|Year : 2019 | Volume
| Issue : 4 | Page : 167-171
Perforator pedicled propeller flap: A reliable coverage of wounds around ankle
Mohd Altaf Mir1, Shahab Faria Shahabuddin2, Dinesh Kumar3
1 Department of Burns, Plastic and Reconstructive Surgery, Adesh Medical College, Kurukshetra, Haryana, India
2 Department of Plastic Surgery, Desun Hospital and Heart Institute, Kolkata, West Bengal, India
3 Department of Surgery, Adesh Medical College, Kurukshetra, Haryana, India
|Date of Submission||19-Nov-2018|
|Date of Acceptance||09-Mar-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Mohd Altaf Mir
Department of Burns, Plastic and Reconstructive Surgery, Adesh Medical College, Mohri, Kurukshetra - 136 135, Haryana
Source of Support: None, Conflict of Interest: None
Background: This study aimed to determine the reliability of perforator pedicled propeller flap for coverage of wounds around the ankle. Materials and Methods: This was a prospective study undertaken between September 2017 and November 2018 in the Division of Plastic and Reconstructive Surgery of our institution. Patients with soft-tissue defect of the ankle referred from the Division of Orthopedic Surgery were included. Those with a scarring in the region of calf in the area of proposed flap were excluded. A detailed history and examination were recorded. A complete blood count, kidney and liver function tests, coagulation profile, and hepatitis B and C and human immunodeficiency viral marker testing were performed following informed consent. Anteroposterior and lateral radiographs of the ankle were taken in all cases. Perforator pedicled propeller flaps were raised in all patients for coverage of soft-tissue defects around the ankle. All patients were followed up regularly. Results: Ten patients with soft-tissue defect around the ankle were referred to our division from the Division of Orthopedic Surgery or admitted through the outpatient department of the Division of Plastic and Reconstructive Surgery of our institution. Eight patients were male and two were female, with the age ranging from 10 to 50 years. The mean operation time was 58 min. Size of the flap varied from 21 cm × 8 cm (168 cm2) to 8 cm × 5 cm (40 cm2). Flaps were rotated through 110°–180°. Out of ten flaps, eight flaps survived completely without any complications. Partial flap loss was found in one patient (10%), marginal flap necrosis in one patient (10%), and none of the flap was lost completely. Thus, the overall success rate of perforator pedicled propeller flap in our study observed was 80%. Conclusion: The perforator-based propeller flap is a versatile and reliable flap for the coverage of soft-tissue defects around the ankle because its vascularity is predictable.
Keywords: Ankle wound, perforator, propeller flap
|How to cite this article:|
Mir MA, Shahabuddin SF, Kumar D. Perforator pedicled propeller flap: A reliable coverage of wounds around ankle. Turk J Plast Surg 2019;27:167-71
| Introduction|| |
Soft-tissue defects in the lower extremity, especially around the ankle, present a formidable challenge due to lack of reliable local flaps, composite tissue defects, inadequate and tight local tissues, and poor circulation. Tendons and bone are frequently exposed because of the thinness of subcutaneous tissues; this makes skin grafting a poor option. A durable flap with good skin texture, dependable vascularity, good arc of rotation, easy to dissect, and minimum donor site morbidity is the most desired parameter for coverage of such defects., The evolution of perforator flaps started when survival of free flaps had already reached 98%. The quest for refinements and reduction in donor-site morbidity resulted in the development of the perforator flap. Nowadays, with increasing application of perforator flaps in lower leg and foot reconstruction, we mainly depend on the perforators from the three main lower leg arteries namely posterior tibial artery perforator, peroneal artery perforator, and anterior tibial artery perforator. Islanded propeller flap has become one of the most reliable options for reconstruction of the defects around ankle since its introduction in 1991 by Hyakusoku et al. In this study, the experience with perforator-based propeller flap based on posterior tibial, anterior tibial, and peroneal arteries has been reported. The flap was rotated from 90° to 180° to cover the defect on the ankle region, and the donor site was grafted with split-thickness skin graft.
| Materials and Methods|| |
This was a prospective study undertaken between September 2017 and November 2018 in the Division of Plastic and Reconstructive Surgery of our institution. The study has been approved by the departmental ethical committee and has therefore been performed in accordance with ethical standards laid down in 1964 Declaration of Helsinki and its later amendments. Patients with soft-tissue defect around the ankle referred from the Division of Orthopedic Surgery were included in the study. Those with a scarring in the region of calf in the area of proposed flap were excluded from the study. A detailed history and examination were recorded. A complete blood count, kidney and liver function tests, coagulation profile, and hepatitis B and C and human immunodeficiency viral marker testing were performed following informed consent. Perforator pedicled propeller flaps were raised in all patients for coverage of soft-tissue defects around the ankle. Ten patients underwent perforator-based propeller flap based on three major vessels of the lower leg. Surgical indication was limited by the location of the defect. Only small-to-moderate-sized defects around the ankle area, especially malleoli, Achilles tendon, and heel regions, were selected for this flap technique. A handheld Doppler probe of 8 MHz was used to identify potential perforators of the flap. Patients with peripheral vascular diseases, diabetes, and degloving injury were excluded from the study. All flaps were based on a single perforator. The perforator-based propeller flap used in our study was a “pedicled perforator flap.”
