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CC BY 4.0 · Arch Plast Surg 2023; 50(02): 194-199
DOI: 10.1055/s-0042-1744416
Extremity/Lymphedema
Case Report

How to Transform a Perforator Propeller Flap into a Keystone Flap in Case of Unsatisfying Perforator Vessel Local Perforator Flap Coverage in Limbs

Elena Ciucur 
1   Department of Plastic Reconstructive Surgery and Burns, Lapeyronie University Hospital, Montpellier, France
,
Hadj Boukhenouna 
1   Department of Plastic Reconstructive Surgery and Burns, Lapeyronie University Hospital, Montpellier, France
,
Benjamin Guena 
2   Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
,
I. Garrido-Stowhas
2   Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
,
Christian Herlin 
1   Department of Plastic Reconstructive Surgery and Burns, Lapeyronie University Hospital, Montpellier, France
,
Benoit Chaput 
2   Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
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Abstract

Moderate soft-tissue defects need stable coverage, ideally with tissue of similar characteristics and low donor site morbidity. We propose a simple technique for the coverage of moderate skin defects in the limbs. It allows intraoperative transformation of a propeller perforator flap (PPF) into a keystone design perforator flap (KDPF) in cases of unsatisfying perforator vessel or in cases of unpredictable intraoperative events. Between March 2013 and July 2019, nine patients with moderate soft-tissue defects (mean defect size 4.5 × 7.6 cm) in the limbs (two on the upper limbs and seven on the lower limbs) were covered using this technique. We performed four PPFs and five KDPFs. The mean follow-up was 5 months. There was one complication, partial distal tip necrosis in a PPF located in the leg, which healed by secondary intention within 3 weeks. The donor site was closed directly in all cases. No functional impairments were noted regardless of the perforator flap utilized. This technique enables us to employ flexible surgical strategies and allows us to make adjustments based on the patient's vascular anatomy.

Keywords

propeller flap - intraoperative transformation - upper extremity - lower extremity - reconstruction

Author Contributions

B.C. has made substantial contribution to the concept and the design of the article. Conceived the technic and provided the clinical cases. E.C. wrote the article provided the clinical cases and contributed to the analysis and interpretation of data. I.G. and H.C. provided the clinical cases. H.B. and B.G. contributed to the acquisition and analysis of the data, drafted the manuscript, and designed the figures.


Patient Consent

Written consent was obtained from the patient for the publication of images or data related to the patient.


Ethical Approval

Toulouse, Rangueil, France; Number: 10.2018.02.




Publication History

Received: 25 May 2021

Accepted: 30 December 2021

Article published online:
28 March 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Paik JM, Pyon J-K. Risk factor analysis of freestyle propeller flaps. J Reconstr Microsurg 2017; 33 (01) 26-31
    Thieme ConnectPubMedSearch in Google Scholar
  • 2 Bekara F, Herlin C, Mojallal A. et al. A systematic review and meta-analysis of perforator-pedicled propeller flaps in lower extremity defects. Plast Reconstr Surg 2016; 137 (01) 314-331
    CrossrefPubMedSearch in Google Scholar
  • 3 Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg 2003; 73 (03) 112-120
    CrossrefPubMedSearch in Google Scholar
  • 4 Mun GH, Jeon BJ. An efficient method to increase specificity of acoustic Doppler sonography for planning a perforator flap: perforator compression test. Plast Reconstr Surg 2006; 118 (01) 296-297
    CrossrefPubMedSearch in Google Scholar
  • 5 Huang J, Yu N, Long X, Wang X. A systematic review of the keystone design perforator island flap in lower extremity defects. Medicine (Baltimore) 2017; 96 (21) e6842
    CrossrefPubMedSearch in Google Scholar
  • 6 Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991; 44 (01) 53-54
    CrossrefPubMedSearch in Google Scholar
  • 7 Pignatti M, Ogawa R, Hallock GG. et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg 2011; 127 (02) 716-722
    CrossrefPubMedSearch in Google Scholar
  • 8 Mohan AT, Sur YJ, Zhu L. et al. The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction. Plast Reconstr Surg 2016; 138 (04) 710e-729e
    CrossrefPubMedSearch in Google Scholar
  • 9 Pauchot J, Chambert J, Remache D, Elkhyat A, Jacquet E. Geometrical analysis of the V-Y advancement flap applied to a keystone flap. J Plast Reconstr Aesthet Surg 2012; 65 (08) 1087-1095
    CrossrefPubMedSearch in Google Scholar
  • 10 Pelissier P, Santoul M, Pinsolle V, Casoli V, Behan F. The keystone design perforator island flap. Part I: anatomic study. J Plast Reconstr Aesthet Surg 2007; 60 (08) 883-887
    CrossrefPubMedSearch in Google Scholar
  • 11 Mohan AT, Rammos CK, Akhavan AA. et al. Evolving concepts of keystone perforator island flaps (KPIF): principles of perforator anatomy, design modifications, and extended clinical applications. Plast Reconstr Surg 2016; 137 (06) 1909-1920
    CrossrefPubMedSearch in Google Scholar
  • 12 Yoon CS, Kim SI, Kim H, Kim KN. Keystone-designed perforator island flaps for the coverage of traumatic pretibial defects in patients with comorbidities. Int J Low Extrem Wounds 2017; 16 (04) 302-309
    CrossrefPubMedSearch in Google Scholar
  • 13 Darrach H, Kokosis G, Bridgham K, Stone JP, Lange JR, Sacks JM. Comparison of keystone flaps and skin grafts for oncologic reconstruction: a retrospective review. J Surg Oncol 2019; 119 (07) 843-849
    CrossrefPubMedSearch in Google Scholar
  • 14 Sorooshian P, King I, Dunkin C. Keystone island flaps for reconstruction following lower leg skin cancer resection: a comparison with split-thickness skin grafts. J Plast Reconstr Aesthet Surg 2019; 72 (03) 513-527
    CrossrefPubMedSearch in Google Scholar
  • 15 Colorado Cogolludo L, Conde-Taboada A, González-Guerra E. et al. Keystone flap used on the legs: case series. Clin Exp Dermatol. Actas Dermosifiliogr 2019; 44 (06) 619-693
    Search in Google Scholar
  • 16 Lese I, Grobbelaar AO, Sabau D, Georgescu AV, Constantinescu MA, Olariu R. The propeller flap for traumatic distal lower-limb reconstruction: risk factors, pitfalls, and recommendations. J Bone Joint Surg Am 2020; 102 (06) 510-518
    CrossrefPubMedSearch in Google Scholar