The propeller flap is a useful reconstructive tool that can achieve good cosmetic and functional results. A flap should be called a propeller flap only if it fulfils the definition above. The type of nourishing pedicle, the source vessel (when known), and the degree of skin island rotation should be specified for each flap.

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The gastrocnemius muscle is rarely considered today as a musculocutaneous flap. Yet, the posterior calf skin by itself can still be used to advantage as a source of local or perhaps free flaps. Fascial perforators in this region were reexamined in an anatomic study in 10 fresh cadaveric specimens to investigate the possibility of a gastrocnemius muscle perforator-based flap. At least two substantive perforators were found in all limbs, and there was always one overlying the medial gastrocnemius muscle (overall mean, 4.0 +/- 1.8 perforators; range, 2-7 perforators). The origin of these perforators in any given specimen was most commonly as a secondary branch from the medial or lateral sural arteries alone (60%), from the median sural artery as a direct cutaneous branch alone (10%), or from either of the muscle pedicles and/or the median sural artery (30%). Thus, in 90% of limbs, the potential for elevating a gastrocnemius perforator-based flap exists without the need for any muscle sacrifice. Otherwise, a more traditional posterior calf fasciocutaneous flap was possible. Other deeper intramuscular collaterals were also identified so that sequential use of the muscle as a separate flap does not seem to be compromised.

Recidivism after flap coverage of ischial and trochanteric pressure sores is predictably common. Available local flap options are limited in number and must be cautiously preserved as long as possible for these patients who are destined to have a lifelong vulnerability for recurrence. Muscle perforator flaps have been introduced as another set of alternatives to solve this conundrum. Since the posteromedial thigh often has been previously unviolated by the usual workhorse flaps selected for this problem, the adductor perforator flap will then usually still be available as an important "backup" option. If designed as a propeller flap, this version after rotation will cover the defect and simultaneously allow direct donor-site closure to avoid the need for a skin graft.

Although many technical modifications have improved and will improve the reliability and versatility of compound flaps, these maneuvers alone should not be confused with creating distinct flap types but rather acknowledged to be only important variations. With this understanding, this revised nomenclature system for compound flaps is intended to be a means of standardizing communication and to facilitate research agendas on a common ground, fully realizing its primary role still only to serve as a convenient guideline.

The traditional role of the gastrocnemius muscles for flap coverage of knee and proximal leg defects and the soleus muscle for the middle third of the leg was reaffirmed. The soleus muscle often also reached distal leg defects as could local fascia flaps, where classically, otherwise, a free flap would have been necessary. The largest or most severe wounds, irrespective of limb location, required free flap coverage. Local fascia flaps proved to be a valuable alternative.