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Why, when and how propeller perforator flaps in reconstructive surgery
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Why, when and how propeller perforator flaps in reconstructive surgeryR Alexandru Valentin Georgescu a,b, Ileana Rodica Matei a,b,∗, Marko Bumbasirevic c,d, N Panayotis Soucacos e a
Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia d School of Medicine. University of Belgrade, Serbia e “Panayotis N. Soucacos” Orthopaedic Research & Education Center (OREC), National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece b c
a r t i c l e
i n f o
Article history: Available online xxx Key words: Tissue defects Microsurgical non-microvascular flaps Propeller perforator flaps
a b s t r a c t Purpose: The aim of this paper was to evaluate the outcomes of propeller perforator flaps used all over the body, and to appreciate their advantages and/or disadvantages over the free perforator flaps. Method: Patients that required propeller perforator flaps used all over the body were eligible to participate in this study. A preoperative Doppler examination was performed for all the flaps in the trunk and thigh, but not regularly in the face, lower leg, foot, forearm and hand. We evaluated the most important technical aspects of harvesting the flaps, the main indications and advantages of using propeller perforator flaps, their disadvantages and complications. For post-excisional face and trunk defects after cancer or decubitus ulcers were performed approximately 25% of flaps. Results: We had very good results in approximately 70% of cases. In the remaining cases, excepting 3 cases in which the flaps were completely lost, we registered only minor complications due to venous congestion, which were solved spontaneously or by skin grafting. Conclusion: The main advantages of propeller perforator flaps, i.e. no need of microvascular anastomoses, replacing like-with-like, faster functional rehabilitation, can reduce in well selected cases the indication for free flaps. The rate of complications is not higher than by using other methods. The single real disadvantage of propeller perforator flaps is the location of the perforator close to the defect, what can be an impediment in trauma cases. © 2019 Elsevier Ltd. All rights reserved.
Introduction A good reconstruction of missing skin and/or other tissues means to find the shortest way and use top quality tissues to obtain the best possible morphological and functional result. That means to use for reconstruction as similar as possible tissues and with absent or very low donor site morbidity. The advances in blood supply knowledge and in microsurgical techniques in the last three decades allowed the development
R This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM) and the Serbian Society for Reconstructive Microsurgery (SSRM). ∗ Corresponding author at: Matei Ileana Rodica, Spitalul Clinic de Recuperare, Str. Viilor 46-50, 400347 Cluj Napoca, Cluj, Romania. E-mail address: [email protected] (I.R. Matei).
of new and more reliable surgical methods in covering simple or complex tissue defects all over the body. Starting with the first perforator flaps performed by Kroll and Rosenfield in 1988 [1] and Koshima and Soeda in 1989 [2], the new era of perforator flaps began. The rational of using these flaps was represented by the diminution of donor site morbidity by sparing the muscles and the main arterial trunks. The perforator flaps have been used initially as free flaps, which very much reduced the donor site morbidity, but which responded only partially to another necessity: the replacement of like-withlike. That’s why a new type of perforator flaps was developed – the local perforator flaps – which allow the reconstruction by using identical or very similar tissues. The aim of this paper was to demonstrate why, when and how the local perforator flaps used in a propeller manner can be used in the reconstruction of tissue defects all over the body [3,4].
https://doi.org/10.1016/j.injury.2019.10.037 0020-1383/© 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
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Fig. 1. Fistulized osteitis after open cominutive fracture of the elbow: (a) Intraoperative aspect after debridement; exposure of the osteosynthesis material (b) Exploratory incision in the attempt to find a perforator (c) After finding the perforator, its foramen is enlarged and all muscular branches and fascial strands are carefully ligated and cutted (d) The perforated is dissected for enough length, but not longer than needed for an optimal rotation of the flap (e) The incision of all the flap is completed (f) The dissection and harvesting of the flap is completed g immediate postoperative aspect h. four months postoperative aspect.
