Propeller flaps for leg reconstruction

Reconstruction Using Perforator Propeller Flaps After Malignant Melanoma Resection of the Lower Extremity

Introduction: Surgical excision with margin of 2 cm is the treatment of choice in malignant cutaneous melanoma when Breslow index is >1 mm. When located on the lower limb, these resections can lead to large defects that require complex reconstruction in order to salvage the limb. The use of propeller-perforator flaps has multiple advantages such as the preservation of adjacent muscles, decrease in morbidity in the donor site, and good aesthetic and functional results. Our objective is to expose our experience and results with the use of propeller-perforator flaps for coverage of this kind of defects. Materials and Methods: Patients with malignant cutaneous melanoma of the lower limb who required reconstruction with a propeller-perforator flap between the years 2015 and 2021 in our plastic surgery department were included in this retrospective research. Demographic, reconstructive, oncologic, and functional data were collected and analyzed. Results: The cohort of 22 patients showed 100% of successful reconstructive outcomes. Only 2 patients experienced distal necrosis of the flap that was resolved with local dressings. Fast recovery and early capacity to walk were achieved in the majority of the patients with an average of 10.1 days until weight-baring walking. The 2-year overall and progression-free survival rates were 86.37% and 81.82%, respectively. Conclusion: The use of propeller perforator flaps for oncological defects coverage in the lower limb location has to be considered as a reliable choice as it takes less surgical time and a faster recovery. It allows limb salvage with an adequate length and functionality, with minimal donor site morbidity and a lower index of complications, contributing to improve patient's quality of life and not delaying other oncological treatments.

Keystone Flap for Closure of Skin Cancer Defects on the Upper Extremity

Background: We sought to examine the efficacy of the Keystone Design Perforator Island Flap (KDPIF) for the reconstruction of skin cancer excision defects isolated to the upper extremity. In particular, to examine the size of defects repaired and the complications associated with the keystone flap procedure isolated to the upper extremity. Methods: This is a retrospective chart review including all patients older than 18 years of age who received a KDPIF procedure between February 2013 and February 2019 for the oncologic reconstruction of skin cancer defects isolated to the upper extremities by a single surgeon. All procedures were done according to the original description by Behan. Results: A total of 32 patients, 18 (56%) male and 14 (44%) female, received 35 keystone flaps between February 2013 and February 2019. The mean age of the males and females was 70.5 and 79.7 years of age, respectively. Thirty-five lesions suspicious for cancer were excised and 14 (40%) basal cell carcinoma (BCC), 11 (31%) squamous cell carcinoma (SCC), 9 (26%) melanoma, and 1 (3%) actinic keratoses diagnoses were histopathologically determined. Skin defect excisions varied from 3.53 cm2 to 31.42 cm2. No intraoperative or postoperative complications occurred. Conclusions: The keystone flap is a successful versatile flap procedure with a low or absent complication rate for the reconstruction of skin cancer excision defects of various locations (eg arm, hand, elbow, forearm, shoulder, and wrist), cancer pathologies, and sizes on the upper extremity. When needed, a Doppler may successfully identify adequate perforating blood vessels for the relatively larger flaps.

A. Perforator-Based Propeller Flap with Additional Venous Pedicle for Lower Limb Reconstruction

Propeller flaps are effective reconstructive tools for small-to-medium sized defects of the lower limb and a reasonable alternative to free flaps. A major vessel of the lower limb remains undisturbed while raising the flap and the flap donor and recipient areas are addressed in the same operative field. Perforator-based propeller flaps are based on single perforator arising from a major vessel and during rotation of the larger paddle there is a possibility of kink in the venous component leading to congestion of flap. In our modification, one superficial vein of the lower limb namely the great saphenous or short saphenous vein was included in the flap territory to enhance the retrograde or antegrade venous drainage of the flap. We observed, no flap congestion or necrosis in the postoperative period. Also, the patency of the incorporated vein was confirmed using handheld and color Doppler.

Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects

BACKGROUND

Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction.

METHODS

A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes.

RESULTS

Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm2, whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm2 (P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%.

CONCLUSIONS

Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.

Comparison of propeller flaps versus skin grafts for coverage of osteocutaneous fibula free flap donor site defects

BACKGROUND

Authors compare use of propeller flaps versus skin grafts in defect coverage after fibula flap harvest.

MATERIALS AND METHODS

Retrospective review of patients who received either PFPF or STSG. Primary predictor variable was technique, and secondary predictor variables were comorbidities. Primary outcome variable was flap/graft healing, and secondary outcome variables were cosmesis, adverse events, effect on activities of daily living (ADLs), pain, additional procedures, and cost. Statistical analysis performed via independent sample t tests, ANOVA, and χ² tests. Logistic regression analysis was performed.

RESULTS

Study sample was 50 patients. PFPFs showed higher rates of success, while STSG showed increased complications and adverse events. Pain and ADLs significantly affected in STSG group. Cosmesis was better in the PFPF group, and overall cost was significantly higher in STSG group.

CONCLUSION

PFPFs show greater success rates, fewer complications, improved cosmesis, less pain, reduced cost compared to STSG for wound coverage after fibula flap harvest.

Propeller Flaps

A propeller flap is an islanded flap that reaches the recipient site through an axial rotation around its vascular axis. The degree of rotation varies from 90 degrees to 180 degrees. It is a highly reliable local reconstructive option. These flaps are simple, single-stage, easy to harvest, and not constrained by routine length-to-width ratios. Since their introduction, the technique has continued to evolve and more applications for the use of propeller flaps are being explored. In spite of their growing use in clinical practice in recent years, many reconstructive surgeons are unaware of their versatility, unsure of their safety, and apprehensive about using propeller flaps confidently. This article aims at understanding the nomenclature, key principles, biogeometry and planning, operative technical details, applications, and complications of propeller flaps.

