The Role of Freestyle Perforator-Based Pedicled Flaps in ...lineacosmeticsurgery.in/pdfs/2009_pedicled_perforator...12 to 45 years. The defects were grouped as acute, subacute, and

HAND SURGERY AND MICROSURGERY

The Role of Freestyle Perforator-Based Pedicled Flaps inReconstruction of Delayed Traumatic Defects

Satish Bhat, MCh, DNB, MRCS(Ed),* Atul Shah, MS, MNAMS,† and Andrew Burd, MD, FRCS, FHKAM*

Abstract: The use of perforator-based flaps as freestyle pedicled flaps fortraumatic defects has been limited. We explored this possible application insmall to moderate sized traumatic defects presenting in the delayed phase,with distinct oedema and induration in the potential flap donor area andposttraumatic vessel disease. Attempts to skeletonize perforator vessels arelikely to compromise the flap perfusion, and inadequate dissection is likelyto limit mobility of the indurated tissues in the flap. Conventionally, an axialpattern pedicled or a free flap would be needed in such cases, thus increasingits magnitude. We used the freestyle technique to cover traumatic defects byretrograde dissection of pedicled perforator-based flaps. As the surgery wasperformed in the delayed phase, the tissues were indurated and a larger tissuecuff was preserved around the pedicle than would be our practice in electivesurgery. In addition, flap dimensions were planned larger than the defect tobe closed. The donor defect was either skin grafted or closed primarily. Ourstudy included 11 cases at various sites over the body. All flaps survived,though 3 flaps encountered major complications, 2 of which needed reop-eration. None of the flaps failed completely.

The pedicled perforator-based flap provides the surgeon with additionalreconstructive options in the setting of trauma. These flaps can be safelyharvested using indurated tissue; thus in selected cases, a free flap can beavoided, and reliable cover can be provided with a pedicled flap. Nevertheless,clinical judgment is essential to assess the potential vascular territory of the flap.

Key Words: pedicled perforator-based flaps, traumatic defects, zone ofinjury, posttraumatic vessel disease

(Ann Plast Surg 2009;63: 45–52)

Fu-Chan Wei first reported the technique of retrograde dissectionto harvest a free-style free flap.1 Though perforator-based pedi-

cled flaps have been used by many authors, using similar principles(Table 1) for various defects such as pressure sores, post cancerexcision, post elective surgery wound dehiscence, only a singlepublication describes flap dissection using the freestyle technique.2

Also, when used in traumatic defects (Table 1), the influence of thezone of injury,3 and post-traumatic vessel disease (PTVD)4 on flapplanning and dissection is yet to be considered.5,6

PTVD includes the changes that progressively occur in thevessel walls and perivascular tissue following trauma. It is because ofthe wound exudates tracking up the perivascular sheath well beyond thezone of initial injury. Its hallmarks include loss of normal easy planesaround the vessels, loss of vasa vasorum, and a marked tendency tovasospasm or vessel damage when dissection is attempted. Their intimaalso lacks the thromboresistant properties of a healthy vessel.

When traumatic defects present in the delayed phase, themediators of inflammation diffuse over a wider area, resulting inmore extensive PTVD changes. With late debridements, the defect islarger and involves more structures; thus compared with an acutetraumatic defect, a free flap is more likely to be needed. This isprecisely the situation where uncommon techniques are needed toexecute the free flap surgery3,7,8 and failure rates are higher, espe-cially for lower limb defects.9 Flap cover for a given traumaticdefect in the acute phase is much simpler.

We explored the use of freestyle pedicled flaps, in cases withdelayed8 (subacute or chronic) presentation involving distinct edemaand induration for small to moderate sized defects. Conventionally,a pedicled axial pattern fascial or muscle flap or a free flap would beused in such cases.

PATIENTS AND METHODS

PatientsBetween July 2006 and June 2007, 11 freestyle pedicled

perforator-based flaps were performed for posttraumatic defects inthe leg, thigh, forearm, elbow, and back.

The procedures which were undertaken in 2 separate insti-tutes were performed by a single plastic surgeon, the first author.There were 9 male and 2 female patients, whose ages ranged from12 to 45 years. The defects were grouped as acute, subacute, and latewhen they present within the first, from second to fourth, andbeyond fifth week post injury, respectively. Perforators were iden-tified using a hand held Doppler device with an 8 MHz probe. Thisprobe has a 2 to 3 cm depth of tissue penetration.