Why and when to use propeller perforator flaps? In any case of soft tissue reconstruction, the duration of surgery should be as short as possible and particularly in old, polytraumatized and/or biologically compromised patients. A shorter operating time will need also a shorter and less invasive anesthesia, that is very important in afore mentioned category of patients. If a microsurgical free flap needs generally at least 3–4 h (or sometimes more), a microsurgical local perforator flap can be done in 60–90 min, because it needs only microsurgical dissection but does not need microvascular anastomoses [3,5–9]. Moreover, depending to the region, such a flap can be performed under local or regional anesthesia, with a lower general biological impact on the patient. In the same time, both the donor and recipient areas are located in the same operative field, that avoids the necessity to turn the patient and, eventually, to work in two teams. By sparing the muscles and main vessels, the perforator flaps, either free or pedicled, minimize the donor site morbidity that represents a significant improvement in flaps’ surgery [10,11]. Moreover, the absence of a muscle in the flap means less bulkiness and the possibility to obtain a much better cosmetic appearance of the reconstructed area (Fig. 1). One of the demands in reconstructive surgery is to use for reconstruction as similar as possible tissues, that allows obtaining both a better cosmetic result and/or a superior functional recovery. The harvesting of the flap from the same anatomical region ensures the use of tissues with the same characteristics, i.e. structure, color, elasticity, and pliability [3,4]. That means to do a reconstruction by replacing like-with-like, which generally allows a better cosmetic appearance. This is perfectly true for reconstruction of defects in the face, where the cosmetic result should be
close to perfect (Fig. 2), but also in the palmar aspect of the hand and fingers and plantar aspect of the foot and toes, were the use of the same supra specialized skin is of paramount importance [12] (Fig. 3). The postoperative evolution is generally shorter than for the free flaps, and the postoperative mobilization and rehabilitation can be started earlier. This is very important especially for flaps covering defects over the joints: the absence of vascular anastomoses in propeller perforator flaps allows the beginning of mobilization immediately after surgery [3,4]. How to use propeller perforator flaps? Design of the flap The preoperative planning of perforator flaps by using various imaging techniques and hand-held Doppler is useful in the trunk and thigh, but is not very useful in the forearm and lower leg because of the proximity of the main source arteries as well as their superficial location. It is also relatively difficult to do this in the hand and fingers [3,13,14]. This is why, generally, the definitive identification and isolation of the perforators is done intraoperatively through a careful dissection and consideration of the defect needs. Harvesting technique [3,4,12,13] (Fig. 1) For the beginning, only one edge of the potential flap is incised (Fig. 1b). The incision can be either supra or subfascial. The dissection is performed under magnification and all the identified perforators are preserved. If more adjacent perforators of similar caliber are found, it is better to decide on which will be used as the vascular pedicle of the flap only after clamping them alternately. The definitive design of the flap is accomplished according
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
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Fig. 2. Preauricular basal cell carcinoma: (a) Preoperative aspect (b) Remaining defect after excision; an exploratory incision is performed distally to the defect and careful undermining of the anterior edge of the defect and of the distal incision is done, what allows the identification and isolation of a perforator from the transverse facial artery (c) the complete incision and harvesting of the flap is performed only after the identification and isolation of the perforator (d) Three months postoperative aspect.
Fig. 3. Plantar mal perforant in the forefoot in a diabetic patient: (a) Preoperative aspect (b) After debridement of the ulcer, the medial edge of the remaining defect is prolonged by a distal incision, what allows the identification of a perforator from the first plantar metatarsal artery (c) The incision around all the flap is completed (d) 7 days postoperative aspect, showing the good integration of the flap; the donor site was closed by direct suture.
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
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to the chosen perforator, and its location, size, number of venae comitantes, course and orientation. The long axis of the flap can be orientated in any direction in the face (Fig. 2b,c), but should be orientated in the long axis of the segment in limbs (Fig. 1b,c,d,e) and transversely in the trunk. The length of the flap should be greater than the distance between the perforator and the most distant edge of the defect adding 1–2 cm. Similar, to the width of the defect is added 0.5–1 cm to allow closure without tension. After enlarging the perforator foramen, the perforator is cleared of all muscular branches and fascial strands for enough length, but not longer than needed for an optimal rotation of the flap (Fig. 1c and d). It is not necessary to completely skeletonize the perforator pedicle, but it is better, especially in the fingers, to retain a small cuff of tissue around it to avoid the vessel spasm. After that, the incision around the flap and its undermining is completed (Fig. 1e). The flap should be rotated only after observing the viability of the flap: pulsation of the perforator, bleeding from the edges, capillary refilling. If those signs are not present, it is better to maintain the flap in its original position for 10–15 min to allow the spasm to disappear and/or to reexamine the perforator. Attention should be paid to the correct rotational direction to avoid kinking of the perforator. Closure of the donor site under tension should be avoided to prevent reduction of the flap’s blood supply by compression of the source vessel and, in the limbs, by swelling of the distal segment. If closure by direct suture is not possible, the use of a free thickness skin graft is indicated. Discussion After a long evolution in flaps surgery, which started with