Fibula osteoseptocutaneous flap with a variant perforator and peroneal artery arising from the anterior tibial artery

Since the report of the first cases of vascularized free fibula graft for treatment of open fracture of the tibia and fibula in 1975, there have been many other reports of the use of vascularized free osteocutaneous fibula flaps for reconstruction of the mandible or lower leg. Usually, these flaps have a single pedicle composed of the peroneal artery, to supply the fibula with septocutaneous or musculocutaneous branches arising from the peroneal artery to supply the lateral skin of the leg. Although some authors have reported variant perforators, there have been no reports of the peroneal artery arising from the anterior tibial artery and perforator arising from the posterior tibial artery. This is the first report of a variant of the peroneal artery and perforator using a vascularized free osteocutaneous fibula flap.     

Skin paddle vascularity of free fibula flap �C A study of 386 cases and a classification based on contribution from axial vessels of the leg

Objective:

The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems.

Materials and Methods:

A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study.

Results:

The skin paddle of the free fibula flap was classified into four different types (a–d) based on the dominance of vascular contribution by axial vessels of the leg.

Conclusion:

The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.KEY WORDS: Free fibula flap, musculocutaneous perforators, septo cutaneous perforators, skin paddle, vascular supply     

Use of fibula pedicle as a composite interposition vascular graft to salvage large skin paddle with anomalous vascular supply

We report a case of free fibula osteomyocutaneous flap whose skin paddle had a dominant blood supply from a soleus musculocutaneous perforator which originated in the posterior tibial artery in addition to contribution from the peroneal septocutaneous perforators and was managed by two sets of anastomosis on either side of the neck, one for the peroneal vessels and the other for the dominant musculocutaneous perforator. The second anastomosis was achieved by using the excess length of the flap pedicle vessels (peroneal) as composite (both artery and vein) autologous interposition vascular graft to reach the opposite side of the neck.     

Lateral lower leg perforator flaps: An anatomical study to localize and classify lateral lower leg perforators

Despite increasing use of lateral lower leg perforator flaps, comprehensive anatomical data are still lacking. The aim of this article was to comprehensively document the pattern of usable lateral lower leg perforators. Systematic mapping of 16 cadaver leg perforators in a well‐defined area was performed to elucidate location, course, length, diameter, and origin. Overall, 197 perforators were found in 16 lateral lower legs. The mean number of perforators per leg with a diameter ≥ 0.3 mm was 13.4 ± 3.6. Most perforators were found in the distal third (39.0%), followed by the middle third (32.0%), and proximal third (29.0%). A musculocutaneous course was found in 26.9% of the perforators, whereas 73.1% revealed a septocutaneous course. Most septocutaneous perforators (50.0%) were found in the distal third and most musculocutaneous perforators (58.5%) in the proximal third (P < 0.001). The majority of perforators originated from the anterior tibial artery (53.0%), followed by the peroneal artery (41.6%), and the popliteal artery (5.1%). Popliteal artery perforators (1.64 mm) were significantly larger than anterior tibial artery (0.91 mm) and peroneal artery perforators (1.02 mm; P < 0.001). These results may facilitate tissue transfer around the lateral lower leg. © 2014 Wiley Periodicals, Inc. Microsurgery 35:140–147, 2015.     

Successful management of free osteocutaneous fibula flap with anomalous vascularity of the skin paddle

The free osteocutaneous fibula flap is an established method of reconstruction of maxillary and mandibular defects. The vascularity of the skeletal and the cutaneous components is provided by the peroneal artery via the nutrient artery and the septo- and musculocutaneous perforators. In rare situations, these perforators may arise from other major leg arteries. In such circumstances, the procedure has to be either abandoned or modified so that neither the vascularity of the flap nor the donor limb is compromised. We present a case of an anomalous musculocutaneous perforator, which originated from the proximal part of the posterior tibial artery, passed through the soleus muscle and supplied the skin paddle. The flap was elevated as a single composite unit and was managed by two separate vascular anastomosis at the recipient site, one for the peroneal vessels and the other for the anomalous perforator.     

