Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 2  |  Page : 45-50

Lower limb reconstruction using propeller flaps


Department of Plastic and Reconstructive Surgery, Government Royapettah Hospital, Chennai, Tamil Nadu, India

Date of Web Publication10-Mar-2016

Correspondence Address:
Sridhar Rajagopal
22 Second Street, Kumaran Colony, Vadapalani, Chennai - 600 026, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.178450

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  Abstract 

Background: The islanded pedicled perforator-based propeller design flap is a versatile local flap for reconstruction of defects of lower limbs from knee to leg to ankle to foot.
Patients and Methods: All patients with small-and moderate-sized defects in lower limbs which required a flap cover are included in the study. Between October 2014 and September 2015, prospective study of patients undergoing perforator-based propeller flap procedure was performed. Patients were evaluated for defect size, defect location, procedure done, and donor site cover. Results and complications of the propeller flap were also analyzed. Atotal of eight flaps were done to cover defects of lower limbs.
Results: Out of the eight flaps, seven were islanded on posterior tibial artery, one on the lateral geniculate artery perforator. Four flaps were used to cover lower one-third leg, three for middle one-third leg, and one for knee. The flap dimensions ranged from 3 cm×7 cm to 7 cm×19 cm. The median angle of rotation was 160°(ranging from 60° to 180°). Sixty-three percent of patients had associated fractures. Seven flaps survived completely and one flap had partial necrosis, which was managed with secondary split skin grafting.
Conclusion: The islanded propeller design pedicled perforator flaps provides reliable coverage for small-to medium-sized defects for lower limbs, particularly lower one-third leg defects. This flap can provide an esthetically acceptable result as well.

Keywords: Lower limb defects, perforator, propeller flaps, small to medium size defects


How to cite this article:
Rajagopal S, Rajagopal S, Murugesan S. Lower limb reconstruction using propeller flaps. Nigerian J Plast Surg 2015;11:45-50

How to cite this URL:
Rajagopal S, Rajagopal S, Murugesan S. Lower limb reconstruction using propeller flaps. Nigerian J Plast Surg [serial online] 2015 [cited 2019 Dec 8];11:45-50. Available from: http://www.njps.org/text.asp?2015/11/2/45/178450


  Introduction Top


In 1981, Ponten demonstrated that inclusion of the deep fascia enabled flaps in the lower leg with dimension ratios in excess of 2.5:1 to be harvested safely in an area where skin flaps had traditionally failed.[1] Defects of the distal third of the lower leg, however, continue to present a difficult reconstructive challenge to the reconstructive surgeon, and free flap reconstruction of the lower extremity has been associated with a failure rate as high as 15–20%.[2] Contention also remains as to whether differences in outcomes exist in terms of osteomyelitis, time to union, and rate of nonunion when muscle or fasciocutaneous flaps are used for coverage of open tibial fractures.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] At our institution, we have been using the islanded propeller design perforator flap to cover small to moderate defects of bone or to cover exposed prostheses or tendons.[15],[16] The posterior tibial artery perforators are consistently the largest and easiest to dissect,[17],[18] and the flap may be transposed or islanded and rotated through up to 180° about the perforator, and may be proximally or distally based, enabling reconstruction of a variety of lower limb defects.[19],[20] The posterior tibial artery, which is the dominant source of blood supply to the foot, is preserved, and the need for microvascular anastomoses is obviated.[21],[22] Flap harvest is relatively quick, and the recipient site has similar texture, thickness, pliability, and pigmentation to that which has been lost. V-Y or propeller flap designs may enable primary closure. These flaps are particularly suitable for complicated defects of the lower third of the leg and ankle, where local flap options have previously been challenging.

The term “propeller flap” was introduced in 1991 by Hyakusoku et al.[23] to describe an adipocutaneous flap, based on a random subcutaneous pedicle, with a skin island of a length largely exceeding its width, made of two portions (the blades of the propeller), one at either side of the pedicle. The flap was rotated 90° on the central pedicle, like a propeller, to resurface burn scar contractures at the elbow and axilla. Subsequently, Hallock [24] used the term propeller to define a fasciocutaneous flap that he raised over the adductor compartment of the posterior thigh. The flap was similar in shape to the one described by Hyakusoku et al., but it was based on a skeletonized perforating vessel and the skin island was rotated 180°. By doing this, a part of the flap (the larger blade) was used to resurface the defect, and the other part of the flap (the minor blade) was positioned over the donor site of the larger blade facilitating its direct closure.

Teo [25] greatly contributed to the definition and to the details of the surgical technique of perforator-based propeller flaps. A number of authors reported the application of the perforator propeller concept to the reconstruction of soft-tissue defects in different areas of the body.[26],[27],[28],[29],[30] This article reports our experience of using the islanded propeller design perforator flap for lower limb reconstruction.


