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Page 2 of 9 Horch et al. Plast Aesthet Res 2018;5:26 I http://dx.doi.org/10.20517/2347-9264.2018.25

the peroneus brevis muscle flap can also be seen as a valuable tool to reconstruct small to medium sized defects at
the ankle, distal tibia, and the heel with an acceptable donor site morbidity. Despite the easily available variety of free
flaps to achieve this purpose, still proper indications remain where a local flap can be a viable option in the hand of
experienced plastic surgeons. However, caution is advisable in patients with peripheral arterial occlusive disease or
venous insufficiency.

Keywords: Free flaps, peroneus brevis, muscle flap, lower extremity reconstruction

INTRODUCTION
Soft tissue defects-with or without bone defects or exposed hardware-in the lower extremity, ankle and the
foot often require coverage with vascularized flaps. Due to the anatomically given thin layer of soft tissue to
cover vital structures and the oftentimes limited blood supply, the amount of locally available skin is very
limited.

Free flaps have become a routine procedure and are a superb option in many cases, especially when large and
complex defects need to be addressed. A variety of available options have been described for this problem
zone [1-15] . However, when either the local conditions or other obstacles including systemic diseases, that limit
an extended operation time or missing microsurgical expertise are hindrances to closure, local flaps may be
a solid option. Proximally based pedicled local flaps have a limited arc of rotation and therefore are no good
candidates to reconstruct defects in the lower third of the leg, ankle or foot. We describe the use of a distally
based peroneus brevis flap for indications where free flaps were not suitable or not deemed the first priority.

In such cases distally based muscle and fasciocutaneous flaps have constantly remained an interesting
alternative to free flap surgery. While the distally based peroneus brevis muscle flap (PBF) was first reported
[16]
by Donski and Fodgestan , it became more popular when Masquelet described the surgical procedure in
[18]
[17]
detail based on of his anatomical findings and by Lyle and Colborn . In our clinical routine it has been
implemented as a workhorse for reconstructing small full thickness defects in the distal lower leg, ankle
and heel [19-24] . Later papers added their experiences and highlighted the key points that need to be taken into
[25]
[26]
account McHenry et al. and Eren et al. .
Because the anatomy is relatively constant this flap can be quickly and reliably harvested and the donor site
poses no relevant clinical or functional problem. This flap has therefore been successfully applied by various
authors to reconstruct the distal lower leg, ankle and Achilles region [4,27-29] . We discuss the peroneus brevis
flap as a part of the surgical armamentarium and hence its specific technical aspects in this paper.

METHODS
[30]
According to the description of Nahai and Mathes who had first reported the peroneus brevis flap as a
proximally based tool in 1974 later on described a distally based version in 1997, we performed the distally
[26]
[18]
based turnover muscle flap. Modifications and standardization of this flap were popularized by Eren et al.
and further propagated by others as a useful muscle flap to reconstruct small defects in the lateral distal
third of the leg [4,31-34] .

In our series the peroneus brevis flap was raised as a reversed muscle flap and, following transfer into the
defect, covered with a split thickness skin graft. Donor sites were closed directly in all flaps . Similar
[35]
to patients with sural flaps, wounds were preconditioned using topical negative pressure with or without
instillation until the wound was deemed clean enough for closure. Dissection of the flap was performed
under general anaesthesia with the patient supine on the operative table and a tourniquet was applied. The
incision was performed straight or slightly curved depending on the localization of the defect. Preserving