propellar flaps for lower leg reconstruction …

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Int. J. Pharm. Med. & Bio. Sc. 2014 Ranganth V S et al., 2014

PROPELLAR FLAPS FOR LOWER LEG

RECONSTRUCTION RESULTS OF A TERTIARY

CARE CENTER

Peddi Manjunath1, Ranganth V S1*, Ramesh K T1 and Shakarappa M1

Research Paper

Reconstruction of defects in the foot and distal lower leg, with exposed tendons, bone, and/orhardware continues to be challenging, and they generally need flaps coverage. A variety of flapswere used in the attempt to achieve excellence in form and function. We present our experiencewith 30 cases of propeller flap for various leg defects. Propeller perforator flaps are best suitedfor small and medium defects, and in trauma patients for defects without extensive avulsion anddegloving injuries.

Keywords: Propeller flap, Leg defect, Perforator flap, Free flap

*Corresponding Author: Ranganth V S � [email protected]

INTRODUCTION

Reconstruction of defects in the foot and distal

lower leg, with exposed tendons, bone, and/or

hardware continues to be challenging, and they

generally need flaps coverage (Byrd et al., 1985;

Godina, 1986; Ninkovic et al., 1999; Georgescu

and Ivan, 2003; Levin, 2006). A variety of flaps

were used in the attempt to achieve excellence

in form and function. After a long evolution of the

reconstructive methods, including random pattern

flaps, axial pattern flaps, musculocutaneous flaps

and fasciocutaneous flaps, the reappraisal of the

works of Manchot and Salmon by Taylor and

Palmer opened the era of perforator flaps. This

era began in 1989, when Koshima and Soeda,

and separately Kroll and Rosenfield described the

first applications of such flaps (Manchot, 1983;

ISSN 2278 – 5221 www.ijpmbs.com

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Int. J. Pharm. Med. & Bio. Sc. 2014

1 Department of Plastic Surgery, Bangalore Medical College and Research Center, Fort, Bangalore.

Salmon et al., 1988; Taylor and Pan, 1998;

Koshima and Soeda, 1989; Kroll and Rosenfield,

1988).

Propeller flaps are a perforator flap based on

a skeletonized perforator vessel and rotated 180o

(Hallock, 2006).

In this study, we present the experience with

perforator-based propeller flap based on posterior

tibial and peroneal artery.

MATERIALS AND METHODS

This is a prospective study done in Bangalore

Medical College and research center in the

department of plastic surgery between January

2012 and June 2013. Patients with defect in the

lower 1/3rd of leg are included in the study. All

patients are evaluated with preoperative

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investigation such as complete blood count

HbA1c and arterial Doppler of the lower limb.

Patients with HbA1c of more then 8 or with

peripheral arterial disease were excluded from

the study. Preoperative marking of the perforators

is done in all the cases. 30 patients were treated

with perforator-based propeller flap for distal leg

and ankle defects. Majority (70%) were post

traumatic due to road traffic accidents. There are

six cases of post burn contracture. Fourteen

patients presented with medial malleolar soft-

tissue defect, ten lateral malleolar defects, three

anteromedial lower tibial defect and three patients

presented with defect over anterior aspect of

lower tibia. Defect size is between 3*8cm to 8*22

cm. Except 4 all are based on posterior tibial

artery. A constant perforator of posterior Tibial

artery is found 9-10 cm above the medial

malleolus in 22 out of 26 cases.

Technique of Flap Dissection

Preoperative detection of the perforators in the

distal lower leg is done in all cases even though

the identification and isolation of a patent

perforator can be very easily done intraoperatively

through careful dissection, considering thedefects’ needs.

One edge of the future flap is incised and thisincision is planned for possible alternative flap, ifa suitable perforator isn’t found. The incision ismade up to or deep to the deep fascia, and isfollowed by subfascial dissection undermagnification and all the identified perforators arepreserved. All through dissection, the perforatorsis humidified with lidocaine to prevent spasm. Iftwo adjacent perforators with samecharacteristics are found, both of them arepreserved until the flap’s dissection is completed

and the tourniquet released. Once the best

perforator(s) is chosen, according with its location,

size, suitability to sustain the flap, number of

venae comitantes, course and orientation, the

definitive design of the flap is accomplished. First,

the long axis of the flap is orientated in the long

axis of the leg 2 cm length is added to distance

between the perforator and the distal edge of the

defect, and the resulting value is transposed

proximally to the skin which will cover the defect,

ensuring the flap’s comfortable inset, without any

tension on the pedicle. Similar, to the width of the

defect is added 0.5-1 cm is added to allow the

closure without tension. The incision around the

flap is done and the harvesting is completed. The

flap is rotated in a clockwise or counter-clockwise

direction, depending on the right rotational

direction to avoid kinking of the vessels. The donor

site is closed primarily. If primary closure isn’t

possible, the donor-site is partially directly

sutured, and the remaining defect skin grafted.