Skin Graft Versus Local Flaps in Management of Post-burn Elbow Contracture

Introduction

Contracture is a pathological scar tissue resulting from local skin tissue damage, secondary to different local factors. It can restrict joint mobility, resulting in deformity and disability. This study aimed to investigate the outcomes of skin grafts compared to local flaps to reconstruct post-burn elbow contractures. These parameters included regaining function, range of movement, recurrence, and local wound complications.

Methodology

A retrospective study reviewed 21 patients for elbow reconstruction over 12 months. Only patients with post-burn elbow contracture were included. Other causes, including previous corrective surgery, associated elbow stiffness, and patients who opted out of post-operative physiotherapy, were excluded. Patients were categorized according to the method of coverage into three groups: graft alone (G1), local flap (G2), or combined approach (G3). 

Results

Females were three times at higher risk to suffer a burn injury, while almost half of the cases were children. Scald injury represented 81% of burn causes. G1,2,3 were used in 47.6%, 42.9% and 9.5% of cases retrospectively. The overall rate of infection was 28.6%. Hundred percent graft taken was recorded in 83.3 % of cases; however, flap take was 91.1%. After 12 months of follow-up, re-contracture was 60% and 22.8% in G1 and G2; however, the satisfaction rate was 70% and 100% in both groups retrospectively. The overall satisfaction was 85.7% in all groups.

Conclusion

Grafts and local flaps are reasonable options for post contracture release; however, flaps are superior. Coverage selection depends on the lost tissue area and exposure of underlying deep structures. Physiotherapy and patient satisfaction are crucial in the outcomes. 

Predictors of the surgical outcome of propeller perforator flap reconstruction, focusing on the effective safe distance between the perforator and the wound edge

Background

Soft tissue defects in the distal third of the leg and malleolus are difficult to cover and often require free tissue transfer, even for small-sized defects. Propeller flaps were designed as an alternative to free tissue transfer, but are reportedly associated with high complication rates. The aim of our study was to assess our institutional experience with the propeller flap technique and to predict its outcome in lower-limb reconstruction.

Methods

All patients who had undergone propeller flap reconstruction of a distal leg defect between 2013 and 2018 were included. Demographic, clinical, and follow-up data were analyzed.

Results

Complications occurred in 17 of 82 propeller flaps (20.7%), comprising 11 cases of partial necrosis and six of total necrosis. There were no significant differences in age, sex, body mass index smoking, diabetes mellitus, and soft tissue defect sites between the groups of patients with versus without flap necrosis (p > 0.05). In univariate analysis, there were also no significant differences between these two groups in the length and width of the fascial pedicle, and the ratio of the flap length to the flap width (p > 0.05). Interestingly, there were significant differences between the two groups in the distance between the flap perforator, the shortest distance from the perforator to the defect location, and the rotation angle of the flap (p < 0.05). In multivariable logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (95% CIs), the shortest distance from the perforator to the defect location was a significant risk factor for flap complications (p = 0.000; OR = 0.806). Receiver operating characteristic curve analysis showed that when the shortest distance from the flap to the wound was less than 3.5 cm, the necrosis rate of the flap was markedly increased (AUC = 76.1); this suggests that the effective safe flap–wound distance was 3.5 cm.

Conclusions

Propeller flaps are a reliable option for reconstruction in carefully selected patients with traumatic defects of the lower limb and malleolus. We found that the effective safe distance was 3.5 cm from the flap to the wound.

Perforator-based propeller flap for coverage of lower leg: Single centre experience

This study was conducted to assess outcomes of propeller flaps for reconstruction of small- to medium-sized defects in the distal third of the leg. Of 53 lower third leg defects covered using the propeller flap, 43 survived without complications. Only minor complications were seen and no flap was lost completely. The propeller flap is thus a safe option for medium-sized defects of the lower leg.

Use of soleus musculocutaneous perforator-based propeller flap for lower extremity wound coverage after osteocutaneous fibula free flap harvest

BACKGROUND

Osteocutaneous fibula free flap (OCFFF) donor sites are often covered with skin grafts, with an additional donor site, more postoperative care, and increased cost. The authors examine posterior tibial artery (PTA) based pedicled propeller flaps (PPF) as an alternative for OCFFF donor site coverage.

PATIENTS AND METHODS

Retrospective review of 16 consecutive patients from 30 to 79 years old, who underwent OCFFF reconstruction of head and neck defects (11 mandibular, 5 maxillary), with the closure of donor site with PPF based on a perforator from PTA. Mean donor site defect measured 12.9 × 5.1 cm, PPF was an elliptical design, and rotated 180 degrees in a propeller fashion, to cover donor site defect. Visual analog scale (VAS) was used to assess esthetic results, functional outcomes assessed using mobility and range of motion (ROM), and secondary complications including infections, hematomas, and seromas were recorded. Follow-up period was noted in months postoperatively. Other information collected included underlying head and neck pathology.

RESULTS

Average dimension of PPF measured 13.9 × 4.1 cm. Successful closure of donor site defects in 14 of 16 patients, with two flaps having partial necrosis, one requiring a secondary skin graft. Follow-up was 6 to 10 months, esthetic results with mean VAS 8.8 of 10, full ROM, and mobility noted. No secondary complications were observed. The most common pathology noted was squamous cell carcinoma (6 of 16 patients).

CONCLUSION

PPFs based on the soleus branch of the PTA represent an excellent alternative to skin grafts for the closure of OCFFF donor site defects.

