Propeller flaps: Classification and clinical applications

ORIGINAL ARTICLE

Propeller flaps: Classification and clinical applicationsLes lambeaux en helice : classification et applications cliniques

B. Ayestaray *, R. Ogawa, S. Ono, H. Hyakusoku

Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku,Tokyo 113-8603, Japan

Received 29 August 2010; accepted 15 November 2010

KEYWORDSPropeller flap;Perforator;Central axis flap;Acentric axis flap;Multilobed flap;Perforator-superchargedflap;Super-thin flap

Summary Propeller flaps feature a highly reliable reconstructive method, based on a perfo-rator vessel. Since their introduction in 1991, a great variety of propeller flaps have beendescribed, according to their shape and their potential of coverage. Indeed, these flaps haveprogressively been refined and modified, concerning their vascularity and space design. Theauthors present a classification of propeller flaps. This anatomical classification is necessary tounderstand the dissection procedure and the differences between the numerous types ofpropeller flaps nowadays described. It is the international classification, which should be usedfor the description and conception of these flaps.# 2010 Elsevier Masson SAS. All rights reserved.

MOTS CLÉSLambeau en hélice ;Perforante ;Lambeau centro-axial ;Lambeau acentro-axial ;Lambeau multilobé ;Lambeau perforantsuperchargé ;Lambeau super-fin

Résumé Les lambeaux en hélice représentent une méthode de reconstruction, fiable et peuinvasive, basée sur un pédicule perforant. Depuis leur introduction en 1991, une grande variété delambeaux en hélice ont été décrits, en fonction de leur forme et de leur potentiel de couverture.Ces lambeaux ont, en effet, fait l’objet de raffinements et de modifications importantes,concernant leur vascularisation et leur représentation spatiale. Les auteurs présentent uneclassification des lambeaux en hélice. Cette classification anatomique des lambeaux en héliceest nécessaire pour comprendre les modalités de dissection et les différences entre les nombreuxtypes de lambeaux en hélice décrits à ce jour. Enfin, elle correspond à la classification inter-nationale, devant être utilisée pour la description et la conception de ces lambeaux.# 2010 Elsevier Masson SAS. Tous droits réservés.

Annales de chirurgie plastique esthétique (2011) 56, 90—98

Introduction

Perforator flaps feature the last advance in the history ofreconstructive surgery. With the evolution of anatomical

* Corresponding author.E-mail address: [email protected] (B. Ayestaray).

0294-1260/$ — see front matter # 2010 Elsevier Masson SAS. All rightdoi:10.1016/j.anplas.2010.11.004

knowledge concerning skin vascularization, perforator ves-sels have been recognized as the main source of supply forteguments. The history of skin flaps began in the 19thcentury, with the anatomical works of Manchot [1] andSpalteholz [2,3], describing different vascular skin terri-tories. These works were completed by the radiographicstudies of Salmon [4] in 1936, who demonstrated the exis-tence of other vascular skin territories. One century later,

s reserved.

http://dx.doi.org/10.1016/j.anplas.2010.11.004

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http://dx.doi.org/10.1016/j.anplas.2010.11.004

[()TD$FIG]

Figure 1 Classification of propeller flaps based on the type of pedicle. a: subcutaneous-pedicled propeller flap (SPP flap); b: muscle-pedicled propeller flap (MPP flap); c: perforator-pedicled propeller flap (PPP flap); d: vascular-pedicled propeller flap (VPP flap).

Propeller flaps: Classification and clinical applications 91

Taylor and Palmer described in 1987 the angiosomes concept[5], and proved in 2003 their implication in the physiology ofperforator flaps [6]. He also proved that vascular territories ofthe skin are defined by perforator arteries, raising from sourcevessels. In 1986, Nakajima et al. already distinguished, ana-tomically, six types of skin arteries [7] and elaborated aclassification of skin flaps in six groups, which is fundamentalfor the understanding of perforator flaps. In reality, right fromthe first World War, Gino Pieri, an Italian military surgeon,published in his atlas in 1918 a map of perforator flaps of thehuman body [8]. Kroll and Rosenfield reworked the idea statedby Pieri and was the first to use the term of ‘‘perforator flap’’in 1988 [9]. One year later, Koshima and Soeda proved thereliability of a skin flap vascularized by a perforator artery,raising fromthedeep inferior epigastric artery (DIEPflap) [10].In 1991,Hyakusokuetal. described an islandflap, vascularizedby a perforator, and rotated from 908, for the reconstructionof skin scar contractures of burn patients [11]. Its skin paddlewas designed with an oval helicoïdal and primary closingshape, centered on the perforator. Its shape and mobilizationreminds these of a propeller; that is the reason why this flap iscalled propeller flap. Initially, the supplying perforator wasincluded in a subcutaneous pedicle, located in the center ofthe flap. During these 20 last years, propeller flaps have beenrefined and modified, concerning their vascularity and spacedesign. A classification is necessary to understand the dissec-tion procedure and the differences between the numeroustypes of propeller flaps nowadays described. These flapsfeature a highly reliable reconstructive method, based on aperforator. Their main interest is to respect major vascularaxis and to avoid the disadvantages of microvascular freeflaps.

