Are There Risk Factors for Complications of Perforator-based Propeller Flaps for Lower-extremity Reconstruction?
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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.
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.
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.
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.
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.
- Baden JM, Warr RP, Khan U. Immediate free tissue transfer for coverage of Achilles tendon injury or reconstruction. Foot Ankle Surg. 2010;16:164–169. CrossRef
- Blondeel PN, Van Landuyt K, Monstrey SJ, Hamdi M, Matton GE, Allen RJ, Dupin C, Feller AM, Koshima I, Kostakoglu N, Wei FC. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112:1378–1382. CrossRef
- D’Arpa S, Cordova A, Pignatti M, Moschella F. Freestyle pedicled perforator flaps: safety, prevention of complications, and management based on 85 consecutive cases. Plast Reconstr Surg. 2011;128:892–906. CrossRef
- Georgescu A. Propeller perforator flaps in distal lower leg: evolution and clinical applications. Arch Plast Surg. 2012;39:94–105. CrossRef
- Georgescu AV, Capota I, Matei I, Ardelean F, Avram A, Ignatiadis I, Olariu O. The place of local/regional perforator flaps in complex traumas of the forearm. J Hand Microsurg. 2009;1:25–31. CrossRef
- Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical non microvascular flaps in forearm and hand reconstruction. Microsurgery. 2007;27:384–394. CrossRef
- Gir P, Cheng A, Oni G, Mojallal A, Saint-Cyr M. Pedicled-perforator (propeller) flaps in lower extremity defects: a systematic review. J Reconstr Microsurg. 2012;28:595–602. CrossRef
- Gokrem S, Sarifakioglu N, Toksoiy K, Terzioglu A, Aslan G. Effects of 360-degree pedicle torsion on island skin flaps: experimental study in rats. J Reconstr Microsurg. 2005;21:313–316. CrossRef
- Innocenti M, Baldrighi C, Delcroix L, Adani R. Local perforator flaps in soft tissue reconstruction of the upper limb. Handchir Mikrochir Plast Chir. 2009;41:315–321. CrossRef
- Jakubietz RG, Jakubietz MG, Gruenert JG, Kloss DF. The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap. Ann Plast Surg. 2007;59:667–671. CrossRef
- Jiga LP, Barac S, Taranu G, Blidisel A, Dornean V, Nistor A, Stoichitoiu T, Geishauser M, Ionac M. The versatility of propeller flaps for lower limb reconstruction in patients with peripheral arterial obstructive disease: initial experience. Ann Plast Surg. 2010;64:193–197. CrossRef
- Karki D, Narayan RP. The versatility of perforator-based propeller flap for reconstruction of distal leg and ankle defects. Plast Surg Int. 2012;2012:303247.
- Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg. 1988;81:561–566. CrossRef
- Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN. A review of propeller flaps for distal lower extremity soft tissue reconstruction: is flap loss too high? Microsurgery. 2013;33:578–586. CrossRef
- Panagiotopoulos K, Soucacos PN, Korres DS, Petrocheilou G, Kalogeropoulos A, Panagiotopoulos E, Zoubos AB. Anatomical study and colour Doppler assessment of the skin perforators of the anterior tibial artery and possible clinical applications. J Plast Reconstr Aesthet Surg. 2009;62:1524–1529. CrossRef
- Pignatti M, Ogawa R, Hallock GG, Mateev M, Georgescu AV, Balakrishnan G, Ono S, Cubison TC, D’Arpa S, Koshima I, Hyakusoku H. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg. 2011;127:716–722. CrossRef
- Rad AN, Singh NK, Rosson GD. Peroneal artery perforator-based propeller flap reconstruction of the lateral distal lower extremity after tumor extirpation: case report and literature review. Microsurgery. 2008;28:663–670. CrossRef
- Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–1544. CrossRef
- Sauerbier M, Erdmann D, Brüner S, Pelzer M, Menke H, Germann G. Covering soft tissue defects and unstable scars over the Achilles tendon by free microsurgical flap-plasty. Chirurg. 2000;71:1161–1166. CrossRef
- Schaverien M, Saint-Cyr M. Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flap. Plast Reconstr Surg. 2008;122:161–170. CrossRef
- Schaverien MV, Hamilton SA, Fairburn N, Rao P, Quaba AA. Lower limb reconstruction using the islanded posterior tibial artery perforator flap. Plast Reconstr Surg. 2010;125:1735–1743. CrossRef
- Selvaggi G, Anicic S, Formaggia L. Mathematical explanation of the buckling of the vessels after twisting of the microanastomosis. Microsurgery. 2006;26:524–528. CrossRef
- Smit JM, Darcy CM, Audolfsson T, Hartman EH, Acosta R. Multilayer reconstructions for defects overlying the Achilles tendon with the lateral-arm flap: long-term follow-up of 16 cases. Microsurgery. 2012;32:438–444. CrossRef
- Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998;102:599–616. CrossRef
- Teo TC. The propeller flap concept. Clin Plast Surg. 2010;37:615–626. CrossRef
- Topalan M, Bilgin SS, Ip WY, Chow SP. Effect of torsion on microarterial anastomosis patency. Microsurgery. 2003;23:56–59. CrossRef
- Tos P, Innocenti M, Artiaco S, Antonini A, Delcroix L, Geuna S, Battiston B. Perforator-based propeller flaps treating loss of substance in the lower limb. J Orthop Traumatol. 2011;12:93–99. CrossRef
- Wu CC, Lin PY, Chew KY, Kuo YR. Free tissue transfers in head and neck reconstruction: complications, outcomes and strategies for management of flap failure: analysis of 2019 flaps in single institute. Microsurgery. 2013 December 8 [Epub ahead of print].
- Are There Risk Factors for Complications of Perforator-based Propeller Flaps for Lower-extremity Reconstruction?
Clinical Orthopaedics and Related Research®
Volume 472, Issue 7 , pp 2276-2286
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- 1. Reconstructive Microsurgery, Department of Oncology, Careggi University Hospital, CTO, Largo Palagi 1, 50139, Florence, Italy
- 2. Reconstructive Microsurgery, CTO-M. Adelaide, Turin, Italy