Local Perforator Flaps Research Articles

Comment to “Free-style local perforator flaps: concept and classification system”

The concept of free-style local perforator flaps is fascinating. It provides us with the possibility to reconstruct a defect with a flap adjacent to it, which then has similar characteristics as the removed tissue, while causing minimal donor site morbidity. The authors describe their experience of 21 flaps performed over a 2-year period to deal with a range of reconstructive challenges. From the excellent results presented they then propose a classification for free-style local perforator flaps, which was intended to give an understanding of how a particular flap is dissected rather than what it is made up of, where it is, or what source vessel supplies it.

The propeller flap for chronic osteomyelitis of the lower extremities: a case report

The goals of the treatment of chronic osteomyelitis are infection eradication with systemic antibiotic therapy and local management with radical excision of the infected tissue and obliteration of the remaining dead space. Adequate debridement and coverage with a well-vascularised tissue are mandatory for successful outcomes. Use of muscle covering for chronic osteomyelitis in the lower extremities is considered the best procedure. However, there have been instances where debridement of the bone tissue did not leave a deep cavity along the leg bones and fasciocutaneous flaps can be used in these instances to cover the defect and to restore function without recurrence of the disease. Recently, free non-muscle flaps have been used and assessed for chronic osteomyelitis or covering of exposed bone. Perforator flaps have been shown to be well vascularised due to a structural haemodynamic enhancement. In the light of these findings we report a successful case of chronic osteomyelitis of the right fibula treated with excision of the affected tissue and covering with a propeller flap. Instead of free flap covering, in order to optimise surgical reconstruction, reducing the operative time, donor and recipient site morbidity and risk of total flap failure, local perforator flaps and particularly the propeller flap may be indicated in the treatment of chronic osteomyelitis in selected patients when the defect is limited and there is no need to fill a deep bone cavity or a dead space. To our knowledge, this the first report of the use of a propeller flap in the treatment of chronic osteomyelitis in the lower extremities.

The 180-Degree Perforator-Based Propeller Flap for Soft Tissue Coverage of the Distal, Lower Extremity

Traumatic and nontraumatic defects of the distal third of the tibia are challenging in regard to soft tissue coverage. While local, pedicled fasciocutaneous perforator flaps allow adequate coverage, the donor site often requires skin grafting. When a local perforator flap is designed as a 180-degree propeller flap, an excellent esthetic result and direct closure of the donor site can be achieved, with minimal morbidity. Eight patients with defects in the malleolar region were treated with 180-degree propeller flaps based on perforators from the tibial and peroneal vessels. One partial flap loss was encountered in an insulin-dependent diabetic. Partial superficial epidermolysis was encountered in 2 cases and healed without further interventions. No other complications were encountered. All patients returned to full ambulation within 8 weeks. The 180-degree propeller flap is an elegant and versatile method to achieve soft tissue coverage with local tissue in defects of the distal tibia. Contrary to other local perforator flaps, this specific design facilitates direct closure of the donor site. As only local, thin tissue is used, no interference with normal shoe wear occurs. Even in older patients, this flap has proven to be a reliable option.

Lotus petal flaps for scrotal reconstruction combined with Integra™ resurfacing of the penis and anterior abdominal wall following necrotising fasciitis

Necrotising fasciitis of the external genitalia following routine circumcision is uncommon. We describe reconstruction of the scrotum with local perforator flaps and a dermal regeneration template (Integra) to cover the penile shaft after debridement. Lotus petal flaps were originally designed to cover vulvo-vaginal defects, but in this instance integrated well with the remaining scrotal sac to produce a good volume neoscrotum for testicular cover. Integra creates an acceptable neodermis usually to cover areas of debrided full thickness burns. In this case, Integra adequately replaced the mobile dermal layer over Bucks fascia over the penis to create a pliable and cosmetically acceptable result with erectile capability.

The ‘propeller’ distal anteromedial thigh perforator flap. Anatomic study and clinical applications

The leg and peripatellar region have always been known as a poor source of available flaps. One flap donor site that has proven to be adequate is the distal anteromedial half of the thigh. Due to the potential and plentiful vascular sources of this anatomic region we decided to study the distal anteromedial thigh and its clinical applications. ANATOMIC STUDY: Sixteen cryopreserved inferior limbs were latex-injected in the femoral artery and the skin perforators of the distal anteromedial thigh and their source vessels were studied. In a period between December 2000 and June 2005, skin islands from the distal anteromedial aspect of the thigh of six patients were transferred, as local perforator flaps, to reconstruct the peripatellar region and upper leg soft tissue defects. Every flap was based on a single adequate perforator vessel. The tissue was rotated, as a 'propeller', through 180 degrees and the flap was named 'the propeller distal anteromedial thigh perforator flap'. In the distal anteromedial thigh the anatomic variability includes not only perforator vessels but also their source vessels. Skin perforators can come from each of the deep vessels. Our clinical results, with a follow up of 1-4 years, show no total flap losses. Partial necrosis > 20% happened in one diabetic patient. The propeller distal anteromedial thigh perforator flap can be reliably transferred based on only one adequate perforator vessel. It reduces the morbidity and improves the availability of the distal anteromedial thigh as a flap donor site and represents an additional reconstructive option for knee and upper leg defects.