]The bio-geometry of our propeller flaps corresponds to two blades of a propeller of unequal length, and the pivot point is formed by the perforator. When the two blades are rotated, the longer blade covers the defect. The distance between the proximal tip of the flap and the perforator equals the distance between the perforator and the farthest limit of the defect, with 1 cm added to the total length to prevent tension in the flap. Preoperatively, perforators near the defect were marked with the help of a handheld 8 MHz Doppler probe. The patient is positioned depending on the site of the defect. The flap was designed around the good caliber perforator closest to the defect. The design of the flap is described above. A tourniquet is inflated without prior exsanguinated. This will facilitate the identification of perforators as they remain filled with the blood. All flaps were dissected under loop magnification. An exploratory incision is given on the posterior margin of the flap. The dissection is done in subfascial plane, keeping in mind the marked site of the perforator. Once a suitable perforator was identified, the dimension of the flap was rechecked or modified to the extent, as required. Flap margins were then incised from all the four sides so as to island it on the selected perforator. If tension was encountered during transfer into the defect, the perforator was further dissected into the muscle or septum to gain additional length and prevent kinking of the vessel. After complete elevation of the flap, deflation of the tourniquet was done and perfusion within the flap was checked, and it was rotated randomly to the defect. Excessive skeletonization was avoided unless required. A light dressing with dorsal splint and limb elevation for 5 days was done. No aspirin or heparin was given routinely. All patients were followed up regularly. The data obtained were analyzed by using one-way analysis of variance using IBM SPSS software version 23 (Armonk, NY: IBM Corp) statistical tool.
Here, we represent two successful cases of reconstruction of wounds around the ankle with perforator pedicled propeller flap.
A 24-year-old male developed an unstable scar over the heel and adjacent posterior aspect of the leg which after excision resulted in tissue defect of size 15 cm × 7.5 cm. Excision of the scar was performed, and the defect was covered with a 21 cm × 8 cm flap based on peroneal artery perforator. The flap was rotated by 180° over its perforator to reach the defect. Secondary defect was covered with a split-thickness skin graft. There was no uneventful event and the flap healed well [Figure 1], [Figure 2], [Figure 3].
|Figure 1: Intraoperative photograph of case 1 showing raised propeller flap|
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|Figure 2: Intraoperative photograph of case 1 showing propeller flap after rotation to cover heal defect|
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|Figure 3: Follow-up photograph of case 1 showing well-healed propeller flap|
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A 35-year-old male developed a nonhealing ulcer over the medial malleolus, and debridement and excision of the scar resulted in tissue defect of size 6 cm × 4.4 cm. After excision, the defect was covered with a 9 cm × 5 cm flap based on posterior tibial artery perforator. The flap was rotated by 180° over its perforator to reach the defect. Secondary defect was covered with a split-thickness skin graft. There was no uneventful event and the flap healed well [Figure 4], [Figure 5], [Figure 6].
|Figure 4: Intraoperative photograph of case 3 showing raised propeller flap|
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|Figure 5: Intraoperative photograph of case 3 showing propeller flap after rotation to cover the defect around the medial malleoli|
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|Figure 6: Follow-up photograph of case 3 showing well-healed propeller flap|
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| Results|| |
Ten patients with soft-tissue defect around the ankle were referred to our division from the Division of Orthopedic Surgery or admitted through the outpatient department of the Division of Plastic and Reconstructive Surgery of our institution. Eight patients were male and two were female, with age ranging from 10 to 50 years. The mean operation time was 58 min. Size of the flap varied from 21 cm × 8 cm (168 cm 2) to 8 cm × 5 cm (40 cm 2). Flaps were rotated through 110°–180°. Out of ten flaps, eight flaps survived completely without any complications.
Partial flap loss was found in one patient (10%), marginal flap necrosis in one patient (10%), and none of the flap was lost completely. Thus, the overall success rate of perforator pedicled propeller flap in our study observed was 80%. Even small donor-site defects after harvesting of the flap in the lower third leg required skin grafting, as they could not be closed primarily. Five flaps were on perforator from peroneal artery, and three and two flaps were each on perforators of posterior tibial and anterior tibial arteries. Marginal wound dehiscence was managed with re-advancement of the flap. However, partial flap necrosis due to venous congestion was managed with subsequent debridement and local transposition flap. One of the patients developed transient edema which was managed by simple limb elevation. None of the other flap complications were seen, and most of the patients were satisfied with the final results. The characteristics of the patients are summarized in [Table 1].
