Transversally oriented pedicled perforator flaps: A reliable alternative for lower leg reconstruction

Background: The use of a transverse pattern for perforator flap design and its possible clinical applications in the field of lower leg reconstruction are previously unreported in the medical literature. The purpose of this report is to describe our clinical experience with the use of transversally oriented pedicled perforator flaps in lower leg reconstruction. Patients and methods: Seven patients underwent lower leg reconstruction with transversally oriented pedicled perforator flaps. Patients age ranged from 42 to 68 years. All defects resulted from skin cancer ablation. Defect sizes ranged from 9 3 5t o 53 2.5 cm. The technique was applied to patients presenting with vertically oriented, long, and narrow defects, not feasible for primary closure, with the only audible perforators detected at a significant distance from the wound. Results: All flaps were based on a single perforator vessel. One of them was converted to a perforator-plus peninsular flap design, which retained an additional source of blood supply from the opposite skin bridge. The flaps were always mobilized in V-Y fashion. Donor sites were always closed primarily. Flap dimensions ranged from 15 3 7t o 83 3.5 cm. Operative time ranged from 40 to 90 minutes. All flaps survived uneventfully. Follow-up ranged from 6 months to 2 years. All patients were satisfied with the surgical outcome. Conclusions: The use of transversally oriented pedicled perforator flaps proved to be a reliable alternative option to reconstruct small to medium size defects of the lower leg. V C 2015 Wiley Periodicals, Inc. Microsurgery 00:000‐000, 2015. Recent experimental studies on the microvascular architecture of perforator flaps have provided a clear anatomical basis for flap orientation in the lower extremity, 1 showing that the dominant distribution of linking vessels in this anatomical region follows the axiality of the limb and the course of superficial veins and nerves. 2 For this reason, perforator flaps should be ideally designed in parallel to the axis of the involved leg to capture the largest and most reliable vascular territory. Nevertheless, many situations exist in the clinical practice which lead the reconstructive surgeon to disregard these suggestions in favor of a pure free style approach, 3 thus adapting flap design to defect location, perforator position and adjacent expendable areas of soft tissue laxity. 4 What should the plastic surgeon do in such cases, when dealing with lower leg defects with no potential to be reconstructed with vertically oriented perforator based flaps? Is there any place in our armamentarium for the use of transversally oriented perforator flaps? Can they be considered a feasible option to reconstruct soft tissue defects of the lower leg? In this report we answer these questions presenting indications, clinical applications and outcomes of this particular flap design applied in a series of seven consecutive lower leg reconstructions.