Propeller Perforator Flaps in Distal Lower Leg: Evolution and Clinical Applications

다국어 초록 (Multilingual Abstract)

Simple or complex defects in the lower leg, and especially in its distal third, continue to be a challenging task for reconstructive surgeons. 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. Perforator flaps, whether free or pedicled, gained a high popularity due to their main advantages:decreasing donor-site morbidity and improving aesthetic outcome. The use as local perforator flaps in lower leg was possible due to a better understanding of the cutaneous circulation, leg vascular anatomy, angiosome and perforasome concepts, as well as innovations in flaps design.
This review will describe the evolution, anatomy, flap design, and technique of the main distally pedicled propeller perforator flaps used in the reconstruction of defects in the distal third of the lower leg and foot.

참고문헌 (Reference)

1 Panse NS, "What is safe limit of the perforator flap in lower extremity reconstruction ? Do we have answers yet?" 2011 : 349357-, 2011

2 Heitmann C, "Vasculature of the peroneal artery: an anatomic study focused on the perforator vessels" 19 : 157-162, 2003

3 Tang M, "Three-dimensional analysis of perforators of the posterior leg" 123 : 1729-1738, 2009

4 Saint-Cyr M, "Three- and four-dimensional computed tomographic angiography and venography for the investigation of the vascular anatomy and perfusion of perforator flaps" 121 : 772-780, 2008

5 Pignatti M, "The “Tokyo” consensus on propeller flaps" 127 : 716-722, 2011

6 Jiga LP, "The versatility of propeller flaps for lower limb reconstruction in patients with peripheral arterial obstructive disease: initial experience" 64 : 193-197, 2010

7 Yoshimura M, "The vasculature of the peroneal tissue transfer" 85 : 917-921, 1990

8 Koshima I, "The vasculature and clinical application of the posterior tibial perforator-based flap" 90 : 643-649, 1992

9 Taylor GI, "The vascular territories (angiosomes) of the body: experimental study and clinical applications" 40 : 113-141, 1987

10 McCraw JB, "The value of fluorescein in predicting the viability of arterialized flaps" 60 : 710-719, 1977

11 Kim JT, "The thin latissimus dorsi perforator-based free flap for resurfacing" 107 : 374-382, 2001

12 Mardini S, "The thigh as a model for free style free flaps" 30 : 473-480, 2003

13 Ger R, "The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions of the leg" 11 : 502-510, 1971

14 Haertsch P, "The surgical plane in the leg" 34 : 464-469, 1981

15 Morykwas MJ, "The safety of intravenous fluorescein administration" 26 : 551-553, 1991

16 Liu K, "The reverse-flow posterior tibial artery island flap: anatomic study and 72 clinical cases" 86 : 312-316, 1990

17 Hallock GG, "The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores" 56 : 540-542, 2006

18 Hyakusoku H, "The propeller flap method" 44 : 53-54, 1991

19 Hansen T, "The prevalence and quantification of atherosclerosis in an elderly population assessed by whole-body magnetic resonance angiography" 27 : 649-654, 2007

20 Parrett BM, "The posterior tibial artery perforator flap: an alternative to free-flap closure in the comorbid patient" 25 : 105-109, 2009

21 Georgescu AV, "The place of local/regional perforator flaps in complex traumas of the forearm" 1 : 25-31, 2009

22 Saint-Cyr M, "The perforasome theory: vascular anatomy and clinical implications" 124 : 1529-1544, 2009

23 Beppu M, "The osteocutaneous fibula flap: an anatomic study" 8 : 215-223, 1992

24 Ger R, "The operative treatment of the advanced stasis ulcer. A preliminary communication" 111 : 659-663, 1966

25 Orticochea M, "The musculo-cutaneous flap method: an immediate and heroic substitute for the method of delay" 25 : 106-110, 1972

26 Hallock GG, "The medial sural MEDIAL GASTROCNEMIUS perforator free flap: an ‘ideal’ prone position skin flap" 52 : 184-187, 2004

