Propeller Flap Research Articles

A Retrospective Study of an Updated and Traditional Surgical Approach of the Distally Based Sural Flap.

The distally based sural flap (DBSF) is one of the armamentarium in the lower limb reconstruction. However, the flap has not gained popularity due to concerns about its reliability and donor site morbidity. Based on the anatomy characterization, we combined and developed five modifications to improve the vascular supply and reduce donor site morbidity. The authors performed a comparison of retrospective study that included patients who underwent either traditional distally based sural flap (tDBSF) or modified distally based sural flap (mDBSF) surgery approach for ankle, heel, and dorsal foot coverage between January 2007 and May, 2019. The five modifications developed to improve the reliability of the flap include: 1. shift the pivot point more proximally 7.0 cm above the lateral malleolus, 2. preserve the lesser saphenous vein and include branches that communicates with the flap, 3. harvest thinner fascial pedicle, 4. change the skin incision to "S" shape, 5. closure of the donor site with a propeller flap. Thirty-one patients underwent mDBSF, and 23 received tDBSF. There were no significant differences in the size of the DBSF. Mean pedicle width was significantly narrower in mDBSF (1.63 ± 0.52 cm vs. 3.81 ± 0.70 in tDBSF). The pivot point was also found to be higher in mDBSF (8.01 ± 0.63 cm vs. 5.46 ± 0.56 cm) above the lateral malleolus. In mDBSF, the size of the propeller flap required for donor site closure was 53.45 ± 19.06 cm2 (range 33-80 cm2). The rate of partial necrosis between mDBSF and tDBSF was significantly different (9.68 vs. 34.78%). While the other complications had no difference. The modifications applied to the harvesting of the DBSF have achieved higher survival rate, lower dehiscence rate, and shorter hospital stay time in comparison with traditional approach in our retrospective study.

Reliability of propeller flaps in post-traumatic reconstruction of wrist and hand defects.

This is a purely observational study with a literature comparison to assess the effectiveness of radial and ulnar arteries propeller perforator-based flaps in post-traumatic soft tissue reconstruction and identify the risk factors for complications. Sixteen patients were involved with post-traumatic wrist and hand soft tissue defects not exceeding 5 × 20cm. Defects were covered with propeller radial and ulnar arteries perforator-based flaps. Patient demographics, soft tissue defects, complications and clinical outcomes were recorded. Assessment of patients' satisfaction for donor site morbidity and aesthetic outcome of the flap were performed. Radial artery propeller perforator flap was performed in seven cases, and ulnar artery propeller perforator flap was done in nine cases. The size of the skin paddle ranged from 2.5 × 5cm to 4.5 × 10.5cm. Primary closure of the donor site was performed in all cases. One flap was lost, while superficial epidermolysis occurred in seven cases (45%). Edge necrosis ranging between 3 and 7 mm occurred in nine cases (60%). Patients' factors, mode of injury, associated injuries and interval between trauma and coverage were all correlated with complication incidence. The patients' satisfaction for donor site morbidity was very good and good in 80% of patients, while satisfaction for aesthetic outcome of the flap was very good and good in only 40%. Radial and ulnar arteries have reliable perforators for flap elevation, which produce reliable outcome for small- and medium-sized soft tissue reconstruction. Effectiveness decreases in post-traumatic reconstructions. Complications are more frequent in crushing injuries especially if associated with bony fractures. Most complications in trauma cases were attributed to venous congestion, for which supercharging with a vein if accessible to the surgeon is recommended.

Synchronous Closure of a Large Medial Perforator-Based Scip Free Flap Donor Site Using an Ipsilateral Lateral Perforator-Based Scip Propeller Flap (Reply).

Synchronous Closure of a Large Medial Perforator-Based Scip Free Flap Donor Site Using an Ipsilateral Lateral Perforator-Based Scip Propeller Flap (Reply).

Comparative analysis of propeller flaps vs. modified perforator-based flaps in foot and ankle reconstruction

