The "Tokyo" consensus on propeller flaps

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.

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.

Perforating cutaneous vessels: A key feature of acupoints - Anatomical evidence from five-Shu acupoints in the upper limbs

Acupuncture has been proven an effective clinical treatment for numerous pathological conditions and malfunctions. However, substantial anatomical evidence for acupuncture points (APs) and meridians is still lacking, so the location of APs is relatively subjective and understanding of the biological mechanisms of acupuncture is limited. All these problems hinder the clinical applications and worldwide acceptance of acupuncture. Our long-term microsurgery experience has indicated that Perforating Cutaneous Vessels (PCVs) are highly relevant to APs but the anatomical evidence is insufficient. To address this lack, two specimens of fresh adult human upper limbs were dissected using an advanced vascular perfusion-fixation method and then examined. The results show that all 30 five-Shu APs in the upper limbs have corresponding PCVs. Both specimens showed a 100% coincidence rate between APs and PCVs, indicating that PCVs could be critical anatomical features of APs. This study also provides an anatomical basis for locating APs objectively via preliminary detection of PCVs. The findings could lead to a better theoretical understanding of mechanisms of acupuncture and the essence of meridians.

Utilization of two methods assisting perforator identification for brachial artery perforator propeller flap application

The brachial artery perforator propeller (BAPP) flap has the advantages of both local and perforator propeller flaps, and it remains relatively underused partly because of the anatomical variations of perforators in the medial arm. We aimed to review our preliminary experience using two different methods for perforator localization of a BAPP flap, including the application of a refined coordinate system (the ABC system) in the medial arm and indocyanine green angiography (ICGA). We evaluated the advantages and disadvantages of these methods and selected the optimal examination mode depending on detailed clinical settings. The perforator was identified for each patient using the ABC system and/or ICGA, depending on the clinical setting. Twenty-two patients underwent soft-tissue reconstructions with 22 BAPP flaps, and perforator localization for all the flaps was performed before surgery using the ABC system. Thirty-one perforators were localized before surgery and marked accordingly, all of which were visualized during surgery, except two, which were not found during the surgery. ICGA was used in six pre-expanded flaps at both stages of surgeries. Twenty-seven perforators were detected before surgery, and all of them were identified during surgery; the previously localized perforators found using the ABC system in the six patients were all reidentified using ICGA. Both the ABC system and ICGA were found to be useful for preoperative perforator localization in BAPP flap transfers. Each method has its unique downsides; however, they can supplement each other to facilitate safe and effective flap elevation. Therefore, selection of the optimal method based on the clinical settings is recommended.

Immediate Soft Tissue Reconstruction in Lower Limb Traumas Using Propeller Perforator Flaps

BACKGROUND

Open bone fractures represent a demanding clinical condition that can be life- or limb-threatening. For small- to medium-size soft tissue defects of the lower extremity, propeller perforator flaps are a viable option for reconstruction. We report our experience in Gustilo IIIB open fractures treatment with immediate coverage through propeller-based perforator flaps performed in acute setting.

METHODS

Between 2019 and 2022, 94 Gustilo III fractures were admitted to our trauma center, and 28 were Gustilo IIIB fractures. Five patients were eligible for an immediate perforator-based propeller flaps reconstruction. The mean age of the patients was 33.8 years. All of them were male. One of them was a heavy smoker (15 cigarettes per day). No other comorbidities were present.

RESULTS

The mean operating time, including fracture reduction and fixation time, was 106 minutes. The length of the defect varied between 5 and 7 cm and the width between 3 and 4 cm. We reported no major complications, and none of the patients required a surgical revision of the flap. A patient with smoking habit reported a superficial flap necrosis. The mean follow-up was 5.5 months. No cases of nonunion or osteomyelitis have developed so far.

CONCLUSIONS

The use of perforator-based propeller flaps, in acute trauma setting, has not been reported in literature so far. In our experience, propeller perforator flaps are a viable reconstructive option in immediate reconstruction during the acute management of open fractures.

Gluteal Propeller Perforator Flaps: A Paradigm Shift in Abdominoperineal Amputation Reconstruction

Abdominoperineal amputation (AAP) is a gold standard procedure treating advanced abdominal and pelvic cancers. The defect resulting from this extensive surgery must be reconstructed to avoid complications, such as infection, dehiscence, delayed healing, or even death. Several approaches can be chosen depending on the patient. Muscle-based reconstructions are a reliable solution but are responsible for additional morbidity for these fragile patients. We present and discuss our experience in AAP reconstruction using gluteal-artery-based propeller perforator flaps (G-PPF) in a case series. Between January 2017 and March 2021, 20 patients received G-PPF reconstruction in two centers. Either superior gluteal artery (SGAP)- or inferior artery (IGAP)-based perforator flaps were performed depending on the best configuration. Preoperative, intraoperative, and postoperative data were collected. A total of 23 G-PPF were performed-12 SGAP and 11 IGAP flaps. Final defect coverage was achieved in 100% of cases. Eleven patients experienced at least one complication (55%), amongst whom six patients (30%) had delayed healing, and three patients (15%) had at least one flap complication. One patient underwent a new surgery at 4 months for a perineal abscess under the flap, and three patients died from disease recurrence. Gluteal-artery-based propeller perforator flaps are an effective and modern surgical procedure for AAP reconstruction. Their mechanic properties, in addition to their low morbidity, make them an optimal technique for this purpose; however, technical skills are needed, and closer surveillance with patient compliance is critical to ensure success. G-PPF should be widely used in specialized centers and considered a modern alternative to muscle-based reconstructions.

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.

