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A. Thacoor et al.
harvest: a meta-analysis. J Reconstr Microsurg.
2019;35(5):362–71.
This paper is the only published Level 1 evidence on the
use of pre-operative angiography in free bula harvest. It
concludes that there is low-quality evidence to suggest a
necessity for routine pre-operative angiography in all
patients undergoing free bula harvest.
• Roser SM, Ramachandra S, Blair H, etal. The accuracy
of virtual surgical planning in free bula mandibular
reconstruction: comparison of planned and nal results. J
Oral Maxillofac Surg. 2010;68(11):2824–32.
This study evaluates the benet of virtual surgery planning in free bula ap reconstruction of mandibular
defects. The authors conclude that a reasonably high
level of accuracy was achieved in the mandibular and
bula osteotomies through use of the surgical cutting
guides.
• Deek NF, Wei FC. Computer-assisted surgery for segmental mandibular reconstruction with the osteoseptocutaneous bula ap: can we instigate ideological and
technological reforms? Plast Reconstr Surg.
2016;137(3):963–70.
This review article draws comparisons between traditional and computer-aided techniques for mandibular
reconstructions and highlights the important factors to be
considered when planning soft tissue reconstruction.
• Al Deek NF, Kao HK, Wei FC.The bula osteoseptocutaneous ap: concise review, goal-oriented surgical tech-
nique, and tips and tricks. Plast Reconstr Surg.
2018;142(6):913e–23e.
This review article describes challenges encountered
when raising the free bula ap and rened techniques to
aid dissection and successful outcomes.
References
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A clinical extension of microvascular techniques. Plast Reconstr
Surg. 1975;55:533–44.
2. Hidalgo DA.Fibula free ap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84:71–9.
3. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Plast Reconstr Surg.
Fibula osteoseptocutaneous ap for reconstruction of composite
mandibular defects 1994;93(2):294–304; discussion 305–6, 442.
4. Fukaya E, Grossman RF, Saloner D, Leon P, Nozaki M, Mathes
SJ.Magnetic resonance angiography for free bula ap transfer. J
Reconstr Microsurg. 2007;23(4):205–11.
5. Alolabi N, Dickson L, Coroneos CJ, Farrokhyar F, Levis
C. Preoperative angiography for free bula ap harvest: a metaanalysis. J Reconstr Microsurg. 2019;35(5):362–71.
6. Akashi M, Nomura T, Sakakibara S, Sakakibara A, Hashikawa
K.Preoperative MR angiography for free bula osteocutaneous ap
transfer. Microsurgery. 2013;33(6):454–9.
7. Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI.Magnetic
resonance angiography and computed tomographic angiography for
free bular ap transfer. J Reconstr Microsurg. 2008;24(6):457–8.
8. Zheng GS, Su YX, Liao GQ, etal. Mandible reconstruction assisted
by preoperative virtual surgical simulation. Oral Surg Oral Med
Oral Pathol Oral Radiol. 2012;113(5):604–11.
Posterior Tibial and Peroneal
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Perforators Flaps
AhmedM.Yassin, MuholanKanapathy,
andGeorgiosPatanis
42
42.1 Introduction
Soft tissue reconstruction of the lower limb, especially the distal third is one the most challenging areas of reconstruction
faced by plastic surgeons. The lack of excess soft tissue in this
region limits the local ap option, hence making free tissue
transfer as the preferred choice. However, the introduction of
the concept of perforator ap by Kroll and Roseneld in 1988
[1] and Koshima and Soeda in 1989 [2], followed by the introduction of propeller aps by Hyakusosku in 1991 [3] transformed the design of local aps, making them a more reliable
option for the lower limb.
The most reliable perforators in the leg arise from the three
main arteries: the posterior tibial (PTA), the peroneal (PA),
and the anterior tibial (ATA). However, aps based on the perforators arising from the rst two arteries are the most commonly used. They can be used for reconstruction of defects in
the distal third of the lower extremity, the foot, Achilles tendon, around the ankle joint including the medial and lateral
malleolus, and down to the nonweight-bearing part of the heel
[4]. They can also provide coverage for defects in the middle
and upper third of the leg and around the knee joint.
