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Islanded Pedicled Perforator Flaps for Various Soft Tissue Defects: Our
Experience in a Tertiary Hospital

Article in International Journal of Science and Research (IJSR) · January 2020


DOI: 10.21275/ART20204472

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International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426

Islanded Pedicled Perforator Flaps for Various Soft


Tissue Defects: Our Experience in a Tertiary
Hospital
Dey Deepanjan1, Mallik Mainak2, Suba Santanu3
1
Senior Resident, Department of Plastic Surgery, Medical College, Kolkata, India
2
Senior Resident, Department of Plastic Surgery, Medical College, Kolkata, India
3
Residential Medical Officer, Department of Plastic Surgery, Medical College, Kolkata, India

Abstract: Introduction: Soft tissue defects requiring flap coverage are resurfaced by peninsular flaps, musculocutaneous flaps or
distant free flaps. Islanding flaps in a single stage avoids unaesthetic standing cutaneous deformity and bulges of local peninsular flaps
and reduces the prolonged duration of hospital stay over certain staged procedures like cross-leg flaps. Aims and objectives: This
prospective interventional study over one year aimed at executing islanded, pedicled perforator flaps and to assess the operative time for
reconstruction, the complications and the post-operative hospital stay. Methodology: Patients were selected based on the defects to be
reconstructed, the pre operative work up and anesthesia check up were done, they were admitted and operated. Planning in reverse was
done in every case, the source vessels and the perforators were identified and marked with hand held Doppler pre-operatively, the
primary defect defined after excision and the flaps were harvested based on the perforator, inset given and donor sites managed. Post-
operatively the flaps were monitored clinically, the complications and issues addressed, dressings changed on frequent intervals and
results interpreted. After discharge, they were followed up at regular intervals. Results: Out of 35 patients, in 15 patients, the flaps were
harvested on perforators as propeller flaps. In 20 patients we dissected up to and included the source vessel of the perforators to gain
additional length. The mean operative time for reconstruction was 105 minutes. Among the overall complications of 14%, minor
complications of wound dehiscence and widened scar in 3% of the cases. The post-operative hospital stay ranged from 3 to 14 days with
a mean of 4.75 days. Conclusion: Islanded perforator flaps can be executed rapidly increasing the daily number of reconstructions in a
high volume centre with reduced hospital stay, less donor site morbidities and more aesthetically pleasing results.

Keywords: Propeller flaps, perforator flaps

1. Introduction Hyakusokuet al.2 in 1991 described an adipocutaneous flap


designed as a propeller, blood supplied through a random
Resurfacing of soft tissue defects comprises a major portion subcutaneous pedicle and rotated 90 degrees.
of the reconstructive work we do in our Department. We
have utilized various non-microsurgical procedures like The term „propeller flap‟ was first time used by Hallock3 and
loco-regional random pattern skin flaps, peninsular the definition was provided by an Advisory Panel of the
fasciocutaneous flaps and musculocutaneous flaps. These First Tokyo Meeting on Perforator and Propeller Flaps in
flaps though are easier to execute, provide poor aesthetic 20094.
results with dog-ears and unsightly bulges near the pedicle.
Staged procedures like cross-leg flaps have further issues of Modification of the perforator flap to include a segment of
increased patient morbidity and prolonged hospital stay. At the source vessel to increase the reach has been described by
the other end of the spectrum, the free flaps have their own Phillip N. Blondeel et al.5 The present general consensus6 is
disadvantages requiring additional operative time in the existence of three different types of perforators: the
microvascular anastomosis thereby reducing the number of direct cutaneous, septocutaneous and the musculocutaneous.
patients that are operated on a given day. Prolonged duration
of anesthesia in these cases also adds to the morbidity in Hence, to overcome the limitations of the loco-regional flaps
certain patient groups. and the free flaps, we planned to find a middle ground
utilizing islanded pedicled perforator flaps. These flaps
With evolving knowledge of anatomy and physiology, we would be superior both to the loco-regional flaps in terms of
have refined random pattern flaps with obscure vascularity aesthetics and hospital stay and to the free flaps in terms of
to present day flaps tailored over precise perforators to operative time.
reduce donor site morbidity with improved aesthetics.
2. Aims and Objectives
It was Koshimaet al1 who first described a thin skin flap
based on a single paraumbilical perforator from the deep We aimed to cover various soft tissue defects with islanded
inferior epigastric artery keeping the rectus abdominis pedicled perforator flaps and asses the outcomes in terms of:
muscle intact. a) Operative time for reconstruction
b) Complications and donor site morbidity
c) Post-operative hospital stay