How to Transform a Perforator Propeller Flap into a Keystone Flap in Case of Unsatisfying Perforator Vessel Local Perforator Flap Coverage in Limbs

Moderate soft-tissue defects need stable coverage, ideally with tissue of similar characteristics and low donor site morbidity. We propose a simple technique for the coverage of moderate skin defects in the limbs. It allows intraoperative transformation of a propeller perforator flap (PPF) into a keystone design perforator flap (KDPF) in cases of unsatisfying perforator vessel or in cases of unpredictable intraoperative events. Between March 2013 and July 2019, nine patients with moderate soft-tissue defects (mean defect size 4.5 × 7.6 cm) in the limbs (two on the upper limbs and seven on the lower limbs) were covered using this technique. We performed four PPFs and five KDPFs. The mean follow-up was 5 months. There was one complication, partial distal tip necrosis in a PPF located in the leg, which healed by secondary intention within 3 weeks. The donor site was closed directly in all cases. No functional impairments were noted regardless of the perforator flap utilized. This technique enables us to employ flexible surgical strategies and allows us to make adjustments based on the patient's vascular anatomy.

The Reversed Flow Hemisoleus Propeller Muscle Flap

BACKGROUND

Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap. The first description of the soleus muscle as an island flap supplied by one distal perforator was reported by Yajima et al (Plast Reconstr Surg. 1995;96:1162-1168). However, its use as a propeller flap supplied by the distal perforators and rotated for more than 90 degrees was not described yet.

OBEJECTIVES

The aims of the study are to study the detailed vascular anatomy of the distal perforators of the soleus muscle flap and to demonstrate the applicability of using it as a propeller flap.

PATIENTS AND METHODS

A total number of 42 patients were included in this study. These patients had various distal leg and foot defects. All patients were assessed preoperatively by Doppler study and computed tomography angiography to define the vascular status of the leg. The muscle was raised as a reversed flow flap, based on 1 or more distal perforators and its feeding vessel (posterior tibial artery) after being dissected and divided proximally. The muscle was rotated for more than 90 degrees to reach distal leg defects and approximately 180 degrees to reach the foot defects.

RESULTS

All flaps survived completely with good and durable coverage. The vascularity of the limb was not affected in all patients. There was no functional donor site morbidity.

CONCLUSIONS

The reversed flow hemisoleus muscle flap supplied by the distal perforators and the posterior tibial artery has a great arc of rotation that can cover all distal leg, ankle, and foot defects. Therefore, it can be used as alternative to free flap in lower extremity reconstruction. A new nomenclature is suggested for this flap which is the propeller hemisoleus muscle flap.

Lower Trapezius Myocutaneous Propeller Flap Based on Dorsal Scapular Artery

BACKGROUND

The pedicled lower trapezius myocutaneous flap is generally transferred to the recipient site through a subcutaneous tunnel, and a portion of the flap buried in the tunnel needs to be de-epithelialized. Thus, considerable amount of normal skin is sacrificed, and the redundant tissue buried in the tunnel can cause bulging deformity. We believe that transferring the lower trapezius myocutaneous flap in a propeller fashion can avoid the aforementioned issues.

METHODS

A retrospective review was performed on all lower trapezius myocutaneous propeller flap reconstructions by a single surgeon from July 2013 to March 2021. Data on patient demographics, diagnosis, features of the defect, characteristics of the flap, and the outcome were collected and analyzed.

RESULTS

Thirty-three lower trapezius myocutaneous propeller flaps were used to reconstruct soft tissue defects in the head, neck, and back. The etiologies were malignancy, trauma, postburn scar contracture, and congenital melanocytic nevus. The mean skin paddle dimensions were 29.0 cm in length (range, 13-45 cm) and 10.9 cm in width (range, 6-15 cm). The donor sites were closed primarily in 30 patients, closed using a skin graft in 1 patient, and covered with the second flap in 2 patients. Venous congestion occurred in the distal portion of 4 flaps and partial necrosis in the distal 6 cm of 1 flap. The average follow-up time was 17.5 months (range, 1-56 months). The normal contour of the back was preserved without bulging deformity. No patient developed a winged scapula or a decrease in shoulder elevation.

CONCLUSIONS

The lower trapezius myocutaneous propeller flap may be an option for reconstruction of soft tissue defects of the head, neck, and back with less waste of normal tissue and bulging deformity.

A three-dimensional visualization of the full-field surgical region based on thin-slice MRI: A helpful approach for simultaneously guiding tumor resection and perforator flap elevation

Background

The goal of the current study was to explore the application of preoperative three-dimensional reconstruction (3DR) based on thin-slice magnetic resonance imaging (MRI) in the simultaneous guidance of en bloc tumor resection and adjacent perforator flap elevation.

Methods

The prospective cohort included 35 patients diagnosed with either soft tissue sarcoma or squamous cell skin cancer between 2019 and 2021. The preoperative 3DR based on thin-slice MRI illustrated the spatial anatomical relationship among the tumor, underlying muscle, adjacent perforator vessels, and bone around the surgical region. The accuracy of preoperative imaging data was verified by intraoperative vessel dissection and postoperative pathological measurements.

Results

Tumor size from 3DR data showed relatively high concordance rates with pathological measurements within the 95% limits of agreement. An average of three perforators (range: 1–7) with a mean diameter of 0.32 cm (range: 0.18–0.74 cm) from the 3DR were present in our study. The average distance between tumor boundary and perforator piercing sites on the 3DR was 2.2 cm (range: 1.2–7.7 cm). The average length of artery perforator coursing along the subcutaneous tissue was 5.8 cm (range: 3.3–25.1 cm). The mean flap harvest time was 55 mins (range: 36–97 min). The average flap size was 92.2 cm² (range: 32–126 cm²). One perforator flap occurred distal partial necrosis.

Conclusion

A thorough understanding of anatomical structures in the surgical region according to full-field 3DR based on thin-slice MRI can improve the performance of radical resection of the tumor and adjacent perforator flap transfer, especially for junior surgeons with a poor experience.

