THE PROXIMAL LATERAL LOWER LEG PERFORATOR FLAP

REVISITED: ANATOMICAL STUDY AND CLINICAL APPLICATIONS

JIUNN-TAT LEE, MD,1,2 PEIR-RONG CHEN, MD,2,3 HONDA HSU, MBChB,2,4* MENG-SI WU, MD,1 LI-FU CHENG, MD,1,2
CHIEH-CHI HUANG, MD,2,4 and SOU-HSIN CHIEN, MD2,5

Background: The proximal lateral lower leg flap is a flap suited for the reconstruction of small and thin defects. The purpose of this study
was to map the position and consistency of the perforator vessels and to review its reliability and technical considerations clinically. Methods: The location, number, and size of perforator vessels in the proximal third of the lateral lower leg were investigated in 20 fresh frozen
cadaveric lower limbs. This was analyzed together with 22 clinical cases. Results: Cadaveric dissection showed that there were 12 perforators in the proximal third of the lateral lower leg and these perforator vessels were found to be 63% septocutaneous and 37% musculocutaneous. The source vessel of the perforators was variable. Clinically the recipient site consisted of the head and neck in 8 cases, the
foot and ankle region in 13 cases, and 1 case in the hand. The mean thickness of this flap was 5.8 6 0.8 mm. Vascular pedicle length
ranged from 5 to 8.5 cm. The mean diameter of flap artery was 1.3 6 0.3 mm. One flap failure was seen due to arterial thrombosis. The
overall flap survival rate was 95%. Conclusions: The proximal lateral lower leg flap has the advantages of being thin and pliable, quick to
harvest with no major arteries sacrificed. There is minimal donor site morbidity and primary closure of the donor site is possible in the
C 2014 Wiley Periodicals, Inc. Microsurgery 00:000000, 2014.
majority of cases. V

Numerous intraoral defects and complicated wounds

with bone or tendon exposure at the hand or the ankle
and foot region often require reconstruction with a relatively thin flap. This is still a challenge to reconstructive
surgeons. The difficulty that arises is not the ability to
provide a soft tissue cover but rather in providing a cosmetically acceptable cover with minimal donor site morbidity. The ideal flap should be thin, pliable, easy to
harvest, with a reliable blood supply and a vascular pedicle of reasonable length and diameter.
The peroneal flap, which was introduced by Yoshimura et al. in 1984,1 is ideal for the reconstruction of
such thin defects. This flap can be harvested with the fibular bone as an osteocutaneous flap or with fibula bone
and soleus muscle as an osteomyocutaneous flap.2 It is
usually designed in the middle and the distal thirds of
the lower leg. The peroneal artery, which is used as its
pedicle, is sacrificed. Yajima et al.3 reported using the
proximal lateral leg flap based on skin perforators as its
pedicle, thus preserving the peroneal artery. However,
prior studies found that the perforator vessel in this area
1
Division of Plastic Surgery, Buddhist Tzu Chi General Hospital, Hualien,
Taiwan
2
School of Medicine, Tzu Chi University, Hualien, Taiwan
3
Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Hualien,
Taiwan
4
Division of Plastic Surgery, Buddhist Dalin Tzu Chi Hospital, Tzu Chi University, Dalin, Taiwan
5
Division of Plastic Surgery, Buddhist Taichung Tzu Chi Hospital, Taichung,
Taiwan
*Correspondence to: Honda Hsu, Division of Plastic Surgery, Buddhist Dalin
Tzu Chi Hospital, Tzu Chi University, Dalin, Taiwan.
E-mail: hondahsu@yahoo.com.tw
Received 21 October 2013; Revision accepted 26 March 2014; Accepted 3
April 2014
Published online 00 Month 2014 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/micr.22264

2014 Wiley Periodicals, Inc.

always penetrated the soleus muscle and there are

conflicting studies reporting that the perforators in the
proximal lateral lower leg are predominantly musculocutaneous in type. At present, there is a lack of detailed
anatomical study with regard the location, characteristics
of the perforator vessels, and properties of the proximal
lateral lower leg flap. The purpose of this study was to
map the position and consistency of the perforator vessels and to review its reliability and technical considerations clinically.
MATERIALS AND METHODS
Cadaveric Dissection

