Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction?

Abstract

Background: 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.

Questions/purposes: 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.

Methods: From 2007 to 2012, 74 patients (44 males, 30 females), 14 to 87 years 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 1 year (mean, 3 years; range, 1-7 years); eight patients (11%) were lost to followup before 1 year. 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.

Results: 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.

Conclusions: 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 of evidence: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Fig. 1A–C

(A) A propeller flap based on a perforator of the posterior tibial artery is harvested to cover a dehiscence of the wound after medial malleolus fracture in a 57-year-old woman. (B) The rotation was 120° and (C) the donor site was closed primarily.

Fig. 2A–C

(A) A propeller flap based on a perforator of the deep femoral artery is used to cover a post-traumatic defect around the knee. (B) The flap is raised on the chosen perforator. The recipient site is covered by the major blade, while the donor area is partially closed with the small blade and partially directly sutured. (C) The result after 1 year is shown.

Fig. 3

The defect is located posterior to the medial malleolus. The ideal design of this propeller flap based on a perforator of the posterior tibial artery is with the main axis located on the projection of the source vessel.

Fig. 4

Assuming that the perforator corresponds to the pivot point, a propeller flap consists of two blades: a longer one proximal to the perforator and a shorter one distal to it. The length of the major blade (A) must be equal to the length of the short blade (B) plus the distance between the proximal and the distal edge of the defect (C). After the rotation of the flap, the short blade is used to cover at least partially the donor site.

Fig. 5A–E

(A) Three perforators of the posterior tibial artery are marked on the skin preoperatively, according to color Doppler imaging. After surgical débridement of the recipient site, the flap is planned and designed. After preoperative mapping of the perforators, direct observation of them is needed to make the critical decision regarding which perforator to use. (B) A long explorative incision is made on one of the major margins of the flap and the best perforator is chosen, taking into account its size and location. (C) Once the pedicle is dissected, raising the flap is straightforward. After release of tourniquet, (D) the perfusion of the skin paddle is checked and (E) the flap then is rotated to the desired location. In case of rotation of 180°, it is advisable to turn the flap first clockwise and then counterclockwise into the defect and eventually choose the direction that has less affect on the patency of the pedicle.

Fig. 6A–D

A propeller flap based on a perforator of the deep femoral artery is used to reconstruct a post-traumatic defect in a 26-year-old man. (A) The flap is shown sutured in place. (B) Skin necrosis of the distal angiosome with a neat border occurred a few days after surgery. In this case, (C) the subcutaneous tissue survived and (D) a skin graft was the only additional surgery needed.

Fig. 7A–B

Owing to the dimensions of the flap and quality of the soft tissue (pliability, thickness, elasticity) in the same anatomic area, direct closure of the donor site (A) may or (B) may not be possible. In the latter case, a skin graft needs to be performed.

Fig. 8

Meticulous dissection of the pedicle is the key to prevent complications. All the muscular branches must be divided and the perforator must be cleared of all the fascial strands for at least 2 cm. If any potential reason for extrinsic compression is removed, the twist of the pedicle after rotation to the recipient site will be gentle and distributed on the entire length of the pedicle.