Volume 9 Issue 1, January 2020


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Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20204472 DOI: 10.21275/ART20204472 1716
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
3. Materials and Methods the defect and designed a flap by planning in reverse over
the marked perforator as the pivot point for rotation (Fig. 4
We conducted this prospective, descriptive non-randomised A).Under tourniquet, we placed the exploring incision in
study in The Department of Plastic and Reconstructive such a manner that an alternative flap could also be designed
Surgery, Medical College, Kolkata. The duration was one if needed8, 9 (Fig. 4 B).With loupe magnification, we
year from May, 2017 to May, 2018. The study population dissected subfascial for identification of the marked
comprised of the patients admitted to our department or perforator andensured the reliability by the caliber of the
referred from other departments in our hospital. We included perforator being at least 1 mm10 and observing pulsations on
all consecutive patients with soft tissue defects indicated for release of tourniquet later on. We dissected out the
flap coverage who consented for the surgery (convenience perforator for at least 3 cm10 (Fig. 4 C).
sampling method).
In case of a regional defect, we traced the perforator to its
We excluded patients less than 5 years and more than 80 source vessel through the septum or by splitting muscles
years and those with comorbidities like uncontrolled when required (Fig. 7 C,D). We sutured the split muscles
Diabetes Mellitus and diagnosed vascular disease to with absorbable sutures to restore anatomy as much as
minimize confounding by other variables. Patients unfit for possible. We ligated the source vessel beyond the origin of
surgery and anaesthesia and those who did not give consent the perforator and included the vessel along with the
were also excluded. perforator shifting the pivot closer to the defect.We
preserved a cuff of muscle or subctunaeous fat around the
For simplification, we defined the perforator flaps as pedicle whenever possible to prevent adverse effects like
fasciocutaneous flaps, islanded on a perforator vessel. It vasospasm or shearing that could happen in a long segment
could be a septocutaneous, a musculocutaneous or a direct of a skeletonised vessel11.
cutaneous perforator. We named the flap on the closest axial
source vessel that the perforator arose from. We committed the flap in an islanded fashion and elevated
from distal towards proximal. We released the tourniquet
A total of 35 patients were studied. In 15 patients, we and let the flap perfuse for 10 mins12.The propeller flaps
covered the soft tissue defects with islanded, pedicled were rotated into the defectin a clockwise or anticlockwise
perforator flaps from the immediate vicinity of the defects as manner whichever arc was shorter (Fig. 4D). The source
propeller flaps rotated to up to 1800. In the other 20 patients, vessel flaps were either tunneled into the defects through the
we dissected out a length of the source vessel along with the subcutaneous tissue or taken through an open route with the
perforatorto gain length to reach regional defects. We pedicle subsequently buried beneath primary skin closure
reduced the size of the defects by approximating the (Fig.7 D, E).We inset the flaps with a corrugated drain
surrounding skin to the wound bed whenever possible, underneath. We closed the donor sites either primarily or by
thereby, reducing the dimension of the flap required. To the skin grafting. We monitored the flap in the post-operative
final defect size, we added 1 cm to the length and 0.5 cm to period to look for ischemia or venous congestion. We
the breadth to get the flap size7. followed up the patients after discharge in the Out Patients
In each case, we used a hand held Doppler device to mark Department at least for 3 months.
out perforators closest to the defects. We made a template of

Table 1: Propeller flaps details.