Perforator propeller flap for coverage of Achilles region defects caused by pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare neutrophilic inflammatory skin disease. Systemic corticosteroid and immunosuppressive agents are the mainstay treatment. PG usually precludes a surgical approach due to pathergy phenomenon. Recent literatures show skin grafting and negative pressure wound therapy are safe if performed under adequate immunosuppression. We present a case of a 61-year-old male patient suffered from PG induced left posterior leg wound with Achilles tendon exposure. We made timely diagnosis and treated him with adequate immunosuppression therapy followed by perforator propeller flap for wound coverage. This case report emphasizes the need for high index of suspicion for PG diagnosis. Furthermore, with adequate immunosuppression, operative intervention may not be an absolute contraindication for PG.

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.

Propeller flaps in partial ear reconstruction: a case series

Background

Ear defect reconstruction still remains a surgical challenge today. Proper reconstruction should result in correction of the deformity with minimum morbidity with the aim of achieving the most esthetically pleasing outcome possible. Herein, we present our clinical experience with propeller flap reconstruction of external ear defects with a focus on indications and surgical technique.

Methods

Fourteen patients underwent surgery at our Plastic Surgery Unit between January 2015 and October 2019. After identifying perforators with a handheld Doppler ultrasound, a tailor-made flap was designed for each patient. Following tumor excision, dissection of the pedicle and of the remaining flap was performed with the aid of surgical loops. Flap in-setting and donor site closure were final steps.

Results

Flaps have survived in their entirety in almost all our patients (13/14) maintaining optimal color and elasticity and showing no complications. In one case, a superficial distal necrosis was observed and, in another patient, tumor recurrence took place.

Conclusions

Propeller flaps offer great advantages when used in ear reconstruction ensuring excellent esthetic results with a one-stage technique. Nevertheless, it must be kept in mind that good dissection skills are required in order to avoid complications.

Level of evidence: Level IV, Therapeutic study.

Autologous Gluteal Augmentation with Parasacral Perforator-Pedicled Propeller Flaps

BACKGROUND

De-epithelialized flaps have been used in gluteal contouring over the last three decades, but most improve the projection rather than the upper quadrants. The authors provide a detailed description of their method of gluteal augmentation using parasacral perforator-pedicled propeller flaps. This technique achieves a volumetric increase and maximal buttock projection at the midlevel and in the medial half of the buttocks.

METHODS

Between January and December of 2019, a series of 18 patients on whom a lower body lift with a parasacral perforator-pedicled propeller flap had been performed by the senior author (F.B.) were prospectively evaluated. Postoperatively, the satisfaction rate was assessed using a 10-point analog scale (1 = unsatisfied, 10 = very satisfied) by the patient and by two independent surgeons based on photographs taken 1 year after surgery.

RESULTS

Eighteen patients underwent this procedure. Their mean age was 32.2 ± 5.6 years (range, 24 to 40 years). The mean flap length was 20.3 cm, their mean width was 10.4 cm, and the mean thickness was 3.4 cm. The authors noted only two minor complications, one seroma and two skin dehiscences that healed without surgery. The rate of satisfaction as assessed by the patients was 8.3 out of 10 (±1.1), and by surgeons, 7.9 and 8.1.

CONCLUSION

This article describes a gluteal autoaugmentation flap technique using parasacral perforator-pedicled propeller flaps to increase projection and volume in the inferomedial gluteal region after lower body lift.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Perforator propeller flaps for lower extremity soft-tissue defect reconstruction: Shortening the learning curve

Background

The perforator propeller flap is an advantageous option for soft tissue reconstruction in the lower limb as it ensures the preservation of the main artery and muscle, eliminates the need for microsurgical reconstruction as well as provides "like with like" resurfacing of the defects. Despite this, it remains a technically demanding reconstructive option for residents and surgeons with little experience in perforator dissection. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects were addressed with propeller flaps.

Methods

A retrospective study of all propeller flap based reconstruction done on patients with soft tissue defects involving the distal third of the leg was undertaken from August 2018 to December 2020.

Results

28 patients were treated with propeller flaps for various lower extremity defects. The median defect size was 12 cm². The posterior tibial artery (PTA) was used in eleven cases (39.3%) and the peroneal artery (PA) in seventeen of the cases (60.7%). The complication rate was 28.6% (n = 8). The complete flap necrosis rate was 10.7% (n = 3) and partial flap necrosis rate was 7.1% (n = 2), The rate of venous congestion was 7.1% (n = 2) and wound dehiscence occurred in 3.5% (n = 1). There was a significant negative correlation between the number of cases performed by a resident and the operative time.

Conclusion

Although propeller flaps are a reliable option to address lower extremity defects, they have a long learning curve and require a good amount of experience and perforator dissection skills to reduce the probability of flap failure. We are of the opinion that residents should be adequately trained in this procedure to ensure optimal outcome delivery.

Análise comparativa do tratamento de lesões cutâneas dos membros inferiores com retalho sural versus retalho propeller

Objective  The objective of the present study was to prospectively compare the sural and propeller flaps for soft-tissues coverage of the lower extremity. The following variables were evaluated: incidence of complete or partial flap loss and donor area morbidity (primary closure versus skin graft).

Methods  Prospective and randomized analysis of data collected from all patients presenting with soft tissue defects of the lower third of the leg and heel treated with reverse sural or propeller flaps.

Results  Twenty-four patients aged between 4 and 60 years old were evaluated between 2011 and 2017. Complete coverage was obtained in 22 of the 24 patients (91.6%). Two flaps failed (8.4%). The sural flap, being the most popular option, continues to represent a safe and versatile alternative for skin defects of the lower third of the leg and heel region. Likewise, the propeller flap was a comparable option to treat these challenging defects.

Conclusion  Sural and propeller flaps are good options for soft tissues coverage of the lower extremity, with low complication rates (partial or total flap loss).

Analysis of risk factors for complications of perforator propeller flaps used for soft tissue reconstruction after malignant tumor resection: A systematic review and meta-analysis

BACKGROUND

Perforator propeller flaps (PPFs) have been widely used due to their numerous advantages; however, they were also associated with various complications. Herein, we analyzed the risk factors for complications of PPFs used for soft tissue reconstruction after malignant tumor resection.

