The Assessment of Postoperative Patency and Flow Pattern of Twisted Vascular Pedicle in Propeller Perforator Flaps in Lower Extremities Reconstruction

Background The propeller perforator flap is a variant of perforator flaps in which complete skeletonization of the perforator with venae commitantes is done to transfer the islanded flap on its pedicle with up to 180 degrees of twisting that predispose to its gradual occlusion by time. These flaps have been recently advocated for lower extremity reconstruction. However, reconstruction of the lower extremity especially in the distal third of the leg quite often involves multistage procedures that might necessitate flap re-elevation and little knowledge is available about postoperative patency of these flaps. Aim of the work The aim of this study is to assess the postoperative patency and flow pattern in twisted vascular pedicle of propeller perforator flaps used in lower extremity reconstruction. Materials and methods A Prospective study was conducted on 15 patients 18 years or older of both genders undergoing lower extremity soft tissue reconstruction by propeller perforator flaps rotated from 90 to 180 degrees at Ain Shams University Hospitals and Nasser Institute between 1st February and 31th December 2019. With exclusion of smoking, peripheral vascular diseases and diabetes mellitus, each patient was evaluated preoperatively in regards to age, gender, comorbidities, bacterial contamination or infection, cause of tissue loss. The flap size, source vessel, arc of rotation, donor site closure was analyzed. The flow pattern was evaluated by handheld Doppler device and used as a control for the study. Postoperatively, the same handheld Doppler device was used to localize the vascular pedicle, evaluate its patency and assess the flow pattern at a minimum follow up period of 3 months postoperatively in all patients. Results The mean age of the fifteen patients included was 35.3 years old. Six patients lost tissue was caused by unstable scar, while post-traumatic in the remaining. Preoperatively, four patients had osteomyelitis and four had wound infection. The rest of patients did not report any infection. Eight out of fifteen patients used perforators from peroneal vessel source, while seven patients used posterior tibial artery source. Forty percent of included participants had a 180 degrees arc of rotation, while 26.7% of participants had an arc rotation angle of 120 degrees, and 33.3% had 90 degrees. Five patients had early post-operative congestion that improved by conservative methods without de-rotation of the flap, one patient had skin graft loss over the donor site of the flap, and another patient suffered in addition to skin graft loss distal congestion leading to superficial skin necrosis. Eight patients had no complications. All patients had patent vessels with biphasic flow pattern postoperatively at a minimum of 3 months postoperatively. Conclusion The perforator propeller flaps are safe, reliable procedures and are considered as an ideal option in reconstructing small-medium defects of the middle and distal third of the leg providing similar skin texture with low rate of vascular obstruction. The present study documented patent vascular pedicle of propeller perforator flaps at three months postoperatively.