Magnetic resonance angiography for free fibula flap transfer

Recent refinements of magnetic resonance angiography (MRA) allow imaging vessels as small as the septocutaneous perforators (< or = 1 to 2 mm diameter), but a Medline review reveals no report of septocutaneous vessel imaging for free flap surgery. Challenges in fibula free flap preparation include knowledge of: (1) tibioperoneal anatomy, (2) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum, and (3) the cutaneous distribution of the perforators. Questioning whether high-resolution MRA could image these, we studied the lower extremities of nine healthy volunteers. MRA demonstrated tibioperoneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease and showed septocutaneous perforators arising from the peroneal artery and coursing in the posterolateral intermuscular septum to the skin. High-resolution MRA provided anatomic and clinical information that conventionally has been impossible to obtain preoperatively or has required multiple tests, often of an invasive nature.     

小腿前外侧岛状皮瓣修复胫骨外露的解剖研究与临床应用

目的 探讨小腿前肌间隔动脉链为蒂的岛状皮瓣修复胫骨外露的术式及手术方法.方法 40侧成人尸体下肢标本经动脉灌注红色乳胶,4侧新鲜成人尸体下肢标本动脉造影,观测小腿前肌间隔内的胫前动脉穿支与腓动脉终末前穿支的位置、走行、外径及相互吻合.临床应用小腿前外侧岛状皮瓣转位修复胫骨外露11例.男7例,女4例;年龄20～59岁,平均36岁.结果 40侧标本腓骨长度为(32.3±2.4)cm.胫前动脉发出腓浅动脉、胫前动脉下段前肌间隔穿支,与腓动脉终末前穿支在小腿前肌间隔内相互吻合,形成动脉链,这三条动脉外径分别为(1.4±0.4)mm、(1.0±0.4)mm及(1.5±0.4)mm,动脉链吻合处外径为(0.6±0.2)mm.动脉链伴腓浅神经走行,营养神经和小腿前外侧皮肤.临床应用小腿前外侧岛状皮瓣修复胫骨外露的11例中,以胫前动脉下段前肌间隔穿支为蒂2例,以胫前动脉下段前肌间隔穿支的升支为蒂3例,以胫前动脉下段前肌间隔穿支的降支为蒂3例,以腓动脉终末前穿支升支为蒂3例.皮瓣切取面积7 cm×5 cm～13 cm×5 cm.随访1～3年,平均1.5年,11例皮瓣全部成活,无破溃、臃肿.结论 根据皮肤缺损部位、面积等灵活选用小腿前肌间隔内动脉链为血管蒂,设计前外侧岛状皮瓣修复胫骨外露,术式灵活,是修复胫骨外露的理想皮瓣.

Abstract：

Objective To explore surgical methods of repairing tibial skin defect using the anterolateral crural island flap.Methods The location,external diameters,anastomosis and distribution of perforators from the anterior tibial artery and the peroneal artery in the anterior septum were observed in 40 cadaveric specimens.Arterial angiography was performed in 4 fresh legs.Clinically,11 cases with tibial skin defect were repaired with the anterolateral crural island flap.There were 7 males and 4 females,with an average of 36 years (20-59 years).The area of the skin defect ranged from 6 cm×4 cm to 12 cm×4 cm.Results An arterial chain was formed by the interconnection of the superficial peroneal artery,the anterior septocutaneous perforator from distal part of the anterior tibial artery and the anterior end-perforator of the peroneal artery.It ran in the anterior septum and went along with the superficial peroneal nerve to supply blood to adjacent fascia and skin.The external diameters of the three perforators were (1.4±0.4) mm,(1.0±0.4) mm and (1.5±0.4) mm respectively,and the external diameter of the arterial chain was (0.6±0.2) mm.Clinically,we designed 4 methods to repair 11 cases of tibial skin defect successfully with the anterolateral cnnal island flap.The anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 2 cases;ascending branch of the anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 3 cases;descending branch of the anterior septocutaneous perforator from distalpart of the anterior tibial artery was used as pedicle in 3 cases;ascending branch of the anterior end-perforator of the peroneal artery was used as pedicle in 3 cases.The area of the flaps ranged between 7 cm×5 cm and 13 cm×5 cm.All patients were followed up with a mean time of 1.5 years.All flaps survived totally without diabrosis and swelling.Conclusion The anterolateral island flaps pedicled with perforators arising from the anterior septum of the lower leg is a good choice for surgeons to repair tibial skin defect.     

