The vasculature and clinical application of the posterior tibial perforator-based flap

Use of the posterior tibial flap pedicled on the posterior tibial vessels has been described by several authors, but with it there is the major disadvantage of an unavoidable transection of the posterior tibial artery. To overcome this disadvantage, we anatomically studied the perforators from the posterior tibial artery and used posterior tibial perforator-based flaps clinically. Based on our anatomic study of 25 cadaveric legs, the cutaneous perforators were considered to be distributed from the distal to the proximal sides of the lower leg through the medial border of the tibia, and they were classified into three types: septocutaneous perforators mainly located in the distal third of the leg, muscle perforators located in the proximal half, and periosteal perforators in the proximal third of the leg. The average size and number of perforators was 0.8 mm and 3.1 in one leg, respectively. A considerable number were located at sites from 70 to 140 mm superior to the medial malleolus. Based on our clinical cases repaired with flaps, we consider this flap to be useful as a free flap for the repair of defects of the extremities and as an island flap for reconstruction of defects on the anteromedial aspect of the lower leg. The territory of the flap is relatively wide, being 19 x 13 cm. The long saphenous vein can be used safely as the venous drainage system in the case of free-flap transfer.