Multiple-Pedicle Peroneal Artery Perforator Propeller Flap for Distal Lower Extremity Reconstruction: Technical Considerations and Preliminary Clinical Outcomes

Background and Objectives: Peroneal artery perforator-based propeller flaps are widely used for reconstruction of distal lower extremity defects. However, venous congestion remains a frequent complication of single pedicle propeller flaps, with reported rates of approximately 15% to over 30%. The clustered perforator anatomy of the peroneal artery may allow incorporation of multiple pedicles within a single propeller flap. This study evaluated the feasibility of multiple pedicle peroneal artery perforator propeller flaps for ankle and distal foot reconstruction. Materials and Methods: This retrospective case series included five patients who underwent reconstruction using multiple pedicle peroneal artery perforator propeller flaps between January 2017 and December 2021. Defect characteristics, number of incorporated perforators, interpedicle distance, rotation angle, and clinical outcomes were reviewed. Results: The cohort consisted of four males and one female (mean age, 47.4 years). Defects involved the lateral ankle (n = 3), anterolateral ankle (n = 1), and posterior foot (n = 1), with sizes ranging from 16 to 30 cm2 (mean, 23.6 cm2). Four flaps incorporated two perforators, and one incorporated three perforators. Interpedicle distances ranged from 32 to 37 mm. Flap rotation ranged from 120° to 180°. None of the cases demonstrated venous congestion, arterial insufficiency, partial necrosis, or total flap loss. All wounds healed within 3–4 weeks (mean, 3.6 weeks). Conclusions: Multiple pedicle peroneal artery perforator propeller flaps were technically feasible in this small case series, with complete flap survival and no vascular complications observed among the five patients. Given the small sample size and retrospective design, these findings should be interpreted as preliminary clinical observations rather than evidence of generalized safety or superiority over conventional single-perforator propeller flaps.