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Bolletta et al. Plast Aesthet Res 2019;6:22 I http://dx.doi.org/10.20517/2347-9264.2019.22 Page 3 of 14

SOFT TISSUE COVERAGE
Local perforator flaps
Over the past two decades the indications for perforator flaps reconstruction have increased due to the
better understanding of the anatomy and distribution of perforator vessels [5,26] . These flaps can be used
as local flaps and transposed to the defect through a wide range of movements (i.e., V-Y advancement,
rotation, etc.) [27-30] . A propeller perforator flap is, according to Tokyo consensus, “a perforator flap with a
skin island made of two paddles, one larger and one smaller, separated by the nourishing perforating vessel
[31]
that corresponds to the pivot point” . Propeller perforator flaps have a low donor-site morbidity due to
conservation of source vessels and muscles and provide like-with-like tissue coverage in terms of color
match, thickness and texture. These flaps can be raised in a short time and can be designed almost in every
location. Local flaps can be contraindicated in trauma patients, when the extent and the characteristics
of the injury affect the viability of the surrounding tissues, for example in degloving injuries. Another
questionable fact is that the vessel chosen for these flaps is usually close to the injured area but, if the
[32]
perforator is not directly damaged, it usually does not undermine the flap survival . In patients with
compromised general conditions, the time and cost saving procedures, sparing multiple surgical sites,
can be a first choice [33-37] . It is also true, though, that propeller perforator flaps have been related to higher
rates of complications, such as partial flap necrosis and venous congestion. Such complications appear to
be related to two main topics, still objects of debate, regarding propeller flaps: dimensional limit and arc
of rotation. The limit in terms of size of these flaps is hard to determine due to the dynamicity of adjacent
[38]
perforasomes recruitment which depends on many different factors . The arc of rotation, instead, has
been determined to be related to the length of the pedicle and its proper and wide dissection [39-41] .

In limb reconstruction, local propeller perforator flaps can be considered as an important tool for the
reconstruction of small and medium size defects. Due to the lack of tissues in the limbs, attention has to be
payed to donor site morbidity. In the upper limb, direct donor site closure can be achieved for flaps with 4 cm
of width or less in the forearm, and 2 cm in the dorsum of the hand. Partial donor site closure can be
performed in greater defects, and total closure attained with skin grafting .
[32]
Useful propeller perforator flaps of the upper limb are the one based on radial artery perforators and ulnar
artery perforators. They are both pliable, thin, have a very good texture match, and can be used as sensate
flaps, which is very important in upper limb reconstructions. If multiple tissue types are needed their
harvest can incorporate bone and portions of tendons and muscles. If these flaps are based on proximal
perforators they can be used for proximal defects, such as the elbow region, whereas, if they are based
on distal perforators they can provide tissue coverage for the wrist area and the hand. In terms of donor
site morbidity, the ulnar artery propeller perforator flaps have the advantage of a minor tendon exposure,
[42]
especially if raised in the proximal forearm . Posterior and anterior interosseous artery propeller
perforator flap can be used for the dorsum of the hand because of their characteristics very similar to the
[43]
hand structure . For small defects of the hand and fingers, both volar and dorsal, another good option is
the dorsal metacarpal artery perforator flap.

In the lower extremity, according to 2016 Bekara’s meta-analysis, the most used propeller perforator flaps
are posterior tibial artery perforator (58.6%), peroneal artery perforator (30.1%), sural artery perforator
(medial or lateral, 5.6%), metatarsal artery perforator (2.0%) and anterior tibial artery perforator (1.6%) .
[44]
Flap selection is usually based on the location of the defect and on the study of the perforators in the
nearby area. Preoperative color Doppler ultrasound can be used to detect adjacent perforator vessels
with suitable caliber and blood flow. Usually vessel selection includes vessels in a 2-10 cm range from the
defect, with caliber greater than 0.6 mm. After the choice of the perforator, the design of the propeller flap
[45]
is performed . In terms of complication rates of propeller perforator flaps in the lower limb, two recent
review articles by Gir and Nelson reported analogous results (11% of partial flap necrosis in both studies,