A. M. Yassin (*)
Plastic Surgery Department, Royal Free Hospital London, London,
UK
Division of Surgery and Interventional Science, University College
London UCL, London, UK
Plastic and Reconstructive Surgery Department, Faculty of
Medicine, Mansoura University, Mansoura, Egypt
e-mail: ahmed.ali37@nhs.net; ahmad.yaseen@mans.edu.org
M. Kanapathy
Plastic Surgery Department, Royal Free Hospital London, London,
UK
e-mail: m.kanapathy@alumni.ucl.ac.uk
G. Patanis
Department of Plastic Surgery, Emergency Care and Trauma
Division (ECAT), The Royal London Hospital, Barts Health NHS
Trust, London, UK
Zhang and colleagues [5] in 1983 were the rst to describe
harvesting a medial leg cutaneous ap based on the PTA and
its cutaneous branches. Venkataramakrishnan et al. [6]
avoided sacricing the PTA and reported raising posterior
tibial artery perforator (PTAP) based V-Y advancement aps.
In a case report by Hallock in 1993 [7], he described the use
of a PTAP ap to cover an exposed medial malleolus after
rotating the ap 180° which is now known as a propeller ap.
A propeller ap can be dened as a fasciocutaneous ap,
completely islanded on a single perforator and designed with
two blades of unequal length. The perforator constitutes the
pivot point of the ap, which allows it be rotated 90–180°.
The long blade of the ap ts into the defect, while the short
blade helps closure of part of the donor site [8].
On the other hand, peroneal artery perforator ap was rst
described by Donski and Fogdestam in 1983 [9], who raised
a fasciocutaneous ap based on the distal cutaneous perforator originating from the peroneal artery about 5–7cm superior to the lateral malleolus to cover the Achilles tendon.
42.2 Anatomy
42.2.1 Posterior Tibial Artery Perforator Flap
A cadaveric study done by Schaverien and Saint-Cyr [10]
reported that perforators of PTA were the largest in the leg and
were found in three clusters between the soleus and the exor
digitorum longus muscles, each being 4–9, 13–18, and
21–26cm from the inter-malleolar line (Fig.42.1a). Each cluster contains 23% of PTA perforators, and a perforator was found
in each of them in 80% of the cadavers in the study. Multiple
musculocutaneous perforators, usually passing through the
soleus or gastrocnemius muscles, were also found in all zones
of the leg, but were mainly located proximally. Two venae comitantes followed each perforator, and in the distal leg they are
occasionally connected to the long saphenous vein [11].
The proximal two-thirds of the leg were found to have
perforators with the largest caliber which pierce the deep fas-
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_42
409
410
ab
Fig. 42.1 Diagram showing
the territories of the PTA and
PA perforator aps. (a)
Medial aspect of the leg
showing the distribution of
PTA perforators with the
distance measures in
centimeters proximal to the
tip of the medial malleolus.
(b) Lateral aspect of the leg
showing the distribution of
PA perforators with the
distance measured in
centimeters proximal to the
lateral malleolus
A. M. Yassin et al.
cia perpendicularly. This was found to be advantageous for
the design of a propeller ap as it minimizes the chance of
the perforators to kink if twisted [12].
When the PTAP ap is based on an appropriate perforator, its territory can extend from the anterior border of the
tibia to the posterior midline, and about 2.5 times this width
The proportion of musculocutaneous to septocutaneous
perforators widely varies between studies [17]. For example,
Heitmann etal. [18] reported 34% of perforators to be musculocutaneous and 66% septocutaneous, while a study done
by Yoshimura etal. reported these to be 71% musculocutaneous and 29% septocutaneous [19].
in terms of proximal to distal extension [13, 14].
