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Mishra JK, Sahu SA, Bodhey NK, Sindhuja A, V. A. Perforator-Based Propeller Flap with Additional Venous Pedicle for Lower Limb Reconstruction. Indian J Plast Surg 2023; 56:373-377. [PMID: 37705822 PMCID: PMC10497330 DOI: 10.1055/s-0043-1769113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
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.
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Affiliation(s)
- Jiten Kumar Mishra
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Shamendra Anand Sahu
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Narendra Kuber Bodhey
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Abi Sindhuja
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Abhijith V.
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Giunta G, Kapila A, Brussaard C, Nistor A, De Baerdemaeker R, Zeltzer A, Hamdi M. Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study. J Plast Reconstr Aesthet Surg 2023; 83:165-171. [PMID: 37276735 DOI: 10.1016/j.bjps.2023.04.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA). METHODS A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin. RESULTS A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%). CONCLUSIONS This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.
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Affiliation(s)
- Gabriele Giunta
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Ayush Kapila
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Carola Brussaard
- Department of Radiology, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Alexandru Nistor
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Randy De Baerdemaeker
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Assaf Zeltzer
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Moustapha Hamdi
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
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Kelahmetoglu O, Mehdizade T, Unal M, Keles MK, Guneren E. Free ALT Perforator Flap in Nonobese Patients: The Recontouring of Soft Tissue Defects Around Foot. Indian J Orthop 2021; 56:445-451. [PMID: 35251508 PMCID: PMC8854467 DOI: 10.1007/s43465-021-00518-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/04/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The anterolateral thigh (ALT) perforator flap is well-described and versatile option for reconstruction of soft tissue defects around foot and ankle. This retrospective review was performed for reconstruction of soft tissue defects around foot with ALT perforator flaps in patients with normal and overweight body mass index (BMI). METHODS Between January 2016 and November 2020, ALT flaps were used in 30 patients for foot defects. RESULTS Etiologic factors were trauma (18 patients), diabetic foot ulcer (6 patients), tumor (3 patients), infection (2 patients) and burn contracture (1 patient). Mean body mass index (BMI) value was 24.9 ± 4.1 (17-30). Mean flap dimension was 145 ± 86 (40-420) cm2. Recipient vessels were anterior tibial artery in 17 patients (56%), posterior tibial artery in 12 patients (40%), reversed flow dorsalis pedis artery in 1 patient (3.3%). In 24 patients (80%), 2 vein anastomoses were done. Debulking were applied in two patients (6.6%). Donor area was grafted in four patients (13.3%). Mean flap score was 1.25 ± 0.5. Mean flap thickness was 10 ± 2 (7-14) mm. Visual Analogue Scale (VAS) score was 7.75 ± 1.04 (6-10). The patients were followed up for a mean of 14 ± 11 (1-30) months. CONCLUSION We think that ALT flap is still reliable and precious option because it provides ideal soft tissue reconstruction by means of recontouring of foot in nonobese patients.
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Affiliation(s)
- Osman Kelahmetoglu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Yeditepe University, Istanbul, Turkey
| | - Turan Mehdizade
- Department of Plastic, Reconstructive and Aesthetic Surgery, Bezmialem Vakif University, Istanbul, Turkey
| | - Mustafa Unal
- Department of Plastic, Reconstructive and Aesthetic Surgery, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Ethem Guneren
- Department of Plastic, Reconstructive and Aesthetic Surgery, Bezmialem Vakif University, Istanbul, Turkey
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Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity. Ann Plast Surg 2021; 84:238-245. [PMID: 31513085 DOI: 10.1097/sap.0000000000001977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.
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Bulla A, Delgove A, De Luca L, Pelissier P, Casoli V. The esthetic outcome of lower limb reconstruction. ANN CHIR PLAST ESTH 2020; 65:655-666. [PMID: 32800462 DOI: 10.1016/j.anplas.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction. OBJECTIVES This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction. DATA SOURCES A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits. STUDY ELIGIBILITY CRITERIA All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search. PARTICIPANTS, AND INTERVENTIONS One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed. RESULTS We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps. LIMITATIONS The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed. CONCLUSIONS Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.
