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Scaglioni et al. Plast Aesthet Res 2019;6:27 I http://dx.doi.org/10.20517/2347-9264.2019.41 Page 9 of 10

To date, there is no certain way of predicting preoperatively the exact size of the flap that will safely be
perfused by one perforator. Nevertheless, there are possible technical refinements of the flap design and
[12]
execution, which help improve the success rate by a large margin. Iida et al. proposed double-axes
propeller flap, intraoperative ICG, and supercharging of the propeller flap to minimize the ratio of (partial)
flap necrosis. When dissecting the flap, the perforators located farther than 3 cm from the main perforator
are clamped and ligated. When perfusion seems insufficient in intraoperative ICG, supercharging can be
performed using the ligated perforators.

Much research has been done into the correlation between the size of the perforator, its blood flow, and the
[26]
volume of tissue it can sustain. Donski and Fodgestam proposed that the suprafascial interconnections
between perforators lying along a septum effectively form an axial type flap, allowing for longer flaps to
[27]
be designed. Taylor et al. demonstrated that a single vascular perforator can, in addition to its own
angiosome, safely supply the angiosome of the adjacent perforator and, depending on the type of the
anastomoses between the angiosomes (choke or true), even part of the territory of the perforator next to
[28]
it. Saint-Cyr et al. described the perforasome theory based on the mechanism of opening “potential”
vascular territories using linking vessels after ligation of adjacent perforators. Further studies should be
conducted on defining the borders of perforasomes and the possibility of turning choke anastomoses into
real anastomoses.

As for the significant risk factors for failure or complications for propeller flaps in lower limb
[14]
reconstruction, Bekara et al. identified age older than 60 years, diabetes, and arteriopathy. Smoking did
not significantly increase the complication rate. In a review of 119 studies from 1991 to 2015, comprising
[29]
1315 propeller flaps in different areas of the body, Sisti et al. found that the complication rate for
propeller flaps was by far the highest in the lower limb (31.8%), compared to trunk (19.5%), head and neck
(15.7%), and upper limb (15.9%).

CONCLUSION
The perforator-pedicled flap has been gaining popularity among plastic surgeons over the past 20 years. In
our experience, it is an excellent option for lower limb soft tissue reconstruction in appropriately chosen
patients, enabling a functional and aesthetically pleasing result.

DECLARATIONS
Authors’ contributions
Senior author and corresponding, performed all surgeries and revised the manuscript: Scaglioni MF
Wrote the manuscript under Scagloni supervision: Macek A

Availability of data and materials
Data from Scaglioni MF, Department of Plastic Surgery Lucerne.

Financial support and sponsorship
Not applicable.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Followed Helsinki Guidelines, Case reports with review.