Twenty proximal lateral lower legs were dissected in

ten fresh frozen cadavers at the Tzu Chi University Medical Simulation Center. Latex injection technique was
used to facilitate identification of the vessels. The popliteal vessel was dissected out and flushed with heparinized warm saline (10 U/mL) followed by 20 mL of
colored latex (Wards, Rochester, NY). The cadaver was
refrigerated at 4 C for 24 hours for the latex to solidify.
The fibula was marked out and divided into three
equal lengths. An incision was made over the anterior
border of the fibula. The flap was elevated from the subfascial layer progressing posteriorly to the posterior septum. In each case, the dissection was performed from the
popliteal fossa till one-third of the total length of the fibula. After confirming the presence of the perforator vessels, they were dissected till the source artery. Only
arterial perforators with diameters greater than 0.3 mm in
size (measured at penetration through the deep fascia)
were included in the study. They were recorded as either
septocutaneous or musculocutaneous perforators (Figs. 1a
and 1b). The number, diameter, length of the pedicle,

Lee et al.

mean age of 52 years. The recipient site consisted of the

head and neck in 8 cases, the foot and ankle region in
13 cases, and 1 case in the hand. The etiology of the tissue defects include: trauma (n 5 5), chronic ulcer (n 5 5),
oral cancer (n 5 5), pressure sore (n 5 3), burn (n 5 2),
hemangioma (n 5 1), and osteoradionecrosis (n 5 1). Flap
thickness, pedicle length, and diameter of the vascular
pedicle as well as the distance of the pedicle from the
fibula head were recorded. The complication rates and
flap failure rates were noted.
Surgical Procedure

Figure 1. (a) Anatomical specimen showing the presence of a musculocutaneous perforator vessel. Intra-muscular dissection was performed to track the perforator to the main trunk. (b) An anatomical
specimen clearly depicting the presence of a septocutaneous perforator vessel. [Color figure can be viewed in the online issue,
which is available at wileyonlinelibrary.com.]

Figure 2. The contour of the fibula was marked out. The presence
and the location of the perforator could easily be detected with a
handheld Doppler flowmeter. The perforators were usually located
along the posterior margin of the fibula, near the distal portion of
the proximal third of the lateral lower leg. [Color figure can be
viewed in the online issue, which is available at
wileyonlinelibrary.com.]

and distance of the perforator from the fibula head were

also noted.
Patients

Twenty-two patients from March 2005 to March

2011 with various defects were reconstructed with the
proximal lateral lower leg flap. The patients charts were
reviewed. There were 13 males and 9 females with a
Microsurgery DOI 10.1002/micr

The surgical procedure has been described in previous literature.3 We describe it with some important modifications. The procedure was performed with the patient
in the supine position with the hip and knee flexed. The
contour of the fibula was marked out and divided into
three equal parts. The location of perforator vessels was
identified preoperatively using a handheld Doppler flowmeter. There were usually one or two points near the distal portion of the proximal third of the lateral lower leg
along the posterior margin of the fibula (Fig. 2). The outline of the flap was then designed to include the marked
out points. The tourniquet was not used as this allowed
us to visualize the perforator, as well as its pulsatile
strength, with greater clarity. The skin was incised anterior to the posterior septum and the flap elevated subfascially. After confirming the presence of the perforator
vessels, the flap was elevated from the posterior border.
The perforator vessel was then dissected intramuscularly
with ligation of the muscular branches if it was found to
be traversing the soleus muscle. If a septocutaneous perforator was found, then the dissection was straightforward (Fig. 3). When multiple perforators were present,
the larger perforator or the septocutaneous perforator was
chosen. The soleus muscle was then detached from the
fibula, and the bifurcation of the perforator vessels from
the main artery was located. The flap was elevated after
ligating the perforator vessels at their bifurcation. The
flap was insetted to the defect with microsurgical anastomosis using 10-0 nylon. The donor site was closed primarily when the width of the flap was less than 6 cm.
RESULTS
Anatomical Observations

