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Cohen-Shohet et al. Plast Aesthet Res 2019;5:28 I http://dx.doi.org/10.20517/2347-9264.2019.030 Page 3 of 13
[12]
off the peroneal artery . Distally, it is located posterior to the medial malleolus and is divided into the
medial and lateral plantar arteries. The posterior tibial artery supplies the posterior compartment of the
leg.

The perforators from the posterior tibial artery are most commonly septocutaneous - between the flexor
[13]
digitorum longus and the soleus muscle . These perforators, concentrated at the middle third of the lower
leg, are some of the largest of the entire lower extremity [12-15] . They are most readily identifiable 10-12 cm
above the medial malleolus. However, flap design can occur anywhere up to 10 cm distal to the popliteal
crease [16-18] .

Historically, flaps based off the posterior tibial system included sacrifice of the main artery. The use of a
[19]
perforator flap with preservation of the main vessel was described by Koshima et al. , and its popularity
quickly increased.

Peroneal Artery perforators
The peroneal artery takes its course off of the posterior tibial artery. From there, it descends through the
[12]
posterior compartment of the leg, next to the posterior intermuscular septum . Peroneal perforators,
although not as numerous, remain another reliable vascular supply to a perforator flap. The perforators are
[18]
located at the middle third of the fibula and are easily found with a Doppler. Schaverien et al. found that
musculocutaneous perforators emerge proximally from within the soleus or the peroneus longus muscles
and septocutaneous perforators between the flexor hallucis longus and peroneus brevis muscles. Most of
these perforators were found to emerge 13-18 cm proximal to the lateral malleolus. Distally, they found that
[18]
these perforators often emerge superficial to the Achilles tendon .
Anterior tibial perforators
The last main vascular territory to the lower extremity is supplied by the anterior tibial artery. The anterior
tibial artery begins at the inferior border of the popliteus muscle. It passes anteriorly through a gap in the
interosseus membrane and descends on the anterior surface of the membrane between the tibialis anterior
[11]
and extensor digitorum longus . It provides the blood supply to the anterior compartment of the leg. The
major perforators from the anterior tibial artery are located proximally - documented 21-26 cm proximal
to the intermalleolar line between the tibia and the tibialis anterior muscle [14,16] . These also happen to be the
largest perforators. There is also a series of smaller perforators that emerge 4-9 cm above the intermalleolar
[20]
line between the tendons of the anterior compartment; these supply the skin over both malleoli .

FLAP DESIGN
While identification of appropriate vasculature was an important step in the evolution of perforator flaps
of the lower extremity, flap design has also played a large role in the evolution of these flaps (including the
need for vascular territories to be studied).

V-Y perforator flaps
V-Y flaps have been designed and utilized for reconstruction over the face, trunk, and extremities.
Although first described based on a random pattern blood supply, they can also be designed along a single
perforator. This increases the reach of the flap as well as the mobility when the flap is isolated on a single
perforator. The primary benefit of the flap is decreased morbidity at the donor site, which in most cases can
be closed primarily.

The flap is designed so that the length is twice the diameter of the defect to accommodate for longitudinal
advancement [19,20-22] . A perforator can be selected via doppler location preoperatively. The skin,
subcutaneous tissue, and muscle fascia are incised.