Classification

The classification of propeller flaps is based on the perforatorvessel, supplying the flap vascularity. The perforator can bemusculocutaneous or septocutaneous [12—16]. The propellerflaps follow this classification, but are also based on the typeand the position of the vascular pedicle in the flap. They aredefined as helicoïdal-shaped island skin flaps, with a rotationaxis centered on the supplying perforator. So far, perforator-pedicled propeller flaps (PPP flaps) are considered as classi-cal perforator flaps. But other flaps including perforators,into the flap pedicle, enter also in this classification. Thispedicle can be subcutaneous (SPP flaps), muscular (MPPflaps) or vascular axial (VPP flaps).

The propeller flaps respond to two classifications, whichare not antinomic but complementary.

Classification based on the type of pedicle

Perforator-pedicled propeller flaps (PPP flaps)These flaps are skin flaps, vascularized by a perforatorpedicle, which is skeletonized on its complete length(Fig. 1c). The dissection of perforator vessels has two advan-tages: it permits a safe rotation of the flap up to 1808; theflap can also be designed effectively and safely according tothe perforator course. In this way, larger skin paddle can beharvested, and more distant defects can be covered [17]. It isrecommended to select a dominant perforator with a calibersuperior to 1 mm, but, in our experience, PPP flaps arereliable even when they are based on a smaller perforator,contained between 0.5 and 1 mm.

Non-perforator pedicled propeller flapsThese flaps, helicoidal-shaped and centered on a sourcepedicle, are classified among propellerflaps. When their bloodsupply is based on a dominant perforator included in the flappedicle, they are considered as perforator-based flaps.

Subcutaneous-pedicled propeller flaps (SPP flaps). SPPflaps are skin flaps based on one or several perforatorsincluded in the flap pedicle, which is dissected into theunderlying subcutaneous adipose tissue (Fig. 1a). If a domi-nant perforator is skeletonized through the subcutaneouspedicle, they become perforator pedicled propeller flaps(PPP flaps). The main interest of these flaps is to reducethe operative time, comparing to PPP flaps. But, they need aperfect knowledge of the anatomy of perforator vessels. Themajor problem of these flaps is a pedicle kinking for rotationssuperior to 908. That is why they generally can not bemobilized more than 908. Moreover, the inclusion of adiposetissue around the perforator vessels reduce the vascularity ofthe flap. In this way, the skin paddle is smaller than PPP flapsand can not cover large defects. Thus, these disadvantageslimit the indications of SPP flaps in reconstructive surgery.Nevertheless, we use SPP flaps for burned patients, if thewound was deep. In this case, perforators may be damaged.Donor sites are very limited in burned patients. SPP flaps canbe harvested, even if a dominant perforator has not beenfound around the recipient site. The flap pedicle mustinclude small perforators.

Muscle-pedicled propeller flaps (MPP flaps). MPP flaps areskin flaps based on one or several perforators included in theflap pedicle, which is dissected through muscle tissue(Fig. 1b). They become perforator pedicled propeller flaps,if a dominant musculocutaneous perforator is skeletonizedthrough the muscular pedicle. We use MPP flaps if a dominant

92 B. Ayestaray et al.

musculocutaneous perforator has not been found. The mus-cular pedicle must include small musculocutaneous perfora-tors. These flaps are also interesting to cover tissues with aweak vascularity or surgical material. In this case, the mus-cular pedicle is rotated and advanced towards the defect.

Vascular-pedicled propeller flaps (VPP flaps). These flapsare based on the direct cutaneous or septocutaneous perfora-tors, raising from an axial arteriovenous pedicle. They aredefined by a skin paddle and a rotation around a pivot point,which is the base of the axial vascular pedicle (Fig. 1d). If adominant perforator is skeletonized and used as a pivot point,the flap becomes a perforator-pedicled propeller flap (PPPflap). On the contrary, if it is not dissected but only included inthe pedicle, the flap can be considered as a perforator-basedflap. A typical example of VPP is the distally-based radialarteryflap.Very large skinpaddles can beharvestedcomparedto perforator flaps. Venous return is very strong, so there is nodoubt of survival. We use VPP flaps, in association with a distalpropeller flap, to cover very distant defects from the donorsite (cf flap-in-flap propeller flaps).