A systematic review of the keystone design perforator island flap in the reconstruction of trunk defects

The keystone design perforator island flap can be utilized in the repair of trunk defects. A systematic review was carried out to identify the complication rates of the use of this flap to treat such defects. The MEDLINE, Embase, Cochrane Library, and PubMed Central databases were searched for articles published between January 2003 and December 2018 that reported the use of keystone design perforator island flaps in the repair of trunk defects. Study selection was conducted in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Eight articles involving a total of 54 flaps satisfied the inclusion criteria. The most frequently reported cause of trunk defects was oncologic resection (64.4%). The overall complication rate was 35.2%, and complications included infection (11.1%), wound dehiscence (7.4%), delayed healing (7.4%), and partial flap loss (1.9%). The keystone design perforator island flap is associated with a high success rate and low technical complexity. Despite minor complications, keystone design flaps could be a preferred choice for trunk reconstruction.

Propeller Flaps in the Upper Extremity: Arm and Forearm Reconstruction

The propeller flap is an island of skin that is raised on its pedicle (most commonly a single perforator) and can rotate 180 degrees to cover a soft tissue defect. Thanks to these features, the propeller flap brings reliable tissue from outside of the zone of injury while sparing the main vessels of the upper extremity. This technique limits the donor site to the same limb, captures skin characterized by having the same color and texture, does not necessarily need a microvascular anastomosis, and overall reduces the operating time and surgical cost. Our intent here is to present 27 cases with different soft tissue defects of the upper arm and forearm that have been successfully reconstructed using propeller flaps. The surgical technique, with emphasis on the anatomy of the upper arm, is described. In particular, use of a freestyle approach to customize a perforator-based propeller flap to cover defects from small to medium size is detailed. In our experience, the use of a perforator propeller flap in the upper extremity for resurfacing represents both a very reliable and aesthetically pleasant option.

Propeller Flaps of the Lower Extremity

Wounds of the lower extremity involving the distal third of the leg remain a significant challenge due to anatomic location and often poor host physiology. Perforator-based propeller flaps may provide rapid coverage of these wounds with a relatively low rate of major complications and often readily managed minor complications. A thorough vascular evaluation must be performed prior to the procedure to ensure adequate flap design and selection of the correct perforator is performed. They have the added advantage over their soft tissue free flap counterparts in that they have significantly less host morbidity with similar rates of total necrosis.

Keystone and Perforator Flaps in Reconstruction: Modifications and Updated Applications

Pedicle perforator flaps and keystone perforator island flaps provide additional tools for the reconstructive surgeon's armamentarium. Advances in understanding of vascular anatomy, dynamic nature of perforator perfusion, interperforator flow, and "hot spot" principle have led to reconstructive methods that allow for autologous tissue transfer, while limiting donor site morbidity. Further modifications in pedicle perforator flap enabled the propeller flap and freestyle perforator free flap for soft tissue reconstruction. Modifications in keystone perforator island flap increased degrees of freedom the reconstructive surgeon has for soft tissue coverage of large defects, with significant reliability, aesthetically pleasing results, and reduced donor site morbidity.

Coverage of cutaneous substance loss in the leg: Techniques and indications

Cutaneous substance loss in the leg is frequent; more often than not, it is trauma-related. It calls for complex management and necessitates the application of all current reconstruction techniques, particularly microsurgery. As regards treatment, the available therapeutic arsenal is highly diversified, ranging from a simple free flap skin graft to local and locoregional flaps. During reconstruction, the surgeon is subjected to several constraints insofar as the objectives of the operation are esthetic as well as functional. Ideally, the fineness of the skin covering the anterior side of the leg will have been scrupulously respected. Reconstruction is aimed at producing a stable and reliable cutaneous envelope while limiting the morbidity of the donor site. The development of free perforator flaps corresponds to these two criteria by producing a fine flap adapted to the cutaneous thickness of the leg and limiting any functional and esthetic sequelae at the donor site.

Our Definition of Propeller Flaps and Their Classification

The term propeller flap was introduced for the first time by Hyakusoku to define an island flap, based on a subcutaneous pedicle hub, that was rotated 90 degrees to correct scar contractures due to burns. With the popularization of perforator flaps, the propeller movement was applied for the first time to a skin island vascularized only by an isolated perforator, and the terms propeller and perforator flap were used together. Thereafter, the surgical technique of propeller flaps evolved and new applications developed. With the "Tokyo consensus," we proposed a definition and a classification schema for propeller flaps. A propeller flap was defined as an "island flap that reaches the recipient site through an axial rotation." The classification included the SPP (SPP) flap, the perforator pedicled propeller (PPP) flap, and the supercharged PPP (SCP) flap. A recent update added a new category, the axial pedicled propeller (APP) flap. Here we propose our updated and comprehensive classification of propeller flaps, taking into account the previous classification and subsequent publications. Based on their vascular pedicle, we consider the following five types of propellers: (1) SPP flap, 2.PPP flap, its subtype (2a) SCP flap, (3) APP flap, (4) muscle propeller flap, and (5) chimeric propeller flap. The variables that can be taken into account in the classification are as follows: type of nourishing pedicle, degrees of skin island rotation, position of the nourishing pedicle, artery of origin of the pedicle, and flap shape.

Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction

Reconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

The Effect of Perforator Skeletonization on Pedicled Fasciocutaneous Flaps of the Lower Extremity: A Systematic Review

Background Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity.

Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used.

Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01).

Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.

