Marco Pignatti*, MonMassimiliano Bruti, G
Plastic Surgery and Burn Unit, Az
Received 7 June 2007; accepted 2
conspicuous, only cosmetic, donor site defect. No flap necrosis was observed, with the excep-
success rate and good cosmetic results without functional impairment. In the light of this they
According to the first reports1,2 and, later, to the Gent con-sensus,3 perforator flaps are described as consisting of skinor subcutaneous fat nourished by vessels originating froma deep vascular system and reaching the surface passingthrough the deep tissues (mostly muscles or intermuscularsepta).
* Corresponding author. Address: Unita Operativa di ChirurgiaPlastica e Centro Ustioni, Ospedale Civile Maggiore, Azienda Ospe-daliera di Verona, Piazzale Stefani 1, 37126 Verona, Italy. Tel.: 39045 8122189; fax: 39 045 8123258.
E-mail address: firstname.lastname@example.org (M. Pignatti).
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 777e783can be considered among the first surgical choices to resurface complex soft tissue defects ofthe leg. 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.tion of a small superficial necrosis of the tip of one flap, due to the inclusion in the design ofscarred tissue. In two cases, transient venous congestion was observed and resolved spontane-ously. Mean operative time was 2 h (ranging from 60 min to 6 h when an orthopaedic procedurewas also needed) and mean hospital stay after surgery was 10 days. Propeller flaps allow thecoverage of wide defects, can be raised with a relatively simple surgical technique, have a highLower limb;Leg reconstructionica Pasqualini, Maurizio Governa,ino Rigotti
ienda Ospedaliera di Verona, Italy
5 October 2007
Summary Leg soft tissue defects with bone or tendon exposure need to be covered witha flap. Various local and free flaps with more or less consistent donor site defects have beendescribed in the past. After the introduction of the perforator-based flap concept, new flapshave also been described for the leg. An evolution and simplification of the perforator flap con-cept, together with the free style flap harvesting method, are the propeller flaps, i.e. localflaps, based on a perforator vessel, which becomes the pivot point for the skin island that can,therefore, be rotated up to 180.
In this prospective study, six consecutive patients, having post-traumatic soft tissue defectsof the leg or knee prosthesis infection, with bone or tendon exposure, were treated with pro-peller flaps.
Complete and stable coverage of the soft tissue losses was obtained in all cases with an in-Propeller flaps for leg reconstruction
methods through the use of pedicled perforator flaps in
778 M. Pignatti et al.different areas of the body.10e14
The main advantage of a pedicled perforator-based flapcompared to a fasciocutaneous flap is the certain presenceof a reliable vascular pedicle. The key element in predict-ing the survival of any cutaneous flap is the nature of theblood supply that is included.15
A propeller perforator flap has the additional advantageof wider mobilisation and rotation options.
The term propeller flap was first introduced in 1991 byHyakusoku16 to define a method of elevating and rotatinga flap with a length largely exceeding its width and basedon a central subcutaneous pedicle. The flap was then ro-tated 90 on the central axis to release a post-burn skincontracture.16e18
The perforator-based propeller flap used in our series,which derives from the above-mentioned flap, is a ske-letonised perforator flap with several peculiarities, asdescribed by Teo (personal communication) and recentlypublished by Hallock19 and Masia20,21:
The skin island design is peculiar, being made of twoportions similar to the two blades of a propeller (whichnecessarily differ in dimensions depending on theposition of the perforator in relation to the defectlocation).
The two blades of the propeller rotate from 9016e18 to180,19e21 around the fixed point of the perforatorvessel.
The donor site defect is partially covered with thetissue raised between the defect and the perforatingvessel (this is also possible, with smaller extent, whenthe rotation is less than 180) (Fig. 1).
Patients and methods
Between December 2006 and May 2007, six patients weretreated with a propeller perforator-based flap for soft tissuedefects of the leg and knee exposing the tibial bone or kneejoint, or the damaged Achilles tendon (Table 1).
Age ranged from 15 to 63 years (mean 52.5 years). Fivepatientsweremale. Four of themalepatients presentedwithpost-traumatic tibial fracture exposure and the fifth male(Patient 2) hadapost-traumaticmalleolar fracturewithwideexposure and disruption of the Achilles tendon (Fig. 2).
