Direction of Flap Rotation in Propeller Flaps: Does It Really Matter?

Abstract

The use of perforator flaps has steadily increased since the introduction of the concept by Koshima and Soeda. 1-3 The perforator flaps offer the advantages of sparing the underlying muscle, resulting in decreased donor-site morbidity. Hyakusoku et al first used the term "propeller flap" in 1991, to describe subcutaneous pedicled island flaps vascularized by a perforator artery and rotated 90°to reconstruct the defect after release of scar contractures in a burn patient. 4 Once a propeller flap has a reliable vascular pedicle, it can be easily mobilized and rotated as a local flap. Furthermore, the harvest is fast and easy and may not require microsurgery. 2 In 2006, combining the concept of propeller flaps and perforator based flaps, Hallock reported a fasciocutaneous flap that was similar in shape to the one described by Hyakusoku et al and further showed that Keywords ► propeller flaps ► rotation of flaps ► perfusion of flaps AbstractBackground This article investigates the effect of 180°rotating propeller flaps and evaluates whether each flap has a "preferable" rotating direction. Methods Part 1 evaluates the flap pedicle velocity and flow volume in neutral, 180°c ounterclockwise, and clockwise rotated position for 29 consecutive flaps. The data (velocity and volume) were divided into three groups: neutral, high value, and low value group then evaluated. Part 2 compares the outcome from the prospective study where a preferable rotation with high value was selected against 29 patients from 2012 to 2016 who had the same operation without selecting a preferable rotation direction. Results In part 1, the three groups (neutral, high value, and low value groups) showed mean velocity of 28.06 AE 7.94, 31.92 AE 10.22, 24.41 AE 8.12 cm/s, respectively, and mean volume of 6.11 AE 4.95, 6.83 AE 6.69, 4.62 AE 3.55 mL/min, respectively. The mean velocity and volume of the perforator in the high value group were significantly higher than that in the low value group (p ¼ 0.0001). In part 2, although no statistical significance in the outcome was observed, there were two cases of total, two cases of partial flap loss, and three cases of wound dehiscence in the patients where preferable rotations was not selected compared with only two wound dehiscence for flaps with preferable rotation. Conclusion The velocity and flow of the flap are significantly different based on the rotation direction of the flap. Using the preferred rotation direction with statistically higher value of velocity and flow may increase the overall outcome of the propeller flap, especially where larger flaps are used.

The Chimeric Propeller Flap

“…17 However, Song et al have used color duplex ultrasound flow dynamics to show that the choice with higher perforator flow volume and flow velocity will have fewer untoward events. 18 Another option available is to use smartphone thermal imaging after any component flap rotation to assess surface temperature, which is directly correlated to flap perfusion as demonstrated in another overview in this issue. 19…”

Smartphone Thermal Imaging Can Enable the Safer Use of Propeller Flaps

“…For darker pigmented individuals, thermography would be a better option as color assessment alone may be difficult. Song et al 19 have used color Duplex ultrasound to obtain physiologic flow data on pedicle flow and volume following the rotation. They concluded that if the direction with higher values is always chosen, no major complications will occur, whereas if based solely on clinical signs in their experience, total flap loss or partial necrosis was a risk that can now be avoided.…”

Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction

“…11,34,35 Color duplex ultrasound in addition allows measurement of the perforator diameter and the velocity of blood flow, especially for comparison if multiple perforators are available [36][37][38][39][40][41] or deciding whether a clockwise or counterclockwise twist should be performed. 42 Some even prefer high-resolution CT scans for more accuracy not only in identifying perfora-tors but also in providing reliable perforators, especially if trauma or peripheral vascular disease coexist. 43,44 Magnetic resonance angiography also may be an alternative, 9,45 but a simpler, readily available complementary method such as thermography can be an option by using a thermal imaging camera attached to a smartphone.…”