|Year : 2016 | Volume
| Issue : 3 | Page : 580-586
The assessment of the clinical applications of propeller flaps of the lower leg
Tarek F Kishk, Ahmed M Elbarah, Yasser M Elsheikh, Waleed S Abd El Sadek
Department of Plastic, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||03-Sep-2015|
|Date of Acceptance||20-Sep-2015|
|Date of Web Publication||23-Jan-2017|
Waleed S Abd El Sadek
Beni Suif, 62511
Source of Support: None, Conflict of Interest: None
The aim of the present study was to assess the clinical applications of the various propeller perforator flaps for the leg in an attempt to evaluate the results and propose an algorithm for the management of various defects of the lower-third of the leg.
The ideal method for the soft-tissue reconstruction of the leg should be reliable, relatively easy to perform, offer viable tissues similar in skin texture and thickness to the lost ones (replace like with like), leave the most inconspicuous donor-site defect possible, and be performed without compromising other body parts. The perforator-based propeller flaps have all these advantages.
Patients and methods
This study included 34 patients who presented with moderate-sized leg defects from August 2013 to June 2015. Out of the 34 patients, 24 were males and 10 were females. Their ages varied from 5 to 50 years with an average age of 27 years. There were 19 posterior tibial artery perforator flaps. There were 12 flaps based on perforators of the peroneal artery. Lastly, there were three anterior tibial artery perforator flaps. Duplex ultrasonography was carried out for 25 patients preoperatively.
All flaps were based on a single perforator except three cases in which the flaps were based on two adjacent perforators. Fourteen of the flaps were proximally based and 20 were distally based. All flaps were designed as propeller flaps and were rotated from 70° to 180°. The donor site was closed by using split-thickness grafts in all except three cases in which the donor site was closed primarily. Out of the 19 flaps of the posterior tibial artery, 11 (57.5%) healed uneventfully and eight (42.5%) cases were complicated. Out of the 12 peroneal artery propeller flaps, nine (75%) flaps healed uneventfully and three (25%) cases were complicated. Lastly, out of the three cases of the anterior tibial artery propeller flaps, one (33%) healed uneventfully and two (66%) were complicated.
Propeller flaps based on perforator vessels are raising interest in the reconstructive surgery of the limbs. These flaps allow efficient coverage of large wounds without the need to sacrifice a major vascular axis. The operative technique does not require microvascular anastomosis and allows the reconstruction of soft-tissue defects using nearby similar tissues. The aim of this study was to evaluate the clinical results of propeller perforator flaps in the treatment of various lower-leg defects.
Keywords: clinical application, lower leg, propeller perforator flaps
|How to cite this article:|
Kishk TF, Elbarah AM, Elsheikh YM, Abd El Sadek WS. The assessment of the clinical applications of propeller flaps of the lower leg. Menoufia Med J 2016;29:580-6
|How to cite this URL:|
Kishk TF, Elbarah AM, Elsheikh YM, Abd El Sadek WS. The assessment of the clinical applications of propeller flaps of the lower leg. Menoufia Med J [serial online] 2016 [cited 2020 Apr 8];29:580-6. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/580/198717
| Introduction|| |
The pioneers of plastic surgery accepted that flap designs that worked well elsewhere on the body commonly failed when applied to soft-tissue defects on the lower limb, because of the paucity of soft tissue in the leg, especially the lower-third of the leg. Traditional advice was to avoid local flaps below the knee unless the defects were small or the surgeon was prepared to use special techniques such as delay incisions  . Reconstructive surgeons relied on cross-leg flaps and flaps transferred from a distance using the tube pedicle technique. Muscle flaps such as the gastrocnemius and soleus flaps allowed for an effective coverage of the upper and middle-thirds of the leg, respectively. However, they are associated with considerable donor-site morbidity  .
Unfortunately, the area least served by these muscle flaps is the lower-third of the leg. The fasciocutaneous flap reported by Ponten in 1981 showed that long narrow flaps could be safely raised below the knee as long as the deep fascia was included. The concept of fasciocutaneous flaps showed that long flaps can safely stretch the length to the width ratio of random pattern flaps from 1: 1 to 3: 1  .
