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Conventional reversed sural flaps have been used to cover lower one-third of the leg defects. However, the experience of the authors indicates that when the soft-tissue defect located at the dorsum of the metatarsophalangeal joint, distal marginal necrosis of the flaps usually occurs, which is the exact part of the flap that one needs the most. Finding a new method to augment the blood supply of the flap can be a difficult task. The authors found there is a constant cutaneous branch emanate from the peroneal artery at the point 11.0 +/- 1.7-cm upon the lateral malleolus. Ten modified distally based reverse sural artery flaps, in which the cutaneous branches from the peroneal artery 11.0 +/- 1.7-cm upon the lateral malleolus were added, were performed for the distal-third of the foot reconstruction between 2003 and 2006. All of the flaps survived completely after the operation. Distal marginal necrosis did not occur in any of the flaps. When conventional local flaps are inadequate, this flap should be considered for its reliability and low associated morbidity.

We tested the hypothesis that the intrinsic vascular plexus of the motor nerve could support viability in a rat hindlimb muscle flap. In a preliminary study, we examined the course and vascularity of the sciatic nerve, the peroneal nerve, and the peroneous longus muscle in the rat hindlimb via anatomic dissection, microangiography, and histologic study (n = 10 animals). On the basis of this examination, the peroneous longus muscle was chosen as our experimental model in this study. In 12 animals, the peroneus longus was acutely elevated, which severed all tendinous and vascular structures, this left the muscle pedicled on the motor nerve only (Group I). Animals in Group II underwent a staged elevation of the flap with division of the vascular pedicle, the tendon of insertion, and the tendon of origin during separate procedures that were 5 days apart (n = 12). Muscle viability was evaluated by gross inspection, measurement of muscle weight and length, nitroblue tetrazlium (NBT) staining, microangiography, and histology. NBT staining demonstrated that immediate elevation of the peroneus longus muscle flaps led to an average necrotic area of 80.6% +/- 9.8% (Group I). A significant improvement in viability was observed for muscle flaps of animals in Group II, with peroneus longus muscle necrosis averaging 25.6% +/- 9.3%. Microangiography demonstrated that the intrinsic vascularity of nerve was increased dramatically in Group II. These data support the hypothesis that the intrinsic vascular plexus of the motor nerve of a skeletal muscle can support at least partial viability of a muscle flap. However, this vascular axis is inadequate to support complete viability of a muscle flap if the flap is elevated immediately. If a staged elevation affects a surgical delay, the viability of a muscle flap elevated on a neural pedicle can be increased significantly. With adjustments in the delay procedure, this strategy may allow transfer of muscle flaps when maintenance or reconstitution of the primary vascular axis is not possible., ((c) 2009 Wiley-Liss, Inc.)

A distally based tenosynovial sheath of peroneal tendons was used as a flap with skin graft to cover the exposed tendo Achilles. The flap has a reliable blood supply being perfused by a constant sizeable musculofascial perforator. Cadaveric dissection with methylene blue dye study has been conducted to prove the rationality and reliability of blood supply. The position of the perforator had been confirmed prior to surgery by a hand-held Doppler. The flap used to cover the exposed Achilles tendon in five cases yielded positive results. To our knowledge, a retrograde flap of this nature is unprecedented though an antegrade flap of similar composition has been described.

The lateral supramalleolar flap (LSMF) is frequently used for covering major tissue defects of the foot and ankle but usually, in case of arteriopathy of the lower limbs, this device is contra-indicated. Twenty-four specimens of amputated limbs of patients suffering from arteriopathy of the lower limbs allowed us to study the vascular anatomy of this flap after intra-arterial injection of colored latex. At the time of the amputation the average age of the patients was 68.5 years. The clinical signs of arteriopathy had been present for 3-16 years. In 10 cases the amputation was performed directly, in 14 cases after an unsuccessful attempt at revascularization. The dissection results revealed certain specificities in the vascularization of the LSMF with arteriopathy. The perforating branch of the peroneal artery was found in all cases. The descending branch of this perforating artery was found to be patent in 22 cases but slim in five cases. It was absent in two cases. The superficial peroneal nerve and its vascular network always participated in the vascularization of the flap. Thus, its preservation in the distal part of the flap offers a second vascular flow to the pedicle of the LSMF. This specificity increases the theoretical feasibility of the LSMF from 17 to 22 cases out of 24 in our dissections. The authors suggest a theory according to which the evolution of arteriopathy and the gradual concomitant development of a supply network, which effects the vascularization of the sensory nerves too, induces the "anticipation" of a flap. The preliminary distal revascularization by bypass grafts or by some kind of endovascular treatment should guarantee the good vascularization of a limb and the reliable use of this neurocutaneous arterial network.

