Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application

Abstract

Background The posterior tibial artery perforator (PTAP) flap is a useful tool for reconstruction of soft tissue defects in the leg. However, the size and reliability of the flap largely depends on the quality of the perforator by which the flap is supplied, and the sensory recovery of the flap is limited. In this study, the anatomy of the saphenous nerve branches and their accompanying vessels was investigated, and a free extended PTAP flap with the neurovascular plexus of a saphenous nerve branch was designed for large soft tissue and sensory reconstruction in a series of clinical cases. Methods Sixteen adult cadaveric legs perfused with red latex in the femoral artery were dissected. The number and location of the saphenous nerve branches and the features of their accompanying vessels were dissected and studied. From January 2016 to December 2017, six patients with soft tissue defects ranged from 8 × 2.5 cm to 21 × 4 cm were repaired by the free extended PTAP flap. The patients' average age was 48 years. The causes of the defects included machine injuries in three patients and traffic injuries in the other three. The defects located at the hand in three cases, foot in two cases, and ankle in one case. The flap was designed based on the perforators of the posterior tibial artery and included a branch of saphenous nerve. The perforator pedicle and the nerve branch were connected to the vessels and nerve in the recipient site, respectively. Results The saphenous nerve gave off 5.8 ± 1.1 branches, with a relatively constant one issuing 8.1 ± 0.7 cm distal to the medial femoral condyle. Every nerve branch had an accompanying vessel, which connected with the PTAPs and supplied the skin. The size of the flap ranged from 10 × 3.5 cm to 23 × 5 cm. All of the flaps survived completely without complications. Follow‐up varied from 6 to 12 months. All the patients obtained cold/hot sensation and pain sensation. The results of Semmes–Weinstein monofilament test ranged from 4.31(2 g) to 5.46 (26 g), and the 2‐point discrimination test varied from 20 to 35 mm. Conclusion The free extended PTAP flap, containing the saphenous nerve branch and its accompanying vessels, may be an alternative for large soft tissue reconstruction with improved sensation recovery.

Comparison between free posterior tibial flap and free radial forearm flap for head and neck reconstruction: an anatomical study and a retrospective comparative cohort study

“…However, no practical significance could be made of the 1 mm difference in thickness, while a 5 cm longer pedicle length could lead to a practical change in application. The number of perforators in the FPRF group was 2.5±1, which is consistent with other reports ( 10 , 22 , 23 ). The perforators of the radial artery were both numerous and thin, as shown in Figure 1 , and thus, were neither counted nor measured.…”

“…Therefore, theoretically, the blood supply risks of FPTF were lower than those of FRFF. Furthermore, no ischemic necrosis of the foot caused by flap harvesting was observed in this study and previous reports (10,11,22,27).…”

Simultaneous reconstruction of septic composite defects in lower extremities: Combination of fasciocutaneous perforator flap and Masquelet technique

“…Furthermore, if taken sensory recovery into consideration, the results were still debatable. The neurocutaneous perforator flap might also have a better outcome according to our previous study ( 22 ). Meantime, sensory recovery of ALT was also proven to have a nice result ( 23 ).…”

Effectiveness of Retrograde Wide Pedicle Double-Blood Supply Flaps from the Medial Lower Leg in Reconstructing Foot and Ankle Soft Tissue Defects

“…In the lower third of the calf, several anastomotic branches of the posterior tibial artery accompany the saphenous nerve in both anterior and posterior directions. These anastomotic branches connect with the peripheral and intrinsic vascular systems of the saphenous nerve, forming a multi-source, chain-like network of saphenous nerves and blood vessels 20,21 .…”

“…The dual blood supply sources from the posterior tibial artery perforating branch and the saphenous nerve nutrient vessels are retained, expanding the blood supply range of the posterior tibial artery perforating branch. This approach allows the skin ap to be elevated to a higher plane, ensuring adequate blood circulation and enabling the repair of large wounds in the lower leg and foot-ankle circumference 20,23 .…”