Preoperative DesignThe extent and severity of the zone of injury is assessed from

the history, clinical examination, and reference to appropriate x-rays. The patient is positioned as they would be for surgery and theperforators around the defect are identified with the hand heldDoppler. Potential flaps are considered based on the availability ofa dominant perforator and the presence of any other defects or scars.

Flap DesignThis is either advancement with V-Y design or rotation

through suitable extent, with the flap axis along the line of perfora-tors. In a V-Y advancement design, the length of the flap isapproximately twice the diameter of the defect in the direction ofadvancement and the base slightly longer than the perpendiculardiameter of the defect.10,11 In a flap that will undergo rotation, skinpaddle is designed 1 to 2 cm greater that the defect in eachdimension, depending on the suppleness of flap tissues.

Surgical TechniqueThe tourniquet is inflated without limb exsanguination to

provide better vessel visibility. The defect is created and evaluated,1 flap design is selected. The flap surgery begins by incising theskin, subcutaneous tissue, and deep fascia on 1 side of the flap, andundermining the deep fascia so that the perforator may be ap-proached.10 When induration prevents perforator visualization, theDoppler signal indicating a dominant perforator is used as a guide.

Received March 20, 2008 and accepted for publication, after revision, August 5,2008.

From the *Department of Surgery, Chinese University of Hong Kong, HongKong, People’s Republic of China; and †Department of Plastic Surgery, GrantMedical College and Sir JJ Group of Hospitals, Mumbai, India.

Reprints: Satish Bhat, MCh, DNB, MRCS(Ed), Department of surgery, 4/FClinical Sciences building, Prince of Wales Hospital, Shatin, NT, Hong Kong,People’s Republic of China. E-mail: at [email protected].

Copyright © 2009 by Lippincott Williams & WilkinsISSN: 0148-7043/09/6301-0045DOI: 10.1097/SAP.0b013e318189383d

Annals of Plastic Surgery • Volume 63, Number 1, July 2009 www.annalsplasticsurgery.com | 45

http://www.annalsplasticsurgery.com

The skin paddle is now completely islandized and the deep fascia isincised all around the flap; the final subfascial dissection is guidedby the amount of terminal mobility required.10

While dividing the subcutaneous tissue, a cutaneous nerve orsuperficial vein entering the flap can be preserved after some mobili-zation to improve the flap quality. Once the flap movement is verified,tourniquet is released, flap perfusion evaluated, and hemostasisachieved using a bipolar diathermy. The final dissection is now done, asneeded for a tension free movement and inset; skeletonizing the perfo-rator is avoided in the face of even minimal induration (Fig. 1).

The flap is moved into the defect by advancement or rotationand then inset.10 A suitable drain is placed and secured beneath theflap as needed. The donor defect is closed primarily in a V-Yadvancement design; elsewhere, it is covered with a split-thicknessskin graft (STSG). Further, postoperative care including splintageand elevation follow standard flap surgery principles.

RESULTSOver a period of 10 months from September 2006 to June

2007, we have used the freestyle pedicled perforator based flaps

TABLE 1. Articles With Pedicled Perforator Flaps: Number of Flaps for Traumatic Defects in Each Series

SerialNumber

Reference Number,Yr

Total Pedicle Flapsin Series

Cases ofTrauma

Other Relevant Details Considered for TraumaticCases

1 2,1988 5 0 —

2 3,1998 18 0 —

3 4,1999 4 0 —

4 5,1999 9 3 None

5 6,1999 18 1 Acute trauma

6 7,2000 40 7 Acute trauma, primary closure of donor defect

7 8,2004 35 — —

8 9,2005 15 7 Degloving injury mentioned as contraindication

9 10,2007 10 9 Skin bridge maintained-perforator plus concept

10 11,2007 24 2 V-Y design, primary closure of donor defect

11 12,2007 35 14 None

12 13,2007 19 10 Assess trauma severity in flap planning,recommends to confirm patency (undamagedvessels) by pre-op Doppler

13 14,2006 10 10 Only leg defects, and those presenting earlyconsidered

14 14,2002 30 27 Brief mention of zone of injury, suggestions made todecrease donor morbidity, suitability compared withfree flaps

15 15,2004 5 — —

16 16,2007 23 — —

FIGURE 1. Schematic diagram toillustrate the technique of using apedicled perforator based flap inacute and delayed trauma.

