Abstract
Background Lower extremity defects often require free tissue transfer due to a paucity of local
donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction
while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described,
yet few studies provide outcome comparisons. Specifically, no study has examined the
impact of perforator flap pedicle skeletonization on reconstructive outcomes. This
systematic review characterizes technique and impact of pedicle skeletonization on
perforator-based fasciocutaneous flaps of the lower extremity.
Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed
for literature examining perforator-based fasciocutaneous flaps from knee to ankle,
from January 2000 through November 2018. The Preferred Reporting Items for Systematic
Reviews-Individual Participant Data (PRISMA-IPD) structure was used.
Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were
skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With
skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees
or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications
in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01).
Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative
to free tissue transfer for lower extremity defects. Though skeletonization increased
the overall reoperative rate, the complication rate for flaps with 90 degrees or more
of rotation was significantly reduced. This suggests skeletonization should be considered
when large rotational movements are anticipated to reduce complications that can arise
from pedicle compression and venous congestion.
Keywords
pedicled perforator flap - fasciocutaneous flaps - lower extremity reconstruction
- pedicle skeletonization
