Redefining Vascular Anatomy of Posterior Tibial Artery Perforators: A Cadaveric Study and Review of the Literature

Introduction Perforator flaps whether in a free or pedicled form are essential in leg reconstruction, requiring meticulous dissection based on a detailed understanding of vascular topographic anatomy. Numerous investigators have addressed this issue. However, the directionality of their fascial exit has not been greatly discussed in the literature. Subfascial course of the perforating vessel is a crucial determinant for optimal perforator selection especially when the propeller perforator flap option is considered, because an angulated fascial penetration would eventually result in perforator kinking which would additionally compromise vascular patency. The aim of the current study was to investigate the vascular anatomy of posterior tibial artery evaluating a wide range of parameters, including perforators' subfascial directionality, to precisely determine constant reliable perforator sites, in relation to surface landmarks on the medial aspect of the lower leg. Material and Methods Dissections in 30 lower legs from 25 fresh cadavers were performed. The lower leg was divided into 3 equal vascular zones. Measurements were taken in reference to anatomical landmarks. Perforator clusters to 5-cm intervals from medial malleolus were recorded and analyzed. Vessels with external diameter less than 0.5 mm were excluded. Data regarding the number, distribution, type, external diameter, length from posterior tibial artery, distance, and subfascial directionality were collected and treated. Results A total of 155 perforators were identified (average number, 5 per leg; average diameter, 1.0 mm). Septocutaneous (127/155) perforators predominated, followed by musculocutaneous (19/155) and septomusculocutaneous (9/155). Most was concentrated in the middle (73/155) and distal (64/155) tertile. There were no septomusculocutaneous perforators at the distal third of the leg, whereas septocutaneous perforators were encountered into all vascular tertiles. An average of 2 comitant veins accompanied each perforator. Length and diameter related to the perforators' location. There was a significant association between perforator length and type. Cluster analysis revealed that reliable perforators were identified within the 21 to 25, 26 to 30, and 16 to 20 cm intervals. Conclusions Clinically optimal perforators for the first time were precisely located in relation to subfascial directionality, vascular diameter, and length from the source artery. Continuous improving details of vascular anatomy will further evolve perforator flaps' applications.