Free versus Pedicled Perforator Flaps for Lower Extremity Reconstruction: A Multicenter Comparison of Institutional Practices and Outcomes

Abstract

Background Of all body regions, lower extremity wounds have been and remain the greatest challenge. Perforator free flaps have been accepted as a reasonable option to solve this dilemma but require the complexity of microsurgery. As a consequence, the possibility that pedicled perforator flaps could supplant even perforator free flaps has recently gained intense enthusiasm.

Methods A retrospective investigation was undertaken to compare the validity for the use of perforator flaps of all types at three dissimilar institutions, that is, a university, a regional center, and a community hospital. All flaps performed in the 5-year period, 2011 to 2015, were included to allow at least 1-year follow-up before data analysis. A total of 433 free perforator flaps and 52 pedicled perforator flaps had been performed specifically for the lower extremity.

Results Patient demographics, wound etiology, and comorbidities were similar for all institutions. Free flaps were more commonly needed after trauma and for chronic ulcers. Pedicled flaps were more likely an option after tumor excision. Large defects or those involving the foot were better served by free flaps. Overall success for free perforator flaps was 90.1% and for pedicled perforator flaps was 92.3%, with no significant difference noted (p = 0.606) between institutions. Peripheral vascular disease was the only significant comorbidity risk factor for both free and pedicled flap failure.

Conclusion Perforator flaps in general have become a reasonable solution for soft tissue defects of the lower extremity. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap could potentially be successful. Pedicled perforator flaps, if adequate healthy soft tissues remain adjacent to the defect, forecast a continuance of the evolution in seeking simplicity yet reliability by the best flap possible for soft tissue closure of the lower limb wound.

Keywords

perforator flaps - pedicled flaps - free flaps - lower extremity

Note

This article was presented in part at the Ninth Congress of World Society for Reconstructive Microsurgery, Seoul, Korea, June, 2017.

• References

• 1 Hallock GG. Evidence-based medicine: lower extremity acute trauma. Plast Reconstr Surg 2013; 132 (06) 1733-1741
• 2 Lachica RD. Evidence-based medicine: management of acute lower extremity trauma. Plast Reconstr Surg 2017; 139 (01) 287e-301e
• 3 Menn ZK, Lee E, Klebuc MJ. Acellular dermal matrix and negative pressure wound therapy: a tissue-engineered alternative to free tissue transfer in the compromised host. J Reconstr Microsurg 2012; 28 (02) 139-144
• 4 Hallock GG. Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds. J Trauma 1989; 29 (09) 1240-1244
• 5 Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 1981; 34 (02) 215-220
• 6 Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg 1986; 16 (01) 1-19
• 7 Hallock GG. A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps. J Reconstr Microsurg 2013; 29 (04) 233-240
• 8 Lee BT, Lin SJ, Bar-Meir ED, Borud LJ, Upton J. Pedicled perforator flaps: a new principle in reconstructive surgery. Plast Reconstr Surg 2010; 125 (01) 201-208
• 9 Schaverien M, Saint-Cyr M. Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps. Plast Reconstr Surg 2008; 122 (01) 161-170
• 10 Pignatti M, Ogawa R, Hallock GG. , et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg 2011; 127 (02) 716-722
• 11 Hong JPJ, Goh TLH, Choi DH, Kim JJ, Suh HS. The efficacy of perforator flaps in the treatment of chronic osteomyelitis. Plast Reconstr Surg 2017; 140 (01) 179-188
• 12 Bekara F, Herlin C, Somda S, de Runz A, Grolleau J, Chaput B. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: what is the safest coverage? A meta-analysis. Microsurgery 2018; 38 (01) 109-119
• 13 Brunetti B, Poccia I, Tenna S, Campa S, Persichetti P. Transversally oriented pedicled perforator flaps: a reliable alternative for lower leg reconstruction. Microsurgery 2015; 35 (07) 541-545
• 14 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 (09) 595-601
• 15 Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery 2007; 27 (05) 384-394
• 16 Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN. A review of propeller flaps for distal lower extremity soft tissue reconstruction: is flap loss too high?. Microsurgery 2013; 33 (07) 578-586
• 17 Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009; 123 (01) 230-235
• 18 Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: a new approach for moderate-sized defects. Ann Plast Surg 2013; 71 (04) 380-383
• 19 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
• 20 Hallock GG. If based on citation volume, perforator flaps have landed mainstream. Plast Reconstr Surg 2012; 130 (05) 769e-771e
• 21 Hallock GG. Is there a “learning curve” for muscle perforator flaps?. Ann Plast Surg 2008; 60 (02) 146-149
• 22 Bevan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg 2003; 73(3): 112-120
• 23 Hallock GG. The medial sural (MEDIAL GASTROCNEMIUS) perforator local flap. Ann Plast Surg 2004; 53 (05) 501-505
• 24 Hallock GG. The role of muscle flaps for salvage of failed perforator free flaps. Plast Reconstr Surg Glob Open 2015; 3 (11) e564
• 25 Hallock GG. In an era of perforator flaps, are muscle flaps passé?. Plast Reconstr Surg 2009; 123 (04) 1357-1363
• 26 Hallock GG. Sequential use of a true perforator flap and its corresponding muscle flap. Ann Plast Surg 2003; 51 (06) 617-620 , discussion 621–622