METHODS

We searched databases for articles on soft tissue reconstruction using PPFs after malignant tumor resection published between January 1991 and April 2021. Studies were selected according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Fixed effects models and relative risks were used for data analysis. Funnel plots and Begg's test were used to evaluate publication bias.

RESULTS

Twenty-six articles met the inclusion criteria. Complications were found in 24.7% of all patients. The four significant risk factors were age equal or older than 60 years (pooled relative risk, 1.83; p = .04), smoking (pooled relative risk, 2.32; p = .03), diabetes (pooled relative risk, 2.59; p = .01) and radiotherapy (pooled relative risk, 2.09; p = .01). Hypertension, defects located in the extremities, flap size equal or greater than 100 cm² , and pedicle rotation equal or greater than 120 degrees were not significant risk factors for complications. No publication bias was found in the included articles.

CONCLUSION

Age equal or older than 60 years, smoking, diabetes and radiotherapy are four risk factors for complications when PPFs are used to reconstruct soft tissue defects resulting from malignant tumor resection.

Combined versus Single Perforator Propeller Flaps for Reconstruction of Large Soft Tissue Defects: A Retrospective Clinical Study

Sufficient wound closure of large soft tissue defects remains a challenge for reconstructive surgeons. We aimed to investigate whether combined perforator propeller flaps (PPFs) are suitable to expand reconstructive options. Patients undergoing PPF reconstruction surgery between 2008 and 2021 were screened and evaluated retrospectively. Of 86 identified patients, 69 patients received one perforator propeller flap, while 17 patients underwent combined PPF reconstruction with multiple flaps. We chose major complications as our primary outcome and defined those as complications that required additional surgery. Postoperatively, 27 patients (31.4%) suffered major complications. The propeller flap size, the type of intervention as well as the operation time were not associated with a higher risk of major complications. A defect size larger than 100 cm², however, was identified as a significant risk factor for major complications among single PPFs but not among combined PPFs (OR: 2.82, 95% CI: 1.01−8.36; p = 0.05 vs. OR: 0.30, 95% CI: 0.02−3.37; p = 0.32). In conclusion, combined PPFs proved to be a reliable technique and should be preferred over single PPFs in the reconstruction of large soft tissue defects at the trunk and proximal lower extremity.

The Homodigital Propeller Flap: A New Tool for Fingertip Reconstruction. Surgical Technique, Anatomical Study, and Clinical Relevance

BACKGROUND

An ideal flap for fingertip injuries should cover a significant loss of substance and avoid joint flexion to prevent later contracture and joint stiffness. In this study, the authors describe a modified homodigital island flap-the homodigital propeller flap-to better meet these requirements.

METHODS

An anatomical model of fingertip loss is used to analyze the advancement achieved without flexion of the finger. Twenty-four fresh-frozen fingers were dissected. Wires were inserted to maintain joints in extension. The skin paddle was similar in location to a homodigital island flap. The neurovascular bundle was dissected without exceeding the proximal interphalangeal joint and was released from the proximal half of the paddle. Then, the homodigital propeller flap was rotated 180 degrees to cover the defect. A mixture of India ink and barium sulfate was injected into the pedicle artery after the release of the proximal half of the flap from the neurovascular pedicle to assess residual flap vascularization. India ink highlights the residual subcutaneous vascularization network of the cutaneous paddle. A radiographic study of the flap was then performed to visualize the subcutaneous vascular network of the cutaneous paddle.

RESULTS

The homodigital propeller flap achieved an average cutaneous advancement of 18 mm (range, 15 to 22 mm) and allowed full coverage of cutaneous defects for all fingers while maintaining the proximal interphalangeal joint in strict extension.

CONCLUSIONS

The homodigital propeller flap is a refinement of the classic homodigital island flap. It allows efficient coverage of fingertip defects because of a large advancement without flexion of the finger reducing the risk of stiffness.

Designing Lateral Thoracic Wall Perforator Flaps for Breast Reconstruction Using the Ultrasound

BACKGROUND

 Lateral thoracic flaps represent a precious source for partial and total breast reconstruction, in some cases as first option and in other cases as alternative of free flaps. This article describes the ultrasound (US)-based planning of the lateral thoracic wall perforator adipocutaneous flaps and it reports our experience on 52 consecutive flaps.

PATIENTS AND METHODS

 From November 2018 to May 2021, 52 consecutive lateral thoracic wall perforator flaps were performed using the US-based method for reconstruction of partial breast defects and total breast reconstruction. High-frequency US was performed in all cases prior to surgery to select the best perforator and design the flap.

RESULTS

 Of the 52 cases, 41 were lateral intercostal artery perforator flaps (78.8%), and 11 were thoracodorsal artery perforator (TDAP) flaps. Of the 11 TDAP flaps, 2 cases were based on the direct cutaneous branch. Moreover, in two other cases clinically scheduled for lateral thoracic perforator flaps due to the presence of an appropriate axillary roll, no suitable local/regional perforators were detected with the preoperative US examination and the latissimus dorsi myocutaneous flap was performed.

CONCLUSION

 Preoperative planning of these flaps using US speeds the surgery and makes it easier and more efficient. Therefore, it is reasonable that the color duplex ultrasound is the operative surgeon's tool for mapping the lateral thoracic wall perforators and to appropriately plan each flap.

Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects

BACKGROUND

Covering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation.

METHODS

Patients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects.

RESULTS

The mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm² (range, 48-125 cm²). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation.

CONCLUSIONS

The propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.

Lower limb reconstruction involving osteosynthesis material: A retrospective study on propeller flaps outcomes

INTRODUCTION

Reconstruction of soft tissue defects in lower limb fractures requiring internal fixation remains a challenging scenario with the optimal surgical treatment still debated. This study aims to recommend, and eventually redefine, surgical indications for propeller flaps reconstruction in the distal lower limb, with a particular focus on the presence or not of metalwork.

METHODS

A retrospective study of lower limb soft tissue reconstructions performed between January 2015 and July 2018 was carried out including all patients treated with a propeller perforator flap (PPF) with at least 6-month follow-up. Patients were further divided in 2 groups depending on the presence of metalwork fixation beneath the flap (F group, propeller on Framework; NF group, propeller with No-Framework).

