RECONSTRUCTIVE

Descending Branch of the Perforating Branch

of the Peroneal Artery Perforator–Based Island
Flap for Reconstruction of the Lateral Malleolus
with Minimal Invasion
Shinsuke Akita, M.D.
Nobuyuki Mitsukawa, M.D.,
Ph.D.
Naoaki Rikihisa, M.D.,
Ph.D.
Juni Himeta, M.D., Ph.D.
Yoshitaka Kubota, M.D.,
Ph.D.
Natsuko Shimada, M.D.
Hideki Tokumoto, M.D.
Takane Suzuki, M.D., Ph.D.
Kaneshige Satoh, M.D.,
Ph.D.
Chiba City, Japan
Background: Reconstruction of intractable ulcers on the lateral malleolus is
challenging because affected patients suffer various complications. A lateral
supramalleolar flap, nourished by the superficial cutaneous branch of the
perforating branch of the peroneal artery, has been described as one of the
most reliable methods for reconstructing this difficult region. Although the
deep descending branch of the perforating branch of the peroneal artery
has a tiny cutaneous perforator, a flap based on this perforator has not been
described.
Methods: The vascular anatomy of an island flap based on the descending
branch perforator of the perforating branch of the peroneal artery was in-
vestigated using 20 cadaver legs. Distances from the lateral malleolus and the
external diameters were investigated. Based on the anatomical study results, a
perforator–based island flap was developed for clinical use and implemented
in five cases.
Results: The anatomical study revealed the descending branch perforator di-
ameter to be smaller than the superficial cutaneous branch diameter, and the
location to be considerably closer to the lateral malleolus. All five island flaps
used clinically survived without complications.
Conclusions: A new perforator-based island flap of the descending branch of
the perforating branch of the peroneal artery for reconstruction of the lateral
malleolus was designed. The territory covered by the flap could be enlarged
by including the adjacent angiosome area of the superficial cutaneous branch.
This flap elevation technique was uncomplicated and sufficiently straightfor-
ward to be used for patients at high risk for complications with extended surgi-
cal procedures. (Plast. Reconstr. Surg. 132: 461, 2013.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