RESULTS

Thirty patients with defect over ankle region were

operated from January 2012 to June 2013, 80%

of them were males. Mean age was 36.4 years.

Three patient had diabetes mellitus. Three patient

developed partial flap necrosis, which was

managed with skin grafting.

Majority of the patients are post trauma with 9

patients is due to post burn contracture with defect

around the ankle.

Three patients developed transient venous

congestion, which subsided spontaneously

without complications. Donor site was closed

primarily in all but 2 patients, whose defect is more

then 20 cm in length. Skin grafting is done in these

patients. Flaps were based on posterior tibial

artery in 26 patients and peroneal artery in four

patients. All patients provided stable coverage of

the defect with good contour and skin cover.

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Patient 1

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Patient 2

Patient 3

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DISCUSSION

The anatomical features of the lower third of the

leg make the wound coverage of the soft tissue

loss into a challenging problem. The bones of the

lower third are vulnerable to injury. Due to the

paucity of soft tissues around them, the fractures

that occur are often open. Most muscles become

tendons at that level and in the case of soft tissue

loss, skin graft may not suffice and flap cover

becomes mandatory. The three major arteries to

the leg, anterior and posterior tibial, and peroneal

are in closed compartments and they do not have

significant communications between them.

Recently lot of work has been done on the

perforators arising from these vessels in the lower

third of the leg. The ones from the posterior tibial

and the peroneal are significant and could be

used for flaps in the region.

The big popularity gained by the local perforator

flaps was due to their main advantages: (1)

Sparing of the source artery and underlying

muscle and fascia, (2) Combining the very good

blood supply of a musculocutaneous flap with the

reduced donor-site morbidity of a skin flap, (3)

Replacing like with like, (4) Limiting the donor-

site to the same area, (5) Possibility of completely

or partially primarily closure. (6) Technically less

demanding, because they are microsurgical

procedures, but without microvascular sutures,

(7) Shorter operating time (Lecours et al., 2010;

Rubino et al., 2006; Georgescu et al., 2007;

Parrett et al., 2009; El-Sabbagh, 2011; Lee et al.,

2010).

Propeller perforator flaps in distal lower leg

provide a valuable option in the reconstructive

armamentarium, due to their main advantages. It

is a relatively easy and less time consuming

procedure, which is beneficial in elderly, multiple

injured patients, or with a compromised general

status. Besides the fact that the reconstruction

can replace like-with-like by using tissues of

similar texture, thickness, pliability, and color, this

method avoid the complexity, the multiple surgical

sites and the extra costs associated with free

flaps and microsurgery. Moreover, in case of

failure of a local perforator flap, alternative

methods can be used, including free flaps. Similar

to free flaps, the local perforator flaps reduce

morbidity of the donor site, because the source

artery and underlying muscle are preserved, and

scars are limited to only one region. For defects

less than 6 cm wide, the donor site can be

primarily closed (Jakubietz et al., 2007), but even

bigger defects can be partially direct sutured. A

significant drawback can be the cosmetic deficit

related to the donor site, which formally

contraindicates this procedure in women. Another

disadvantage is related to the fact that the

perforator can be within the zone of injury, which

can prejudice the viability of the flap.

Propeller perforator flaps are best suited for

small and medium defects, and in trauma patients

for defects without extensive avulsion and

degloving injuries. An obvious contraindication of

local perforator flaps are patients with peripheral

vascular diseases and/or insulin-dependent

diabetes. However, because the peroneal artery

is least likely to have atherosclerosis, or is the

last affected, local perforator flaps based on this

artery can be relatively safely harvested in elderly,

atherosclerotic and diabetic patients

The posterior tibial artery propeller perforator

flap is indicated for defects over the pretibial and

medial aspect of the distal leg, heel, medial

malleolus, calcaneum, Achilles tendon, and

dorsum of the foot. The best perforator to base

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CONCLUSION

Propellar flaps are very reliable in covering defects

of the foot and distal lower leg, and may be

alternative for free flaps.