the works on skin blood supply of Manchot [15], Salmon [16], Taylor and Palmer [17], a step forward was represented by the work of Saint-Cyr et al. [18] which focused on the perforator vessels and not the source vessel anymore. After conducting several anatomical studies, they defined the “perforasome” as the vascular territory of a single perforator and described some principles: a. the perforasomes are interconnected by direct and indirect linking vessels; b. the design of a flap should respect the orientation of linking vessels: axial in the extremities and transversal in the trunk; c. the perforasome of a perforator emerging from a specific source vessel is preferentially filled before filling perforasomes from adjacent source vessels; d. the blood flow in linking vessels is distal from joints or non-mobile skin, but for perforators centrally located in between two joints, the flow is multi-directional. As a result of this evolution, and following the harvesting of the first flaps sparing the source artery and underlying muscle performed by Kroll and Rosenfield in 1988 [1] and Koshima and Soeda in 1989 [2], the use of perforator flaps became increasingly more extensive. They were used for the beginning more as free flaps, but the distant donor site, the difficulties in obtaining a similar reconstruction, and the technical high-demand procedure are some of the factors that stimulated surgeons to find alternatives to free flaps. In recent years, the use of local perforator flaps gained a big popularity, mainly due to some advantages: (1) replacing like with like, (2) donor site in the same area, (3) possibility of complete or partial donor site primary closure, (4) less demanding from technical point of view, because they do not need microvascular sutures (microsurgical non-microvascular flaps), and (5) shorter operating time [3,13,19,20]. Chang et al. [21] described for the first time in 1988 a fasciocutaneous forearm reverse flap by sparing the radial artery, but the real interest in using local perforator flaps only became manifest from 1994. Starting with this moment, the use of local perforator flaps became increasingly extensive. Even if these flaps can be used as pedicled and transposition flaps, their use as propeller flaps seems to be more useful and is preferred by most surgeons.
Hyakusoku et al. [22] introduced in 1991 for the first time the term propeller flap, to describe an adipocutaneous flap with blood supply through a random subcutaneous pedicle and rotated about for 90°. Later on, Hallock [23] used this term for the first time to define a perforator flap rotated for 180°. The Advisory Panel of the First Tokyo Meeting on Perforator and Propeller Flaps established in 2009 the definition and terminology of propeller perforator flaps: a skin island with two paddles demarcated by the perforator vessel, which has to rotate for at least 90–180° [24]. Of great importance is the very thoughtful planning and design of the flap, as well as the length of the perforator. One of the most important factors in diminishing the complication rate is the necessity to establish the realistic dimensions of such a flap, in other words the safe vascular limits of a perforator pedicle. While at the beginning it was considered that the dimensions of a perforator flap should not exceed the distance between two perforators, Saint-Cyr et al. [18] demonstrated that the single perforator of a flap is hyperperfused, which increases its filling pressure and opens the linking vessels with adjacent territories. It is easy to understand that the possibility of establishing before or during surgery the safer dimensions of a flap can dramatically ameliorate the success rate. A lot of methods were used for this purpose, such as handheld Doppler, color Doppler, Duplex ultrasound, arteriography, magnetic resonance angiography, and high-resolution computed tomography. No single method provides information regarding flap viability, but only about the perforator’s distribution and/or caliber [20]. The flap perfusion, but not the dimensions of a flap, can be tested during surgery by fluorescein [20,25,26] or indocyanine green near-infrared angiography [20,27–29]. The main advantages of propeller perforator flaps recommend them as a valuable option in the reconstruction armamentarium. The surgical procedure is relatively easy and little time consuming, which offers a lot of benefits to the elderly, polytraumatized patients, or to those with a compromised general health status. A potential disadvantage can be related to the location of the perforator within the zone of injury, but generally this fact does not interfere with the viability of the flaps. The main indication for propeller perforator flaps is the coverage of small to medium size defects, but sometimes their dimensions could be larger. The explanation for survival of such big flaps can be found in the perforasome concept of Saint-Cyr et al. [18], according to which the hyperperfusion in a perforator allows the capture of multiple adjacent perforasomes through direct and indirect linking vessels. The most common complication of propeller perforator flaps is represented by venous congestion of the tip or of the entire flap, and is due to the insufficient flow in the perforator pedicle. This happens either because of inadequate selection of the perforator, or due to its insufficient dissection and mobilisation, especially around the vein. If venous congestion is observed intra-operatively, venous supercharging of the flap can be done by performing a microvascular venous anastomosis. In instances of signs of ischemia, derotation of the flap to its original position can be attempted. In instances of vascular problems appearing after surgery, some flaps can be saved by removing the stitches, by doing small punctures or incisions and applying local heparinization, or by using leeches. But, if compared with free flaps, the loss of a propeller perforator flap, involves generally only partially the thickness of the flap. While generally in a propeller perforator flap only the superficial part is lost, if a free flap is lost, everything is lost. This means that the flap has done its job of covering the denuded anatomical elements, because after debridement the granulation of the wound is very fast and allows skin grafting [4]. In conclusion the presence of numerous perforator vessels all over the body makes reasonable and reliable the harvesting of local perforator flaps in order to cover small and medium size defects.
