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Year : 2020  |  Volume : 33  |  Issue : 4  |  Page : 1315-1321

Complications of the peroneal artery perforator propeller flap in soft tissue coverage of leg defects

Department of Plastic and Reconstructive Surgery, Menoufia University Hospital, Menoufia, Egypt

Date of Submission07-Apr-2020
Date of Decision30-Jun-2020
Date of Acceptance05-Jul-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Mahmoud A Abdelaty
New Damietta, Damietta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_114_20

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To highlight the complications of peroneal artery perforator propeller flaps in coverage of leg defects and how to avoid and manage.
Complex soft tissue defects of the leg represent a difficult reconstructive problem. The lateral aspect of the leg, which is perfused by a number of perforators from the peroneal artery, is one of the most suitable areas for harvesting perforator flaps.
Patients and methods
This descriptive study included 31 patients presented by soft tissue loss of leg from January 2018 to January 2020. All patients were examined for the site, the size, and the extent of the defect. Floor of the defect was examined for exposed bone, fractures, or exposed tendons. The flaps were evaluated regarding achieving the preoperative goal for coverage of the soft tissue defects, limb function, and patient satisfaction.
Of 31 cases, 18 healed uneventfully, and 13 cases were complicated. Five patients had partial loss of the distal end of the flap. There was a complete flap loss in two patients. Three cases had wound infection with partial dehiscence. Two cases had partial loss of the skin graft on the donor site. One case had hematoma collection under the skin graft.
Peroneal artery perforator propeller flaps provide durable coverage for complex leg defects. Complications are avoidable and easy to manage.

Keywords: complications, flap, leg, perforator, peroneal artery, propeller, reconstruction

How to cite this article:
Keshk TF, Taalab AA, Abdelaty MA. Complications of the peroneal artery perforator propeller flap in soft tissue coverage of leg defects. Menoufia Med J 2020;33:1315-21

How to cite this URL:
Keshk TF, Taalab AA, Abdelaty MA. Complications of the peroneal artery perforator propeller flap in soft tissue coverage of leg defects. Menoufia Med J [serial online] 2020 [cited 2021 Apr 18];33:1315-21. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1315/304476

  Introduction Top

Complex soft tissue defects of the leg represent a difficult reconstructive problem owing to exposure of bone, joint, or tendons. The major problems are poor vascularity and limited mobility of the skin around. Decreased thickness of subcutaneous tissue makes skin grafting a poor option. The quality of flap thickness, minimal donor site morbidity, lack of functional loss, short recovery time, as well as wide arc of rotation are the main advantages of propeller flaps[1].

The concept of perforator flaps that was described in 1990s provided a better option to cover leg defects. Anatomical studies of the fibula osteoseptocutaneous flap showed that the peroneal artery perforator flap was reliable because it supplies a wider area and has a constant arterial blood supply[2].

The propeller flap is a local island fasciocutaneous flap based on a single perforator. It is designed like a propeller with two blades of unequal length, and the perforator forms the pivot point so that when the blades are switched, the long arm fills in the defect with the ability to rotate up to 180°[3].

In the 1980s, Ponten[4] and Barclay et al.[5] published their clinical reports on fasciocutaneous flaps, showing that long flaps can safely increase the length to width ratio of random pattern flaps from 1:1 to 3:1.

The term 'propeller flap' was first used in 1991 by Hyakusoku et al.[6] as a description of an adipocutaneous flap based on a central pedicle, with a shape resembling a propeller that was rotated 90°.

In 2006, Hallock[7] reported a fasciocutaneous flap that was similar to the one described by Hyakusoku but was based on a single skeletonized perforating vessel and was rotated 180° on an eccentric pivot point.

Perforator-based propeller flaps are now considered a good option for soft tissue coverage of leg defects. These flaps have a reliable blood supply, spare the major blood vessels and muscles, avoid microvascular anastomosis, and can provide thin fasciocutaneous tissue for leg reconstruction. The lateral aspect of the leg, which is perfused by a number of perforators from the peroneal artery, is one of the most suitable areas for harvesting perforator flaps[8].

