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Page 2 of 13 Cohen-Shohet et al. Plast Aesthet Res 2019;5:28 I http://dx.doi.org/10.20517/2347-9264.2019.030
[2]
[1]
1854 . It was not until 1971 that Ger published his techniques on rotation muscle flaps. In 1981, Pontén [3]
published his technique on fasciocutaneous flaps, showing that long narrow flaps, including the fascia,
could be safely raised on the lower extremity. With a greater understanding of vascular anatomy, it was
soon discovered that flaps could be safely based off of single septocutaneous or myocutaneous perforators.

Pedicled perforator flaps expand the possibility of coverage and salvage. They can be performed with basic
surgical equipment and without need for microsurgery training. Additionally, they offer a quicker operative
time, thus making them an option for nearly any patient, regardless of age and medical comorbidities.
They also spare underlying musculature and vasculature, preserving in-line flow and therefore minimize
morbidity.

The purpose of this article is to review the historical evolution and development of pedicled-perforator
flaps for reconstruction in the lower extremity. Case examples are presented to illustrate the use of different
flaps for coverage in the lower extremity.

VASCULAR TERRITORIES
Defining the vascular territories of the lower extremity has helped greatly in safe flap design.
Fasciocutaneous flaps based on random pedicles for lower extremity reconstruction demonstrated high
[4]
necrosis rates of up to 25% . With the careful anatomic study of cutaneous arteries and the emergence
of the “angiosome” concept , axial flaps were described all over the body. Some of this early work was
[5]
[6]
performed by Salmon , who in 1936 published his work on cadavers, mapping the entire cutaneous
circulation. Taylor and Pan specifically evaluated the angiosomes of the leg. They determined that source
[7]
vessels to the skin arise directly from arteries or their muscular branches, piercing the deep fascia in
longitudinal rows at the intermuscular septum or alongside tendons. They also noted interconnections
between vascular territories, and that, as vessels traveled down the leg, the perforators made a more direct
course for the skin. Ultimately, they defined the territories of the popliteal, posterior tibial, peroneal, and
anterior tibial arteries.

The introduction of perforasome theory further increased possibilities for flap design by introducing
the concept of perforator flaps. This began with the deep inferior epigastric perforator flap described by
[8]
Koshima and Soeda , but many other flaps were subsequently described. There were many attempts to
[10]
define perforator flaps . Finally, in 2002, the Gent Consensus was published, defining what a perforator
[9]
[11]
flap was, standardizing terminology, and offering examples. Saint-Cyr et al. defined the territories
of perforators through an anatomic cadaveric study studying flaps over different territories. Flaps were
injected with methylene blue dye for the dissection. Once the perforator was identified, contrast was
injected to perform CT scans. Direct and indirect linking vessels were noted between perforasomes. Based
on their anatomic study, they recommended that flaps should be designed in direction of linking vessels,in
an axial direction.

The design and reliability of the perforator flap depends on the location of the perforating vessels and
number of vessels included in the flap. Perforator flap design begins with understanding the anatomy based
on the territories described above.

Perforator territories in the lower extremity
Posterior tibial perforators
The posterior tibial artery is the continuation of the popliteal artery as it exits the popliteal fossa and is
the largest terminal branch. It extends in an oblique and inferior direction into the lower leg, behind the
tendinous arch of the soleus, spending the majority of its course behind the tibialis posterior after it gives