  Patients and Methods Top


Between October 2014 and September 2015, eight cases of propeller design islanded perforator flaps were done in our department. Demographic information was collected, as were details of the trauma, peri-operative data, and complications, including flap loss.

Anatomy

In the case of the posterior tibial artery, perforators are each accompanied by two venae comitantes and are predominantly septocutaneous, arising from within the intermuscular septum between the soleus and the flexor hallucis longus.[17],[31] A large flap territory can be raised on a single perforator from the posterior tibial artery because of axial vessels communicating between the posterior tibial artery perforators within the flap.

In the case of lateral geniculate artery, the cutaneous perforator of the superior lateral geniculate artery (SLGA) penetrates the deep fascia 5 cm from the plane of knee joint. The communications between SLGA perforator and the lateral perforators of the profunda femoris artery forms the vascular basis of this flap.[32] Flap harvest does not necessitate the exposure of the artery or skeletonization of the perforator, reducing the risk of damage to the perforator and delicate venae comitantes.

Surgical technique

Preoperatively, the posterior tibial artery perforators are identified and marked on the skin using hand-held Doppler ultrasonography. The flap is designed with respect to the defect and a limited anterior incision as for a fasciotomy is made through which the perforators are identified by direct visualization [Figure 1]. The most reliable perforators are found at 6–8 cm and 10–12 cm from the tip of the medial malleolus, and the flap can be reliably harvested within 10 cm of the popliteal skin crease. If the perforator is of sufficient caliber, the anterior and posterior flap incisions are completed and the flap raised from proximal to distal in the subfascial plane, identifying and preserving all of the perforators encountered, leaving the flap bridges proximally and distally. The largest suitable distal perforator is selected and single clamps are placed on all other perforators. If flap perfusion is reliable, the other perforators are ligated and the proximal incision is made. The flap is only islanded if bleeding at the tip can be demonstrated. Care is taken to preserve the saphenous vein and saphenous nerve. After islanding, the septum around the perforator is gently released to allow rotation of the flap up to 180° without occluding the pedicle. The donor site may be closed directly, but often requires application of a split-thickness skin graft.
Figure 1:(a) Lower one-third leg defect (b) X-ray showing fracture and ilizarov fixator (c) intraoperative view showing perforator (d) immediate postoperative view (e) 2 months postoperative view revealing excellent esthetic outcome and good contour

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In the case of SLGA perforator flap, skin island is designed in the lateral aspect of lower thigh. The distal end of flap must cover skin over the lateral condyle of femur so that the SLGA perforator will be included. Midpoint between greater trochanter and lateral condyle of femur forms the proximal limit of flap [Figure 2].
Figure 2:(a) Unstable scar with knee defect (b) markings for superior lateral geniculate perforator and flap (c) intraoperative view (d) 6 months follow-up (e) lateral view (f) medial view

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Contraindications

Contraindications to the use of the islanded posterior tibial artery perforator flap included suspicion of injury to the posterior tibial artery or lateral genicular artery or presence of a degloving injury. Where in doubt, the wound should be explored with a backup plan (free flap) should conditions be unfavorable for local flap options.


  Results Top


Seven flaps were islanded on a single perforator from the posterior tibial artery and one based on SLGA perforator. The mean age was 37.6 years (range, 25–48 years) and all patients were men. High-energy injuries occurred in 60% of patients, and 25% of flaps were harvested for chronic osteomyelitis or unstable scarring, [Table 1]. Fifty percent of defects were at the lower third of the leg, 37.5% were at the middle third of leg, and 12.5% in knee [Table 2]. Sixty-three percent of flaps were associated with fractures. The flap dimensions ranged from 3 cm×7 cm to 7 cm×19 cm. The median angle of rotation of the flap about the perforator was 160°(range, 60–180°). The mean operation duration was 2 h and the mean hospital stay was 12 days (range 10–14 days). Donor site was covered with split thickness skin graft in 75% of cases and primary closure in 25% of cases.{Table 1}{Table 2}

Complications

One patient had partial flap loss [Figure 3]. Cigarette smoking and peripheral vascular disease were associated with partial flap loss. In the case of partial flap loss, secondary split thickness skin graft was used to reconstruct the defect.
Figure 3:(a) Osteomyelitis with exposed bone (b) X-ray showing osteomyelitis (c) clamp in one of the perforators (d) immediate postoperative, donor site closed primarily (e) partial flap loss in a smoker (f) flap loss managed with secondary split skin autograft