RESULTS

21 patients were retained (F group, 11 patients; NF group, 10 patients). There were no significant differences between the two groups in age, BMI, ASA scores, comorbidities or defect size. There was a statistically significant difference between the groups (p<0.05) in the cumulative hospital stay with a mean cumulative hospital stay of 22 ± 9 days in the F group and 12 ± 8 days in NF group. Failures were higher where PPF were used to cover hardware material, with 3 patients requiring a major secondary procedure in F group versus 1 patient in NF group.

CONCLUSION

The presence of underlying metalwork significantly reduced the margin for small, day-case revision procedures such as flap readvancement or STSG. This study emphasizes clinical intuition that whilst PPF are a useful and elegant tool in lower limb reconstruction, their use should be limited when underlying metalwork is present.

[Application of free-style perforator pedicled propeller flap to repair the wound after extensive resection of skin malignant tumor on the thigh]

OBJECTIVE

To explore the effectiveness of free-style perforator pedicled propeller flap to repair the wound after extensive resection of skin malignant tumor on the thigh.

METHODS

Between December 2016 and June 2019, 12 patients with skin malignant tumor on the thigh were treated. There were 9 males and 3 females, aged from 8 to 65 years (median, 38.5 years). The etiologies included basal cell carcinoma in 3 cases, squamous cell carcinoma in 7 cases, fibrosarcoma in 1 case, and malignant melanoma in 1 case. The disease duration ranged from 5 months to 10 years (median, 7.5 years). Color Doppler ultrasound was used to detect and mark at least one perforator vessel before operation. After extensive resection, the size of wound ranged from 5.0 cm×3.5 cm to 8.5 cm×6.5 cm. In the range of 1-3 cm from the edge of the lesion, the perforator vessels were explored again from the deep surface of the deep fascia to confirm and mark. The perforator vessel with diameter greater than 0.5 mm and closest to the edge of the lesion was taken as the rotation point of the flap. According to the wound size and shape, the free-style perforator pedicled propeller flap in size of 8.0 cm×3.5 cm to 12.5 cm×6.0 cm was designed. The wound was repaired with the big blade of the flap. The donor site was closed directly with the aid of the small blade.

RESULTS

The distal part of the skin flap was necrosis after operation, and healed after symptomatic treatment such as dressing change; the other flaps survived successfully and the wounds healed by first intention. All incisions at the donor site healed by first intention. All patients were followed up 5-24 months (mean, 10.2 months). During the follow-up, there was no recurrence of tumor. The flap had good elasticity and texture with no obvious swelling or scar hyperplasia, and the appearance was satisfactory; the hip and knee joint activities were normal.

CONCLUSION

Based on the extensive skin blood supply and abundant perforator vessels of the thigh, the free-style perforator pedicled propeller flap is an ideal flap for repairing small or medium wound after extensive resection of skin malignant tumor on the thigh.

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.

Propeller Flaps in Lower Extremity Reconstruction

Propeller flaps represent an outstanding alternative to conventional pedicled and free flap options in lower extremity reconstruction, offering significant advantages over the latter. An understanding of the perforasome concept, hot and cold perforator locations, and basic flap design enable the surgeon to readily harvest flaps based on any clinically relevant perforator in freestyle fashion. The purpose of this article is to review fundamentals of propeller flap design and harvest in the lower extremity and discuss reconstructive strategies by level of injury.

A randomized trial of use of a modified reverse sural neurofasciocutaneous flap to extend the reconstruction range

Background

When a reverse sural neurofasciocutaneous flap is used to reconstruct a forefoot defect, usually, the transverse length of the flap is increased or the pivot point is lowered to ensure the reconstruction range. Therefore, proximal partial necrosis leading to surgery failure is sometimes caused by insufficient arterial supply if the flap is too long or the pivot point is too low and has no a reliable perforator in the pedicle. Herein, we describe a new method for extending the reconstruction range of the reverse sural neurofasciocutaneous flap that can provide a higher survival rate.

Methods

Between July 2010 and July 2014, 24 patients with forefoot defect were randomly assigned into two groups. In the research group, 12 modified reverse sural neurofasciocutaneous flaps with extended reconstruction range were used to reconstruct forefoot defect. We dissected the septum along the last perforator to locate the main trunk of the peroneal artery, disconnected the proximal end of the peroneal artery at the root of the perforator, and separated the peroneal artery more distally to obtain a lower rotation point to extend the reconstruction range. The last perforator and a section of the peroneal artery were contained in the pedicle. In the control group, 12 traditional reverse sural neurofasciocutaneous flap procedures were performed.

Results

In the research group, 11 flaps survived with good quality and esthetic contours. Partial distal necrosis occurred in 1 flap. In the control group, 7 flaps survived. Partial necrosis occurred in the other 5 flaps. Compared with control group, the survival rate in the research group was significantly higher while the healing time was significantly shorter. All patients were satisfied with the therapeutic outcome in the research group.

Conclusions

Our modified method proved efficacious in extending the reconstruction range of the reverse sural neurofasciocutaneous flap. Meanwhile, partial necrosis was avoided because the length of the flap was shortened, and a reliable perforator was preserved in the artery pedicle.

Trial Registration

Chictr.org Identifier: ChiCTR2100046323.

Reconstruction of Lagophthalmos of Upper Eyelid With a Subcutaneous Pedicled Propeller Flap

ABSTRACT

An 11-year-old boy presented with lagophthalmos of the left upper eyelid after traumatic scar contracture. Chronic eyelid hypophasis could produce dryness, foreign body sensation, cornea exposure. To reconstruct the upper eyelid defects after scar release represented a significant challenge in terms of recreating functional eyelids. The authors applied the orbital subcutaneous pedicled propeller flap for one-stage reconstruction of the lagophthalmos. Four weeks after surgery, the patient had functional eyelid with no ectropion, cornea exposure or conjunctivitis and the appearance of eyelid was improved. And the final result was found to be acceptable at 6 months follow-up. The authors consider that to repair the lagophthalmos of upper eyelid, the use of orbital subcutaneous propeller flap can achieve both functional and appearance improvement, it is an effective method with flexibility and personalization.