However, local fasciocutaneous flaps were still unable to cover larger soft-tissue defects of the lower-third of the leg. Other flaps such as the cross-leg flap were used. However, cross-leg flaps require prolonged bed rest and the adoption of uncomfortable postoperative positions. They are also very difficult to use in the presence of external fixation to treat associated bone fractures, and may give rise to articular restrictions because of long immobilization. The role of cross-leg flaps has been recently restricted to very difficult cases in which local flap tissues are limited and free-flap coverage is unavailable or has failed  .
Later, with the advent of microsurgery, it became a common practice to use free flaps as a first choice in covering difficult lower-third leg defects. Although free flaps offer an excellent solution for covering wide defects of the lower leg with massive loss of tissue, special microvascular facilities are required, and long operating times limit their availability as a method of coverage  .
Recent advances in the study of fasciocutaneous flaps, with better understanding of their blood supply, led to the development of alternative flaps in the leg to the traditional, rigid, proximally-based designs. Of particular significance was the description of the septocutaneous vessels of the leg and the extension of the concepts of reverse flow and distally-based flaps to the leg  .
Rather than sacrificing the whole vascular axis in the process of transferring a flap, it was soon appreciated that flaps could be based on a single septocutaneous perforator of one of the main vessels of the leg such as the tibial or peroneal perforators. Surgeons who realized the importance of perforators began to preserve the myocutaneous or septocutaneous perforators when designing new flaps. Donski and Fogdestam  demonstrated that such long flaps could just as safely be based distally on the lower peroneal perforators and used for reconstruction of defects around the lower-third of the leg.
Perforator flaps represent the latest milestone in the evolution of reconstructive flap surgery. Knowledge of the vascular anatomy of perforators throughout the body has advanced to the point that any skin flap can be safely harvested as long as it incorporates a perforator vessel that can be dissected  .
Aim of the work
The aim of the present study was to assess the clinical applications of the various propeller perforator flaps for the leg in an attempt to evaluate the results and propose an algorithm for the management of various lower-third leg defects.
| Patients and methods|| |
This study included 34 patients with moderate-sized leg defects who presented to Menoufia University Hospital in the period from August 2013 to June 2015. Out of the 34 patients, 24 were males and 10 were females. Their ages varied from 5 to 50 years with an average of 27 years.
All patients signed a written consent, and the approval for the study was obtained from the research ethical committee.
History taking and general examination were conducted for all patients to detect any comorbidity such as diabetes or steroid intake. Only four patients were found to be diabetic.
All the defects were due to road traffic accidents except two patients who had gunshot injuries, one patient who suffered high energy electric burn, and four patients who had chronic nonhealing wounds.
All patients were examined for the site, size, and extent of the defect. Floor of the defect was examined for exposed bone, fractures, or exposed tendons. All the defects were examined to evaluate the different possible options for coverage.
- Post-traumatic defects of the leg.
- Postphlebitic limb
- Ischemic limb.
- All patients were photographed preoperatively
- Plain radiographies for concomitant bone fractures were carried out
- Hand-held Doppler was used for the identification and marking of the perforators near the raw area. The perforators most prominent and closest to the raw area were selected
- Color duplex ultrasonography was used in 25 patients for whom the results of the hand-held Doppler examination were not conclusive
- Angiocomputed tomography has been shown to obtain more accurate anatomical findings than has Doppler sonography. Three-dimensional images of microvascular anatomical vessels can provide a better understanding of how skin is perfused and may aid in the future design of new flaps, but because of its cost benefit, exposure to radiation, and risk for allergic reaction, the Doppler was our preferable tool: it is easy to use and shows a colored picture, which helps us to know the number and direction and diameter of the selected perforator.
Posterior tibial artery perforator flap: 19 flaps
Preoperative identification of the perforators using a Doppler probe was helpful. The perforators were fairly constant and a large perforator was usually located around a point in the middle of a line drawn between the medial malleolus and the medial tibial plateau. This territory lies over the medial calf between the greater and lesser saphenous veins. The flap can be safely designed to cover large defects, with the largest flap in our study being 20 × 14 cm based on a single perforator. Greater saphenous vein was marked preoperatively and was included in the flap design when appropriate. After marking the approximate location of the perforator, a preliminary flap design was made.
The flap was raised with the patient in the supine position and under tourniquet control. An incision was made along the posterior border of the flap and was extended down to the deep fascia, exposing the muscles of the deep posterior compartment. The fascia was reflected anteriorly exposing the intramuscular septum where the exact location of the perforators could be verified. It was not necessary to expose the posterior tibial vessels or skeletonize the perforators. The design and size of the flaps were adjusted according to the size of the defect and the position of the discovered perforator. Elevation of the flap proceeded at the subfascial level by incising through the anterior and superior margins.