Bhat et al Annals of Plastic Surgery • Volume 63, Number 1, July 2009

46 | www.annalsplasticsurgery.com © 2009 Lippincott Williams & Wilkins


in 11 cases following trauma; wound cover was provided fordefects in leg, thigh, forearm, elbow, and back. Table 2 showspatient profile, operative details are in Table 3. Ten defects werecompletely covered by a single flap, 1 defect needed 2 flaps. Ofthe 11 cases, 9 were based on septocutaneous perforators (SCp),2 on musculocutaneous perforators.12

Illustrative CasesDissection for the anterior tibial pedicle revealed induration

with loss of normal planes; a distal-based islanded flap was dissectedbased on the marked perforators and rotated.

Case 5A 42-year-old man sustained a near circumferential low

velocity wrist injury involving flexor and extensor tendon and bothradial and ulnar arterial injury. Following initial tendon repair andbone stabilization, he developed necrosis of the dorsal wound edgesnecrosis over 3 weeks, resulting in exposure of the distal forearmfracture and extensor tendons. After debridement, cover to thewound was provided with a 7 � 5-cm island flap fed by perforators(SCp) of the posterior interosseus artery that rotated through 110degrees (Fig. 2). The STSG on the donor site and the flap healeduneventfully.

Case 6A 24-year-old man sustained an open supracondylar fracture

femur; this was fixed using implants and a fibular graft. There wasa breakdown of the wound, and a sinus persisted when he wasreferred for a flap cover in the ninth week post injury. A 12 � 6-cmfasciocutaneous flap supplied by the lower profunda perforators wasdissected from the posterolateral thigh. The flap was rotated through160 degrees and inset, the donor defect was covered with a split-thickness skin graft, and healing was uneventful (Fig. 3).

Case 7A 34-year-old man sustained an open fracture of the middle

third of his left leg following a moderate velocity road trafficaccident. He underwent bone stabilization on the second day afterthe injury and simultaneous flap cover using an island V-Y fascio-cutaneous flap fed by perforators (SCp) from the posterior tibialartery (Fig. 4). Donor area was closed primarily. The flap healedwell and gave a stable cover to the wound; with bony union over 18weeks, he returned back to his work as a manual laborer with a goodesthetic and functional reconstruction.

Case 10A 10-year-old girl fell from a height of 4 meters and sustained

a fracture of thoracolumbar spine; this was stabilized with animplant. However, wound breakdown resulted in implant exposure;she was referred for a flap cover in the third week post trauma.Indirect perforators from the lumbar artery through the quadratuslumborum were identified and used to design a V-Y advancementflap on either side of the defect. Each flap, 10 � 8 cm in size, wasadvanced into the defect and tension free inset achieved along withprimary donor site closure (Fig. 5). Further healing was uneventful.

DISCUSSIONAbout 80% of free flaps are used for wound cover alone.13

Similarly, most local flaps are also used for wound cover, but in theirconventional design they have limited applications when used tocover small to moderate sized traumatic defects, especially in thelower limb and trunk.11,14 Ponten15 first described fasciocutaneousflaps in 1981 for soft tissue defects in the limbs. Though manyvariations were developed over the years, a free flap is still neededwhen local fasciocutaneous or muscle flaps are not possible. In fact,in specific situations, free tissue transfer is considered the goldstandard for traumatic distal limb defects.16

Following the landmark anatomic study by Palmer and Taylorin 1986,17 the term “perforator-based flap” was first used by Krolland Rosenthal.18 This was soon followed by their wide use as freeflaps for distinct advantages over conventional free flaps.2 Thoughapplication of these principles for pedicled flaps in trauma has beenbriefly mentioned so far, issues concerning traumatic defects withdelayed presentation have not been elaborated (Table 1). ThePTVD4 with tissue edema and induration in the zone of injury3

makes conditions difficult for a local flap compared with a defectpresenting in the acute phase.

