title: Lateral retromalleolar perforator-based flap: anatomical study and preliminary clinical report for heel coverage.
abstract: BACKGROUND
  Repair of heel soft-tissue defects remains a challenging problem in reconstructive surgery. The distally based sural neurofasciocutaneous flap is among the flaps of choice for coverage of this difficult region. The authors describe a modified lateral retromalleolar perforator-based neurocutaneous flap with a lower pivot point.
  
  
  METHODS
  This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 12 cadavers were injected with red gelatin, and all fasciocutaneous perforators between the lateral malleolus and Achilles tendon (called the lateral retromalleolar space) were identified. Clinically, based on the anatomical study, five cases of heel soft-tissue defects were reconstructed with the modified lateral retromalleolar perforator-based sural neurofasciocutaneous flap.
  
  
  RESULTS
  The anatomical study showed that there are usually two to three retromalleolar cutaneous perforators arising from the terminal part of the peroneal artery in the lateral retromalleolar space. Their outer diameters range from 0.1 to 0.8 mm. A direct venous communicator, usually accompanied by the larger perforator, connected the superficial lesser saphenous vein and the deep peroneal venae comitantes. Five patients with heel soft-tissue defects were treated with flaps ranging from 3 x 6 cm to 5 x 12 cm. The distal pivot point was designed at 1 to 3 cm above the tip of the lateral malleolus. All flaps survived without complications.
  
  
  CONCLUSIONS
  The lateral retromalleolar perforator is predictable and reliable for the design of a lower pivot point, distally based sural neurocutaneous flap. The procedures are simple and rapid, and the flap can be rotated easily without dog-ear deformity. This flap should be considered among the preferred flaps for heel reconstruction.
authors: Shanghai and Guangzhou, China; and Jackson, Miss. From the Department of Orthopedic Surgery, Tongji Hospital, Tongji University; Division of Plastic Surgery, University of Mississippi Medical Center; Institute of Clinical Anatomy, Nanfang Medical University; and Department of Orthopedic Surgery, Changzhen Hospital, Second Military Medical University.
authors: Shi-Min
authors: SM
authors: Chang
authors: Feng
authors: F
authors: Zhang
authors: Da-Chuan
authors: DC
authors: Xu
authors: Guang-Rong
authors: GR
authors: Yu
authors: Chun-Lin
authors: CL
authors: Hou
authors: William C
authors: WC
authors: Lineaweaver
mesh_terms: D000328:Adult; D000368:Aged; D002102:Cadaver; D005260:Female; D016523:Foot Ulcer / Q000601:surgery*; D006365:Heel / Q000601:surgery*; D006801:Humans; D008297:Male; D013524:Surgical Flaps / Q000098:blood supply
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