Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction?

BACKGROUND: Conventional pedicled flaps for soft tissue reconstruction of lower extremities have shortcomings, including donor-site morbidity, restricted arc of rotation, and poor cosmetic results. Propeller flaps offer several potential advantages, including no need for microvascular anastomosis and low impact on donor sites, but their drawbacks have not been fully characterized.

QUESTIONS/PURPOSES: We assessed (1) frequency and types of complications after perforator-based propeller flap reconstruction in the lower extremity and (2) association of complications with arc of rotation, flap dimensions, and other potential risk factors.

METHODS: From 2007 to 2012, 74 patients (44 males, 30 females), 14 to 87 years old, underwent soft tissue reconstruction of the lower extremities with propeller flaps. General indications for this flap were wounds and small- and medium-sized defects located in distal areas of the lower extremity, not suitable for coverage with myocutaneous or muscle pedicled flaps. This group represented 26% (74 of 283) of patients treated with vascularized coverage procedures for soft tissue defects in the lower limb during the study period. Minimum followup was 1 year (mean, 3 years; range, 1-7 years); eight patients (11%) were lost to followup before 1 year. Complications and potential risk factors, including arc of rotation, flap dimensions, age, sex, defect etiology, smoking, diabetes, and peripheral vascular disease, were recorded based on chart review.

RESULTS: Twenty-eight of 66 flaps (42%) had complications. Venous congestion (11 of 66, 17%) and superficial necrosis (seven of 66, 11%) occurred most frequently. Eighteen of the 28 complications (64%) healed with no further treatment; eight patients (29%) underwent skin grafting, and one patient each experienced total flap failure (2%) and partial flap failure (2%). In those patients, a free anterolateral thigh flap was used as the salvage procedure. No correlations were found between complications and any potential risk factor.

CONCLUSIONS: We were not able to identify any specific risk factors related to complications, and future multicenter studies will be necessary to determine which patients or wounds are at risk of complications. Propeller flaps had a low failure rate and risk of secondary surgery. These flaps are particularly useful for covering small- and medium-sized defects in the distal leg and Achilles tendon region and are a reliable and effective alternative to free flaps.

LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.