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 � ranganath.vitlapur@gmail.com
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
Vol. 3, No. 2, April 2014
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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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Int. J. Pharm. Med. & Bio. Sc. 2014 Ranganth V S et al., 2014
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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Int. J. Pharm. Med. & Bio. Sc. 2014 Ranganth V S et al., 2014
Patient 1
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Int. J. Pharm. Med. & Bio. Sc. 2014 Ranganth V S et al., 2014
Patient 2
Patient 3
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Int. J. Pharm. Med. & Bio. Sc. 2014 Ranganth V S et al., 2014
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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Int. J. Pharm. Med. & Bio. Sc. 2014 Ranganth V S et al., 2014
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”,
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2. El-Sabbagh A H (2011), “Skin perforator
flaps: an algorithm for leg reconstruction”,
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3. Georgescu A V and Ivan O (2003),
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4. Georgescu A V, Matei I, Ardelean F et al.
(2007), “Microsurgical nonmicrovascular
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6. Hallock G G (2006), “The propeller flap
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7. Jakubietz R G, Jakubietz M G, Gruenert J G,
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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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Int. J. Pharm. Med. & Bio. Sc. 2014 Ranganth V S et al., 2014
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.
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