Preoperative MR angiography for free fibula osteocutaneous flap transfer

Introduction: Magnetic resonance angiography (MRA) is currently considered the most useful test to evaluate the vascular anatomy of the lower leg prior to free fibula osteocutaneous flap transfer. This study aimed to confirm the validity of preoperative MRA. Methods: In 19 patients underwent free fibula osteocutaneous flap transfer for maxillary and mandibular reconstruction, the MRA and intraoperative findings and the postoperative complications were retrospectively analyzed. The location and number of distal septocutaneous perforators (dSCPs) that were preoperatively identified and harvested with flaps were documented. Results: Preoperative MRA detected dSCPs with 100 % sensitivity. MRA findings also revealed the diversity of vascular structures, such as the tibio‐peroneal bifurcation location and the anatomical relationship between the peroneal vessels and the fibula. No patients suffered postoperative ischemic complications in the donor leg. The total flap survival rate was 95 %. Conclusions: Preoperative MRA effectively excluded large vessel anomalies and peripheral vascular disease, and precisely identified the septocutaneous perforators. Additionally, preoperative MRA contributed to a safer fibular osteotomy by predicting the anatomical relationship between the peroneal vessels and the fibula. © 2013 Wiley Periodicals, Inc. Microsurgery 33:454–459, 2013.     

腓动脉穿支跨区供血的腓肠神经营养血管逆行岛状皮瓣的解剖和临床应用

目的　观察小腿皮肤腓浅动脉与腓动脉穿支之间的吻合联系 ,设计以腓动脉穿支为蒂的岛状皮瓣。方法　 10具新鲜尸体 2 0侧肢体血管灌注氧化铅—明胶混合液 ,通过X线片显示小腿皮肤内的血管结构和血管之间的吻合。在此基础上应用了跨区供血的腓动脉穿支蒂逆行岛状皮瓣 2 6例。结果　解剖研究表明小腿腓肠神经营养血管主要来自腓浅动脉。在外踝后上方 4～ 7cm处腓动脉穿支与腓浅动脉或动脉网形成广泛吻合。以腓动脉穿支为蒂设计包含腓肠神经及其伴行的腓浅动脉和小隐静脉的返流岛状皮瓣 2 6例 ,皮瓣全部成活。结论　跨区供血的腓动脉穿支为蒂的岛状皮瓣 ,为修复小腿远端及足跟部软组织缺损提供了一种简单有效的方法。     

Sural perforator flap: Assessment of the posterior calf region as donor site for a free fasciocutaneous flap

Three kinds of free fasciocutaneous flap from the posterior calf region have been described in the literature: the medial sural perforator flap, the lateral sural perforator flap, and the traditional posterior calf fasciocutaneous flap that is supplied by superficial cutaneous vessels. Moreover, it has been reported that superficial cutaneous vessels are of a suitable size for microanastomosis when deep musclocutaneous perforators are absent or relatively tiny. To establish a safe technique for free fasciocutaneous flap elevation from the posterior calf region, we examined the number and location of the musculocutaneous perforators and the size of superficial cutaneous vessels at their origin from the popliteal artery in six formalinized cadavers. We found that all legs had at least one perforator either from the medial sural artery or the lateral sural artery. By contrast, we failed to find superficial cutaneous vessels of suitable size for microanastomosis in three legs, and there was no significant inverse relationship between the diameter of the superficial cutaneous artery and the number of musculocutaneous perforators. Our results suggest that the medial sural perforator flap and the lateral sural perforator flap might be the surgeon's first and second choice, respectively. The traditional posterior calf fasciocutaneous flap should be the third choice because our study suggests that its availability is doubtful. Another site is recommended, when preoperative Doppler study suggests that the existence of musculocutaneous perforator is in doubt. Two clinical cases, with a medial sural perforator flap and a lateral sural perforator flap, respectively, are presented. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