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
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The functional and aesthetic outcome is more than acceptable, but their use needs further research especially regarding the real possible dimensions of this kind of flaps. Declaration of Competing Interest All authors have nothing to declare in relation to the content of this manuscript. References [1] Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988;81:561–6. [2] Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645–8. [3] Georgescu AV, Matei I, Ardelean F, et al. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery 2007;27:384–94. [4] Georgescu AV. Propeller perforator flaps in distal lower leg: evolution and clinical applications. Arch Plast Surg 2012;39:94–105. [5] Quaba O, Quaba AA. Pedicled perforator flaps for the lower limb. Semin Plast Surg 2006;20:103–11. [6] 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. [7] Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: clinical results and vascular anatomy. Plast Reconstr Surg 2010;126:1589–603. [8] El-Sabbagh AH. Skin perforator flaps: an algorithm for leg reconstruction. J Reconstr Microsurg 2011;27:511–23. [9] Lee BT, Lin SJ, Bar-Meir ED, et al. Pedicled perforator flaps: a new principle in reconstructive surgery. Plast Reconstr Surg 2010;125:201–8. [10] Wei FC, Celik N. Perforator flap entity. Clin Plast Surg 2003;30:325–9. [11] Koshima I, Itoh S, Nanba Y, Tsutsui T, Takahashi Y. Medial and lateral malleolar perforator flaps for repair of defects around the ankle. Ann Plast Surg 2003;51:579–83. [12] Georgescu AV, Matei IR, Llusa M. Plantar flaps based on perforators of the plantar metatarsal/common digital arteries. J Reconstr Microsurg 2014;30:469–74.
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[13] Matei I, Georgescu AV, Chiroiu B, et al. Harvesting of forearm perforator flaps based on intraoperative vascular exploration: clinical experiences and literature. Microsurgery 2008;28:321–30. [14] Saint-Cyr M, Mujadzic M, Wong C, et al. The radial artery pedicle perforator flap: vascular analysis and clinical implications. Plast Reconstr Surg 2010;125:1469–78. [15] Manchot C. The cutaneous arteries of the human body. New York: Springer-Verlag; 1983. [16] Salmon M. Arteries of the skin. Taylor GI, Tempest M, editors. London: Churchill Livingstone; 1988. [17] Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40:113–41. [18] Saint-Cyr M, Wong C, Schaverien M, et al. Perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529–44. [19] Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: clinical results and vascular anatomy. Plast Reconstr Surg 2010;126:1589–603. [20] Lee BT, Lin SJ, Bar-Meir ED, et al. Pedicled perforator flaps: a new principle in reconstructive surgery. Plast Reconstr Surg 2010;125:201–8. [21] Chang YT, Wang XF, Zhou ZF, et al. The reversed forearm fasciocutaneous flap in hand reconstruction: 10 successful cases. Chin J Plast Surg Burns 1988;4:41–9. [22] Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991;44:53–4. [23] 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. [24] Pignatti M, Ogawa R, Hallock GG, et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg 2011;127:716–22. [25] McCraw JB, Myers B, Shanklin KD. The value of fluorescein in predicting the viability of arterialized flaps. Plast Reconstr Surg 1977;60:710–19. [26] Morykwas MJ, Hills H, Argenta LC. The safety of intravenous fluorescein administration. Ann Plast Surg 1991;26:551–3. [27] Eren S, Rubben A, Krein R, et al. Assessment of microcirculation of an axial skin flap using indocyanine green fluorescence angiography. Plast Reconstr Surg 1995;96:1636–49. [28] Holm C, Mayr M, Hofter E, et al. Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green. Br J Plast Surg 2002;55:635–44. [29] Matsui A, Lee BT, Winer JH, et al. Real-time intraoperative near-infrared fluorescence angiography for perforator identification and flap design. Plast Reconstr Surg 2009;123:125e–127e.