We identified the potential dominant perforators19 over awide area around the defect before surgery. Possible flap designs areconsidered, seating the flap axis along the line of dominant perfo-rators. This ensures that a dominant perforator will feed the flapbase. Though use of a Doppler probe has certain limitations, they areunlikely to pose a problem, as distinct PTVD changes make formalsubfascial dissection of the perforators unlikely. We agree withprevious authors, this decision needs experience initially, but after afew cases it can be done quite easily.19–22 Perforators from super-ficial arteries as in the distal limbs have signals that overlap with theaxial vessel. To distinguish the 2 signals, we use the following

TABLE 2. Patient Profile for Freestyle Pedicled Perforator Flaps

Patient Numberand Initials Age Sex

Trauma-SurgeryInterval Defect Site Medical Risk Factors

1 FD 45 M 37 d Middle third L leg with open fracture tibia Nil

2 NK 10 M 9 yr Lower third R leg unstable scar with osteomyelitis Nil

3 AK 48 M 30 d Middle-proximal third L leg open fracture Nil

4 ES 52 M 43 d R lower third leg open fracture Nil

5 NS 42 M 29 d R wrist injury with lower third forearm fracture andextensor tendon injury

Nil

6 BP 29 M 62 d Comminuted L supracondylar fracture femur withbone graft and exposed implant

Nil

7 SB 34 M 1 d Open fracture middle third L leg Nil

8 AB 37 M 27 d Open supracondylar fracture L femur Nil

9 SG 48 M 5 d Open R ankle fracture 5 cigarettes/d since past 15 yr

10 SM 12 F 18 d Exposed implant thoracolumbar spine Nil

11 LYS 42 F 9 d Exposed L olecrenon Nil

Annals of Plastic Surgery • Volume 63, Number 1, July 2009 Freestyle Perforator-Based Pedicled Flaps

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techniques: (a) with the Doppler probe at right angles to the skin,direct pressure on the skin surface with the probe will decrease theperforator signal intensity, and finally obliterate it totally; the axialvessel signal intensity will be essentially unchanged by probepressure; (b) keeping the Doppler probe head at the same point,moving the long axis of the probe to describe a cone will alter theperforator signal, but not the axial vessel signal; (c) moving theDoppler probe over the skin along the path of the vessel will changethe perforator signal, but not the main vessel signal.

Additional imaging such as a Color Doppler or a Duplex scanmay be used when: (a) the surgeon has a doubt whether theperforator signal detected is dominant or not; (b) degree of antici-pated rotation involved and possible twist of the pedicle pose a riskof flap congestion; (c) surgeon is unfamiliar with the anatomy aswith an axial vessel in an uncommon area (posterior thigh or back ofthe trunk) or with an underlying vascular injury; (d) clinical risk forperipheral vascular disease exists as with smoking, hypertension orobesity, high velocity injury. We did not need additional imaging in

any of the cases, and only in case 9 did we think (in retrospect) thatit might have helped, as explained further.

The use of perforators outside the zone of injury permits safeskeletonization with good mobility, as in choosing a recipient pediclefor free tissue transfer in trauma.3 But unlike a free flap, options anddimensions while choosing a pedicled flap are more limited; so indelayed traumatic defects, excision of all tissue with induration, andresolving edema is frequently not feasible, with emphasis solely onremoval of contaminated and devitalized tissue. Thus, it is difficult toprovide supple tissue for flap inset. It is this indurated tissue lying justbeyond the defect edges that is likely to have a dominant perforator init, which may be used to design a perforator based freestyle flap. Anearly debridement totally avoids this difficult situation.

We used a V-Y advancement design in 2 of our 11 cases;when the induration within the flap tissue is unlikely to permitadequate advancement (about 4–5 cm), it is safer to use 2 V-Yisland flaps or a single rotation islandized flap though the donor sitewill need a STSG.

TABLE 3. Operative Details of Freestyle Pedicled Perforator Flaps

PatientNumber

DefectDimension

(cm)

Name of thePerforator-Based

Flap 12Relevant Flap

Features

PerforatorVisualized

Y/N

FlapDimension

(cm)

MovementImparted toFlap Pedicle

DonorDefect

Outcomes

Soft Tissue HealingBone

Healing (wk)Return to

Work (wk)

1 9 � 7 Posterior tibial artery

perforator-based

flap (SCp)

Y 12 � 9 90-degree

rotation

STSG Uneventful, stable

cover

23 32


perforator-based

flap (SCp)

Edematous, scarred soft

tissue—flap margins

needed SSG

N 6 � 8 100-degree

rotation

STSG Partial loss of STSG

to margins of

thick flap, treated

with dressings,

flap healed well

Intact bone at

time of flap

surgery

4

3. 6 � 8 Posterior tibial

artery perforator-based

flap (SCp)

Y 10 � 8 70-degree

rotation


cover

24 38

4 6 � 4 Peroneal (supramalleolar)


flap (SCp)

To cover residual defect

after partial necrosis

of distal sural artery

flap

N 9 � 5 80-degree

rotation


cover

36 46

5 7 � 5 Posterior interosseus


flap (SCp)

Associated dorsal wrist

injury precluded use

of axial flap

N 10 � 7 110-degree

rotation

STSG Flap settled well

without compromise

in flow to distal

hand.