The results of cadaveric dissection are summarized in

Table 1. The fibula length ranged from 31 to 39 cm.
A sizable perforator (arterial diameter > 0.3 mm) can
always be found within a 3-cm radius from the junction
of the proximal and middle third of the fibula bone. The
distance of this perforator from the fibular head was
710 cm (mean 8.4 6 1.8 cm). In 20% of the cases, a
further perforator can be found within the proximal third

Proximal Lateral Lower Leg Perforator Flap Revisited

tor was used and in 59% of the cases a musculocutaneous perforator was used (Table 2).
One venous thrombosis developed in a patient with
oral cancer (case 6) and this was successfully salvaged.
One flap developed total necrosis in a patient with diabetes mellitus due to arterial thrombosis and one further
flap developed partial necrosis. The other 20 flaps survived completely. The flap survival rate was 95%
(21/22). The donor site was closed primarily in 20 cases.
Skin grafts were required in 2 cases. There was no sensory or motor deficit at the donor leg. Apart from the
skin grafted donor legs, cosmesis of the linear scar was
good to excellent (Fig. 4).
CASE REPORTS
Figure 3. Schematic illustration depicting the course of the perforator vessels. It could pass either straight through the septum as a
septocutaneous perforator or traverse the muscle as a musculocutaneous perforator. [Color figure can be viewed in the online issue,
which is available at wileyonlinelibrary.com.]
Table 1. Summary of Pertinent Cadaveric Findings
Number of legs with one perforator
Number of legs with two perforators
Number of musculocutaneous perforators
Number of septocutaneous perforators
Distance from fibula head
Length of pedicle
Diameter of perforator artery

16
4
9
15
8.35 6 1.78 cm
5.15 6 1.25 cm
1.01 6 0.31 mm

of the lower leg. However, there was a wide variation in

the number of perforators seen in both inter- and intracadaver legs. The perforators were found in these 20 legs
to be 63% septocutaneous and 37% musculocutaneous
perforators. The length of the perforators ranged from
4 to 8 cm (mean 5.2 6 1.3 cm). The mean arterial diameter, at its bifurcation from the main trunk, had a range of
range 0.51.8 mm (mean 1.0 6 0.3 mm). The source vessel of the perforators arose from peroneal artery (13/24,
54%), tibioperoneal trunk (6/24, 25%), posterior tibial
artery (4/24, 17%), and popliteal artery (1/24, 4%).
Clinical Applications

The flap size ranged from 4 3 3 cm to 11 3 8 cm.

The mean thickness of the flap had a range of 4.57 mm
(mean 5.8 6 0.8 mm). The mean diameter of the perforator artery was 1.3 6 0.3 mm and the mean length of the
vascular pedicle was 6.5 6 1.2 cm. Six flaps had a single
conmitant vein and the other sixteen flaps had two conmitant veins. The diameter of the vena comitante ranged
from 0.7 to 2.8 mm (mean 2.0 6 0.8 mm). The mean distance from the fibula head was 8.6 6 2.1 cm. The mean
time of flap harvesting was 62 minutes (range 42120
minutes). In 41% of the cases, a septocutaneous perfora-

Case 1

A 54-year-old female patient sustained an avulsion

injury over her right lower leg and posterior heel with
exposure of the Achilles tendon (Fig. 5a). An 11 3 5 cm
flap was designed on the distal portion of the proximal
third of the right leg (Fig. 5b). The largest perforator,
which was musculocutaneous type and found to penetrate
through the soleus muscle, was used. After intramuscular
dissection of the perforator, the flap was elevated and
transferred to the recipient site. End-to-side anastomosis
of the pedicle artery to posterior tibial artery was performed with 10-0 Nylon sutures. The pedicle veins, of
which there were two, were both anastomosed to the
conmitant veins of posterior tibial artery by end-to-end
fashion (Fig. 5c). The remaining defect was skin grafted.
The donor site was closed primarily. Follow-up at 1 year
showed complete survival of the flap (Fig. 5d).
Case 2

A 56-year-old man with squamous cell carcinoma of

the right buccal area underwent wide excision with a
resultant defect of 8 3 5 cm (Fig. 6a). This was reconstructed with a proximal lateral lower leg flap designed
over the right lower leg (Fig. 6b). The artery was anastomosed to a branch of the facial artery in end-to-end anastomosis. The pedicle with only one conmitant vein was
anastomosed to a branch of the facial vein also in an
end-to-end anastomosis (Fig. 6c). The flap healed well
and showed good contouring to the buccal surface at
1 year follow up (Fig. 6d).
DISCUSSION

