Risk factors related to the partial necrosis of the posterior tibial artery perforator-plus fasciocutaneous flap


Purpose and background

The posterior tibial artery perforator-plus fasciocutaneous (PTAPF) flap is commonly used for defects over the distal lower extremity. However, the causes of partial necrosis of the PTAPF flap are unknown. This paper aimed to explore the factors related to the partial necrosis of the PTAPF flap.


A retrospective study was conducted on 59 patients who received the PTAPF flap for soft-tissue defects between September 2007 and September 2017. The clinical outcomes of the flap were evaluated, and the patient and surgical factors related to flap survival were analyzed.


Of the 59 patients, 9 (15.25%) flaps exhibited partial necrosis. No significant differences were found between the survival and partial necrosis groups regarding gender, age, soft tissue defect site, length and width of the fascia pedicle, length of the skin island, length–width ratio (LWR), and pivot point (P > 0.05). However, the survival group showed significantly less width of the skin island and total length of the flap than the partial necrosis group (P < 0.05). Multiple logistic regression analysis revealed that the width of the skin island was an independent risk factor affecting partial flap necrosis (OR = 4.028; P = 0.041).


The PTAPF flap can be effectively used to repair small and medium wounds of the lower and middle leg, ankle and foot. As the width of the skin island exceeds 6 cm, the risk of partial flap necrosis significantly increases.

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  1. 1.

    Wei JW, Ni JD, Dong ZG, Liu LH, Luo ZB, Zheng L. Distally based perforator-plus sural fasciocutaneous flap for soft-tissue reconstruction of the distal lower leg, ankle, and foot: comparison between pediatric and adult patients. J Reconstr Microsurg. 2014;30(04):249–54.

    Article  Google Scholar 

  2. 2.

    Zheng L, Zheng J, Dong ZG. Reverse sural flap with an adipofascial extension for reconstruction of soft tissue defects with dead spaces in the heel and ankle. Eur J Trauma Emerg Surg. 2016;42:503–11.

    CAS  Article  Google Scholar 

  3. 3.

    Cheng L, Yang X, Chen T, Li Z. Peroneal artery perforator flap for the treatment of chronic lower extremity wounds. J Orthop Surg Res. 2017;12:170.

    Article  Google Scholar 

  4. 4.

    Balan JR. Medial sural artery perforator free flap for the reconstruction of leg, foot and ankle defect: an excellent option. ANZ J Surg. 2018;88:E132–6.

    Article  Google Scholar 

  5. 5.

    Seth AK, Iorio ML. Super-thin and suprafascial anterolateral thigh perforator flaps for extremity reconstruction. J Reconstr Microsurg. 2017;33(07):466–73.

    Article  Google Scholar 

  6. 6.

    Amarante J, Costa H, Reis J, Soares R. A new distally based fasciocutaneous flap of the leg. Br J Plast Surg. 1986;39(03):338–40.

    CAS  Article  Google Scholar 

  7. 7.

    Erdmann MW, Court-Brown CM, Quaba AA. A five years review of islanded distally based fasciocutaneous flaps on the lower limb. Br J Plast Surg. 1997;50(06):421–7.

    CAS  Article  Google Scholar 

  8. 8.

    Nenad T, Reiner W, Michael S, Reinhard H, Hans H. Saphenous perforator flap for reconstructive surgery in the lower leg and the foot: a clinical study of 50 patients with posttraumatic osteomyelitis. J Trauma. 2010;68(05):1200–7.

    Article  Google Scholar 

  9. 9.

    Dai JZ, Chai YM, Wang CY, Wen G. Distally based saphenous neurocutaneous perforator flap for reconstructive surgery in the lower leg and the foot: a long-term follow-up study of 70 patients. J Reconstr Microsurg. 2013;29(07):481–6.

    Article  Google Scholar 

  10. 10.