A Study of Clinical Applications of Perforator-Based Propeller Flaps in Leg Reconstructive Surgery: A Single-Center Experience of 40 Cases

Soft tissue management in lower limb poses a considerable challenge to a reconstructive plastic surgeon. Perforator-based propeller flaps can cover large wounds without sacrificing a major vascular axis and allows reconstruction using nearby similar tissues, thereby following the principle of replace like with like. This study was undertaken with the objective to look for the results of propeller flap in lower limb reconstruction and how the results can be improved. This was a retrospective study on 40 patients who underwent the reconstruction of soft tissue defects of lower limb with propeller flap. All the relevant data were collected and analyzed. Patients with soft tissue defect anywhere in the leg were included, but patients who had history of degloving injury, peripheral vascular disease, and diabetes mellitus were excluded. All these patients were divided in 2 groups according to the angle of rotation of propeller flap. Group I had 20 patients in which the flap was rotated by 150° to 180°. Group II had 20 patients, and the flap was rotated by 90° to 150°. Postoperatively, the first 2 cases in Group I showed total flap congestion and had complete necrosis, which were debrided and an alternate method was used to reconstruct. Thereafter, no patient had total flap necrosis. Minor complications were seen in 3 patients who showed transient venous congestion of the flap. Group II had no flap necrosis except for mild dehiscence, which was managed by secondary suturing. In most cases, the aesthetic result was acceptable and patients were completely satisfied. When parameters of the defect are suitable for treatment with a propeller-based local flap, this technique may be considered as the first option for surgical reconstruction. Proper planning, location of perforator with preoperative and intraoperative audio Doppler, and use of magnification would make this procedure more successful and definitely decrease the use of long-duration microvascular surgery.

Color Doppler ultrasonography targeted reconstruction using pedicled perforator flaps-a systematic review and meta-analysis

Background

Flaps are increasingly popularized in reconstructive surgery and there is need to test and increase their reliability. Color Doppler ultrasound has been stated to be valuable in flap planning. The aim of this study was to conduct a systematic review and meta-analysis of the literature of Color Doppler ultrasound targeted pedicled perforator flaps and provide information on outcomes and complication rates.

Method

A systematic review and meta-analysis were conducted for articles published until April 2017 in PubMed and Embase. We aimed to include randomized clinical trials, meta-analysis, prospective studies, case-control studies, and cohort studies written in English. We included studies where CDU was used to identify the perforator(s) prior to surgery. We evaluated the quality of the included studies using checklists recommended by the Cochrane group.

Results

From the initial 219 studies, only 12 studies using Color Doppler targeted pedicled perforator flaps in 252 cases met the inclusion and exclusion criteria. Eleven of these were case series and one a prospective study. The incidence of major complications was 8% (21/252) and minor complications was 14%, comprising of mostly necrosis 8% (24/252) and venous congestion 8% (21/252).

Conclusions

The reconstructive success rate following pedicled perforator flap reconstruction targeted by CDU appears to be high and the procedure provides a wide scope of applications and margin of safety. It is evident that the risk of venous congestion is 11 times greater in the lower extremities than the truncus, a finding that needs further attention in future studies.

Level of Evidence: Level IV, risk/prognostic study

Fasciocutaneous Propeller Flap Based on Perforating Branch of Ulnar Artery for Soft Tissue Reconstruction of the Hand and Wrist

Background

A skin defect of the hand and wrist is a common manifestation in industrial crushing injuries, traffic accidents or after excision of tumors. We reconstructed a skin defect in the ulnar aspect of the hand and wrist with a perforator-based propeller flap from the ulnar artery. The aims of our study are to evaluate the utility and effectiveness of this flap and to discuss the advantages and disadvantages of the flap in hand and wrist reconstruction with a review of the literature.

Methods

Between April 2011 and November 2016, five cases of skin defect were reconstructed with a perforator-based propeller flap from the ulnar artery. There were four males and one female. The age of patients ranged from 36 to 73 years. Skin defect sites were on the dorso-ulnar side of the hand in three cases and palmar-ulnar side of the wrist in two cases. The size of the skin defect ranged from 4 × 3 cm to 8 × 5 cm. We evaluated the viability of the flap, postoperative complication and patient's satisfaction.

Results

There was no failure of flap in all cases. The size of the flap ranged from 4 × 4 cm to 12 × 4 cm. One patient, who had a burn scar contracture, presented with limited active and passive motion of the wrist after the operation. The other patients had no complications postoperatively. Cosmetic results of the surgery were excellent in one patient, good in three patients, and fair in one patient.

Conclusions

The fasciocutaneous propeller flap based on a perforating branch of the ulnar artery is a reliable treatment option for the ulnar side skin defect of the hand and wrist.

Keystone and Pedicle Perforator Flaps in Reconstructive Surgery: New Modifications and Applications

Pedicle perforator flaps and keystone perforator island flaps are additional tools for reconstructive surgeons. Advances in understanding of vascular anatomy, the dynamic nature of perforator perfusion, inter-perforator flow and the hot-spot principle have led to reconstructive techniques that allow innovative autologous tissue transfer while limiting donor site morbidity. Further modifications of the pedicle perforator flap have led to a multitude of freestyle pedicle perforator flap options, as well as freestyle free flaps for soft tissue reconstruction. Modifications in the keystone perforator island flap have increased the degrees of freedom for soft tissue coverage of large defects, with reliable and aesthetically pleasing results.

A review and critical appraisal of central axis flaps in axillary and elbow contractures

Contractures of the axilla and elbow can produce a significant impact on quality of life by reducing the ability to perform activities of daily living. Varieties of techniques are available for resurfacing defects following contracture release but graft or flap loss, donor-site morbidity, esthetics, and recurrences are still challenges for reconstructive surgeons. Central axis "propeller" flaps based on a random, subcutaneous pedicle were first described for axillary and elbow contractures to deploy the unburnt skin of axillary dome in type I and II contractures (Kurtzman and Stern) by moving them 90° to straddle the contracting bands. This strategy provided better esthetics and avoided prolonged splinting. Over more than two decades, there have been several design modifications of these flaps with extended applications to cubital fossa. A comprehensive review of published literature on the topic is presented to discuss classifications, design modifications, and applications of such flaps in managing axillary and elbow contractures.

