Foot reconstruction using a free proximal peroneal artery perforator flap: Anatomical study and clinical application

Background: When a small, thin, and durable flap is required for coverage of the foot, the proximal peroneal artery perforator (PPAP) free flap may be a novel option. However, few clinical results and anatomical studies on the PPAP flap have been published. Methods: A total of 24 PPAP flaps used in 22 patients from January 2013 to December 2016 were analyzed. All flaps were elevated in the subfascial plane based on a single perforator from the peroneal artery between the soleus and peroneus muscles. Results: The average harvested flap size was 18.9 cm ² (range, 9–40 cm ² ), pedicle length was 4.3 cm (range, 3.1–5.5 cm), and pedicle artery diameter was 1.1 mm (range, 0.8–1.5 mm). Twenty-three of the 24 PPAP flaps survived. Average time to harvest the flap was 35 minutes (range, 20–55 minutes). Perforator location (ratio by fibula length) was confirmed at the 0.32 site (standard deviation, ±0.04) from the fibular head. Percentages of septocutaneous and musculocutaneous types were 42% (10/24) and 58% (14/24), respectively, for perforator vessel course; average intramuscular course was 1.3 cm (range, 0.7–2.4 cm). Vessel graft was conducted in four cases, with an average length of 2.2 cm (range, 1.5–3.0 cm). Conclusions: The PPAP flap is one of the thinnest flaps available and is relatively easy to elevate. Moreover, it can be elevated in the same operative field as the foot, and primary closure is available for the donor site. Thus, the PPAP flap may be a good surgical option for soft tissue coverage of the foot.