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  Discussion Top


This article reports our 1year experience of using the islanded propeller design perforator flap for lower limb reconstruction. The flap may be rotated through up to 180°, and the distal perforators, in particular, can be used for coverage of defects of the knee, Achilles tendon [Figure 4], and distal two-thirds of the tibia [Figure 5], where there have previously been few reliable local flap options. In this series, the median angle of rotation of the flap about the perforator was 160°(range, 60–180°).
Figure 4:(a) Preoperative view tendoachilles region defect (b) perforator isolated (c) postoperative view (d) postoperative with good contour

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Figure 5:(a) Osteomyelitis leg (b) X-ray showing osteomyelitis (c) osteomyelitis leg after debridement with cavity (d) perforator identified (e) donor sit covered with split skin autograft (f) de-epithelialized distal part to fill bony defect (g) after flap inset (h) long-term postoperative image flap (i) long-term postoperative image donor site

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Flap harvest is relatively quick, and the recipient site has similar texture, thickness, pliability, and pigmentation to that which has been lost, and without sacrificing muscle. Alarge flap territory can be raised on a single perforator because of extensive axial communications between the perforators within the flap,[18] and the flap can be reliably harvested to within 10 cm of the popliteal skin crease. The posterior tibial artery, which is the dominant source of blood supply to the foot, is preserved, and the need for microvascular anastomoses is obviated. Preservation of the posterior tibial artery avoids the risk of complications, including transient ankle edema and vascular insufficiency.[20],[21] Key requirements for soft-tissue reconstruction in the lower leg include provision of a stable bony framework and vessels outside the zone of injury. Both muscle and fasciocutaneous flaps have their limitations and indications for reconstruction of the leg. Muscle flaps fill complex three-dimensional defects and provide well-vascularized tissue that may have the advantage of controlling bacterial inoculation in heavily contaminated or chronically infected wounds.[5],[6],[7] Fasciocutaneous flaps are indicated for the coverage of shallow wounds and can restore contour and, when based on a single perforator, may have enhanced perfusion properties that may be advantageous in controlling local bacterial load.[8],[9],[33] In the lower third of the leg, thin and pliable soft-tissue coverage is required to achieve a satisfactory esthetic outcome.

Although experimental evidence would suggest a superiority of using muscle flaps in terms of osteomyelitis, time to union, and rate of nonunion, clinical studies have largely failed to demonstrate a difference,[1],[34],[35],[36] which may be attributable to adequate debridement reducing the bacterial load of the wound. Yazar et al. compared outcomes in 98 free muscle flaps and 79 free fasciocutaneous flaps for reconstruction of the lower third of the leg for open tibial fractures and found no statistically significant differences between the two flaps, with a complete flap failure rate of 7.1% and 8.9%, respectively; a postoperative infection rate of 11.2% compared with 12.7%; and chronic osteomyelitis in 9.3% and 12.7%, respectively.[4] Mean time to bony union was 11.4 months for muscle flaps and 13.3 months for fasciocutaneous flaps. Rodriguez et al. performed a long-term outcome study comparing 20 patients with anterolateral thigh perforator flaps with 22 patients with muscle flaps for lower limb salvage. They found that time to bony union, union in the presence of infection, and infection after flap surgery were not related to flap type.[14] In this study, there was a 12.5% partial flap failure rate, which is comparable to that currently reported for free flap reconstruction. However, if patients who were smokers or peripheral vascular disease were excluded from the analysis, the flap failure was nil. In this study, 75% of patients required split skin grafting for donor site. For this reason, we avoid using this flap in young women and have a preference for using free fasciocutaneous flap coverage to achieve good contour.


  Conclusion Top


The islanded propeller design posterior perforator flap is a useful addition to the reconstructive surgical techniques available for defects of the lower limb. This flap provides reliable coverage for small-to medium-sized defects for lower limbs, particularly lower one-third leg defects. This flap can provide an esthetically acceptable result as well.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pontén B. The fasciocutaneous flap: Its use in soft tissue defects of the lower leg. Br J Plast Surg 1981;34:215-20.  Back to cited text no. 1
    
2.
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Small JO, Mollan R A. Management of the soft tissues in open tibial fractures. Br J Plast Surg 1992;45:571-7.  Back to cited text no. 3
    
4.
Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006;117:2468-75.  Back to cited text no. 4
    
5.
Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plast Reconstr Surg 1982;70:1-10.  Back to cited text no. 5
    
6.
Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: Experimental and clinical correlation. Plast Reconstr Surg 1982;69:815-29.  Back to cited text no. 6
    
7.
Eshima I, Mathes SJ, Paty P. Comparison of the intracellular bacterial killing activity of leukocytes in musculocutaneous and random-pattern flaps. Plast Reconstr Surg 1990;86:541-7.  Back to cited text no. 7
    