Lower leg, ankle, and foot defects pose a challenge for the surgeon due to the thin soft tissue cover and presence of important structures like bone, tendons, ligaments, and neurovascular bundles superficially. Since this region is prone to trauma and infection, the need arises to select an ideal flap to give a stable soft tissue cover. Propeller and perforator-based flaps are the most commonly used local flaps which can offer a durable soft tissue cover. However, they have disadvantages. Propeller flaps are more prone to venous congestion which can lead to partial or complete flap failure. Perforator-based flaps do not enjoy the freedom of rotation like propeller flaps. In this study we present a simple modification in perforator-based flaps by retaining a thin continuity of subcutaneous tissue to the minor blade of the perforator flap, which can be rotated up to 180° like propeller flaps, thus avoiding the complications of venous congestion. All patients in whom perforator-based flaps were used in the reconstruction of the lower leg, foot, and ankle region from November 2015 to January 2019 were incuded in this study. Degree of rotation, venous congestion grade, and success rate between modified-perforator flaps (MPF) and propeller flaps were compared. A total of 47 patients were included in the study. In 27 cases, traditional propeller flap technique was used. Eight cases presented with complications. In the 20 cases where a MPF was performed, one partial flap loss was observed. The mean degree of rotation was significantly higher in the MPF group (155°) if compared with the propeller flap group (137.6°) (p = 0.003).There was a statistically significant reduction in incidence of venous congestion in the MPF group (p = 0.019). The MFP herein presented seems a simpler solution to reconstruct foot and lower leg defects as it has a lesser complication rate in comparison with traditional propeller flaps. Level of evidence: Level III, therapeutic study.

Pedicled vertical posteromedial thigh (vPMT) flap for the reconstruction of extensive perianal-genital defects

Perianal and genital defects occur because of a vast etiology making the reconstruction of function and esthetics remain challenging. Depending on the extent of the defect, different techniques have been employed for coverage including skin grafts, local skin flaps, musculocutaneous flaps, and pedicled perforator flaps. The pedicled vertical posteromedial thigh (vPMT) flap is a new perforator flap that has rarely been employed for this kind of reconstruction. The purpose of this article is to focus on the vPMT perforator flap, which is mainly used as a propeller flap, for reconstructing the perianal and genital region as a feasible option in this area. From July 2013 to December 2018, we treated twelve patients with extensive perianal and/or genital defects with 21 pedicled vPMT flaps. Three patients needed unilateral reconstruction, while 9 patients bilateral needed bilateral reconstruction. The location of the defects included the scrotal region (3 cases), the perianal region (8 cases), and the vulvar region (5 cases), whereby some cases had combined defects. The flap sizes varied from 5-9 cm in width to 18-35 cm in length and all flaps were harvested as perforator-based island flaps. The flap movements used for defect coverage included V-Y advancement in three cases and rotation in propeller fashion in eighteen cases. All flaps survived without any major complications and all donor sites were closed primarily. Our case series showed an exemplary model for the coverage of the perianal and genital region by using the pedicle vPMT flap and the achievement of a sustainable treatment with a minor morbidity of the donor site. We believe that the vPMT flap could be an alternative option for the reconstruction of the perianal and genital region and could be inserted in the armamentarium of the reconstructive microsurgeon.

Our Definition of Propeller Flaps and Their Classification.

The term propeller flap was introduced for the first time by Hyakusoku to define an island flap, based on a subcutaneous pedicle hub, that was rotated 90 degrees to correct scar contractures due to burns. With the popularization of perforator flaps, the propeller movement was applied for the first time to a skin island vascularized only by an isolated perforator, and the terms propeller and perforator flap were used together. Thereafter, the surgical technique of propeller flaps evolved and new applications developed. With the "Tokyo consensus," we proposed a definition and a classification schema for propeller flaps. A propeller flap was defined as an "island flap that reaches the recipient site through an axial rotation." The classification included the SPP (SPP) flap, the perforator pedicled propeller (PPP) flap, and the supercharged PPP (SCP) flap. A recent update added a new category, the axial pedicled propeller (APP) flap. Here we propose our updated and comprehensive classification of propeller flaps, taking into account the previous classification and subsequent publications. Based on their vascular pedicle, we consider the following five types of propellers: (1) SPP flap, 2.PPP flap, its subtype (2a) SCP flap, (3) APP flap, (4) muscle propeller flap, and (5) chimeric propeller flap. The variables that can be taken into account in the classification are as follows: type of nourishing pedicle, degrees of skin island rotation, position of the nourishing pedicle, artery of origin of the pedicle, and flap shape.

Propeller Flaps in the Upper Extremity: Arm and Forearm Reconstruction.

The propeller flap is an island of skin that is raised on its pedicle (most commonly a single perforator) and can rotate 180 degrees to cover a soft tissue defect. Thanks to these features, the propeller flap brings reliable tissue from outside of the zone of injury while sparing the main vessels of the upper extremity. This technique limits the donor site to the same limb, captures skin characterized by having the same color and texture, does not necessarily need a microvascular anastomosis, and overall reduces the operating time and surgical cost. Our intent here is to present 27 cases with different soft tissue defects of the upper arm and forearm that have been successfully reconstructed using propeller flaps. The surgical technique, with emphasis on the anatomy of the upper arm, is described. In particular, use of a freestyle approach to customize a perforator-based propeller flap to cover defects from small to medium size is detailed. In our experience, the use of a perforator propeller flap in the upper extremity for resurfacing represents both a very reliable and aesthetically pleasant option.