18 48 (due to

associated

polytrauma)

6 12 � 6 Profunda femoris artery

perforator-based

flap (SCp)

Thick soft tissue cuff

retained with pedicle

due to extensive

induration

N 10 � 5 160-degree

rotation

STSG Delayed healing

of STSG donor area,

flap settled well

72 Ambulation

with support

by 90 wk,

needed job

change


perforator-based

flap (SCp)

V-Y design to skin

paddle

Y 12 � 6 Advancement

by 3 cm

Primary

closure

Uneventful, stable

cover

18 23

8 10 � 7 Vastus medialis

perforator-based

flap (MCp)

Y 13 � 10 Rotation of

100 degrees

STSG Partial dehiscence of

inset, settled with

dressings

28 42


perforator-based

flap (SCp)

Y 15 � 9 170-degree

rotation

STSG Necrosis of distal

third of skin

paddle, needed

debridement and

STSG

Lost to

follow-up

10 8 � 6 Quadratus lumborun

perforator-based

flap (MCp)

2 flaps each designed

as V-Y

N 10 � 8 cm

each flap

Two advancement

flaps

Primary

closure

Sound healing with

stable flap

She stayed bed-ridden due

to residual paraparesis

following primary trauma

11 6 � 8 Sup ulnar collateral

artery perforator

flap (SCp)

N 7 � 11 180-degree

rotation

Primary

closure

Necrosis of 40% of flap,

needed debridement

and STSG

No fracture

involved

6

MCp indicates musculocutaneous perforator.




A retrograde technique of pedicle dissection can be easilyapplied when dissecting in virgin tissue as with a pedicled flap for anontraumatic defect or while harvesting a freestyle free flap.1,23

However, with a pedicled flap for a traumatic defect, the situation isdifferent.

We avoid any attempt to skeletonize the vessels lying close tothe zone of injury, especially in cases with a formal debridementdone later than 1 week after injury. Acland has emphasized the lackof thromboresistant properties of normal vessel in presence ofPTVD; we believe attempts to skeletonize will pose a threat to flapcirculation. We also appreciate the fact that PTVD extends beyondthe zone of injury.4 In fact, we maintain a good soft tissue cuffaround the area with a dominant perforator signal, avoiding anyattempts to identify the actual vessels. An intact Doppler signal fromthe subfascial soft tissue can guide to avoid the pedicle and ensurea safe final dissection. This limited dissection results in a wider pivotpoint and limited flap mobility that needs to be anticipated wellbefore committing on the skin paddle. By making the skin paddle 1to 2 cm larger in each dimension (compared with the defect), thislimited mobility can be compensated and stable cover provided tothe defect. In case 2, we failed to anticipate this issue; multiplesurgeries over the previous 9 years resulted in significant induration.The thick flap covered the floor of the defect completely, butprimary closure of skin at the distal inset was not possible. Theedges of the flap had to be skin grafted, but healed uneventfully.

When possible, we did include a superficial vein in the flap.It was not possible to preserve a skin bridge and yet achieveadequate movement in a tissue with resolving edema and induration.Few local flaps fed by perforators have been described, where a skinbridge is left intact as an additional source of perfusion6,24; theseflaps need to be differentiated from perforator based flaps.25 Thoughthe Gent consensus recommends avoiding the term “cutaneousisland,” with pedicle flaps, it is essential to restrict use of termperforator-based flap only where perforators alone are responsiblefor flap perfusion.25 In our technique, creating an islandized skinpaddle is an essential step, given the limitations on mobility imposedby scarring and limited perforator dissection.

Trauma often results in major variations in axial vessel flow.However, as with a freestyle technique elsewhere, these unexpected

variations do not interfere in the flap surgery and knowledge of thesource vessel is not required.1,26 Case 5 illustrates this point; wherenear circumferential wrist injury resulted in uncertain retrogradeflow for a conventional reverse posterior interosseus artery flap. A

FIGURE 2. Case 5: A, B, Open fracture lower forearm withexposed extensor tendons. C, Flap elevated keeping poste-rior interosseus pedicle (arrow) intact. D, Flap transferredand healing, flap defect with STSG.