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
JID: JINJ
[m5G;November 9, 2019;9:16]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Why, when and how propeller perforator flaps in reconstructive surgeryR Alexandru Valentin Georgescu a,b, Ileana Rodica Matei a,b,∗, Marko Bumbasirevic c,d, N Panayotis Soucacos e a
Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia d School of Medicine. University of Belgrade, Serbia e “Panayotis N. Soucacos” Orthopaedic Research & Education Center (OREC), National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece b c
a r t i c l e
i n f o
Article history: Available online xxx Key words: Tissue defects Microsurgical non-microvascular flaps Propeller perforator flaps
a b s t r a c t Purpose: The aim of this paper was to evaluate the outcomes of propeller perforator flaps used all over the body, and to appreciate their advantages and/or disadvantages over the free perforator flaps. Method: Patients that required propeller perforator flaps used all over the body were eligible to participate in this study. A preoperative Doppler examination was performed for all the flaps in the trunk and thigh, but not regularly in the face, lower leg, foot, forearm and hand. We evaluated the most important technical aspects of harvesting the flaps, the main indications and advantages of using propeller perforator flaps, their disadvantages and complications. For post-excisional face and trunk defects after cancer or decubitus ulcers were performed approximately 25% of flaps. Results: We had very good results in approximately 70% of cases. In the remaining cases, excepting 3 cases in which the flaps were completely lost, we registered only minor complications due to venous congestion, which were solved spontaneously or by skin grafting. Conclusion: The main advantages of propeller perforator flaps, i.e. no need of microvascular anastomoses, replacing like-with-like, faster functional rehabilitation, can reduce in well selected cases the indication for free flaps. The rate of complications is not higher than by using other methods. The single real disadvantage of propeller perforator flaps is the location of the perforator close to the defect, what can be an impediment in trauma cases. © 2019 Elsevier Ltd. All rights reserved.
Introduction A good reconstruction of missing skin and/or other tissues means to find the shortest way and use top quality tissues to obtain the best possible morphological and functional result. That means to use for reconstruction as similar as possible tissues and with absent or very low donor site morbidity. The advances in blood supply knowledge and in microsurgical techniques in the last three decades allowed the development
R This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM) and the Serbian Society for Reconstructive Microsurgery (SSRM). ∗ Corresponding author at: Matei Ileana Rodica, Spitalul Clinic de Recuperare, Str. Viilor 46-50, 400347 Cluj Napoca, Cluj, Romania. E-mail address: [email protected] (I.R. Matei).
of new and more reliable surgical methods in covering simple or complex tissue defects all over the body. Starting with the first perforator flaps performed by Kroll and Rosenfield in 1988 [1] and Koshima and Soeda in 1989 [2], the new era of perforator flaps began. The rational of using these flaps was represented by the diminution of donor site morbidity by sparing the muscles and the main arterial trunks. The perforator flaps have been used initially as free flaps, which very much reduced the donor site morbidity, but which responded only partially to another necessity: the replacement of like-withlike. That’s why a new type of perforator flaps was developed – the local perforator flaps – which allow the reconstruction by using identical or very similar tissues. The aim of this paper was to demonstrate why, when and how the local perforator flaps used in a propeller manner can be used in the reconstruction of tissue defects all over the body [3,4].
https://doi.org/10.1016/j.injury.2019.10.037 0020-1383/© 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
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Fig. 1. Fistulized osteitis after open cominutive fracture of the elbow: (a) Intraoperative aspect after debridement; exposure of the osteosynthesis material (b) Exploratory incision in the attempt to find a perforator (c) After finding the perforator, its foramen is enlarged and all muscular branches and fascial strands are carefully ligated and cutted (d) The perforated is dissected for enough length, but not longer than needed for an optimal rotation of the flap (e) The incision of all the flap is completed (f) The dissection and harvesting of the flap is completed g immediate postoperative aspect h. four months postoperative aspect.