Dissection proceeded from the proximal to distal through the depth of the intramuscular septum until the previously marked perforator was reached. The septum distal to the site of the perforator can also be incised to facilitate transposition. This latter maneuver was not necessary with a flap transposition of 30°-45° (five patients). However, with 90°-180° rotation (14 patients), complete islanding was done.
Using the same principles, propeller flaps were designed on a single perforator in which the longer proximal limb was rotated into the defect, while the shorter distal limb was rotated proximally to decrease the size of the donor site, or allow for the primary closure, which was done in two cases. The tourniquet was released before completely islanding the flap.
Anterior tibial artery perforator flap: three flaps
The flap was designed over the anterolateral aspect of the leg, in accordance with the site of the defect and the site of the anterior tibial artery perforators that were identified preoperatively. The flap was raised with the patient in the supine position under tourniquet control. The lateral border of the flap was raised first until the anterior tibial artery perforators could be identified. The flap design was later modified according to the actual site of the perforator. The medial and proximal borders of the flap were then incised and the flap was raised in the subfascial plane.
Flaps based on the perforators of the peroneal artery: 12 flaps
The flap was designed over the anterolateral aspect of the leg, in accordance with the site of the defect and the site of the peroneal perforators that were identified preoperatively. The flap was raised with the patient in the supine position under tourniquet control. First, the lateral border of the flap was raised until the marked perforators could be visualized. The flap design was later modified according to the actual site of the perforators. The most prominent perforators closest to the site of the defect were used; other perforators were killed. The medial and proximal borders of the flap were then incised and the flap was raised in the subfascial plane. The superficial peroneal nerve was encountered in the lower part of the leg and it was preserved. For 10 cases, a propeller flap was designed over a single perforator of the peroneal artery and rotated 150°-180° to cover a defect over the lower-third of the leg.
Light dressing was applied to all flaps, with a window for flap monitoring.
The skin paddle of the flap was observed starting at 6 h postoperatively, then every 12 h for the first 48 h, and then once every day.
The patient's leg was elevated. Special precaution was taken to ensure that there was no pressure applied over the site of the pedicle.
All patients received third-generation cephalosporin intraoperatively and for 7 days postoperatively.
Split-thickness grafts were uncovered on the third postoperative day. This was followed by repeated dressing every other day.
- Complications of flap viability:
- Flap necrosis.
- Hematoma formation
- Seroma formation
The early signs of flap necrosis were monitored, signs such as the following.
- Lowering of temperature
- Fine shrinkage of the epidermis at the distal part
- Appearance of small blisters
- Dark blood on pin prick.
Criteria for the evaluation of results
- Flap viability
- Color duplex ultrasonography
All patients were photographed immediately postoperatively, every 24 h for the first 3 or 5 days postoperatively.
Sutures were removed after 3 weeks.
Patients were followed up for a period of 4-12 weeks. The flaps were evaluated as regards achieving the preoperative goal of coverage of the soft-tissue defects, limb function, and patient satisfaction.
| Results|| |
Out of the 19 flaps that were based on the posterior tibial artery, all were based on a single perforator except three cases that were based on two adjacent perforators.
Five flaps were proximally based; 14 were distally based.
All flaps were designed as propeller flaps that were rotated from 70° to 180°. The donor site was closed by split-thickness grafts in all cases except three cases in which the donor site was closed primarily.
Out of the 19 flaps of the posterior tibial artery, 10 (52.6%) healed uneventfully and nine (47.3%) cases were complicated.
Five cases had loss of the distal 2 cm of the flap, but no further surgical intervention was necessary. Another case had loss of the dermis with healthy granulation tissue underneath, which was covered after 3 weeks by using split-thickness graft. In addition, two cases had loss of distal-half of the flap.
There was a complete loss of one flap. The patient was diabetic. Congestion appeared on the first postoperative day and was not relieved by heparin soaks and nitroglycerin patches. Complete sloughing of the flap occurred on the fourth postoperative day. The defect was covered by using a vacuum-assisted closure device for two cycles, and then by using split-thickness skin graft after 2 weeks.