| Discussion|| |
Reconstruction of soft-tissue defects at the ankle region remains a frequent and challenging problem for reconstructive surgeons. As there are thin nonexpendable soft tissues and predisposition for massive edema, even small tissue defects can become a huge problem in this region. There are many options available for the reconstruction of defects in this region such as local flaps, distant flaps, and free flaps. Local flaps may include random pattern flaps, fasciocutaneous flaps, reverse sural fasciocutaneous flaps, and muscle flaps. Distant flaps include cross-leg flaps and free flaps. Random skin flaps have high failure rates. Local pedicled fasciocutaneous flap in this region may give unsightly scar and large dog ear appearance. Free microvascular flaps need special expertise and skill for vascular anastomosis, and it is also a time-consuming procedure. Flap in this region may lead to loss of muscle function. After the introduction of the concept of angiosomes by Taylor, a large number of techniques of perforator-based local flaps in the leg have been developed.,, Perforator-based propeller flap is based on a reliable vascular supply. Perforator flaps play an important role in the reconstruction of various regions of the body.,,,, The main advantage of this perforator-based propeller flap over the conventional flap lies in the preservation of the main source vessel, high mobility of the flap, and minimal donor-site morbidity, and it avoids the debulking procedure maintaining high mobility. It also replaces like-with-like tissue in color, texture, and thickness that is very similar to the tissue lost. Harvesting the local perforator flap requires microsurgical dissection, but it does not need vascular anastomosis and can be defined as a microsurgical nonmicrovascular flap. In the lower leg and ankle regions, perforators of the three main arteries, namely anterior tibial artery, posterior tibial artery, and peroneal artery, can be chosen according to the site of the defect. A systematic review was done by Gir et al. on pedicled perforator flaps in the lower-extremity defects, and it was noted that the posterior tibial artery perforator flap and the peroneal artery perforator flap were the most frequently used flaps. Nearby island perforator-based propeller flap not only provides many alternatives, but it also gives an ideal solution for the small-to-medium-sized defect of the region around ankle, especially in the malleoli. Perforator flaps have evolved as a reliable option for the soft-tissue defects of the lower limb, especially in wounds around the ankle region irrespective of the size, location, and depth of the wound. Perforator-based propeller flap is one of the most useful options for repairing soft-tissue defects or chronic wounds around the ankle and heel. In the present study, we did not observe any major donor-site morbidity or sensorineural deficit; however, complete sensorineural recovery requires further follow-up of cases. It carries minimum donor-site morbidity, is a comparatively simpler operative technique to harvest and inset the flap rather than a microsurgical free flap, and follows the principles of replacement of tissue using “like with like.”
| Conclusion|| |
The perforator-based propeller flap is a versatile and reliable flap for the coverage of soft-tissue defects around the ankle because its vascularity is predictable.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fraccalvieri M, Bogetti P, Verna G, Carlucci S, Fava R, Bruschi S, et al.
Distally based fasciocutaneous sural flap for foot reconstruction: A retrospective review of 10 years experience. Foot Ankle Int 2008;29:191-8.
Akhtar S, Hameed A. Versatility of the sural fasciocutaneous flap in the coverage of lower third leg and hind foot defects. J Plast Reconstr Aesthet Surg 2006;59:839-45.
Xu G, Lai-Jin L. The coverage of skin defects over the foot and ankle using the distally based sural neurocutaneous flaps: Experience of 21 cases. J Plast Reconstr Aesthet Surg 2008;61:575-7.
Ahmed SK, Fung BK, Ip WY, Fok M, Chow SP. The versatile reverse flow sural artery neurocutaneous flap: A case series and review of literature. J Orthop Surg Res 2008;3:15.
Wei FC, Celik N. Perforator flap entity. Clin Plast Surg 2003;30:325-9.
Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991;44:53-4.
Jakubietz RG, Jakubietz MG, Gruenert JG, Kloss DF. The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: A new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap. Ann Plast Surg 2007;59:667-71.
Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003;30:331-42, v.
Venkataramakrishnan V, Mohan D, Villafane O. Perforator based V-Y advancement flaps in the leg. Br J Plast Surg 1998;51:431-5.
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;90:643-9.
Lees V, Townsend PL. Use of a pedicled fascial flap based on septocutaneous perforators of the posterior tibial artery for repair of distal lower limb defects. Br J Plast Surg 1992;45:141-5.
Hamdi M, Van Landuyt K, de Frene B, Roche N, Blondeel P, Monstrey S, et al.
The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg 2006;59:644-52.
Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction: A new concept. Br J Plast Surg 2004;57:531-9.
Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg 2006;35:199-207.
Kim JT. Latissimus dorsi perforator flap. Clin Plast Surg 2003;30:403-31.
Karki D, Singh A. The distally-based island ulnar artery perforator flap for wrist defects. Indian J Plastic Surg 2007;40:12-7.
Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery 2007;27:384-94.
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;28:595-601.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]