R
econstruction of soft-tissue defects of the
lateral malleolus is a common but chal-
lenging problem. When the fibula or ten-
don is exposed, a microsurgical tissue transfer or
a pedicled flap is required to cover the defect.1
Several types of perforator flaps, including lateral
calcaneal,2 lateral supramalleolar,3–7 reverse pero-
neal,7–9 reverse anterior tibial,10–12 reverse sural,13–15
From the Department of Plastic, Reconstructive and Aesthetic
Surgery and the Department of Bioenvironmental Medicine,
Chiba University, Faculty of Medicine; and the Department
of Plastic and Reconstructive Surgery, Chiba Rosai Hospital.
Received for publication September 7, 2012; accepted October
17, 2012.
Copyright © 2013 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318295885d
and anterolateral malleolar,16 have been applied
in this region. Among these, the lateral supra-
malleolar flap based on the superficial cutaneous
branch of the perforating branch of the peroneal
artery has been considered to be one of the most
suitable methods.3–7 This flap is designed on the
lateral aspect of the lower leg. It is typically used
as a distally based pedicled flap to cover defects of
the lateral malleolus, after which the perforating
branch of the peroneal artery is ligated. This flap
is also used as a rotation flap; however, a very large
flap is necessary to cover the defect of the lateral
malleolus because the pivot point is farther away.
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 461
 Plastic and Reconstructive Surgery • August 2013
Although the deep descending branch of
the perforating branch of the peroneal artery
also has a tiny cutaneous perforator (descend-
ing branch perforator), a flap based on this per-
forator has not been described. Patients with an
intractable ulcer on the lateral malleolus suffer
various problems that inhibit surgical treatments.
Thus, we designed a new perforator-based island
flap based on the descending branch perforator
(descending branch of the perforating branch of
the peroneal artery perforator–based island flap)
to reconstruct this difficult region as uncomplicat-
edly as possible.
We first investigated the location, number,
size, and anatomical angiosome territory of the
tiny perforator emerging from the deep descend-
ing branch of the perforating branch of the
peroneal artery (Fig. 1). Based on the anatomi-
cal study, a descending branch of the perforating
branch of the peroneal artery perforator–based
island flap, which could be elevated easily with
minimum invasion, was designed and developed
for clinical application.
MATERIALS AND METHODS
Anatomical Study
The perforating branch of the peroneal artery
always divides into two branches immediately after
it perforates the interosseous membrane between
the tibia and fibula approximately 5 cm proxi-
mal to the lateral malleolus. There is a superfi-
cial cutaneous branch that runs proximally and
a deep descending branch that runs distally and
connects to the anterolateral branch of the tibi-
alis anterior artery. As presented by Masquelet et
al. in their article describing the lateral supra-
malleolar flap,3 the deep descending branch has
several tiny perforators after the bifurcation. The
descending branch perforator number, loca-
tion, diameter, and territory were recorded and
compared with the superficial cutaneous branch,
which feeds the lateral supramalleolar flap. A total
of 20 fresh human lower limbs were investigated;
10 were injected with blue latex (Microfil; Flow
Tech, Inc., Carver, Mass.) by means of the pero-
neal artery to investigate the perforator number,
location, and diameter. A 20-ml latex injection was
initiated from the peroneal artery and discontin-
ued when the toes became blue. Specimens were
kept at 4°C, and the perforating branch of the
peroneal artery and its branches were dissected
48 hours later. The most distal point of the lateral
malleolus was used as a location benchmark for
the perforators. When more than one descending
462
branch perforator was identified, the most distal
perforator was adopted as the main perforator for
that specimen. The distance from the distal point
of the lateral malleolus to the starting point of
the superficial cutaneous branch and descending
branch perforator and the external diameter of
the artery at the level penetrating the fascia were
measured and compared. The distance between
the perforating branch of the peroneal artery
bifurcation and descending branch perforator
was also measured. In the other 10 cadavers, pat-
ent blue dye was injected into the perforating
branch of the peroneal artery after the superfi-
cial cutaneous branch and distal end of the deep
descending branch were ligated to determine the
anatomical angiosome territory of the descending
branch of the perforating branch of the peroneal
artery perforator–based island flap.
Statistical Analysis
Statistical analysis was performed using IBM
SPSS Version 20.0 (IMB Corp., Armonk, N.Y.).
A Wilcoxon signed rank test was used to deter-
mine whether there were significant differences
between the superficial cutaneous branch and
descending branch perforator with regard to
distance from the lateral malleolus and external
diameter.
RESULTS
Anatomical Study Results
The anatomical study results are listed in Table 1.
One or two descending branch perforators were
identified in all specimens. The median descend-
ing branch perforator diameter was 0.42 mm and
the median superficial cutaneous branch diam-
eter was 0.72 mm. The descending branch perfo-
rator diameter was considerably smaller than the
superficial cutaneous branch diameter (Fig. 2).
The descending branch perforator was located
19 mm closer to the distal point of the lateral mal-
leolus than was the superficial cutaneous branch
(Fig. 3). The subcutaneous connection between
the descending branch perforator and superficial
cutaneous branch consisted of reduced caliber ves-
sels, referred to as choke vessels by Taylor et al.,
which could be detected in all specimens17 (Fig. 4).
The median distance from the superficial cutane-
ous branch to descending branch perforator was
18 mm (range, 14 to 27 mm).
The size of the patent blue–stained area varied
considerably from a minimum of 20 × 42 mm to
a maximum of 32 × 64 mm, with a median of 24 ×
57 mm. The long axis of the stained area followed
Volume 132, Number 2 • Lateral Malleolus Repair

Fig. 1. The general pattern of arterial distribution in the lateral malleolar area. (1)
Peroneal artery (PA) bifurcates into the calcaneal branch and (2) the perforating
branch of the peroneal artery. The perforating branch of the peroneal artery (PBPA)
bifurcates into (3) the superficial cutaneous branch (SCB) and (4) the deep descend-
ing branch (DB). The deep descending branch bifurcates (5) into descending branch
perforator(s) (DBP).

Table 1.  Deep Descending Branch Perforator and Superficial Cutaneous Branch Anatomical Study Results
Median (mm) Range (mm)
External diameter of the DBP 0.42 0.36–0.53
External diameter of the SCB 0.72 0.60–1.02
Distance from the lateral malleolus to the DBP 60 54–68
Distance from the lateral malleolus to the SCB 43 33–48
Distance from the SCB to the DBP 18 14–27
Patent blue–stained area 24 × 60 20 × 42–32 × 64
DBP, descending branch perforator; SCB, superficial cutaneous branch.

