Propeller Flap For Reconstruction Research Articles

Phalloplasty Flap Salvage Using a Superficial Circumflex Iliac Artery Perforator Propeller Flap.

Partial phalloplasty flap loss presents an evolving challenge, largely due to the complex demands required for both aesthetics and function. We describe our novel experience using the superficial circumflex iliac perforator (SCIP) propeller flap for neophallus salvage when skin grafting alone provides insufficient soft tissue bulk or coverage. We retrospectively reviewed patients who underwent SCIP propeller flap reconstruction after phalloplasty partial flap loss. After suprafascial dissection, superficial circumflex iliac vessel perforator(s) were isolated toward the femoral origin. The flap was rotated 180 degrees and inset into the ventral or distal neophallus depending on the region of flap loss. If glans reconstruction was required, the flap was tubularized before inset. Division and inset were performed at a second stage, followed by subsequent glansplasty, urethral creation, and/or penile implant placement. SCIP propeller flap reconstruction was performed for four patients after one to six debridements at a mean of 6.5 (range 1.0-19.2) months following the initial phalloplasty. Three patients had lost the ventral phallus due to venous insufficiency, arterial insufficiency, and excessive postoperative swelling, respectively. The fourth patient experienced near-total loss of the glans following penile implant insertion. Division and inset was performed at an average of 7.5 (range 5.0-12.0) weeks after SCIP flap. There were no complications related to SCIP flap viability. The SCIP propeller flap allows salvage of partial flap loss following phalloplasty by providing thin, pliable soft tissue bulk and skin coverage with minimal donor site morbidity, without the need for microsurgery, allowing progression with subsequent reconstructive stages.

Propeller flaps in partial ear reconstruction: a case series

BackgroundEar defect reconstruction still remains a surgical challenge today. Proper reconstruction should result in correction of the deformity with minimum morbidity with the aim of achieving the most esthetically pleasing outcome possible. Herein, we present our clinical experience with propeller flap reconstruction of external ear defects with a focus on indications and surgical technique.MethodsFourteen patients underwent surgery at our Plastic Surgery Unit between January 2015 and October 2019. After identifying perforators with a handheld Doppler ultrasound, a tailor-made flap was designed for each patient. Following tumor excision, dissection of the pedicle and of the remaining flap was performed with the aid of surgical loops. Flap in-setting and donor site closure were final steps.ResultsFlaps have survived in their entirety in almost all our patients (13/14) maintaining optimal color and elasticity and showing no complications. In one case, a superficial distal necrosis was observed and, in another patient, tumor recurrence took place.ConclusionsPropeller flaps offer great advantages when used in ear reconstruction ensuring excellent esthetic results with a one-stage technique. Nevertheless, it must be kept in mind that good dissection skills are required in order to avoid complications.Level of evidence: Level IV, Therapeutic study.

Brachial artery perforator propeller flap reconstruction of post electrical burn defect axilla

In the current scenario, propeller flaps are an attractive choice for single stage coverage of a large number of defects. They have a more reliable vascular pedicle than traditional flap and allow for greater freedom in design and wide mobilization and minimal donor-site morbidity. Harvesting of a propeller flap requires appropriate patient selection, preoperative planning, and meticulous dissection and these techniques greatly reduce the complication rates. Here, we present a case of a post burn raw area of the right axilla which was debrided and covered with a brachial artery perforator propeller flap.

Predictors of the surgical outcome of propeller perforator flap reconstruction, focusing on the effective safe distance between the perforator and the wound edge