42.3 Preoperative Investigation
42.2.2 Peroneal Artery Perforator Flap
PA supplies the posterolateral aspect of the leg through 5±2
musculocutaneous and septocutaneous perforators, making
the PA angiosome to extend from the posterior border of the
bula medially to the central raphe of Achilles tendon laterally [15]. These perforators are located at 3–5cm interval,
and most of them are found at about 13–18cm superior to
the lateral malleolus [10] (Fig. 42.1b). The musculocutane-
ous perforators predominate in the proximal leg and come
through the soleus or peroneus longus muscles, while the
septocutaneous perforators appear distally through the septum between the exor hallucis longus and peroneus brevis
[10]. About 5cm above the lateral malleolus, a good-caliber
perforator emerges from the PA, penetrates the interosseous
membrane then divides into a supercial branch which supplies the skin of the lateral supramalleolar ap and a deep
descending branch which anastomoses with the anterolateral
branches of the anterior tibial artery [16].
Perforators of the PTA and PA can be identied preoperatively using hand-held Doppler, color Doppler, Duplex ultrasound, thermal imaging, arteriography, high-resolution
computed tomography, or magnetic resonance angiography
[8, 20]. These modalities are useful in detecting the ap perforators, but they cannot provide information about the ap
viability.
Hand-held Doppler is a simple useful tool for preoperative localization of adequate perforators; however, color
Doppler is a more accurate method in terms of providing
more data about the internal diameter of perforators [21].
Thermography has now also become an affordable and
easy obtainable method for preoperative mapping, intraoperative decision-making and postoperative monitoring of
propeller aps using smartphone-compatible thermal
imaging cameras [22]. On the other hand, computed
tomography angiography (CTA) is now considered by
many studies as the gold standard technique for mapping
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411
the cutaneous vasculature of the lower extremities. It can
provide detailed information about the PTA and PA, and
the anatomical data of their perforators including the
diameter and course. Such data facilitated the preoperative
mapping and the intraoperative dissection of the perforators [20, 23, 24].
It is also important to nd a tool that can be used intraoperatively to detect the ap perfusion and the safe ap
dimensions. Intravenous uorescein administration is one of
the methods used for prediction of aps perfusion [25].
However, the indocyanine green near-infrared uorescence
angiography was found to be more accurate than the conventional uorescein angiography in evaluating skin perfusion [26].
42.4 Flap Design andMarkings
The most promising perforator near to the defect should be
marked preoperatively using hand-held Doppler or any of the
aforementioned modalities (Fig.42.2). A pedicled perforator
ap can be designed as a peninsular or islanded ap. In a
peninsular ap, a skin bridge should be left intact during ap
harvest in addition to the isolated perforator, and examples of
this include the uni-bladed propeller, the transposition, and
rotation aps. On the other hand, an islanded ap, such as a
twin-bladed propeller, keystone, and V-Y advancement, is
only vascularized by the isolated perforator [15].
The most common design in the lower limb is the twinbladed propeller ap (two blades of unequal sizes). For a
proper design of this ap, the perforator should act as the
pivot point of the ap. Then, the distance between the perforator and the distal end of the defect is measured and transferred proximally along the axis of the main source vessel.
The distance between the perforator and the proximal border
of the ap is equal to this measured distance plus 1cm. The
width of the proximal part of the ap, which should ll in the
defect, equals to the width of the defect plus 0.5cm. This
compensates the expected ap contraction and allows for
tensionless wound closure [27]. The short arm of the ap,
which is the part between the perforator and the proximal tip
of the defect, will be used to help closure of the secondary
defect either completely or with a skin graft after complete
ap dissection and rotation (Fig.42.3).
a
b
c
Fig. 42.3 The preoperative design for a twin-bladed propeller ap. (a)
Marking of the ap. The distance between the perforator, marked as x,
and the proximal tip of the ap (A) is equal to the length of the defect
(C) plus the distance between the perforator and the proximal edge of
the defect (B). Note that 1–2cm should be added to (A) to compensate
for the tissue retraction and help tension-free closure. (b) The ap will
be rotated to cover the defect after complete dissection. (c) The defect
will be completely covered with the long arm of the ap, while the short
arm will help closure of part of the donor site. The remaining part can
be covered with a split thickness skin graft or closed primarily if
Fig. 42.2 Preoperative marking of the posterior tibial artery perforators
possible
412
42.5 Flap Raise/Elevation – A Step-By-Step
guide
1. Incision
The posterior border of the designed ap is incised as
an exploratory incision down through the deep fascia
(Fig.42.4).