Out of the 12 peroneal artery propeller flaps, nine (75%) flaps healed uneventfully and three cases were complicated with partial loss of the dermis, for which frequent dressings were used until secondary intention was achieved defect ([Figure 1], [Figure 2], [Figure 3]).
|Figure 1: Patient 1: (a) preoperative picture of the degloved skin. (b) Interoperative picture of the most distal two perforates. (c) Adipofascial propeller flap after rotation. (d) Meshed split-thickness skin grafts 2: 1 were used for coverage. (e) Postoperative after 3 weeks.|
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|Figure 2: Patient 2: (a) exposed lateral malleolus and the defect was about 7 × 5 cm. (b) A color dupplex displayed two peroneal artery perforators (c) intraoperative. (d) The peroneal artery perforator propller flap was (10 × 6 cm) rotated 145° (e) after 3 weeks.|
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|Figure 3: Pateint 3: (a) with degloved skin over the lower 9 cm of the right tibia, (b) the wound was clean. (c) A color duplex ultrasonography displays ATA perforator. (d) An intraoperative demonstration of the ATA perforator adjacent to the defect (8 × 6 cm). (e) The ATA perforator flap was rotated 80° (f) after 2 weeks. ATA, anterior tibial artery.|
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| Discussion|| |
Soft-tissue defects and compound fractures of the leg have always presented difficulty to the reconstructive surgeon. This is more evident in the lower-third of the leg. This is due to the paucity of soft tissue in the lower-third of the leg, making the available options for soft-tissue coverage limited. Many options exist for the coverage of upper and middle-third defects including muscle flaps such as gastrocnemius flaps for the upper-third and soleus flaps for the middle-third. However, the use of muscle flaps leads to functional donor-site morbidity in an already traumatized limb. Fasciocutaneous flaps have also been used successfully. However, in the lower-third of the leg, the limited soft tissue available has led many surgeons to consider free flaps as the first choice for coverage  .
Free flaps, especially free anterolateral thigh flaps, can be reliably harvested without incurring serious donor morbidity. They possess workhorse attributes (no repositioning, remote from defect, and long pedicle) and are extremely versatile, making them ideal for the heterogeneous group of extensive soft-tissue head and neck defects  .
But free flaps are not readily available to all cases. Special training in microvascular surgery, highly equipped operating theaters, long operating times, which may not be feasible for older patients with several comorbidities, and the high cost of such surgeries are all factors that limit the availability of free flaps as an option for coverage. Special consideration to the coverage of leg defects with free flaps is the possibility of the initial trauma injuring the blood vessels around the site of the defect making microvascular anastomosis, especially venous anastomosis, increasingly difficult  .
Also drawbacks of free flap for the lower leg usage the posterior tibial, anterior tibial and peroneal vessels as recipient vessels were considered drawbacks of free flap for the lower leg usage  .
Since the concept of propeller flaps was first applied by Hyakusoku and colleagues to release scar contracture, the flap has been widely applied to cover defects all over the body. Application of the propeller flap design permits greater flexibility and versatility in the coverage of difficult wounds  .
It has recently become popular in the reconstruction of the lower extremities, because of advantages such as having a reliable blood supply while sparing the major blood vessel, no need for microvascular anastomosis, and the flap being thin and pliable for soft-tissue cover in areas like the lower-leg and ankle where bulk is undesirable. In addition, its greater rotation arch makes it popular for distal lower-leg reconstruction  .
In the current study, perforator flaps have been used to cover defects in 34 cases in the lower-third of the leg. Defects over the medial and lateral malleolus and the heel were also covered by using perforator flaps.
Flaps based on the posterior tibial artery up to 15 × 8 cm were safely elevated on a single perforator. Rotation of up to 180° can be allowed as long as the flap is based on a single perforator, with adequate dissection of the fascia surrounding the perforator to allow free rotation of the flap. Similarly flaps can be raised along the anterolateral aspect of the leg based on the perforators of the anterior tibial artery and the peroneal artery.
The concept of free-style perforator flaps allows the design of local flaps near the edges of the defect as long as a suitable perforator has been identified near the defect to allow for rotation of the flap  .
In 10 cases, the position of the identified perforator allowed for the design of a propeller flap that could be rotated up to 180° so that the longer limb of the flap covered the defect while the shorter limb could decrease the size of the donor site, and allow for primary closure, which was done in one case.