A systematic review of the keystone design perforator island flap in lower extremity defects

BACKGROUND

The keystone design perforator island flap is useful for the reconstruction of lower extremity defects. We performed a systematic review with the objective of identifying complication rates associated with using the keystone design perforator island flap to treat such defects.

METHODS

The MEDLINE, PubMed Central, Embase, and Cochrane databases were searched from January 2003 to August 2016 for articles describing keystone design perforator island flaps in lower extremities. The study selection was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Nine articles that involved a total of 282 keystone design perforator island flaps satisfied the inclusion criteria. In these articles, the most common cause of lower extremity defects was oncologic resection (89.0%). Most such defects were in the middle third of the lower leg (32.7%). Complications occurred in 9.6% of patients; these complications included partial flap loss (1.1%) and complete flap loss (0.7%).

CONCLUSION

Given its high success rate and low technical complexity, if applicable, the keystone design perforator island flap should be the preferred approach for lower extremity reconstruction.

Single stage management of Gustilo type III A/B tibia fractures: Fixed with nail & covered with fasciocutaneous flap

PURPOSE

To evaluate the role of immediate and definitive management of Gustilo type III A/B tibia fractures with intramedullary nailing and fasciocutaneous flap.

METHODS

From August 2010 to July 2012, 22 patients with Gustilo Grade III A/B tibia fractures were managed with a single stage treatment of ipsilateral fasciocutaneous flap & reamed intramedullary nailing and were included in the study. The severity of the injury was calculated with Ganga Hospital injury severity score.

RESULTS

The mean age of patients was 41 years and the follow-up time ranged from six months to one year. Among the 22 patients, 73% were type III B fractures with upper leg involved in 55% of them. The time interval from injury to completion of surgery was 8-14 h. The incidence of bone infection requiring secondary procedure was 9%; the major and minor soft tissue complication rate was 9% and 14% respectively. The limb salvage rate was 100%.

CONCLUSION

Multidisciplinary management of severe lower limb trauma is important and provides good outcomes. Intramedullary nailing and immediate flap fixation can achieve early bone union and good soft tissue coverage, leading to good outcomes in patient with Grade III A & B tibia fractures.

Peroneal perforator pedicle propeller flap for lower leg soft tissue defect reconstruction: Clinical applications and treatment of venous congestion

Objective To describe the characteristics of the perforator vessel in the peroneal artery of the lower leg and to explore the use of perforator pedicle propeller flaps to repair soft tissue defects in the lower leg, heel and foot. Methods This retrospective study enrolled patients with soft tissue defects of the distal lower leg, heel and foot who underwent surgery using peroneal perforator-based propeller flaps. The peroneal artery perforators were identified preoperatively by colour duplex Doppler ultrasound. The flap was designed based on the preoperatively-identified perforator location, with the posterior border of the fibula employed as an axis, and the perforator vessel as the pivot point of rotation. Patients were followed-up to determine the outcomes. Results The study analysed 36 patients (mean age, 39.7 years). The majority of the soft tissue defects were on the heel (20; 55.6%). The donor-site of the flap was closed in 11 patients by direct suturing and skin grafting was undertaken in 25 patients. Postoperative complications included venous congestion (nine patients), which was managed with delayed wound coverage and bleeding therapy. All wounds were eventually cured and the flaps were cosmetically acceptable. Conclusions The peroneal perforator pedicle propeller flap is an appropriate choice to repair soft tissue defects of the distal limbs.

A Systematic Review and Meta-Analysis of Perforator-Pedicled Propeller Flaps in Lower Extremity Defects: Identification of Risk Factors for Complications

BACKGROUND

Currently, increased interest in the perforator-pedicled propeller flap should not obscure the fact that it is, in reality, a complex procedure requiring experience and monitoring similar to free flaps. Through a meta-analysis, the authors aimed to identify the risk factors of perforator-pedicled propeller flap failure in lower extremity defects.

METHODS

The MEDLINE, PubMed Central, Embase, and Cochrane databases were searched from 1991 to May of 2014 for articles describing perforator-pedicled propeller flaps in the lower extremity. The study selection met the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Fixed-effects models were used.

RESULTS

Forty articles complied with the inclusion criteria, representing 428 perforator-pedicled propeller flaps. The most common cause was posttraumatic (55.2 percent). Most of the defects were at the distal third of the lower leg (45.6 percent). The arc of rotation was 180 degrees for 34.3 percent. Complications were found in 25.2 percent, including partial necrosis (10.2 percent) and complete necrosis (3.5 percent). Complete flap survival was found in 84.3 percent. The authors identified three significant risk factors: age older than 60 years (relative risk, 1.61; p = 0.03), diabetes (relative risk, 2.00; p = 0.02), and arteriopathy (relative risk, 3.12; p = 0.01). No significant results were found regarding smoking status other than a tendency (p = 0.06), acute cause (p = 0.59), posttraumatic cause (p = 0.97), distal third of the lower leg (p = 0.66), fascia inclusion (p = 0.70), and pedicle rotation greater than 120 degrees (p = 0.41).

CONCLUSION

Age older than 60 years, diabetes, and arteriopathy are significant risk factors of perforator-pedicled propeller flap complications in the lower extremity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Distally Based Saphenous Neurocutaneous Perforator Flap: A Versatile Donor Site for Reconstruction of Soft Tissue Defects of the Medial Malleolar Region

Repair of both simple and complex defects in the medial malleolar region continues to be a challenging task for surgeons because of the local paucity of soft tissue available for transfer. The popular neurocutaneous flap has provided a reliable and less technically demanding method for resurfacing defects of the lower extremities. We present our experience with the versatile design of the distally based saphenous neurocutaneous perforator flap to provide coverage of complex post-traumatic medial malleolar defects by harvesting multiple tissue components in various combinations. Our series included 11 patients (8 males [72.7%] and 3 females [27.3%]); mean age 39.2 (range 22 to 58) years, who were followed for a mean duration of 13.3 (range 9 to 18) months. Three flaps (27.3%) were harvested with massive subcutaneous tissue to obliterate dead space. The procedure was uneventful in 10 patients (90.9%). Venous congestion was noted in 1 patient (9.1%), in whom secondary healing was achieved with conservative treatment.

