The suprafascial course of lower leg perforators: An anatomical study

Abstract

Background Perforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design. Methods An anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported. Results During suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them. Conclusions Our study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.

Are Perforators Reliable as Recipient Arteries in Lower Extremity Reconstruction? Analysis of 423 Free Perforator Flaps

“…55,[57][58][59] Perforators often follow a variable course on their route to the skin once piercing the deep fascia. 4,60 It is therefore critical to map the route of the perforator. This significantly speeds up recipient dissection and avoids inadvertent injury to the vessels.…”

Technical Aspects of High-Resolution Color-Coded Duplex Sonography for the Design of Perforator Flaps

“…4 5 The suprafascial architecture of perforators and sub-branches may now be assessed in real-time imaging. 6 7 Applying correct settings, modern standard devices are capable to detect vessels of 0.2 mm and less in diameter. 5 8 9 Anatomic and hemodynamic data may be provided in real-time imaging by CCDS of both, vascular structures of the donor and recipient sites of flap reconstructions.…”

“…5 8 9 Anatomic and hemodynamic data may be provided in real-time imaging by CCDS of both, vascular structures of the donor and recipient sites of flap reconstructions. 6 10 Besides qualitative parameters as number and precise location of microvessels, quantitative parameters as vessel diameter and B-Flow velocities may be measured for a better comprehension of perforator flap physiology. Flow direction of arterial and venous vascular structures, turbulences, and muscular/subcutaneous course can be assessed and visualized.…”

The Effect of Muscle Exercise on Perforators Flow: A Prospective Cohort Study

“…It passes between the two heads of the tibialis posterior and enters the extensor compartment, crossing the interosseous membrane. Along its course, the ATA gives out 3–4 perforators on average, both musculocutaneous and septocutaneous [ 7 , 8 ]. Morrison and Shen [ 9 ] demonstrated that in most cases the main perforator is a septocutaneous vessel that originates within 7 cm from the fibular head and penetrates the deep fascia through the anterior intermuscular septum between the extensor digitorum longus and peroneus muscles.…”

“…Doppler ultrasonography is the cornerstone of perforator flap surgery; perforators are identified during the pre-operative planning guide flap design, as well as during the surgical approach. Having great accuracy during pre-operative planning saves time, eases flap elevation and may help in avoiding unnecessary exploration [ 8 ]. We place great emphasis on getting to know perforators blood flow variations to ensure the best surgical outcome with no complications.…”