BackgroundSoft tissue defects in the distal third of the leg and malleolus are difficult to cover and often require free tissue transfer, even for small-sized defects. Propeller flaps were designed as an alternative to free tissue transfer, but are reportedly associated with high complication rates. The aim of our study was to assess our institutional experience with the propeller flap technique and to predict its outcome in lower-limb reconstruction.MethodsAll patients who had undergone propeller flap reconstruction of a distal leg defect between 2013 and 2018 were included. Demographic, clinical, and follow-up data were analyzed.ResultsComplications occurred in 17 of 82 propeller flaps (20.7%), comprising 11 cases of partial necrosis and six of total necrosis. There were no significant differences in age, sex, body mass index smoking, diabetes mellitus, and soft tissue defect sites between the groups of patients with versus without flap necrosis (p > 0.05). In univariate analysis, there were also no significant differences between these two groups in the length and width of the fascial pedicle, and the ratio of the flap length to the flap width (p > 0.05). Interestingly, there were significant differences between the two groups in the distance between the flap perforator, the shortest distance from the perforator to the defect location, and the rotation angle of the flap (p < 0.05). In multivariable logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (95% CIs), the shortest distance from the perforator to the defect location was a significant risk factor for flap complications (p = 0.000; OR = 0.806). Receiver operating characteristic curve analysis showed that when the shortest distance from the flap to the wound was less than 3.5 cm, the necrosis rate of the flap was markedly increased (AUC = 76.1); this suggests that the effective safe flap–wound distance was 3.5 cm.ConclusionsPropeller flaps are a reliable option for reconstruction in carefully selected patients with traumatic defects of the lower limb and malleolus. We found that the effective safe distance was 3.5 cm from the flap to the wound.

Perforator-based propeller flap for coverage of lower leg: Single centre experience.

This study was conducted to assess outcomes of propeller flaps for reconstruction of small- to medium-sized defects in the distal third of the leg. Of 53 lower third leg defects covered using the propeller flap, 43 survived without complications. Only minor complications were seen and no flap was lost completely. The propeller flap is thus a safe option for medium-sized defects of the lower leg.

Propeller Flaps for Reconstruction around the Foot and Ankle.

The propeller flap challenges conventional wisdom for the safe raising of flaps. Its unique design is based on a belief that a sizeable fasciocutaneous flap can be perfused by only a single perforator. What is more remarkable is the concept that this cleanly dissected pedicle can continue to safely perfuse the flap even when it is twisted 180 degrees. Clearly, meticulous technique is essential and the key points in raising this flap and its versatility for reconstruction of defects around the foot and ankle are discussed in this article.

Oncologic safety of propeller flap and free flap in reconstruction after soft tissue sarcoma resection.

The propeller flap is a reliable option for reconstruction after soft tissue sarcoma resection. However, some parts of the resection margin may move away from its original position during flap rotation and thus can be excluded from the clinical target volume of adjuvant radiotherapy. This study aimed to evaluate local recurrence after soft tissue sarcoma resection with propeller flap or free flap reconstruction. Patients who underwent resection of soft tissue sarcoma followed by a free flap or propeller flap reconstruction and adjuvant radiotherapy at a single institution were retrospectively reviewed. The 1- and 3-year local control rates were 94.6% and 88.6% in the free flap group vs 90.6% and 87.5% in the propeller flap group, without statistical significance. There were no statistically significant differences in 5-year local recurrence-free survival (88.6% vs 87.5%) and disease-free survival (82.5% vs 74.8%) between the groups. Although there was no significant difference in local control and disease-free survival rates between propeller flap and free flap reconstruction after soft tissue sarcoma resection, a multidisciplinary approach is needed to obtain surgical information for determining the accurate clinical target volume of adjuvant radiotherapy and the area for meticulous follow-up postoperatively.

Comparison of V-Y advancement fasciocutaneous flaps and Gluteal perforator propeller flaps for reconstruction of sacral pressure sore

Comparison of V-Y advancement fasciocutaneous flaps and Gluteal perforator propeller flaps for reconstruction of sacral pressure sore