Keystone flap: versatile flap for reconstruction of limb defects

BACKGROUND

There is always a constant search for a new solution to tackle defects in the limbs. The technique has to be simple, easily reproducible and performed within a short duration. The answer is keystone island flap keystone flap is a simple, less time consuming, durable and easily reproducible option to reconstruct most of the limb defects.

AIM

The aim of this article is to study the usefulness of keystone flap in reconstruction of various upper and lower limb defects.

MATERIALS AND METHODS

This retrospective review involves study of 20 patients undergoing keystone flap reconstruction for various defects from 2012 to 2014. Patient demographic data, medical histories, comorbidities, surgical indications, defect characteristics and locations, hospitalization, complications and follow-up were evaluated and are presented as uncontrolled case series.

RESULTS

Ages of the patients were ranging from 18 to 65 y with an average of 38.75y. Among the defects, 10 were following trauma (50%), 5 were due to tumour resection (25%), 3 followed debridement of abscess (15%) and another 2 defects were due to surgical wound dehiscence (10%). The largest defect covered by this flap in our study measured 45 x 18 cm and the smallest defect was 8 x4 cm. The average intra-operative time was 45.5 min (range 20-90 min). Fourteen flaps were done to cover lower limb defects (70%), 4 for upper limb defects and 2 were for defects in the axilla. Partial flap necrosis was observed in one case. The average duration of hospital stay of patients was 3.45 d. All patients were followed until they achieved stable, healed wound.The overall success rate was 95%.

CONCLUSION

Keystone flap can be safely used to cover various limb defects with minimal pain, a sensate cover and excellent cosmetic outcome, minimizing the need for microsurgical techniques or prolonged operative time.

Reconstruction of Heel With Propeller Flap in Postfasciotomy and Popliteal Artery Revascularization State

Free flaps are still the gold standard for large defects of the lower limb, but propeller perforator flaps have become a simpler and faster alternative to free flaps because of some advantages such as reliable vascular pedicle, wide mobilization and rotation, great freedom in design, low donor site morbidity, and easy harvest with no requirement for anastomosis. But when the vessels show insufficient findings in preoperative evaluation using a Doppler probe or the vessel is injured, the surgeon should avoid performing free flap surgery to prevent flap failure and should select a propeller perforator flap as an alternative method on the condition that more than one perforator is intact. In this study, we report reconstruction of soft tissue defects of the heel with a pedicled propeller flap in postfasciotomy and popliteal artery revascularization state by making an incision on the central portion above the Achilles tendon, which can be covered by the posterior tibial artery perforator or the peroneal artery perforator based flaps. In conclusion, we showed that although the popliteal artery was injured, the soft tissue defect can be reconstructed using a perforator propeller flap if intact distal flow in the anastomosis site was confirmed.

Bilateral propeller flap closure of large meningomyelocele defects

BACKGROUND

Meningomyelocele is a defect of the spinal cord, vertebral spine, and overlying skin and is the most common form of spinal dysraphism. Multiple methods of soft tissue closure for larger myelomeningocele defects have been described, including skin grafting, random fasciocutaneous flaps, skin undermining with relaxing incisions, and musculocutaneous flaps. Most current methods for closure of defects of 8 cm and greater and kyphotic spines usually remains inadequate. In this study, we present our clinical experience with a new surgical procedure, bilateral propeller (BP) flaps based on dorsal intercostal and lumbar artery perforator, for the closure of large thoracolumbar meningomyelocele defects.

PATIENTS AND METHOD

Between January 2011 and April 2012, 7 newborns (5 males and 2 females) with thoracolumbar large meningomyelocele were included in the study. Six patients had lumbar kyphosis. Myelomeningocele defects with a mean size of 89.3 cm (range, 58.9-136.8) were closed with BP flaps.

RESULTS

All flaps survived; hematoma, seroma, wound dehiscence, flap necrosis, or infection was not observed. No patients required any surgical revisions. The patients had a follow-up of 4 to 16 months with a mean of 10 months, and no long-term complications, including necrosis of flap edges, wound breakdown, or instability, have been apparent in our series.

CONCLUSIONS

We believe that the BP flaps represent a useful tool in the management of soft tissue defects associated with especially kyphotic large thoracolumbar and lumbosacral myelomeningoceles.

Versatility of the Perforator-Based Adipose, Adipofascial, and Fasciocutaneous Flaps in Reconstruction of Distal Leg and Foot Defects

Reconstruction of the distal leg, ankle, and foot is challenging, and local perforator flaps have emerged as valuable options. The aim of the present study was to evaluate the outcomes of local perforator flaps in the distal lower extremity. A total of 14 local perforator flaps were used in 12 patients (9 males [75%] and 3 females [25%], aged 19 to 83 years). The etiologies included 7 motor vehicle accidents (50%), 2 acute burns (14.29%), 2 chronic wounds (14.29%), 1 postburn contracture (7.14%), 1 gunshot wound (7.14%), and 1 malignancy (7.14%). The defects were localized to the mid-leg in 3 cases (21.43%), ankle in 4 (28.57%), calcaneus in 4 (28.57%), and foot in 3 (21.43%). A peroneal artery perforator flap (11 sites [78.57%]) or a posterior tibial artery perforator flap (3 sites [21.43%]) was used. Of the 14 flaps, 8 (57.14%) were fasciocutaneous, 4 (28.57%) were adipofascial, and 2 (14.29%) were adipose. The flap transfers were rotational in 9 cases (64.29%), flipped in 2 (14.29%), propeller in 2 (14.29%), and transcrural in 1 (7.14%). The flap dimensions ranged from 8 cm × 5 cm to 22 cm × 5 cm. Finally, 12 flaps (85.71%) remained viable, 1 (7.14%) had partially sloughed, and 1 (7.14%) had completely died owing to a hypercoagulable state. Overall, 13 flaps (92.86%) had good outcomes after a median follow-up period of 19 (range 12 to 37) months. Perforator flaps in the lower extremity are versatile in terms of size, design, composition, and axis of rotation. They are reliable and safe when used to reconstruct local defects.

