Perforator Propeller Flap Research Articles

Improving the Versatility of the Latissimus Dorsi Myocutaneous Flap Using the Perforator Propeller Flap Concept.

The latissimus dorsi myocutaneous flap is widely used in reconstructive surgery; however, primary donor-site closure remains challenging when a wide flap is harvested. A large latissimus dorsi myocutaneous flap was elevated and transferred to repair defects. Perforators adjacent to the donor site of the myocutaneous flap were explored using an ultrasound Doppler probe or a technique of extensive exploration along the margins of the donor site wound. A single or multiple perforator propeller flaps based on these perforators were used to close the donor site defect. From June 2012 to April 2018, this method was used to restore posttraumatic and oncologic defects of the chest wall in 14 cases, upper extremity in 6 cases, and lower extremity in 1 case. The size and width of the latissimus dorsi myocutaneous flaps ranged from 16 × 11 cm to 33 × 17 cm (mean area, 335.6 cm) and 9 cm to 20 cm (mean width, 14 cm), respectively. The donor site defect was closed primarily by using a single flap in 11 cases, dual flap in 9, and triple flap in one. Donor site breakdown was not observed in any of the cases. The perforator propeller flap could be used to reconstruct a latissimus dorsi myocutaneous flap donor site defect, ensuring not only the harvesting of a wide flap but also achieving primary donor site closure, thus greatly improving the versatility and capability of the latissimus dorsi myocutaneous flap in the reconstruction of large-sized defects.

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

Anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap for foot and ankle defect

To investigate the clinical application of the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap in repair of foot and ankle defects. Between October 2014 and October 2018, 18 cases with foot and ankle defects were treated. There were 12 males and 6 females with an average age of 32.8 years (range, 8-56 years). There were 11 cases of traffic accident injuries, 3 cases of falling from height injuries, and 4 cases of heavy objects injuries. The wound was at the dorsum of the foot in 9 cases, the heel in 4 cases, the lateral malleolus in 5 cases. The time from injury to flap repair was 7-34 days (mean, 19 days). The size of wound ranged from 6.0 cm×2.5 cm to 11.0 cm×6.0 cm. The foot and ankle defects were repaired with the peroneal artery terminal perforator propeller flap in size of 6 cm×3 cm-18 cm×7 cm, which donor site was repaired with the anterior tibial artery perforator propeller flap in size of 8 cm×3 cm-16 cm×6 cm. One patient had a hemorrhagic swelling in the peroneal artery terminal perforator propeller flap, and survived after symptomatic treatment. All recipient and donor sites healed by first intention. Eighteen patients were followed up 6-15 months (mean, 12.5 months). At last follow-up, the shape, color, texture, and thickness of the flaps in the donor sites were similar with those in the recipient sites. There were only linear scars on the donor sites. The two-point discrimination of the peroneal artery terminal perforator propeller flap ranged from 10 to 12 mm (mean, 11 mm). According to American Orthopaedic Foot and Ankle Society (AOFAS) score criteria, the results were excellent in 15 cases and good in 3 cases, with an excellent and good rate of 100%. The foot and ankle defects can be repaired with the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap. The procedure is not sacrificing the main vessel and can avoid the skin grafting and obtain the good ankle function.

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.