In addition, the peroneal artery is least likely to be affected by atherosclerosis[9].

Propeller flaps also have the advantage of supplying same tissue quality (replace like with like), and rotation of 180° avoids dog ear formation[10].

Unfortunately, there are complications associated with the use of perforator-based propeller flaps including vascularity-related problems (venous or arterial), donor site morbidity, and wound infection. Venous congestion cannot be totally avoided with propeller flaps because the walls of the perforator veins are more delicate compared with the perforator arterial wall, and it is difficult to control venous wall damage after the 180° rotation of the pedicle, which may give rise to partial or total flap necrosis[11].

Partial necrosis seems to occur in ∼5% of cases and is often limited to the skin. After eschar removal, an adequate bed for a skin graft is often present[7].

The aim of the study was to highlight the complications of peroneal artery perforator propeller flaps in coverage of leg defects and how to avoid and manage.

  Patients and Methods Top

This descriptive study was conducted after approval of the ethical committee of Menoufia Faculty of Medicine and included 31 patients presented with soft tissue loss of leg at the Department of Plastic Surgery, Menoufia University Hospital, and Al-Babtain Center for Plastic Surgery; Ministry of Health, Kuwait, from January 2018 to January 2020. Informed consent was obtained from all patients who agreed voluntarily to share and use photographs for research with protection of their confidentiality and anonymity. Of the 31 patients, 24 were males and seven were females. Their ages varied from 12 to 58 years, with an average of 35 years. RTA was the cause in 25 patients; six patients had chronic nonhealing wounds with variable defect size ranged from 3 × 4 to 13 × 15 cm. All flaps were designed as propeller flaps that were rotated from 100 to 180°. The donor sites were closed by split-thickness grafts in 28 cases, and primary closure was done in three cases [Table 1] and [Figure 1].
Table 1: Criteria of used flap

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Figure 1: Distribution of etiology and site among patients.

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Statistical analysis

Data were collected regarding thorough history, basic clinical examination, and laboratory investigations. Outcome measures were coded, entered, and analyzed using Microsoft Excel software. Data were then imported into Statistical Package for the Social Science (SPSS Inc., Chicago, Illinois, USA; https://www.ibm.com/analytics/spss-statistics-software), version 20.0 software for analysis where quantitative variables were expressed as mean, SD, and range and qualitative variables as number and percentage. P value less than 0.05 was considered significant.

Inclusion criteria

  1. Soft tissue defects of the distal leg were the inclusion criteria.

Exclusion criteria

The following were the exclusion criteria:

  1. Peripheral vascular diseases
  2. Post-phlebitic limb.

Preoperative preparation

History taking and general examination were done on all patients to detect comorbidities such as diabetes or peripheral vascular disease. Only six patients were diabetic. 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 defects were examined to evaluate the different possible options for coverage.

Preoperative investigations

Preoperative investigations included the following:

  1. All patients were photographed preoperatively
  2. Routine laboratory investigations
  3. Plain radiograph for concomitant bone fractures were done
  4. Hand-held Doppler 8 MHz was used for identification and marking of perforators near the raw area. Color Duplex was done for 10 patients in whom results of hand-held Doppler were not conclusive.

Operative technique

Preoperative planning

A hand-held Doppler probe or color duplex ultrasonography was sufficient for preoperative vascular assessment. A flap was marked around the perforator with the best pulse and location. An exploratory incision was planned without interfering with the alternative local flap(s).

Flap dissection

Through the exploratory incision, suprafascial or subfascial dissection under loupe magnification was used to identify all the perforators around the defect. Once all perforators were identified, the best one was chosen based on caliber, pulsatility, course and orientation, and number and caliber of accompanying veins. The perforator was freed from any surrounding tissue and dissected as long as possible (up to the source vessel) to achieve an adequate length of the pedicle to distribute the torsion. Side branches were ligated and not cauterized to avoid thermal damage to the perforator. The design and size of the flap were adjusted according to size of the defect and the position of the discovered perforator.