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Affiliation(s)
- A Bulla
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France.
| | - A Delgove
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - L De Luca
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - P Pelissier
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - V Casoli
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
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Pignatti M, Ogawa R, Mateev M, Georgescu AV, Balakrishnan G, Ono S, Cubison T, Pinto V, D'Arpa S, Koshima I, Hyakusoku H, Hallock GG. Our Definition of Propeller Flaps and Their Classification. Semin Plast Surg 2020; 34:139-144. [PMID: 33041682 PMCID: PMC7542214 DOI: 10.1055/s-0040-1715158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Marco Pignatti
- Department of Plastic Surgery, Policlinico di Sant'Orsola - DIMES, University of Bologna, Bologna, Italy
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Musa Mateev
- Department of Plastic Surgery, Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan
| | - Alexandru V. Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Rehabilitation, University of Medicine Iuliu Hatieganu, Cluj-Napoca, Romania
| | - Govindasamy Balakrishnan
- Plastic, Hand & Microvascular Surgery, Right Hospitals, Dr. M.G.R. Medical University, Chennai, Tamil Nadu, India
| | - Shimpei Ono
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Tania Cubison
- Department of Plastic Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Valentina Pinto
- Department of Plastic Surgery, Policlinico di Sant'Orsola - DIMES, University of Bologna, Bologna, Italy
| | - Salvatore D'Arpa
- Division of Plastic and Reconstructive Surgery, Department of Surgical, Oncological, and Oral Sciences (DICHIORONS), University of Palermo, Palermo, Italy
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiko Hyakusoku
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Geoffrey G. Hallock
- Division of Plastic Surgery, Sacred Heart Campus, St. Luke's Hospital, Allentown, Pennsylvania
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Lese I, Grobbelaar AO, Sabau D, Georgescu AV, Constantinescu MA, Olariu R. The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations. J Bone Joint Surg Am 2020; 102:510-518. [PMID: 31804239 DOI: 10.2106/jbjs.19.00648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Defects in the distal third of the leg are difficult to cover and often require free tissue transfer, even for defects of limited sizes. Propeller flaps have been designed specifically as an alternative to free tissue transfer but at times have been associated with unacceptably high complication rates. We therefore aimed to prospectively assess our own institutional experience with this technique and to define its role in lower-limb reconstruction. METHODS All patients who had been managed with reconstruction of the distal part of the leg with a propeller flap between 2014 and 2017 were included in the study. Demographic, clinical, and follow-up data on the patients and surgical procedures were recorded with special focus on the complication profile. RESULTS Twenty-six patients underwent propeller flap reconstruction of the distal part of the leg: 12 flaps were based on the posterior tibial artery, and 14 were based on the peroneal artery. Postoperative complications developed in association with 1 of the 12 flaps based on the posterior tibial artery, compared with 8 of the 14 flaps based on the peroneal artery (p = 0.015). Moreover, the presence of a higher Charlson comorbidity index (≥2) was strongly associated with the development of postoperative complications (p < 0.001). CONCLUSIONS Propeller flaps are a reliable option for traumatic reconstruction in carefully selected patients with lower-limb defects. In our experience, the rate of complications was higher for propeller flaps based on the peroneal artery and for patients with a Charlson comorbidity index of ≥2, whereas posterior tibial artery-based propeller flap reconstruction was a reliable surgical option for patients with a small defect in the distal third of the lower limb. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Adriaan O Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Dan Sabau
- Department III, Surgical Clinic, Lucian Blaga University of Sibiu, Sibiu, Romania
| | - Alexandru V Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, and Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, University of Medicine Iuliu Hatieganu, Cluj Napoca, Romania
| | - Mihai A Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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Mb O, Aksan T, Ertekin C, Tezcan M. Coverage of exposed bone and hardware of the medial malleolus with tibialis posterior artery perforator flap after ankle fracture surgery complications. Int Wound J 2019; 17:429-435. [PMID: 31880089 DOI: 10.1111/iwj.13289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/24/2019] [Accepted: 12/05/2019] [Indexed: 11/26/2022] Open
Abstract
Ankle fractures are among the most common orthopaedic surgical procedures. Skin-related complications of these surgeries are difficult to reconstruct due to the inadequacy of soft tissue in the region. Although free flaps are generally considered as the first choice in reconstruction of this area, free flaps may not be a suitable option especially in patients with advanced age and comorbidities. Perforator flaps offer a fast and safe alternative in lower extremity reconstruction. In the literature, there are a limited number of studies using perforator flaps in managing the postoperative complications of the lower extremity trauma surgeries. In our study, we report our experience with reconstruction of soft-tissue defects of medial malleolar region using posterior tibial artery perforator flap for postoperative complications of ankle fracture-related surgeries.