Hybrid perforator flaps: Introducing a new concept in perforator flap surgery

Although perforator propeller flaps provide a safe and reliable reconstructive option, they are often limited in size, reach and degrees of freedom due to venous insufficiency. As a result, partial flap necrosis, particularly at the tip of the flap, may occur in some cases causing the loss of substance. To overcome this problem, we present a new concept of hybrid perforator flaps. From May 2014 to October 2017, 25 Hybrid perforator flaps were performed to reconstruct a variety of defects in upper and lower extremities following the removal of soft-tissue malignancies. Hybrid flaps included 14 hybrid radial collateral artery perforator propeller (RCAP) flaps, 7 hybrid propeller anterolateral thigh perforators (ALTs), 3 hybrid medial sural perforator flaps and one hybrid saphenous perforator flap. Following the excision of malignancy, several superficial skin veins were dissected on the edge of defect to be used as potential recipient vessels for venous supercharging. Hybrid flap design included the dissection of one or two superficial veins on the edge of the flap, which was used for prophylactic supercharging. The perforator flap was then raised in a usual fashion and rotated into the defect. Microsurgical venous anastomosis was performed between the previously prepared superficial flap vein and vein on the edge of defect. Venous stasis was encountered following flap rotation in 12 out of 25 flaps and was immediately resolved following venous anastomosis. No venous congestion was encountered perioperatively in the remaining 13 flaps. Healing was uneventful in 24 flaps with 100% flap surface area healed primarily and excellent functional/aesthetic outcome. Partial loss was found in only one single flap, with overall 96% success rate and 4% complication rate. Hybrid perforator flaps have the advantage of improved reliability, versatility and safety. In the author's experience, technique is reliable and obviates the need for flap monitoring. By including a superficial vein in the initial flap design and resectional defect, larger flaps can be harvested more reliably. The hybrid flap concept could potentially improve outcomes of propeller flaps. Our experience shows reduced complications when this technique is utilised with success rates comparable to free flaps.

Propeller perforator flaps from the dorsal digital artery perforator chain for repairing soft tissue defects of the finger

BackgroundWhen restoring the appearance and function of the fingers, hand surgeons face a challenge in choosing a suitable surgical method to repair finger skin defects.MethodsIn this study, we designed a long elliptical flap based on a propeller perforator flap and located slightly toward the dorsal lateral aspect of the finger. The flap with a pedicle consisting of the dorsal perforator of the distal digital artery and dorsal digital artery perforator chain is rotated to cover a large wound on the distal end. From December 2014 to December 2017, 10 patients with finger soft tissue defects were treated with the propeller perforator flap described in this study.ResultsAll flaps survived after surgery, and 2 had a transient venous congestion. After a follow-up period of 3 to 12 months, the static two-point discrimination of the flap was 8.06 ± 1.75 mm, and the range of motion was 149.4 ± 12.9°. This designed flap can span several angiosomes supplied by the perforators. Due to the inclusion of a vessel chain between the dorsal digital artery perforators, the length-to-width ratio of the flap can be up to 3:1.ConclusionsThis technique increases the size of flap that can be harvested safely while retaining a reliable blood supply. The present study describes a new method for repairing soft tissue defects of the finger by using the technique of propeller perforator flaps based on dorsal digital artery perforator chains.Trial registrationThe registration number of this study is ChiCTR1800014588; it has been retrospectively registered with Chinese Clinical Trial Registry (chictr.org.cn), 18/11/2019.

Perforator propeller flaps in lower limb reconstruction: a literature review and case reports

Perforator-pedicled propeller flaps, which base their blood supply on isolated perforators, have been gaining popularity among plastic surgeons over the past two decades. They have proven to be of great value in the reconstruction of soft tissue defects in different areas of the body but are, thanks to their maximal mobility, mostly used in the reconstruction of extremities. In this article, we focus on perforator-pedicled propeller flaps in lower limb reconstruction, where they can be implemented in the coverage of primary as well as secondary soft tissue defects. Firstly, a brief literature review on evolution of propeller flap use in lower extremity is provided. Moreover, we present our surgical technique including the use of indocyanine green real-time angiography for reliable flap transfer. In addition, we report 3 cases of patients in whom we used a local propeller flap for the closure of skin defects in different parts of the leg.

Extended Central Artery Perforator Propeller Flap for Large Nasal Defects.

Various local flaps have been defined for small skin defects of the nose. However, the repair of large nasal defects is only possible with flaps allowing a large tissue transfer, such as a free flap, forehead flap, and nasolabial flap. In this study, large nasal defects were reconstructed with extended central artery perforator propeller (CAPP) flaps in an attempt to describe a single-stage procedure as an alternative technique to the median forehead flap. Thirteen large nasal skin defects, including dorsum and nasal sidewall and/or dome, were repaired with a CAPP flap between January 2015 and March 2018. A total of 13 patients aged 19 to 92 years were included. The mean follow-up period was 14.9 months. Pathological diagnoses were basal cell carcinoma in 5 patients, squamous cell carcinoma in 6 patients, and trauma in 2 patients. Defect size ranged between 3 × 3 and 4 × 5 cm. Flap size ranged between 3 × 7 and 5 × 10 cm. No major complications including total flap failure, hematoma, or infection were observed. However, a partial flap necrosis occurred in 1 patient. In 3 patients, scar revision surgery was performed at the postoperative period. In conclusion, CAPP flap use is a safe and reliable option to repair large nasal defects. This flap is able to cover large nasal defects including dorsal, dome, and nasal sidewall defects in a single-stage procedure. Requiring no pedicle separation, this flap is an alternative option to the conventional median forehead flap.