FIGURE 3. Case 6: A, Treated open fracture lower femur withresidual sinus (arrow), profounda perforators marked and flap de-signed. B, The comminuted fracture with fibular graft. C, The flaptransferred with good healing, with STSG to the donor area.




freestyle technique ensured a safe outcome to the flap, with theadded benefit of maintaining the compromised axial flow to thedistal hand.

Nirinjan et al achieved primary closure of flap defect in all 7cases of flaps done for acute trauma.11 All 3 cases in our series (7,10, and 11) with primary closure of donor area had the flap surgerywithin first few days of the trauma. This was possible in thesubsequent few cases, as we acquired experience over the initialprocedures. When donor area induration is present, the subdermaldissection needed for an adipofascial flap may leave the skin flapsunreliable; we avoided this in our cases to ensure timely donor sitehealing.

We encountered complications in 3 of our 11 cases, 1 minorwound dehiscence in case 8 and 2 major complications (Fig. 6).Case 9 with a high velocity trauma and open fracture of lower thirdleg developed distal third flap necrosis on the third day followingsurgery. Though larger skin paddles supplied by single lower legperforators have been used,27 we believe flap ischemia resulted froma large paddle, given the high velocity injury with altered bloodflow, and his history of smoking. In retrospect, a Duplex ultrasoundto evaluate status of the accompanying veins would have helped,given the high velocity trauma involved.16

Necrosis of distal 40% of flap in case 11 was possibly due tocongestion following primary closure of flap defect in the arm.Unexpected disparity in thickness of flap and defect necessitated aflap thinning just before inset, which contributed to distal ischemia.It is recommended that relative thickness of defect and flap bealways considered before designing a flap, and flap location or skinpaddle dimensions be altered to avoid such problems. Also, pedicletwist following flap rotation is likely to cause congestion, in pro-

portion to the degree of twist. To counter this: (a) a tissue cuff ispreserved around the pedicle to blunt some of the tendency toocclude as may occur with skeletonized vessels; (b) we include anintact superficial vein (that has been dissected for some distancebeyond the flap limits) with the flap while mobilizing it, providingadditional venous drainage; (c) we evaluate the capillary refill in the

FIGURE 4. Case 7: A, B, Open, displaced fracture middlethird leg. C, D, V-Y flap designed on posterior tibial perfora-tors, advanced and donor defect closed primarily. E,Advanced flap healing well.

FIGURE 5. Case 10: A, Open fracture lumbar spine. B, Defectcreated and flap elevated. C, Advanced and settling well; donorclosed primarily.




skin paddle as the limits of tension free mobility is reached. Anydelay in refill in the rotated flap position lasting more than 30minutes is unsafe.

By using these guidelines, complete cover to defect could beprovided in a single stage in all our cases. Even in the 2 cases withmajor flap complications (necrosis needing intervention), no salvageflap was needed. Staged debridement of the necrotic part of the flapwas done to obtain a healthy bed, definitive cover was provided witha STSG. Thus, we did not have any flap with total failure.

Our initial cases included smaller defects, where conventionalpedicled fasciocutaneous flaps or muscle flaps might have providedcover, but with greater morbidity and inferior aesthesis. We alsoused the opportunity to gain familiarity and experience with thetechnique of a freestyle perforator based flap, before using them inmore demanding situations. We recommend this approach for sur-geons unfamiliar with islanded perforator-based flaps.

Though conventional teaching suggests use of a muscle flapto cover all open fractures that need a flap cover, recent experiencesuggests otherwise.28,29 Accordingly, we suggest use of a muscleflap only for an open fracture with a high potential for infection aswith: (a) a severely fragmented fracture; (b) deep dead space such asafter bone loss. For other open fractures, fasciocutaneous flapsprovide an acceptable outcome, similar to muscle flap with STSG interms of flap survival, early postoperative infection, chronic osteo-myelitis, and bone healing. In addition to improved morbidity andappearance, use of a fasciocutaneous (perforator based) flap by thefreestyle technique provides more options with greater freedom ofseating the pivot point and skin paddle orientation. An additionaladvantage is the ease of limb positioning to harvest the flap in somecases, which is otherwise restricted by the external fixator used to

stabilize the fracture. Thus, in case 1, we used a fasciocutaneous flaprather than a soleus muscle with skin graft. The flap provided astable cover, the underlying fracture united well over 23 weeks.Once ambulation without support was possible, he returned to hisprevious office work at 8 months of initial injury.

