Depatment of Hand and Plastic Surgery, Luzerner Kantonsspital, Spitalstrasse 6000 Luzern 16, Lucerne, Switzerland.
Depatment of Hand and Plastic Surgery, Luzerner Kantonsspital, Spitalstrasse 6000 Luzern 16, Lucerne, Switzerland.
Injury. 2020 Dec;51(12):2922-2929. doi: 10.1016/j.injury.2020.02.031. Epub 2020 Feb 15.
Propeller flaps have gained great popularity among reconstructive surgeons; however, the inability to directly close the donor site of large propeller flaps constitutes a well-known limitation of this technique. Skin grafting of the donor area is not always feasible nor desirable. To address large propeller flaps secondary defects, we investigated the use of a second propeller flap harvested from a nearby region of relative skin redundancy to assist the donor site closure generated by the first. Since the donor defect of the second flap is closed by direct suture, the aim of this "sequential" propeller flaps technique is to achieve complete, like-with-like, soft tissue restoration while avoiding skin grafting.
From April 2018 to September 2019, eight patients presenting post-traumatic soft tissue defects were planned to be reconstructed by means of the sequential propeller flaps technique, for a total of 16 propeller flaps. The locations of the defects included the distal leg in four cases, the heel in two cases, the proximal lateral thigh in one case and proximal posterior thigh in the remaining one. All the flaps but one were harvested as a perforator-based propeller type and rotated by different degrees around the skeletonized perforator. In one patient, due to an intraoperative complication following the first flap harvest, the harvest of the second flap was abandoned.
In all but one patient, a complete, tension free primary closure of all wounds was achieved without complications, the functional recovery as well the esthetic outcome were excellent. One patient showed intraoperative signs of vascular insufficiency involving 15% of the first flap. The plan of harvesting the second flap was intraoperatively abandoned and the definitive wound closure with a free muscle gracilis was carried out the following week.
In some selected cases, the use of multiple propeller flaps performed in sequence allows the surgeon to obtain complete, like-with-like wound closure with vascularized tissue avoiding a free tissue transfer procedure, however, it requires a vast experience with propeller flaps and meticulous preoperative planning.
推进皮瓣在重建外科医生中越来越受欢迎；然而，无法直接关闭大推进皮瓣的供区是该技术的一个众所周知的局限性。皮片移植并不总是可行或理想的。为了解决大推进皮瓣的次级缺损问题，我们研究了使用从相对皮肤冗余的附近区域采集的第二个推进皮瓣来辅助第一个皮瓣产生的供区关闭。由于第二个皮瓣的供区缺损通过直接缝合闭合，因此这种“顺序”推进皮瓣技术的目的是在避免皮片移植的情况下实现完全、相似的软组织修复。
自 2018 年 4 月至 2019 年 9 月，8 例创伤后软组织缺损患者计划采用顺序推进皮瓣技术进行重建，共 16 个推进皮瓣。缺损部位包括 4 例小腿远端、2 例足跟、1 例大腿近端外侧和 1 例大腿近端后侧。所有皮瓣均为穿支型推进皮瓣，并围绕骨化穿支不同程度旋转。在 1 例患者中，由于第一次皮瓣采集术中并发症，放弃了第二次皮瓣采集。
除 1 例患者外，所有患者均实现了无张力的一期伤口完全闭合，无并发症，功能恢复和美观效果均极佳。1 例患者出现了第一次皮瓣的血管功能不全迹象，涉及 15%的皮瓣。术中放弃了采集第二个皮瓣的计划，在接下来的一周内进行了游离股薄肌的确定性伤口闭合。
在某些选定的病例中，顺序使用多个推进皮瓣可以使外科医生获得用带血管组织完成的完全、相似的伤口闭合，避免游离组织转移手术，但需要有丰富的推进皮瓣经验和细致的术前规划。
