Free versus Pedicled Perforator Flaps for Lower Extremity Reconstruction: A Multicenter Comparison of Institutional Practices and Outcomes

Abstract

Perforator flaps in general have become a reasonable solution for soft tissue defects of the lower extremity. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap could potentially be successful. Pedicled perforator flaps, if adequate healthy soft tissues remain adjacent to the defect, forecast a continuance of the evolution in seeking simplicity yet reliability by the best flap possible for soft tissue closure of the lower limb wound.

Comparing Outcomes for Fasciocutaneous versus Muscle Flaps in Foot and Ankle Free Flap Reconstruction

“…While the perennial dispute on the superiority of muscle versus fasciocutaneous flaps remains undecided, we provide important evidence supporting fasciocutaneous flaps to add to this growing body of literature. 40 Our study only included an analysis of outcomes of free fasciocutaneous flaps; however, local options in foot and ankle reconstruction should not be discounted. While they may not be possible in the setting of trauma due to a larger zone of injury which can oftentimes be difficult to identify, pedicled perforator flaps have been shown to have comparable outcomes to free flaps in foot and ankle reconstruction when adequate healthy soft tissue remains adjacent to the defect.…”

“…While they may not be possible in the setting of trauma due to a larger zone of injury which can oftentimes be difficult to identify, pedicled perforator flaps have been shown to have comparable outcomes to free flaps in foot and ankle reconstruction when adequate healthy soft tissue remains adjacent to the defect. 40 This study has several limitations, including the lack of inclusion of preoperative risk factors including patient comorbidities and smoking status. The retrospective nature of our review lends itself to selection bias as there is no way to determine the intraoperative decision-making process that guided flap selection for each case.…”

The Effect of Perforator Skeletonization on Pedicled Fasciocutaneous Flaps of the Lower Extremity: A Systematic Review

“…6 Given these constraints, pedicled, perforator-based flaps have become increasingly popular and are accepted as reliable options when patient factors and comorbidities preclude microsurgical free tissue transfer. 2,[7][8][9] According to the Gent Consensus, perforator flaps are defined as tissue areas with blood supply from perforating arterial branches of a major vessel with either an intramuscular or septal course. [10][11][12] This type of local flap is useful for the reconstruction of defects with tissue of similar color, volume and pliability, while avoiding excess bulk and donorsite morbidity inherent to local muscle flaps.…”

“…10,11,[13][14][15][16] Success rates of pedicled perforator flaps have been shown to be comparable to free perforator flaps in the lower extremity. 9 In contrast to a random pattern local flap without a named blood supply, perforator flaps have reliable vascular pedicles and dependable flap survival rates. 9,17 Thus, perforatorbased flap reconstruction offers simple yet reliable, singlestage reconstructive options particularly in resource limited health-systems, and centers where microsurgery is not routinely performed.…”

Our Premise for Lower Extremity Reconstruction

“…Even though this is a journal theoretically dealing with microsurgery, many answers can be solved more simply with local flaps as will also be demonstrated. 3 Remember Georgescu, et al's 4 admonition that even though these may be nonmicrovascular flaps, still an ability to perform a microsurgical dissection as needed is a prerequisite that will always be an advantage of the true microsurgeon. 5 Also, remember that although the rage today may be perforator flaps, traditional muscle flaps as Hollenbeck reiterates cannot be forgotten!…”