2. Pedicle Dissection
The ap elevation is performed subfascially, identify-
ing and preserving all potentially suitable perforators.
Once all perforators are allocated, the best one should be
selected based on the caliber, pulsatility, proximity to the
defect, number and caliber of venae comitantes, orientation, and course (Fig.42.5).
A. M. Yassin et al.
Fig. 42.6 Tenotomy scissor pointing to the most appropriate perforator of the ap
Fig. 42.4 Intraoperative photograph showing the incision of the posterior border of the ap down through the deep fascia
Fig. 42.5 Intraoperative photograph of a posterior tibial artery perforator ap. The incision was carried out down through the deep fascia
(arrows). Three perforators were marked in this image; P1, P2, and P3
from distal to proximal. P1 and P2 were septocutaneous perforators
passing through the septum between the soleus (S) and the exor digitorum longus (FDL) and were traced down to the posterior tibial vessels
(asterisk), while P3 was a musculocutaneous perforator piercing
through the soleus muscle
Fig. 42.7 The most appropriate perforator and its accompanying vein
were dissected all around for a suitable length
3. Pedicle Preparation
Once the most appropriate perforator is chosen, all
other perforators must be ligated (Fig.42.6). The perforator and its accompanying veins should then be dissected
long enough to prevent kinking of the vessels when the
ap is repositioned (Fig.42.7). When high degree of rotation is required (more than 90–100°), perforator skeletonization or exposure of the source vessels will be necessary
to minimize torsion (Fig.42.8).
4. Flap Adjustment
The ap can then be reevaluated and adjusted based on
the chosen perforator (Fig.42.9). The remaining outline
of the ap is incised and dissected until completely
islanded. The raised ap can now be transferred to the
defect as a twin-bladed propeller, keystone, V-Y advancement, or even as a free perforator ap. The following
steps should be undertaken to inset the ap as a twinbladed propeller ap.
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413
Fig. 42.10 The ap was rotated 180° to reach the recipient site
Fig. 42.8 Skeletonization of the perforator was carried out to mini-
mize torsion of the pedicle
Fig. 42.9 The ap dimensions were adjusted based on the dissected
perforator
5. Flap Transfer and Insetting
The ap can be rotated up to 180° to reach the recipi-
ent site. The long blade of the propeller ap lls the
defect, while the short blade is used to help closure of part
of the donor site (Figs.42.10, 42.11, and 42.12). This can
be done using skin staples or 3–0 half-buried prolene
Fig. 42.11 Intraoperative photograph of the ap after being rotated
180° showing minimal torsion of the skeletonized perforator
Fig. 42.12 After being rotated, the long blade of the ap lled the
defect, while the short blade helped to cover part of the donor site
sutures. Penrose or rubber drain can be used, but should
be placed and secured well away from the perforator
(Fig.42.13).
414
Fig. 42.13 Complete inset of the ap in its new position. A rubber
drain was placed and secured away from the perforator. The donor
site was partially closed primarily and the remaining part was skin
grafted
6. Donor Site Closure
After complete inset of the ap in its new position, the
donor site can be closed primarily if the ap area is small
which enables tensionless closure and gives the best aesthetic result. In the case of a large donor site defect, a splitthickness skin graft can be used (Fig.42.13).
42.6 Core Surgical Techniques inFlap
Dissection (Propeller Flaps)
The use of a thigh tourniquet without exsanguination is
advised to allow engorgement of the venae comitantes and
optimize visualization of the perforators. An incision is rst
made along the posterior border of the planned ap down
through the deep fascia using a blade (size 15 or 10), and
then followed by subfascial dissection under loupe magnication by the means of sharp, blunt as well as bipolar dissection. Placing anchoring sutures at the ap edges helps to
prevent the deep fascia from being separated from the skin
and the subcutaneous fat with shearing forces during dissection and gives a better retraction and exposure.
