RECONSTRUCTIVE SURGERY

The Distally Based Peroneus Brevis Flap

The 5-Step Technique
Luigi Troisi, MD, FEBOPRAS,*† Thomas Wright, FRCS (Plast),* Umraz Khan, FRCS (Plast),*
Ahmed T. Emam, FEBOPRAS,* and Thomas W.L. Chapman, FRCS (Plast)*

Abstract: The peroneus brevis flap was first described as proximally based by
Mathes et al (Surg Clin North Am. 1974;54:1337–1354) and later by Jackson
and Scheker (Injury. 1982;13:324–330). A distally based version of this flap by
Mathes and Nahai (Reconstructive Surgery: Principles, Anatomy and Technique.
1997:1437e46) was subsequently described in 1997. The first case series of distally
based flaps was published by Eren et al (Plast Reconstr Surg. 2001;107:1443–1448).
In our experience, the distally based flap is a useful muscle flap to reconstruct
small defects in the lateral distal third of the leg. Initial interest and confidence
in the use of this flap in our unit were hindered by lack of direct experience
and descriptive detail in the literature. We have now developed a systematic ap-
proach to harvest the distally pedicled peroneus brevis muscle flap in 5 reproduc-
ible, safe steps. This has allowed the flap to become adopted as a standard
technique of limb reconstruction in our unit with no cases of flap loss.
Key Words: reconstructive surgical procedures, lower extremity, pedicled flap
(Ann Plast Surg 2017;00: 00–00) FIGURE 1. Case 3, superficial branch of the peroneal
nerve (arrows).
T he peroneus brevis flap is a muscle flap harvested from the lateral
compartment of the leg. It was first described as a proximally based
flap1 and then as a distally based flap.2,3 The peroneus brevis muscle, The patient leg is prepped, and the sterile drapes are applied. The
according to the Mathes and Nahai classification,4 was classified as a dissection of the flap is performed under tourniquet control.
type II (dominant pedicles plus minor pedicles) to be then reclassified The 5 steps:
as a type IV (segmental vascular pedicles).5 It is a thin muscle in the lat- 1. The incision line is marked as a lazy S on the palpable surface of the
eral compartment of the leg that lies on the lateral surface of the fibula, fibula. Skin flaps are raised with the deep fascia, and care is taken to
originating from the lower third of the fibula, distal and deep to the protect the superficial branch of the peroneal nerve. This is found
peroneus longus, to insert on the base of the fifth metatarsal. It acts with just deep to the deep fascia in the proximal calf and pierces the deep
the peroneus longus to evert the foot. The vascular supply is from per- fascia around 15 cm proximal to the lateral malleolus (Fig. 1).
forator vessels from the peroneal artery and veins and anterior tibial ar- 2. The peroneus longus and brevis are identified. This is facilitated by
tery and veins5–7; it is innervated by the superficial peroneal nerve. The finding the 2 tendons distally. The longus tendon is more posterior
morbidity to the donor site is very low when the peroneus longus is left and superficial (Fig. 2). Tracing the tendons towards the muscle at-
intact, with almost no functional impairment.8–10 In this paper, we show tachments proximally allows the muscle bellies of the longus and
our technique to harvest this flap. It is a 5-step technique that allows safe brevis to be easily identified and separated, revealing the lateral sur-
harvesting owing to a reproducible approach. We believe that this ap- face of the fibula between them. Branches of the peroneal vessels
proach would be useful to others with limited experience of this flap, running posterior to the fibula can be seen to segmentally pierce
who wish to add it to the spectrum of lower limb reconstruction proce-
dures. In our experience, the flap has been useful especially in covering
lateral defects of the ankle, which would otherwise require free flap re-
construction. This is in particular useful for elderly and less fit patients.

IDEA
The dissection of the flap is performed under general anaesthesia
or regional block with the patient supine on the operative table with a
sand bag underneath the ipsilateral hip.

Received May 12, 2017, and accepted for publication, after revision July 29, 2017.
From the *Plastic Surgery Department, Southmead Hospital, North Bristol NHS Trust,
Westbury-on-Trym, Bristol, United Kingdom; and †Department of Plastic and
Reconstructive Surgery, “Sapienza” University, Policlinico Umberto I, Rome, Italy.
Conflict of interest and sources of funding: none declared.
Reprints: Mr. Luigi Troisi MD, FEBOPRAS, Plastic Surgery Department, Southmead
Hospital, Southmead Rd, Westbury-on-Trym, Bristol, United Kingdom. E-mail:
luigitroisi@gmail.com.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/17/0000–0000 FIGURE 2. Case 3, identification of peroneus longus and
DOI: 10.1097/SAP.0000000000001224 peroneus brevis muscles. Tendons identified distally.

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Troisi et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2017

FIGURE 3. Case 3, peroneus brevis muscle isolated. Dissection of the muscle onto the surface of the fibula. A, Muscle elevated off the
fibula surface, vascular branches from the peroneal artery ligated (arrows). B, Pivot point; large vascular branch at the distal third of the
muscle belly (arrow point).

FIGURE 4. Case 3, flap insetted. A, Donor site closure. B, Muscle covered with a split thickness skin graft.

the muscle, and these should be protected. There is usually 1 large
proximal vessel, and 1 large distal vessel, with other smaller vessels
in between (Fig. 3a).
3. The peroneus brevis is detached from the anterior intermusclar sep-
tum onto the anterior surface of the fibula. The entire peroneus brevis
muscle is now isolated (Fig. 3b).
4. The muscle is elevated from the fibula surface, en bloc, with the
periosteum starting proximally and working distally. The vascular
branches arising from the peroneal artery and veins will need to
be ligated as it is raised. The pivot point where raising is stopped
will be at the large distal vascular branch normally found around
2/3 along the muscle belly (Fig. 3b).