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Affiliation(s)
- Ozturk Mb
- Department of Plastic and Reconstructive Surgery, T.C. Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Tolga Aksan
- Department of Plastic and Reconstructive Surgery, T.C. Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Cengiz Ertekin
- Department of Plastic and Reconstructive Surgery, T.C. Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Tezcan
- Department of Plastic and Reconstructive Surgery, T.C. Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
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Innocenti M, Dell'Acqua I, Famiglietti M, Vignini L, Menichini G, Ghezzi S. Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases. Injury 2019; 50 Suppl 5:S11-S16. [PMID: 31706586 DOI: 10.1016/j.injury.2019.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects. PATIENTS AND METHODS 179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques. RESULTS In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps. CONCLUSIONS Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.
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Affiliation(s)
- Marco Innocenti
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy.
| | - Irene Dell'Acqua
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Matteo Famiglietti
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Livia Vignini
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Giulio Menichini
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Serena Ghezzi
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy.
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Algorithm for Free Perforator Flap Selection in Lower Extremity Reconstruction Based on 563 Cases. Plast Reconstr Surg 2019; 144:1202-1213. [DOI: 10.1097/prs.0000000000006167] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shahabuddin SF, Khurram MF. A Study of Clinical Applications of Perforator-Based Propeller Flaps in Leg Reconstructive Surgery: A Single-Center Experience of 40 Cases. INT J LOW EXTR WOUND 2019; 19:70-77. [DOI: 10.1177/1534734619876797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | - Mohammed Fahud Khurram
- Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
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12
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Dhua S, Manashree S, Tilak BG. The Clinical Outcome of Perforator Based Sural Artery and Propeller Flaps in Reconstruction of Soft Tissue of Extremities. World J Plast Surg 2019. [PMID: 30873356 DOI: 10.29252/wjps.8.1.3.] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2022] Open
Abstract
BACKGROUND The reconstructive options for the soft tissues in extremities present serious challenges due to thin non-expendable soft tissues and predisposition to massive edema formation, thus frequently requiring flap cover. This study was undertaken to assess the outcome of a modified version of the sural artery flap with that of propeller perforator flaps for the reconstruction of lower extremities, particularly the heel defects. METHODS This prospective study was conducted on 40 consecutive patients, of which 20 treated with sural artery flap and another 20 with perforator based propeller flap cover for soft tissue reconstruction in extremities based on predefined inclusion criteria. The clinical outcome of the flap was assessed after three months. RESULTS Inclusion of the posterior tibial perforators (along with the sural artery and the peroneal artery) was shown to enhance the flap territory. The raising of the flap was quick with minimal blood loss and the modified flap had a wide arc of rotation for reconstruction of the heel defects. The younger patients regained sensation on the flap earlier, while the durability of the fasciocutaneous flap was excellent in the heel weight bearing areas. The success rate was 95% flap take. CONCLUSION Careful selection of the perforator and optimal designing of the flap result in favorable outcomes with the use of local perforator flaps for reconstruction in extremities. It provides predictable clinical outcomes with minimal donor site morbidity, is cost-effective, relatively easy technique and requires no special microsurgical setup or instruments.
