Background: Perforator flaps have led to a revolution in reconstructive surgery by reducing donor site morbidity. However, many surgeons have witnessed partial flap necrosis. Experimental methods to increase inflow have relied on adding a separate pedicle to the flap. The aim of our study was to experimentally determine whether increasing blood flow in the perforator pedicle itself could benefit flap survival. Methods: In 30 male Lewis rats, an extended posterior thigh perforator flap was elevated and the pedicle was dissected to its origin from the femoral vessels. The rats were assigned to three groups: control (group I), acute inflow (group II) and arterial preconditioning (group III) depending on the timing of ligation of the femoral artery distal to the site of pedicle emergence. Digital planimetry was performed on postoperative day (POD) 7 and all flaps were monitored using laser Doppler flowmetry perioperatively and postoperatively in three regions (P1-proximal flap, P2-middle of the flap, P3-distal flap). Results: Digital planimetry showed the highest area of survival in group II (78.12%±8.38%), followed by groups III and I. The laser Doppler results showed statistically significant higher values in group II on POD 7 for P2 and P3. At P3, only group II recorded an increase in the flow on POD 7 in comparison to POD 1. Conclusions Optimization of arterial inflow, regardless if performed acutely or as preconditioning, led to increased flap survival in a rat perforator flap model.

The reconstruction of lower leg and foot is very challenging due to their anatomical characteristics. In the last half century, we assisted to a dramatical change in thinking and approaching the lower leg and foot complex tissue defects. This became possible due to the new knowledge in vascular anatomy and advances in microsurgical techniques and instrumentation. The main way to well treat this kind of lesions is to ensure a multidisciplinary approach by collaboration between the specialists involved in approaching them. That’s why, in the later part of the last millennium, a new specialty appeared: Orthoplastic Surgery. Orthoplastic extremity reconstructive surgery may be addressed to the treatment of traumatic, oncologic, and septic conditions. This paper will discuss the timing of tissue transfer and the armamentarium of tissue reconstructive techniques for surgery of the lower leg and foot, from traditional flaps to the modern perforator flaps.