The female patient had undertaken, elsewhere, severalorthopaedic surgical procedures for infection of a kneeThe main advantage of these flaps is the low donor sitemorbidity, due to the preservation of the muscular struc-ture and function. Asko Seljavaara4 in 1983 introduced theterm freestyle free flaps to describe the flap harvestingtechnique based on the direct visualisation of the main ves-sel, the identification of a perforator/cutaneous vessel,and the design of a skin island over it. Wide clinical appli-cation of this technique followed.5
Knowledge of the vascularisation of the subcutaneousand cutaneous tissues was boosted by the studies of Tayloron the angiosomes of the body6e8 and focused by recentanatomic studies.9
The fusion of the concept of freestyle free flaps and thediscovery of the angiosomes, led to simpler reconstructiveprosthesis. A prosthesis coverage with the gastrocnemiusmuscle had already been attempted without success.Prosthesis removal and coverage with a long propellerflap was performed.
The size of the flaps ranged from 8 9 cm to 25 12 cm.
Preoperative Doppler sonography was routinely performedas a guide to locate the vessels. The patients were operatedon in the supine position in five cases (four of them withthigh abducted and knee flexed) and in the lateral decubi-tus in one case.
Radical debridement of all the macroscopically-infectedand non-viable tissues was carried out before flap coverage.
According to the position of the soft tissue defect, anexploratory incision was performed, keeping in mind theexpected emerging sites of the perforating vessels from theintermuscular septa and from the muscular bellies8,9 andgrossly guided by the preoperative Doppler examination.The dissection was performed under the fascia in the firstfour cases (patients 1, 2, 3 and 5) and above it thereafter (pa-tients 4 and 6). No difference in flap vitality was observed.
All the functionally reliable perforating vessels, wellpositioned with respect to the defect to be covered and ofthe skin island design, were preserved.
The flap design was redrawn over the perforators found,trying to avoid the scars already present in the area, inorder to optimise the coverage of the defect with oneportion of the flap and the donor site with the otherportion. The perforator vessel best positioned in theoptimal skin island design was chosen as nourishing pedicle.
The flap margins were then incised and the flap harvestwas completed (Figs. 1e3).
Accurate release of all the fascial adhesions around theperforating pedicle and dissection of the vessels for a shorttract into the muscle belly or in the septa were then carriedout. Four flaps were raised on one perforator pedicle, oneflap was raised on two pedicles (one arterial and onevenous) and one flap on two artero-venous pedicles.
Complete and stable coverage of the soft tissue losses wasobtained in all cases with an inconspicuous and cosmeticonly donor site defect (Table 1; Figs. 1e3). No flap necrosiswas observed, except for a small superficial necrosis of thetip of one flap, due to the inclusion in the design of an al-ready scarred tissue at the tip of the flap (Fig. 1). In two pa-tients a transient venous congestion was observed thatresolved spontaneously. Mean operative time was 2 h (rang-ing from 60 min to 6 h when an orthopaedic procedure onthe bone was also needed). Mean hospital stay after surgerywas 10 days, largely due to the maintenance of the cathe-ters positioned at the fracture site.
In one case the perforator vessels were found so close tothe defect area that the flap design could not include thetwo typical blades of the propeller.
The donor site defects in all the patients were in partcovered by one portion of the flap while skin was graftedover the residual part (Figs. 2, 3).
Propeller flaps for leg reconstruction 779Discussion
The ideal method for the soft tissue reconstruction ofthe leg should be reliable, relatively easy to perform,offer viable tissues similar in skin texture and thicknessto the lost ones (replace like with like3), leave themost inconspicuous donor site defect possible, and beperformed without compromising other body regions.
Figure 1 Patient number 1. (a) Preoperative view of the post-trathe central bone fragment. The de-epithelialised area of the posteterior leg 12 days before flap surgery. (b) After an exploratory inciincised. Note the scarred area on the proximal posterior leg and, pkeeping in site the central fragment of the fractured tibia. The pinflap design in this case was influenced by these two factors and by thsurgical option. (c) The flap is harvested, and the perforating vesscluded at the tip of the flap underwent superficial necrosis.The perforator-based propeller flaps have all theseadvantages.
Direct visualisation of the vessels gives the surgeon theopportunity to choose the pedicle with the best character-istics, both for position and calibre, therefore increasingthe chance of a successful reconstruction.