Use of propeller flaps for reconstruction of extensor side elbow defects

Introduction: Extensor side elbow defects are difficult to repair among upper extremity injuries. The bulk of surrounding soft tissue is limited and often affected by the trauma, although seems to be ideal, propeller flaps are not being widely adopted for upper extremity soft-tissue reconstructions. In the present study, we set out to share the results of the perforator propeller flaps that are based on either the arm or the forearm, which we thought the perforator vessel anatomy is relatively constant. Patients and Methods: All patients who underwent elbow defect repair between June 2016 and June 2018 were evaluated retrospectively. Patients were evaluated in terms of the etiology and demographic parameters. Flaps were assessed by the artery system, on which they were based on the dimensions of skin island, the rotation angle of the skin paddle, and closure method of the donor site. Outcomes were noted during bimonthly follow-up visits. Results: In 11 patients, the dominant etiology was chronic bursitis. The mean flap skin paddle size was 48.8 ± 16.9 cm2. For defect repair, radial collateral artery (RCA) perforator flaps were used in six patients. Posterior interosseous artery (PIA) perforator flaps were used in remaining five patients. All the flaps were based on a single perforator artery. The mean rotation degree was measured as 165° ±11.6°. In nine cases, the flap donor site was closed primarily, whereas split-thickness skin grafts were used in two cases. The average follow-up period was 13 ± 5 months. No limitation in the range of motion of the elbow joint was noted. Distal marginal necrosis was observed in two flaps. Conclusion: We advocate that both PIA and RCA perforator flaps are very useful options for soft-tissue reconstruction of extensor side elbow defects.

Squamous cell carcinoma in an atrophic scar of Porphyria Cutanea Tarda

Introduction: Porphyria’s are group of inherited metabolic disorders of heme biosynthesis. Porphyria cutanea tarda (PCT) the most frequent type of porphyria worldwide and present with skin symptoms only. PCT develops due to acquired deficiency in fifth enzyme Uroporphyrinogen deaminase (UROD) in hepatocytes. Skin cancers are known to arise from site of trauma or chronic irritation like scars, ulcers, sinuses of diverse aetiology. Squamous cell carcinoma, Basal cell carcinoma, Adenocarcinoma are the common carcinoma identified in these situations. Hereby we present a case squamous cell carcinoma in an atrophic scar of PCT. Case Report: A 65 years old male, diagnosed case of PCT since 20 years, presented with non-healing ulcer on left cheek since 6 months. It was overlying a preexisting scar of PCT and was progressively increasing in size. Dermatological examination shows single well-defined ulcer on left malar area with rolled out edge and pale granulation tissue on floor. Diagnosis of Squamous cell carcinoma was confirmed on histopathological examination. Patient underwent wide local excision with 1cm margin all around with propeller flap reconstruction which was conducted by plastic surgeons. Conclusion: Patients of Porphyria Cutanea Tarda are at high risk of facial malignancy and need stringent monitoring for early detection and timely management. Keywords: Porphyria cutanea tarda squamous cell carcinoma atrophic scar.

The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations.

Defects in the distal third of the leg are difficult to cover and often require free tissue transfer, even for defects of limited sizes. Propeller flaps have been designed specifically as an alternative to free tissue transfer but at times have been associated with unacceptably high complication rates. We therefore aimed to prospectively assess our own institutional experience with this technique and to define its role in lower-limb reconstruction. All patients who had been managed with reconstruction of the distal part of the leg with a propeller flap between 2014 and 2017 were included in the study. Demographic, clinical, and follow-up data on the patients and surgical procedures were recorded with special focus on the complication profile. Twenty-six patients underwent propeller flap reconstruction of the distal part of the leg: 12 flaps were based on the posterior tibial artery, and 14 were based on the peroneal artery. Postoperative complications developed in association with 1 of the 12 flaps based on the posterior tibial artery, compared with 8 of the 14 flaps based on the peroneal artery (p = 0.015). Moreover, the presence of a higher Charlson comorbidity index (≥2) was strongly associated with the development of postoperative complications (p < 0.001). Propeller flaps are a reliable option for traumatic reconstruction in carefully selected patients with lower-limb defects. In our experience, the rate of complications was higher for propeller flaps based on the peroneal artery and for patients with a Charlson comorbidity index of ≥2, whereas posterior tibial artery-based propeller flap reconstruction was a reliable surgical option for patients with a small defect in the distal third of the lower limb. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Propeller Flaps for Reconstructing Leg and Foot Defects: The Relation between Flap Length and the Incidence of Ischemia