In our center, as well as in others, the radial forearm

flap is still the favored flap for small and thin defects.
However, donor site morbidity and complications remain
a major concern for this workhorse flap.46 They often
need to be skin grafted for wound closure. Wound
Microsurgery DOI 10.1002/micr

Microsurgery DOI 10.1002/micr

74/M
65/F
70/F
25/F
54/F
47/M
62/F
20/F
42/M
15/F
53/M
51/M
68/F
49/M
64/M
49/M
55/M
54/M
66/F
56/M
65/M
42/M

Case

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

Lateral Foot
Left Heel
Left Ankle
Dorsal Foot
Right Ankle
Tongue Base
Mouth Floor
Scalp
Left Face
Left Thumb
Left Ankle
Left Ankle
Left Foot
Left Mandible
Right Heel
Dorsal Foot
Plantar foot
Left Buccal
Left Buccal
Right Buccal
Right Foot
Right Ankle

Defect
Location
734
835
633
633
11 3 5
734
734
434
11 3 8
635
433
734
634
13 3 5.5
11 3 5
937
935
734
933
835
534
12 3 4

Flap Size
(cm)
68
54
70
46
50
75
50
47
75
45
70
73
53
73
71
70
69
68
51
70
68
68

5
6
5
6
7
6
6
7
5
7
5.5
6
6.5
6
5.5
4.5
5
5
7
5.5
5
5

Flap
Thickness
(mm)
Mc
Mc
Mc
Mc
Mc
Mc
Mc
Mc
S
S
S
S
S
Mc
S
S
Mc
S
Mc
Mc
Mc
S

Septo/
Musculocutaneous
8
7
9
7
7
7
8
7
8
8
9
7
10
15
8
7
11
13
7
8
10
9

Distance
from fibular
Fibular head
Head (cm)

M 5 Malemale, F 5 Femalefemale, Mc 5 Musculocutaneousmusculocutaneous, S 5 Septocutaneousseptocutaneous.

Age/
Sex

Patient
Weight
(kg)
6
7
7
5
7
8
6
8.5
6
5
7
8
7
8
5
7
5
5
6
8
7
5

Pedicle
Length (cm)

Table 2. Patient Demographics

1.5
1.2
1.4
0.8
1.4
1.4
0.8
1.5
1.5
1.0
1.4
1.6
1.5
1.4
1.5
0.8
1.4
1.5
1.5
1.6
1.2
1.5

Artery
Diameter
(mm)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes

Flap
Survival

Nil
Nil
Nil
Nil
Nil
Venous thrombosis
Nil
Nil
Partial wound dehescence
Nil
Nil
Nil
Nil
Nil
Nil
Partial flap necrosis
Arterial thrombosis with flap failure
Nil
Nil
Nil
Nil
Nil

Complications

4
Lee et al.

Proximal Lateral Lower Leg Perforator Flap Revisited

Figure 4. Only a fine linear scar was visible at the donor site upon
follow up. [Color figure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]

complications include partial loss of the skin graft, exposure of tendons, and delays in wound healing. Long-term
morbidities include reduced range of motion of the wrist,
reduced pinch and grip strength, loss of superficial radial
nerve sensation, and cold intolerance.46 Cosmesis
remains a major problem, especially in the Asian population. Hyperpigmentation and hypertrophic scar is commonly seen in this population group.
The introduction of perforator flaps has gradually
gained widespread acceptance amongst the reconstructive
surgeons. The anterolateral thigh perforator flap is the
most commonly used perforator flap for various kinds of
defects. It functions well when a larger and thicker flap
is required.79 However, it is usually too bulky in some
female and obese patients and hence primary thinning of
the flap or secondary debulking are required. Some studies have shown that these flaps can be thinned till a
thickness of 35 mm.10,11 But in our experience and
others, this is technically demanding and runs the risk of
damaging the subdermal plexus, resulting in flap ischemia and partial flap necrosis.12,13 A number of other perforator flaps had been described, but thin perforator flaps
for the reconstruction of small and thin defects are still
uncommon.
The lateral lower leg is a good donor site for perforator flaps and a great majority of cutaneous perforators
here originate from the peroneal artery.14,15 The average
number of perforators from the peroneal artery is
4.8 6 1.4 (range 38). The peroneal artery nourishes