Classification based on the pedicle position

Central axis propeller flapsThe pedicle is located at the center of the flap. These flapsare highly reliable, because of an homogenous blood supplyof the skin paddle [11,20]. The main indication of central axispropeller flaps is the coverage of two adjacent defects. Inthis way, the flap must be raised between them and rotatedup to 908 (Fig. 2).

Acentric axis propeller flapsThe advantage to displace the rotation arc of the flap at itsperiphery is to increase the distance between the defect andthe perforator, chosen as pivot point [17,21—23]. Then,these flaps are very useful to cover defects, located in areasdistant from regions rich in perforators [24—28]. It is recom-mended to analyse the perforator course by MultiDetector-row Computed Tomography (MDCT) before designing the skinpaddle. Indeed, only perforators with a long course, and adirectionality parallel to the longitudinal axis of the flap, canbe selected for raising acentric axis propeller flaps (Fig. 2).

Technical refinements

Coverage area of the flap: multilobed propellerflaps

Different types of multilobed propeller flaps can bedesigned, in view to cover several defects at the same time.They are very useful for the treatment of adjacent scar
[()TD$FIG]
Figure 2 Classification based on the pedicle position. a: c

contractures. Then, different shapes have been described[29]:

� the first shape consists in harvesting small triangular flaps,on both sides of the propeller, which permits to closedirectly the donor site in a V-Y design;� the second shape consists in harvesting two lobes, of

equal area, pedicled on the same perforator;� the third shape consists in harvesting non-symmetrical

bilobed flaps, i.e. with lobes of unequal area. The largerlobe is useful to treat a scar contracture.

Length of rotation axis: flap-in-flap propeller flap

This concept is possible only with propeller flaps pedicled ona dominant perforator and non-perforator pedicles (axial forVPP flaps, muscular for MPP flaps). These flaps imply a doublerotation of the skin paddle, around two distinct vascularpivot points [30]. The first rotation is performed with thenon-perforator pedicle of the flap; the second rotation isperformed around the dominant perforator. Then, the skinpaddle can be mobilized more distantly from the donor site,and cover more distant defects from the supplying perfora-tor.

Vascularity of the flap: perforator-superchargedpropeller flaps

Very long and large perforator flaps must be superchargedwith other vessels, in view to increase their survival area(Fig. 3). These flaps are generally used as super-thin flaps,which implies a supercharging with other perforators (‘‘per-forator supercharging’’), but not axial pedicles [31,32]. Theskin paddle design of such flaps is not so easy. Indeed, it musttake into account the perforators anatomy, but also thetopography of recipient vessels.

Thickness of the skin paddle: super-thinpropeller flaps

The super-thin flap technique consists in ‘‘defatting a skinflap, until the subdermal vascular network can be identifiedthrough a minimal fat layer’’ [33—37]. This method suitsparticularly well the perforator flaps concept. Indeed, it ispossible to remove easily the adipose tissue from a perfora-tor which has been skeletonized. Then, their vascularitydepends on the perforator, which supplies the subdermalvascular network. Concerning the terminology, ‘‘super-thinflap’’ et ‘‘subdermal vascular network flap’’ are respectivelythe generic and the anatomical names of the same clinicalentity. The main interest of this technique is to increase thesurvival area of the flap, especially in its distal region [38].

entral axis propeller flap; b: acentric axis propeller flap.

[()TD$FIG]

Figure 3 Perforator-supercharged propeller flap. The flap is rotated around the first perforator pedicle at the proximal part of theflap. A second perforator pedicle is raised at the distal extremity of the flap. This second pedicle is cut and anastomosed to recipientvessels. This technique increases the flap survival area and avoid a venous congestion in the distal part of the flap.


Clinical cases

Case 1: superior gluteal artery perforator-pedicled propeller flap

A 37-year-old male suffered from pilonidal cysts on the sacralregion for several years. Cysts were completely resected andthe defect was reconstructed using 12 cm � 5 cm of a super-ior gluteal artery perforator (SGAP) pedicled propeller flap(Fig. 4). The musculocutaneous superior gluteal artery per-forator was confirmed preoperatively using MDCT and intrao-peratively (Fig. 5). Two months after the surgery, the flapsurvived completely and no recurrence of pilonidal cystswere observed (Fig. 6).