Why and when to use propeller perforator flaps? In any case of soft tissue reconstruction, the duration of surgery should be as short as possible and particularly in old, polytraumatized and/or biologically compromised patients. A shorter operating time will need also a shorter and less invasive anesthesia, that is very important in afore mentioned category of patients. If a microsurgical free flap needs generally at least 3–4 h (or sometimes more), a microsurgical local perforator flap can be done in 60–90 min, because it needs only microsurgical dissection but does not need microvascular anastomoses [3,5–9]. Moreover, depending to the region, such a flap can be performed under local or regional anesthesia, with a lower general biological impact on the patient. In the same time, both the donor and recipient areas are located in the same operative field, that avoids the necessity to turn the patient and, eventually, to work in two teams. By sparing the muscles and main vessels, the perforator flaps, either free or pedicled, minimize the donor site morbidity that represents a significant improvement in flaps’ surgery [10,11]. Moreover, the absence of a muscle in the flap means less bulkiness and the possibility to obtain a much better cosmetic appearance of the reconstructed area (Fig. 1). One of the demands in reconstructive surgery is to use for reconstruction as similar as possible tissues, that allows obtaining both a better cosmetic result and/or a superior functional recovery. The harvesting of the flap from the same anatomical region ensures the use of tissues with the same characteristics, i.e. structure, color, elasticity, and pliability [3,4]. That means to do a reconstruction by replacing like-with-like, which generally allows a better cosmetic appearance. This is perfectly true for reconstruction of defects in the face, where the cosmetic result should be
close to perfect (Fig. 2), but also in the palmar aspect of the hand and fingers and plantar aspect of the foot and toes, were the use of the same supra specialized skin is of paramount importance [12] (Fig. 3). The postoperative evolution is generally shorter than for the free flaps, and the postoperative mobilization and rehabilitation can be started earlier. This is very important especially for flaps covering defects over the joints: the absence of vascular anastomoses in propeller perforator flaps allows the beginning of mobilization immediately after surgery [3,4]. How to use propeller perforator flaps? Design of the flap The preoperative planning of perforator flaps by using various imaging techniques and hand-held Doppler is useful in the trunk and thigh, but is not very useful in the forearm and lower leg because of the proximity of the main source arteries as well as their superficial location. It is also relatively difficult to do this in the hand and fingers [3,13,14]. This is why, generally, the definitive identification and isolation of the perforators is done intraoperatively through a careful dissection and consideration of the defect needs. Harvesting technique [3,4,12,13] (Fig. 1) For the beginning, only one edge of the potential flap is incised (Fig. 1b). The incision can be either supra or subfascial. The dissection is performed under magnification and all the identified perforators are preserved. If more adjacent perforators of similar caliber are found, it is better to decide on which will be used as the vascular pedicle of the flap only after clamping them alternately. The definitive design of the flap is accomplished according
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
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Fig. 2. Preauricular basal cell carcinoma: (a) Preoperative aspect (b) Remaining defect after excision; an exploratory incision is performed distally to the defect and careful undermining of the anterior edge of the defect and of the distal incision is done, what allows the identification and isolation of a perforator from the transverse facial artery (c) the complete incision and harvesting of the flap is performed only after the identification and isolation of the perforator (d) Three months postoperative aspect.
Fig. 3. Plantar mal perforant in the forefoot in a diabetic patient: (a) Preoperative aspect (b) After debridement of the ulcer, the medial edge of the remaining defect is prolonged by a distal incision, what allows the identification of a perforator from the first plantar metatarsal artery (c) The incision around all the flap is completed (d) 7 days postoperative aspect, showing the good integration of the flap; the donor site was closed by direct suture.
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
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to the chosen perforator, and its location, size, number of venae comitantes, course and orientation. The long axis of the flap can be orientated in any direction in the face (Fig. 2b,c), but should be orientated in the long axis of the segment in limbs (Fig. 1b,c,d,e) and transversely in the trunk. The length of the flap should be greater than the distance between the perforator and the most distant edge of the defect adding 1–2 cm. Similar, to the width of the defect is added 0.5–1 cm to allow closure without tension. After enlarging the perforator foramen, the perforator is cleared of all muscular branches and fascial strands for enough length, but not longer than needed for an optimal rotation of the flap (Fig. 1c and d). It is not necessary to completely skeletonize the perforator pedicle, but it is better, especially in the fingers, to retain a small cuff of tissue around it to avoid the vessel spasm. After that, the incision around the flap and its undermining is completed (Fig. 1e). The flap should be rotated only after observing the viability of the flap: pulsation of the perforator, bleeding from the edges, capillary refilling. If those signs are not present, it is better to maintain the flap in its original position for 10–15 min to allow the spasm to disappear and/or to reexamine the perforator. Attention should be paid to the correct rotational direction to avoid kinking of the perforator. Closure of the donor site under tension should be avoided to prevent reduction of the flap’s blood supply by compression of the source vessel and, in the limbs, by swelling of the distal segment. If closure by direct suture is not possible, the use of a free thickness skin graft is indicated. Discussion After a long evolution in flaps surgery, which started with