mainly the middle third to the lower third of the lateral

aspect of the lower leg.14 However, perforators of the
proximal lateral lower leg can originate from several different source arteries, these include: inferior lateral geniculate, popliteal, anterior tibial, tibio-peroneal trunk,
posterior tibial or peroneal artery.3 These cutaneous perforators can be classified into musculocutaneous perforators that penetrate into muscle before reaching the skin
or septocutaneous perforators that traverse through the
septum before reaching the skin. Yajima et al.3 introduced the proximal lateral leg flap. They based the flap
on the cutaneous branches of the major nutrient artery to
the lateral half of the soleus muscle, thereby sparing the
peroneal artery. They further described that there are usually one or two points near the distal portion of the
proximal third of the lower leg where a major nutrient
artery could be found by using a Doppler flowmeter.3 In
2005, Kawamura together with Yajima and others
described in two separate reports the use of this flap and
renamed it soleus perforator flap, as they found that
the perforator vessels always pierce the soleus muscle
prior to reaching the skin.16,17
Yoshimura et al.1 initially reported that the musculocutaneous branch is distributed from the lower part of
the upper third of the lateral side of the lower leg to the
middle third and that the direct cutaneous artery is distributed from the middle third to the lower third. In
1990, he performed a further cadaver study, where he
divided the length of the fibula into 10 equal parts.
According to them even though the septocutaneous-type
vessels were found all along the lateral leg except the
proximal 2/10 of the leg, but at the proximal third of lateral lower leg, the musculocutaneous perforators predominated and septocutaneous perforators were rare.11
Chen in 1985 found that the first artery is usually a
direct cutaneous artery and that the others are predominately musculocutaneous.18 Our findings showed that in
our anatomical dissection (20 legs), 63% of all perforators in the proximal one-third of the lateral leg were septocutaneous and clinically (22 legs) showed that 41% of
the flap perforators used were septocutaneous. These perforator vessels do not necessarily have to penetrate the
soleus muscle. Wolff et al. used perforator flaps from the
proximal one-half of the lateral lower leg for intraoral
reconstruction. In their earlier studies, they described that
30% of the perforators were septocutaneous.19,20 But in
their latest study in 2012, 70% of the vessels were found
to be septocutaneous and they used the term peroneal
perforator flap because in their cases, the perforators all
originated from the peroneal artery.21 In light of the findings that at the proximal lateral lower leg, the perforators
do not always penetrate the soleus muscle, and the perforator can originate from several different source arteries;
other than the peroneal artery, we would recommend the
Microsurgery DOI 10.1002/micr

Lee et al.

Figure 5. (a) The defect over the Achilles tendon was debrided and suitable vessels for anastomosis were identified and prepared for
anastomosis. (b) A proximal lateral lower leg flap with a septocutaneous perforator was elevated. (c) The flap was insetted over the
exposed Achilles tendon defect. (d) One year follow up showed good survival of the flap and good contouring of the area reconstructed.
[Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 6. (a) A 56-year-old male patient with primary squamous cell carcinoma of the right buccal area, after wide excision a 8 3 5 cm
defect remained, with exposure of the mandibular bone. (b) A 8 3 5 cm proximal lateral lower leg flap was designed over the right lower
leg. The perforator was located 8 cm distal to the fibula head. (c) Immediate post-reconstruction photograph showed the flap fitting the
defect well. (d) Post-operative follow up at 1 year showed a small, thin flap with absence of trismus. [Color figure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]

