Combined Use of a Pedicled Medial Sural Artery Perforator Flap and a V-Y Advancement Flap Based on an Anterior Tibial Artery Perforator for Pretibial Defect Reconstruction: A Case Report.

Reconstruction of pretibial defects remains challenging due to frequent bone exposure, lack of local flap options, and thin soft tissue coverage. These factors make achieving durable and aesthetically pleasing coverage difficult, often necessitating the use of free flaps to ensure successful reconstruction. This case report presents the case of a 68-year-old woman with a pretibial undifferentiated pleomorphic sarcoma treated with neoadjuvant radiotherapy and wide local excision, resulting in a 12 × 10 cm soft tissue defect with tibial bone exposure. Reconstruction was achieved using a combination of two perforator-based local flaps: A pedicled medial sural artery perforator (MSAP) flap for the medial aspect and a V-Y advancement flap based on an anterior tibial artery perforator for the lateral aspect. Postoperative recovery was uneventful. At one-year follow-up, the reconstruction showed stable coverage, satisfactory contour, and no signs of recurrence of the tumor or lymphedema. The combination of local perforator flaps offers a reliable and aesthetically favorable solution for complex pretibial defects. It allows surgeons to avoid microsurgical procedures, thereby reducing operative time, technical demands, and perioperative risks. This case highlights the potential of combining local flaps, preserving uninvolved donor sites, and minimizing overall morbidity. This solution represents a practical and effective alternative to free flap reconstruction and may contribute to expanding the reconstructive options available for managing complex lower limb defects.