Background: Reconstruction of soft tissue defects in theleg and the foot remains challenging. Anatomical constraintslimit the options available for reconstructing complex defectsespecially lower third of leg. Perforator propeller flaps areraising interest in reconstructive surgery of the limbs. Wepresent our experience with perforator propeller flaps forreconstruction of soft tissue defects in leg and foot with anemphasis on the safe limit of a perforator flap in the lowerlimb.Methods: The study was carried prospectively and 32patients with leg or foot defects treated with various perforatorpropeller flaps (both elective as well as emergency) wereincluded in the study. A hand-held ultrasound Doppler wasused pre-operatively and intraoperatively to detect the perforatorvessels.Results: Out of the 32 cases, we witnessed total flap lossin one and distal necrosis in 6 cases. In 4 of them the flapslengths were more than one third of the limb length. 8 patientshad minor complications which included congestion, infectionor graft loss.Conclusion: Perforator flaps may represent a good alternativeto the free flaps in the areas were other local reconstructiveprocedures are not possible. This is a versatiletechnique and with decreased donor site morbidity limited toa single body area. There is a specific like to like soft tissuereplacement leading to a better cosmetic and reconstructiveoutcome. The main drawback of the perforator flaps howeveris the higher risk of venous congestion. The incidence of distalnecrosis increases with flap length more than one third of thelimb provided other factors affecting flap vitality are constant.

The Clinical Outcome of Perforator Based Sural Artery and Propeller Flaps in Reconstruction of Soft Tissue of Extremities

The reconstructive options for the soft tissues in extremities present serious challenges due to thin non-expendable soft tissues and predisposition to massive edema formation, thus frequently requiring flap cover. This study was undertaken to assess the outcome of a modified version of the sural artery flap with that of propeller perforator flaps for the reconstruction of lower extremities, particularly the heel defects.This prospective study was conducted on 40 consecutive patients, of which 20 treated with sural artery flap and another 20 with perforator based propeller flap cover for soft tissue reconstruction in extremities based on predefined inclusion criteria. The clinical outcome of the flap was assessed after three months.Inclusion of the posterior tibial perforators (along with the sural artery and the peroneal artery) was shown to enhance the flap territory. The raising of the flap was quick with minimal blood loss and the modified flap had a wide arc of rotation for reconstruction of the heel defects. The younger patients regained sensation on the flap earlier, while the durability of the fasciocutaneous flap was excellent in the heel weight bearing areas. The success rate was 95% flap take.Careful selection of the perforator and optimal designing of the flap result in favorable outcomes with the use of local perforator flaps for reconstruction in extremities. It provides predictable clinical outcomes with minimal donor site morbidity, is cost-effective, relatively easy technique and requires no special microsurgical setup or instruments.

The Clinical Outcome of Perforator Based Sural Artery and Propeller Flaps in Reconstruction of Soft Tissue of Extremities

BACKGROUNDThe reconstructive options for the soft tissues in extremities present serious challenges due to thin non-expendable soft tissues and predisposition to massive edema formation, thus frequently requiring flap cover. This study was undertaken to assess the outcome of a modified version of the sural artery flap with that of propeller perforator flaps for the reconstruction of lower extremities, particularly the heel defects. METHODSThis prospective study was conducted on 40 consecutive patients, of which 20 treated with sural artery flap and another 20 with perforator based propeller flap cover for soft tissue reconstruction in extremities based on predefined inclusion criteria. The clinical outcome of the flap was assessed after three months.RESULTSInclusion of the posterior tibial perforators (along with the sural artery and the peroneal artery) was shown to enhance the flap territory. The raising of the flap was quick with minimal blood loss and the modified flap had a wide arc of rotation for reconstruction of the heel defects. The younger patients regained sensation on the flap earlier, while the durability of the fasciocutaneous flap was excellent in the heel weight bearing areas. The success rate was 95% flap take. CONCLUSIONCareful selection of the perforator and optimal designing of the flap result in favorable outcomes with the use of local perforator flaps for reconstruction in extremities. It provides predictable clinical outcomes with minimal donor site morbidity, is cost-effective, relatively easy technique and requires no special microsurgical setup or instruments.