Postoperative complications were observed in 14 out of 34 cases. There was one case with a total loss of the flap. She was a 50 years old diabetic for whom a propeller flap was rotated 160°. Venous congestion appeared on the first postoperative day and was not relieved through conservative measures. This was most probably attributed to the kink of the veins around the perforator resulting in venous congestion.
Two cases had superficial sloughing, with a healthy granulation tissue underneath that was grafted in the later session. Nine cases had loss of the distal edge of the flap. And two cases had partial loss of the distal-half of the flap and both had vacuum-assisted closure device for 10 and 14 days until the raw areas were ready to be covered by using split-thickness skin grafts.
Similar results were observed by Bhattacharya et al., in a study in which 22 cases of perforator-based flaps were used over a period of 4 years. Postoperative complications were observed in nine patients. Another study reported similar results in a series of 10 cases in which one case showed total loss of the flap  .
We believe that the rate of the complications was high but those complications were not disastrous on the terminal fate. We advocate the following.
- The chosen perforator should be at least 1 mm in diameter and 30 mm in length. Therefore, we usually try to mobilize the entire perforator segment to obtain the longer length for less strain on the vessels
- The preservation of more than one perforator may limit the range of rotation and potentially cause kinking. We did this in one case and we recommend the distance between the two perforators should not exceed 1 cm
- A delay procedure for 7 days for risky patients, for example, those with peripheral arterial obstructive disease, to augment the vascularity and promote the angiogenesis effect; it will help to decrease the complication
- If mild venous congestion is encountered, massaging the flap from the peripheral margins toward the center can sometimes relieve the problem
- Venous congestion might be overcome by the inclusion of the superficial veins of the leg such as the greater and lesser saphenous veins in the design of the flap. The tributaries of those veins that we included in the flap can allow for a reversed flow overcoming the presence of the valves
- Adequate dissection of the fascial strands around the perforator that could compress the vessels after rotation of the flap and may reduce the venous congestion 
- The anterior tibial artery perforator flap has only been described in a limited number of published reports. In addition, it was found to have a greater complication rate than that of other distal leg perforator flaps, although the difference was not statistically significant  . We believe that using the anterior perforating branch of the peroneal artery instead would provide a wider and safer flap, without exposing some of the anterior compartment tendons and the tibial bone; this is in agreement with the findings of a study by Acarturk et al.  .
The maximum flap size that can safely be based on a single perforator is still a matter of debate, and may lead to a partial flap loss with ischemia of the edges. Larger flaps can be raised on the medial side of the leg compared with the anterolateral aspect. This is due to the fact that perforators arising from the posterior tibial axis, although small in number, are of larger diameter than those from the anterior tibial and peroneal axes, where the converse holds true  .
Comorbidities such as old age and diabetes might have a negative effect on the viability of perforator flaps and caution should be considered in those patients by designing smaller flaps with lesser arc of rotation  .
Preoperative identification of the arterial perforators with hand-held Doppler is a skill that can be acquired with practice. It should be performed by the operating team, and supervised by the main surgeon to accurately identify perforators and to choose the ones most suitable for the design of the flap.
In many cases the identification of a perforator preoperatively was difficult. In such cases preoperative duplex was necessary to identify the perforators. During surgery an exploratory incision was made to identify the perforator before the design of the flap could be settled and the complete dissection of the flap could proceed.
The aim of the current study was the evaluation of the clinical applications of different perforator-based flaps in the coverage of various leg defects in an attempt to develop an algorithm for the management of various leg and foot defects.
Defects over the upper-third of the leg can be covered by medial sural artery perforator flaps, or flaps based on the perforators of the anterior tibial artery and the peroneal artery.
Defects over the middle and lower-third of the leg can be covered by flaps based on perforators of the posterior tibial artery if the defect is on the medial side of the leg. If the defect is on the lateral side of the leg, then flaps based on the peroneal artery can be used.
| Conclusion|| |
The use of propeller flaps to cover defects on the leg showed satisfactory results as regards flap viability and providing a suitable cover of various defects. The use of handheld Doppler proved satisfactory in the preoperative delineation of the perforators and also for the postoperative evaluation of the flow in the perforators. The angle of rotation of the flaps varied from 45° to 90° and to 180°. Flap morbidity occurred in cases of more than 90°. The use of propeller flaps proved to be effective as regards viability of the flap and decreasing the donor-site.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]