A Review of Pedicled Perforator Flaps for Reconstruction of the Soft Tissue Defects of the Leg and Foot

O-Wern Low; Sandeep J. Sebastin; Andre E. J. Cheah

doi:10.1055/s-0039-1688103

Indian Journal of Plastic Surgery, Inhaltsverzeichnis

CC BY-NC-ND 4.0 · Indian J Plast Surg 2019; 52(01): 026-036
DOI: 10.1055/s-0039-1688103

Review Article

Association of Plastic Surgeons of India

A Review of Pedicled Perforator Flaps for Reconstruction of the Soft Tissue Defects of the Leg and Foot

O-Wern Low

¹Department of Hand and Reconstructive Microsurgery, University Orthopaedic and Hand Reconstructive Microsurgery Cluster, National University Health System, Singapore, Singapore

,

Sandeep J. Sebastin

¹Department of Hand and Reconstructive Microsurgery, University Orthopaedic and Hand Reconstructive Microsurgery Cluster, National University Health System, Singapore, Singapore

,

Andre E. J. Cheah

¹Department of Hand and Reconstructive Microsurgery, University Orthopaedic and Hand Reconstructive Microsurgery Cluster, National University Health System, Singapore, Singapore

› Institutsangaben

Abstract

Lower extremity soft tissue defects frequently result from high-energy trauma or oncological resection. The lack of suitable muscle flap options for the distal leg and foot makes defects in these locations especially challenging to reconstruct and free tissue transfer is commonly used. Another option that has become more popular in the past two decades are pedicled perforator flaps. Based on a thorough literature review and the authors’ experience on leg perforator flaps for over a decade, this article presents a historical review, the anatomical basis of common perforator flaps of the leg and foot, patient selection, wound selection, perforator selection, flap design, surgical techniques, refinements, and postoperative care. A review of the clinical outcomes and complications of these flaps was also performed and was noted to be comparable to the outcomes of free tissue transfer with significantly lower total flap failure rate. It is hoped that this review will assist surgeons in the formulation of a comprehensive step-by-step guide in performing pedicled perforator flap reconstruction of the lower extremity.