Perforator pedicled propeller flaps for soft tissue coverage of lower leg and foot defects

OBJECTIVE

To investigate the efficiency of perforator pedicled propeller flaps for soft tissue coverage of lower leg and foot defects.

METHODS

Twenty patients (12 male, 8 females; mean age 28 years, range, 5-75) with soft tissue defects of the lower leg and foot were retrospectively reviewed. Their defects had been repaired with perforator pedicled propeller flaps from September 2011 to October 2013 and included five cases of injuries caused by spokes, four of infection with postoperative skin necrosis, two of dorsal skin defects caused by heavy objects and nine caused by car accidents. The areas of soft tissue defect were from 2 cm × 8 cm to 10 cm × 20 cm. Fifteen cases had terminal branch of the peroneal artery perforator flaps and five posterior tibia artery perforator flaps, flap size ranging from 5 cm × 11 cm to 12 cm × 28 cm. Color Doppler ultrasound was used to locate all perforator vessels, the calibers of which ranged from 0.8 mm to 1.0 mm.

RESULTS

The intraoperative coincidence rate of the color Doppler ultrasound was 96.7%. The donor sites were sutured directly in 12 cases and skin grafted in 8. One case had a venous crisis within 24 h that was treated by removal some sutures and drainage. All cases were followed up for 1-18 months; all flaps survived well and pedicles had a satisfactory appearance. The patients were extremely satisfied with the results for repair.

CONCLUSION

Perforator pedicled propeller flaps have the advantages over other pedicle flap of being simple, safe, and effective and not involving vascular anastomosis.

Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique

BACKGROUND

Distally based perforator propeller sural flaps that pedicled on an isolated perforator from the peroneal artery or posterior tibial artery are a versatile local reconstructive option for defects of the foot and ankle region. However, flap venous congestion is yet a difficult problem after operation. We hypothesize that containing some adipofascial tissues around the axial perforator can preserve some tiny venous return routes, improve venous drainage, and ultimately enhance flap safety in distally based sural flaps.

METHODS

A prospective case series of 12 patients undergoing distally based perforator sural flaps for foot and ankle coverage were included in this study from January 2008 to December 2010. There were 7 posterior tibial artery perforator flaps from the posteromedial sural region and 5 peroneal artery perforator flaps from the posterolateral sural region. After identifying the proper viable perforator during operation as the pivot point, the whole flap was designed in an eccentric propeller shape. The proximal larger blade was a fasciocutaneous flap, whereas the distal smaller blade was a subdermal vascular plexus flap, preserving at least a quarter area of adipofascial tissue intact around the perforator. Postoperatively, flap swelling was classified into a 5-grade assessment scale. Flap survival, complications, and patient functional recovery were evaluated.

RESULTS

The proximal fasciocutaneous flap measured 4 × 8 to 6 × 18 cm (mean, 57.8 cm), and the distal subdermal cutaneous flap measured 2 × 2 to 4 × 4 cm (mean, 9.2 cm). The flaps were rotated 160 to 180 degrees. Postoperatively, flap swelling was noted under grade 2 in 9 cases, grade 3 in 2, and grade 4 in 1 with some distal superficial skin necrosis, which occurred in the largest flap in our series. All flaps survived uneventfully. After a mean of 13 months of follow-up, the wounds were cured successfully. All patients recovered walking and shoe wearing function.

CONCLUSION

Keeping a quadrant adipofascial tissue around the distal pivot perforator to form a perforator-adipofascial-pedicle can preserve more venous return routes and relieve flap swelling. This technique should be recommended in distally perforator-pedicled propeller flaps because it enhances flap safety yet does not increase the difficulty of 180-degree rotation.

Perforator based propeller flaps in limb reconstructive surgery: clinical application and literature review

The reconstruction of loss of substance due to trauma or oncological excision may have relevant functional and aesthetic implications. We report our experience in twenty-one cases of propeller flaps for the treatment of loss of substance of the upper and lower limbs. The etiology of defect was tumor excision in nine cases, trauma in seven cases, surgical wound complications in four cases, and chronic osteomyelitis in one case. Clinical results were favorable in most cases and eighteen flaps survived. We observed an overall complication rate of 33% with four cases of superficial epidermolysis that spontaneously healed and three cases of partial flap loss ranging from 10 to 50% that required surgical revision by means of skin graft (two cases) or ALT free flap (one case). Propeller flap harvesting requires great care and experience, and potential complications may occur even in expert hands. When indicated by the characteristic of the defect, these flaps can be a useful surgical option for the treatment of loss of substance of upper and lower limbs.

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

Background:

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent.

Materials and Methods:

We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series.

Results:

63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.

Conclusion:

Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects.

Level of Evidence:

Therapeutic IV.

