Perforator‐based propeller flap for fibula free flap donor site repair: A novel surgical technique

Closure of the osteocutaneous fibula flap donor site with a tonearm (propeller) flap: Anatomic considerations and surgical indications

BACKGROUND

Skin graft is frequently used for donor site closure after osteocutaneous fibula free flap (OCFFF) harvest when primary closure is not possible. Partial skin graft loss requiring wound care is a common complication. The purposes of this prospective study were to investigate the perforator anatomy for local propeller or tonearm flap closure and compare the outcomes to those of skin graft closure.

METHODS

All patients undergoing OCFFF for head and neck reconstruction from February 2022 to October 2023 were considered for the tonearm flap. Intraoperative perforator anatomy was prospectively recorded. Surgical techniques and criteria for tonearm flap reconstruction were described. A minimum follow-up period of 6 months was required. Outcome measures included the rate of flap success and wound complications.

RESULTS

Forty consecutive patients were included. The tonearm flap was not possible in 16 patients (40%) due to unfavorable perforator anatomy and 2 patients underwent primary closure. All successful tonearm flaps were eccentrically designed on a proximal lower leg perforator, located 13.5 ± 1.99 cm from the fibular head. Most proximal perforators were musculocutaneous through the soleus muscle (n = 20, 90.9%), whereas the rest were septocutaneous (n = 2, 9.1%), originating from the peroneal artery. Three patients experienced distal partial flap loss; one required an additional skin graft. Only half of the skin graft cohort (n = 99, 50.8%) achieved complete skin graft take. The average skin graft loss was 34.3%, and wound care was required for an average period of 51.6±52.8 days.

CONCLUSIONS

The study findings demonstrate that local tonearm flaps, when anatomically feasible, can be successfully performed with superior outcomes compared to skin graft closures.

Comparison of propeller flaps versus skin grafts for coverage of osteocutaneous fibula free flap donor site defects

BACKGROUND

Authors compare use of propeller flaps versus skin grafts in defect coverage after fibula flap harvest.

MATERIALS AND METHODS

Retrospective review of patients who received either PFPF or STSG. Primary predictor variable was technique, and secondary predictor variables were comorbidities. Primary outcome variable was flap/graft healing, and secondary outcome variables were cosmesis, adverse events, effect on activities of daily living (ADLs), pain, additional procedures, and cost. Statistical analysis performed via independent sample t tests, ANOVA, and χ² tests. Logistic regression analysis was performed.

RESULTS

Study sample was 50 patients. PFPFs showed higher rates of success, while STSG showed increased complications and adverse events. Pain and ADLs significantly affected in STSG group. Cosmesis was better in the PFPF group, and overall cost was significantly higher in STSG group.

CONCLUSION

PFPFs show greater success rates, fewer complications, improved cosmesis, less pain, reduced cost compared to STSG for wound coverage after fibula flap harvest.

Crescent-shaped skin paddle for a fibular flap: Avoiding skin grafting at the donor site

A fibular osteocutaneous flap is the mainstay of oromandibular reconstruction. This report aimed to present a crescent-shaped skin paddle, a novel fibular skin paddle designed to achieve both sufficient intraoral lining and primary closure of the donor site. A 3-5-cm-wide crescent-shaped skin paddle was harvested according to the locations of the distal septocutaneous perforators on preoperative color Doppler sonography. This narrow skin paddle fits well morphologically into the mucosal defect, enabling a reliable intraoral lining. This advantage becomes more evident when the mandibular defect crosses the midline or extends posteriorly to the maxillary tuberosity as the shape of the mucosal defect becomes arcuate. Primary closure of the donor site is easier to achieve because the required width of the crescent-shaped skin paddle is minimized. This method reduces donor-site morbidity associated with skin grafting while ensuring safe intraoral closure with a fibular osteocutaneous flap.

