A review of propeller flaps for distal lower extremity soft tissue reconstruction: Is flap loss too high?

Abstract

Soft tissue coverage in the distal lower extremity remains a significant challenge. While free flaps are often utilized for larger defects, local perforator-based propeller flaps may be ideal for smaller wounds requiring coverage. Propeller flaps can provide excellent form and function for both traumatic and atraumatic defects with minimal donor site morbidity but can have concerning rates of flap loss. We reviewed the literature, identifying 21 studies presenting 310 propeller flaps for distal lower extremity reconstruction. Total flap necrosis was noted in 5.5% of flaps, with partial necrosis in 11.6%. While these flaps do enable transfer of local, healthy tissue to the defect site without the need for a microsurgical anastomosis, this rate of flap loss is concerning and appropriate patient selection is crucial. This review provides a brief history and overview of the clinical application and research into distal lower extremity perforator propeller flaps to place this technique into a clinical context.

Use of Perforator-Based Fasciocutaneous Flaps for Pressure Sore Reconstruction: Single-Perforator-Based Versus Multiple-Perforator-Based Flaps

“…In Lazzeri et al's [43] review, propeller perforator flaps for trunk and upper limb reconstruction resulted in the total complication rate of approximately 13.8 %, with a major complication rate of 3.4 %. However, the complication rate is higher in the lower extremities than in the other parts of the body, with frequent venous congestion and partial flap necrosis, and the total flap failure rate has been reported to be 1.1-5.6 % in the lower extremities [42,44,45]. In our study, age, sex, and comorbidities, including diabetes mellitus, hypertension, coronary artery disease, were similarly distributed between the two groups.…”

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

“…This approach also avoids any need for micro‐anastomosis, which is surgically time‐consuming and stressful. Although such flaps have become commonly used to cover lower‐extremity defects, their reliability remains to be thoroughly assessed . Also, free flaps remain the first choice when wide cutaneous areas are to be covered and when complex reconstructive tasks require composite or functional flaps.…”

Propeller Flaps With Reduced Rotational Angles

“…Nevertheless, if compared with other techniques, the rate of vascular complications associated with pedicle rotation has been reported to be significantly higher, justifying the skepticism shown by many surgeons toward the procedure. 17 A systematic review by Gir et al, 18 The reliability of such flaps, which are intentionally twisted on their vascular pedicle up to 180-degree angles, has been experimentally documented by Wong and colleagues, 16 who showed how the degree of pedicle rotation means nothing when the pedicle length and the twisting density are not concomitantly considered. In their study the authors advice to optimize the conditions for maintaining perforator patency: in particular, the angle of twist should be kept less than 180 degrees, perioperative blood pressure should be kept stable, avoiding periods of hypotension, and the selected perforator should be approximately 1 mm in diameter and dissected for a length of 3 cm.…”

“…In fact, it represents the design of choice in patients presenting with a short perforator-defect distance and the wound located over the axis of the chosen perforasome, condition more frequently observed in upper and lower limb reconstructions: in these patients, which represent the most complicated and technically challenging cases, the 180-degree propeller flap design should be adopted without hesitation, taking advantage of all the described technical tricks to make the rotational movement as much comfortable as possible. [16][17][18][19][20][21][22] CONCLUSIONS Propeller flaps with reduced rotational angles represent a safe and versatile option to reconstruct soft tissues defects at different anatomical sites.…”