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Affiliation(s)
- Subha Dhua
- Department of Plastic and Reconstructive Surgery, Vydehi Institute of Medical Science and Research Centre, Bangalore, India
| | - Sankhe Manashree
- Department of Plastic and Reconstructive Surgery, Vydehi Institute of Medical Science and Research Centre, Bangalore, India
| | - Bal Gangadhar Tilak
- Department of Plastic and Reconstructive Surgery, Vydehi Institute of Medical Science and Research Centre, Bangalore, India
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Dhua S, Manashree S, Tilak BG. The Clinical Outcome of Perforator Based Sural Artery and Propeller Flaps in Reconstruction of Soft Tissue of Extremities. World J Plast Surg 2019; 8:3-11. [PMID: 30873356 PMCID: PMC6409133 DOI: 10.29252/wjps.8.1.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The reconstructive options for the soft tissues in extremities present serious challenges due to thin non-expendable soft tissues and predisposition to massive edema formation, thus frequently requiring flap cover. This study was undertaken to assess the outcome of a modified version of the sural artery flap with that of propeller perforator flaps for the reconstruction of lower extremities, particularly the heel defects. METHODS This prospective study was conducted on 40 consecutive patients, of which 20 treated with sural artery flap and another 20 with perforator based propeller flap cover for soft tissue reconstruction in extremities based on predefined inclusion criteria. The clinical outcome of the flap was assessed after three months. RESULTS Inclusion of the posterior tibial perforators (along with the sural artery and the peroneal artery) was shown to enhance the flap territory. The raising of the flap was quick with minimal blood loss and the modified flap had a wide arc of rotation for reconstruction of the heel defects. The younger patients regained sensation on the flap earlier, while the durability of the fasciocutaneous flap was excellent in the heel weight bearing areas. The success rate was 95% flap take. CONCLUSION Careful selection of the perforator and optimal designing of the flap result in favorable outcomes with the use of local perforator flaps for reconstruction in extremities. It provides predictable clinical outcomes with minimal donor site morbidity, is cost-effective, relatively easy technique and requires no special microsurgical setup or instruments.
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Affiliation(s)
- Subha Dhua
- Corresponding Author: Subha Dhua, MBBS, MS, MCh, Associate Professor of Department of Plastic and Reconstructive Surgery, Vydehi Institute of Medical Science and Research Centre, Bangalore, India. E-mail:
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Kerfant N, Monnerie C, Henry AS, Ta P, Hu W, Letissier H, Le Nen D. Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations. Orthop Traumatol Surg Res 2018; 104:1227-1230. [PMID: 30393069 DOI: 10.1016/j.otsr.2018.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/31/2018] [Accepted: 06/17/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Covering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects. HYPOTHESIS The posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot. MATERIAL AND METHOD Patients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit. RESULTS Thirteen patients with a mean age of 46.9 years (range: 25-73 years) were reviewed after a mean follow-up of 19.5 months (range: 16-63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients. DISCUSSION The posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Nathalie Kerfant
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France.