Flap insetting

The flap was left in place for at least 20 min after releasing the tourniquet to allow its reperfusion and the release of any perforator's spasm before flap rotation. Clockwise and counterclockwise rotations were evaluated, and the best one in terms of vessel rotation was chosen to avoid any kinking of the vessels. After rotating the flap to its new position, its pedicle was checked for twisting and further dissected if needed to allow even distribution of the torsion. The flap was then secured in position and observed for color, capillary refilling, and bleeding [Figure 2].
Figure 2: a)flap rotation with good vascularity b)post operative mild venous congestion

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Donor site closure

Tension free closure was done to avoid impairment of the flap blood supply by compressing the source vessel, and also to avoid swelling of the distal leg. Cases in which primary closure was not possible, the donor site was partially directly sutured, and the remaining defect was covered by skin graft.


The operated limb was kept in a splint and elevated for the first postoperative days; compression on the flap was avoided and elevation was maintained. Flap was checked every second hour during the first postoperative days, to allow for prompt identification of eventual complications. All patients were photographed immediately postoperatively, every 24 h for the first 3 day, and 5 days postoperatively. Sutures were removed after 2 weeks.

Patients were followed up for a period of 4–12 weeks. The flaps were evaluated regarding achieving the preoperative goal of coverage of the soft tissue defects, limb function, and patient satisfaction.

  Results Top

Of 31 cases, 18 (58%) healed uneventfully, and 13 (42%) cases were complicated [Table 2].
Table 2: Complications of the operation

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Five patients had partial loss of the distal end of the flap, and two of them had loss of the distal 2 cm of the flap, but no further surgical intervention was necessary. The other three cases had superficial sloughing with healthy granulation tissue underneath and were covered after 2 weeks by split-thickness skin graft [Figure 3].
Figure 3: a)Wound infection b)partial flap loss

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There was a complete flap loss in two patients, and one of them was diabetic. Congestion appeared few hours postoperatively in one case. Surgical exploration was done for the pedicle that was found twisted. More dissection was done to increase the pedicle length in a trial to save the flap. Unfortunately, the congestion was progressive and was not relieved by heparin soaks and nitroglycerin patches. Complete sloughing of the flap occurred on the fourth day postoperatively. The second patient showed mild congestion started after 24 h with marked flap edema. Release of some sutures, flap massage toward the center, and application of heparin soaks were done and resulted in mild improvement but eventually most of the flap was lost. In both cases, the defect was managed by VAC = vacuum assisted closure therapy and then was covered by split-thickness skin graft after 2 weeks [Figure 4].
Figure 4: a)Total flap loss b)debridement of the flap c)defect covered by skin graft

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Three cases had wound infection with partial dehiscence and responded to antibiotic therapy based on culture and sensitivity result.

Two cases had partial loss of the skin graft on the donor site and required regrafting.

One case had hematoma collection under the skin graft that was evacuated.

  Discussion Top

The reconstruction of leg defects continues to be a challenge for the reconstructive surgeon, who must achieve a satisfactory functional and aesthetic outcome. The use of perforator propeller flaps has revolutionized the field of lower limb reconstruction.

The perforator flaps are based on perforating vessels and can be harvested without significant damage to associated muscles, thereby reducing the postoperative morbidity associated with muscle-based flaps. Elevation of perforator flaps requires meticulous technique and can be more challenging than raising muscle-based flaps.

The peroneal artery perforator propeller flap is considered to be one of the most reliable methods used in leg reconstruction. The aim of this study was to evaluate the clinical outcomes and complications of the peroneal artery perforator propeller flap in leg reconstruction.

Successful soft tissue reconstruction is a vital step for limb salvage in patients with complex leg defects. The use of local cutaneous flaps is usually not feasible being involved in massive edema that limits their rotation[1]. The major advantage of free-style flaps is that an unlimited number of flaps can potentially be designed on its related pedicles with reduced donor site morbidity and functional deficit.

According to this study, peroneal artery perforators incorporated in our flaps were found 7–13 cm proximal to the lateral malleolus. All perforators were found to be septocutaneous and were dissected to an average length of 27 mm. The degree of flap rotation ranged from 100 to 180°, with an average of 162°. The mean operative time was 130 min. The largest uncomplicated flap size was 21 × 9 cm.

