RECONSTRUCTIVE SURGERY
Distally Based Perforator Propeller Sural Flap for
Foot and Ankle Reconstruction
A Modified Flap Dissection Technique
Shi-Min Chang, MD, PhD, Xin Wang, MD, Yi-Gang Huang, MD, PhD, Xiao-Zhong Zhu, MD,
You-Lun Tao, MD, and Ying-Qi Zhang, MD
Background: Distally based perforator propeller sural flaps that pedicled on an
isolated perforator from the peroneal artery or posterior tibial artery are a
versatile local reconstructive option for defects of the foot and ankle region.
However, flap venous congestion is yet a difficult problem after operation. We
hypothesize that containing some adipofascial tissues around the axial perfo-
rator can preserve some tiny venous return routes, improve venous drainage,
and ultimately enhance flap safety in distally based sural flaps.
Methods: A prospective case series of 12 patients undergoing distally based
perforator sural flaps for foot and ankle coverage were included in this study
from January 2008 to December 2010. There were 7 posterior tibial artery
perforator flaps from the posteromedial sural region and 5 peroneal artery
perforator flaps from the posterolateral sural region. After identifying the proper
viable perforator during operation as the pivot point, the whole flap was designed
in an eccentric propeller shape. The proximal larger blade was a fasciocutaneous
flap, whereas the distal smaller blade was a subdermal vascular plexus flap,
preserving at least a quarter area of adipofascial tissue intact around the per-
forator. Postoperatively, flap swelling was classified into a 5-grade assessment
scale. Flap survival, complications, and patient functional recovery were evaluated.
Results: The proximal fasciocutaneous flap measured 4  8 to 6  18 cm
(mean, 57.8 cm2), and the distal subdermal cutaneous flap measured 2  2 to
4  4 cm (mean, 9.2 cm2). The flaps were rotated 160 to 180 degrees. Post-
operatively, flap swelling was noted under grade 2 in 9 cases, grade 3 in 2,
and grade 4 in 1 with some distal superficial skin necrosis, which occurred in
the largest flap in our series. All flaps survived uneventfully. After a mean of
13 months of follow-up, the wounds were cured successfully. All patients re-
covered walking and shoe wearing function.
Conclusion: Keeping a quadrant adipofascial tissue around the distal pivot
perforator to form a perforator-adipofascial-pedicle can preserve more venous
return routes and relieve flap swelling. This technique should be recommended
in distally perforator-pedicled propeller flaps because it enhances flap safety yet
does not increase the difficulty of 180-degree rotation.
Key Words: perforator flap, distally based flap, propeller flap, sural flap,
venous drainage, foot and ankle
(Ann Plast Surg 2014;72: 340Y345)
S oft tissue defects in the foot and ankle, especially with bone,
tendon, or hardware exposure, present a formidable challenge
because of the lack of reliable local flap options.1 Since the devel-
opment of fasciocutaneous,2 neurocutaneous,3 and perforator flaps4,5
Received February 21, 2012, and accepted for publication, after revision, May 23,
2012.
From the Department of Orthopedic Surgery, Yangpu Hospital, and Tongji Hospital,
Tongji University School of Medicine, Shanghai, People’s Republic of China.
Conflict of interest and sources of funding: The study is supported by Natural
Science Fundation of China (NSFC): No. 81271993 and 81201411.
Reprints: Shi-Min Chang, MD, PhD, Department of Orthopedic Surgery, Yangpu
Hospital, Tongji University School of Medicine, 450 Tengyue Road, Shanghai
200090, People’s Republic of China. E-mail: shiminchang@yahoo.com.cn.
Copyright * 2014 by Lippincott Williams & Wilkins
ISSN: 0148-7043/14/7203-0340
DOI: 10.1097/SAP.0b013e31826108f1
340 www.annalsplasticsurgery.com
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in the past 3 decades, various techniques for using the ipsilateral
uninjured lower leg as a distally based locoregional flap donor site
have been developed and modified.6
Distally based perforator propeller flaps harvested from the sural
region and pedicled on an isolated perforator with up to 180 degrees
of rotation for foot and ankle reconstruction are an innovative option
because they provide robust axial blood perfusion to flaps with sig-
nificantly greater surface area and ease of transposition.7,8 However,
venous congestion, either at the distal tip or along its entire length, is
the most frequent complication encountered postoperatively.9 In this
article, we present a modified dissection technique to improve ve-
nous return of distally based perforator propeller flaps by pedicle
evolution and report its clinical applications for foot and ankle
reconstruction.
PATIENTS AND METHODS
Patients
From January 2008 to December 2010, we performed the
modified distally based perforator lower-leg fasciocutaneous flap
transfers for coverage of foot and ankle wounds in 12 patients. After
institutional board approval, the patients were enrolled in a prospective
trial. There were 9 males and 3 females. The age of patients ranged
from 12 to 65 years, with a mean of 43 years. The wounds were caused
by direct trauma in 6, iatrogenic skin necrosis or infection in 4, tumor
resection in 1, and pressure sore in 1. Five patients were complicated
with fractures. The wound size ranged from 9 to 66 cm2. The details
of the patients are summarized in Table 1.
Flap Design
There are 2 rows of perforators in the distal sural region.9,10 The
medial one originates from the posterior tibial artery, located between
the tibia and the Achilles tendon. The lateral one originates from the
peroneal artery, located between the fibula and the Achilles tendon
(Fig. 1). Previous anatomical studies have already demonstrated that
these perforators in the distal lower leg are mainly septocutaneous.
From our experience in Chinese people, perforators can be found
above the medial or lateral malleolus tip at (1) approximately 2 cm
(the retromalleolar space perforator), (2) approximately 5 cm (the
distalmost septocutaneous perforator), and (3) approximately 10 cm
(middle septocutaneous perforator), respectively. The authors rec-
ommend using the closest perforator to the defect because locating
the pivot point of the flap 2 cm nearer to the wound would result in a
reduction of the flap length of a total of 4 cm, thus reducing the donor-
site morbidity of the lower leg and increasing the safety by reducing
the total flap length. However, for chronic trauma wounds, we prefer
the perforators to be at least 3 cm away from the defect edge, which is
outside the zone of injury-related inflammation and fibrosis. Because
the diameter of these distal perforators was usually small, preoperative
Doppler probe mapping is useful, and the freestyle technique is applied.
A longitudinal line roughly representing the course of the
posterior tibial artery (or peroneal artery) is drawn from the midpoint
between Achilles tendon and medial malleolus (or lateral malleolus) in
Annals of Plastic Surgery & Volume 72, Number 3, March 2014
 TABLE 1. Clinical Summary of Patient Data
Annals of Plastic Surgery

