Reply: The Concepts of Propeller, Perforator, Keystone, and Other Local Flaps and Their Role in the Evolution of Reconstruction.

Abstract

Sir: We would like to thank Dr. Brunetti et al. for the their interest in our article entitled “The Concepts of Propeller, Perforator, Keystone, and Other Local Flaps and Their Role in the Evolution of Reconstruction.” The authors describe their philosophy for progressive complexity (simple to complex) in perforator flap selection based on defect type. We follow and recommend a similar approach to reconstruction with pedicle perforator flaps and multiperforator advancement flaps (e.g., keystone, V-Y). Although we focused on pedicle propeller flaps and keystone flaps in our article, there are multiple other variations of perforator flaps possible, too numerous to mention in our publication. As the authors mentioned, V-Y perforator advancement flaps offer a simple and easy way to cover various defects. These flaps are similar to keystone flaps and are based on multiple perforators, all of which do not need to be skeletonized or even identified (Figs. 1 and 2). The skin paddle for multiperforator advancement flaps can essentially be designed any way to suit the defect and donor site. The V-Y design is one example among many, and any geometric shape can be designed as needed (e.g., keystone, oval, teardrop, circle, rectangle, parallelogram). The donor sites for all of these flaps do not always require a V-Y closure when donor-site skin laxity is high. Any block of tissue with a sufficient number of underlying perforators can be advanced in any direction. Multiperforator advancement flaps provide an easy and reliable form of reconstruction with early postoperative mobilization.1Fig. 1.: Perforator V-Y advancement flap for upper lateral chest coverage following melanoma resection. The perforators for this V-Y flap were not skeletonized, and loose areola tissue allowed for tension-free advancement.Fig. 2.: Result 6 weeks postoperatively after perforator V-Y advancement flap surgery for upper lateral chest coverage following melanoma resection.As the authors mentioned, we also recommend designing pedicle perforator flaps for a 90-degree rotation whenever possible.2 This limits the amount of perforator dissection required, and minimizes the risk of venous congestion because multiple perforators can often be incorporated within the flap. (See Figure, Supplemental Digital Content 1, which shows a pedicle perforator flap rotated 90 degrees for left knee coverage, https://links.lww.com/PRS/C150. See Figure, Supplemental Digital Content 2, which shows that skeletonization of the superficial femoral artery perforator was not required to achieve proper flap inset, https://links.lww.com/PRS/C151.) This is especially true in areas that have ample loose areolar tissue where the flap can be rotated with minimal constraints (e.g., abdomen, trunk, proximal limbs). For 90-degree rotation, the flap should be harvested from the side with the loosest skin laxity and most numerous perforators, identified by handheld Doppler imaging, at the pivot point. The perforators often do not need to be isolated, and multiple ones can be included within the flap base to maximize venous drainage and arterial perfusion. With the advent of multiple dominant perforators throughout the body, a freestyle approach to reconstruction is a natural evolution and departure from traditional flap design.3 There are many high- and low-density perforator locations (hot spots and cold spots) throughout the body. Whenever possible, high-density areas should be preferred for perforator flap donor-site selection. Another type of pedicle perforator flap that lends itself well to a freestyle approach is the adipofascial pedicle perforator flap. This can be harvested based on multiple perforators and either rotated into place or used as a turnover flap. Keeping a wide flap base ensures high reliability, and adipofascial tissue provides high mobility for either rotation or turnover flaps. (See Figure, Supplemental Digital Content 3, which shows a right forearm exposed extensor tendon, https://links.lww.com/PRS/C152. See Figure, Supplemental Digital Content 4, which shows elevation of a freestyle pedicle perforator adipofascial flap based on perforators from the posterior interosseous artery, https://links.lww.com/PRS/C153. See Figure, Supplemental Digital Content 5, which shows final flap insetting, https://links.lww.com/PRS/C154. See Figure, Supplemental Digital Content 6, which shows use of a split-thickness skin graft over the pedicle perforator adipofascial flap for final closure, https://links.lww.com/PRS/C155.) Also, areas with a high perforator density (hot spots) can be identified and used for their design (e.g., radial artery adipofascial flap). With the presence of multiple dominant perforators throughout the body, a freestyle approach to reconstruction based on high-density vascular zones can be considered. As mentioned by Brunetti et al., using a stepwise approach to reconstruction can simplify harvest and increase reliability. We follow a similar algorithm, starting with (1) advancement multiperforator perforator flaps (e.g., V-Y, keystone), (2) adipofascial pedicle perforator flap, (3) limited rotation (≤90 degrees) pedicle perforator flap, and (4) fully rotated (180 degrees) perforator flaps. In summary we would like to thank the authors for their meaningful insight and experience on making perforator flap surgery simpler and safer. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Michel Saint-Cyr, M.D.Anita T. Mohan, M.B.B.S., B.Sc.Yoo Joon Sur, M.D., Ph.D.Lin Zhu, M.D.Mohamed Morsy, M.B.B.Ch., M.S.Peter S. Wu, M.D., M.S.Steven L. Moran, M.D.Samir Mardini, M.D.Baylor Scott & White HealthTemple, Texas