Case 2: circumflex scapular artery perforator-pedicled bilobed propeller flap

A 42-year-old male suffered from severe axillary contracturecaused by burn (Fig. 7). A bilobed flap consisted of 17 cm �10 cm flap and 12 cm � 6 cm flap was harvested (Fig. 8). Theflap was based on one septocutaneous perforator of thecircumflex scapular artery. It was elevated from the periph-ery and the circumflex scapular vessels were identified. Thelarge flap was rotated 908 and covered the defect aftercontracture removal. The small flap was also rotated 908and covered the recipient site of the large donor flap (Fig. 9).Two weeks after the operation, the flap survived completelyand the axilla was recovered functionally (Fig. 10).[()TD$FIG]

Figure 4 Case 1. a: design of the superior gluteal artery perforator flof the flap is the dominant musculocutaneous perforator, raising fr

Case 3: collateral radial artery perforator-pedicled propeller flap

A 53-year-old man presented an open fracture of the rightelbow. His right elbow had struck the door during a caraccident. There was a 6 cm � 4 cm skin defect. A bonetip harvested from ilium was grafted to the right olecranonusing stainless steel wire. The skin defect over the fracturewas covered with a rotated PPP flap based on a septocuta-neous perforator of the collateral radial artery, raising fromthe deep brachial artery (Fig. 11). The perforator pedicle waslocated on an acentric portion of the flap (Fig. 12). After 1808rotation, no kinking of the perforator was observed. 1 monthafter the surgery, the flap survived completely (Fig. 13).

Discussion

Advantages of propeller flaps

Propeller flaps represent a new reconstructive technique,having many advantages. First, they permit to cover verylarge defects, because of their vascular reliability. More-over, their vascularity can be supplied by perforators locateddistantly from the anatomical regions to reconstruct, whichis particularly interesting when they are functional regions.Indeed, it is better to limit the morbidity at the donor site,when it is a functional area, and to use a skin paddle locateddistantly, in a non-functional region. As every perforatorflap, propeller flaps do not sacrifice major vascular axis, and

ap based on a musculocutaneous perforator. b: the acentric axisom the right superior gluteal artery.

[()TD$FIG]

Figure 5 Case 1. Intraoperative view of the musculocutaneousperforator.

[()TD$FIG]

Figure 7 Case 2. Preoperative view of the axillary scar con-tracture.


then limit the donor site morbidity, in terms of muscularforce, sensibility and trophicity. Eventually, the surgicaltechnique is based on the flap rotation, around an axisrepresented by the perforator. There is no need of micro-vascular anastomoses, which reduces the operative time andpostoperative failure risks. In our clinical experience, PPPflaps, raised as acentric axis propeller flaps, are the mostuseful propeller flaps. The main interest of SPP flaps is whenperforators of the donor area are damaged, especially inburned patients. We use MPP flaps if a dominant musculo-cutaneous perforator has not been found, or for the coverageof implants. VPP flaps are interesting to perform flap-in-flappropeller flaps for very distant defects.

Preoperative analysis

Because of the variability of the perforators course andvascular territory in human beings, it is recommended toperform a preoperative analysis by color Doppler ultrasono-graphy or MultiDetector-row Computed Tomography (MDCT).This analysis permits to evaluate the size and to adapt theshape of the skin paddle, reducing the operative time and thepostoperative necrosis risk [16]. Moreover, the analysis ofthe suprafascial perforator directionality (Fig. 14) is funda-
[()TD$FIG]
Figure 6 Case 1. a: clinical result 3 months postoperatively;

mental to determinate the survival area of propeller flaps[18,19]. That is why we always perform preoperatively aMDCT before designing a propeller flap.

Microvascular patency

The vascularity of propeller flaps is based on perforatorvessels, undergoing a torsion between 0 to 1808. Despitethe important torsion of the pedicle, the skin paddle hasclinically no suffering or necrosis area. Wong advocates toselect a perforator having a caliber superior to 1 mm and a

b: after rotation of the flap, donor site is closed primarily.

[()TD$FIG]

Figure 8 Case 2. a: design of the circumflex scapular artery perforator bilobed flap, based on a septocutaneous perforator. b: theaxis of the flap is the dominant septocutaneous perforator, raising from the left circumflex scapular artery. This perforator is locatedbetween the 2 lobes of the flap.

