Supermicrosurgical perforator-to-perforator flap reconstruction for lower limb defects: a single-center case series

Lower limb soft tissue defects remain a major reconstructive challenge due to frequent exposure of critical structures and compromised vascularity. In complex cases where local tissue is insufficient, free tissue transfer is required. Advances in supermicrosurgery have enabled perforator-to-perforator (P-to-P) anastomoses allowing reliable perfusion while preserving major axial vessels and minimizing donor-site morbidity. A retrospective review was conducted of five patients who underwent P-to-P free flap reconstruction for lower limb defects between January 2018 and January 2023. Preoperative CT angiography and intraoperative duplex ultrasound were used for perforator mapping. Two anterolateral thigh, one medial sural artery perforator, and two gracilis muscle flaps were utilized. Anastomoses were hand-sewn using 10-0 to 12-0 nylon under high-magnification microscopy. Flap perfusion was monitored with Vioptix Tissue Oximeter. The mean age was 60.8 years and defect sizes ranged from 5 × 4 cm to 20 × 8 cm. All flaps survived without partial or total loss. One patient developed minor wound dehiscence that healed without intervention. Reconstruction was successful across varied etiologies including infection, chronic wounds, and postoperative defects, with low morbidity and no re-explorations. P-to-P supermicrosurgical reconstruction offers a reliable, vessel-preserving approach for complex lower limb defects. This technique maintains major vascular axes, minimizes donor-site morbidity, and achieves outcomes comparable to conventional microsurgical methods across diverse etiologies such as infection, chronic wounds, and postoperative defects. In our series, flap survival was universal with no re-explorations and minimal morbidity. Wider clinical adoption and continued experience may further define its role in contemporary lower extremity reconstruction.