The Distally Perforator-Pedicled Propeller Flap

Abstract

Sir:FigureWe read with great interest the article by Pignatti et al. entitled “The Tokyo Consensus on Propeller Flaps.”1 It was the result of discussion of terminology by the Advisory Panel of the First Tokyo Meeting on Perforator and Propeller Flaps, which was held in 2009. After a brief review of the propeller method, the article defined the propeller flap as “an island flap that reaches the recipient site through an axial rotation.” The combination of the propeller technique and the perforator flap led to the concept of perforator pedicled propeller flap, which was nourished by an isolated perforating vessel. The flap can be rotated on the perforator pivot point as much as 180 degrees easily and safely, thus effectively transposing the skin island from an area diagonally opposite the defect. At present, the perforator-pedicled propeller fasciocutaneous flap is the one used most commonly in clinical practice. The distal eccentric perforator-pedicled propeller flap was probably first reported by us in 2004.2 We raised a distally based sural neurofasciocutaneous island flap from the posterior lower leg for foot and ankle reconstruction, with 180-degree rotation. The flap was based on the isolated lowermost septal perforator that originated from the peroneal artery, usually located at 5 cm above the lateral malleolus. We termed the flap the “distally perforator-based flap,” not propeller flap. Subsequently, we3 introduced the lateral retromalleolar perforator–based flap for heel coverage in 2007, and the distal perforator–based sural neurofasciomyocutaneous flap (with a piece of gastrocnemius muscle attachment) for heel pad reconstruction and tibial osteomyelitis treatment in 2009.4 All of our flaps were distal septocutaneous perforator based, not musculocutaneous. From our experience, after identifying the septal perforator, further dissection to skeletonize and free it from the septal fascia is not necessary and may be dangerous. The septum usually has 1- to 2-cm depth in the distal part of the lower leg, which results in the same vascular pedicle length to share the twisting torsion (Fig. 1). The septum also provides protection for the perforators from stretching. In our opinion, for septocutaneous perforator-based propeller flaps, tension by pull and retraction after flap rotation was the most significant risk factor for flow impairment. Thus, increasing flap size, especially its length, keeps the flap inset tension-free.Fig. 1: A 28-year-old man with an open Achilles tendon rupture was referred to us 2 weeks after primary closure breakdown. (Above, left) The Achilles tendon rupture had overlying skin necrosis. (Above, right) A distally posterior tibial artery perforator-based propeller fasciocutaneous flap was raised. The fascial septum containing one perforating artery and its two venae comitantes was kept intact. The arrow indicates the depth of the septum, which was the length of pedicle, to share rotation. (Below, left) The flap was propelled to cover the defect. The donor site was closed directly. (Below, right) Two weeks later, the flap survived completely. The donor site was closed directly.The distally perforator-pedicled propeller flap has unique characteristics. It is very useful for small to medium defects in the extremities. However, further clarification in flap design and evolution in surgical technique may be necessary for a variety of clinical applications. Shi-Min Chang, M.D., Ph.D. You-Lun Tao, M.D. Ying-Qi Zhang, M.D. Department of Orthopedic Surgery, Tongji Hospital, Tongji University, Shanghai, People's Republic of China