SLR - July 2017 - Michelle T. Suh
Reference: Ha Y, Yeo KK, Piao Y, Oh SH. Peroneal Flap: Clinical Application and Cadaveric Study. Arch Plast Surg. 2017 Mar;44(2):136–143.Scientific Literature Review
Reviewed By: Michelle T. Suh, DPM
Residency Program: MetroWest Medical Center
Podiatric Relevance: Microsurgery can be used in reconstructive surgery of the foot and ankle and is a viable option for covering defects following trauma or tissue necrosis. Appropriate anatomical knowledge is required to use the peroneal flaps to their full extent. This study provides anatomical information via cadaveric study, as well as a retrospective review of clinical research.
Methods: This study had two parts. One was an anatomical dissection of four cadaver legs to identify the location of perforators. The other was a retrospective review of 29 patients in which peroneal flaps were used for reconstructing a defect between February 2005 and June 2012 with a mean follow-up of 154.8 days. The retrograde island peroneal flap was used for reconstructing the lower third of the lower limb and ankle. The anterograde island peroneal flap was used for reconstructing the upper third of the lower limb and knee. The free peroneal flap was positioned between the upper third and the middle third so that the donor site could be closed directly, if possible. Otherwise, donor sites were generally treated with a split-thickness skin graft.
Results: Of the 29 patients, 10 cases had a defect by carcinoma removal. The remaining 19 had a traumatic defect. Nine had a defect in the lower third of a lower limb or an ankle, five in the upper third of the lower limb or knee, four in a foot or a toe, four in an upper limb or hand and seven in the head and neck. Partial flap necrosis occurred as a complication in five cases, seen in both the anterograde and retrograde island peroneal flap. Necrosis of a free flap surgery was not seen in this study. In four legs of two cadavers, 19 perforators were identified. Five were found in the upper third of a lower limb (all musculocutaneous), nine in the middle third and five in the lower third (all septocutaneous). Lengths ranged from 3.5 to 7.5 cm. Twelve of these were septocutaneous perforators, and seven were musculocutaneous perforators.
Conclusions: Necrosis of either an anterograde or retrograde island flap could be due to the requirement of a long pedicle in order to reach the defect through subcutaneous tunneling. Postoperative edema could inhibit blood circulation in these circumstances. In the case of trauma, elevating a flap from the same trauma site would be difficult. Advantages of peroneal flaps include flexibility of the graft, direct closure of the donor site, alternative use as a composite flap and ease of dissection of a free flap allowing for exposure of the major vessel without causing injury to the major vessel in the lower limb. Disadvantages include injury to the peroneal artery, failed direct closure of the donor site, positioning of patient intraoperatively in the prone position for easier dissection and possible variations and malformations of the vessel. Clinical application of a peroneal flap is a viable option for reconstructing diverse sites, including the foot and ankle, when indications are properly determined, resulting in a lower morbidity rate at the donor site as compared with other flaps.