Flap Size, cm
Sex/ Wound Perforator Perforator Follow-Up,
Case Age Etiology Defect Site Size, cm Source Location,* cm Flap Head Flap Tail Comorbidities Flap Result mo Sequela
1 M/35 Trauma Lateral heel 73 Peroneal artery 3 4  13 32 Smoking Complete flap 24
survival

* 2014 Lippincott Williams & Wilkins

2 M/25 Traffic trauma Posterior heel 64 Peroneal artery 5 5  11 33 None Complete flap 20 None
survival
3 F/62 Skin necrosis after Medial ankle 64 Posterior tibial 5 4  10 33 Diabetes Complete flap 20 None
plating of open artery survival
tibial pilon fracture
4 M/12 Traffic trauma Posterior heel 54 Posterior tibial 6 4  10 33 None Complete flap 18 None
artery survival
5 M/65 Resection of Medial side 85 Posterior tibial 10 5  12 43 Hypertension Complete flap 15 None
squamous cancer of distal leg artery survival
6 F/65 Breakdown of incision Lateral heel 53 Peroneal artery 5 4  12 32 Diabetes Complete flap 13 None
skin after plating of survival minor
& Volume 72, Number 3, March 2014

calcaneal fracture wound dehiscence

7 M/44 Infection after Distal tibia 84 Posterior tibial 10 5  13 43 Diabetes and Complete flap 12 None
plating of open artery heavy smoking survival
tibial fracture
8 M/37 Skin necrosis after Achilles tendon 43 Peroneal artery 5 4  12 32 Heavy smoking Complete flap 10 None
repair of Achilles survival
tendon
9 M/35 Traffic trauma Posterior and 11  6 Posterior tibial 6 6  18 44 None Distal superficial 10 Paresthesia of
plantar heel artery necrosis lateral dorsal
foot
10 M/28 Traffic trauma Posterior heel 54 Posterior tibial 5 5  15 33 None Complete flap 8 None
artery survival
11 M/54 Traffic trauma, open Medial distal tibia 94 Posterior tibial 10 5  14 43 Smoking Complete flap 7 None
tibial pilon fracture artery survival
12 F/52 Paraplegia pressure Posterior heel 33 Peroneal artery 2 48 22 None Complete flap 6 None
ulcer survival
M indicates male; F, female.
*Distance of perforator from the tip of medial or lateral malleolus.

