1):13–21. https://doi.org/10.1002/micr.30745 DOI: https://doi.org/10.1002/micr.30745
Shih YJ, Wang YC, Lin CT, Chang SC, Tzeng YS, Dai NT, et al. Clinical application of the peroneal artery perforator flap for reconstruction of lateral malleolus defects. Int J Low Extrem Wounds. 2023;22(2):378–384. https://doi.org/10.1177/15347346211015828 DOI: https://doi.org/10.1177/15347346211015828
Franchi A, Fritsche E, Scaglioni MF. Sequential propeller flaps in the treatment of post-traumatic soft tissue defects of the lower limb – a case series. Injury. 2020;51(12):2922–2929. https://doi.org/10.1016/j.injury.2020.02.031 DOI: https://doi.org/10.1016/j.injury.2020.02.031
Schaverien M, Saint-Cyr M. Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps. Plast Reconstr Surg. 2008;122(1):161–170. https://doi.org/10.1097/PRS.0b013e3181774386 DOI: https://doi.org/10.1097/PRS.0b013e3181774386
Cang ZQ, Xu Y, Wang M, Xu MN, Yuan SM. Application of digital subtraction angiography in reconstruction of plantar forefoot with reverse medial plantar flap. Ann Plast Surg. 2021;86(5):573–576. https://doi.org/10.1097/SAP.0000000000002521 DOI: https://doi.org/10.1097/SAP.0000000000002521
Cang ZQ, Xu Y, Wang M, Xu MN, Yuan SM. Anterior tibial artery injury is not the contraindication of medial plantar flap: digital subtraction angiography evidence and clinical application. J Plast Reconstr Aesthet Surg. 2021;74(10):2512–2518. https://doi.org/10.1016/j.bjps.2021.03.054 DOI: https://doi.org/10.1016/j.bjps.2021.03.054
Gong J, Jia YP, Luo WD, Li CJ. Preoperative high-frequency color Doppler ultrasound assessment of the blood vessels of the fibular myocutaneous flap. J Plast Reconstr Aesthet Surg. 2022;75(11):3964–3969. https://doi.org/10.1016/j.bjps.2022.08.045 DOI: https://doi.org/10.1016/j.bjps.2022.08.045
Haribhakti VV, Thorat TS, Powle VR, Virarkar MK. Prospective study to analyse the efficiency of Acoustic Doppler v/s Colour Duplex Ultrasound in locating perforators for antero-lateral thigh flap in reconstructive head and neck surgery. J Plast Reconstr Aesthet Surg. 2021;74(9):2026–2033. https://doi.org/10.1016/j.bjps.2020.12.088 DOI: https://doi.org/10.1016/j.bjps.2020.12.088
Yoshimura M, Shimada T, Hosokawa M. The vasculature of the peroneal tissue transfer. Plast Reconstr Surg. 1990;85(6):917–921. https://doi.org/10.1097/00006534-199006000-00012 DOI: https://doi.org/10.1097/00006534-199006000-00012
Lykoudis EG, Koutsouris M, Lykissas MG. Vascular anatomy of the integument of the lateral lower leg: an anatomical study focused on cutaneous perforators and their clinical importance. Plast Reconstr Surg. 2011;128(1):188–198. https://doi.org/10.1097/PRS.0b013e3182174303 DOI: https://doi.org/10.1097/PRS.0b013e3182174303
Sharma M, Balasubramanian D, Thankappan K, et al. Propeller flaps in the closure of free fibula flap donor site skin defects. Ann Plast Surg. 2013;71(1):76–79. https://doi.org/10.1097/SAP.0b013e318248b813 DOI: https://doi.org/10.1097/SAP.0b013e318248b813
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Copyright (c) 2025 Yong-Pei Chen, Hai-Yan Zhong, Rui Yang, Ming-Li Zou, Qian Wang, Yong Chen, Min Wang, Si-Ming Yuan
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Acta Chirurgica Scandinavica Society owns the copyright for all material published until Volume 57 (2023) unless otherwise specified. As from Volume 59 (2024) all published articles, unless otherwise specified, are published under CC-BY licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, with the condition of proper attribution to the original work.
