Propeller Perforator Flaps of Extremities Seem Less Reliable

We read with great interest the manuscript of Paik and Pyon entitled “Risk factor analysis of freestyle propeller flaps.”[1] Through their retrospective review, the authors tried to identify risk factor of propeller perforator flaps (PPFs). Comparing PPF of trunk and extremities, they find that this latter shown more complications and we completely agree with their results. At the lower limb, PPF experienced more venous complications and overall complications than other localizations. We recently performed two meta-analyses concerning PPF with similar results concerning lower limb complications.[2] [3] Increasing numbers of reconstructive surgeons consider that PPF failure rates, especially concerning the lower leg, are too high, and thus prefer to return to using free flaps, where failure rates are frequently <5% in the hands of trained surgical teams.[3] Nonetheless, the coverage failure appears similar. Increased interest in the PPF should not obscure the fact that it is, in reality, a complex procedure requiring experience and monitoring similar to free flaps.

During the early hours after surgery, often during the first night, a propeller flap can become edematous and swell. It is frequent to remove stitches or use rescue methods such as puncture/dressing heparinization or leeches. Many risk factors cannot be found in publications[4] [5] and we are convinced that one of the major causes of failure of PPF, on all locations of the body but especially in the lower limbs, are the stitches.[6] This risk factor is almost never mentioned in the publications, although we have frequent experiences of distal necrosis with PPF directly related to the stitches that were too tight. We consider that this risk is widely underestimated. Moreover, Paik and Pyon did not mention this issue in their study and it is surprising that complications related to stitches are too little discussed by the authors in the literature.

The dissection plane, sub or suprafascial, is also an important point to take into account that has not been analyzed by the authors. The PPF harvested with suprafascial dissection seem more susceptible to congestion in our experience.[7]

Concerning lower limb, we highlighted three risk factors, namely age older than 60 years, diabetes, and arteriopathy, which should be considered systematically before performing this procedure.[2] For smoking status, we found a tendency toward statistical significance.

An interesting procedure that has been less studied for PPF is the venous supercharging. It is a well-known procedure for transverse rectus abdominis myocutaneous flap or sural flap, but concerning PPF, the literature is quite poor. Venous supercharging can reduce the period of initial congestion, which can sometimes be very worrying soon after surgery and is linked to rheology adaptation within the first 48 hours inside the flap, especially at lower limb.

Ultimately, some elements remain unknown in the PPF procedure, especially the question of the size of the flap that can be harvested on one perforator. We are convinced that the venous perforasome is different for each person and for each localization of the body, and anatomical studies are not sufficient to answer those questions that require dynamic analyzes.[8]

• References

• 1 Paik JM, Pyon JK. Risk factor analysis of freestyle propeller flaps. J Reconstr Microsurg 2016; DOI: 10.1055/s-0036-1586748.
• 2 Bekara F, Herlin C, Mojallal A. , et al. A systematic review and meta-analysis of perforator-pedicled propeller flaps in lower extremity defects: identification of risk factors for complications. Plast Reconstr Surg 2016; 137 (01) 314-331
• 3 Bekara F, Herlin C, Somda S, de Runz A, Grolleau JL, Chaput B. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: what is the safest coverage? A meta-analysis. Microsurgery 2016; DOI: 10.1002/micr.30047.
• 4 Vitse J, Bekara F, Bertheuil N, Sinna R, Chaput B, Herlin C. Perforator-based propeller flaps reliability in upper extremity soft tissue reconstruction: a systematic review. J Hand Surg Eur Vol 2016; DOI: 10.1177/1753193416669262.
• 5 Chaput B, Gandolfi S, Ho Quoc C, Chavoin JP, Garrido I, Grolleau JL. Reconstruction of cubital fossa skin necrosis with radial collateral artery perforator-based propeller flap (RCAP). Ann Chir Plast Esthet 2014; 59 (01) 65-69
• 6 Chaput B, Herlin C, Grolleau JL, Bertheuil N, Bekara F. Reply: The stitches could be the main risk for failure in perforator-pedicled flaps. Plast Reconstr Surg 2016; 138 (02) 383e-385e
• 7 Chaput B, Herlin C, Bekara F, Bertheuil N. Thinning: the difference between free and propeller perforator flaps. Arch Plast Surg 2015; 42 (02) 241-242
• 8 Chaput B, Mojallal A, Bertheuil N. , et al. Delayed procedure in propeller perforator flap: defining the venous perforasome. JPRAS 2016; DOI: 10.1016/j.bjps.2016.11.011.