Though case 6 (Fig. 3) involved a shattered fracture with boneloss needing a bone graft, the orthopedic team was satisfied with thebone reconstruction; debridement of the soft tissue presented ashallow defect, and hence a fasciocutaneous flap was consideredadequate. Further the defect site did not permit any pedicled muscleor conventional fascial flap, a pedicled fasciocutaneous flap waspossible using the freestyle technique. A free flap was thus avoidedand adequate soft tissue reconstruction was provided using a muchsimpler means.

In select cases, this technique is likely to be superior to freeflaps as well, when used for cover of lower third leg defects,especially for delayed defects in trauma. This has already beenestablished for acute phase defects.16 In the lower limb, failure ratesfor free flap transfer are the highest for subacute and chronicdefects.8,30 Our short case series has 6 cases, involving defects in asimilar phase with 1 minor complication (16.6% rate) and no failureswith an acceptable final outcome. Though, the safety in the tech-nique we used appears comparable or even better than with free flapsfor delayed traumatic lower limb defects, the evidence31 availablefrom our experience is insufficient to justify such a conclusion at thisstage. Nevertheless, the advantages of this technique are distinctcompared with: (a) a free flap as it is technically simpler and lessdemanding on resources; (b) a conventional pedicled fascial flap dueto superior aesthesis and morbidity; (c) a pedicled muscle flap withSTSG as an intact skin component permits venous and lymphaticdrainage.

Thus, we suggest pedicled perforator-based island flaps areindicated when: (a) defect size is moderate, 8 to 10 cm in adult, (b)conventional pedicled flap options are not available, due to previousinjury or surgery, or positioning problem; (c) underlying axial vesselinjury exists; (d) free flap is not possible due to patient factors(systemic status), surgeon factor (technically demanding), inade-quate resources (a smaller surgical unit), or when resources areprecious as in a mass casualty (war zone or natural disaster).

We believe this technique will be particularly useful to plasticsurgeons working alone, in smaller units with limited resources; ahand held Doppler and an operative loupe comprise the only man-datory equipment. In recent events of natural disaster (such as theearthquake in China or cyclone in Myanmar) or war zones, whereresources are inadequate, this technique may provide an alternativein the absence of any other solution. These events are likely topresent with a large number of such delayed traumatic defects.

As our study is limited, a longer follow-up is needed to verifythe flap stability following wear and tear. Finally, a learning curve isbound to exist in this procedure, which has many variables andlimitations. It is also helpful to have microsurgical services as abackup to tackle a difficult situation or unexpected problems duringsurgery, until adequate experience can be gained to execute theseflaps reliably. We did not need this in our any of cases.

CONCLUSIONSAs a freestyle procedure, the pedicled perforator flap provides

the reconstructive surgeon with additional options, provided theseprinciples can be applied in the common setting of trauma. In casespresenting late, when options for conventional local flaps are evenless likely, this is a distinct and safe alternative to a free flap.However, there exists a critical judgment of deciding the skin paddledimensions to compensate for the limited mobility due to theinduration in the pedicle vicinity. If this does not seem safe, it is

FIGURE 6. Results with complications. A, B, Case 9: necrosisof distal third of posterior tibial perforator flap. C, D, Case11: Necrosis of distal 40% of superior ulnar collateral perfo-rator flap.




preferable to plan a free transfer using a pedicle well outside theinjury zone. However, when used with caution, this procedure canbe safely executed.

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3. Godina M, Arnez ZM, Lister GD. Preferential use of the posterior approachto blood vessels of the lower leg in microvascular surgery. Plast ReconstrSurg. 1991;88:287–291.

4. Acland RJ. Refinements in lower extremity free flap surgery. Clin Plast Surg.1990;17:733–744.

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6. Bisson MA, Spyriounis PK, Miller JG. Perforator-based flaps in distal upperand lower extremity defects. Eur J Plast Surg. 2002;25:86–90.

7. Devansh S. Prefabricated recipient vascular pedicle for free compositetissue transfer in the chronic stage of leg trauma. Plast Reconstr Surg.1995;96:392.

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