Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 777e783

Propeller flaps for leg reconstruction

Marco Pignatti*, Monica Pasqualini, Maurizio Governa,Massimiliano Bruti, Gino Rigotti

Plastic Surgery and Burn Unit, Azienda Ospedaliera di Verona, Italy

Received 7 June 2007; accepted 25 October 2007

KEYWORDSPropeller;Perforator flap;Lower limb;Leg reconstruction

* Corresponding author. Address: UPlastica e Centro Ustioni, Ospedale Cidaliera di Verona, Piazzale Stefani 1, 3045 8122189; fax: þ39 045 8123258.

E-mail address: marco_pignatti@e

1748-6815/$-seefrontmatterª2008Britdoi:10.1016/j.bjps.2007.10.077

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-conspicuous, only cosmetic, donor site defect. No flap necrosis was observed, with the excep-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 highsuccess rate and good cosmetic results without functional impairment. In the light of this theycan be considered among the first surgical choices to resurface complex soft tissue defects ofthe leg.ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

nita Operativa di Chirurgiavile Maggiore, Azienda Ospe-7126 Verona, Italy. Tel.: þ39

mail.it (M. Pignatti).

ishAssociationofPlastic,Reconstruc

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).

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

778 M. Pignatti et al.

The 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 reconstructivemethods through the use of pedicled perforator flaps indifferent 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 90�16e18 to

180�,19e21 around the fixed point of the perforatorvessel.� The donor site defect is partially covered with the

tissue 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). Fivepatients weremale. Four of the male patients presented withpost-traumatic tibial fracture exposure and the fifth male(Patient 2) had a post-traumatic malleolar fracture with wideexposure and disruption of the Achilles tendon (Fig. 2).

The female patient had undertaken, elsewhere, severalorthopaedic surgical procedures for infection of a knee

prosthesis. 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.

Surgical technique

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.

Results

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).

Figure 1 Patient number 1. (a) Preoperative view of the post-traumatic soft tissue defect on the middle third of the tibia overthe central bone fragment. The de-epithelialised area of the posterior leg is visible. A skin graft had been performed on the pos-terior leg 12 days before flap surgery. (b) After an exploratory incision and choice of the perforator, the skin island is drawn andincised. Note the scarred area on the proximal posterior leg and, proximal to the defect, the presence of the external fixator pinkeeping in site the central fragment of the fractured tibia. The pin could not be removed without compromising bone healing. Theflap design in this case was influenced by these two factors and by the desire to preserve the superficial sural artery flap as a secondsurgical option. (c) The flap is harvested, and the perforating vessel is visible. (def) Postoperative results. The scarred tissue in-cluded at the tip of the flap underwent superficial necrosis.

Propeller flaps for leg reconstruction 779

Discussion

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 like’3), leave themost inconspicuous donor site defect possible, and beperformed without compromising other body regions.

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.

Table 1 Patients, methods and results

Patientsand age(years)

Trauma/aetiology

Site Soft tissuedefectdimensions(cm)

Flap design Flapdimensions(cm)

Details Rotationdegrees

Number ofperforators

Perforatoremerging site

Flapcomplications

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

Motorcycleaccident

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

Transientvenouscongestion

Patient 441 years

Motorcycleaccident

Lower 1/3 tibia 9� 11 Posteriorlongitudinalpropeller

25� 12 Previousorthopaedicsurgeries on thetibial fracture

180 1 AeV From soleusmuscle

Patient 563 years

Knee prosthesisinfection

Knee 12� 11 Laterallongitudinal

23� 11 Multiple scars(gastrocnemiusmuscle flap,prosthesisremoval).Diabetes,vasculopathy.

90 2 AeV Between EDL,PL and TAmuscles

Patient 656 years

Motorcycleaccident

Middle 1/3 tibia.Bone fragment

and k-wires removal

15� 3 Posteriorpropeller

16� 15 135 1 Aþ 1 V From medialgastrocnemiusmuscle

A, arterial perforator; V, venous perforator; FDL, flexor digitorum longus; EDL, extensor digitorum longus; PL, peroneus longus; TA, tibialis anterior.

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Figure 2 Patient number 2. (a) Soft tissue defect over the medial malleolus and damaged Achilles tendon. (b) Exploratory inci-sion in search of a perforator preoperatively localised by Doppler. (c) The perforator vessel nourishing the flap. Pivot point of the180� rotation. (d) The propeller flap has been completely harvested and rotated. The skin island was planned to preserve the su-perficial sural artery flap as a secondary surgical option. (e) Postoperative results after 6 months. (f) The moderate thickness of theflap has allowed reconstruction with an adequate contour of the ankle.

Propeller flaps for leg reconstruction 781

In 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 vessels’dissection phase, that should be carried out under loupemagnification, in order to preserve the small perforatingvessels and to follow the chosen nourishing vessels for

a 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

Figure 3 Patient number 4. (a) Soft tissue defect on the distal third of the tibia with the exposed osteosynthesis plate. (b) Anexternal fixator was positioned, the plate was removed and all non-viable tissue was debrided, leaving a wide defect over the tibialfracture. (c, d) The flap is harvested. The perforating vessel is visible. (e, f) Early postoperative results.

