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Cohen-Shohet et al. Plast Aesthet Res 2019;5:28 I http://dx.doi.org/10.20517/2347-9264.2019.030 Page 11 of 13

GENERAL CONSIDERATIONS
For all perforator and propeller flaps of the lower extremity, the senior author offers several key points
essential to maximize chances of success in reconstruction:

1. Preoperative imaging of the lower extremity to help identification of perforators. This can include CT
angiography, utilizing thin cuts (≤ 1 mm), color duplex, and Doppler.
2. Intra-operative use of tourniquets to the lower extremity to aid in dissection.
3. Minimizing tension by completely dissecting a visualized perforator free from surrounding tissue.
4. Do not extend propeller perforator flaps in the distal third of the leg beyond the junction of the proximal
1/3 and distal 2/3 of leg to reduce chance of partial necrosis.
5. Observe flap 10 min after rotating to confirm no kinking of pedicle and good perfusion after flap
rotation.
6. A period of post-operative immobilization with splint to prevent undue tension and breakdown with
excessive movement.

LIMITATIONS OF PEDICLED PERFORATOR FLAPS
While the benefits of perforator flaps have been listed above, there are several limitations. First while donor
site morbidity related to a local or free muscle flap is decreased, local donor site morbidity remains. Skin
grafting of the donor site is often required. The skin graft donor site may heal with a hypertrophic scar in
[30]
some skin types. Wong et al. reported data on 61 pedicled-perforator flaps used for reconstruction of
lower extremity defects with 50% of donor sites requiring skin grafts.

[31]
Another risk is flap necrosis. Gir et al. performed a systematic review of pedicle perforator flaps in 2012
that included 186 cases and reported an overall complication rate of 25.8% with the most common being
[32]
partial flap loss (11.3%). The overall failure rate was low at 1.1%. Bekara et al. performed a meta-analysis
of 428 perforator-pedicled propeller flaps and reported a similar overall complication rate of 25.2%.
The authors further went on to identify three significant risk factors: age greater than 60, diabetes, and
arteriopathy. Although these reported risks are significant, the senior author’s experience is that proper
patient selection, preoperative imaging, and careful intraoperative evaluation of the flap intra-operatively
can reduce risk of partial flap necrosis.

CONCLUSION
Lower extremity soft tissue coverage proves challenging to reconstructive surgeons due to the complexity
of wounds and paucity of available local soft tissue. Reconstructive options continue to evolve, through
skin grafts, local flaps and free tissue transfer and more recently pedicled-perforator flaps. Compared with
free tissue transfer, they can be performed without advanced microsurgical training, with basic surgical
equipment, and with minimal donor site morbidity. Perforator flaps provide the surgeon with flexibility in
design as they can be based off of any of the three main vascular territories of the lower extremity. These
flaps have proved to be both safe and efficacious and can be used to reconstruct smaller lower extremity
defects without the need for free tissue transfer.

DECLARATIONS
Authors’ contributions
Synthesized literature review, performed most of manuscript drafting: Cohen-Shohet R
Contributed to literature review, manuscript formatting, and editing: McLaughlin M
Assisted with formatting and final editing: Kerekes D
Provided case series, expert knowledge, and final editing review: Chim H