The harvesting of a propeller perforator-based flap isrelatively easy.
umatic soft tissue defect on the middle third of the tibia overrior leg is visible. A skin graft had been performed on the pos-sion and choice of the perforator, the skin island is drawn androximal to the defect, the presence of the external fixator pincould not be removed without compromising bone healing. Thee desire to preserve the superficial sural artery flap as a secondel is visible. (def) Postoperative results. The scarred tissue in-
Table 1 Patients, methods and results
Site Soft tissuedefectdimensions(cm)
Flap design Flapdimensions(cm)
Patient 149 years
Car accident Middle 1/3tibia. Boneexposure
9 16 Posteriorlongitudinalpropeller
10 21 Ext fixator pin.Superficial suralartery flappreserved.(See text)
90 1 AeV From soleusmuscle
Superficialnecrosis offlap tip(scar area).Transientvenouscongestion
Patient 215 years
Achilles tendonrupture and medialmalleolus fracture
7 9 Posteriorlongitudinalpropeller
25 9 Exposure ofAchilles tendonand malleolus.Superficial suralartery flappreserved
180 1 AeV Between FDLand soleusmuscle
Patient 361 years
Car accident Middle 1/3 tibia 7 8 Round 8 9 135 1 AeV Between tibiaand soleusmuscle
Patient 441 years
Lower 1/3 tibia 9 11 Posteriorlongitudinalpropeller
25 12 Previousorthopaedicsurgeries on thetibial fracture
180 1 AeV From soleusmuscle
Patient 563 years
Knee 12 11 Laterallongitudinal
23 11 Multiple scars(gastrocnemiusmuscle flap,prosthesisremoval).Diabetes,vasculopathy.
90 2 AeV Between EDL,PL and TAmuscles
Patient 656 years
Middle 1/3 tibia.Bone fragmentand k-wires removal
15 3 Posteriorpropeller
16 15 135 1 A 1 V From medialgastrocnemiusmuscle
A, arterial perforator; V, venous perforator; FDL, flexor digitorum longus; EDL, extensor digitorum longus; PL, peroneus longus; TA, tibialis anterior.
Propeller flaps for leg reconstruction 781In the propeller flap literature the dissection plane isusually subfascial.19,21 We believe that there is no big dif-ference in flap survival between the fasciocutaneous andadipocutaneous propeller flaps. A difference can be seenin the ease of dissection. Sub-fascial flap raising is fasterand the perforator is more clearly localised and freed.Supra-fascial dissection leaves a less consistent donor sitedefect and makes flap dissection easier at the sites wherethe muscular septa join the muscular fascia.
Microsurgical expertise is usually needed in the vesselsdissection phase, that should be carried out under loupemagnification, in order to preserve the small perforatingvessels and to follow the chosen nourishing vessels for
Figure 2 Patient number 2. (a) Soft tissue defect over the mediasion in search of a perforator preoperatively localised by Doppler.180 rotation. (d) The propeller flap has been completely harvesteperficial sural artery flap as a secondary surgical option. (e) Postopeflap has allowed reconstruction with an adequate contour of the aa short tract into the muscle belly or inside the septa.Special care is needed to accurately release all the fascialadhesions around the perforating artery and vein. Theserigid bands, in fact, can compromise the blood flow,especially the venous drainage, after the torsion of thepedicle during flap rotation.
Due to the fact that the propeller perforator-based flap isa local flap, the characteristics of skin texture and thicknessof the subcutaneous tissue are very similar to the missingones, making debulking and thinning unnecessary.
The morbidity of the donor site is limited to the samearea of the body already affected and it is almost onlycosmetic, the muscle being completely preserved during
l malleolus and damaged Achilles tendon. (b) Exploratory inci-(c) The perforator vessel nourishing the flap. Pivot point of thed and rotated. The skin island was planned to preserve the su-rative results after 6 months. (f) The moderate thickness of thenkle.
782 M. Pignatti et al.the flap harvesting. The donor site is partially covered bythe flap (minor blade of the propeller).
The conditioning factors in planning the flap designare the position and the size of the defect, the exactlocation of the perforator found during dissection, thepresence of external fixator pins, the pre-existing scarsand the need to preserve other useful local flaps forsalvage procedures (especially the superficial sural arteryflap) (Fig. 1).
The amount of donor site that will be directly covered bya portion of the propeller flap strictly depends on the abovementioned factors limiting the skin island design.
Recent studies seem to demonstrate that vascularisedtissue in the form of muscle or non-muscle flaps provide
Figure 3 Patient number 4. (a) Soft tissue defect on the distal texternal fixator was...