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Perforator Propeller Sural Flap

341
Chang et al
FIGURE 1. Two rows of perforators in the posterior lower-leg
sural region, originating from peroneal artery (1, 2, and 3)
and posterior tibial artery (4, 5, and 6), respectively.
the leg. This also represents the course of the posterior branch of the
saphenous nerve in the posteromedial aspect or the superficial sural
nerve and the lesser saphenous vein in the posterolateral aspect, re-
spectively. All distally pedicled perforator propeller flaps are centered
on either of these 2 lines. Therefore, the perforator flap based on the
posterior lateral sural region resembles the distally based sural artery
neurocutaneous flap, whereas the perforator flap based on the pos-
terior medial sural region resembles the distally based saphenous neu-
rocutaneous flap. The flap is then outlined on the lower leg according to
location and the size of the tissue defect.
Operative Technique
Under continuous epidural anesthesia, the patient is placed in
the prone (for heel coverage), supine (for medial ankle coverage), or
lateral position (for lateral ankle coverage). A thigh pneumatic tour-
niquet is used, and the leg is exsanguinated by elevation and hand
compression for 1 minute. This allows emptying most of the blood
from the leg but retains enough in the perforator vessels to allow for
easier identification during exploration. After debridement of the de-
fect, a sharp, long exploratory incision (5Y7 cm in length) is first made
straight down to the deep fascia from the wound to the distal half of
the flap along its posterior margin (Achilles side). Some stitches are
put to hold the deep fascia layer with the overlying skin together. Then,
the incision is elevated forward from the subfascial plane to the septum
to search the perforator. After a proper perforator is identified, the flap
design is re-evaluated and tailored according to the exact location of
the perforating vessels. Then, the dissection proceeds from the sub-
fascial plane in the proximal-to-distal direction, until the distal per-
forating vessel is reached. No attempts are made to preserve the
superficial cutaneous nerves if they are located in flap dimension.
After confirming the axial perforator, some modifications are
made in the distal pedicle rather than raising the whole flap as an island
that is supplied by the isolated perforator. The skin between the vas-
cular pivot point and the recipient wound is raised as a proximal pedicled
subdermal vascular plexus flap (superthin flap), from the superficial
adiposal fat layer, thus forming a ‘‘perforator-plus-adipofascial’’
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Annals of Plastic Surgery & Volume 72, Number 3, March 2014
pedicle. Usually, at least a quarter area of adipofascial tissue should be
preserved intact around the perforator. No further intraseptal dissec-
tion of the perforator is performed. Then, the pneumatic tourniquet
is released, and blood circulation of the flap is observed. Usually, the
whole flap is arterially perfused in 2 to 3 minutes after tourniquet
release. If the large subcutaneous vein in the flap becomes extremely
engorged, it is ligated and dissected at the distal adipofascial base
to interrupt venous ingress.11 The whole flap is composed of a larger
neurofasciocutaneous blade (the proximal flap head), which is the
object to be propelled up to 180 degrees to cover the defect, and a
smaller subdermal vascular plexus blade (the distal flap tail), which is
transferred to the donor site to make an easy and smooth rotation
without dog-ear deformity of the pedicle (Fig. 2). No venous anas-
tomosis for super drainage or neurorrhaphy is performed at the re-
cipient site. The donor areas are closed directly or in split-thickness
skin grafts.
For foot and calcaneus coverage, a plaster splint is used for
immobilization. After 2 weeks, the patient begins an active and passive
physical rehabilitation program to achieve the maximum range of
ankle motion.
RESULTS
There were 5 peroneal artery perforator-adipofascialYbased
propeller flaps harvested from the posterolateral sural region and 7
posterior tibial artery perforator-adipofascialYbased propeller flaps
harvested from the posteromedial sural region. The whole flap, which
consisted of a proximal larger neurofasciocutaneous flap, measured
from 4  8 cm to 6  18 cm (mean area, 57.8 cm2), and a distal smaller
subdermal vascular plexus flap measured from 2  2 cm to 4  4 cm
(mean, 9.2 cm2). In 5 patients, the negative role of large subcutaneous
vein (rapid engorgement) was present in these distally based flaps, and
it was ligated in the distal adipofascial base.
Postoperatively, flap circulation, in specific reference to venous
return, was monitored and measured according to modified Flap
FIGURE 2. Schematic drawing to show the pedicle evolution
in perforator propeller flap design. The flap is composed of
a large proximal fasciocutaneous blade and a small distal
subdermal blade, which is rotated on the pivot pedicle,
composed of a perforator and a quadrant adipofascial tissue.
* 2014 Lippincott Williams & Wilkins
Annals of Plastic Surgery & Volume 72, Number 3, March 2014 Perforator Propeller Sural Flap