the longitudinal direction of the leg and included
the skin at the perforating branch of the peroneal
artery bifurcation in all specimens.
Clinical Application
Between April of 2010 and June of 2011, five
patients who presented with soft-tissue defects of the
lateral malleolar region underwent reconstruction
with descending branch of the perforating branch
of the peroneal artery perforator–based island
flaps. The characteristics of the patients are listed in
Table 2. The causes of intractable skin ulcers were
decubital ulcers in two patients, diabetic ulcers in
two patients, and previous injury to the limb with
open fracture in one patient with diabetes.
Preoperatively, all patients were examined
by color Doppler sonography to confirm the
presence and identify the site of the descending
branch perforator and superficial cutaneous
branch (Fig. 5). The bifurcation of the perforat-
ing branch of the peroneal artery was located
approximately 5 cm above the lateral malleolus.
The deep descending branch coursed forward
and distal until it communicated with the lat-
eral malleolar artery or the lateral tarsal artery.
The cutaneous perforator(s) was probed and
detected along the course of the deep descend-
ing branch. The location of the descending
branch perforator was supposed to be 10 to
30 mm from the perforating branch of the
peroneal artery. The location of the pulsating
descending branch perforator by color Dop-
pler sonography was set as a pivotal point, and
the long axis of the skin paddle was designed
according to the direction of the perforating
branch of the peroneal artery bifurcation. Thus,

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 Plastic and Reconstructive Surgery • August 2013

Fig. 2. The external diameters of perforators measured at the level where

they penetrated the fascia. The descending branch perforator (DBP) diam-
eters were considerably smaller than the superficial cutaneous branch
(SCB) diameters. The median descending branch perforator diameter was
0.42 mm, whereas the median superficial cutaneous branch diameter was
0.72 mm.

the distal part of the skin paddle was designed
on the cutaneous territory of the superficial
cutaneous branch.
When similar operations are performed
under general or spinal anesthesia, a pneumatic
tourniquet is placed on the thigh for better iden-
tification of the vessels. However, it was possible
to perform this operation under local anesthesia
without a pneumatic tourniquet because, except
for the area around the perforator, the deep layer
did not have to be harvested.
The surgical procedure began with an incision
through the flap outline and careful dissection
of the subcutaneous layer to avoid neurovascular
injury. Once the perforators were identified, there
was no need to identify the main feeding arter-
ies or to dissect the perforators under the fascia.
Although the fascia around the perforator was ele-
vated with the flap to avoid needless vascular injury,
this process is not necessary for flap nourishment.
The flap was elevated on the fascia to avoid injury
to the superficial fibular nerve. Although the posi-
tional relationship between nerve and descending
branch perforator varied between different indi-
viduals, the nerve was so thick that it was easy to
preserve. When the superficial cutaneous branch

Fig. 3. The descending branch perforator (DBP) was located 19 mm closer
to the most distal point of the lateral malleolus than the superficial cutane-
ous branch (SCB).

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Volume 132, Number 2 • Lateral Malleolus Repair
Fig. 4. Lateral view of the arterial anatomy associated with the
peroneal artery. 1, Descending branch perforator; 2, superficial
cutaneous branch; 3, a cutaneous perforator adjacent to the
superficial cutaneous branch; 4, bifurcation of the perforating
branch of the peroneal artery; 5, subcutaneous connection
between the descending branch perforator and superficial
cutaneous branch consisting of reduced caliber vessels; 6, the
subcutaneous connection between the superficial cutaneous
branch and the adjacent perforator; 7, lateral calcaneal branch
of the peroneal artery; and 8, superficial fibular nerve.
above the fascia was identified, attention was paid
to avoid injury to the subcutaneous connection
between the descending branch perforator and
the superficial cutaneous branch. The elevated flap
was then transposed and sutured to the recipient
site. The donor site was sutured in three patients,
and skin grafting was performed in two.
Clinical Study Results
The maximum flap size raised in this case
series was 35 × 80 mm. All flaps had stable post-
operative blood circulation and complete survival.
Intraoperative and postoperative complications
such as nerve injuries, wound dehiscence, and
Table 2.  Case Summary*
Case Age (yr) Sex Underlying Disease
1 52 M Diabetes
2 74 F Paraplegia
3 84 F Hemiparesis
4 56 M Open fracture
5 59 M Diabetes
M, male; F, female; STSG, split-thickness skin graft.
*All flaps survived completely; there were no complications.
wound infections were absent. The donor site was
sutured in three patients and skin grafting was
performed in two. The donor-site wound healed
in all cases within 2 weeks of surgery.
The mean follow-up was 6 months (range, 3 to
10 months). The descending branch of the perfo-
rating branch of the peroneal artery perforator–
based island flaps offered stable coverage of the
defects, with no signs of recurrence or related
ulcers. Morbidity of the donor area was minimal.
Scars were well accepted by the patients. No par-
esthesia of the superficial peroneal nerve was
observed.
CASE REPORTS
Case 1
A 52-year-old man sustained a 30 × 50-mm skin defect, infec-
tion, and exposure of the distal fibula in the lateral malleolus of
the right ankle. The patient was diabetic and treated with insu-
lin. Although conservative treatment had been provided to treat
infection in the lateral malleolus, the skin defect grew larger and
the fibula became exposed. Surgery was subsequently performed
under local anesthesia.
Débridement was performed and the defect was covered
with a 35 × 80-mm descending branch of the perforating branch
of the peroneal artery perforator–based island flap. The super-
ficial fibular nerve was detected intraoperatively and preserved.
The donor site was closed partially and a 25 × 50-mm split-thick-
ness skin graft was placed on the residual donor-site defect. The
flap and skin graft survived completely without any complica-
tions (Fig. 6).
Case 2
A 70-year-old woman developed a 20 × 25-mm decubital
ulcer of the lateral malleolus of the right ankle as a result of para-
plegia. Despite conservative treatment, her skin defect did not
decrease over an extended period. Therefore, surgery was initi-
ated under local anesthesia. Débridement was performed and
the defect was covered with a 25 × 50-mm descending branch of
the perforating branch of the peroneal artery perforator–based
island flap. The superficial fibular nerve was detected and pre-
served. The donor site was closed primarily. The flap survived
completely without infection (Fig. 7).
DISCUSSION
Even small ulcerations on the lateral mal-
leolus are sometimes refractory to conservative
Flap Size (mm) Donor Site
35 × 80 STSG
25 × 50 Primary suture
25 × 35 Primary suture
35 × 70 STSG
25 × 65 Primary suture
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 Plastic and Reconstructive Surgery • August 2013