27 McGregor IA, "The groin flap" 25 : 3-16, 1972

28 Song YG, "The free thigh flap: a new free flap concept based on the septocutaneous artery" 37 : 149-159, 1984

29 Ponten B, "The fasciocutaneous flap: its use in soft tissue defects of the lower leg" 34 : 215-220, 1981

30 McCraw JB, "The dorsalis pedis arterialized flap. A clinical study" 55 : 177-185, 1975

31 Quaba AA, "The distally-based dorsal hand flap" 43 : 28-39, 1990

32 Dhar SC, "The delay phenomenon: the story unfolds" 104 : 2079-2091, 1999

33 Manchot C, "The cutaneous arteries of the human body" Springer-Verlag 1983

34 Wu WC, "The anatomic basis and clinical applications of flaps based on the posterior tibial vessels" 46 : 470-479, 1993

35 Taylor GI, "The Doppler probe for planning flaps: anatomical study and clinical applications" 43 : 1-16, 1990

36 Jakubietz RG, "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" 59 : 667-671, 2007

37 El-Sabbagh AH, "Skin perforator flaps: an algorithm for leg reconstruction" 27 : 511-523, 2011

38 Torii S, "Reverse-flow peroneal island flap for the reconstruction of leg and foot" 11 : 26-31, 1988

39 Almeida MF, "Reverse-flow island sural flap" 109 : 583-591, 2002

40 Barclay TL, "Repair of lower leg injuries with fascio-cutaneous flaps" 35 : 127-132, 1982

41 Khan UD, "Reliability of handheld Doppler in planning local perforator-based flaps for extremities" 31 : 521-525, 2007

42 Wee JT, "Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibial flap: preliminary report of a new fasciocutaneous flap" 39 : 327-337, 1986

43 Matsui A, "Real-time intraoperative near-infrared fluorescence angiography for perforator identification and flap design" 123 : 125e-127e, 2009

44 Pignatti M, "Propeller flaps for leg reconstruction" 61 : 777-783, 2008

45 Saint-Cyr M, "Preexpanded second intercostal space internal mammary artery pedicle perforator flap: case report and anatomical study" 123 : 1659-1664, 2009

46 Morris SF, "Predicting the survival of experimental skin flaps with a knowledge of the vascular architecture" 92 : 1352-1361, 1993

47 Zhang X, "Posterior tibial artery-based multilobar combined flap free transfer for repair of complex soft tissue defects" 28 : 643-649, 2008

48 Rad AN, "Peroneal artery perforator-based propeller flap reconstruction of the lateral distal lower extremity after tumor extirpation: case report and literature review" 28 : 663-670, 2008

49 Schaverien M, "Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps" 122 : 161-170, 2008

50 Mehrotra S, "Perforator-plus flaps: a new concept in traditional flap design" 119 : 590-598, 2007

51 Tos P, "Perforator-based propeller flaps treating loss of substance in the lower limb" 12 : 93-99, 2011

52 Kroll SS, "Perforator-based flaps for low posterior midline defects" 81 : 561-566, 1988

53 Teo TC, "Perforator local flaps in lower limb reconstruction" 32 : 15-16, 2006

54 Saint-Cyr M, "Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction" 123 : 132e-145e, 2009

55 Koshima I, "Perforator flaps in lower extremity reconstruction" 34 : 251-256, 2002

56 Kamath BJ, "Perforator based flap coverage from the anterior and lateral compartment of the leg for medium sized traumatic pretibial soft tissue defects: a simple solution for a complex problem" 59 : 515-520, 2006

57 Lee BT, "Pedicled perforator flaps: a new principle in reconstructive surgery" 125 : 201-208, 2010

58 Quaba O, "Pedicled perforator flaps for the lower limb" 20 : 103-111, 2006

59 Masia J, "Our experience in lower limb reconstruction with perforator flaps" 58 : 507-512, 2007

60 Wong CH, "Nonlinear finite element simulations to elucidate the determinants of perforator patency in propeller flaps" 59 : 672-678, 2007

61 Georgescu AV, "Microsurgical nonmicrovascular flaps in forearm and hand reconstruction" 27 : 384-394, 2007

62 Hwang WY, "Medial leg skin flap: vascular anatomy and clinical applications" 15 : 489-491, 1985

63 Koshima I, "Medial and lateral malleolar perforator flaps for repair of defects around the ankle" 51 : 579-583, 2003

64 Bhattacharya V, "Measurement of perfusion pressure of perforators and its correlation with their internal diameter" 58 : 759-764, 2005