wound dehiscence in 1 case. In 6 to 24 months of follow-up (mean,

TABLE 2. Flap Swelling Scale by Gu12 13 months), all patients presented with healed wounds. One patient
No. Current had minor complains about lack of sensation at the lateral dorsal foot.
Flap Swelling Grade Description Case Series
0 No venous congestion, normal skin V Case Reports
appearance after flap transfer
Case 1
1+ Mild congestion, normal skin 2
wrinkles still present A 35-year-old male farmer was referred to us with untreated
closed comminuted calcaneal fracture for 3 months. A skin necrosis,
2+ Moderate congestion, normal 7
skin wrinkles disappear measuring 5  2 cm, was present in the lateral heel side. The fracture
needed open reduction and internal fixation to restore its normal
3+ Marked congestion, skin 2
blister present shape, including axis, width, height, and length. Through an extended
L-shaped skin incision, the skin necrosis was excised. The fracture was
4+ Severe congestion, leading 1
to partial skin necrosis fully exposed. Then, the fragments were relocated to form the shape of
calcaneus and were fixed with screws and titanic plate. Subtalar ar-
throdeses and Achilles lengthening were also performed. Then, the
Swelling Scale by Gu12 (Table 2). This is a standard scale in Chinese skin defect was measured as 7  3 cm. A distally based peroneal
literature. It is determined by skin appearance such as wrinkle, blister, perforator-adipofascialYpedicled flap was designed to cover the de-
and necrosis. Our group (microsurgical physicians and nurses) have fect. The closest perforator was located 3 cm above the lateral mal-
practiced this scale in clinic for more than 20 years and felt that it is leolar tip (a retromalleolar perforator). The flap was raised in propeller
consistent and reliable among interobservers. Nine flaps were graded shape, with a proximal large fasciocutaneous blade of 4  13 cm and a
as under 2 (skin wrinkles disappear); 2, as 3 (skin tension blister); and distal small cutaneous blade of 3  2 cm. The fasciocutaneous flap
1, as 4 (partial skin necrosis). The largest flap had a superficial skin was rotated 180 degrees in counterclockwise to reach and inset the
necrosis in part of the distal portion. No further surgery was needed, heel defect with no tension. The thin cutaneous flap was rotated
and it heeled uneventfully through dressing exchange. No other re- proximally to cover the pedicle. The donor site was closed directly.
cipient and donor-site complications were observed except minor The postoperative period was very smooth, and no venous congestion

FIGURE 3. Distally based peroneal perforator-adipofascialYpedicled propeller flap for calcaneus coverage in case 1. A, Skin
necrosis measuring 5  2 cm over the lateral calcaneus, in an untreated comminuted calcaneal fracture in a 35-year-old man.
An extended L-shaped skin incision for calcaneal open reduction and internal fixation and the distally based sural flap are outlined.
B, A distally based peroneal perforator-adipofascialYpedicled flap, with a proximal large fasciocutaneous blade and a distal small
cutaneous blade, is elevated. The pivot point is located 3 cm above the lateral malleolar tip (a retromalleolar perforator). C, The
fasciocutaneous flap is propelled 180 degrees in counterclockwise to reach and inset the heel defect with no tension. The thin
subdermal flap is rotated proximally to cover the pedicle. The donor site is closed directly. D, The postoperative period is very
smooth, and no venous congestion is observed. The flap survives completely.

