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Original Article

ARMS

pISSN 2383-5257 eISSN 2288-6184
Arch Reconstr Microsurg 2016;25(2):37-42
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Archieves of Reconstructive Microsurgery

Close-by Islanded Posterior Tibial Artery Perforator Flap:
For Coverage of the Ankle Defect
Sujin Bahk, SeungHwan Hwang, Chan Kwon, Euicheol C. Jeong1, Su Rak Eo*
Department of Plastic and Reconstructive Surgery, Dongguk University Ilsan Medical Center, Goyang,
1
Department of Plastic Surgery, SMG-SNU Boramae Medical Center, Seoul, Korea

Received April 24, 2016
Revised July 31, 2016
Accepted August 17, 2016
*Correspondence to: Su Rak Eo
Department of Plastic and Reconstructive
Surgery, Dongguk University Ilsan Medical
Center, 27 Dongguk-ro, Ilsandong-gu,
Goyang 10326, Korea
Tel: +82-31-961-7342
Fax: +82-31-961-7347
E-mail:
ORCID: />Financial support: None.
Conflict of interest: None.

Purpose: Soft tissue coverage of the distal leg and ankle region represents a surgical

challenge. Beside various local and free flaps, the perforator flap has recently been replaced
as a reconstructive choice because of its functional and aesthetic superiority. Although
posterior tibial artery perforator flap (PTAPF) has been reported less often than peroneal
artery perforator flap, it also provides a reliable surgical option in small to moderate sized
defects especially around the medial malleolar region.
Materials and Methods: Seven consecutive patients with soft tissue defect in the ankle
and foot region were enrolled. After Doppler tracing along the posterior tibial artery, the
PTAPF was elevated from the adjacent tissue. The average size of the flap was 28.08±9.31
cm2 (range, 14.25 to 37.84 cm2). The elevated flap was acutely rotated or advanced.
Results: Six flaps survived completely but one flap showed partial necrosis because of
overprediction of the perforasome. No donor site complications were observed during the
follow-up period and all seven patients were satisfied with the final results.
Conclusion: For a small to medium-sized defect in the lower leg, we conducted the closeby islanded PTAPF using a single proper adjacent perforator. Considering the weak point
of the conventional propeller flap, this technique yields much better aesthetic results as a
simple and reliable technique especially for defects of the medial malleolar region.
Key Words: Surgical flaps, Perforator flap, Posterior tibial artery, Ankle

INTRODUCTION
Reconstructive surgical soft tissue coverage of the distal leg
and ankle region is a challenge due to paucity of adjacent soft
tissues. Although conventional local flaps such as sural flap or
free flap could be safely used with good results, surgeons have
to consider the donor site morbidity while choosing the best
reconstructive option for the patients.
Nowadays, with wide application of perforator flaps in
lower leg reconstruction, we can mainly rely on the perforators
from the three main lower leg arteries: posterior tibial artery
perforator (PTAP), peroneal artery perforator (PAP), and

anterior tibial artery perforator (ATAP). Among them, PAP flap

(PAPF) and PTAP flap (PTAPF) are most commonly used for
the reconstructions and the PAPF use has been reported twice
as much as that of PTAPF.1 When considering the various
anatomical advantages of PTAP over PAP, the option for
applying PTAPF should not be overlooked.
Islanded propeller flap has become the method of choice
for reconstruction of the distal lower leg defects since its
introduction in 1991 by Hyakusoku et al.2 This conventional
propeller form also has a shortcoming aesthetically in that it
leaves a long scar on the proximal lower leg. However, island
flap elevated from just next to the defect, though it may not be

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Copyright © 2016 by the Korean Society for Microsurgery. All Rights Reserved.
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38