Defect Donor Operative time
Hospital stay
S. no Region Lesion (size in cm) (size in Flap (size in cm) site for Complications
post-op (days)
cm) closure reconstruction
Broad donor site
1 Back DFSP,7*11 10*14 Lumbar APF, 7*12 Primary 1 hr 10 mins 3
scar
Decubitus ulcer sacrum, Superior Gluteal
2 Back 5*10 Primary 1 hr 40 mins None 3
4*9 APF, 5*10
Circumflex scapular Hematoma under
3 Shoulder SCC Rt shoulder, 6*8 8*10 Primary 55 mins 6
APF, 9*11 flap, 20 suture
Circumflex scapular
4 Shoulder DFSP Lt shoulder, 5*7 9*13 Primary 1 hr None 3
APF, 10*14
Thoracodorsal APF,
5 Upper limb PBC Lt axilla 15*20 Primary 2 hrs 15 mins None 4
15*20
Proximal Radial
6 Upper limb PBC Lt elbow 10*14 STSG 1 hr 55 mins None 5
APF, 8*6 with STSG
Soft tissue sarcoma Lt Lateral circumflex
7 Lower limb 17*10 Primary 2 hrs 10 mins None 4
upper thigh, 15*8 femoral APF, 15*8
PBC Lt popliteal fossa Medial Sural APF,
8 Lower limb 16*10 Primary 1 hr 40 mins None 5
with non-healing ulcer 11*7 with STSG
Post-traumatic mid third
Posterior Tibial APF,
9 Lower limb leg defect with exposed 4*8 Primary 1 hr 10 mins None 3
4*10
tibia
10 Lower limb SCC Rt leg, 7*10 9*12 Peroneal APF, 9*12 STSG 1 hr 55mins None 5
PBC Lt lower leg, Peroneal APF, 4*11
11 Lower limb 4*25 STSG 2 hrs None 5
anterior ankle, dorsum with STSG
Volume 9 Issue 1, January 2020
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Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20204472 DOI: 10.21275/ART20204472 1717
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
of foot
Post-traumatic wound Lt
12 Lower limb 6*12 Peroneal APF, 6*12 STSG 2 hrs None 5
anterior ankle
Post-traumatic wound Lt
13 Lower limb 3*10 Peroneal APF, 3*12 STSG 1 hr 50 mins None 5
posterior heel
Benign skin lesion Lt
14 Lower limb 5*8 Peroneal APF,5*10 STSG 1 hr 20 mins None 5
anterior ankle
First Dorsal
15 Lower limb PBC Lt dorsum of foot 2*6 STSG 1 hr None 5
Metatarsal APF, 2*6

Table 2: Source vessel perforator flaps details.


Defect Hospital stay
Donor site Operative time for
S no Region Lesion (size in cm) (size in Flap (size in cm) Complications post-op
closure reconstruction
cm) (days)
1 Post electric burn scalp Dorsal Scapular
Head and neck 13*10 Primary 2 hrs 10 mins None 3
wound, 5*9 APF, 8*12
Verrucous carcinoma
2 Head and neck 6*8 Submental APF,6*8 Primary 2 hrs None 5
buccal mucosa, 4*6
HidradenitisSuppurativa Lt Thoracodorsal APF,
3 Upper limb 9*12 Primary 2 hrs 5 mins None 4
axilla, 4*6 9*12
Lt arm non healing ulcer, Thoracodorsal APF,
4 Upper limb 8*14 Primary 1 hr 55 mins None 3
8*14 7*15
Ulnar collateral APF,
5 Upper limb PBC Rt elbow, 4*6 10*13 STSG 2 hrs None 5
6*12 with STSG
Radial collateral
6 Upper limb PBC Lt elbow, 4*5 5*10 Primary 2 hrs 5 mins None 3
APF, 5*10
Posterior
Post-traumatic wound over
7 Upper limb 8*10 Interroseous STSG 2 hrs None 5
Rt elbow, 8*10
APF,6*10
Posterior
Benign soft tissue tumor, Rt Marginal
8 Upper limb 5*10 Interroseous STSG 2 hrs 10 mins 8
dorsum of hand, 4*9 necrosis
APF,5*10
Post-traumatic
9 Upper limb wound,dorsum of Rt hand, 10*16 Radial APF,10*16 STSG 1 hr 40 mins None 6
10* 15
Circumflex scapular
10 Shoulder DFSP Lt shoulder, 6*10 10*14 Primary 1 hr 30 mins None 3
APF, 10*15
Circumflex scapular
11 Shoulder SCC Rt shoulder, 12*16 14*20 Primary 1 hr 15 mins None 3
APF, 13*20
Desmoid tumor Right iliac Lateral circumflex
12 Abdomen 8*20 Primary 2 hrs 30 mins None 4
fossa, 6*18 femoral APF, 6*15
Lateral circumflex
13 Abdomen Ectopiavesicae, 5*6 6*12 Primary 2 hrs 10 mins None 5
femoral APF, 6*10
Post traumatic wound Lt Lateral circumflex
14 Groin 9*15 Primary 2 hrs 15 mins None 4
groin, 9*15 femoral APF, 9*15
Lt groin malignant ulcer, Lateral circumflex
15 Groin 8*16 Primary 2 hrs 20 mins Flap loss 14
5*12 femoral APF, 6*14
Squamous cell carcinoma Lateral Genicular
16 Lower limb 7*11 Primary 1 hr 20 mins None 3
Lt knee, 5*9 APF, 7*11
Post- traumatic wound Rt Lateral Genicular Partial flap
17 Lower limb 5*10 Primary 1 hr 10 mins 10
knee, 5*10 APF, 5*10 loss
Post- traumatic wound Lt Medial Sural APF,
18 Lower limb 4*6 Primary 1 hr 40 mins None 3
knee, 2*3 4*6
Post –traumatic wound Lt Anterior Tibial APF,
19 Lower limb 4*8 STSG 2 hrs None 6
medial malleolus, 4*6 4*8
Post –traumatic Rt medial MedialisPedis APF,
20 Lower limb 3*4 STSG 1 hr 15 mins None 5
malleolar wound, 3*4 3*3
0
Abbreviations : 2 -Secondary, APF-Artery perforator flap, cm-Centimeter, DFSP-Dermatofibrosarcoma protuberance, Lt-
Left, PBC- Post burn contracture, Post-op-Post-operative, Rt-Right, SCC- Squamous cell carcinoma, Sl.no- Serial number,
STSG-Split thickness skin graft