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Chang et al Annals of Plastic Surgery & Volume 72, Number 3, March 2014

was observed. The flap survived completely (Fig. 3). The patient was
followed up for 24 months; good function was achieved with normal
walking and shoe wearing.
Case 4
A 12-year-old boy injured his right heel in a bicycle spoke,
resulting in Achilles rupture and overlying skin avulsion. After pri-
mary suture, he was referred to us 2 weeks later because of infection
and skin necrosis. After thorough debridement, the skin defect mea-
sured 5  4 cm with ruptured Achilles tendon exposure. The tendon
was repaired to calcaneus by 2 suture anchors. A distally based pos-
terior tibial artery perforator-adipofascialYpedicled flap was de-
signed to cover the heel defect. The closest perforator was located
6 cm above the medial malleolar tip (a septal perforator). The flap was
raised in propeller shape, with a proximal large fasciocutaneous blade
of 4  10 cm and a distal small cutaneous blade of 3  3 cm. The
fasciocutaneous flap was rotated 180 degrees in clockwise to reach
the posterior heel defect with no tension. The thin cutaneous flap was
rotated proximally to cover the pedicle. The donor site was closed in
tension-release suture and skin graft. Postoperatively, the flap dem-
onstrated a grade 2 swelling. However, the flap survived uneventfully
(Fig. 4). The prominence at the rotated base was subsided and flattened
in time. The patient was followed up for 18 months with satisfied
walking and running.
DISCUSSION
Treatment of soft tissue defects of foot and ankle still remains
a challenging problem for reconstructive surgeons. Even a small de-
fect in this region may justify the need for flap coverage because
the common exposure of bone, tendon, and metal hardware results in
a chronic intractable wound. Clinically, there are several options of
reconstructive procedures including pedicled and microsurgical free
transfers of muscle and myocutaneous flaps and fascial and fascio-
cutaneous flaps. Each procedure has its own advantages and disadvan-
tages on technical requirement, flap size, range of vascular pedicle, and
limitations of patient’s local and general conditions.
The proximal uninjured ipsilateral leg with a large skin territory
may provide a tissue source for foot and ankle coverage. Considering
the pedicle, there are 3 types of distally based lower-leg flaps in clinical
applications, that is, (1) the retrograde-flow island flap supplied by
the distal vascular bundle, such as the posterior tibial artery flap, the
anterior tibial artery flap, and the peroneal artery flap, which sacrifice
a main artery to the foot13; (2) the distally based fasciocutaneous or
neurofaciocutaneous flap supplied by the chain-linked longitudinal
vascular plexuses of a wide and thick neuroadipofascial pedicle, which
often results in contour deformity and dog ear after rotation14; and (3)
the distally based perforator local flap, such as the posterior tibial
artery perforator and peroneal artery perforator flap from the sural
region.15,16 The distal perforators in particular can be used for cov-
erage of defects of the heel, malleolus, Achilles tendon, and distal third
of the tibia.
Single perforator-pedicled propeller flap, also called pedicled
perforator flap, island perforator flap, or local perforator flap,17 has
the greatest freedom of rotation, which can reach up to 180 degrees.18
In recent years, there is a great increasing use of perforator-based
propeller flaps in limb reconstruction, especially for the lower limb,
with a distal rotation.19 These flaps combine the advantages of ped-
icled local flaps (good color and texture match), pedicled regional
flaps (up to 180 degrees arc of rotation), pedicled distant flap (vascular
reliable and larger size), and without microsurgical vascular anasto-
mosis. In addition, for most small to medium-sized defects, it allows
linear closure of the donor site.20,21
Arterial inflow, even in large and long distally based propeller
flaps from the lower extremity, is usually sufficient. However, venous
drainage is a special concern. Veins are inherently provided with
valves to prevent retrograde outflow in distally based flaps. Further-
more, the 180-degree torsion more likely jeopardizes the venous
drainage because decreased venous wall thickness and lower intra-
luminal pressure make veins more susceptible to collapse and subse-
quent thrombosis. Therefore, venous complications, such as swelling
and congestion, occurred more often in distally based perforator flaps.
Wong et al,22 using a finite-element simulation model, pointed out
that, for a 1 mm diameter perforator after 180-degree rotation, at least
30 mm is needed to distribute the twist over a long distance to min-
imize kinking. This is possible for musculocutaneous perforators by
intramuscular dissection. However, because the deep main artery trunk
is located superficial in the distal leg, the septocutaneous perforating
vessels are usually very short.
Our modification of the pedicle is an evolution from isolated
perforator to perforator-plus-adipofascial. Besides the partner perfo-
rating veins, this refinement keeps more venous return routes in the
attached distal adipofascial layer. Valveless venous plexuses of the
adipofascial tissue serve as oscillating channels, allowing venous flow
in any direction under pressure. Preservation of the septum and 1
quadrant of adipofascial tissue around the feeding perforator prevents
vascular kinking and stretching. In this case series, the rotation angle
of the flap was 160 to 180 degrees, and no flap showed vascular crisis,