Outcomes of Propeller Flap in Eyelid Reconstruction

The purpose of this case report is to demonstrate the outcomes of reconstruction in small-to-moderate-sized benign tumors of eyelids by using the propeller flap technique. Propeller flaps have been used by plastic surgeons for facial reconstruction and other body parts. However, very few oculoplastic surgeons have utilized this technique in eyelid reconstructive surgeries. We have substantiated this technique and its outcomes in this case report. It is a case series consisted of two patients reporting in the orbit-oculoplastics clinic with suspicious basal cell carcinoma of eyelids, covering less than half of the eyelid. Both the patients underwent tumor excision and reconstruction, with a cutaneous propeller flap supplied by a pedicle. Both the patients recovered well and without any complication. The specimens removed from both the patients were sent for histopathology and the biopsy results revealed both lesions were margin-free basal cell carcinoma. The reconstruction of eyelid defects is challenging due to the small area and cosmetic appearance. Propeller flaps are a reasonable choice of treatment in small to moderately large-sized defects with minimal complications, yet better cosmetic appearance.

Superior epigastric artery perforator flap for reconstruction of deep sternal wound infection

BACKGROUND

The treatment of deep wound sternal infection requires loco-regional pedicled flaps, usually with muscular flaps. Perforator propeller flaps represent the ultimate progress in the history of reconstructive surgery. We report here our experience with the superior epigastric artery perforator (SEAP) flaps to repair sternal defect.

PATIENTS AND METHODS

Six patients presenting deep sternal wounds infection were treated with SEAP propeller flap, between March 2015 and June 2017. The mean age was 71.5 (range 53-83) years. The mean length and width of the defect were 16.2 × 7 cm (ranging 8-20 × 4-10). An elliptical skin flap pedicled on the SEAP was harvested in the inframammary fold and rotated up to 90° to cover the defect.

RESULTS

All SEAP flaps achieved a successful entire coverage of the defect. The mean size of the skin paddle of the flap was 20.2 × 7.3 cm (ranging 14-27 × 6-9). All flaps were able to provide a complete sternal wound cover. Venous congestion was present in five cases and adequately treated by leech therapy; necrosis was distal in one case, and interesting the entire superficial flap in two cases but with deep tissues remaining viable and able to cover the mediastinum: an infected flap required revision. Satisfyingly, at 2-years postoperative follow-up all-patients were alive with a successful mediastinal cover.

CONCLUSIONS

The SEAP Perforator propeller flap is an alternative to muscle flaps to achieve treatment of deep and large sternal wound infection.

Defect Reconstruction Using the Propeller Flaps Based on the Perforators Derived From the Lateral Circumflex Femoral Artery System

BACKGROUND

Although propeller flaps are a useful option for soft tissue defect reconstruction, reports based on the perforators of the lateral circumflex femoral artery (LCFA) are rare. We aimed to present our experience in defect reconstruction using the propeller flaps based on perforators from different branches of LCFA and apply these flaps in soft tissue defect reconstruction of the lower extremities.

METHODS

Twenty nine patients (32 flaps) underwent defect reconstruction using propeller flaps based on the perforator of the LCFA. Defects were located from the groin to the proximal leg. According to the source vessels from which the perforator originated, flaps were categorized into types I, II, III and IV, which represented perforators from the transverse, descending, oblique, and rectus femoris branches, respectively. Type II flaps were subdivided into types IIa and IIb flaps based on antegrade and reverse flows of the descending branch.

RESULTS

Flap sizes ranged from 12 × 6 cm to 30 × 15 cm (average, 22.69 × 9.19 cm) with the length of the vascular pedicle ranging from 3 to 7 cm (average, 4.86 cm). Flaps were rotated from 60° to 180° (average, 144.06°). There were 3 type I, 10 type IIa, 4 type IIb, 13 type III and, and 2 type IV flaps. Twenty-nine flaps survived after surgery. Total flap necrosis and venous congestion of the distal flap portion occurred in 1 and 2 patients, respectively.

CONCLUSIONS

Reconstruction using propeller flaps based on perforators of the LCFA is a safe, reliable, and versatile option for defect reconstruction of the lower extremities; however, it requires meticulous surgical dissection and patience.

Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity

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.

Perforator-Based Flaps for Defect Reconstruction of the Posterior Trunk

INTRODUCTION

Full-thickness soft tissue defects of the back remain challenging clinical problems for reconstructive surgeons. Among a vast variety of local flap options, perforator-based local flaps gain increasing popularity lately. Because mostly heterogeneous patient cohort comparison of different perforator flaps is difficult and decision-making algorithms are lacking.

METHODS

Patients, who received a local perforator-based soft tissue reconstruction between 2012 and 2019, were evaluated retrospectively. Patients' data were evaluated in terms of flap type and dimension, wound size and cause, surgery time, postoperative complications, and hospitalization. A focus was set on decision making concerning reconstructive techniques and flap choice for defect closure.

RESULTS

Thirty-six patients (17 women, 19 men) were included, who received 40 perforator-based local flaps to reconstruct extended defects of the posterior trunk. Mean patient age was 56.3 years and mean hospitalization was 29 days. Average time of flap surgery was 179.7 minutes. Mean flap size was 160.8 cm and average defect size was 110 cm. Defects occurred because of tumor resection (50%), orthopedic/trauma surgery (16.7%), or pressure sores (33.3%). Twenty-eight propeller flaps (PPFs, 70%) and 12 perforator-based VY-advancement flaps (P-VYF, 30%) were transferred. In 4 patients, a bilateral approach using more than one flap was necessary. Revision surgery was required in 9 patients (25%) because of postoperative hematoma (n = 3), postoperative wound infection (n = 3), partial flap necrosis (1× P-VYF) and 2 flap losses (2× PPFs).

