Perforator Based Propeller Flap for Soft Tissue Reconstruction

INTRODUCTION: Reconstruction of soft tissue defects is one of the difficult assignments for plastic surgeons. A framework from skin graft, to local flap, to regional flap, to microvascular free flap can be applied to any reconstructive situation. The challenge is to utilize a single stage reconstruction to seek a safe flap with functional restoration and less morbidity. Skin grafts require a vascular bed and will seldom take on exposed bone, cartilage, or tendon devoid of their periosteum, perichondrium or paratenon. Flaps are usually required for covering recipient beds that have poor vascularity, covering vital structures and padding bony prominences. Local skin flap provide functional and cosmetic requirements for wound coverage but limited by its application in the face, particularly around the eyes, nose, and mouth. Fascial and adipofascial flaps provide thin, pliable tissue which serve as a highly vascularized support for skin grafts but limited by post operative edema, contour deformity at the donor and recipient site. Fasciocutaneous flaps are simple to elevate, quick, and fairly reliable in healthy patients. The flaps are elevated with the knowledge of orientation of the fascial plexus, the fasciocutaneous perforators, and the fascial septum. Fasciocutaneous flaps are less bulky with less functional loss. Limitation of the fasciocutaneous flaps includes donor site morbidity and difficulty in monitoring flap failure. AIMS AND OBJECTIVES: The aim of this study was to evaluate the usefulness of perforator based propeller flap for soft tissue reconstruction in various sites and to study the reliability of the surgical algorithm in soft tissue defect reconstruction using this flap. MATERIALS AND METHODS: The study was conducted in the Department of Plastic Surgery, Government General Hospital, and Madras Medical College over a period of 31 months September 2006 to March 2009. Twenty cases where a fasciocutaneous flap was used in the reconstruction of a soft tissue defect– either primarily or secondarily – were included in the study. The proforma for the collection of data was made. All the relevant details of the patient during preoperative, surgical, and postoperative and follow up periods were collected and analyzed. All patients in addition to routine investigation were submitted to Doppler examination of the perforators near the soft tissue defect. Patient selection: Inclusion criteria: 1. Post-excision defects in patients with malignancies. 2. Soft tissue defects in patients acute trauma. 3. Patients presenting with post traumatic soft tissue defects at a later date. 4. Patient presenting with a post-surgical defect. Exclusion criteria: 1. Infected wound. 2. Patients with peripheral vascular diseases. 3. Irradiated patients. 4. Patients who cannot withstand prolonged anesthesia. In infected cases, seen late, they were already on appropriate culture and sensitivity. In acute situations were immediate cover was done the wound was debrided by plastic surgeon prior to planning of the flap. Trauma wounds were debrided initially by orthopedic team or general surgery team and again during the cover by plastic surgeon. OBSERVATIONS & RESULTS: Twenty patients with soft tissue defect were included in the study for a period of 31 months from September 2006 to March 2009. Mean age at presentation was 37 (range 21-54 yrs). A total of 14 male patients and 6 female patients were included in this study group. Patients characteristics: Number of patients 20 ; Age range 21-54 yrs ; Male 14, Female 6. Among twenty cases, 11 cases were soft tissue defects in the gluteal region (55%) and 9 cases were soft tissue defects in the lower extremity. Most common cause of soft tissue defect in the lower extremity was trauma (77.7%). Most common site of soft tissue reconstruction using propeller flap method in our study was sacral region which constitutes about 30% among the total cases. Among twenty patients, four patients had the habit of smoking, one patient was diabetic on regular medication, one patient had the habit of consuming alcohol and one patient underwent treatment for tuberculosis before fifteen years. In this series maximum number of flaps were done in the chronic phase (70%) and least in the subacute phase (5%). Soft tissue defects dimensions were ranging from 3x3 cm to 13x 10cm. Rotation degrees of the flap was ranging from 400 -1800. In the gluteal region, perforators chosen for defect reconstruction were from inferior and superior gluteal artery. Anteromedial thigh perforators, medial leg perforators from posterior tibial artery & perforator from medial gastrocnemius were chosen for lower extremity soft tissue defect coverage. CONCLUSION: Vascularised tissue in the form of muscle or non-muscle flaps are currently the option for wound coverage following adequate surgical wound debridement. Twenty patients with soft tissue defect in the age range of 21-54 yrs were prospectively studied by reconstruction with perforator based propeller flaps. The following findings were observed from the study: • The pedicle perforator propeller flaps offer viable tissues similar in skin texture and thickness to the lost ones (‘replace like with like’). • Propeller flaps allows the surgeon the freedom to select, tailor or compose the flap independent of the limited indications of conventional flaps. • Pedicle perforator propeller flaps of the refined design can be used effectively in various reconstructions when difficult wound reconstruction is anticipated. • Propeller flaps are relatively easy to perform while allowing the coverage of wide defects. • Propeller flaps leave the most inconspicuous donor site defect possible, preserving muscles both with their functions and sparing the main vascular trunks. • Local perforator flaps and particularly the propeller flap could be a safer and lesser invasive reconstructive option than free flaps. • Propeller flaps saves on operating time and does not rely on expensive microsurgical facilities without compromising the reconstruction. • Propeller flaps provides better aesthetic results and higher patient satisfaction