None
Tibia
17.02
6.93
Medial malleolar area
Traffic accident

59
7

Male

None

None
Tibia

Metal hardware and tibia
26.37

30.71
9.45

11.46
Medial malleolar area

Medial malleolar area
Wound infection

Traffic accident
Male

Male

56

50

6

45

5

Partial venous congestion

None
Achilles tendon

Metal hardware and tibia
35.79

34.58
12.10

10.33 with adjacent skin defect
Medial malleolar area

Achilles tendon (heel)
Burn injury

Traffic accident
59

4

Male

None

3

Female

Achilles tendon

Extensor hallucis longus
37.84

14.25
4.29

14.70
Anteromedial lower tibial area

Achilles tendon (heel)
Traffic accident

Traffic accident

29

Location of defect
Cause of injury
Sex

Male
58

Seven cases of islanded PTAPF were performed. Mean
operation time was 79 minutes. Size of the flaps varied from

Patient No. Age (yr)

RESULTS

Table 1. Summary of the patient characteristics

Preoperatively, perforators of the posterior tibial artery
(PTA) near the defect were marked on the skin with handheld Doppler. The patient was positioned in supine position
and a temporary elliptical design was made around the medial
malleolar region near the defect. A pneumatic tourniquet was
cautiously placed around the thigh to prevent excess bleeding.
Under loupe magnification, the margin of the flap closer to the
defect was raised first and dissection proceeded in a suprafascial
plane while paying attention to the expected location of the
traced perforator. Once a suitable perforator was found, the
flap was again designed adjacent to the defect while the main
perforator was located at the center of the flap. Designed outline
of the flap was incised and islanded on the selected perforator.
Excessive skeletonization of the perforator was avoided and
moderate intermuscular dissection was performed to obtain
adequate release and additional length. After complete elevation
of the flap, perfusion within the flap was evaluated and it was
rotated randomly according to the defect. Secondary defects
were covered with split thickness skin graft in two cases and
closed primarily in one case.

Defect size (cm2)

Surgical technique

1

Flap dimension (cm2)

Exposed structure

Seven patients underwent islanded PTAPF between 2013
and 2014. Surgical indication was limited by size and location
of the defect. Only small to moderate-sized defects around
the ankle area, especially medial malleolar region and achilles
tendon-exposed region were selected for this flap technique.
Angiography was performed before the reconstruction to
exclude vascular anomalies. Patient details are summarized in
Table 1.

2

MATERIALS AND METHODS

Male

Complication

suitable for large defects, can show much better aesthetic results
when covering small to moderated sized defects. Accordingly
we suggest a simple and reliable method using a small islanded

PTAPF close by the defect as ideal for the reconstruction of
relatively small distal leg and ankle defects.

Minimal wound dehiscence

Arch Reconstr Microsurg Vol. 25. No. 2. November 2016


Sujin Bahk, et al. Posterior Tibial Artery Perforator Flap

14.25 to 37.84 cm2. Average size of the flap was 28.08±9.31
cm2. Out of 7 flap donor sites, 4 were repaired by primary
closure and 3 were repaired with skin grafting. Small marginal
wound dehiscence was present in Case 2 and it was managed
with simple re-suture. Complications like osteomyelitis or
soft tissue infection were not encountered. However, patient
in Case 3 developed partial flap necrosis due to venous
congestion, which was managed with subsequent debridement
and local transposition flap. Short leg splinting was maintained
for 3 weeks and then ambulation was started. No other flap
complications were encountered and patients were satisfied
with the final results.

Case 1

A 58-year-old man developed a 14.70 cm2 soft tissue defect

A

with exposure of the extensor hallucis longus tendon after

repetitive course of cellulitis (Fig. 1A). Debridement was
performed and the defect was covered with a 37.84 cm2 island
PTAPF that was elevated and 60-degree rotated. Secondary
defect was covered with split thickness skin graft (Fig. 1B, C).