At this stage, the ap dissection technique depends on the
type of the ap harvested:
(a) Posterior tibial artery perforator ap:
Subfascial dissection is carried on over the exor
digitorum longus muscle, and the perforators can be
identied and preserved on the undersurface of the fascia between the exor digitorum longus and soleus muscles. PTA should be located and mobilized in the distal
part of the initial incision to make dissection much easier, and then retracted towards the soleus muscle to make
the intermuscular septum more dened. The identied
perforators can then be followed down the septum until
their origin from the PTA.
A. M. Yassin et al.
(b) Peroneal artery perforator ap:
Subfascial dissection is performed laterally until the
musculocutaneous or septocutaneous perforators are
identied, and then traced retrograde to the peroneal
vessels. If the perforators are found piercing the soleus,
peroneus longus or exor hallucis longus muscles, they
should be traced intramuscularly with ligation of any
encountered muscular branches.
Multiple useful perforators are usually identied and the
most appropriate one is selected based on its size, location,
number of venae comitantes, subcutaneous course, and orientation. This chosen perforator might not be the one identied preoperatively using the hand-held Doppler or the
CTA. If in doubt, an Acland clamp can be used to select
between two similar-sized perforators.
Once this decision is made, the ap design is rechecked
and modied accordingly to make sure that the proximal
edge of the ap can be transferred to the distal edge of the
defect without tension. The pedicle is then prepared by division of all fascial strands and muscular side branches associated with the perforator, especially those around the venae
comitantes, for at least 2cm to help the ap to rotate up to
180° without signicant spiral twist of the pedicle. A long
pedicle will result in a gentler twist, and therefore, less blood
ow obstruction in this high degree of ap rotation.
Once the pedicle is prepared, the incision around the ap
is completed and the rest of the ap is harvested. When the
ap is totally islanded, it usually becomes hyperemic. The
tourniquet is then released and the ap should not be rotated
into the defect immediately after being completely islanded,
but left in its original position for 10–15min. This helps to
relieve any vascular spasm involving the perforator, which
usually happens following meticulous pedicle dissection,
and the ap to reperfuse.
After conrming good perfusion of the ap, it can be
rotated into the defect. At this stage, the ap is lifted from its
position without applying too much tension on the pedicle,
and then pivoted around the perforator. The ap can be
rotated to t into the defect in a clockwise or anticlockwise
direction. This mainly depends on the angle between the longitudinal axis of the ap and the defect, and the perfect direction of rotation is one that causes the least tension and torsion
of the pedicle.
The maximal angle of ap rotation is 180°, and it should
not be rotated more than this angle as it can simply be rotated
in the opposite direction. If the ap has to be rotated 180° to
cover the defect, it should be rotated rst in a clockwise
direction. Then the degree of pedicle torsion is noted, any
extra fascial strands causing compression on the venae comitantes are divided, and the ap perfusion is monitored. The
same procedure should be repeated with the ap rotated in
the anti-clockwise direction. The direction of rotation is then
decided based on the angle which causes the least torsion to
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the perforator and maintains best ap perfusion. The results
of a study done by Song etal. [28] emphasized the importance of this step and how the direction of ap rotation when
a 180° of rotation is required can signicantly affect the
overall outcome of propeller aps. They hypothesized that
each perforator, and therefore each ap, might have a preferred direction of rotation over another. They also found out
that the perforator ow can signicantly be affected by the
rotation direction, and the use of the preferred perforator
direction may subsequently reduce the rate of the ap loss.
The rst two skin sutures should be placed on the proximal
and distal ends of the ap to guard against any further traction
on the pedicle, then the rest of the ap is sutured in its new
position. The donor site should not be closed under excess
tension, as this will cause compression on the main vessel,
affecting the blood supply of the ap, and causing edema of
the distal leg. If complete primary closure of the donor site
cannot be achieved, the remaining defect can be skin grafted.
