Propeller Flaps in Hand Reconstruction

Introduction: Perforator flaps increasingly find acceptance and use in hand reconstructive surgery, but they are more prone to vascular compromise when are twisted more than 90 grade. It is now possible to design propeller flaps based on a single perforator, so-called “perforator-based propeller flaps.” These flaps permit flap rotation up to 180°. We present the results of hand complex tissue reconstruction using perforator-based propeller flaps. We constructed a treatment strategy and some tricks based on the location of the soft tissue defect and the perforator anatomy to increase flap survival.

Methodology and Material: We did a computer simulation of the vascular pedicle rotation (one artery and two veins) using commercially available Abaqus standard finite element software package by Dassault Systemes. All perforator-based propeller flaps that were used for hand reconstruction were retrospectively analyzed. The parameters studied included the size and location of the defect, the size and shape of the flap, the perforator (length and location) that was used, the degree of twisting of the perforator, the degree of perforator dissection, the management of the donor site, and flap survival area.

Results: In this study we investigated the circulatory compromise induced by twisting of the pedicle on a true perforator flap. All flaps survived completely with the exception of partial skin necrosis in four cases. Some of these cases required debridement and skin grafting. The donor site was closed primarily in the majority of cases.

Conclusions: Perforator-based propeller flaps provide a reliable option for covering small- to medium-size hand complex tissue defects. They have the advantages of using similar tissues in reconstruction, not damaging another area, they do not require main vessels sacrifice, and the donor site can be generally directly closed. Risk of venous insufficiency increases with: each degree of rotation beyond 90°, increasing flap surface (≥40 cm²), reducing perforator size (length, diameter), increasing flap and pedicle tension, increasing pressure from neighboring tissues on the vessel (hematoma...).