The peroneal artery is the posterior lateral branch of the tibial-peroneal trunk and originates 2–3 cm distal to the popliteal fossa. The diameter of the peroneal artery near its origin is approximately 3.7 mm (2.0–5.3 mm). The peroneal artery courses down the interosseous membrane and ends slightly proximal to the malleoli by giving off a communicating branch to the posterior tibial artery and perforating branch to the anterior tibial artery, and a lateral calcaneal branch. After piercing the interosseous membrane, the perforating branch of the peroneal artery emerges 5 cm proximal to the lateral malleolus and gives off one to three ascending cutaneous branches and a deep descending branch. The ascending cutaneous branches supply a large area of skin over the lower lateral leg. The peroneal artery is relatively spared from the terminal stages of atherosclerosis and is often the last tibial vessel to become occluded in diabetes or end-stage vascular disease. This special characteristic makes the peroneal artery-based flap a reliable option for leg reconstruction with reduced incidence of complications[12].

Chang et al.[13] in his study found that peroneal artery supplies the lateral leg skin through its septocutaneous and musculocutaneous perforators. Musculocutaneous perforators are more numerous and located more proximally than septocutaneous perforators. Blondeel et al.[14] stated that peroneal artery perforators are located along the distal three-fourths of a line drawn from the lateral femoral epicondyle to the Achilles' tendon; most of the distal perforators are septocutaneous. The average number of cutaneous perforators 0.5 mm or more in diameter arising from the peroneal artery is 5 ± 1. Their average internal diameter is 0.8 ± 0.3 mm. The average pedicle length from the deep fascia is 36 ± 20 mm. The average cutaneous vascular territory supplied by the peroneal artery is 172 ± 42 cm2, which is 19 ± 5% of the leg integument (measured from the femoral epicondyles to the malleoli)[14].

Wei et al.[15] noted that septocutaneous perforators near the junction between the middle and lower thirds of the fibula can supply a skin paddle about 22–25 cm long and 10–14 cm wide.

D'Arpa et al.[16] recommended the use of hand-held Doppler or color duplex ultrasonography for preoperative vascular assessment. The Doppler probe should be angled 45° to the skin surface to avoid false signal from the source vessel. According to our study, the use of a Doppler device enables reliable identification of the perforating vessels and aids in the design of free-style propeller flaps, where the flaps are designed purely according to the perforators located. In our study, hand-held Doppler was accurate for identification and marking of perforators near the raw area in 21 patients. Color Duplex was done for 10 patients in whom the results of hand-held Doppler were not conclusive. Color Duplex imaging provides information about the presence or absence of blood flow to allow localization of blood vessels, the flow direction toward or away from the probe, the flow pattern whether arterial or venous, and the blood flow velocity. The ultrasound examination should be performed with a high-frequency linear array probe. Usually a multifrequency (5–7.5 to 10 MHz) or broadband (5–10 MHz or 5–12 MHz) linear array probe is used. We noted a less complication rate in terms of flap vascularity (arterial and venous insufficiency) with the use of color Duplex. Although being more expensive and time consuming, color Duplex gives a clearer picture about perforator anatomy and its venae comitantes therefore helps to avoid intraoperative surprise and to minimize the operative time.

Lu et al.[1] reported venous congestion rate of 27.7% in their study that included 18 patients. Shen et al.[17] in their study included 36 patients and reported overall complication rate of 33.3%, and venous congestion occurred in 25%. Innocenti et al.[18] reported 42% complications. Venous congestion (17%) and superficial necrosis (11%) occurred most frequently. Total flap failure (2%) and partial flap failure (2%) were less common.

Two review articles analyzed the frequency of complications in propeller flaps used for lower-extremity reconstruction. Gir et al.[19] studied 186 cases performed in 15 different institutions and Nelson et al.[20] studied 310 flaps performed in 21 centers. The results of the two studies in terms of flap survival are comparable, with 11% of partial flap necrosis in both reviews and 1 and 5% of total necrosis in the reviews of Gir et al.[19] and Nelson et al.[20], respectively.