CONCLUSIONS

Pedicled perforator flaps are a reliable option for soft tissue reconstruction of complex wounds of the posterior trunk. A flexible surgical strategy is mandatory, and the individual perforator anatomy has to be considered. In most cases, P-VYFs or PPFs are reliably possible and allow sufficient defect reconstruction. However, skin incisions should always be performed in a way that classic random pattern flaps are still possible. Even in large defects combined, local perforator flaps may lead to sustainable soft tissue reconstructions without functional donor site deficits.

Outcome of distal lower leg reconstruction with the propeller perforator flap in diabetic patients

In diabetic foot patients, wound coverage options are quite limited due to vascular abnormalities. However, even though significant atherosclerotic changes are found in major vessels of the lower leg in diabetic foot patients, perforating vessels, which are used as the vascular pedicle of propeller perforator flaps, are often spared from atherosclerosis. Therefore, the propeller perforator flap could be an alternative option for diabetic foot patients. The purpose of this study was to compare the outcome of the propeller perforator flap between diabetic and nondiabetic patients in reconstruction of the distal lower leg. We retrospectively included all patients who underwent reconstruction of the distal lower leg with a propeller flap between 2014 and 2018. Thirty-five propeller perforator flaps in 20 diabetic patients and 15 nondiabetic patients were included. Of the 35 patients, 21 showed complete healing, and 14 showed flap complications. The rate of complications in diabetic patients was approximately 85.7%. Sex (p = .002), diabetes (p = .007), chronic renal failure (p < .001), and diabetic neuropathy (p = .011) were associated with flap complications. Crude regression analysis showed that the female sex (p = .002), diabetes (p = .01), and diabetic neuropathy (p = .012) were significant risk factors for the occurrence of any complications, but the significance of diabetes and diabetic neuropathy was not maintained in the adjusted models. Therefore, the propeller perforator flap might not be effective for reconstructing diabetic foot ulcers.

Propeller Flap Perineal Urethrostomy Revision

OBJECTIVE

To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis.

METHODS

Our technique utilizes the consistent posterior thigh perforators for a local flap with ideal length and thickness for repair. The stenotic PU is incised. Potential flaps are marked around a perforator blood supply closest to the defect. The flap is then elevated and rotated on its pedicle with its apex placed directly in the defect. Absorbable sutures partially tubularize the flap apex at the level of the urethrotomy which is calibrated to 30 Fr. We subsequently monitored the patient's clinical progress.

RESULTS

With 17 months of follow-up the patient is voiding well without complaint, reports improved quality of life with a patent PU. Post void residuals have been less than 100cc. The patient, who has had a long history of urinary tract infections requiring hospitalization, has only reported one infection during follow up which was treated as an out-patient.

CONCLUSION

For challenging PU revisions a distant local propeller flap of healthy tissue outside the zone of injury is the ideal choice for length, thickness, and minimal morbidity resulting in excellent clinical results for our patient.

A sequence of flaps and dissection exercises in the living model to improve the learning curve for perforator flap surgery

INTRODUCTION

The training to learn how to perform perforator flaps requires practice on a living model to optimize dissection and to evaluate outcome. The purpose of this study was to describe a training model that optimizes the use of animals in order to perform the maximum number of exercises per animal.

MATERIAL AND METHODS

The sequence has been planned and practiced by the first and last author, recorded perfected and implemented in a two-day surgical course. The sequence was then evaluated by the trainers and the trainees by means of a questionnaire.

RESULTS

All students were able to complete the sequence of exercises before the end of the second day except two (8/10) who could not complete one exercise each. The students considered the Deep Superior Epigastric Artery Perforator flap the most difficult to perform, being the most technically demanding. The sequence of exercises was judged either easily reproducible or reproducible by all the students. Two students suggested to postpone the DSEAP flap to the second day, after some training, to optimize the experience with the most challenging and rewarding flap.

CONCLUSIONS

The training sequence proposed offers a wide range of exercises and allows four trainees, divided in two teams, to work and learn on the same animal. They can perform a wide range of flaps and also harvest the internal mammary vessels. The living model allows for evaluation of the quality of the surgical performance, judged by the difficulties and complications encountered during dissection, and finally through the feedback of flap perfusion.

Sequential propeller flaps in the treatment of post-traumatic soft tissue defects of the lower limb - a case series

INTRODUCTION

Propeller flaps have gained great popularity among reconstructive surgeons; however, the inability to directly close the donor site of large propeller flaps constitutes a well-known limitation of this technique. Skin grafting of the donor area is not always feasible nor desirable. To address large propeller flaps secondary defects, we investigated the use of a second propeller flap harvested from a nearby region of relative skin redundancy to assist the donor site closure generated by the first. Since the donor defect of the second flap is closed by direct suture, the aim of this "sequential" propeller flaps technique is to achieve complete, like-with-like, soft tissue restoration while avoiding skin grafting.

METHODS

From April 2018 to September 2019, eight patients presenting post-traumatic soft tissue defects were planned to be reconstructed by means of the sequential propeller flaps technique, for a total of 16 propeller flaps. The locations of the defects included the distal leg in four cases, the heel in two cases, the proximal lateral thigh in one case and proximal posterior thigh in the remaining one. All the flaps but one were harvested as a perforator-based propeller type and rotated by different degrees around the skeletonized perforator. In one patient, due to an intraoperative complication following the first flap harvest, the harvest of the second flap was abandoned.

RESULTS

In all but one patient, a complete, tension free primary closure of all wounds was achieved without complications, the functional recovery as well the esthetic outcome were excellent. One patient showed intraoperative signs of vascular insufficiency involving 15% of the first flap. The plan of harvesting the second flap was intraoperatively abandoned and the definitive wound closure with a free muscle gracilis was carried out the following week.