65 Byrd HS, "Management of open tibial fractures" 76 : 719-730, 1985

66 Hallock GG, "Lower extremity muscle perforator flaps for lower extremity reconstruction" 114 : 1123-1130, 2004

67 Angrigiani C, "Latissimus dorsi musculocutaneous flap without muscle" 96 : 1608-1614, 1995

68 Lee GK, "Invited discussion: Harvesting of forearm perforator flaps based on intraoperative vascular exploration: clinical experiences and literature review" 28 : 331-332, 2008

69 Holm C, "Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green" 55 : 635-644, 2002

70 Koshima I, "Inferior epigastric artery skin flaps without rectus abdominis muscle" 42 : 645-648, 1989

71 Matei I, "Harvesting of forearm perforator flaps based on intraoperative vascular exploration: clinical experiences and literature review" 28 : 321-330, 2008

72 Rubino C, "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" 59 : 636-643, 2006

73 Yildirim S, "Freestyle perforator-based V-Y advancement flap for reconstruction of soft tissue defects at various anatomic regions" 58 : 501-506, 2007

74 D’Arpa S, "Freestyle pedicled perforator flaps: safety, prevention of complications, and management based on 85 consecutive cases" 128 : 892-906, 2011

75 Lecours C, "Freestyle pedicle perforator flaps: clinical results and vascular anatomy" 126 : 1589-1603, 2010

76 Wei FC, "Free-style free flaps" 114 : 910-916, 2004

77 Wallace CG, "Free-style flaps: A further step forward for perforator flap surgery" 124 : e419-e426, 2009

78 Koshima I, "Free tensor fasciae latae perforator flap for the reconstruction of defects in the extremities" 107 : 1759-1765, 2001

79 Asko-Seljavaara S, "Free style free flaps" 1983

80 D’Arpa S, "Free style facial artery perforator flap for one stage reconstruction of the nasal ala" 62 : 36-42, 2009

81 Levin LS, "Foot and ankle soft-tissue deficiencies: who needs a flap?" 35 : 11-19, 2006

82 Koshima I, "Flow-through thin latissimus dorsi perforator flap for repair of soft-tissue defects in the legs" 103 : 1483-1490, 1999

83 Koshima I, "Flow-through anterior thigh flaps for one-stage reconstruction of soft-tissue defects and revascularization of ischemic extremities" 95 : 252-260, 1995

84 Wei FC, "Fibular osteoseptocutaneous flap: anatomic study and clinical application" 78 : 191-200, 1986

85 Cormack GC, "Fasciocutaneous vessels. Their distribution on the trunk and limbs, and their clinical application in tissue transfer" 6 : 121-131, 1984

86 Niranjan NS, "Fascial feeder and perforator-based V-Y advancement flaps in the reconstruction of lower limb defects" 53 : 679-689, 2000

87 Georgescu AV, "Emergency free flaps" 23 : 206-216, 2003

88 Yu P, "Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap" 118 : 928-933, 2006

89 Godina M, "Early microsurgical reconstruction of complex trauma of the extremities" 78 : 285-292, 1986

90 Blondeel PN, "Doppler flowmetry in the planning of perforator flaps" 51 : 202-209, 1998

91 McGregor IA, "Axial and random pattern flaps" 26 : 202-213, 1973

92 Eren S, "Assessment of microcirculation of an axial skin flap using indocyanine green fluorescence angiography" 96 : 1636-1649, 1995

93 Salmon M, "Arteries of the skin" Churchill Livingstone 1988

94 Whetzel TP, "Arterial fasciocutaneous vascular territories of the lower leg" 100 : 1172-1183, 1997

95 Taylor GI, "Angiosomes of the leg: anatomic study and clinical implications" 102 : 599-616, 1998

96 Geddes CR, "Anatomy of the integument of the lower extremity, In rforator flaps: anatomy, technique & clinical applications" Quality Medical Publishing, Inc 541-578, 2006

97 Carriquiry C, "An anatomic study of the septocutaneous vessels of the leg" 76 : 354-363, 1985

98 Parrett BM, "A review of local and regional flaps for distal leg reconstruction" 25 : 445-455, 2009

99 Ninkovic M, "A new classification for the standardization of nomenclature in free flap wound closure" 103 : 903-914, 1999