In our study, we reported complications in 13 (42%) patients. Flap complications related to vascular compromise (arterial and venous) were reported in seven (22.5%) patients. Five (16.1%) patients had partial necrosis of the distal end of the flap. Two (6.5%) patients had total flap necrosis. Venous congestion was encountered in four (12.9%) patients. Surgery site infection occurred in three (9.7%) patients. Two (6.5%) patients had partial loss of STSG= split thickness split graft on the donor site, and one (3.2%) patient had hematoma collection beneath the skin graft.

Venous congestion is the most frequent and difficult complication of propeller flaps, because vein wall is more delicate and prone to torsion than arteries. A small number of cases progress to necrosis, which is usually superficial. Arterial insufficiency is usually uncommon and can be avoided by accurate planning of the flap and choice of the perforator. In case of persistent arterial spasm, the flap remains pale owing to insufficient arterial inflow. The flap can be derotated to its original position for a few days before rotating it[21].

Careful dissection of the vascular pedicle to adequate length up to the source vessel is important to avoid twisting of the vessels. Release of tight fascial strands that might compress the pedicle is a crucial step to increase flap viability. It has been demonstrated that the risk of vessel buckling is decreased when the perforator is of 1-mm diameter and the vessel length is more than 3 cm[22].

We think that proper choice of the perforator with two venae comitantes, proper leg elevation, and close monitoring of the flap during the early postoperative time will markedly reduce the risk of vascularity-related complications. The direction of rotation is also very important, and it is crucial to try different directions of rotation during the operation (i.e., clockwise or anticlockwise rotation). Side branches should be ligated and not cauterized to avoid thermal damage of the pedicle.

We believe that proper and early management of venous congestion is crucial to increase flap survival. We advise to avoid tight dressing with proper leg elevation to help venous return and close monitoring of the flap for early detection of color change or marked edema. Release of sutures on the periphery and leave the wound open for late secondary sutures after edema subsides will help to prevent progression of venous congestion. If congestion is established, the surgeon can do flap massage from the periphery toward the center to help venous drainage. Bleeding therapy by small incisions of 5 mm with application of heparin soaks will allow bleeding from the flap with close monitoring of blood pressure. The surgeon should consider early surgical exploration for further pedicle dissection, evacuation of any hematoma, and microsurgical venous anastomosis to a recipient vein to increase venous drainage.

Bajantri et al.[23] in his study stated that the donor defect can be closed primarily only in narrow longitudinal defects. Skin grafting of the donor site is often required. In our study, we have similar finding, as 28 (90.3%) of our cases required skin graft for donor site closure, and we managed to close the donor site primarily only in three (9.7%) cases. We strictly advise to avoid attempts for donor site closure under tension as this might highly endanger flap viability owing to compression of the source vessel. Partial loss of skin graft may occur and can be managed either conservatively or by another skin graft according to the size of the raw area. Hematoma beneath the skin graft should be evacuated early to avoid skin graft necrosis.

Wound infection remains a considerable complication although it does not directly endanger the flap viability. Proper use of perioperative aseptic techniques and culture based antibiotics will reduce the risk of surgery site infection.

