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Peroneal artery perforator flaps are the most widely used pedicled flaps for soft tissue defects of the distal lower extremity. Most research regarding peroneal artery flaps focuses on the location, diameter, and number of peroneal artery perforators. However, there is little literature regarding interperforator flow patterns within the peroneal artery perforator flaps. The aims of the present study were to describe interperforator flow patterns of the distally based extended peroneal artery perforator flaps through digital subtraction angiography and review their clinical application.
Twelve consecutive patients underwent digital subtraction angiography of the lower-limb arteries. The number and classification of peroneal artery perforators and the interperforator flow patterns were observed. Based on these observations, distally based extended peroneal artery perforator flaps were designed to repair nonhealing wounds located on the ankles and feet of 14 patients.
The peroneal artery gives out grades I to IV perforators in the lateral leg. There were 2 to 7 grade I perforators and true anastomoses between adjacent grade II perforators, which generate directly linked vessels in the middle leg. The grade III or IV perforators form a reticular vascular network through a large number of chock and potential anastomoses. All flaps survived and had excellent appearance and texture.
Distally based extended peroneal artery perforator flaps appear reliable for repairing wounds located on or around the ankle and front foot. However, whether the middle perforator or peroneal artery should be used depends on the condition of the anastomosis between direct linking vessels and the distal perforator.

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