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

viable options for wound coverage of osteomyelitis defectsfollowing adequate surgical debridement.22

Perforator-based propeller flaps are simpler and lessfunctionally compromising compared with muscular flapsand can be chosen to cover soft tissue defects even overinfected bones and tendons.

As already stated by Taylor in 1987,6 the position andcalibre of cutaneous perforators are highly variable be-tween individuals and often asymmetric even in the sameindividual.

Pre-operative Doppler flowmetry is often used to rapidlyidentify the perforating vessels in the anatomical area ofinterest. However, the procedure is operator dependent,time-consuming, and not always accurate in localising the

Propeller flaps for leg reconstruction 783

perforating vessels.23,24 Therefore, Doppler evaluationcould be limited to confirm intraoperatively the choice ofthe perforator vessel performed under direct visualisationduring the dissection.

Other imaging methods (Doppler ultrasound,23 andmultislice CT angiography25) are used worldwide to preop-eratively localise the vessels in perforator flap surgery.However, in our small series, we did not feel the need forsuch investigations.

In conclusion, propeller flaps allow the coverage of widedefects, thanks to the large skin islands that can safely beharvested on a single perforator, and to their remarkableexcursion granted by the pedicle dimensions.

In our view, the relatively simple surgical technique andthe good cosmetic and functional results make the pro-peller flaps an excellent choice to resurface complex softtissue defects of the leg.

References

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2. Kroll SS, Rosenfield L. Perforator-based flaps for low posteriormidline defects. Plast Reconstr Surg 1988 Apr;81:561e6.

3. Blondeel P, Van Landuyt K, Monstrey S, et al. The Gent consen-sus on perforator flap terminology: preliminary definitions.Plast Reconstr Surg 2003;112:1378e82.

4. Asko Seljavaara S. In: Abstracts seventh congress of the inter-national society of reconstructive microsurgery. New York;1983.

5. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg2004 Sep 15;114:910e6.

6. Taylor GI, Palmer JH. The vascular territories (angiosomes) ofthe body: experimental study and clinical applications. Br JPlast Surg 1987;40:113e41.

7. Taylor GI. The angiosomes of the body and their supply toperforator flaps. Clin Plast Surg 2003;30:331e42.

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9. Tanaka K, Matsumura H, Miyaki T, et al. An anatomic study ofthe intermuscular septum of the lower leg; branches fromthe posterior tibial artery and potential for reconstruction ofthe lower leg and the heel. J Plast Reconstr Aesthet Surg2006;59:835e8 [Epub 2006 Feb 21].

10. Rehman N, Kannan RY, Hassan S, et al. Thoracodorsal arteryperforator (TAP) type I V-Y advancement flap in axillary hidra-denitis suppurativa. Br J Plast Surg 2005 Jun;58:441e4.

11. Kim DY, Cho SY, Kim KS, et al. Correction of axillary burn scarcontracture with the thoracodorsal perforator-based cutane-ous island flap. Ann Plast Surg 2000 Feb;44:181e7.

12. Roche NA, Van Landuyt K, Blondeel PN, et al. The use of ped-icled perforator flaps for reconstruction of lumbosacraldefects. Ann Plast Surg 2000;45:7e14.

13. Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforatorflaps in breast reconstruction: a new concept. Br J Plast Surg2004;57:531e9.

14. Van Landuyt K, Hamdi M, Blondeel P, et al. Autologous breastaugmentation by pedicled perforator flaps. Ann Plast Surg2004 Oct;53:322e7.

15. Milton SH. Pedicled skin flaps: the fallacy of the length:widthratio. Br J Surg 1970;57:502e8.

16. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flapmethod. Br J Plast Surg 1991;44:53e4.

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18. Murakami M, Hyakusoku H, Ogawa R. The multilobed propellerflap method. Plast Reconstr Surg 2005 Aug;116:599e604.

19. Hallock GG. The propeller flap version of the adductor muscleperforator flap for coverage of ischial or trochanteric pressuresores. Ann Plast Surg 2006 May;56:540e2.

20. Masia J, Moscatiello F, Pons G, et al. Our experience in lowerlimb reconstruction with perforator flaps. Ann Plast Surg2007 May;58:507e12.

21. Moscatiello F, Masia J, Carrera A, et al. The ‘propeller’ distalanteromedial thigh perforator flap. Anatomic study and clinicalapplications. J Plast Reconstr Aesthet Surg; 2007 May 10 [Epubahead of print].

22. Salgado CJ, Mardini S, Jamali AA, et al. Muscle versusnonmuscle flaps in the reconstruction of chronic osteomyelitisdefects. Plast Reconstr Surg 2006 Nov;118:1401e11.

23. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetryin the planning of perforator flaps. Br J Plast Surg 1998 Apr;51:202e9.

24. Yu Peirong, Youssef Adel. Efficacy of the handheld doppler inpreoperative identification of the cutaneous perforators inthe anterolateral thigh flap. Plast Reconstr Surg 2006;118:928.

25. Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, et al. Preopera-tive planning of deep inferior epigastric artery perforator flapreconstruction with multislice-CT angiography: imaging find-ings and initial experience. J Plast Reconstr Aesthet Surg2006;59:585e93.