小腿后部各区穿支间的关系与皮瓣设计

目的 研究小腿后部各区穿支间的关系,为穿支皮瓣的临床应用提供解剖学依据.方法 选择6具动脉灌注明胶-氧化铅混悬液的新鲜成人整尸标本,将小腿后部分为上、中、下三等份,层次解剖观测各区穿支的分布状况,拍摄X线片测量穿支的定位、直径、走行、分支及其相互之间的吻合状况.结果 小腿后部共有外径为0.5 mm的穿支13支,平均外径0.8 mm,平均供血面积38 cm2.上区来自腘动脉的穿支起于胭窝中部,其浅出深筋膜的位置,通常位于股骨内、外上髁之连线与小腿后正中线交点4 cm范围内,其单穿支供血面积高达55 cm2.此穿支向下与来自胫后动脉、腓动脉之穿支形成不减少口径的真性吻合:下区穿支较细,但沿跟腱两侧呈链状分布.结论 小腿后部穿支皮瓣可以移植到下肢或身体其它部位,中区可切取穿支皮瓣游离移植,上区与下区可分别切取近端蒂与远端蒂穿支皮瓣.     

New nomenclature concept of perforator flap.

Confusion regarding the perforator flap concept has arisen partly from the use of ill-defined nomenclature without consistency; flaps have been named according to either the proximal vessel, the location harvested or the muscle dissected. Since, a variety of conflicting terms can distort the exact understanding of the flap and the true perforator concept, a precise and scientific system of nomenclature is promptly needed. In order to remedy such confusion, the author reviewed 54 recently published articles and 38 abstracts for vague or inaccurate nomenclatures, and compared the perforator flaps with the conventional flaps. A new nomenclature was then drawn up according to three perforator types: direct cutaneous, septocutaneous and musculocutaneous perforator. Even though only musculocutaneous perforators were considered to be true perforators in the initial concept, some perforator flaps have subsequently been added based on septocutaneous or direct cutaneous perforators. Discrimination is necessary and made possible by use of the following nomenclature: a perforator flap based on a musculocutaneous perforator is named according to the name of the muscle perforated, and perforator flaps based on other types of perforators, are named according to the name of the proximal vessel. The term 'perforator based' further defines those flaps harvested without sacrificing the proximal vessel. This new nomenclature concept would be a great help in discriminating among the various patterns of perforator flaps and also in preventing confusion arising from the misnaming of new perforator flaps in the future. Furthermore, the perforator pattern used in the flap can easily be comprehended, and especially in extremities, various perforator flaps, based on the musculocutaneous or septocutaneous perforator, can plainly be distinguished with this new nomenclature concept.     

Reversed sural island flap supplied by the lower septocutaneous perforator of the peroneal artery

The current study was conducted to document the vascular anatomy of the distally based superficial sural artery flap and to study the vascular anastomoses between the superficial sural artery and the septocutaneous perforator of the peroneal artery. Five fresh human cadavers were injected with lead oxide, gelatin, and water. Ten legs were then dissected and an overall map of the cutaneous vasculature by source vessel was constructed. Vascular communication between the superficial sural artery and the lowest septocutaneous perforator of the peroneal artery was evaluated to determine the cutaneous vascular territory of the superficial sural flap. This anatomic information enhances our understanding of flap design. The authors' clinical experience with the usefulness of the distally based island flap as a method of reconstruction in the lower leg and foot in a series of 26 patients is presented.     