Fig. 5. In clinical cases, all patients were examined by color Doppler sonography before the flap
was designed, to identify the site of the descending branch perforator (DBP) and superficial cutane-
ous branch (SCB) perforator. In this figure, successive still photographs along the course of the deep
descending branch (DB) of the perforating branch of the peroneal artery (PBPA) are conjoined. The deep
descending branch coursed forward and distal. The location of the descending branch perforator was
supposed to be 10 to 30 mm from the perforating branch of the peroneal artery.

management in patients with diabetes, chronic
arterial obstruction, or paralysis. There are six
angiosomes of the foot and ankle originating
from the three main arteries and their branches,
including the two branches of the peroneal artery
that supply the anterolateral portion of the ankle
and rear foot.18,19 Blood flow to the foot and ankle
is redundant because the three major arteries
feeding the foot have multiple arterial-arterial
connections. The deep descending branch com-
municates frequently with the lateral malleo-
lar artery or the lateral tarsal artery, which are
branches of the anterior tibial artery. This system
of communication is the potential basis for reverse
flow into the deep descending branch to sustain
a distally based flap. Although it may not matter
whether a branch of the peroneal artery is ligated
in normal individuals, the circulation of the foot
may be compromised in patients with peripheral
vascular disease or those who have sustained sig-
nificant trauma.
Furthermore, with these surgical methods, as a
result of the dissection of vessels in the deep layer,
it becomes difficult to preserve sensory nerves on
the fascia, and the survival rate of skin grafts at
the donor site can be reduced. These operations
are difficult to perform under local anesthesia.
Patients with intractable ulcers on the malleolus
suffer significant complications such as diabetes,
impaired circulation of the leg, and paralysis. The
risks of general anesthesia or spinal anesthesia in
these patients are not insignificant.
Perforator flaps have been developed as a
less invasive method to deal with these issues.
Koshima et al. described a perforator flap based
on the anterolateral branch of the tibialis anterior
artery and posterolateral branch of the peroneal
artery.16 They emphasized the advantages of the
perforator flap, which include ease of elevation,
short surgery time, and preservation of the major
vessels. However, the disadvantages include the
fact that the donor site often requires a skin graft,
pedicles are short and small, and there are ana-
tomical variations in the localization and caliber
of the perforators. To reduce these disadvantages,
it is important to select a perforator as close as
possible to the defect as the flap pedicle. Although
the descending branch perforator is insignificant
and seems to have been ignored as a pedicle for
the perforator flap, our anatomical study revealed
that it existed consistently in all specimens and
is located considerably closer to the lateral mal-
leolus than the superficial cutaneous branch. The
descending branch of the perforating branch of

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Volume 132, Number 2 • Lateral Malleolus Repair

Fig. 6. (Above, left) A 52-year-old man with a 30 × 50-mm skin defect. (Above, right) A 35 ×
80-mm descending branch of the perforating branch of the peroneal artery perforator–
based island flap elevated above the fascia, with preservation of the superficial fibular
nerve (arrow). (Below, left) The donor site was closed partially and a 25 × 50-mm split-
thickness skin graft was performed on the residual donor-site defect. (Below, right) The
flap and skin graft survived completely without any complications.

