“Free or Perforator-Pedicled Propeller Flaps in Lower Extremity Reconstruction: Defining the Coverage Failure”: Response
06 April 2018 (eFirst)
We read with interest the letter from Bekara et al entitled “Free or perforator-pedicled propeller flaps in lower extremity reconstruction: Defining the Coverage Failure.” We thank the authors for their comments as they raised an interesting discussion about how to evaluate complications.
We agree that the most important aspect for the assessment of lower limbs reconstruction is the “coverage failure,” since the main goal is defect coverage, and flap survival is the way we achieve it.
We do disagree, as our results show, that partial necrosis is not an issue with free flaps (FF); it is rather a problem common to both FFs and perforator-pedicled propeller flaps (PPPF). Partial necrosis takes on particular importance because of the possible exposure of important structures such as bone, tendons, or other tissues.
This event necessarily requires secondary surgery and we would like to introduce this as the main discriminating factor, since there is difference between a partial necrosis that would allow defect coverage with only conservative wound care, a minor necrosis that needs a minor operation, and a partial necrosis that needs major surgery (a second flap, pedicled, or free).
In our case series, complications requiring secondary surgery were 20% for FF and 23% for PPPF, but minor revision surgery was mostly necessary. We believe that, instead of talking about “coverage failure” or when talking about it, it would be more accurate to distinguish major secondary surgery from minor surgery or wound care, since these are the means that will allow to obtain successful coverage after a non-better identified partial necrosis.
Also, we agree with the authors' conclusions that the chosen flap should also reflect the surgeon's experience. However, the results of their recent meta-analysis show that it is possible to identify a class of patients at increased risk of PPPF reconstruction. We believe that surgeons enfacing lower limb reconstruction should be familiar with pertinent reconstruction techniques, and the appropriate technique should be based on local and general risk factors as suggested in our algorithm. We would like to point out that besides correctly comparing outcomes of FF and PPPF, one should also consider different indications, since there are indications and contraindications for each of them.  
- 1 Cajozzo M, Toia F, Innocenti A. , et al. Retrospective analysis in lower limb reconstruction: propeller perforator flaps versus free flaps. J Reconstr Microsurg 2017; 33 (S 01): S34-S39
- 2 Bekara F, Herlin C, Mojallal A. , et al. A systematic review and meta-analysis of perforator-pedicled propeller flaps in lower extremity defects: identification of risk factors for complications. Plast Reconstr Surg 2016; 137 (01) 314-331
- 3 D'Arpa S, Toia F, Pirrello R, Moschella F, Cordova A. Propeller flaps: a review of indications, technique, and results. BioMed Res Int 2014; 2014: 986829
- 4 Cherubino M, Corno M, D'Arpa S. , et al. Muscle versus fasciocutaneous flap in lower limb reconstruction: is there a best option?. J Reconstr Microsurg 2017; 33 (S 01): S27-S33
- 5 D'Arpa S, Cordova A, Pignatti M, Moschella F. Freestyle pedicled perforator flaps: safety, prevention of complications, and management based on 85 consecutive cases. Plast Reconstr Surg 2011; 128 (04) 892-906