| | - Charlotte Monnerie
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Anne-Sophie Henry
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Pierre Ta
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Weiguo Hu
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Hoel Letissier
- Service de chirurgie du membre supérieur, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - Dominique Le Nen
- Service de chirurgie du membre supérieur, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
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Jang HS, Lee YH, Kim MB, Chung JY, Seok HS, Baek GH. Fasciocutaneous Propeller Flap Based on Perforating Branch of Ulnar Artery for Soft Tissue Reconstruction of the Hand and Wrist. Clin Orthop Surg 2018; 10:74-79. [PMID: 29564050 PMCID: PMC5851857 DOI: 10.4055/cios.2018.10.1.74] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/19/2017] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Hyo Seok Jang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Min Bom Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Young Chung
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Sik Seok
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Goo Hyun Baek
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Karki D, Ahuja RB. A review and critical appraisal of central axis flaps in axillary and elbow contractures. BURNS & TRAUMA 2017; 5:13. [PMID: 28473994 PMCID: PMC5415992 DOI: 10.1186/s41038-017-0079-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/05/2017] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Durga Karki
- Department of Burns, Plastic and Maxillofacial Surgery, VM Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Rajeev B. Ahuja
- Department of Burns and Plastic Surgery, Lok Nayak Hospital and associated Maulana Azad Medical College, New Delhi, 110 002 India
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Zhong W, Lu S, Chai Y. Distally Based Saphenous Neurocutaneous Perforator Flap: A Versatile Donor Site for Reconstruction of Soft Tissue Defects of the Medial Malleolar Region. J Foot Ankle Surg 2015; 55:391-6. [PMID: 26024559 DOI: 10.1053/j.jfas.2015.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Wanrun Zhong
- Orthopedist, Department of Repair and Reconstruction Surgery, Affiliated Sixth People's Hospital of Shanghai Jiaotong University, Shanghai, China
| | - Shengdi Lu
- Orthopedist, Department of Repair and Reconstruction Surgery, Affiliated Sixth People's Hospital of Shanghai Jiaotong University, Shanghai, China
| | - Yimin Chai
- Professor, Department of Repair and Reconstruction Surgery, Affiliated Sixth People's Hospital of Shanghai Jiaotong University, Shanghai, China.
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Horta R, Valença-Filipe R, Nascimento R, Monteiro D, Silva A, Amarante JM. Perforator-based propeller flap with venous axial supercharging for reconstruction of a leg defect. Injury 2014; 45:2118-9. [PMID: 25282300 DOI: 10.1016/j.injury.2014.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 09/14/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Ricardo Horta
- Department of Plastic, Reconstructive and Maxillo-Facial Surgery, and Burn Unity, Centro Hospitalar de São João, Porto Medical School, Porto, Portugal.
| | - Rita Valença-Filipe
- Department of Plastic, Reconstructive and Maxillo-Facial Surgery, and Burn Unity, Centro Hospitalar de São João, Porto Medical School, Porto, Portugal
| | - Ricardo Nascimento
- Department of Plastic, Reconstructive and Maxillo-Facial Surgery, and Burn Unity, Centro Hospitalar de São João, Porto Medical School, Porto, Portugal
| | - Diana Monteiro
- Department of Plastic, Reconstructive and Maxillo-Facial Surgery, and Burn Unity, Centro Hospitalar de São João, Porto Medical School, Porto, Portugal
| | - Alvaro Silva
- Department of Plastic, Reconstructive and Maxillo-Facial Surgery, and Burn Unity, Centro Hospitalar de São João, Porto Medical School, Porto, Portugal
| | - José Manuel Amarante
- Department of Plastic, Reconstructive and Maxillo-Facial Surgery, and Burn Unity, Centro Hospitalar de São João, Porto Medical School, Porto, Portugal
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Perforator based propeller flaps in limb reconstructive surgery: clinical application and literature review. BIOMED RESEARCH INTERNATIONAL 2014; 2014:690649. [PMID: 25250327 PMCID: PMC4163455 DOI: 10.1155/2014/690649] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/21/2014] [Accepted: 08/17/2014] [Indexed: 11/29/2022]
Abstract
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.
