Axial propeller flaps: A proposal for update of the "Tokyo consensus on propeller flaps"

Clinical effects of different types of flaps selected according to local conditions in the treatment of diabetic foot defects

BACKGROUND

The repair of diabetic foot defects (DFD) is a major challenge in clinical practice. The purpose of this study was to investigate the difference in clinical efficacy of different flap techniques in repairing DFD wounds, and to compare the difference in clinical efficacy of anterolateral thigh perforator flap (ALTP) in repairing DFD and non-DFD.

METHODS

This study is a retrospective clinical study of different types of flap reconstruction in patients with DFD admitted to our hospital from January 2010 to December 2021. A total of 40 patients with DFD and 43 patients with non-DFD were included in this study. Detailed preoperative basic information, intraoperative details, postoperative complications and long-term follow-up results were collected.

RESULT

The comorbidities, wound infection and wound duration of DFD group were more serious than those of non-DFD group. In addition, the incidence of complications was higher in DFD group, the wound healing time was longer, the aesthetic evaluation, the functional recovery rate of ankle joint and the sensory recovery effect of flaps were worse.

CONCLUSION

In this study, it is concluded that different flap techniques can obtain better clinical efficacy in repairing DFD wounds. Compared with non-DFD wounds, the postoperative risk of DFD wounds using free ALTP flaps is higher, but the risk can be reduced by reasonable preoperative vascular examination. Free flap can deal with various irregular wounds and provide more options for clinical repair.

LEVEL OF EVIDENCE

III, Case-control study.

Superficial circumflex iliac artery perforator propeller flap for penoscrotal extramammary Paget's disease

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare intra-epidermal adenocarcinoma, and reconstruction of the penoscrotal region remains a clinical challenge. The superficial circumflex iliac artery perforator (SCIP) flap has been successfully used as a free flap, while its application as a propeller flap in the reconstruction of penoscrotal EMPD defect is rarely reported. The objective was to evaluate the safety and efficacy of the SCIP propeller flap in the reconstruction of penoscrotal defects in EMPD.

METHODS

Between September 2010 and August 2022, consecutive patients diagnosed with penoscrotal EMPD were enrolled. All patients underwent penoscrotal EMPD excision and reconstruction with SCIP propeller flap combined with other flaps or skin grafts on individual defects. Demographic information, surgical parameters, postoperative complications, patient satisfaction, and recurrence rates were analyzed.

RESULTS

Twenty-four patients (mean age, 73 ± 8.8 years; mean BMI, 23.98 ± 3.62 kg/m2) with 33 SCIP propeller flaps (mean size 120.1 cm2; range, 24-208 cm2) were included, and the mean defect size was 67.4 cm2 (range, 12-255 cm2). The mean operative duration was 385.4 ± 146.8 min. Fifteen patients received autologous full-thickness skin grafts, and four received other flaps simultaneously. All flaps survived without total or partial loss, and all donor sites achieved primary closure, though local hematoma (one case) and limited skin graft necrosis (two cases) were observed. All patients experienced complete wound healing and maintained penoscrotal morphology and function without recurrent lesions over a mean follow-up of 59 months.

CONCLUSIONS

The SCIP propeller flap seems a safe and effective reconstructive method for penoscrotal EMPD.

LEVEL OF EVIDENCE

IV.

Ortho-oncoplastic surgery in foot and ankle: A narrative overview on reconstruction of soft-tissue defects after oncologic resections

INTRODUCTION

Malignant tumors of the foot are rare, and treatment strategies are challenging considering the complex anatomy of this area. In recent years, dramatic advances in technology and collaborations between different specialties (such as orthopedic, oncology, radiology, plastic, and vascular surgery) significantly changed the approach to complex malignant tumors without resorting to limb removal. The combination of the strengths of both orthopedic surgery and plastic surgery constitutes the modern definition of "orthoplasty." The aim of this review article is to provide treatment strategies that are available for reconstruction of foot and ankle in limb-salvage surgery after tumor resection, with a specific focus on microsurgical techniques in plastic surgery.

METHODS

We conducted a comprehensive search for relevant papers across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with small and large soft tissue defects. Indications, pros and cons, and technique tips are discussed for each type of reconstructive technique.

RESULTS

The search was done using literature of the past 30 years (from 1990 to date), resulting in about 725 articles describing over 2000 cases. Cutaneous flaps included lateral supramalleolar flap, medial plantar flap, reverse sural neurocutaneous island flap, medial leg flap, and lateral leg flap. Free flaps included anterolateral thigh flap, radial forearm flap, latissimus dorsi flap, gracilis muscle flap, lateral arm flap, and rectus abdominis flap.

CONCLUSIONS

The orthoplastic approach in musculoskeletal oncology is a collaborative model of orthopedic and plastic surgeons working together, resulting in a higher rate of successful limb salvage in patients at risk for amputation. Protocols, biologic substitutes, and surgical techniques are largely improved in the last decades increasing the possibility of functional reconstruction. Microsurgical strategies represent the new frontiers in these demanding reconstructions.

Versatility of unilateral propeller groin flap for coverage of large scrotal defects and its impact on testicular function

Background

There are many options for scrotal reconstruction, each having its own benefits and drawbacks. In the last years, the introduction of the propeller flaps gained great popularity, while the use of groin flap as propeller in scrotal reconstruction remains anecdotal, with only a few cases reported in the literature.

Objectives

In this research, we study the versatility of unilateral propeller groin flaps in the reconstruction of large scrotal defects.

Patients and Methods

This study was done on 10 patients with scrotal defects who were admitted to the plastic unit of the general surgery department at Benha University Hospital from 2019 to 2021 for scrotal reconstruction.

Results

All surgeries were successful with a mean operative time of 103.5 min, ranging from 90 to 130 min. All flaps survived well with no flap necrosis, and only one case showed flap congestion. Donor site healed well with the scar hidden in a natural crease, with no affection on the testicular functions.

Conclusions

The use of groin flap as a propeller allows for free movement and rotation of the flap, which allows for better coverage of a large scrotal defect with good vascularity, lesser complications, no need for further operations to separate the pedicle, and the lowest donor site morbidity.

Level of evidence

Level IV, therapeutic study

Propeller Flaps in the Head and Neck

Propeller flaps have significantly expanded the reconstruction possibilities in the head and neck region. They allow for increased flap mobility and better scar concealing, and/or to perform a one-stage reconstruction with local tissue of similar color and texture, where multiple surgeries would be needed with traditional flaps or even free flaps would be required. This article describes the main propeller flaps for one-stage reconstruction in the head-neck region (facial artery perforator, supratrochlear artery axial perforator, deep lingual artery axial perforator, and anterior supraclavicular artery perforator flaps), their indications, and possible complications. Aesthetic and functional results of propeller flaps in the head and neck region are very good and the complication rate is low, but due to their surgical complexity and the availability of many simpler local flaps, they are indicated only in select cases where local flaps are unavailable or would require multiple staged procedures to complete the construction.

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.