  Conclusion Top

The reconstruction of leg defects continues to be a challenge for the reconstructive surgeon, who must achieve a satisfactory functional and aesthetic outcome.The use of perforator propeller flap in leg reconstruction can provide durable coverage for complex leg defects with good thickness and texture, reliable vascularity, wide arc of rotation and easy dissection with minimum donor site morbidity. Most of the complications could be avoided with increased flap survival if properly managed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lu T-C, Lin C-H, Lin C-H, Lin Y-T, Chen R-F, Wei F-C. Versatility of the pedicled peroneal artery perforator flaps for soft tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg 2011; 64:386–393.  Back to cited text no. 1
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; 90:643–649.  Back to cited text no. 2
Teo TC. The Propeller flap concept. Clin Plast Surg 2010; 37:615–626.  Back to cited text no. 3
Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 1981; 34:215–220.  Back to cited text no. 4
Barclay TL, Cardoso E, Sharpe DT, Crockett DJ. Repair of lower leg injuries with fascio-cutaneous flaps. Br J Plast Surg 1982; 35:127–132.  Back to cited text no. 5
Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991; 44:53–54.  Back to cited text no. 6
Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg 2006; 56:540–542.  Back to cited text no. 7
Chen YL, Zheng BG, Zhu JM. Microsurgical anatomy of the lateral skin flap of the leg. Ann Plast Surg 1985; 15:313–318.  Back to cited text no. 8
Hansen T, Wikstrom J, Johansson LO, Lind L, Ahlstrom H. The prevalence and quantification of atherosclerosis in an elderly population assessed by whole-body magnetic resonance angiography. Arterioscler Thromb Vasc Biol 2007; 27:649–654.  Back to cited text no. 9
Soltanian H, Garcia RM, Hollenbeck ST. Current concepts in lower extremity reconstruction. Plast Reconstr Surg 2015; 136:815e–829e.  Back to cited text no. 10
Selvaggi G, Anicic S, Formaggia L. Mathematical explanation of the buckling of the vessels after twisting of the microanastomosis. Microsurgery 2006; 26:524–528.  Back to cited text no. 11
Ballotta E, Da Giau G, Gruppo M, Mazzalai F, Martella B. Infrapopliteal arterial revascularization for critical limb ischemia: is the peroneal artery at the distal third a suitable outflow vessel? J Vasc Surg 2008; 47:952–959.  Back to cited text no. 12
Chang SM, Zhang F, Xu DC, Yu GR, Hou CL, Lineaweaver WC. Lateral retromalleolar perforator-based flap: anatomical study and preliminary clinical report for heel coverage. Plast Reconstr Surg 2007; 120:697–704.  Back to cited text no. 13
Blondeel PN, Morris SF, Neligan P, Hallock GG. Perforator flaps: anatomy, techniques, and clinical application s. 2nd ed. St Louis: Quality Medical Publishing; 2013. 45. 832–834.  Back to cited text no. 14
Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteoseptocutaneous flap anatomic study and clinical application. Plast Reconstr Surg 1986; 78:191–200.  Back to cited text no. 15
D'Arpa S, Toia F, Pirrello R, Moschella F, Cordova A. Propeller flaps: a review of indications, technique, and results. BioMed Res Int 2014; ID 986829:1–7.  Back to cited text no. 16
Shen L, Liu Y, Zhang C, Guo Q, Huang W, Wong KKL. Peroneal perforator pedicle propeller flap for lower leg soft tissue defect reconstruction, clinical applications and treatment of venous congestion. J Int Med Res 2017; 45:1074–1089.  Back to cited text no. 17
Innocenti M, Menichini G, Baldrighi C, Delcroix L, Vignini L, Tos P. Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction?. Clin Orthop Relat Res 2014; 472:2276–2286.  Back to cited text no. 18
Gir P, Cheng A, Oni G, Mojallal A, Saint-Cyr M. Pedicled-perforator propeller flaps in lower extremity defects: a systematic review. J Reconstr Microsurg 2012; 28:595–602.  Back to cited text no. 19
Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN. A review of propeller flaps for distal lower extremity soft tissue reconstruction: is flap loss too high? Microsurgery 2013; 33:578–586.  Back to cited text no. 20
Pignatti M, D'Arpa S, Cubison TCS. Novel fasciocutaneous flaps for the reconstruction of complicated lower extremity wounds. Tech Orthop 2009; 24:88–95.  Back to cited text no. 21
Wong CH, Cui F, Tan BK. Nonlinear finite element simulations to elucidate the determinants of perforator patency in propeller flaps. Ann Plast Surg 2007; 59:672–678.  Back to cited text no. 22
Bajantri B, Bharathi R, Sabapathy S. Wound coverage considerations for defects of the lower third of the leg. Indian J Plastic Surg 2012; 45:283–290.  Back to cited text no. 23


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

  [Table 1], [Table 2]


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