吻合腓肠内侧血管穿支皮瓣的应用解剖和临床应用

目的 报道腓肠内侧血管穿支皮瓣的解剖学研究与游离移植的临床效果.方法 用明胶-氧化铅液灌注12侧标本的胭动脉,观测腓肠内侧血管及其穿支的分支、蒂长、管径等;取下标本皮肤软组织拍摄X线片,利用Photoshop与Scion Image分析穿支分布的趋向性和供血面积.临床上吻合腓肠内侧血管穿支皮瓣修复5例手部软组织缺损,皮瓣面积为7 cm×4 cm～12 cm×8 cm. 结果 所有标本的腓肠内侧血管至少存在1支穿支,平均2.1支;位于距横纹9～18 cm、距后中线1～5 cm的范围内;其深筋膜处的外径为(1.03±0.22)mm;穿支供血的总面积为(107.5±23.9)cm2,单穿支的供血面积为(58.3±17.0)cm2.5例移植皮瓣全部成活,随访6～12个月,手部修复后外形与功能恢复满意.结论 明胶-氧化铅液灌注造影是皮瓣血管解剖学研究的可靠方法;腓肠内侧血管恒定存在的穿支,可作为腓肠内侧血管穿支皮瓣的血供来源;该皮瓣外形美观,是修复手部中、小面积皮肤软组织缺损的良好选择.     

An anatomic study of the superficial peroneal nerve accessory artery and its perforators, and clinical application of superficial peroneal nerve accessory artery perforator flaps

In the 1990s, skin island flaps supplied by the vascular axis of sensitive superficial nerves, like the sural and saphenous nerves, were introduced. Flaps supplied by the superficial peroneal nerve accessory artery (SPNAA), however, are still not commonly used. The aim of this study is to understand the anatomic structure of the SPNAA and its perforators in the anterior intermuscular septum and to use SPNAA perforator flaps in the clinic. We dissected 16 cadavers and assessed the location and number of the SPNAA, its perforators, and the septocutaneous perforators originating from the anterior tibial artery. A SPNAA perforator flap was applied to 12 patients, the free flap was applied to 11 patients, and the pedicled flap was applied to 1 patient. SPNAA varied from 7 to 16 cm in length, with an average of 4.5 perforators to supply the lateral aspect. An average of 3.13 septocutaneous perforators originated from the anterior tibial artery. The mean size of the SPNAA perforator flaps was 65.5 cm. The complete follow-up period was 3-20 months. Although 1 flap was lost as a result of arterial thrombosis, the procedure was successful in the remaining 11 patients. In addition, reduced flap thickness made them more esthetically appealing. SPNAA perforator flaps could be an excellent alternative to perforator flaps that use the lower leg as a donor site.     

The osteocutaneous fibula flap: an anatomic study.

Recent studies related to the fibula flap have disagreed regarding the anatomy of the cutaneous branches of the peroneal artery. To clarify this issue, various dissections of 35 injected fresh cadaver legs were done. Identifiable skin branches were found in 23 of 25 dissections. Skin branches from the proximal third of the peroneal artery always travelled an intramuscular course. Skin branches from the distal two-thirds of the peroneal artery were usually affixed to the posterior crural septum. Legs with peroneal artery skin branches had from three to seven branches (average: 4.7); each branch contributed to the fibular periosteal blood supply. The most reliably found skin branch was located within 2 cm of the fibula midpoint. These findings reinforce the fact that a large skin island supplied by branches of the peroneal artery can be harvested with the fibula flap, and that the most reliable cutaneous vessels are found in the lower two-thirds of the leg, run posterior to the fibula in the posterior crural septum, and are always associated with muscular side branches.     