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Jabir S. Algorithms in plastic surgery—expansive or restrictive? EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-014-0973-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Panse N, Sahasrabudhe P. Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction! Indian J Plast Surg 2014; 47:77-84. [PMID: 24987209 PMCID: PMC4075222 DOI: 10.4103/0970-0358.129628] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Nikhil Panse
- Department of Plastic Surgery, B.J.Government Medical College & Sassoon Hospital, Pune, Maharashtra, India
| | - Parag Sahasrabudhe
- Department of Plastic Surgery, B.J.Government Medical College & Sassoon Hospital, Pune, Maharashtra, India
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Tremp M, Largo RD, Borens O, Schaefer DJ, Kalbermatten DF. Bone propeller flap: a staged procedure. J Foot Ankle Surg 2013; 53:226-31. [PMID: 23876983 DOI: 10.1053/j.jfas.2013.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Mathias Tremp
- Department of Plastic, Reconstructive Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - René D Largo
- Department of Plastic, Reconstructive Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Olivier Borens
- Orthopedic and Traumatology Department, Septic Surgical Unit, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Dirk J Schaefer
- Department of Plastic, Reconstructive Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.
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Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN. A review of propeller flaps for distal lower extremity soft tissue reconstruction: Is flap loss too high? Microsurgery 2013; 33:578-86. [DOI: 10.1002/micr.22134] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/04/2013] [Accepted: 04/17/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Jonas A. Nelson
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - John P. Fischer
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - Philip S. Brazio
- Department of Surgery; University of Maryland School of Medicine; Baltimore MD
| | - Stephen J. Kovach
- Division of Plastic Surgery; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - Gedge D. Rosson
- Department of Plastic Surgery; Johns Hopkins Hospital; Baltimore MD
| | - Ariel N. Rad
- Department of Plastic Surgery; Johns Hopkins Hospital; Baltimore MD
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Hafeez K, Siddiqui A, Rashid HU, CH SI, Cheema TA. The posterior tibial island flap for coverage in complex injuries of the lower extremity. Microsurgery 2012; 32:539-45. [DOI: 10.1002/micr.21999] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 04/13/2012] [Indexed: 11/07/2022]
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Propeller perforator flaps in distal lower leg: evolution and clinical applications. Arch Plast Surg 2012; 39:94-105. [PMID: 22783507 PMCID: PMC3385316 DOI: 10.5999/aps.2012.39.2.94] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 01/31/2012] [Accepted: 02/01/2012] [Indexed: 12/22/2022] Open
Abstract
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.
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Bous A, Ronsmans C, Nizet JL, Jacquemin D, Nardella D. Couverture de pertes de substance du tibia distal par lambeau pédiculé perforant en hélice : deux cas cliniques. ANN CHIR PLAST ESTH 2011; 56:562-7. [DOI: 10.1016/j.anplas.2010.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 10/11/2010] [Indexed: 10/18/2022]
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Perforator-based propeller flaps treating loss of substance in the lower limb. J Orthop Traumatol 2011; 12:93-9. [PMID: 21544548 PMCID: PMC3102808 DOI: 10.1007/s10195-011-0136-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 04/07/2011] [Indexed: 11/05/2022] Open
Abstract
Background Local flaps based on perforator vessels are raising interest in reconstructive surgery of the limbs. These flaps allow efficient coverage of large wounds without the need to sacrifice a major vascular axis. The operative technique does not require microvascular anastomosis and allows reconstruction of soft tissue defects using nearby similar tissues. The aim of this study was to evaluate the clinical results of local perforator flaps in the treatment of complex lower-limb defects. Materials and methods Twenty-two local perforator flaps were retrospectively studied. Loss of substance was due to postsurgical complications in seven cases, oncological resection in six, posttraumatic defect in five, pressure sores in three, and osteomyelitis in one. Results Postoperatively, two patients showed partial flap necrosis. In five patients, a superficial epidermolysis occurred. Minor complications were seen in three patients who showed transient venous congestion of the flap. Furthermore, transient leg edema was sometimes observed in patients with large propeller flaps. All but one patient healed without further major surgical procedures. In three cases, secondary skin grafts were performed. In most cases, the aesthetic result was optimal and patients were fully satisfied. Conclusions When characteristics of the defect are suitable for treatment with a propeller-based local flap, this technique should be considered as one of reasonable options for surgical reconstruction. Microsurgical techniques facilitate the management of complex trauma in emergency and may allow planning reconstructive procedures and limb salvage in elective orthopedic surgery.
