Free or Perforator-Pedicled Propeller Flaps in Lower Extremity Reconstruction: Defining the Coverage Failure

Retrospective Analysis in Lower Limb Reconstruction: Propeller Perforator Flaps versus Free Flaps

“Free or Perforator-Pedicled Propeller Flaps in Lower Extremity Reconstruction: Defining the Coverage Failure”: Response

We read with great interest the article by Cajozzo et al[1] entitled “Retrospective Analysis in Lower Limb Reconstruction: Propeller Perforator Flaps versus Free Flaps.” We would like to congratulate the authors for this study, to date no comparison with a retrospective study of the reliabilities of free flaps (FFs) and perforator pedicled-propeller flaps (PPPF) used in lower extremity reconstruction is available in the literature.

Despite widespread enthusiasm for the PPPF procedure in the past decade, it remains in reality a complex procedure that requires experience and monitoring comparable to that for FFs. The complications analyzed in the series of Cajozzo et al[1] were partial flap loss, complete flap loss, infection, split-thickness skin graft loss, and donor-site complication. It is important to use the concept of “coverage failure”[2] to embrace both total failure and partial necrosis creating a need for second coverage. When comparing FF and PPPF in lower extremity reconstruction, the critical indicator is “coverage failure.” Complete PPPF flap failure is very rare but, because necrosis develops distally, even partial necrosis can expose bone, tendons, or other tissue. When using FF, the problem is different; partial necrosis is quite rare and does not develop above the elements for which coverage is most important. Therefore, to compare flap reliabilities, it is necessary to compare “coverage failure” rates. In our meta-analysis,[2] the weight coverage failure rate was 5.24% (95% confidence interval [CI]: 3.86–6.81%) for FF and 2.99% (95% CI: 0.38–5.60%) for PPPF; these rates were not significantly different (p = 0.016).

In recent years, FF transfer has become the first choice in treatment of lower extremity injuries[3] because the failure rate is very low (< 5%).[4] Flap selection is generally based on the location of the defect, the tissue components that are deficient, the volume of such components, the required pedicle length, the donor site and the risk of site morbidity, the size and type of defect, and the experience of surgical team.[5] In our study,[2] the five most commonly used flaps were latissimus dorsi, anterolateral thigh, rectus abdominis, gracilis, and serratus. The use of muscular flaps, which are more robust has gradually been replaced by free perforator flap, allowing the restoration of an “ad integrum” anatomy, with lower donor-site morbidity. PPPF replace like-with-like tissue, with the preservation of nerves and muscles and the main vascular trunks. However, PPPF are limited by the lack of surrounding tissue in the distal third of the lower leg, and the donor site is not always self-closing. Following important devascularization of tegument with subdermal and suprafascial plexus injuries, we believe that it seems better to avoid PPPF.

We recommend that, confronted with a loss of tissue in the distal third of the lower leg, the chosen flap should minimize donor-site morbidity and should also be the flap type which the surgeon has more experience with. However, a PPPF is a viable choice, and our work suggests that the indications for the placement of such a flap may develop further in future.

Ethical Approval

Not applicable.

• References

• 1 Cajozzo M, Toia F, Innocenti A. , et al. Retrospective analysis in lower limb reconstruction: propeller perforator flaps versus free flaps. J Reconstr Microsurg 2017; 33 (S 01): S34-S39
• 2 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 2018; 38 (01) 109-119
• 3 Acland RD. Refinements in lower extremity free flap surgery. Clin Plast Surg 1990; 17 (04) 733-744
• 4 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
• 5 Wettstein R, Schürch R, Banic A, Erni D, Harder Y. Review of 197 consecutive free flap reconstructions in the lower extremity. J Plast Reconstr Aesthet Surg 2008; 61 (07) 772-776