Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction

Comparing the Clinical Effects of Free and Pedicled Flap in Repairing Small Area of Distal Lower Limb Soft Tissue Defects: A Retrospective Comparative Study

Background and Aims

The exposure of tendons, blood vessels, nerves, and bone due to soft tissue defects in the foot poses a significant challenge for microsurgeons. Free perforator flaps and pedicled perforator flaps are currently the most common methods used for repairing small areas of soft tissue defects in the distal lower limb.

Methods

A retrospective analysis was carried out on 124 patients with small soft tissue defects in the distal lower limb from January 2009 to December 2021. The evaluation criteria encompassed the patient's intraoperative condition, the occurrence of short-term and long-term postoperative complications, as well as the esthetic and functional outcomes.

Results

In this study, two groups of patients with similar soft tissue defects were included. However, the free perforator flap group showed more severe wound damage compared to the pedicled perforator group. Intraoperatively, the pedicled perforator group needed a larger flap area for wound repair, and the free perforator group had higher intraoperative blood loss and longer operation time. Postoperatively, the incidence of complications was significantly higher in the pedicled perforator group, while the esthetic outcomes were poorer, but the functional evaluation results were better.

Conclusion

For small soft tissue defects in the distal lower limb, both free perforator flap and pedicled perforator flap are effective in wound repair. The free perforator flap has the advantage of being able to handle more complex wounds with less limitation by location. In cases where the microsurgical expertise is relatively limited and the injuries are minor, pedicled perforator can be considered as the primary choice.

Level of Evidence

III, case-control study.

Extensive Defect Reconstruction Using Multiple Perforator Propeller Flaps in a Jigsaw Puzzle Approach

BACKGROUND

Reconstruction of extensive defects remains a challenge. The authors report their experience with extensive defect reconstruction using multiple perforator propeller flaps and provide a systematic review of the literature on this approach.

METHODS

This retrospective study included patients who underwent defect reconstruction with multiple perforator propeller flaps from 2014 to 2021. A systematic review was conducted by retrieving studies on reconstructive strategy from PubMed, Web of Science, Embase, and Scopus published before December 1, 2022.

RESULTS

Thirty patients underwent defect reconstruction using 65 perforator propeller flaps. The posterior trunk (66.7%) was the most common site of defects. Complete flap survival was achieved in 61 flaps (93.8%). Partial necrosis of 4 flaps in 3 patients and venous congestion of 1 flap resulted in an overall complication rate of 13.3%. One flap experienced distal tip necrosis in 21 patients undergoing posterior trunk or perineal defect reconstruction, leading to an overall complication rate of 4.7%. Other complications were observed during the reconstruction of defects in the lower extremities (1 of 5 patients) and anterior trunk (2 of 4 patients). In the systematic review, 11 articles involving 74 patients were identified. Commonly reported locations of the defects were the perineum (55.4%) and posterior trunk (33.8%). Flap-related complications included venous congestion; no flaps were lost.

CONCLUSION

This study on the use of multiple perforator propeller flaps in a jigsaw puzzle approach demonstrated that the method can be used effectively for extensive posterior trunk and perineal defect reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Ortho-oncoplastic surgery in foot and ankle: A narrative overview on reconstruction of soft-tissue defects after oncologic resections

INTRODUCTION

Malignant tumors of the foot are rare, and treatment strategies are challenging considering the complex anatomy of this area. In recent years, dramatic advances in technology and collaborations between different specialties (such as orthopedic, oncology, radiology, plastic, and vascular surgery) significantly changed the approach to complex malignant tumors without resorting to limb removal. The combination of the strengths of both orthopedic surgery and plastic surgery constitutes the modern definition of "orthoplasty." The aim of this review article is to provide treatment strategies that are available for reconstruction of foot and ankle in limb-salvage surgery after tumor resection, with a specific focus on microsurgical techniques in plastic surgery.

METHODS

We conducted a comprehensive search for relevant papers across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with small and large soft tissue defects. Indications, pros and cons, and technique tips are discussed for each type of reconstructive technique.

RESULTS

The search was done using literature of the past 30 years (from 1990 to date), resulting in about 725 articles describing over 2000 cases. Cutaneous flaps included lateral supramalleolar flap, medial plantar flap, reverse sural neurocutaneous island flap, medial leg flap, and lateral leg flap. Free flaps included anterolateral thigh flap, radial forearm flap, latissimus dorsi flap, gracilis muscle flap, lateral arm flap, and rectus abdominis flap.

CONCLUSIONS

The orthoplastic approach in musculoskeletal oncology is a collaborative model of orthopedic and plastic surgeons working together, resulting in a higher rate of successful limb salvage in patients at risk for amputation. Protocols, biologic substitutes, and surgical techniques are largely improved in the last decades increasing the possibility of functional reconstruction. Microsurgical strategies represent the new frontiers in these demanding reconstructions.