4. Results region, the shoulder, the abdomen, the groin, the upper and
the lower limbs.
With the propeller flaps, we covered defects over the back,
shoulder, the upper and the lower limbs. With source vessel Overall, the etiology of the defects were post-traumatic,
perforator flaps, we covered defects in the head and neck malignancy, post burn contracture release, post-infective non

Volume 9 Issue 1, January 2020


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Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20204472 DOI: 10.21275/ART20204472 1718
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
healing wounds and one case of a congenital defect (ectopia secondary suturing of the flap inset in one patient who had a
vesicae). dehiscence due to hematoma under the flap (3%). The
overall complication rate was 14%.
The ages of the patients ranged from 16 to 71 years.

The overall mean defect size was 101.15 sq cm and the


mean flap size was 85.67 sq cm. In 4 patients (11.43%) with
large defects spanning joints, the perforator flaps were used
to cover only the joints and remaining part of the defects
were skin grafted. None of the flaps in the limbs exceeded
one third of the limb length.

In all the flaps, we found the perforators at the site of the


Doppler markings. In one patient where a lateral circumflex
Figure 2: Overall complications
femoral artery based perforator flap was designed, we found
the perforator to arise about 5 cm proximally from the
The post-operative hospital stay ranged from 3 to 14 days.
source vessel i.e. the descending branch of the lateral The patients who needed a skin graft along with the flap or
circumflex femoral artery, perforate the fascia and travel for
in the donor sites generally took more time to be discharged.
5 cm suprafascially to terminate at the site of the audible
One patient where the entire flap was lost stayed the longest
Doppler marking. In one patient with a mid-third leg defect
time (14 days) as a skin graft was done after the flap
where a peroneal artery perforator flap was planned,
completely necrosed. The overall mean hospital stay in the
exploring incision revealed multiple closely spaced small post-operative period was 4.75 days.
caliber perforators. None of these perforators seemed
adequate to support the required flap independently and so
the procedure was converted to a lateral hemisoleus flap.

In 13 patients (37.14%) we covered the donor site with a


split thickness skin graft. Rest of the 22 patients (62.86%)
had primary closure of the donor site.

The operative time for reconstruction in our study ranged


from 55 minsto 2hrs and 30 mins. The operative time was
more in cases where a part of the defect or the donor site
needed a skin graft coverage. The mean operative time in
case of the source vessel perforator flaps was more than that
of the propeller flaps. The need for vessels dissection which Figure 3: Mean post-operative hospital stay
in most cases was intramuscular added to the duration of the
surgeries in those cases. 5. Discussion
With a success rate of 97%, we found the islanded, pedicled
perforator flaps to be very reliable for a wide range of soft
tissue defects. Recognized complications like venous
congestion11 can be avoided by adhering to the already
established perforator dissection techniques described in
literature8, 9. Reducing the size of the defect, whenever
possible, helps to keep the flap size within safe limits13 and
minimizes donor site morbidity.