An anatomical study of the saphenous nerve, artery, and artery perforators within the thigh using cadaveric dissection

Although the saphenous flap has been used in reconstruction as a free flap, there has not yet been an anatomic study about the perforators of the saphenous artery. The aim of this study is to investigate the anatomy of the saphenous artery and the number and locations of its perforators. We dissected parts of 10 legs from 5 cadavers. Measurements of the positions of the dissected saphenous arteries and their perforators were taken from the medial epicondyle of the femur. We observed the origin, end point, and the diameter of each of the arteries, and we investigated the numbers and locations of both septocutaneous and musculocutaneous perforators. The average length of saphenous artery was 14.8 cm, and it was located 12.0 cm above the medial epicondyle of the femur. The average diameter was 1.63 mm. A median average of 4 perforators branched out from a single saphenous artery. There was a median average of 2 septocutaneous perforators and 2 musculocutaneous perforators from the saphenous artery. The perforators were mainly located at 7 cm proximal to the medial epicondyle of the femur. The saphenous artery has many perforators and is therefore useful as the pedicle of the perforator flap. The saphenous artery perforator flap can be designed within 7 cm proximal to the medial epicondyle of the femur. Our results may be helpful in the applications of the neurocutaneous flap using the saphenous artery or the perforator flap based on septocutaneous perforators.     

Anatomical and clinical studies on peroneal vascularized composite tissue transfer

An anatomical study of the peroneal artery and vein and their branches was carried out on 86 cadaver legs. The number of cutaneous branches was 4.8 +/- 1.4 per leg. The length of the cutaneous branches was 5.5 +/- 1.6 cm. The external diameters of cutaneous branches at the skin distribution site were 0.6 +/- 0.2 mm for the artery and 0.8 +/- 0.3mm for the vein. The peroneal vessels gave off communicating branches to anterior or posterior tibial vessels 6.1 +/- 2.4 cm proximal from the lateral malleolus. The range of rotation of island flap when transposed proximally was 14.3 +/- 3.3 cm proximal from the head of the fibula, and when transposed distally, the range of rotation was 16.9 +/- 5.3 cm distal from the lateral malleolus. Based on the results obtained from these experimental studies, we have been performing peroneal vascularized tissue transfer since 1982. A total of 72 cases have been performed, and the results have been encouraging.     

The 'superficial' peroneal artery: a variation in cutaneous branching from the peroneal artery, nourishing the distal third of the leg.

Two different vascular patterns were encountered in cutaneous branches from the peroneal artery to the posterolateral aspect of the distal third of the leg in 22 flaps from 22 patients who underwent cutaneous or osteocutaneous peroneal flap surgery. In the type 1 vascular pattern, a branch from the peroneal artery, named the 'superficial peroneal artery', nourished the posterolateral aspect of the leg by splitting into several septocutaneous branches. In the type 2 pattern a few septocutaneous branches originated directly from the main peroneal artery and nourished the same area as that fed by the type 1 branch. The type 1 vascular pattern has not been reported to date but was seen in nine out of the 22 consecutive peroneal flaps. The superficial peroneal artery, with its considerable vascular diameter, may serve as a recipient vessel for free flaps or may serve as a donor nutrient vessel for a cutaneous flap, which can be transferred without sacrificing the main peroneal artery. Awareness of these two vascular patterns in the distal third of the leg should also help to reduce the small percentage of skin-flap failures that occur when the cutaneous or osteocutaneous peroneal flap is used.     

Lateral lower leg skin flap

Use of a lower leg lateral skin flap in 7 patients since January 1982 is described. Satisfactory results were obtained in 6 of 7 patients. The blood supply of this new flap is based on the peroneal artery, which gives rise to cutaneous or musculocutaneous branches to nourish the flap. The venous blood of the flap is drained by the venae comites accompanying these cutaneous or musculocutaneous branches. In clinical practice, the beginning portion of the peroneal artery and the vein arising from the posterior tibial vein are used for vascular anastomosis. The caliber of the peroneal artery is 2.5 to 3.0 mm, and that of the peroneal vein is 3 to 4 mm. The vascular pedicle can be as long as 8 to 12 cm. In 4 of these patients, the flaps were freely transferred using a microvascular technique; in the remaining 3, a reversed transfer for treating defects over the foot was used.