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Moshrefi et al. Propeller flaps for trunk wounds

to find that the highest rate of complication was with addition to multi-detector row computed tomography,
venous congestion but that no permanent flap loss the authors find these modalities time consuming
was noted in any case. All cases of venous congestion and costly in a climate of American healthcare costs
identified were transient, whether they were managed that continue to rise. However, there is significant
expectantly or with some intervention (i.e. leeches, value in these modalities in the authors’ opinions
derotation of flap, etc.). The other complications were with respective to complex reconstruction or those of
with much less frequency and reviewing the patient’s reoperative reconstructive fields. Some colleagues
risk factors, they did not seem to adversely affect the at our institution utilize these modalities routinely and
outcomes. Unfortunately, many series did not identify so there remains no consensus nor compelling data
preoperative risk factors in patients and so drawing in the literature to support use of these methods over
conclusions from this are limited in this review. In handheld Doppler ultrasound or even dissection with
addition, of those that did specify the risks factors, the direct visualization. Indeed, a palpable pulse of the
patient-specific data was often combined with flaps of perforator in question is always a reassuring finding
other areas of the body and/or there was not enough and indicator of flap viability. In keeping dissection
detailed information provided to determine if the principles in mind, we try to adhere in line with the
complications occurred in those with risks factors (i.e. findings of Wong et al. [26] in that a 3-cm pedicle length
transient venous congestion occurrence in relation to dissection is attempted to be obtained when safe.
patients that smoked). This is particularly prudent when utilizing degrees of
rotation beyond 90 degrees in propeller fashion, but is
Interestingly, none of the etiologies for the defects only done when skeletonization is deemed appropriate
mentioned in any of the studies were traumatic. This and safe.
may be that trunk wounds are generally not as likely
to be traumatic compared to lower extremity wounds. As discussed in the Tokyo criteria of 2011, the
Anecdotally, traumatic wounds do raise some concern perforator-based propeller flap can be rotated a
in the reconstruction of a wound using a propeller maximum of 180 degrees for wound reconstruction [27] .
flap as the perforator may be captured in the zone of This has to do with torsion and kinking of the pedicle,
injury. ultimately which can lead to flap compromise and
loss. If flap compromise in the form of venous
One of limitations of this study is that the search terms congestion develops, return to the operating room
and search database is limited. One of the challenges and releasing the flap from its inset position is of the
of broadening this search would be to search for each first consideration. Following this, if the compromise
propeller flap by a described name or technique (i.e. is not addressed then the flap should be rotated back
LICAP flap) as it relates to the trunk, which would to the donor site and observed for improvement. Still if
be much more extensive of a search. However, this minimal or no improvement is noted, dissection of the
provides an opportunity for further delving into the flap to its pedicle should occur to ensure the vascular
literature and providing a larger review that may be leash is not the complicating factor.
more inclusive than the broader search terms listed
as part of our study. Another notable limitation is With respect to management of the donor site, the
[7]
that publication bias of positive findings with relation authors agree with the conclusion of D’Arpa et al. in
to propeller flap outcomes of the studies currently the decision tree of when a perforator-based propeller
available. flap is utilized for reconstruction. Specifically, if the
donor site cannot be closed primarily, then a free flap
Variability in design of propeller flaps of course reconstructive option is sought first that would lead to
depends upon the shape, size, depth, and location less to donor site morbidity and improved cosmesis.
of the defect. In general, axes of the flaps designed In other words, a perforator-based propeller flap may
should be based perpendicular or oblique on the trunk be designed as large as the defect dictates so long
and in parallel in extremities [7,24] . as the donor site may be closed primarily. As with all
reconstructions in plastic surgery, each defect poses
When identifying perforators for dissection, it is the its own challenges and nuance that the plastic and
authors’ preferred method to do so via handheld reconstructive surgeon must take into consideration
Doppler ultrasound as well as visual inspection upon prior to surgical intervention.
dissection. Ono et al. [25] provided a recent publication
in 2017 with an excellent overview with preoperative In conclusion, propeller f laps are a viable
modalities to identify perforators. While CTA, MRA, reconstructive option for trunk wounds and should be
and CDU have grown tremendously as modalities in in the armamentarium of plastic and reconstructive

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