the works on skin blood supply of Manchot [15], Salmon [16], Taylor and Palmer [17], a step forward was represented by the work of Saint-Cyr et al. [18] which focused on the perforator vessels and not the source vessel anymore. After conducting several anatomical studies, they defined the “perforasome” as the vascular territory of a single perforator and described some principles: a. the perforasomes are interconnected by direct and indirect linking vessels; b. the design of a flap should respect the orientation of linking vessels: axial in the extremities and transversal in the trunk; c. the perforasome of a perforator emerging from a specific source vessel is preferentially filled before filling perforasomes from adjacent source vessels; d. the blood flow in linking vessels is distal from joints or non-mobile skin, but for perforators centrally located in between two joints, the flow is multi-directional. As a result of this evolution, and following the harvesting of the first flaps sparing the source artery and underlying muscle performed by Kroll and Rosenfield in 1988 [1] and Koshima and Soeda in 1989 [2], the use of perforator flaps became increasingly more extensive. They were used for the beginning more as free flaps, but the distant donor site, the difficulties in obtaining a similar reconstruction, and the technical high-demand procedure are some of the factors that stimulated surgeons to find alternatives to free flaps. In recent years, the use of local perforator flaps gained a big popularity, mainly due to some advantages: (1) replacing like with like, (2) donor site in the same area, (3) possibility of complete or partial donor site primary closure, (4) less demanding from technical point of view, because they do not need microvascular sutures (microsurgical non-microvascular flaps), and (5) shorter operating time [3,13,19,20]. Chang et al. [21] described for the first time in 1988 a fasciocutaneous forearm reverse flap by sparing the radial artery, but the real interest in using local perforator flaps only became manifest from 1994. Starting with this moment, the use of local perforator flaps became increasingly extensive. Even if these flaps can be used as pedicled and transposition flaps, their use as propeller flaps seems to be more useful and is preferred by most surgeons.
Hyakusoku et al. [22] introduced in 1991 for the first time the term propeller flap, to describe an adipocutaneous flap with blood supply through a random subcutaneous pedicle and rotated about for 90°. Later on, Hallock [23] used this term for the first time to define a perforator flap rotated for 180°. The Advisory Panel of the First Tokyo Meeting on Perforator and Propeller Flaps established in 2009 the definition and terminology of propeller perforator flaps: a skin island with two paddles demarcated by the perforator vessel, which has to rotate for at least 90–180° [24]. Of great importance is the very thoughtful planning and design of the flap, as well as the length of the perforator. One of the most important factors in diminishing the complication rate is the necessity to establish the realistic dimensions of such a flap, in other words the safe vascular limits of a perforator pedicle. While at the beginning it was considered that the dimensions of a perforator flap should not exceed the distance between two perforators, Saint-Cyr et al. [18] demonstrated that the single perforator of a flap is hyperperfused, which increases its filling pressure and opens the linking vessels with adjacent territories. It is easy to understand that the possibility of establishing before or during surgery the safer dimensions of a flap can dramatically ameliorate the success rate. A lot of methods were used for this purpose, such as handheld Doppler, color Doppler, Duplex ultrasound, arteriography, magnetic resonance angiography, and high-resolution computed tomography. No single method provides information regarding flap viability, but only about the perforator’s distribution and/or caliber [20]. The flap perfusion, but not the dimensions of a flap, can be tested during surgery by fluorescein [20,25,26] or indocyanine green near-infrared angiography [20,27–29]. The main advantages of propeller perforator flaps recommend them as a valuable option in the reconstruction armamentarium. The surgical procedure is relatively easy and little time consuming, which offers a lot of benefits to the elderly, polytraumatized patients, or to those with a compromised general health status. A potential disadvantage can be related to the location of the perforator within the zone of injury, but generally this fact does not interfere with the viability of the flaps. The main indication for propeller perforator flaps is the coverage of small to medium size defects, but sometimes their dimensions could be larger. The explanation for survival of such big flaps can be found in the perforasome concept of Saint-Cyr et al. [18], according to which the hyperperfusion in a perforator allows the capture of multiple adjacent perforasomes through direct and indirect linking vessels. The most common complication of propeller perforator flaps is represented by venous congestion of the tip or of the entire flap, and is due to the insufficient flow in the perforator pedicle. This happens either because of inadequate selection of the perforator, or due to its insufficient dissection and mobilisation, especially around the vein. If venous congestion is observed intra-operatively, venous supercharging of the flap can be done by performing a microvascular venous anastomosis. In instances of signs of ischemia, derotation of the flap to its original position can be attempted. In instances of vascular problems appearing after surgery, some flaps can be saved by removing the stitches, by doing small punctures or incisions and applying local heparinization, or by using leeches. But, if compared with free flaps, the loss of a propeller perforator flap, involves generally only partially the thickness of the flap. While generally in a propeller perforator flap only the superficial part is lost, if a free flap is lost, everything is lost. This means that the flap has done its job of covering the denuded anatomical elements, because after debridement the granulation of the wound is very fast and allows skin grafting [4]. In conclusion the presence of numerous perforator vessels all over the body makes reasonable and reliable the harvesting of local perforator flaps in order to cover small and medium size defects.
