Reconstruction of soft tissue defects of the Achilles region: a simple algorithm through a lateral approach

Background: Soft tissue defects of the lower leg represent a reconstructive challenge. The peroneal side offers multiple reconstructive options through one surgical incision: from propeller peroneal artery perforator (PAP) flap to extended peroneal artery perforator (EPAP) flap or distally-based peroneus brevis muscle flap (db-PB). Methods: Patients who underwent soft tissue reconstruction of Achilles tendon region from June 2016 to June 2021 were reviewed. Patient’s age, comorbidities, defect size, type of flap, operating time and complication rate were retrospectively analyzed. Results: 30 patients underwent a soft tissue reconstruction of the Achilles tendon region between June 2016 and June 2021. Total number of flaps was 33: 22 propeller PAP flaps, 8 db-PB and 3 EPAP flaps. Defects length varied between 4 cm and 10 cm and width between 2 cm and 5 cm. Two cases of partial necrosis (9%) and one complete necrosis (4.5%) were encountered in the PAP series, one case of partial necrosis and one case of skin graft loss in the db-PB flaps (12.5%). No complications reported in EPAP series. Mean operating time was 90 min for PAP flaps, 117 min for EPAP flaps and 112 min for db-PB muscle flaps. Conclusions: Peroneal artery perforators are safe for the elevation of a perforator-based flap. In case of no suitable perforator, it is possible to harvest a db-PB flap through the same surgical incision. EPAP flap can be used as rescue-procedure after harvesting a propeller PAP flap. For small-to-moderate defects, a lateral approach provides a reconstructive armamentarium that ranges from the propeller perforator flaps, to those extended up to peroneal artery to the distally-based peroneus brevis muscle. Level of Evidence: Level IV, Therapeutic Study.