42.7 Clinical Scenario
415
Fig. 42.15 Debridement of the recipient site was done. All the perforators were ligated except the most distal one on which the ap was harvested and the rest of the ap was then elevated
A 55-year-old hypertensive and diabetic male who works as a
butcher presented with an exposed Achilles tendon of his right
leg with supercial tendon necrosis. He sustained knife laceration to the back of his right lower leg 8weeks before, followed
by wound infection and skin necrosis which was surgically
debrided, leaving the distal part of the Achilles tendon exposed.
Supercial debridement of the necrotic part of the tendon was
performed by the orthopedic team. Debridement of the wound
edges was performed, resulting in a 11 × 6 cm defect. The
defect was reconstructed using a posterior tibial artery perforator propeller ap. The ap was raised on a distal perforator
closest to the defect, rotated about 160° and lled into the
defect. Donor site was closed partially with the short blade of
the ap and the remaining part was covered with a split-thickness skin graft. The ap survived completely and the patient
had an uneventful postoperative recovery (Figs.42.14, 42.15,
42.16, 42.17, 42.18, 42.19, and 42.20).
Fig. 42.16 The ap was not transferred immediately into the defect
after being completely islanded, but sutured in its position for 10–15min
before rotation
Fig. 42.17 The ap was then rotated into the defect. The long blade of
the ap tted into the defect, while the short blade covered part of the
donor site
Fig. 42.14 Preoperative photo of right leg showing a skin loss and
exposed Achilles tendon with supercial necrosis
416
Fig. 42.18 The ap was sutured in its new position using 3–0 halfburied prolene sutures. A rubber drain was used and placed away from
the pedicle. The remaining part of the donor site was covered with a
split-thickness skin graft
Fig. 42.19 5days postoperative
A. M. Yassin et al.
42.8 Pearls andPitfalls
Pearls
• The initial incision over the ap should be designed
with the possibility of becoming an edge for an
alternative ap in case a suitable perforator is not
detected intraoperatively.
• Avoid perforators that are too far from the defect, as
they can cause the ap to be unnecessarily long.
• On the medial side of the leg, care should be taken
not to include the long saphenous vein in the ap to
avoid the vein becoming engorged with blood with
nowhere to drain. Saphenous nerve should also be
preserved to avoid postoperative distal numbness.
On the lateral side of the leg, try to exclude the sural
nerve to avoid loss of sensation of the lateral aspect
of the distal leg and foot.
• When a perforator is chosen, it is best to make sure
that the lateral dimensions of either sides of the
pedicle are equidistant before cutting the other edge
of the ap in order to avoid any excessive sideway
traction on the pedicle after ap inset.
• If there is a reasonable cutaneous vein at the proximal border of the ap, it is recommended to dissect
it for about 1–2cm before ligating so it can be used
as a lifeboat in case of ap congestion. In 2019,
Kosutic [29] discussed the concept of hybrid perforator aps. In this study, 25 perforator aps were
included, and in all of them, 1–2 supercial veins
were dissected on the ap edge and used for prophylactic supercharging. After ap rotation, this
prepared supercial ap vein was anastomosed
microscopically with another vein on the edge of
the defect. This additional step could enable the surgeon to harvest a larger ap more safely, use the
entire raised ap more reliably, reduce the complications rate and improve the overall outcome of
propeller aps.
• Topical vasodilators as papaverine or verapamil can
be applied around the perforator after completion of
dissection and before ap rotation.
Fig. 42.20 Two weeks postoperative. The ap and the skin graft were
both healing well
42 Posterior Tibial and Peroneal Perforators Flaps
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Pitfalls
• Perforators in an area of scar, granulation tissue, or
zone of injury are more fragile and can be easily
injured. According to the latest British Orthopaedic
Association and British Association of Plastic,
Reconstructive and Aesthetic Surgeons (BOA/
BAPRAS) 2020 guidelines for the management of
open fractures, the use of local perforator aps
should be limited to relatively low-energy injuries
with a small-sized zone of injury. Free tissue transfer is recommended in cases of higher energy type
of traumas and those associated with degloving
injuries [30].