Repairing of recurrent leg ulcer induced by hydroxyurea with posterior tibial artery perforator propeller flap: Case report

INTRODUCTION AND IMPORTANCE

Hydroxyurea is a cytotoxic drug commonly used to treat various myeloproliferative disorders. However, prolonged oral administration of this drug may trigger skin side effects and ulcers. There are few clinical reports on treating leg ulcers caused by hydroxyurea and even fewer clinical reports on managing recurrent ulcers after treatment.

CASE PRESENTATION

An 87-year-old woman with essential thrombocythemia presented with a painful skin ulcer on her left calf. After failed outpatient treatment, she opted for hospitalisation for free skin grafting. Four months later, ulcers reappeared at the transplant site, leading to her readmission to the hospital. The diagnosis revealed that the leg ulcers were caused by hydroxyurea. Despite this, she persisted with hydroxyurea treatment and subsequently underwent posterior tibial artery perforator flap surgery. During the two-year follow-up, a new ulcer developed on the medial condyle of her other calf. However, no new ulcers or local pain were observed in the area where perforator flap grafting was performed.

CLINICAL DISCUSSION

Leg ulcers caused by hydroxyurea are rare clinically and can easily be misdiagnosed. There is currently minimal research on ulcer recurrence after treatment. Posterior tibial perforator flaps may more effectively promote the healing of recurrent ulcers.

CONCLUSION

Compared to conservative treatment and skin grafting surgery, the posterior tibial artery perforator flap offers a dependable blood supply and enhances the likelihood of wound healing. It can be considered an option, particularly for recurrent and refractory ulcers, even without discontinuing medication.

The UQ Flap: A Novel Modification of the Keystone Flap

Wound closure following excisions on the leg (between the knee and ankle), including the distal leg, is challenged by limited skin laxity. The keystone flap, first described by Behan in 2003, was proposed as one solution, but with a significant complication rate on the distal leg. This pilot study introduces a novel modification of the keystone flap, named the UQ flap, differing from other modifications, with an un-incised portion on one flap border and a unique curved leading-edge to absorb tension and distribute shearing forces in different directions, providing improved flap security and vascularization. The UQ flap was performed on 10 patients in two formats of "U" and "Q" also with two different orientations as base-proximal and base-distal. Other variations including minor deviation from the longitudinal axis, and double flap, were also performed. Except for one case with minor infection, there were no complications, and the results were favorable. No fasciotomy or undermining was required. The UQ flap proved to be a safe and convenient method of wound closure on the leg, including the distal leg. Compared with the keystone flap, there were reduced incisions leading to improved vascularity and less healthy tissue trimming. Its unique shape provided flap flexibility facilitating easy adjustment to the defects. The order and direction of wound closure after the excision of the lesion and incision of the flap are critical.

A three-dimensional visualization of the full-field surgical region based on thin-slice MRI: A helpful approach for simultaneously guiding tumor resection and perforator flap elevation

Background

The goal of the current study was to explore the application of preoperative three-dimensional reconstruction (3DR) based on thin-slice magnetic resonance imaging (MRI) in the simultaneous guidance of en bloc tumor resection and adjacent perforator flap elevation.

Methods

The prospective cohort included 35 patients diagnosed with either soft tissue sarcoma or squamous cell skin cancer between 2019 and 2021. The preoperative 3DR based on thin-slice MRI illustrated the spatial anatomical relationship among the tumor, underlying muscle, adjacent perforator vessels, and bone around the surgical region. The accuracy of preoperative imaging data was verified by intraoperative vessel dissection and postoperative pathological measurements.

Results

Tumor size from 3DR data showed relatively high concordance rates with pathological measurements within the 95% limits of agreement. An average of three perforators (range: 1–7) with a mean diameter of 0.32 cm (range: 0.18–0.74 cm) from the 3DR were present in our study. The average distance between tumor boundary and perforator piercing sites on the 3DR was 2.2 cm (range: 1.2–7.7 cm). The average length of artery perforator coursing along the subcutaneous tissue was 5.8 cm (range: 3.3–25.1 cm). The mean flap harvest time was 55 mins (range: 36–97 min). The average flap size was 92.2 cm² (range: 32–126 cm²). One perforator flap occurred distal partial necrosis.

Conclusion

A thorough understanding of anatomical structures in the surgical region according to full-field 3DR based on thin-slice MRI can improve the performance of radical resection of the tumor and adjacent perforator flap transfer, especially for junior surgeons with a poor experience.

A Propeller Perforator Flap in the Distal Lower Extremity: An Alternative to Free Flap Coverage Near the Ankle

As perfusion assessment technologies and microsurgical techniques have evolved, plastic surgeons have become increasingly aggressive and creative in offering reconstructive solutions to limb salvage problems. In the distal lower extremity, pedicled perforator flap transfer has grown in popularity as compared to the historically reliable option of free tissue transfer. Pedicled perforator flaps typically avoid muscle harvest and restore the thin, supple soft tissue in the distal extremity, where there is a relative lack of redundancy of soft tissues. They also allow for a shorter operative time and recovery in otherwise complex wounds of the foot and ankle. This case report highlights the indications, nuance, and post-operative course of a patient who underwent peroneal perforator flap for coverage of a complex ankle wound in the setting of a calcaneal fracture.