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Page 6 of 10 Scaglioni et al. Plast Aesthet Res 2019;6:27 I http://dx.doi.org/10.20517/2347-9264.2019.41

Figure 6. Upper left: penetrating injury of the distal lower limb dorsally to the medial ankle (after debridement), measuring 4 cm × 3.5 cm
× 2.5 cm. Upper right: perforator flap measuring 12 cm × 4 cm was harvested, based on a perforator of the posterior tibial artery. Another
more distally located perforator was found but was ligated due to the close proximity of the wound. Lower left: the proximal tip of the flap
was de-epithelized to fill the dead space. Lower right: the flap was rotated 180° and filled the defect

DISCUSSION
The propeller flap is an extremely useful reconstructive tool and enables exceptional functional and
cosmetic results in the lower extremity. Similar to a local flap, it provides the possibility of reconstructing
“like with like”, covering the defect with tissue of similar color and thickness but without the awkward
dog ears. Being a perforator flap, it offers the freedom of choice regarding the skin island shape and
dimension as well as a safe perfusion. Compared with a free flap, it requires a simpler operation without
the need of microsurgical anastomosis and, thus, significantly shorter operating times. In a review of 21
[13]
studies, spanning from 2004 to 2012 and describing 310 propeller flaps, Nelson et al. noted a total flap
[14]
loss in 5.5% and a partial flap loss in 11.6%. Bekara et al. observed a 10.2% rate of partial necrosis and
a 3.5% rate of complete necrosis in their meta-analysis of 40 publications on propeller flaps in lower limb
reconstruction, representing 428 flaps and spanning from 2003 to 2014. These values are notably lower than
[15]
those for free flaps in lower extremity, as observed by Wettstein et al. . Furthermore, the decline of the
[14]
[13]
complication rate seen when comparing the reviews of Nelson et al. from 2013 and Bekara et al. from
2014 could imply a reduction of complications with the surgeons’ experience.
Propeller flaps can be used to reconstruct many different types of defects of the lower extremity, both
traumatic and non-traumatic in origin. Most commonly , they are performed for coverage of primary
[14]
[16]
defects in the distal third of the leg, as described by Teo . More and more authors apply them in
reconstructing the wounds of the foot, an example being the medial plantar artery perforator flap for