Closure of a free osteofasciocutaneous fibula flap donor site using local skin grafts or flaps: A systematic review and meta-analysis

BACKGROUND

In free osteofasciocutaneous fibula flaps, secondary donor sites are avoided using one of three local closure methods: full-thickness skin grafts (FTSGs), split-thickness skin grafts (STSGs), or flaps. This systemic review aimed to evaluate the differences in outcomes among the three groups of closure methods used for free fibula flap defects.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the PubMed and Web of Science medical databases from inception to January 2021 for articles focused on closure of the free fibula flap donor site using the lower leg area-local skin graft or flap-that mentioned the free fibula flap defect size, and/or complications of the donor site. Study characteristics, free fibula flap size, and short-term complication rates were extracted for analysis. The pooled complication rates and confidence intervals were calculated based on the random-effects model.

RESULTS

Eleven studies were included in the qualitative synthesis, and ten studies were included in the quantitative synthesis (meta-analysis). The FTSG (n = 79, 52.3%) was the most widely used method, while both STSG (n = 36, 23.8%) and flap (n = 36, 23.8%) were the least commonly used methods. The mean free fibula flap length and width were largest for the flap method (11.5 ± 2.5 cm and 6.0 ± 1.8 cm), and all closure methods were used for free fibula flap widths ≥3 cm. Rates of partial and complete necrosis were highest for the FTSG method (20.3%, p = .95, I²  = 0%) and lowest for the flap method (12.7%, p = .95, I²  = 0%).

CONCLUSION

This systemic review indicated that any closure method could be adapted for a free fibula flap width ranging from 3 to 9 cm, and the flap method was associated with the lowest rate of short-term complications.

Use of soleus musculocutaneous perforator-based propeller flap for lower extremity wound coverage after osteocutaneous fibula free flap harvest

BACKGROUND

Osteocutaneous fibula free flap (OCFFF) donor sites are often covered with skin grafts, with an additional donor site, more postoperative care, and increased cost. The authors examine posterior tibial artery (PTA) based pedicled propeller flaps (PPF) as an alternative for OCFFF donor site coverage.

PATIENTS AND METHODS

Retrospective review of 16 consecutive patients from 30 to 79 years old, who underwent OCFFF reconstruction of head and neck defects (11 mandibular, 5 maxillary), with the closure of donor site with PPF based on a perforator from PTA. Mean donor site defect measured 12.9 × 5.1 cm, PPF was an elliptical design, and rotated 180 degrees in a propeller fashion, to cover donor site defect. Visual analog scale (VAS) was used to assess esthetic results, functional outcomes assessed using mobility and range of motion (ROM), and secondary complications including infections, hematomas, and seromas were recorded. Follow-up period was noted in months postoperatively. Other information collected included underlying head and neck pathology.

RESULTS

Average dimension of PPF measured 13.9 × 4.1 cm. Successful closure of donor site defects in 14 of 16 patients, with two flaps having partial necrosis, one requiring a secondary skin graft. Follow-up was 6 to 10 months, esthetic results with mean VAS 8.8 of 10, full ROM, and mobility noted. No secondary complications were observed. The most common pathology noted was squamous cell carcinoma (6 of 16 patients).

CONCLUSION

PPFs based on the soleus branch of the PTA represent an excellent alternative to skin grafts for the closure of OCFFF donor site defects.

Perforator-based propeller flaps for reconstruction of massive anterolateral thigh donor site wounds

BACKGROUND

Wide anterolateral thigh (ALT) flap donor site defects may make primary closure difficult or impossible, with split thickness skin grafting and/or negative pressure therapy often used instead. Here, we describe a technique using propeller flaps based on varying thigh perforating vasculature in donor site reconstruction for these larger deformities.

METHODS

Case series RESULTS: Three patients are described that had perforator-based propeller flap reconstruction of large ALT donor site wounds that were not amenable to primary closure. Two propeller flaps were supplied by perforators of the transverse branch of the lateral circumflex femoral artery and one by a perforator of the deep femoral system. One patient experienced partial loss of the propeller flap, but completely healed with local wound care.

CONCLUSION

The propeller flap is a safe method to reconstruct large ALT donor sites not amenable to primary closure.