Perforator Based Propeller Flaps in Limb Reconstructive Surgery: Clinical Application and Literature Review

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.

The Effect of Perforator Skeletonization on Pedicled Fasciocutaneous Flaps of the Lower Extremity: A Systematic Review

“…In perforator-based flaps, increasing length to width ratio and flap size does impact the risk of partial necrosis; however, at present there is no standardized limitation of these values for perforator flaps of the lower extremity. 10,18,30,31 The reoperative rate was significantly higher for skeletonized flaps with length to width ratios greater than 1.75 (OR: 33.33, p ¼ 0.01), and for flap size over 48 cm 2 (OR: 7.52, p ¼ 0.03) that is consistent with what one would expect given the knowledge of perforasomes and blood supply of perforator flaps. 49 To reduce the risk of partial necrosis, magnetic resonance imaging or other more specific methods to predict vascularity of lower extremity perforator flaps were discussed, especially in regard to avoiding necrosis of large flaps at the distal tip.…”

“…Five articles discussed salvage operations required for these patients including free anterolateral thigh flap, cross leg flap, sural artery perforator flap, skin graft, and one patient unfortunately requiring amputation. 10,15,16,23,[27][28][29] Additionally, complications of major infection and major dehiscence required reoperation. The most common minor complication was transient venous congestion (3.2%) which was treated conservatively.…”

“…2,[7][8][9] According to the Gent Consensus, perforator flaps are defined as tissue areas with blood supply from perforating arterial branches of a major vessel with either an intramuscular or septal course. [10][11][12] This type of local flap is useful for the reconstruction of defects with tissue of similar color, volume and pliability, while avoiding excess bulk and donorsite morbidity inherent to local muscle flaps. Locoregional perforator flaps can offer the same benefits of free tissue transfer to the lower extremity without the need for certain microsurgical resources-including an operative microscope, specialized flap monitoring devices, and staff trained in free flap monitoring and rehabilitation.…”

“…As a result of these benefits, pedicled, perforator-based flaps have thus been described as a "microsurgical non-microvascular flap." 10,11,[13][14][15][16] Success rates of pedicled perforator flaps have been shown to be comparable to free perforator flaps in the lower extremity. 9 In contrast to a random pattern local flap without a named blood supply, perforator flaps have reliable vascular pedicles and dependable flap survival rates.…”

The effects of optimizing blood inflow in the pedicle on perforator flap survival: A pilot study in a rat model

“…In recent years, major efforts have been made to conduct anatomical studies of skin vascularization [14]. This constitutes the basis for the development of reconstructive techniques with low donor site morbidity, especially after oncological excision and trauma leading to a loss of substance with major functional and aesthetic implications [15]. Perforator-based flaps, either as free flaps or local pedicled flaps, have been established as a reconstructive method.…”