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Page 6 of 9 Horch et al. Plast Aesthet Res 2018;5:26 I http://dx.doi.org/10.20517/2347-9264.2018.25

The surgical procedure is comparatively straight forward and basically safe, when anatomical landmarks
and precautions are taken into account. Although we no longer use the distally based sural fasciocutaneous
flap our group has compared the efficacy and donor site morbidity following use PBF (when compared to
[32]
a sural flap) which had not been studied earlier . Using the foot and ankle outcome score (FAOS) a direct
comparison between the sural flap and the peroneus flap group did not show significant differences in any of
[36]
the FOAS subscales . Interestingly, the general quality of life (QOL) in patients with distally based flaps was
more reduced in both groups than the actual function in daily living (ADL). In an attempt to exclude the
influence of initial defect-related problems on ankle stability and function, subgroups of patients with defects
caused by open fractures, osteomyelitis or Achilles tendon-related defects were compared with defects
[36]
secondary to tumor resection or ulcers . The results from the patient-administered FOAS questionnaire
were confirmed by the physical examination which did not identify any significant differences in terms of
[36]
ankle joint stability or range of motion .

Ulrasonic investigation may further enhance the safety of the procedure. As with other meta-analyses
it is a commonly known problem in studying outcomes in reconstructive surgery, that most series
comprise only small numbers of patients and lack randomized trials, which is a classical scenario in
plastic surgery. This holds especially true for studies comparing different types of flaps, where personal
experience and preferences as well as local conditions significantly influence decision-making and prevent
randomization [9,36] . The use of near infrared laser angiography with indocyanine green intraoperatively
might help further optimize the design and flap survival, as has been shown previously in other flaps [14,74] .

In conclusion, distally based peroneus brevis flaps remain valuable options for the reconstruction of full
thickness defects in the distal lower leg when the routine use of free flaps is not indicated. Vascular integrity
of the affected leg is a prerequisite, and if local perfusion is compromised by peripheral vascular disease,
failure rates are higher. In such cases we strongly advocate the use of free flaps with vascular reconstructions
and optimization of blood flow. Studies have shown that harvesting of PBF does not affect stability and ROM
of the ankle joint.

Whenever free flaps are not the first choice in distal lower leg reconstructions we therefore would recommend
the peroneus brevis muscle flap as an alternative procedure to close small to medium sized defects at the distal
tibia, fibula, ankle and heel.

DECLARATIONS
Acknowledgments
[36]
Some of the results have been part of Silke Brockmann’s doctoral thesis and have been published previously .

Authors’ contributions
Performed operations, wrote the manuscript draft, literature research, and corrected versions: Horch RE
Performed operations, helped analyze results and worked on the manuscript: Ludolph I, Schmitz M, Boos
AM, Kneser U, Beier JP, Arkudas A

Availability of data and materials
Results are reported in the manuscript, patient´s individual data are not available to the public for the sake of
data protection laws.

Financial support and sponsorship
None.

Conflicts of interest
All authors declare that there are no conflicts of interest.