8.
Guerra AB, Gill PS, Trahan CG, Ruiz B, Lund KM, Delaune CL, et al. Comparison of bacterial inoculation and transcutaneous oxygen tension in the rabbit S1 perforator and latissimus dorsi musculocutaneous flaps. J Reconstr Microsurg 2005;21:137-43.  Back to cited text no. 8
    
9.
Gravvanis A, Tsoutsos D, Karakitsos D, Iconomou T, Papadopoulos O. Blood perfusion of the free anterolateral thigh perforator flap: Its beneficial effect in the reconstruction of infected wounds in the lower extremity. World J Surg 2007;31:11-8.  Back to cited text no. 9
    
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Verhelle N, Vranckx J, Van den Hof B, Heymans O. Bone exposure in the leg: Is a free muscle flap mandatory? Plast Reconstr Surg 2005;116:170-7.  Back to cited text no. 10
    
11.
Arnold PG, Yugueros P, Hanssen AD. Muscle flaps in osteomyelitis of the lower extremity: A 20-year account. Plast Reconstr Surg 1999;104:107-10.  Back to cited text no. 11
    
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Gayle LB, Lineaweaver WC, Oliva A, Siko PP, Alpert BS, Buncke GM, et al. Treatment of chronic osteomyelitis of the lower extremities with debridement and microvascular muscle transfer. Clin Plast Surg 1992;19:895-903.  Back to cited text no. 12
    
13.
Anthony JP, Mathes SJ, Alpert BS. The muscle flap in the treatment of chronic lower extremity osteomyelitis: Results in patients over5 years after treatment. Plast Reconstr Surg 1991;88:311-8.  Back to cited text no. 13
    
14.
Rodriguez ED, Bluebond-Langner R, Copeland C, Grim TN, Singh NK, Scalea T. Functional outcomes of posttraumatic lower limb salvage: A pilot study of anterolateral thigh perforator flaps versus muscle flaps. J Trauma 2009;66:1311-4.  Back to cited text no. 14
    
15.
Erdmann MW, Court-Brown CM, Quaba AA. Afive year review of islanded distally based fasciocutaneous flaps on the lower limb. Br J Plast Surg 1997;50:421-7.  Back to cited text no. 15
    
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Quaba O, Quaba A. Pedicled perforator flaps for the lower limb. Semin Plast Surg 2006;20:103.  Back to cited text no. 16
    
17.
Schaverien M, Saint-Cyr M. Perforators of the lower leg: Analysis of perforator locations and clinical application for pedicled perforator flaps. Plast Reconstr Surg 2008;122:161-70.  Back to cited text no. 17
    
18.
Heymans O, Verhelle N, Peters S. The medial adiposofascial flap of the leg: Anatomical basis and clinical applications. Plast Reconstr Surg 2005;115:793-801.  Back to cited text no. 18
    
19.
Shalaby HA. The blood supply of the posterior tibial perforator-based flap. Plast Reconstr Surg 1994;93:440.  Back to cited text no. 19
    
20.
Koshima I, Moriguchi T, Ohta S, Hamanaka T, Inoue T, Ikeda A. The vasculature and clinical application of the posterior tibial perforator-based flap. Plast Reconstr Surg 1992;90:643-9.  Back to cited text no. 20
    
21.
Liu K, Li Z, Lin Y, Cao Y. The reverse-flow posterior tibial artery island flap: Anatomic study and 72 clinical cases. Plast Reconstr Surg 1990;86:312-6.  Back to cited text no. 21
    
22.
Satoh K, Sakai M, Hiromatsu N, Ohsumi N. Heel and foot reconstruction using reverse-flow posterior tibial flap. Ann Plast Surg 1990;24:318-27.  Back to cited text no. 22
    
23.
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24.
Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg 2006;56:540-2.  Back to cited text no. 24
    
25.
Teo TC. Perforator local flaps in lower limb reconstruction. Cir Plast Ibero Lat Am 2006;32:15-6.  Back to cited text no. 25
    
26.
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27.
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29.
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30.
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31.
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32.
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33.
Rubino C, Coscia V, Cavazzuti AM, Canu V. Haemodynamic enhancement in perforator flaps: The inversion phenomenon and its clinical significance. A study of the relation of blood velocity and flow between pedicle and perforator vessels in perforator flaps. J Plast Reconstr Aesthet Surg 2006;59:636-43.  Back to cited text no. 33
    
34.
Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am 1991;73:1316-22.  Back to cited text no. 34
    
35.
Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg Am 2000;82-A: 1681-91.  Back to cited text no. 35
    
36.
Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000;82:959-66.  Back to cited text no. 36
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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