REFERENCES

1. Byrd H S, Spicer T E and Cierney G (1985),

“3rd Management of open tibial fractures”,

Plast Reconstr Surg., Vol. 76, pp. 719-730.

2. El-Sabbagh A H (2011), “Skin perforator

flaps: an algorithm for leg reconstruction”,

J Reconstr Microsurg., Vol. 27, pp. 511-523.

3. Georgescu A V and Ivan O (2003),

“Emergency free flaps”, Microsurgery, Vol.

23, pp. 206-216.

4. Georgescu A V, Matei I, Ardelean F et al.

(2007), “Microsurgical nonmicrovascular

flaps in forearm and hand reconstruction”,

Microsurgery, Vol. 27, pp. 384-394.

5. Godina M (1986), “Early microsurgical

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6. Hallock G G (2006), “The propeller flap

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667-671.

the flap is located 5 cm above the medial

malleolus (Georgescu et al., 2007), but with

bigger flaps the larger perforators from the middle

third of the leg can also be used.

The peroneal artery propeller perforator flap

based on the most distal, but very well

represented perforator located 5 cm above the

lateral malleollus, is very useful in covering the

Achilles region, calcaneum, and the lateral

malleolus, but, if very long flaps are harvested, is

possible to cover also the plantar and dorsal

aspect of the foot. Flaps based on more proximal

perforators can also be used, but with the price

of bigger flaps.

The venous congestion of the tip or of the entire

flap is the most common complication, and is

due to the insufficient flow in the perforator pedicle,

either because of an inadequate selection of the

perforator, or because of an insufficient dissection

and clearing of the vascular pedicle, especially

around the vein. Very rarely it happens to loose

the entire flap, and from this point of view, in some

cases is better to choose a local perforator flap,

rather than a free flap. If a free flap is lost,

everything is lost, while generally in a local

perforator flap only the superficial part is lost,

which means that the flap did its’ job of covering

the denuded anatomical elements. After

debridement, the remaining part of the flap

generally granulates very fast, and can be grafted.

If signs of congestion or ischemia are

observed intraoperatively, a venous microsurgical

anastomosis or the derotation of the flap in its

original position can be attempted. If the vascular

problems appear only postoperatively, the flap

sometimes can be saved by removing the

stitches, performing incisions, applying local

heparinization or using leeches.

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8. Koshima I and Soeda S (1989), “Inferior

epigastric artery skin flaps without rectus

abdominis muscle”, Br J Plast Surg., Vol.

42, pp. 645-648.

9. Kroll S S and Rosenfield L (1988),

“Perforator-based flaps for low posterior

midline defects”, Plast Reconstr Surg., Vol.

81, pp. 561-566.

10. Lecours C, Saint-Cyr M, Wong C et al.

(2010), “Freestyle pedicle perforator flaps:

clinical results and vascular anatomy”, Plast

Reconstr Surg., Vol. 126, pp. 1589-1603.

11. Lee B T, Lin S J, Bar-Meir E D et al. (2010),

“Pedicled perforator flaps: A new principle

in reconstructive surgery”, Plast Reconstr

Surg., Vol. 125, pp. 201-208.

12. Levin L S (2006), “Foot and ankle soft-tissue

deficiencies: who needs a flap?”, Am J

Orthop., Belle Mead N J, Vol. 35, pp. 11-19.

13. Manchot C (1983), “The cutaneous arteries

of the human body”, Springer-Verlag, New

York.

14. Ninkovic M, Mooney E K, Kleistil T et al.

(1999), “A new classification for the

standardization of nomenclature in free flap

wound closure”, Plast Reconstr Surg., Vol.

103, pp. 903-914.

15. Parrett B M, Talbot S G, Pribaz J J et al.

(2009), “A review of local and regional flaps

for distal leg reconstruction”, J Reconstr

Microsurg., Vol. 25, pp. 445-455.

16. Rubino C, Coscia V, Cavazzuti A M et al.

(2006), “Haemodynamic enhancement in

perforator flaps: the inversion phenomenon

and its clinical significance: A study of the

relation of blood velocity and flow between

pedicle and perforator vessels in perforator

flaps”, J Plast Reconstr Aesthet Surg., Vol.

59, pp. 636-643.

17. Salmon M, Taylor G I and Tempest M (1988),

“Arteries of the skin”, Churchill Livingstone,

London.

18. Taylor G I and Pan W R (1998), “Angiosomes

of the leg: anatomic study and clinical

implications”, Plast Reconstr Surg. Vol. 102,

pp. 599-616.

propellar flaps for lower leg reconstruction …

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