Finger defect coverage with digital artery perforator flaps

AimThe aim of this paper is to demonstrate the advantages of using local resources in the coverage of such defects. Our approach in fingers’ defects is the use of local perforator flaps, both as propeller flaps or bi-lobed pedicled flaps. Patients and methodsAfter performing an anatomical study on cadaver segments injected with latex followed by transparentation, 81 local perforator flaps in 80 patients during a period of 10 years (2007–2016), i.e. 47 digital artery propeller perforator flaps (DAPP), 10 island transposition perforator flaps (DATP), and 24 bi-lobed pedicled perforator flaps (BLP) were performed in our department. The patients were evaluated regarding finger mobility (ROM), two-points discrimination (TPD), and degree of satisfaction (DS) from cosmetic point of view. ResultsThe mean interval for social and professional reintegration was 12 days. As complications, we registered only venous congestion in 7 cases followed by epidermolysis in 4 cases and superficial necrosis in 3 cases, which healed by reepithelialization. The range of motion (ROM) of the reconstructed fingers was normal in all the patients. All the flaps regain a satisfactory degree of sensibility (TPD between 4 mm and 14 mm). The DS was relatively high, with 67 patients very satisfied, 11 satisfied, and 2 unsatisfied. ConclusionsThis fast and less invasive method, which replaces like-with-like, allows an early and good reinervation and a rapid social and professional reintegration, proves to be a very reliable alternative in digital defects coverage.

Why, when and how propeller perforator flaps in reconstructive surgery

The aim of this paper was to evaluate the outcomes of propeller perforator flaps used all over the body, and to appreciate their advantages and/or disadvantages over the free perforator flaps. Patients that required propeller perforator flaps used all over the body were eligible to participate in this study. A preoperative Doppler examination was performed for all the flaps in the trunk and thigh, but not regularly in the face, lower leg, foot, forearm and hand. We evaluated the most important technical aspects of harvesting the flaps, the main indications and advantages of using propeller perforator flaps, their disadvantages and complications. For post-excisional face and trunk defects after cancer or decubitus ulcers were performed approximately 25% of flaps. We had very good results in approximately 70% of cases. In the remaining cases, excepting 3 cases in which the flaps were completely lost, we registered only minor complications due to venous congestion, which were solved spontaneously or by skin grafting. The main advantages of propeller perforator flaps, i.e. no need of microvascular anastomoses, replacing like-with-like, faster functional rehabilitation, can reduce in well selected cases the indication for free flaps. The rate of complications is not higher than by using other methods. The single real disadvantage of propeller perforator flaps is the location of the perforator close to the defect, what can be an impediment in trauma cases.

Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity.

Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.

Saphenous Artery Perforator/Propeller Flap in the Reconstruction of Perigenual Soft Tissue Defects.

Introduction In this article, we investigate the saphenous artery perforator propeller flap for the reconstruction of perigenual defects. We describe the anatomy of the saphenous artery and the method of raising a perforator propeller flap based on our study and early clinical experience. Aim To assess the effectiveness of the saphenous artery perforator propeller flap in the reconstruction of perigenual defects. Materials and Methods A preliminary cadaver dissection and injection study was conducted to discern the anatomical details of the perforator system of the saphenous vessel in 35 cadaveric specimens in 18 fresh cadavers. From March 2016 to March 2018, 16 clinical cases (5 females and 11 males, in the average age group of 33.5 years) with perigenual defects were reconstructed with saphenous artery perforator propeller flap. They were followed up for an average period of 12.5 months. Results Cadaver study established anterior sartorial perforators as the dominant system of the saphenous vessel and brought to the forefront the type 2 blood supply of the saphenous nerve. All patients had well-settled flaps at the end of the follow-up period, with good return of knee function. Conclusion Saphenous artery perforator propeller flap is a viable option for the reconstruction of defects around the knee joint. Level of Evidence Type V, therapeutic study.