• A pedicle that is skeletonized more than required
increases the risk of occlusive twist and hence
affects the ap perfusion.
• Raising a propeller ap on two adjacent perforators
can compromise its blood supply after inset, as they
can be twisted around each other with ap
rotation.
• Bulky dressing should be avoided as it can cause
compression on the ap and vascular embarrassment. Bandaging should be soft and light, and a
window should be made in the dressing to observe
the ap.
• Venous congestion is the most common complication and the primary cause of ap necrosis. Flap
salvage in that case should be commenced as soon
as possible by removing some distal stitches to
release excess tension, local heparinization of the
ap or applying leeches. Negative pressure wound
therapy will be valuable in such cases especially
those that end with partial supercial ap necrosis.
42.9 Selected Readings
• Teo TC. The propeller ap concept. Clin Plast Surg.
2010;37(4):615–626, vi.
• In this article, TC Teo describes the propeller ap concept
as a versatile technique for reconstruction of defects in
different parts of the body. He provides us with a very
detailed description of the ap design and the surgical
technique in harvesting propeller perforator aps.
• Low OW, Sebastin SJ, Cheah AEJ.A review of pedicled
perforator aps for reconstruction of the soft tissue
defects of the leg and foot. Indian J Plast Surg.
2019;52(1):26–36.
• This paper provides a historical review, the anatomical
basis, the preoperative investigations and design of the
417
common perforator-based aps for reconstruction of leg
and foot defects. It also focuses on the surgical technique and the postoperative follow-up of this kind of
aps.
• Schaverien M, Saint-Cyr M. Perforators of the lower
leg: analysis of perforator locations and clinical application for pedicled perforator aps. Plast Reconstr Surg.
2008;122(1):161–70.
• This cadaveric study provides a comprehensive anatomi-
cal illustration of the perforators arising from the main
arteries of the leg (the anterior tibial, the posterior tibial,
and the peroneal arteries), and how this can be applied
clinically in the design of pedicled perforator aps for
reconstruction of the lower leg defects.
• Georgescu AV. Propeller perforator aps in distal lower
leg: evolution and clinical applications. Arch Plast Surg.
2012;39(2):94–105.
• The author highlighted some of the tips for the design and
harvesting technique of propeller perforator aps in the
lower leg. He also addressed the most common complications that could happen postoperatively and the best way
to deal with them.
• Tajsic N, Winkel R, Husum H.Distally based perforator
aps for reconstruction of posttraumatic defects of the
lower leg and foot. A review of the anatomy and clinical
outcomes. Injury. 2014;45(3):469–77.
• Tajsic etal. reviewed the surgical anatomy and techniques
of the perforator aps in the lower leg, analyzed the clinical outcomes in the included studies and illustrated some
of the future trends that will be promising especially in
terms of microvascular imaging for better monitoring of
the healing capacity of perforator aps.
• Pignatti M, Pinto V, Docherty Skogh AC, Giorgini FA,
Cipriani R, De Santis G, Hallock GG.How to design and
harvest a propeller ap. Semin Plast Surg. 2020;34(3):
152–60.
• This article provided a good illustration for the preopera-
tive investigation and planning for a propeller ap. Then
the authors went through their standard step-by-step
approach for the ap harvesting technique and a number
of harvesting variations. They also discussed their postoperative ap monitoring protocol and their recommendations for the ap salvage in case of postoperative
venous congestion.
References
1. Kroll SS, Roseneld L. Perforator-based aps for low posterior
midline defects. Plast Reconstr Surg. 1988;81(4):561–6.
2. Koshima I, Soeda S. Inferior epigastric artery skin aps without
rectus abdominis muscle. Br J Plast Surg. 1989;42(6):645–8.
3. Hyakusoku H, Yamamoto T, Fumiiri M.The propeller ap method.
Br J Plast Surg. 1991;44(1):53–4.
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