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Ono S, Sebastin SJ, Yazaki N, Hyakusoku H, Chung KC. Clinical applications of perforator-based propeller flaps in upper limb soft tissue reconstruction. J Hand Surg Am 2011; 36:853-63. [PMID: 21489723 DOI: 10.1016/j.jhsa.2010.12.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 12/15/2010] [Accepted: 12/16/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE A propeller flap is an island flap that moves from one orientation to another by rotating around its vascular axis. The vascular axis is stationary, and flap movement is achieved by revolving on this axis. Early propeller flaps relied on a thick, subcutaneous pedicle to maintain vascularity, and this limited the flap rotation to 90°. With increasing awareness of the location and the vascular territory perfused by cutaneous perforators, it is now possible to design propeller flaps based on a single perforator, so-called "perforator-based propeller flaps." These flaps permit flap rotation up to 180°. We present the results of upper limb soft tissue reconstruction using perforator-based propeller flaps. We constructed a treatment strategy based on the location of the soft tissue defect and the perforator anatomy for expedient wound coverage in 1 stage. METHODS All perforator-based propeller flaps derived from 3 institutions that were used for upper limb soft tissue reconstruction were retrospectively analyzed. The parameters studied included the size and location of the defect, the perforator that was used, the size and shape of the flap, the direction (ie, clockwise or counter-clockwise) of flap rotation, the degree of twisting of the perforator, the management of the donor site (ie, linear closure or skin grafting), and flap survival (recorded as the percentage of the flap area that survived). RESULTS Twelve perforator-based propeller flaps were used to reconstruct upper limb soft tissue defects in 12 patients. Six different perforators were used as vascular pedicles. The donor defects of 11 flaps could be closed primarily. One flap was partially lost in a patient with electrical burns. CONCLUSIONS Perforator-based propeller flaps provide a reliable option for covering small- to medium-size upper limb soft tissue defects.
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Affiliation(s)
- Shimpei Ono
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
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Abstract
BACKGROUND Over the past few years, the use of propeller flaps, which base their blood supply on subcutaneous tissue or isolated perforators, has become increasingly popular. Because no consensus has yet been reached on terminology and nomenclature of the propeller flap, different and confusing uses of the term can be found in the literature. METHODS In this article, the authors report the consensus on the definition and classification of propeller flaps reached by the authors that gathered at the First Tokyo Meeting on Perforator and Propeller Flaps in June of 2009. Some peculiar aspects of the surgical technique are discussed. RESULTS A propeller flap can be defined as an "island flap that reaches the recipient site through an axial rotation." The classification is based on the nourishing pedicle (subcutaneous pedicled propeller flap, perforator pedicled propeller flap, supercharged propeller flap), the degrees of skin island rotation (90 to 180 degrees) and, when possible, the artery of origin of the perforator. CONCLUSIONS The propeller flap is a useful reconstructive tool that can achieve good cosmetic and functional results. A flap should be called a propeller flap only if it fulfils the definition above. The type of nourishing pedicle, the source vessel (when known), and the degree of skin island rotation should be specified for each flap.