Propeller perforator flaps for coverage of soft tissue defects in the middle and distal lower extremities

The middle and distal leg coverage is demanding procedure for reconstructive surgeon until evolution of local perforator flaps which becomes as valuable options in lower limb reconstruction. The goal of our study was to assess the results, reliability, safety, and possible complications of the local propeller perforator flaps in lower extremity reconstruction. We demonstrate a case series of 11 patients in whom we cover small-to-medium soft-tissue defects of the middle and distal leg by application of local propeller perforator flaps. The site of soft tissue defects were in the distal third in 9 cases (81.8%) and 2 cases (18.1%) in the middle third. Flap dimensions ranged from 48 to 192cm2, with an average size of 88.9 cm2. The flap rotation was 180 degrees in (63.6%) of cases. The flaps were based on a single perforator of the posterior tibial artery in 8 (72.7%) cases and peroneal artery perforator in 3 (27.2%) cases. Complications were present in 18% of the perforator flaps which were based on peroneal artery perforator, one partial necrosis and one flap with a superfacial epidermolysis. The donor area is covered by split thickness skin graft in 63.6% of our cases and primary closure of in 36.3% of cases. The perforator propeller flaps are safe, relatively simple procedure and consider as an ideal option in reconstructing small-medium defects of the middle and distal third of the leg which provide similar skin texture with low donor site morbidity.

Penoscrotal reconstruction with superficial circumflex iliac artery perforator propeller flap.

Successful penoscrotal reconstruction requires proper resurfacing of the defect and maintenance of the original shape of the penis and scrotum. We examined the feasibility of using the superficial circumflex iliac artery perforator (SCIP) propeller flap to effectively reconstruct penoscrotal defects. Eleven male patients with an average age of 62.2 years were retrospectively evaluated. The average defect size was 21.3 × 10.5 cm2 (range: 10 × 8-24 × 16 cm2 ). An eccentrically located elliptical flap was constructed using a handheld Doppler device after detecting the perforator as the pivot point. The medial branch of the superficial circumflex iliac artery was used for all cases. Flaps were designed to cover 70-80% of the defect area and the average rotation arc was 165°. The average flap dimension was 19.7 × 7.7 cm2 . Two cases showed partial necrosis in the flap tip area. There were no instances of total flap loss or lymphorrhea, or complications such as scar contracture, urination problems, erectile dysfunction, or discomfort during intercourse. The SCIP flap is an effective and ideal method for penoscrotal reconstruction considering the loose, elastic, and thin nature of the tissue. Elevation is easily facilitated, and the thickness of the SCIP flap can be adjusted without microsurgery.

Impact of internal mammary artery perforator propeller flap in neck resurfacing and fistula closure after salvage larynx cancer surgery: Our experience.

Salvage total laryngectomy (TL) and laryngopharyngectomy (LP) after chemoradiotherapy may produce disfiguring defects with severe complications that require complex reconstructions. Between January 2012 and December 2018, we enrolled 25 patients who underwent internal mammary artery perforator (IMAP) flap reconstruction after salvage TL or LP. We performed retrospective review of clinical charts to collect information such as history, timing of reconstruction, type of defect, follow-up, donor and recipient site complications, and overall flap survival (OFS) rate. Three years overall survival (OS), relapse-free survival (RFS), and disease-specific survival (DSS) were calculated. The OFS rate was 95%. One partial flap necrosis was recorded. No donor-site complications were found. The mean follow-up was 18 months. Three years OS was 44%, RFS was 47%, and DSS was 54%. IMAP flap appears to be safe, versatile, and easy to harvest, with minimal donor site morbidity. It is a reliable option in Head&Neck reconstruction, in salvage surgery as well.

