The Role of Freestyle Perforator-Based Pedicled Flaps in Reconstruction of Delayed Traumatic Defects

Abstract

The use of perforator-based flaps as freestyle pedicled flaps for traumatic defects has been limited. We explored this possible application in small to moderate sized traumatic defects presenting in the delayed phase, with distinct oedema and induration in the potential flap donor area and posttraumatic vessel disease. Attempts to skeletonize perforator vessels are likely to compromise the flap perfusion, and inadequate dissection is likely to limit mobility of the indurated tissues in the flap. Conventionally, an axial pattern pedicled or a free flap would be needed in such cases, thus increasing its magnitude. We used the freestyle technique to cover traumatic defects by retrograde dissection of pedicled perforator-based flaps. As the surgery was performed in the delayed phase, the tissues were indurated and a larger tissue cuff was preserved around the pedicle than would be our practice in elective surgery. In addition, flap dimensions were planned larger than the defect to be closed. The donor defect was either skin grafted or closed primarily. Our study included 11 cases at various sites over the body. All flaps survived, though 3 flaps encountered major complications, 2 of which needed reoperation. None of the flaps failed completely. The pedicled perforator-based flap provides the surgeon with additional reconstructive options in the setting of trauma. These flaps can be safely harvested using indurated tissue; thus in selected cases, a free flap can be avoided, and reliable cover can be provided with a pedicled flap. Nevertheless, clinical judgment is essential to assess the potential vascular territory of the flap.

A Systematic Review and Meta-analysis of Free-style Flaps: Risk Analysis of Complications

“…There were 9 6 , 13 , 14 , 17 – 20 , 22 , 24 included studies describing the dissection plane. In 68.4% (n = 171) of cases, the flaps were raised on the supra-fascial plane, whereas the other 31.6% (n = 79) were dissected to the sub-fascial plane.…”

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

“…The group repaired defects in all regions of the lower leg, with reported complication rates being 9% complete and 12% partial flap loss rate . Several groups have described this flap in much smaller numbers of patients, but overall with good results . More recently, Robotti et al and Tos et al presented series of 24 and 13 flaps, respectively.…”

“…Chai et al utilized this flap for large defects of plantar surface and heel, whereas Lu et al used it extensively in numerous pretibial, achilles, and lateral malleous injuries with good results. Lastly, several smaller case studies of peroneal artery propeller flaps have been presented . Rubino et al describe this flap for treatment following debridement of chronic osteomyelitis of the fibula.…”

Pedicled-Perforator (Propeller) Flaps in Lower Extremity Defects: A Systematic Review

“…Articles not available in English, without accessible full text, or single case reports were excluded. Fifteen articles [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] were identified that met these criteria which represented 186 cases of pedicled-perforator (propeller) flaps in lower extremity. These references are summarized in ►Table 1.…”