Case 2
A 29-year-old man was referred to our department due
to the soft tissue defect of the posterior ankle. He had been
injured in a traffic accident and Achilles tendon of the left ankle
was ruptured. He was treated in a local clinic by repetitive
tenorrhaphy and primary closure. But the wound dehiscence
progressed resulting in a 4.29 cm2 sized defect (Fig. 2A). A
14.25 cm2 sized PTAPF was elevated from a near site and
advanced posteriorly to cover the defect (Fig. 2B). A branch of

B

C

D

Fig. 1. A case of anterior ankle defect. (A) Ankle defect with exposure of extensor hallucis longus tendon. (B) Perforator from posterior tibial artery (arrow).
(C) Immediate appearance after surgery. (D) Appearance of 3 weeks after surgery.

A

B

C

D

E

Fig. 2. A case of posterior ankle defect. (A) Defect with exposure of the Achilles tendon. (B) Perforator from posterior tibial artery (arrow). (C) Close-by
flap is advanced posteriorly and a branch of the small saphenous vein is preserved. (D) Immediate appearance after surgery. (E) Appearance of 3 weeks
after surgery.
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Arch Reconstr Microsurg Vol. 25. No. 2. November 2016

the small saphenous vein was preserved during the dissection
for the augmentation of venous drainage (Fig. 2C). Secondary
defect was closed primarily without additional skin graft (Fig.
2D).

mobility. It also provides for a like-for-like tissue in color, texture
and thickness that is very similar to the missing tissue. For the
technique, we simply search for suitable perforators in close
proximity to the defect in the foot and ankle region and we
describe as being “close-by”. Harvesting the local perforator flap
requires microsurgical dissection, however, it does not require
vascular anastomosis and can be defined as a microsurgical
non-microvascular flap.7
In the lower leg and ankle region, perforators of the main
three arteries, anterior tibial artery (ATA), PTA, and peroneal
artery, can be chosen according to the defect site. This might aid

in the design of pedicled perforator flaps of the lower leg as the
most clinically useful one in each case. Gir et al.1 systematically
reviewed the pedicled-perforator flaps in the lower extremity
defects and noted that the PAPF and the PTAPF were the most
frequently used flaps. However, compared to the PAPF, PTAPF
has rarely been reported in the literature until now. This is
assumed to result from the fact that lateral aspect of lower leg
is more frequently injured or ulcerated than the medial aspect,
or that there is the bias of surgeon’s relative familiarity of fibular
bone free flap. Because ATA perforators are clustered in the
proximal rather than the distal segment of the lower leg, ATAPF
has been rarely used in the lower leg and ankle reconstructions.8
Schaverien and Saint-Cyr9 analyzed the locations of the
reliable perforators from the three main arteries in the lower
leg and found that those of the PTA were distributed evenly
compared to the other two arteries. PTA perforators are

Case 3
A 59-year-old woman was referred to our department with
a 10.33 cm2 sized soft tissue defect accompanying exposure
of the metal fixator after the surgery for an open tibial fracture
(Fig. 3A). The defect had been previously managed with
PAPF but partial necrosis was encountered. After the course
of debridement and conservative treatment, conventional
propeller flap based on PTAP was planned. Longitudinal, 35.79
cm2 sized flap was elevated in a suprafascial plane from her
middle lower leg and 120-degree rotated to cover the defect (Fig.
3B). Secondary defect was covered with split thickness skin
graft (Fig. 3C). However, partial flap necrosis was encountered
and this was managed with local transposition flap afterwards.

DISCUSSION
Since Taylor 3 introduced the concept of angiosomes,
various techniques of perforator based local flaps in the leg
have been developed.4-6 Main advantage of this procedure
over the conventional flap resides in the preservation of the
source vessel, high mobility and minimal donor site morbidity,
avoiding the debulking procedure and maintaining high

A

B

C

D

Fig. 3. Ankle defect with metal fixator exposure. (A) Ankle defect with exposure of the metal fixator. peroneal artery perforator flap had been
performed previously. (B) Flap is elevated based on a perforator of the posterior tibial artery (arrow). (C) Immediate appearance after surgery. (D)
Appearance of 6 months after surgery.