Penoscrotal Reconstruction With Superficial Circumflex Artery Perforator Propeller Flap

Penoscrotal Reconstruction With Superficial Circumflex Artery Perforator Propeller Flap

Upper body lift and breast reshaping with lateral chest wall perforator propeller flap following massive weight loss

After massive weight loss (MWL), female patients often develop upper trunk laxity and severe breast deformities. Usually several procedures are required to address upper body contouring issues. To achieve better breasts and improve upper body contour, the authors employed a combined approach, associating lateral chest wall perforator propeller flaps with an upper bodylift (UBL). Between September 2015 and March 2017, nine post-bariatric patients underwent simultaneously an UBL and autologous augmentation breast reshaping with lateral chest wall perforator propeller flaps. The authors analyzed the clinical indications, results and complications of this procedure. Eighteen lateral perforator propeller flaps for autologous breast augmentation-mastopexy associated with an UBL were performed successfully. Mean pre-MWL body mass index (BMI) was 54.3±10.9kg/m2, with a mean preoperative pre-UBL BMI of 28.7±3.6kg/m2. The average weight loss before surgery was 67.7±22.4kg. The flaps were harvested on intercostal and/or lateral thoracic arteries. All donor sites had been closed primarily. Following the classification of Dindo and Clavien, four minor complications (I, II), and two major complications (IIIb), including two hematomas requiring reoperation, were reported. No flap necrosis occurred. Follow-up averaged 27.9±8.4months. The patients' satisfaction with their improved breast shapes and chest wall contours was "good", with an aesthetic outcome mean ranked 3.8±0.8 (out of 5). After MWL, upper body deformities can be treated safely and reliably by a combined approach, associating an UBL and autologous lateral chest wall perforator flaps to provide more natural and durable breast shapes, as well as an upper circumferential reshaping.

Perforator Flap Reconstruction for the Distal Third of Lower Extremity Defects: Clinical Application and Guideline Recommendation

A distal third of lower extremity defect is challenging for plastic surgeons. The standard for treatment is microsurgery. Recently, perforator flap has been reported for small to medium defects. The objective was to analyze the outcomes of perforator flaps for distal third of lower extremity defects and to establish surgical guidelines. A retrospective review of patients with defects in distal third of lower extremities was conducted. Patients with multiple levels of lower extremity defects were excluded. A total of 8 patients with distal third of lower extremity defects were included. Seven patients were male. Overall mean age was 35.3 (18-60) years. Patients had 3 anterior, 3 lateral, and 2 medial defects. Lateral and anterior defects in 6 patients were closed using a peroneal-based propeller perforator flap with an angle of rotation of 90° to 160°. Medial defects in 2 patients were closed using a posterior tibial-based perforator advancement flap. Three patients (37.5%) developed venous congestion. No complications occurred for patients with medial defect closure using an advancement posterior tibial-based perforator flap. No total flap loss was observed. The perforator flap provides a similar texture to the skin at recipient area and a wide range of rotation. Perforator flaps should be the first choice for defects reconstruction in distal third lower extremities. Perforator flaps can be used for small to large defects, and can be moved by propeller or advancement depending on the perforator location. A guideline for perforator flaps reconstruction of the distal third of lower extremity defects was established.

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.

Clinic application of CTA and HHD: mapping for propeller perforator flaps in shank

Objective To localise and evaluate the precise position of the shank perforators preoperatively with the CTA and hand-held color Doppler (HHD) , then evaluate the clinical efficacy of the method. Methods From April, 2013 to June, 2017, designed 36 propeller perforator flaps in 36 patients by following methods. Firstly, the CTA test was performed to calculate the parameters of perforator vessel positioning. Secondly, a HHD was typically used to verify the location of perforators found on preoperative CTA. At last, according to the with like principle, the propeller perforator flaps were accurately designed. The regular followed-up was performed. Results All patients were followed-up for 3-24 months after operation. Thirty-six propeller perforator flaps survived, and 3 cases among them showed partial epidermal necrosis and healed after skin grafting. Donor sites were closed primarily in 24 cases, and skin grafting were performed in 12 cases. The skin graft sites survived without necrosis, and the average time of cutting flaps was 45 min. Conclusion By the methods of mapping the perforator propeller flaps with CTA and HHD, the perforator vessel can be positioned more accurately and quickly. The operation time was shortened, and the clinical efficiency can be achieved with the good clinical application values. Key words: Propeller flap, perforator flap; CT angiography; Hand-held Doppler ultrasound; Shank