The History of Propeller Flaps.

Several pedicled flaps were developed by Hyakusoku at the Nippon Medical School Hospital, Tokyo, Japan, in the 1980s to treat a large number of patients with postburn contractures. In this setting, the propeller flaps were described for the first time in 1991. The term propeller was used because of the blade shape of the skin island rotating on its axis. In 1989, Koshima introduced the term perforator flaps , whereas Hallock, in 2006, applied the perforator flap concept to the propeller flap. The name perforator pedicled propeller flap followed. Propeller flap had developed to be an important operative technique and a hot topic in the field of reconstructive microsurgery, with the important contribution of Teo. In 2009, the First Tokyo Meeting on Perforator and Propeller Flaps was held, where Pignatti reported the consensus on the definition and classification of propeller flaps that was given by the advisory panel of the meeting. Further evolutions developed since then will be described in this dedicated issue of Seminars of Plastic Surgery .

How to Design and Harvest a Propeller Flap.

Propeller flaps are local flaps based either on a subcutaneous pedicle, a single perforator, or vessels entering the flap in such a way so as to allow the flap to rotate on their axis. Depending on the kind of pedicle and the anatomical area, the preoperative investigation and the harvesting techniques may vary. An adequate knowledge of skin and subcutaneous tissue perfusion in the different areas of the body is very important to plan a propeller flap to be successful. The surgeon should begin by finding the most suitable perforators in the area surrounding the defect using available technology. The position, size, and shape of the flap are planned about this point. For perforator-pedicled propeller flaps, the procedure starts with an exploration from the margins of the defect or through a dedicated incision to visualize any perforators in the surroundings. The most suitable perforator is selected and isolated, the skin island is replanned, and the flap is harvested and rotated into the defect. The variations in surgical technique for other types of propellers and in specific anatomical areas are also described. Compared with free flaps, propeller flaps have the advantage of a simpler, shorter operation, without the need for a recipient vessel for microanastomosis. Yet, from a technical point of view, an adequate experience in dissecting perforators and the use of magnifying glasses are almost always required.

Introduction to "Propeller Flaps".

The editors of this issue of Seminars in Plastic Surgery dedicated to propeller flaps met in 2009 at the "1st Tokyo Meeting on Perforator and Propeller Flaps." On that occasion, as part of the advisory panel of the meeting, they contributed to the definition and classification of these flaps. Since then, several evolutions and new applications of propeller flaps appeared in the literature. In 2019, the editors met again in Bologna, Italy, where they decided to collect the experiences from prominent authors in propeller flap surgery and provide them to the readers in this monographic dedicated publication.

Propeller Flaps for the Anterior Trunk.

Various types of propeller flaps from multiple donor sites can be used to reconstruct anterior trunk skin defects. The actual selection depends on the condition and location of the recipient site, especially if it is to be the chest or abdomen that requires attention. Before surgery commences, it is always important to use an imaging analyses such as computed tomography angiography to examine and identify perforators that could perfuse a perforator-pedicled propeller flap (PPPF), as it is the most multifaceted imaging technique. Clusters of perforators that can be commonly used for the "workhorse" PPPFs for the thoracic and abdominal regions are the internal mammary artery perforator, the musculophrenic artery perforator, and the deep inferior epigastric perforator. These perforators are reliable and large enough to support long and large propeller flaps that will cover most defects in this region, while still allowing primary donor-site closure.

The Chimeric Propeller Flap.

A chimeric flap consists of multiple discrete tissues or flaps connected only by a common source vessel. Each component must have an independent source of circulation. Rotation of any included part only about its specific vascular supply, such as done with a propeller flap, would be possible. These characteristics, whereby the chimeric flap concept and propeller flap concept are combined, would result in a chimeric propeller flap . Such a choice will enhance overall flap insetting capabilities and versatility, while often limiting the reconstructive need to but a single donor site!

Smartphone Thermal Imaging Can Enable the Safer Use of Propeller Flaps.

The use of thermography for the identification of cutaneous "hot spots" that coincide with perforators is not a new concept, but the required professional cameras may be prohibitively expensive. Only relatively recently, incredibly cheap but adequate thermal imaging cameras have become available that work in concert with the ubiquitous cell phone. This can now serve as a rapid, accurate, and complementary method for finding a perforator sufficient to serve as the hub for a perforator pedicled propeller flap. In addition, the preferred direction of rotation about that hub, effect of flap insetting on perfusion, and then postoperative monitoring are possible by proper interpretation of corresponding thermograms. Every reconstructive surgeon should be able to obtain this device, and then easily learn what potential attributes for them are available when planning a propeller flap.

Propeller Flaps for Hand and Digit Reconstruction.