Microsurgery DOI 10.1002/micr

Proximal Lateral Lower Leg Perforator Flap Revisited

use of the previous name, the proximal lateral lower leg

flap. This is in accordance to the location of the flap.
The small diameter of pedicle vessels was the main
challenge for anastomosis, but it was not especially difficult in the hands of an experienced microsurgeon.
Venous thrombosis was seen in 5 of 18 flaps (28 percent)
in Kawamuras series.16 They commented that the venous
wall of these perforator flaps running through the
muscles were very thin contributing to the high complication rate. In our series, only one venous thrombosis
developed in case 6. This was successfully salvaged.
There was one total flap failure due to arterial thrombosis
with a flap success rate of 95%. This is comparable to
the use of radial forearm flap or anterolateral thigh flap.
We also noticed that due to the small size of the vessels
they tend to undergo vessel spasm during dissection. If
this does occur, one should give the vessel some time,
flush with Lidocaine or Prostagladin E1, and wait for the
spasm to pass.
The donor site of proximal lateral lower leg flap can
usually be closed primarily when the width of this flap
was less than 6 cm. Only a linear scar is seen. We usually perform a pinch test to determine whether the donor
site can be closed primarily. When compared to the
peroneal perforator flap located at distal lower leg in
Kawamuras study,16 the proximal lateral leg lower flap
has the advantage of being located in a region where the
surrounding skin is looser. This permits a slightly larger
flap to be harvested while still allowing for primary closure of the donor site. The proximal lateral lower leg
flap also has a longer pedicle than the peroneal perforator flap that was described by Kawamura et al.16
Some surgeons recommend the use of computed
tomographic angiography22,23 or magnetic resonance
angiography24 for flaps with variable anatomy such as
anterolateral thigh flap, deep inferior epigastric perforator
flap, and fibula osteocutaneous flap. However, we found
this unnecessary with this flap, because the vascular anatomy of this flap is simple and the skin at proximal lateral
lower leg is thin; even if the perforator was a musculocutaneous type, the intramuscular course was short. In all
our cases, 12 perforator vessels could easily be located
using Doppler flowmeter preoperatively. The location of
the perforator always lies on the posterior margin of the
fibula bone about 715 cm distal to proximal end of fibula. We always made the anterior incision first. This was
different to a previous surgical technique described. We
found that by making the anterior incision first, it was
easier to locate the septocutaneous perforator. Patients
with peripheral artery occlusive disease are excluded
from the use of this flap. However, patients with diabetes
mellitus and old age d not preclude the use of this flap.
We used this flap in five diabetic patients and in four
patients aged greater than 65 years. The only flap failure

in our series was found in a diabetic patient. Although

the flap perfusion was intact during elevation, severe atherosclerosis was noted in the recipient artery during anastomosis. Postoperative arterial thrombosis was considered
to be the primary cause of flap failure. One should still
be cautious of the possibility of poor quality of recipient
vessels, leading to a higher complication rate and ultimately total flap failure as seen in this case.
In head and neck reconstruction, the anterolateral
thigh flap and the radial forearm flap have become the
workhorse flaps at our center. Anterolateral thigh flaps
are often used when a larger flap with bulk is required.
The radial forearm flap is utilized mainly for small and
thin defects. In this series, we used the proximal lateral
lower leg perforator flap in eight selected patients taking
advantage of the minimal donor site morbidities associated with this flap. All the flaps in our eight patients survived well. Due to the short pedicle of this flap, we
chose the lingual artery and the facial artery as their
donor vessels. Numerous veins can be used at this area.
In our opinion, we would not recommend the use of this
flap as the first choice for patients who had undergone
previous surgery or radiotherapy. One would encounter
difficulties with anastomosis when considering the small
vessel caliber and short pedicle. We suggest that this flap
can be used for reconstruction of small defects in
selected cases as an alternative to the radial forearm flap.
CONCLUSION

The proximal lateral lower leg flap provides a thin

and pliable flap, which has constant anatomical structures
and blood supply. Our anatomical study shows that a
sizeable perforator can always be found within a 3-cm
radius from the junction of the proximal and middle third
of the fibula bone and these perforator vessels are 63%
septocutaneous and 37% musculocutaneous. Clinically,
the harvesting of this flap does not require any major
arteries to be sacrificed. There is minimal donor site morbidity with primary closure possible if the width of the
flap did not exceed 6 cm. However, this flap demands
mature microsurgical skills due to small vessels with a
short pedicle. This flap is a useful option in selected
patients with small to medium soft-tissue defects.

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