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Masià J, Sommario M, Cervelli D, Vega C, León X, Pons G. Extended deep inferior epigastric artery perforator flap for head and neck reconstruction: A clinical experience with 100 patients. Head Neck 2010; 33:1328-34. [DOI: 10.1002/hed.21628] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2009] [Revised: 07/06/2010] [Accepted: 08/12/2010] [Indexed: 11/11/2022] Open
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Demirtas Y, Kelahmetoglu O, Cifci M, Tayfur V, Demir A, Guneren E. Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity. Microsurgery 2010; 30:24-31. [PMID: 19774628 DOI: 10.1002/micr.20696] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objective of this study was to compare the free muscle-musculocutaneous flaps and free perforator skin flaps used for soft tissue reconstruction of the lower extremities. METHODS Fifty-three patients whose skin and soft tissue of the lower extremities had been reconstructed were divided into two groups: a perforator flap group, reconstructed using anterolateral thigh (ALT) free flap (23 cases), and a muscle-musculocutaneous flap group, in whom latissimus dorsi and rectus abdominus muscle-musculocutaneous free flaps were used (30 cases). Postoperative complications, long-term results, and donor site morbidities were studied in the two groups. RESULTS Complete flap survival was 78.3% with four total and one partial flap loss in the ALT group and 90.0% with one total and two partial failure in the muscle-musculocutaneous flap group. Muscle-musculocutaneous flaps were the flaps of choice in Gustillo grade IIIB-C injuries and for reconstruction of more proximal localizations. ALT was preferred in relatively younger patients and was typically used for coverage of the distally localized defects. Flap complication rate was significantly higher in the ALT group, but the overall complication rate was similar between the groups. CONCLUSION ALT perforator flap is a precious option for lower extremity soft tissue reconstruction with minimal donor site morbidity. Nevertheless, the beginners should be attentive to an increased rate of flap complications with the ALT flap and free axial muscle-musculocutaneous flaps would still be the tissue of choice for coverage of leg defects for a surgeon before gaining enough experience with perforator flap dissection.
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Affiliation(s)
- Yener Demirtas
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ondokuz Mayis University Medical School, Samsun, Turkey. yenerdemirtas@hotmail. com
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Rubino C, Figus A, Mazzocchi M, Dessy L, Martano A. The propeller flap for chronic osteomyelitis of the lower extremities: a case report. J Plast Reconstr Aesthet Surg 2009; 62:e401-4. [DOI: 10.1016/j.bjps.2007.12.053] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 12/09/2007] [Accepted: 12/15/2007] [Indexed: 11/26/2022]
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Saggini R, Figus A, Troccola A, Cocco V, Saggini A, Scuderi N. Extracorporeal shock wave therapy for management of chronic ulcers in the lower extremities. ULTRASOUND IN MEDICINE & BIOLOGY 2008; 34:1261-1271. [PMID: 18394777 DOI: 10.1016/j.ultrasmedbio.2008.01.010] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Revised: 12/02/2007] [Accepted: 01/15/2008] [Indexed: 05/26/2023]
Abstract
Management of chronic ulcers in the lower extremities is still a challenge for patients and health providers. Recent studies showed extracorporeal shock waves (ESW) as effective in stimulating growth factors, inducing angiogenesis and healing of fractures and injuries. This study was planned to investigate the opportunity of introducing the ESW in the treatment of chronic wounds. Thirty consecutive patients with chronic posttraumatic, venous and diabetic ulcers, unresponsive to conservative or advanced dressing treatments, were counseled about the use of ESW as alternative treatment for their wounds. Thirty-two wounds were treated and 16 wounds healed completely within six sessions of ESW. In all of the nonhealed wounds, decrease of the amount of exudates, increased percentage of granulation tissue compared with fibrin/necrotic tissue and decrease of wounds' size were statistically significant after four to six sessions of ESW (p < 0.01). Significant decrease of pain was reported (p < 0.001). Comparison with a control group of 10 patients with chronic ulcer treated on the basis of regular dressings confirmed the statistical significant improvement in the healing process (p < 0.01). ESW therapy seems to be a safe, feasible and cost-effective treatment for chronic ulcers in the lower extremities. Further research and clinical trials are necessary to evaluate dose and time intervals of sessions to standardize a protocol of treatment in the management of chronic wounds.
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Affiliation(s)
- R Saggini
- Department of Physical Medicine and Rehabilitation, University of Chieti "G. D'Annunzio," Chieti, Italy
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Pignatti M, Pasqualini M, Governa M, Bruti M, Rigotti G. Propeller flaps for leg reconstruction. J Plast Reconstr Aesthet Surg 2008; 61:777-83. [DOI: 10.1016/j.bjps.2007.10.077] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 10/06/2007] [Accepted: 10/25/2007] [Indexed: 11/15/2022]
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