the peroneal artery perforator–based island flap
could be designed smaller to cover the defect on
the lateral malleolus, subsequently decreasing
donor-site defects. In our five clinical cases, they
could be sutured up to approximately 25 mm in
width.
According to the results of the anatomical
study with patent blue, the size of the stained area
varied considerably. The stained area did not equal
the anatomical territory of the descending branch
perforator because the stained area included the
skin on the perforating branch of the peroneal
artery bifurcation and a part of the angiosome ter-
ritory of the superficial cutaneous branch in all
specimens. The stained area did not indicate the
survival territory of the descending branch of the
perforating branch of the peroneal artery perfo-
rator–based island flap, because it did not cover
the entire anatomical territory of the superficial
cutaneous branch. The actual flaps elevated in the

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 Plastic and Reconstructive Surgery • August 2013

Fig. 7. (Left) A 70-year-old woman developed a 20 × 25-mm decubital ulcer on the lat-
eral malleolus of the right ankle as a result of paraplegia. (Right) The defect was covered
with a 25 × 50-mm descending branch of the perforating branch of the peroneal artery
perforator–based island flap. The donor site was closed primarily and the flap survived
completely.

clinical cases were larger than the stained area in
the anatomical study. However, it should be noted
that the patent blue spread beyond the subcutane-
ous connection between the descending branch
perforator and superficial cutaneous branch, and
the long axis of the stained area was parallel to
the axis of the limb in all specimens. Saint-Cyr et
al. reported that the vascular territory of each per-
forator is connected by linking vessels, which have
an orientation that is predominantly parallel to
the axis of the limb, based on the results of their
cadaveric study.20 They advocated that perforator
flaps should be designed parallel to the axis of the
linking vessels of the limb to capture the largest
and most reliable vascular territory. Taylor et al.
indicated that individual perforators have their
own anatomical territories, and one adjacent ana-
tomical cutaneous perforator territory in all direc-
tions can be safely captured on the perforator at
the flap base.17 Because the descending branch
perforator diameter is small, the associated ana-
tomical territory may also be small. However,
the superficial cutaneous branch is the adjacent
perforator of the descending branch perforator,
and the subcutaneous connection between the
descending branch perforator and superficial
cutaneous branch consists of reduced caliber ves-
sels, a finding consistently confirmed in the ana-
tomical study (Fig. 4). By including the anatomical
territory of the superficial cutaneous branch, the
clinical territory of the descending branch of the
perforating branch of the peroneal artery perfo-
rator–based island flap could be enlarged. With
regard to the skin territory of the descending
branch of the perforating branch of the peroneal
artery perforator–based island flap, it depends on
the location of the descending branch perfora-
tor, superficial cutaneous branch, and perforator
beyond the angiosome of the superficial cutane-
ous branch (Fig. 4). Surgeons should confirm the
location of these markers by color Doppler sonog-
raphy before designing a flap. The long axis of
the flap should be designed in the direction of
the superficial cutaneous branch to capture the
largest and most reliable vascular territory. In our
experience, a 35 × 80-mm flap survived safely.
The median descending branch perforator
was of supermicrosurgery caliber and 0.42 mm in
diameter. Color duplex scanning should be per-
formed in all cases to confirm the existence of
this perforator after surgery. Particularly in those
patients with severe peripheral vascular disease,
this would often not be an option. The perfora-
tor is close to the lateral malleolus and is at risk
for involvement in the zone of injury, particularly
after the requisite wound débridement. For all
these reasons, this is not a first-line flap choice but
may perhaps be the only option in those patients
with significant other risk factors precluding the
use of safer alternatives such as a simple free flap.

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Volume 132, Number 2 • Lateral Malleolus Repair
CONCLUSIONS
A new perforator-based island flap of the
descending branch of the perforating branch of
the peroneal artery perforator for reconstruction
of the lateral malleolus was designed and evalu-
ated. This perforator existed consistently and was
the closest to the tip of the lateral malleolus. The
procedure of flap elevation is sufficiently straight-
forward and uncomplicated that this method can
be used for patients at high risk of complications
with extended surgery.
Shinsuke Akita, M.D.
Department of Plastic, Reconstructive,
and Aesthetic Surgery
Chiba University
Faculty of Medicine
1-8-1, Inohana, Chuo-ku
Chiba City, Chiba 260-8677, Japan
sakita-chiba@umin.ac.jp
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