Propeller flaps in the closure of free fibula flap donor site skin defects

The free fibula is a versatile and commonly used free flap in microvascular reconstruction. It allows for reconstruction of both bone and soft tissue defects. In head and neck reconstruction, the skin paddle harvested along with the flap allows for the reconstruction of skin or oral mucosal defects. After skin paddle harvest, the donor site can be closed primarily or with skin grafts. Grafting the donor area is the common method used. However, this could lead to delayed healing because of the poor graft over the area of peroneal tendons. Propeller flaps have been extensively reported for closure of leg skin defects. We report a series of 10 patients in whom we used a local propeller flap for the closure of the fibula flap skin donor site. The donor defects could be satisfactorily closed without the need of a skin graft in 9 patients. This method is simple, reliable, and suitable for closing small to medium defects.

Freestyle propeller flaps from the lower abdomen: a valuable reconstructive option for proximal thigh defects

The concepts of freestyle flap design allows for flap creation from virtually every place in the body. Descriptions of named flaps based on their arterial origin are commonly described in the literature, allowing for predictable flap design. However, in certain cases, isolating a flap based on a Doppler signal and retrograde perforator dissection will allow for appropriate flap creation and wound coverage. We describe a 52-year-old female with a chronic open wound that failed wound care and local soft tissue rearrangement. This led to detection of a strong perforator signal in the lower lateral abdomen prompting the use of a freestyle propeller flap. The patient recovered without complication. Twelve-month follow-up demonstrated trunk and lower extremity mobility without impairment. We describe a successful and novel use of a rare, unnamed perforator from the lower, lateral abdomen by employing the freestyle propeller flap for coverage of a proximal thigh wound.

Bone propeller flap: a staged procedure

The ideal reconstruction technique for complex defects of the lower limb consists of replacing tissue with similar tissue in an attempt to achieve a good functional result. A 23-year-old white male sustained a crush injury with a grade IIIB open ankle dislocation. After open reduction and fixation, the patient developed severe osteomyelitis at the tibiotalar joint requiring a staged and radical debridement with a substantial combined soft tissue and bony defect over the distal tibia, fibula, and talus area. The reconstructive approach consisted of a modified model of the propeller flap, implementing the spare part concept in a 2-stage procedure using a prefabricated and vascularized "double-barrel" fibular graft. At 17 months postoperatively, a plain radiograph showed bony union with complete and stable coverage of the soft tissue defect. The patient was fully weightbearing. In conclusion, there is evidence to suggest that the established concept of a soft tissue propeller flap can be implemented on bone.

Free-style puzzle flap: the concept of recycling a perforator flap

Theoretically, a flap can be supplied by any perforator based on the angiosome theory. In this study, the technique of free-style perforator flap dissection was used to harvest a pedicled or free skin flap from a previous free flap for a second difficult reconstruction. The authors call this a free-style puzzle flap. For the past 3 years, the authors treated 13 patients in whom 12 pedicled free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects at various anatomical locations. One free-style free puzzle flap was harvested from a previous anterolateral thigh flap for buccal cancer to reconstruct a foot defect. Total flap survival was attained in 12 of 13 flaps. One transferred flap failed completely. This patient had received postoperative radiotherapy after the initial cancer ablation and free anterolateral thigh flap reconstruction. Another free flap was used to close and reconstruct the wound. All the donor sites could be closed primarily. The free-style puzzle flap, harvested from a previous redundant free flap and used as a perforator flap to reconstruct a new defect, has proven to be versatile and reliable. When indicated, it is an alternative donor site for further reconstruction of soft-tissue defects.

Reconstruction of soft tissue defects in the extremities with a pedicled perforator flap: series of 25 patients

Since the introduction of perforator-based flaps, new flaps have been described for reconstruction of soft tissue defects in the extremities. Pedicled perforator flaps, often called propeller flaps, are based on a single perforator and are local axial flaps that can be rotated up to 180(0) with the single perforator as the pivotal point. Pedicle perforator flaps have gained popularity because they have a shorter operating time than free flaps. However, some concern has been raised about their reliability. Here we report our results of 11 soft tissue reconstructions in the lower leg and 14 in the upper extremity. The defects were mostly traumatic or caused by release of burn scars. The mean size of the flaps in the lower leg was 52 cm(2) (range 126-15 cm(2)). In the upper extremity it was 24 cm(2) (range 12-35 cm(2)). All patients were followed until the wound had healed. In the upper extremity there was only one partial necrosis of the flap, and one patient had an infected wound. One haematoma was evacuated postoperatively, and all the rest healed uneventfully. In the lower leg we had one total necrosis and one partial necrosis of the flap and one infected wound. A free scapular flap was used for salvage in one case, and revision and skin grafting in two. The pedicled perforator flap is reliable, particularly in the upper extremity. The operation is quick and can be done under regional anaesthesia. The flap is thin and has a local texture that gives a good functional and aesthetic result. The pedicled perforator flap is a little unpredictable in the lower leg, probably because the directions of the vessels that arise from the perforator are not consistent.

Propeller perforator flaps in distal lower leg: evolution and clinical applications

Simple or complex defects in the lower leg, and especially in its distal third, continue to be a challenging task for reconstructive surgeons. A variety of flaps were used in the attempt to achieve excellence in form and function. After a long evolution of the reconstructive methods, including random pattern flaps, axial pattern flaps, musculocutaneous flaps and fasciocutaneous flaps, the reappraisal of the works of Manchot and Salmon by Taylor and Palmer opened the era of perforator flaps. This era began in 1989, when Koshima and Soeda, and separately Kroll and Rosenfield described the first applications of such flaps. Perforator flaps, whether free or pedicled, gained a high popularity due to their main advantages: decreasing donor-site morbidity and improving aesthetic outcome. The use as local perforator flaps in lower leg was possible due to a better understanding of the cutaneous circulation, leg vascular anatomy, angiosome and perforasome concepts, as well as innovations in flaps design. This review will describe the evolution, anatomy, flap design, and technique of the main distally pedicled propeller perforator flaps used in the reconstruction of defects in the distal third of the lower leg and foot.