Tissue of similar characteristics in the loco-regional area of


a defect is used while avoiding dog-ears associated with
peninsular flaps and bulges of musculocutaneous flaps.
Figure 1: Mean operative time in both the groups Hence the aesthetic outcome is also superior and being a
local flap, it requires a healthy, usable skin territory with
One patient in whom a lumbar artery perforator based good perforators in the vicinity of the defect unlike a free
propeller flap was done had donor site morbidity in the form flap. This is a limitation of these flaps.
of a widened scar due to secondary healing of a small
segment of donor site closure (3%). We lost one flap Replacing cross-leg flaps and abdominal flaps with
pedicled on the lateral circumflex femoral vessel due to perforator flaps, we have alleviated patient discomfort
pedicle compression causing irreversible venous congestion associated with those morbid procedures and reduced the
(3%). A skin graft was done after application of negative hospital stay at the same time.
pressure wound therapy. Two flaps had a partial and a
marginal necrosis requiring additional skin graft and Though these flaps require microvascular dissection
secondary suturing respectively (6%). We had to do a techniques, unlike free flaps they do not require vessel
Volume 9 Issue 1, January 2020
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Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20204472 DOI: 10.21275/ART20204472 1719
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
anastomosis and so are less time consuming. This advantage 6. Conclusion
provides better reconstructive opportunities in certain group
of patients like the elderly or those with multiple injuries Islanded, pedicled perforator flaps are a reliable option for
where their compromised general condition contraindicates a covering a wide range of soft tissue defects. They are
time consuming free flap procedure. A reduced operative simpler and quicker than free flaps. They are aesthetically
time also allows us to operate upon more patients on a given better than other loco-regional flaps and have a shorter post-
day. This along with a short post-operative hospital stay can operative hospital stay.
help increase the patient turn-over rate without
compromising on the standard of care. 7. Photographs:

Case 1:

Figure 4: A. The flap planned over a Peroneal perforator marked with a hand-held Doppler. B. Anterior exploring incision
placed and subfacial dissection done to trace the perforator. C. At least 3 cm length of perforator dissected out and flap
islanded. D. Flap rotated into the defect. E. Donor site skin grafted. F. Follow-up after 3 months.

Volume 9 Issue 1, January 2020


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Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20204472 DOI: 10.21275/ART20204472 1720
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
CASE 2:

Figure 5: A. Axillary hidradenitis. B. Thoracodorsal artery perforator marked C. Perforator dissected out D. Flap inset into
the defect and the donor site closed primarily. E, F. Flap and the donor site after 3 months.

Case 3:

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Paper ID: ART20204472 DOI: 10.21275/ART20204472 1721
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ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426

Figure 6: A. Post-burn contracture of the elbow. B. Propeller flap elevated over proximal radial artery perforator. C. Close-up
of the perforator. D. Flap rotated into the defect. E. Donor site skin grafted. F. Flap and donor site on follow-up after 2 weeks.

CASE 4:

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Figure 7: A. Ectopia vesicae defect on lower abdomen. B. Flap planned over Dopplered Anterolateral thigh perforator. C.
Intramuscular dissection of the perforator through vastus lataralis. D. Perforator dissected proximally to include the source
vessel i.e. Lateral circumflex femoral artery. E. Flap inset into defect and donor site closed primarily F. Flap after 3 months
of follow-up.

CASE 5:

Figure 8: A. Verrucous carcinoma oral mucosa. B. Submental artery perforator flap planned over a Dopplered perforator. C.
Flap islanded on the source vessel. D. Donor site closed primarily. E. Flap after inset. F. Flap on follow-up visit after 10 days

Conflict of interest- none

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Paper ID: ART20204472 DOI: 10.21275/ART20204472 1723
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ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
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[10] Wong CH, Cui F, Tan BK, et al. Nonlinear finite
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[11] Hýža P, Streit L, Schwarz D, Kubek T, Gilboe HE,
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Paper ID: ART20204472
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