This study included 25 patients with lower limb tumors who had reconstruction by vascularized fibula osteoseptocutaneous flap performed at least 24 months before the end of the study. Hypertrophy of the transplanted fibula was estimated on serial radiographs by a modification of the formula of De Boer and Wood (J Bone Joint Surg [Br] 71:374-378, 1989). A significant graft was observed in 90% of the patients at an average follow-up of 27 months (range, 30-200%). The time to graft union (start of partial weight-bearing) positively correlated with the time to significant graft hypertrophy (r = 0.9, P < 0.01). The final amount of graft hypertrophy was affected by the age of the patient (P < 0.01) and the length of follow-up (P < 0.05). Graft hypertrophy progressed at an average rate of 3.3% per month (range, 2.3-4.9%) until the end of the 30th month; thereafter, little or no increase in graft hypertrophy was observed. The rate of graft hypertrophy showed two significant peaks at 6-12 months (P < 0.001) and at 18-24 months (P < 0.05). Patients younger than age 20 years showed faster hypertrophy, with a peak at the 12th month. Hypertrophy progressed faster in patients who received chemotherapy until the 12th month, and then declined sharply compared to those who did not receive chemotherapy., (Copyright 2002 Wiley-Liss, Inc. MICROSURGERY 22:367-370 2002)

An anatomic study performed on 64 fresh injected legs has shown the role of the vascular axis that follows the superficial sensitive nerves in supplying the skin. Three nerves were studied: the saphenous nerve, the superficial peroneal nerve, and the sural nerve. Conclusions are the same for the three nerves: The vascular axis, which can be either a true artery or an interlacing network, ensures the vascularization of the nerves, gives off several cutaneous branches in the suprafascial course of the nerve, and anastomoses with the septocutaneous arteries issuing from a deep main vessel. The superficial nerves that course the leg can therefore be considered as vascular relays owing to their neurocutaneous arteries. The concept of a neuroskin island flap has been developed and applied to six clinical cases for coverage of some specific areas of the knee and of the lower part of the limb.

Satisfactory replacement of skin defects over the lower leg remains a difficult problem. Various forms of coverage, including, local rotation flaps, muscle flaps, and fascial and free flaps, have their specific indications and inherent disadvantages. In this work, a new axial skin flap based on perforating vessels in the territory of the anterior tibial artery is described. A series of 50 lower leg dissections was carried out in 25 fresh cadavers after latex injection into the femoral artery. Detailed studies of the cutaneous distribution of the anterior tibial artery showed that three main arteries perfuse the anterior lateral portion of the lower leg. The superior lateral peroneal artery and the inferior lateral peroneal artery interseptal cutaneous perforators arise at an average of 25.6 and 17.2 cm from the lateral malleolus, respectively. The superior lateral peroneal artery was present in 100 percent of the specimens, whereas the inferior lateral peroneal artery was present in 70 percent of the specimens. In their course, they give several muscular branches to the peroneus longus and brevis prior to perforating the fascia and arborizing in the subcutaneous tissues of the anterolateral portion of the leg. The average external diameter was 1.6 cm for the superior and 1.4 cm for the inferior lateral peroneal artery. The superficial peroneal nerve accessory artery is the third artery which contributes to the skin of the lower leg. It arises from the superior lateral peroneal artery in 30 percent of cases, from the inferior lateral peroneal artery in 40 percent, and from both in 30 percent. The artery runs along with the superficial peroneal nerve and gives several cutaneous perforators along its descending course. Several cutaneous axial flaps can be fashioned around this anatomy. The operative technique along with demonstrative clinical cases is presented followed by pertinent discussion.