The reconstruction of soft tissue defects of the hand, as seen often after trauma or tumor excision, is a challenge due to the great differentiation of tissues depending on the hand area involved. The classical intrinsic "workhorse flaps" of the hand are associated with a significant donor-site morbidity. Capturing perforator vessels in discrete donor areas can reduce the amount of soft tissue that has to be dissected and included in what now would be a perforator flap, while also insuring robust vascularization of those transferred tissues. Moreover, the presence of perforator vessels both on the dorsal and volar sides of the hand allows harvest of perforator flaps that will respect the like-with-like principle by maintaining the main characteristics of volar and dorsal skin as desired. However, the dissection of these flaps, especially those based on volar palmar and digital perforators, still requires microsurgical skills to preserve the fine vascularization of these flaps. These small flaps are also amenable for application of the propeller flap concept. This is an especially valuable means for preserving the length of an amputated finger where bone is exposed by using more proximal uninjured tissues. Although in general only a short dissection is required to raise a propeller flap in this region, most often the donor site will have to be closed by a skin graft.

Imaging in Propeller Flap Surgery.

Since propeller flaps are elevated as island flaps and most often nourished by a single perforator nearby the defect, it is challenging to change the flap design intraoperatively when a reliable perforator cannot be found where expected to exist. Thus, accurate preoperative mapping of perforators is essential in the safe planning of propeller flaps. Various methods have been reported so far: (1) handheld acoustic Doppler sonography (ADS), (2) color duplex sonography (CDS), (3) perforator computed tomographic angiography (P-CTA), and (4) magnetic resonance angiography (MRA). To facilitate the preoperative perforator assessment, P-CTA is currently considered as the gold standard imaging tool in revealing the three-dimensional anatomical details of perforators precisely. Nevertheless, ADS remains the most widely used tool due to its low cost, faster learning, and ease of use despite an undesirable number of false-positive results. CDS can provide hemodynamic characteristics of the perforator and is a valid and safer alternative particularly in patients in whom ionizing radiation and/or contrast exposure should be limited. Although MRA is less accurate in detecting smaller perforators of caliber less than 1.0 mm and the intramuscular course of perforators at the present time, MRA is expected to improve in the future due to the recent developments in technology, making it as accurate as P-CTA. Moreover, it provides the advantage of being radiation-free with fewer contrast reactions.

Propeller Flaps in the Head and Neck.

Propeller flaps have significantly expanded the reconstruction possibilities in the head and neck region. They allow for increased flap mobility and better scar concealing, and/or to perform a one-stage reconstruction with local tissue of similar color and texture, where multiple surgeries would be needed with traditional flaps or even free flaps would be required. This article describes the main propeller flaps for one-stage reconstruction in the head-neck region (facial artery perforator, supratrochlear artery axial perforator, deep lingual artery axial perforator, and anterior supraclavicular artery perforator flaps), their indications, and possible complications. Aesthetic and functional results of propeller flaps in the head and neck region are very good and the complication rate is low, but due to their surgical complexity and the availability of many simpler local flaps, they are indicated only in select cases where local flaps are unavailable or would require multiple staged procedures to complete the construction.

Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction.

Reconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

Propeller Flaps.

This issue of Seminars in Plastic Surgery is dedicated to propeller flaps. These flaps, which are defined as island flaps that reach the recipient site through an axial rotation, have a relevant role in soft tissue reconstruction of different anatomical areas, and provide an elegant, moderately invasive, “like with like” solution, in a reasonable operating time. Depending on the anatomical area, microsurgical skills and magnification means may be necessary to obtain good results.

Geoffrey G. Hallock, MD, and Marco Pignatti, MD.

I want to thank Dr. Geoffrey Hallock and Dr. Marco Pignatti for serving as guest editors and the exceptional group of knowledgeable and experienced authors that they have brought together to write on “Propeller Flaps” for Seminars in Plastic Surgery.

Synchronous Closure of A Large Medial Perforator-Based Superficial Circumflex Iliac Artery Perforator Free Flap Donor Site Using an Ipsilateral Lateral Perforator-Based Superficial Circumflex Iliac Artery Perforator Propeller Flap.

A superior advantage of the superficial circumflex iliac artery perforator flap is that any donor site residue can easily be hidden by clothing. Usually designed as narrow or moderate-sized flaps based on medial perforators of the superficial branch, this readily allows primary donor site closure. However, for larger flaps, tension-free closure requires that the thigh remain flexed or even a skin graft used. Another alternative would be to use an adequate lateral perforator of the deep branch, if available, as the vascular hub of a propeller flap that extended into the adjacent flank, that could then be rotated into the medial groin to facilitate simultaneous direct closure of both flap donor sites.