CONCLUSION

In some selected cases, the use of multiple propeller flaps performed in sequence allows the surgeon to obtain complete, like-with-like wound closure with vascularized tissue avoiding a free tissue transfer procedure, however, it requires a vast experience with propeller flaps and meticulous preoperative planning.

Risk of translocated soft-tissue sarcoma recurrence using perforator propeller flap: Case report and literature review

Tumor seeding after intra-abdominal and head and neck cancer surgery is a well-known entity. The risk of disseminating cancerous cells during surgery is also described for soft-tissue sarcoma of the extremities. Nonetheless, after reconstructive surgery using flaps, the risk of recurrence at the donor site is extremely rare. Up to this date, the literature describes only three cases, but none of them reported a translocated recurrence after a reconstruction with a propeller flap. Here, we report a case of high-grade pleomorphic sarcoma of the knee, which recurred at the proximal edge of a propeller flap 28 months after the first excision surgery. The reasons for such local recurrences are not clear and previous works have advocated different theories: direct contamination by tumor cells, physical manipulation of the tumor and creation of surgical wounds with tumor supportive properties. Although these particular cases of recurrence are exceedingly rare, certain precautionary meticulous surgical techniques and a thorough preoperative planning are pivotal to avoid the contamination of "clean" areas during the first excision surgery.

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.

Regenerative Limb Salvage: A Novel Technique for Soft Tissue Reconstruction of Pediatric Extremities

Background In complex extremity wounds, free flap-based limb salvage (fLS) is the standard of care. However, fLS is resource- and cost-intensive, and the limited availability of pediatric microsurgical expertise exacerbates these challenges. Regenerative LS (rLS) addresses these barriers to care. The aim of this study was to quantify the efficacy, safety, and cost-effectiveness of rLS in complex pediatric extremity wounds.

Methods We conducted a retrospective cohort study of pediatric LS at a single hospital. Subjects were treated with fLS or rLS based on surgeon preference. Primary outcome measures were: definitive wound closure rates and time, rates of return to ambulation, number and length of procedures to achieve definitive closure, and rates of perioperative complications. Statistical analyses were performed utilizing the Wilcoxon Mann–Whitney U test with statistical significance set at p < 0.05.

Results Over a 2-year period, nine consecutive patients presented with complex extremity wounds requiring fLS (n = 4) or rLS (n = 5). Demographics and wound characteristics were similar between groups. Compared with fLS, the rLS group achieved definitive wound closure 85.8% more quickly (13.8 vs. 97.5 days, p < 0.02), required 64.5% less operative time (132.6 vs. 373.0 minutes, p < 0.02), had fewer perioperative complications (0 vs. 5), and required fewer intensive care unit stays (0 vs. 1.3 days).

Conclusion These data indicate that rLS is a safe and efficacious option in pediatric patients requiring soft tissue reconstruction for LS. Use of this novel technique can restore the reconstructive ladder, thereby expand patient access to pediatric LS while minimizing morbidity and reducing LS-related resource utilization.

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.

Reconstructive microsurgery in upper limb reconstruction: 30 years' experience of a single surgeon

The reconstruction of compound tissue defects in upper extremity injuries often represents a challenge. The goal of reconstruction is to obtain not only a good cosmetic result, but also the best possible function. Microsurgery highly contributes to the management of upper limb simple or complex defects by offering a large number of surgical possibilities. Due to advances in understanding of blood supply to tissues and microsurgical techniques in the last 50 years, microsurgeons have renounced more and more to the use of traditional flaps in favour of the more reliable perforator flaps. This article presents the experience of a single surgeon performing post-traumatic upper limb reconstructive microsurgery over the last 30 years.

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.

Propeller Flaps in the Posterior Trunk

The reconstruction of complex posterior trunk defects remains challenging. But now with an increased knowledge of angiosomes and the practice of perforator flaps, the posterior trunk offers a new plethora of options for reconstruction. Propeller flaps based on such perforator(s) offer an elegant solution for managing defects while achieving primary donor-site closure without significant morbidity. We will discuss the relevant anatomy and design principles for propeller flaps based on a review of the literature and our experience. Steps beginning with preoperative planning, perforator selection, and intraoperative surgical technique will be discussed, together with pearls on both avoiding and managing complications.

Introduction to "Propeller Flaps"

The editors of this issue of Seminars in Plastic Surgery dedicated to propeller flaps met in 2009 at the "1st Tokyo Meeting on Perforator and Propeller Flaps." On that occasion, as part of the advisory panel of the meeting, they contributed to the definition and classification of these flaps. Since then, several evolutions and new applications of propeller flaps appeared in the literature. In 2019, the editors met again in Bologna, Italy, where they decided to collect the experiences from prominent authors in propeller flap surgery and provide them to the readers in this monographic dedicated publication.

Oncologic safety of propeller flap and free flap in reconstruction after soft tissue sarcoma resection

BACKGROUND AND OBJECTIVES

The propeller flap is a reliable option for reconstruction after soft tissue sarcoma resection. However, some parts of the resection margin may move away from its original position during flap rotation and thus can be excluded from the clinical target volume of adjuvant radiotherapy. This study aimed to evaluate local recurrence after soft tissue sarcoma resection with propeller flap or free flap reconstruction.

METHODS

Patients who underwent resection of soft tissue sarcoma followed by a free flap or propeller flap reconstruction and adjuvant radiotherapy at a single institution were retrospectively reviewed.

RESULTS

The 1- and 3-year local control rates were 94.6% and 88.6% in the free flap group vs 90.6% and 87.5% in the propeller flap group, without statistical significance. There were no statistically significant differences in 5-year local recurrence-free survival (88.6% vs 87.5%) and disease-free survival (82.5% vs 74.8%) between the groups.

CONCLUSIONS

Although there was no significant difference in local control and disease-free survival rates between propeller flap and free flap reconstruction after soft tissue sarcoma resection, a multidisciplinary approach is needed to obtain surgical information for determining the accurate clinical target volume of adjuvant radiotherapy and the area for meticulous follow-up postoperatively.

Lower limb perforator flaps: Current concept

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.