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037
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The functional and aesthetic outcome is more than acceptable, but their use needs further research especially regarding the real possible dimensions of this kind of flaps. Declaration of Competing Interest All authors have nothing to declare in relation to the content of this manuscript. References [1] Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988;81:561–6. [2] Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645–8. [3] Georgescu AV, Matei I, Ardelean F, et al. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery 2007;27:384–94. [4] Georgescu AV. Propeller perforator flaps in distal lower leg: evolution and clinical applications. Arch Plast Surg 2012;39:94–105. [5] Quaba O, Quaba AA. Pedicled perforator flaps for the lower limb. Semin Plast Surg 2006;20:103–11. [6] 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. [7] Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: clinical results and vascular anatomy. Plast Reconstr Surg 2010;126:1589–603. [8] El-Sabbagh AH. Skin perforator flaps: an algorithm for leg reconstruction. J Reconstr Microsurg 2011;27:511–23. [9] Lee BT, Lin SJ, Bar-Meir ED, et al. Pedicled perforator flaps: a new principle in reconstructive surgery. Plast Reconstr Surg 2010;125:201–8. [10] Wei FC, Celik N. Perforator flap entity. Clin Plast Surg 2003;30:325–9. [11] Koshima I, Itoh S, Nanba Y, Tsutsui T, Takahashi Y. Medial and lateral malleolar perforator flaps for repair of defects around the ankle. Ann Plast Surg 2003;51:579–83. [12] Georgescu AV, Matei IR, Llusa M. Plantar flaps based on perforators of the plantar metatarsal/common digital arteries. J Reconstr Microsurg 2014;30:469–74.
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[13] Matei I, Georgescu AV, Chiroiu B, et al. Harvesting of forearm perforator flaps based on intraoperative vascular exploration: clinical experiences and literature. Microsurgery 2008;28:321–30. [14] Saint-Cyr M, Mujadzic M, Wong C, et al. The radial artery pedicle perforator flap: vascular analysis and clinical implications. Plast Reconstr Surg 2010;125:1469–78. [15] Manchot C. The cutaneous arteries of the human body. New York: Springer-Verlag; 1983. [16] Salmon M. Arteries of the skin. Taylor GI, Tempest M, editors. London: Churchill Livingstone; 1988. [17] Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40:113–41. [18] Saint-Cyr M, Wong C, Schaverien M, et al. Perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529–44. [19] Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: clinical results and vascular anatomy. Plast Reconstr Surg 2010;126:1589–603. [20] Lee BT, Lin SJ, Bar-Meir ED, et al. Pedicled perforator flaps: a new principle in reconstructive surgery. Plast Reconstr Surg 2010;125:201–8. [21] Chang YT, Wang XF, Zhou ZF, et al. The reversed forearm fasciocutaneous flap in hand reconstruction: 10 successful cases. Chin J Plast Surg Burns 1988;4:41–9. [22] Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991;44:53–4. [23] 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. [24] Pignatti M, Ogawa R, Hallock GG, et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg 2011;127:716–22. [25] McCraw JB, Myers B, Shanklin KD. The value of fluorescein in predicting the viability of arterialized flaps. Plast Reconstr Surg 1977;60:710–19. [26] Morykwas MJ, Hills H, Argenta LC. The safety of intravenous fluorescein administration. Ann Plast Surg 1991;26:551–3. [27] Eren S, Rubben A, Krein R, et al. Assessment of microcirculation of an axial skin flap using indocyanine green fluorescence angiography. Plast Reconstr Surg 1995;96:1636–49. [28] Holm C, Mayr M, Hofter E, et al. Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green. Br J Plast Surg 2002;55:635–44. [29] Matsui A, Lee BT, Winer JH, et al. Real-time intraoperative near-infrared fluorescence angiography for perforator identification and flap design. Plast Reconstr Surg 2009;123:125e–127e.
Please cite this article as: A.V. Georgescu, I.R. Matei and M. Bumbasirevic et al., Why, when and how propeller perforator flaps in reconstructive surgery, Injury, https://doi.org/10.1016/j.injury.2019.10.037