Tunneled Peroneal Perforator Propeller Flap With De-Epithelialized Bridge for Coverage of Anterior Mid-Tibial Defect...

Anterior mid-tibial defects are difficult to cover because the tibial crest lacks soft tissue and excess bulk impairs function and contour. Different procedures can be used in these cases, including split thickness skin graft (STSG), local random pattern flaps, or pedicled muscular flaps. STSG represents the most common and simple procedure; however, the aesthetic results are often poor and it cannot be performed if bone tissue is directly exposed. Local flaps are suboptimal in this region due to high skin tension, whereas muscle flaps yield poor aesthetic outcomes and are associated with increased morbidity and prolonged healing time. In this setting, there is still not a definitive solution able to provide the right amount of tissue, with a safe donor site morbidity. Here, we report a case of anterior tibial reconstruction after wide local excision of basal cell carcinoma in a 71 years old man using a peroneal artery perforator propeller flap. Color Doppler localized a reliable distal-lateral perforator, enabling a single-perforator skin island flap measuring 19 × 6 cm, with careful pedicle skeletonization; indocyanine-green angiography confirmed perfusion before inset. A generous subcutaneous tunnel minimized kinking, and a de-epithelialized central bridge created two paddles, one for the defect and one to assist tension-free donor closure. Recovery was uncomplicated; at 6 months the flap was stable, with good contour, color match, and no need for refinements. Key reliability enhancers were judicious perforator selection, gravity-assisted design, liberal tunneling, and the protective bridge. Compared with skin grafting, this approach improves durability and integration; compared to free flaps, it preserves major vessels while reducing operative complexity and morbidity.