TABLE 1. Patient Details, Indications, and Complications

Sex Age, y Defect Location Defect size, cm Indication Complication Follow-up, mo

1 F 35 Right lateral ankle 3  3 (28 cm )
2
Infected metalwork None 13
2 F 46 Right lateral ankle 10  5 (157 cm2) Infected metalwork None 6
3 M 61 Right ankle 7  4 (88 cm2) Right open ankle fracture dislocation None 10
4 M 47 Right ankle 10  3 (94 cm2) Infected metalwork None 8
5 M 72 Right ankle 10  4 (125 cm2) Infected metalwork None 3
6 F 45 Right ankle 8  4 (100 cm2) Infected metalwork Skin graft loss 1.5  1 cm → dressing 5
7 M 42 Left ankle 11  4 (138 cm2) Infected metalwork Skin graft loss 1.5  1 cm → dressing 5
8 M 62 Right Achilles 5  4 (63 cm2) Nonhealing wound None 3
9 F 42 Left ankle 7  3 (66 cm2) Infected metalwork None 2
10 F 35 Left ankle 12  5 (188 cm2) Infected metalwork None 2
11 M 24 Right ankle 8  3 (75 cm2) Infected metalwork None 1

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Annals of Plastic Surgery • Volume 00, Number 00, Month 2017 The Distally Based Peroneus Brevis Flap

FIGURE 5. Case 3, 2 months postoperative follow-up. A, Lateral view. B, Frontal view.

5. Turnover of the flap to cover the defect and cover with split skin graft
(Fig. 4a, b).
There is no requirement for flap monitoring, and the flap is
checked 5 days postoperatively.
RESULTS
Since May 2015, we have used this technique in 11 patients
(Table 1). The average deft size was 102 cm2 (28–188 cm2). All the
flaps have been used to cover defect in the lateral distal third of the
leg (Figs. 4–7), but 1 was used to resurface a nonhealing wound over
the Achilles tendon (Figs. 8, 6). In our practice, when a patient
requires a reconstruction of the lateral distal third of the leg, we
examine the condition of the muscle during debridement and removal
of metalwork (if required). If the muscle looks compromised, we then
opt for a free flap reconstruction.
The mean follow-up is 5 months (range, 1–13 months). We have
had no flap failures; 2 patients have suffered partial loss of the skin graft
that healed with dressings.

FIGURE 6. Case 11. A, Defect. B, Flap insetted. C, Immediate postoperative result.

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Troisi et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2017

FIGURE 7. Case 11, 1 month postoperative follow-up.

All patients have been able to restart their normal activities with
no or minimal restriction.

DISCUSSION
The distally based pedicled peroneus brevis flap is a useful flap
to cover small/middle size defect in the lateral distal third of the leg. It
is a reliable flap with constant anatomy; the muscle is classified as type
IV according to the Mathes and Nahai classification.4 McHenry et al11
in 2001 have published an interesting anatomical study showing that
each dissected muscle had an average of 3.5 vascular pedicles. In this
article, they also presented a case series in which a proximally based
peroneus brevis flap has been used to cover defects in the distal third
of the leg. In 2013, Bajantri et al12 published their experience with the
peroneus brevis flap, proposing that this muscle should not be classified
as type IV, neither type II, because of the presence of an axial pedicle,
proposing to classify it like a type VI. Based on the anatomical findings
described by Villarreal et al,6 Abd-Al Moktader13 has described “Open-
book Splitting of a Distally Based Peroneus Brevis Muscle Flap to
Cover Large Leg and Ankle Defects.”
The morbidity due to the flap harvesting is very low when the
peroneus longus muscle is left intact.8–10
The flap is thin but robust, providing well vascularized tissue
to cover exposed bone/metal work in the lateral distal third of the
leg (Figs. 5–9). Despite its uses, the flap was not part of our routine
spectrum in reconstruction because of paucity of description in
the literature and lack of experience. We believe this to be a
familiar problem. Our staged approach is logical and safe for those
considering the use of this flap for reconstructive surgery. In
particular, we have found it useful because this flap can be harvested

FIGURE 9. Case 8. A, Defect. B, Flap harvested, forceps

FIGURE 8. Case 8, wound check at day 5. A, Close view. B, indicating the main vessel. C, Flap insetted. D, Immediate
Wide view. postoperative result.

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Annals of Plastic Surgery • Volume 00, Number 00, Month 2017
under regional anaesthesia with an operative time around 90 minutes
and hence suitable in patients with multiple comorbidities rather than
microsurgical reconstruction.
The distally based peroneus brevis flap is a useful flap in selected
patients with small/medium size defect at the lateral aspect of the distal
third of the leg. In our hands, the 5-step technique is a safe, reliable, and
reproducible surgical technique and would recommend it to those who
wish to employ this flap but have limited experience.
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1982;13:324–330.
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tal and clinical correlation. Plast Reconstr Surg. 1981;67:177–187.
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anatomic studies and clinical applications. J Foot Ankle Surg. 2005;44:259–264.
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The Distally Based Peroneus Brevis Flap
6. Villarreal PM, Monje F, Gañán Y, et al. Vascularization of the peroneal muscles.
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micr.22294. Epub 2014 Jul 21.
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