Reconstruction of soft tissue defects of the distal third of the leg, ankle and foot using perforator-based local flaps: anatomical-clinical narrative review

Abstract

Introduction: Soft tissue defects of the distal third of the leg, ankle and foot are a reconstructive challenge due to the limited availability of local tissue, frequent exposure of deep structures and the need to preserve the main vascular axes. Objective: To synthesize the anatomical-clinical evidence on anatomically identified perforator-based local flaps and compare them with regional or free alternatives in terms of survival and complications. Methodology: A narrative review guided by SANRA was conducted, with a search in PubMed/MEDLINE, Scopus, Web of Science, Embase, and Cochrane Library, limited to publications from 2016 to 2026 in Spanish and English. We included relevant clinical studies, comparative studies, systematic reviews/meta-analyses, and narrative reviews; the selection flow was documented descriptively with a scheme adapted from PRISMA 2020, with no formal counts available. Results: The included evidence shows high survival and low total failure of local perforator flaps in small and medium defects. The comparative meta-analysis reported comparable global failure between free flap and perforator helix flap, although with greater partial necrosis in the latter. In comparative studies and clinical series, venous congestion appears as a relevant and cross-sectional complication, also observed in the reverse sural flap. Conclusions: Local perforator-based flaps are a reasonable first-line option in small and medium defects, especially where microsurgery is not available. No clear reduction in complications compared to the free flap was demonstrated; The decision should be individualized according to the size of the defect, comorbidity, availability of microsurgery, and team experience.