Our Experience in Lower Limb Reconstruction With Perforator Flaps

The application of Taylor's concept about body angiosomes, referred to tissue transfers, has meant that the development of the perforator flaps and muscles is no longer needed as a carrier of skin flap vascularity. In this paper, we revise 59 lower limb reconstructions with local and free perforator flaps performed in the last 5 years, and a basic reconstructive algorithm is also suggested to help with the management of the lower limb soft tissue reconstruction with perforator flaps. The advantages of the perforator flaps are (1) muscles and their function are preserved; (2) the main vascular trunks are spared; (3) it is possible to make a more specific reconstruction, replacing "like with like" (even performing compound or chimeric flaps); (4) the donor site can often be closed primarily; (5) the general morbidity is reduced; (6) a better cosmetic result can be achieved.

Microsurgical nonmicrovascular flaps in forearm and hand reconstruction

Relatively new method in flap's surgery, perforator flaps tends to monopolize nowadays the surgeon's interest. The question is: could these flaps be used not only as free flaps, as were mainly used until now, but also as local or regional flaps? On the basis of our experience with 115 operated cases, we will try to demonstrate that a lot of simple or composite defects in the forearm and hand could be covered, in selected cases, by using local or regional perforator flaps. This may have as result, in the future, a dramatic decrease in the indication for free flap transfers. Because these flaps need a microsurgical dissection, but do not need microvascular sutures, they could be defined as "microsurgical nonmicrovascular flaps." The main advantages of these flaps could be summarized as: no microsurgical sutures, no main vascular pedicles sacrifice, same surgical field, shorter hospitalization time.

Experience with Local Perforator Flaps in Lower Limb Reconstruction Using the “Propeller Principle”

Experience with Local Perforator Flaps in Lower Limb Reconstruction Using the “Propeller Principle”

The Proximal Pedicled Anterolateral Thigh Flap for Lower Limb Coverage

Although primarily considered as a versatile free-flap donor site, the anterolateral thigh can also be a source of a local muscle perforator flap. This attribute has previously been rarely considered for lower limb coverage. This small series of 3 additional cases demonstrates the usefulness of a proximal pedicled anterolateral thigh flap for medial and lateral thigh wounds. This flap can also be part of a combined flap, in particular when transferred with the vastus lateralis muscle as a local chimeric flap. The peninsular version of the anterolateral thigh local flap avoids venous congestion and is very reliable. The orthograde pedicled anterolateral thigh muscle perforator flap should be considered as another useful alternative for any upper thigh wound if a flap is essential.

Distally based dorsal metacarpal flaps: a review of a series of patients treated in a 6-month period

The management of dorsal digital and hand injuries can pose a difficult problem to the trainee surgeon. Often repair involves using tissue from neighbouring digits. Our experience using local perforator flaps based on the direct cutaneous branch of the dorsal metacarpal arteries shows that these can be dissected and used successfully in the management of complex injuries of the dorsum of the hand and proximal phalanges. The flap has been used in a series of seven patients treated over a 6-month period by plastic surgery trainees with 100% success. This one-stage procedure resulted in good functional and aesthetic outcome and left an acceptable donor scar.

P‐I‐05 Flap Repairs for Incurable Lower Leg Ulcers

Incurable ulcer in the lower legs means avascular skin defects exposing bone and osteomyelitis which cannot be repaired even with skin grafting. A total of 151 patients with incurable ulcers were operated with flaps; 60 cases of traumatized avascular defects, 20 diabetic ulcers, 17 osteomyelitis, 14 malignant tumors, 5 arterial obstructions, and 5 arteriovenous malformations, and others. A total of 61 island flaps were used; 20 posterior tibial perforator flaps, 7 saphenous flaps, 7 peroneal flaps, 4 anterior tibial flaps, 4 malleolar perforator flaps, 4 medialis pedis flaps, and others. In addition, a total of 82 free flaps using microvascualr anastomosis were sued; 24 flow‐through anterior thigh flaps, 13 flow‐throuh thoracodorsal artery perforator flaps (or latissimus dorsi MC flap), 8 paraumbilical (or deep inferior epigastric artery ) perforator flap, 6 saphenous venous flaps, 7 combined flaps, and 24 others. In conclusions, small ulcers could be repaired with minimal invasive methods including local perforator flaps and small muscle flaps under local anesthesia. Free flow‐through flaps and free bypass flaps (for diabetic gangrene with ASO), and combined osteocutaneous flaps (for massive segmental defects after resecting advanced carcinoma) are indicated for large ischemic defects.

The medial circumflex femoral (gracilis) local perforator flap--a local medial groin perforator flap.

The medial circumflex femoral(GRACILIS) perforator free flap has been previously used to capture the superior medial thigh skin territory. This can also be valuable as a local flap, especially for adjacent groin wounds that are not uncommon after vascular interventions. Uncomplicated healing without vascular compromise was achieved using this as a local flap in 4 recent cases. Because the gracilis muscular branches can be independently dissected from the musculocutaneous perforators, the muscle itself can be separately included to form a combined conjoint flap, where the muscle is specifically only used to wrap around and protect any exposed vascular structures while the cutaneous component simplifies skin wound closure. The axis of rotation of the medial circumflex femoral perforator local flap extends throughout the groin region and potentially to the lateral thigh. This is an ideal local perforator flap because the source pedicle has a consistent location already well known to most plastic surgeons, the boundaries of the potential skin territory are reliable and well defined, and the scar from closure of the donor site within the medial groin can be readily concealed by clothing.