40


Sujin Bahk, et al. Posterior Tibial Artery Perforator Flap

found to be the largest of the lower leg and easier to dissect
compared to the PAP. They are predominantly septocutaneous,
arising from within the intermuscular septum between soleus
and flexor hallucis longus.10 Ozdemir et al.11 also performed

comprehensive cadaver studies to conclude that distal lower leg
is suitable for PTAPF elevation because PTA perforators are
larger and concentrated in the lower leg and ankle region which
they categorized zone I and II. Moreover, Jakubietz et al. 12
recently described that the PTA perforator was most favorable
as source vessel due to its constant subfascial directionality,
which is almost always about 90~100 degrees. The PTA
perforators are connected in an axial network and this enables
the surgeon to raise large flaps reported up to 19×13 cm.5,13
In terms of location, the largest PTA perforators are clustered
in the middle third, at 6 to 8 cm and 10 to 12 cm from the tip
of the medial malleolus, and the flap can be reliably harvested
within 10 cm of the popliteal crease.14 On this anatomical basis,
propeller flap based on the perforators of the middle clusters has
been widely studied and used clinically. However, conventional
islanded-propeller type of flap leaves a long scar on the
proximal lower leg and these results in rather unsatisfactory
aesthetic outcome and the possibility of venous congestion
followed by partial necrosis always exists. We also experienced
partial flap necrosis after venous congestion in Case 3. This was
assumed to be caused by suprafascial elevation design of the
flap over the perforasome and kinking of the pedicle. Though
it is unclear which factors matter most, this provides a lesson
that if tendon, bone or hardware is exposed, it is important to
include maximal amount of fascia in the proximal portion of
the flap when elevating a conventional propeller flap. Therefore,
the best method is covering the defect with very near tissue and
this means focus should be changed to the distal perforators.
Fortunately, though the largest perforators are clustered in
the middle third, septocutaneous form of perforators, which

are relatively large and easy to dissect distally. They can be
adequately used for coverage of complex defects of the heel,
medial malleolus and Achilles tendon as in our cases. We simply
searched suitable perforators very near the defect, which we
described as “close-by” above.
Once a suitable perforator was found, the flap was designed
again as Robotti et al.15 described as “on demand” considering
the arc of rotation and location of the defect. If a proper
perforator was not encountered, initial island flap scheme was

abandoned and alternative random pattern transposition flap
could be attempted. This situational progressing provides a
guarantee against risk though needs surgeon’s experience.
As Taylor and Palmer16 divided septocutaneous perforators
of the lower leg into three groups of medial, anterolateral,
posterolateral, most medially located defects can be effectively
reconstructed by using PTAP. However, the position and caliber
of perforators are highly variable between individuals and are
often asymmetric even within the same individual. If ATAP
or PAP is superior to the PTAP, medial defects can be covered
using them, location permitting. Accordingly, preoperative
imaging study such as high-resolution computed tomography
angiography or magnetic resonance angiography should be
preceded to exclude patients with anatomic variations and to
establish a surgical plan.
PTAPF is an anatomically excellent option though it is
occasionally overlooked due to its low frequency of use
compared to the PAPF. Close-by islanded perforator flap form
has many advantages for the small to moderate-sized defect of
the medial malleolar region compared to the previous methods.

In addition to the advantages of the perforator flap such as
minimal donor-site morbidity, preservation of the main vessel
which supplies to the foot, excellent color, texture and thickness
match, it is aesthetically appealing. Close-by islanded PTAPF
does not just provide more choice alternatives but it also gives
an ideal solution for the small to medium-sized complex defect
of the ankle, especially in the medial malleolar region.

CONCLUSION
Posterior tibial artery perforator based propeller flaps is one
of the most useful methods for repairing soft tissue defect or
chronic wound in the medial malleolar area and in heel around
ankle. It carries minimal donor site morbidity, and is a relatively
simple surgical technique rather than a microsurgical free flap,
and it conforms to replacement of tissue using “like-for-like”
principles.

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Arch Reconstr Microsurg Vol. 25. No. 2. November 2016

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