Propeller flap reconstruction of irradiated sarcoma defects: A comparison✰

The treatment for soft tissue sarcomas has evolved to include radiotherapy, wide local excision and plastic surgical reconstruction. Goals for the reconstruction of these irradiated defects are the introduction of non-irradiated healthy tissue, tension-free closure and obliteration of potential dead space. Although many defects once required free tissue transfer for reconstruction, greater knowledge of anatomical vascular pattern has led to the increasing use of propeller perforator flaps, islanded and transposed into the defect. Propeller flap outcomes for the reconstruction of irradiated skin defects have only been reported in case reports. We evaluated the use of propeller perforator flaps at St Vincent's Hospital Melbourne in a series of patients for the reconstruction of irradiated sarcoma defects. All patients who underwent sarcoma resection with plastic surgical reconstruction at St Vincent's Hospital from January 2009 to February 2017 were identified from unit audits and medical record data and compared depending on the type of reconstruction. Propeller perforator flaps were evaluated compared to other methods of reconstruction. Thirty-nine cases involved single perforator propeller flaps for reconstruction. The frequency of propeller flap reconstruction has greatly increased from 3 in their first year of use in 2013 to 12 in 2015. Most propeller flaps were used to reconstruct thigh defects (43.6%) followed by shoulder defects (17.9%). Generally the defects were smaller (138.7cm2) than free flaps (214.2cm2), and the usual composition of the defect was skin and subcutaneous tissue only. Patients who underwent propeller flap reconstruction had a significantly short length of inpatient stay (p < 0.01), and there were no total failures. Propeller perforator flaps are useful for the reconstruction of irradiated defects in sarcoma reconstruction surgery, particularly small- to moderate-sized fasciocutaneous defects. They offer less morbidity, faster recovery and better aesthetic results than free or standard pedicle flaps. The success of propeller flaps has changed the algorithm for how we approach towards the reconstruction of irradiated sarcoma defects to consider their use as the first reconstructive option for superficial sarcoma defects.

Current applications of propeller flaps in reconstruction of trunk wounds

Current applications of propeller flaps in reconstruction of trunk wounds

Perforator-based propeller flaps for leg reconstruction in pediatric patients

Perforator-based propeller flaps provide adequate soft tissue coverage for leg reconstruction. The aim of this study was to assess the versatility and reliability of the use of propeller flaps for leg reconstruction in pediatric patients. Seven male pediatric patients ranging in age from 2 to 13 years with a mean age of 6.7 underwent perforator-based propeller flap surgery over a four-year period. The defects resulted from burn injuries (n=4) and traffic accidents (n=3). The injuries were located on the ankles of four patients and on the knee, anterior lower tibia, and foot dorsum of the other three patients, respectively. The flap sizes ranged from 5×3 to 10×6cm with a mean flap size of 7.6×4.3cm. Flap harvesting time ranged from 38 to 56m with a mean of 46m. The rotation degree range of the flaps was from 90° to 180°. The propeller flaps were based on the posterior tibial artery (n=4), anterior tibial artery (n=2), and the descending branch of the lateral circumflex femoral artery (n=1). All flaps survived completely without surgical complication; however, one patient developed disseminated intravascular coagulation syndrome two days post-surgery and died within four days. Perforator-based propeller flap reconstruction is a safe, reliable, and versatile method for lower extremities in pediatric patients; however, it requires meticulous surgical dissection and extreme patience during the surgical procedure.

Freestyle multiple propeller flap reconstruction (jigsaw puzzle approach) for complicated back defects.

The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk. From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance. The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery. Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the tension to multiple flaps, supplying sufficient volume to obliterate dead space, and have reliable vascularity as the flaps do not need to be oversized. This can be a viable approach to reconstruct extensive defects on the posterior trunk.

Are There Risk Factors for Complications of Perforator-based Propeller Flaps for Lower-extremity Reconstruction?

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 87years 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 1year (mean, 3years; range, 1-7years); eight patients (11%) were lost to followup before 1year. 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 IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Peroneal Artery Perforator-Based Propeller Flaps for Reconstruction of Soft Tissue Defect around the Ankle Joint: A Report of Four Cases

Peroneal Artery Perforator-Based Propeller Flaps for Reconstruction of Soft Tissue Defect around the Ankle Joint: A Report of Four Cases