The versatility of perforator-based propeller flap for reconstruction of distal leg and ankle defects

Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases

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.

[Back loss cover in orthopedic surgery by helical lumbar perforator flaps: About 6 cases]

INTRODUCTION

The existence of voluminous paralumbar perforators allows a simplification of the coverage of the lumbar region.

MATERIALS AND METHODS

The authors present a series about lumbar loss substance following orthopedic surgery, from 2012 to 2017. Coverage was provided by a fascio-cutaneous lumbar perforator flap.

RESULTS

Six patients were operated with mean age of 62.3 years, with an average follow-up of 16 months (up 6 to 41 months). Substance losses were secondary to a carcinologic excision, to a radiodermitis excision and to four debridements after infection of the operative site. In five cases, the reconstruction was performed by one lumbar perforator flap, and in one case by two lumbar perforator flaps. The average size of the substance losses was 171.91 cm² (up 78 to 250 cm²). The average size of the flaps taken was 161 cm² (up 50 to 250 cm²). The donor site was self-closing without sequelae. The postoperative sequences were simple and marked by a single partial necrosis of a flap, with a favorable evolution after directed healing. The quality of the cover was good with excellent trophicity.

CONCLUSION

Lumbar perforator helical fascio-cutaneous flaps are a reliable means of covering the loss of substances in the lumbar region. The use of these flaps makes it possible to avoid the taking of complex myo-cutaneous flaps, causing sequelae of the donor site in a location difficult to cover.

Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis

INTRODUCTION

Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?"

METHODS

This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I² index were computed.

RESULTS

We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016).

CONCLUSION

In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.

Propeller Flap for Complex Distal Leg Reconstruction: A Versatile Alternative when Reverse Sural Artery Flap is Not Feasible

Reverse sural artery fasciocutaneous flap has become a workhorse for the reconstruction of distal leg soft tissue defects. When its use is not feasible, perforator-based propeller flap offers a better, easier, faster, and cheaper alternative to free flap. We present our experience with two men both aged 34 years who sustained Gustilo 3B injuries from gunshot. The donor area for reversed sural artery flap was involved in the injuries. They had early debridement, external fixation, and wound coverage with perforator-based propeller flaps. The donor sites were covered with skin graft. All flaps survived. There were minor wound edge ulcers due to the pressure of positioning that did not affect flap survival and the ulcers healed with conservative management. Perforator-based propeller flap is a versatile armamentarium for reconstruction of soft tissue defects of the distal leg in resource-constrained settings, especially when the donor area for a reverse flow sural flap artery is involved in the injury.

Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction?

BACKGROUND

Conventional pedicled flaps for soft tissue reconstruction of lower extremities have shortcomings, including donor-site morbidity, restricted arc of rotation, and poor cosmetic results. Propeller flaps offer several potential advantages, including no need for microvascular anastomosis and low impact on donor sites, but their drawbacks have not been fully characterized.

QUESTIONS/PURPOSES

We assessed (1) frequency and types of complications after perforator-based propeller flap reconstruction in the lower extremity and (2) association of complications with arc of rotation, flap dimensions, and other potential risk factors.

METHODS

From 2007 to 2012, 74 patients (44 males, 30 females), 14 to 87 years old, underwent soft tissue reconstruction of the lower extremities with propeller flaps. General indications for this flap were wounds and small- and medium-sized defects located in distal areas of the lower extremity, not suitable for coverage with myocutaneous or muscle pedicled flaps. This group represented 26% (74 of 283) of patients treated with vascularized coverage procedures for soft tissue defects in the lower limb during the study period. Minimum followup was 1 year (mean, 3 years; range, 1-7 years); eight patients (11%) were lost to followup before 1 year. Complications and potential risk factors, including arc of rotation, flap dimensions, age, sex, defect etiology, smoking, diabetes, and peripheral vascular disease, were recorded based on chart review.

RESULTS

Twenty-eight of 66 flaps (42%) had complications. Venous congestion (11 of 66, 17%) and superficial necrosis (seven of 66, 11%) occurred most frequently. Eighteen of the 28 complications (64%) healed with no further treatment; eight patients (29%) underwent skin grafting, and one patient each experienced total flap failure (2%) and partial flap failure (2%). In those patients, a free anterolateral thigh flap was used as the salvage procedure. No correlations were found between complications and any potential risk factor.

CONCLUSIONS

We were not able to identify any specific risk factors related to complications, and future multicenter studies will be necessary to determine which patients or wounds are at risk of complications. Propeller flaps had a low failure rate and risk of secondary surgery. These flaps are particularly useful for covering small- and medium-sized defects in the distal leg and Achilles tendon region and are a reliable and effective alternative to free flaps.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Fasciocutaneous flaps for covering foot and ankle injuries

Objective

to present some cases from our service and to confirm that sural and lateral supramalleolar flaps are good options for covering the soft tissues of the foot and ankle.

Methods

twenty-two flaps were constructed in 21 patients of ages ranging from 15 to 72 years. Male patients predominated (66.6%) and in 47.6% of the cases the injury resulted from accidents involving motorcycles.

Results

among the 22 flaps, 12 were sural and 10 were lateral supramalleolar; in one case, two flaps were used. In all the cases, the injuries were successfully covered and the patients recovered well. During the postoperative follow-up, the commonest complication was epidermolysis, occurring in eight cases (three in a sural flap and five in a supramalleolar flap), among which two cases progressed to distal necrosis of the flap (one sural and the other supramalleolar). One patient wanted the flap reviewed for esthetic reasons.

Conclusions

sural and supramalleolar flaps are very reliable. They preserve the main trunk arteries, are quickly dissected, have low hospital cost, enable coverage of extensive areas, present esthetically acceptable damage to the donor area and do not impair motor function.

[Flaps for soft tissue defect closure in the distal lower leg]

Soft tissue defects in the distal lower leg region are challenging to treat, especially in trauma cases. To achieve early closure of the defect, pediculated adipofascial or muscle flaps can be used as well as free flaps. The pediculated adipofascial suralis flap has a reliable blood supply and a broad radius so this flap can be used for almost every defect location on the distal lower leg except for defects larger than 10 × 10 cm. The donor site defect does not lead to major problems and is well tolerated. The soleus flap can cover defects in the middle third and proximal distal third of the lower leg with its muscle. The donor site defect is occasionally associated with reduced calf functioning but is tolerated well most of the time. Because of these advantages, the pediculated adipofacial suralis flap and the soleus muscle flap can be used instead a microvascular free flap for the closure of defects in the distal lower leg region.