Keywords

foot defects - leg defects - pedicled flap - perforator flap - propeller flap

Volltext

Referenzen

References
1 Soltanian H, Garcia RM, Hollenbeck ST. Current concepts in lower extremity reconstruction. Plast Reconstr Surg 2015; 136 (06) 815e-829e
2 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
3 Georgescu AV. Propeller perforator flaps in distal lower leg: evolution and clinical applications. Arch Plast Surg 2012; 39 (02) 94-105
4 Yoshimura M, Shimada T, Imura S, Shimamura K, Yamauchi S. Peroneal island flap for skin defects in the lower extremity. J Bone Joint Surg Am 1985; 67 (06) 935-941
5 Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988; 81 (04) 561-566
6 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42 (06) 645-648
7 Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991; 44 (01) 53-54
8 Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg 2006; 56: 540-542
9 Blondeel PN, Van Landuyt KH, Monstrey SJ. et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 2003; 112: 1378-1383 quiz 1383, 1516, discussion 1384–1387
10 Pignatti M, Ogawa R, Hallock GG. et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg 2011; 127 (02) 716-722
11 Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, & Technique. St Louis: Quality Medical Publishing; 1997
12 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40 (02) 113-141
13 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124 (05) 1529-1544
14 Hamilton WJ. 1976. Textbook of Human Anatomy. London, UK: Palgrave Macmillan UK; DOI 10.1007/978-1-349-06486-1
15 Meissner MH. Lower extremity venous anatomy. Semin Intervent Radiol 2005; 22 (03) 147-156
16 Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006; 117 (07) Suppl 261S-293S
17 Geddes CR, Tang M, Yang D. et al Anatomy of the integument of the lower extremity. In: Blondeel PN, Morris SF, Hallock GG. et al. eds. Perforator Flaps: Anatomy, Technique & Clinical Applications. St. Louis: Quality Medical Publishing, Inc.; 2006: 541-578
18 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
19 Koshima I, Itoh S, Nanba Y, Tsutsui T, Takahashi Y. Medial and lateral malleolar perforator flaps for repair of defects around the ankle. Ann Plast Surg 2003; 51 (06) 579-583
20 Winaikosol K, Punyavong P, Jenwitheesuk K, Surakunprapha P, Chowchuen B. Dorsalis pedis perforator flap: cadaveric Anatomical Study. J Med Assoc Thai 2016; 99 (Suppl. 05) S137-S140
21 Russo A, Delia G, Casoli V, Colonna MR, Stagno d'AlcontresF. Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: anatomical study and clinical applications. J Plast Reconstr Aesthet Surg 2014; 67 (04) 550-554
22 Yeo CJ, Sebastin SJ, Ho SY, Tay SC, Puhaindran ME, Lim AY. The dorsal metatarsal artery perforator flap. Ann Plast Surg 2014; 73 (04) 441-444
23 El-Sabbagh AH. Skin perforator flaps: an algorithm for leg reconstruction. J Reconstr Microsurg 2011; 27 (09) 511-523
24 Quaba O, Quaba A. Pedicled perforator flaps for the lower limb. Semin Plast Surg 2006; 20 (02) 103-111
25 Yang D, Yang JF, Morris SF, Tang M, Nie C. Medial plantar artery perforator flap for soft-tissue reconstruction of the heel. Ann Plast Surg 2011; 67 (03) 294-298
26 Masquelet AC, Beveridge J, Romana C, Gerber C. The lateral supramalleolar flap. Plast Reconstr Surg 1988; 81 (01) 74-81
27 Hansen T, Wikström J, Johansson LO, Lind L, Ahlström H. The prevalence and quantification of atherosclerosis in an elderly population assessed by whole-body magnetic resonance angiography. Arterioscler Thromb Vasc Biol 2007; 27 (03) 649-654
28 Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009; 124 (06) Suppl e419-e426
29 Ono S, Sebastin SJ, Yazaki N, Hyakusoku H, Chung KC. Clinical applications of perforator-based propeller flaps in upper limb soft tissue reconstruction. J Hand Surg Am 2011; 36 (05) 853-863
30 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
31 Mehrotra S. Perforator-plus flaps: a new concept in traditional flap design. Plast Reconstr Surg 2007; 119 (02) 590-598
32 Yasir M, Wani AH, Zargar HR. Perforator flaps for reconstruction of lower limb defects. World J Plast Surg 2017; 6 (01) 74-81
33 Wang C, Yang S, Zhang J. et al. An overview of pre-expanded perforator flaps: part 1, current concepts. Clin Plast Surg 2017; 44 (01) 1-11
34 Moscatiello F, Masià J, Carrera A, Clavero JA, Larrañaga JR, Pons G. The ‘propeller’ distal anteromedial thigh perforator flap. Anatomic study and clinical applications. J Plast Reconstr Aesthet Surg 2007; 60 (12) 1323-1330
35 Ono S, Ogawa R, Eura S, Takami Y, Hyakusoku H. Perforator-supercharged perforator-based propeller flaps. Plast Reconstr Surg 2012; 129 (05) 875e-877e
36 Horta R, Valença-Filipe R, Nascimento R, Monteiro D, Silva A, Amarante JM. Perforator-based propeller flap with venous axial supercharging for reconstruction of a leg defect. Injury 2014; 45 (12) 2118-2119
37 Chiu DT, Hu G, Wu J, Rhee S, Rogers L, Gorlick N. Extended rat-ear flap model: a new rodent model for studying the effects of vessel supercharging on flap viability. J Reconstr Microsurg 2002; 18 (06) 503-508
38 Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast Reconstr Surg 1999; 104 (07) 2079-2091
39 Morris SF, Taylor GI. The time sequence of the delay phenomenon: when is a surgical delay effective?. An experimental study. Plast Reconstr Surg 1995; 95 (03) 526-533
40 Acartürk TO, Dinçyürek H, Dağlıoğlu K. Delay by staged elevation of flaps and importance of inclusion of the perforator artery. J Hand Microsurg 2015; 7 (01) 1-5
41 Christiano JG, Rosson GD. Clinical experience with the delay phenomenon in autologous breast reconstruction with the deep inferior epigastric artery perforator flap. Microsurgery 2010; 30 (07) 526-531
42 Bektas G, Ozkan O, Cinpolat A, Bassorgun IC, Ciftcioglu MA, Ozkan O. Comparing the effects of pedicle torsion on axial or perforator flaps; improving the perforator flap resistance to pedicle torsion with delay phenomenon. J Reconstr Microsurg 2014; 30 (08) 531-538
43 Innocenti M, Menichini G, Baldrighi C, Delcroix L, Vignini L, Tos P. Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction?. Clin Orthop Relat Res 2014; 472 (07) 2276-2286
44 Robotti E, Carminati M, Bonfirraro PP. et al. “On demand” posterior tibial artery perforator flaps: a versatile surgical procedure for reconstruction of soft tissue defects of the leg after tumor excision. Ann Plast Surg 2010; 64 (02) 202-209
45 Lu TC, Lin CH, Lin CH, Lin YT, Chen RF, Wei FC. Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg 2011; 64 (03) 386-393