Freestyle Pedicled Perforator Flaps: Applying the Reconstructive Ladder to Optimize Outcomes

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We read with great interest the article by Mohan et al.,1 who properly summarized the possible reconstructive options available when approaching soft-tissue reconstruction with the use of local perforator flaps. In their revision, the authors focused mainly on the propeller and the keystone flap designs, forgetting to mention other reliable alternatives (e.g., V-Y advancement flaps, perforator-plus flaps).
At our institution, the use of free-style pedicled perforator flaps has become the gold standard for skin and soft-tissue reconstruction at different anatomical sites, even in elective cases when vital structures are not exposed and perforator flaps are preferred to skin grafts to prevent contour deformity and improve the long-term aesthetic result. In such cases, where the reconstructive elevator concept is chosen, much more attention should be paid to prevent any complication, even partial flap necrosis, and optimize the final outcome.
With this purpose, we routinely apply the reconstructive ladder concept to local perforator flap planning, starting from simpler options (e.g., V-Y advancement perforator flaps, propeller flaps with reduced rotational angles) and increasing the level of technical difficulty (e.g., 180-degree propeller flaps) only when the clinical situation requires it.
As our published experience may prove,2 the V-Y advancement design represents the beginner’s level, guaranteeing a straightforward dissection combined with increased vascular safety (more than one perforator can be included in the flap), in spite of a limited advancement and a more difficult insetting. When that approach is contraindicated (e.g., perforators in close proximity to the defect, short perforators, bony prominences to be overstepped), we proceed to the next technical level, adopting the propeller design without any hesitation. Nevertheless, not all propeller flaps have to be rotated 180 degrees to reach the recipient site. Even if the degree of rotation has been found to be unrelated to complication rates,3 our recent experience4 documented that propeller flaps with reduced rotational angles are as simple to perform as advancement perforator flaps and present similar complication rates (10 percent). Consequently, we tend to use them as a first-line strategy when a propeller flap is needed, considering that they combine the advantages of wide arc of rotation and high vascular reliability (Fig. 1). This design is highly reproducible and can be applied to almost all anatomical regions of the body.
Last but not least, we select the 180-degree propeller flap design. These flaps are much more difficult to manage in the intraoperative and postoperative periods, as they should be considered microsurgical nonmicrovascular flaps, thus requiring a microsurgical dissection with complete release of the perforator from its muscular, septal, or fascial adhesions to accommodate rotation. There is no clear evidence that supports an extended dissection as far as the source vessel, but we usually obtain a pedicle length of 2 to 3 cm at least, as suggested by Wong et al.,5 to reduce the risk of venous insufficiency. We congratulate the authors for the information provided in their article, believing that the application of the reconstructive ladder concept to local perforator flap planning may help to optimize outcomes and reduce vascular complication rates.
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