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Page 2 of 10 Scaglioni et al. Plast Aesthet Res 2019;6:27 I http://dx.doi.org/10.20517/2347-9264.2019.41
[5]
The first authors to use the term “propeller flap” were Hyakusoku et al. in 1991. His group designed an
adipocutaneous flap with a skin island of a length largely exceeding its width, based on a random pedicle
in the center, on which the flap was then rotated through 90° similar to a propeller to release burn scar
contractures in the cubital and axillary regions.

Thanks to the advances in microsurgical techniques and anatomical knowledge, perforator flaps have been
[6]
developed, where a skin island flap is harvested without the underlying muscle. Koshima and Soeda were
the first to use the name “perforator flaps” in 1989 and since then perforator flaps have broadened our
armamentarium in reconstructive microsurgery.

[7]
The two terms were first combined by Hallock in 2006 when he described an adductor perforator flap
of the posteromedial thigh designed in a propeller fashion for coverage of ischial or trochanteric pressure
sores. This flap was comparable in shape to the one developed by Hyakusoku, but it was based on a
skeletonized perforator and rotated through 180°.

[8]
Already in the 1990s, Teo greatly developed the surgical technique of perforator-based propeller flap in
the reconstruction of the distal third of the lower limb (without having named it as such) and more recently
also contributed to the definition.

[9]
What is a propeller flap? By the definition of the “Tokyo” Consensus on Propeller Flaps from 2011, a
propeller flap is an island flap that reaches the recipient site through an axial rotation of more than 90°.
It can be thought of as a propeller with 2 blades of unequal length with the perforator forming the pivot
[9]
point. Pignatti et al. proposed a further classification based on the nourishing pedicle (subcutaneous,
perforator and supercharged), degree of rotation of the skin island (90°-180°), and the artery of origin of
[10]
the perforator vessel (as defined for perforator flaps by the “Gent” consensus ).
Due to the conus-like shape of the lower leg, there is a shortage of local soft tissue for reconstruction of
defects. Using a proximally based peninsular fasciocutaneous flap, it is difficult to get a sufficient amount
of healthy tissue into the defect without exposing the anterior tibial crest or the Achilles tendon, both
of which are difficult to graft. The propeller flap circumvents these challenges/problems by transferring
healthy tissue from the proximal calf into the primary defect. Thus, the secondary defect is moved to the
area over the proximal muscle bellies, which is easily graftable or even primarily closed, either through a
direct mobilization and closure of the skin or even through another propeller flap, as already described by
[11]
our department . Another advantage of the propeller flap, compared to the local flap, is that it avoids the
awkward twisting at the base of the flap. This twist is unsightly, and it might even compress or stretch the
pedicle, which may endanger the flap survival. Furthermore, the propeller flap design expands the reach of
the flap and enables an easier inset.

SURGICAL TECHNIQUE
Preoperatively, the most appropriate perforator is identified using CT-angiography and a handheld Doppler
device. With the perforator used as the pivot point, a provisional flap design is drawn. First, the proximal
limit of the flap is determined by transposing the distance between the perforator and the distal border
of the defect proximally over the axis of the source artery and adding 1 cm to that length. Thus, the flap
is easily inset without tension and allowed to contract. Next, the width of the proximal flap is determined
by measuring the width of the defect and adding 0.5 cm for the same reason. A thigh tourniquet is used
but without exsanguination of the limb, which makes for an easier identification and dissection of the
perforator. The raising of the flap begins with an initial exploratory incision under loupe magnification and,
thereupon, usually several potentially applicable perforators are found. Based on the position and size, the
best one is chosen, and it may not necessarily be the one identified on Doppler sonography. The design of