FIGURE 4. Distally based posterior tibial artery perforator-adipofascialYpedicled flap for Achilles coverage in case 4.
A, Wound infection and skin necrosis over Achilles rupture in a 12-year-old boy. B, Distally based posterior tibial artery
perforator-adipofascialYpedicled flap is raised. The pivot point is located 6 cm above the medial malleolar (a septal perforator).
C, The flap is propelled 180 degrees in clockwise to reach the posterior heel defect with no tension. The donor site is closed in
tension-release suture and skin graft. Postoperatively, the flap demonstrates a grade 2 swelling. The flap survives uneventfully.

344 www.annalsplasticsurgery.com * 2014 Lippincott Williams & Wilkins

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Annals of Plastic Surgery & Volume 72, Number 3, March 2014
except the largest one. This flap (case 9) measured 18  6 cm and
showed severe congestion in the distal part of the flap after surgery.
After eschar removal, there was enough underlying surviving tissue,
and the wound was allowed to heal secondarily. We think that surgical
delay or super drainage by microsurgical venous anastomosis may
be a useful armament to enhance the reliability, especially in larger
flaps, and patients with comorbidities such as heavy smokers and
diabetes.23,24 Compared with previous results using isolated perfo-
rator sural flaps for foot and ankle coverage, although the number of
cases is limited, it is our impression that the overall venous congestion
grade in this modified perforator-adipofascial group (a total sum of
26 positive mark in 12 flaps; mean, 2.17) is lower than that in isolated
the perforator group (a total of 83 positive mark in 33 flaps; mean,
2.52). Our flap failure rate (1 partial necrosis, 8.3%) was relatively
lower than those of other reports. Schaverien et al25 reported 106
posterior tibial artery perforator island flaps for lower leg, ankle, heel,
and foot coverage, and the results showed 8.5% complete and 12%
partial flap failure rate. In a report by D’Arpa et al26 with freestyle
pedicled perforator flaps in 85 cases throughout the body, 6 (10.5%)
of 57 180-degree propeller flaps had complications, and in 10 lower-
leg 180-degree propeller flaps, 2 had partial necrosis (20%). Rezende
et al27 reported 24 cases of distally pedicled perforator flaps to cover
defects in the middle and distal segment of the leg, with a mean flap
size of 5 cm in width and 12 cm in length, and encountered 4 cases
of flap partial failure (16.7%).
The whole flap island is composed of 2 parts, 1 larger fascio-
cutaneous flap and 1 smaller subdermal cutaneous flap, separated by
the nourishing perforating vessel that corresponds to the pivot point.
The 2 portions of the skin island can rotate around the pedicle, for as
many degrees as the anatomical situation requires (90Y180 degrees).
This kind of modification is not seen in the Tokyo propeller flap
classification.28 We think that it is a new subtype perforator-based
propeller flap.
In conclusion, keeping a quadrant adipofascial tissue around
the pivot perforator can preserve more tiny venous return routes and
relieve flap congestion and swelling. This pedicle evolution technique
should be recommended in perforator-pedicled propeller flaps be-
cause it enhances flap circulatory safety without increasing the dif-
ficulty of 180 degrees rotation.
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