    Dong ZG, Wei JW, Ni JD, et al. Anterograde-retrograde method for harvest of distally based sural fasciocutaneous flap: report of results from 154 patients. Microsurgery. 2012;32(08):611–6.

    Article  Google Scholar 

  11. 11.

    Mehrotra S. Perforator-plus flaps: a new concept in traditional flap design. Plast Reconstr Surg. 2007;119(02):590–8.

    CAS  Article  Google Scholar 

  12. 12.

    Lu TC, Lin CH, Lin CH, Lin YT, Chen RF, Wei FC. Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg. 2011;64(03):386–93.

    Article  Google Scholar 

  13. 13.

    Wei JW, Dong ZG, Ni JD, Liu LH, Luo ZB, Zheng L. The importance of a skin bridge in peripheral tissue perfusion in perforator flaps. Plast Reconstr Surg. 2012;130(05):757e–8e.

    CAS  Article  Google Scholar 

  14. 14.

    Parrett B, Pribaz JJ, Matres E, Przylecki W, Sampson CE, Orgill DP. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg. 2009;123(05):1499–504.

    CAS  Article  Google Scholar 

  15. 15.

    Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg. 2003;112(01):129–40.

    Article  Google Scholar 

  16. 16.

    Saint-Cyr M, Wong C, Schaverien MV, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124(05):1529–44.

    CAS  Article  Google Scholar 

  17. 17.

    Taylor GI, Chubb DP, Ashton MW. True and “choke” anastomoses between perforator angiosomes: part I. anatomical location. Plast Reconstr Surg. 2013;132(06):1447–56.

    CAS  Article  Google Scholar 

  18. 18.

    Gascoigne AC, Taylor GI, Corlett RJ, Briggs C, Ashton MW. The relationship of superficial cutaneous nerves and interperforator connections in the leg: a cadaveric anatomical study. Plast Reconstr Surg. 2017;139(04):994e–1002e.

    CAS  Article  Google Scholar 

  19. 19.

    Cheng Z, Wu W, Hu P, Wang M. Distally based saphenous nerve-greater saphenous venofasciocutaneous flap for reconstruction of soft tissue defects in distal lower leg. Ann Plast Surg. 2016;77(01):102–5.

    CAS  Article  Google Scholar 

  20. 20.

    Bulla A, De Luca L, Campus GV, Rubino C, Montella A, Casoli V. The localization of the distal perforators of posterior tibial artery: a cadaveric study for the correct planning of medial adipofascial flaps. Surg Radiol Anat. 2015;37(01):19–25.

    CAS  Article  Google Scholar 

  21. 21.

    Hupkens P, Westland PB, Schijns W, van Abeelen MHA, Kloeters O, Ulrich DJO. Medial lower leg perforators: An anatomical study of their distribution and characteristics. Microsurgery. 2017;37(04):319–26.

    Article  Google Scholar 

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National Natural Science Foundation of China, Grant/Award Number: 81672188; Health and Family Planning Commission of Hunan Province, Grant/Award Number: B20180313.

Author information




PP and JWW designed the research and drafted the manuscript. ZGD and LHL performed the surgical treatment, participated in its design and coordination, and helped to write the manuscript. ZBL and LZ helped to collected and analyzed the patient data. All authors had read and approved the final manuscript and ensured that this is the case.

Corresponding author

Correspondence to Jianwei Wei.

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The authors declare that they have no competing interests.

Ethics approval

This study was approved by the medical ethics committee of the Second Xiangya Hospital Central South University. All patients involved in this study gave informed written consent to participate.

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Written informed consent was obtained from all participants.

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Peng, P., Dong, Z., Wei, J. et al. Risk factors related to the partial necrosis of the posterior tibial artery perforator-plus fasciocutaneous flap. Eur J Trauma Emerg Surg (2021). https://doi.org/10.1007/s00068-021-01616-0

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  • Posterior tibial artery
  • Perforator flap
  • Risk factors
  • Soft-tissue defect
  • Survival