[()TD$FIG]

Figure 9 Case 2. a: intraoperative view. After releasing the scar contracture, coverage of the axillary defect by the large lobe of theflap. b: intraoperative view. Donor site is closed by the small lobe of the flap. c: rotation is made around the septocutaneous perforatorof the left circumflex scapular artery.


[()TD$FIG]

Figure 10 Case 2. Postoperative view. The function of the shoulder has been recovered, 2 weeks after the surgery.

[()TD$FIG]

Figure 11 Case 3. a: design of the collateral radial artery perforator flap, based on a septocutaneous perforator. b: the axis of theflap is the dominant septocutaneous perforator, raising from the collateral radial artery.

[()TD$FIG]

Figure 12 Case 3. Intraoperative view of the septocutaneousperforator.


length superior to 30 mm, and to rotate the flap with arotation angle inferior to 1808 [39]; in other words, if thisangle exceeds 1808, it is recommended to change the rota-tion direction for keeping an angle inferior to 1808 [40].Different experimental studies on animals were performed,in view to study the microvascular patency, after a pedicletorsion more or less important and a microsurgical anasto-mosis. All these studies demonstrate that the torsion of amicrovascular pedicle leads to a significant reduction of thevascular patency rate [41—46]. This reduction is more impor-tant for the veins than the arteries. Experimentally, in rats,the microvascular patency is around 80% for the femoralartery and vein after a torsion of 908; 70% for a femoral arteryafter a torsion of 1808; 25% for a femoral vein after a torsionof 1808 [41]. Veins are more sensitive to a torsion, because ofa weaker wall, a lower intraluminal pressure and a biggerelasticity [39,41,45,46]. The odds ratio concerning thethrombotic risk is around 2 for an artery and 6 for a vein,with a torsion of 908; it becomes 4 for an artery and 37 for a

[()TD$FIG]

Figure 14 MDCT analysis of the Suprafascial perforator direc-tionality (SPD) of the second musculocutaneous perforator,raising from the left internal mammary artery.

[()TD$FIG]

Figure 13 Case 3. a: clinical result 6 months after the surgery. b: after rotation of the flap, donor site is closed primarily.


vein, with a torsion of 1808 [41]. Selvaggi et al. demonstrate,mathematically, that the buckling phenomenon, favouringthrombosis, begins with torsions of 5218 for arteries, and1058 for veins [44]. Nevertheless, these datas tally withmeasurements taken either immediately, either 1 hour afterperforming the torsion of microvascular pedicles. Topalanet al. [45] and Bilgin et al. [46] demonstrate that, 1 weekafter performing the pedicle torsion, the microvascularpatency rate is 100% with torsions of 908 and 1808, forarteries and veins respectively. There is, in reality, a criticalphase during 72 h, while thrombotic risk is high for veins, ifthe torsion is superior to 908. After this delay, the micro-vascular patency rate returns at a normal level, and the riskof venous thrombosis is almost non-existent. In this way, apreventive anticoagulation during 72 h could be justified, forpropeller flaps with a rotation superior to 908. Nevertheless,in our clinical experience, propeller flaps, with a rotationsuperior to 908, do not suffer from any venous congestion anddo not have a superior necrosis rate. That is why no pre-ventive anticoagulation is needed, in clinical practice, inview to limit the venous thrombosis risk of propeller flaps.

Conclusion

Since more than 20 years, perforator flaps have proved theirreliability and their great interest in reconstructive surgery.Perforator vessels can be used to cover local or regional

defects, through rotation flaps, without necessity of anymicrovascular anastomosis. Perforator-pedicled propellerflaps (PPP flaps) can be considered as one of ‘‘the mostsophisticated method to raise a perforator flap’’ [47]. Theseflaps have many advantages, comparing to classical axialflaps, because they do not sacrifice source arteries andrespect the vascularity of nearby anatomical elements(i.e. muscle, fascia, nerve, bone and fat tissue). Perfora-tor-pedicled propeller flaps are, in this way, a new step in theera of less-invasive reconstructive surgery. The evolution ofideas and surgical techniques has progressively followed theanatomical knowledges of the skin vascularization. From theIndian forehead flap to the studies of Spalteholz, Pieri andSalmon, more than 1500 years have passed. More than 50years after these anatomical studies, perforator flaps wereconcretely used in clinical practice. Among perforator flaps,propeller flaps mark a decisive step in the history of plasticsurgery.

Conflicts of interest

None.

Acknowledgments

Figures 1, 2 and 3 were drawn by Kazuyuki Sugiu. Figures 4, 6,8, 9, 11 and 13 were conceived by Benoit Ayestaray, MD.

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Propeller flaps: Classification and clinical applications