ORIGINAL ARTICLE Our Experience in Lower Limb Reconstruction With Perforator Flaps Jaume Masia, MD, PhD, Fabrizio Moscatiello, MD, Gemma Pons, MD, Manuel Fernandez, }"fD, Susana Lopez, MD, and Pere Serret, MD Abstraet: The application of Taylor's concept about body angio- somes, referred to tissue transfers, has meant that the development of the perforator flaps and musc1es is no longer needed as a carrier of skin flap vascularity. In this papel', \Ve revise 59 lower limb reconstructions with local and free perforator flaps perfonned in the last 5 years, and a basic reconstructive algorithm is also suggested lo help with the management of the lower limb soft tissue reconstruc- tion with perforator flaps. The advantages of the perforator flaps are (1) muscles and their function are preserved; (2) the main vascular lrunks are spared; (3) it is possible to make a more specific rcconstruclion, replacing "likc with like" (even perfonning compound or chimeric flaps); (4) the donar site can often be c10sed primarily; (5) the general morbidity is reduced; (6) a bener cosmetic result can be achieved. Key Words: perforator flap, propeller, lower limb reconstruction (Ann Plus! Surg 2007;58: 507-512) T he lower limb has always been known for poor wound healing ami, since the first steps of the plastic surgery, as a scarce sourcc 01'flaps. Before the introduction of microsur- gcry, surgeons had few reconstructive options such as local flaps (random skin flaps, muscular or musculocutancous flaps) and performed cross-legs, immobilizing the limbs for weeks, to transfer a large amount of skin. 1 With the introduction 01' microsurgery, tissue transfers have become one 01' the main reconstructive options for the lower limb, above al! in those arcas where there is a scarce availability of local flaps. In the distal third 01'the leg or in orthopedic problcms, a muscular local flap could worsen a significant muscular function. With the deveIopment 01'perforator flaps,2.3newer and more reliable flaps have become avai]able for lower limb recon- Received July 4, 2006 and accepted for publication July 20, 2006. From the Department of Plastic Surgery, Hospital dc la Santa Creu i Sant Pau (Universitat Autonoma de Barcelona), Barcelona, Spain. No sources of support that require acknowledgment. Reprints: Jaume Masia, MD, PhD. Chief ofDepartmentiAssociate Profcssor, Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau (Universitat Autonoma de Barcelona), Sant Antoni M. Claret 167,08025 Barcelona, Spain. E-mail: jmasia@santpau.es. Copyright rg 2007 by Lippincott Williams & Wilkins ISSN: 0148-7043/07/5805-0507 DOI: 10.1097/0 l.s"p.0000239841.47088.a5 Annals of Plastic Surgery . Volume 58, Number 5, May 2007 struction. Referring to Taylor and Palmer's4 and Taylor's5 con- cept 01' angiosomes, almost al! the tissues 01' an angiosome can be harvested on I adequate perforator vessel. The per- forator pedic1es 01' these flap s originate from one 01' the main vessels 01' the lower extremity, course through I or more musc1es or one 01' the intermuscular septa IIp to the fascia, and ramify at a sllprafascial level in the subcuta- neous fat. Perforator flaps can be used as local or free flaps. Whenever the defect size and the vascular condition 01' the neighboring tissues alJow a reconstruction with local perfo- rator flaps, the surgicaJ intervention and the morbidity ought to be limited to a single body region. The early designs of the local flaps along the vertical axis of the leg or the thigh with a proximal pedicle have been modified by the use 01'perfo- rator flaps. To transfer a larger amount of tisslle rather than random local flaps, a surgeon can carefully isolate the whole course of a perforator vessel and effectively rotate through 180°, like a "propeller," almost all the tissues 01'an angio- some or more (descending genicular,6 posterior tibial,7,8 per- oneaI9). Tissue transfer through a rotation like a propelJer was firstly dcscribed by Hyakusoku et allOin 1991 to release scar contractllres ofthe lIpper limb by subcutaneOLlSpedicled flaps rotated through 90°. The propeller method applied to perfo- rator flaps becomes a microsurgical technique where the dissection of the pedicJe is carried out with binocular mag- nifying glasses but a microvasclllar anastomosis is not needed. When it is not possible to choose a local perforator flap, limiting the morbidity to a single region 01' the body, free perforator tissue transfers from other regions can be per- formed. GeneralJy, we use anterolateral thigh (AL T)! t or thoracodorsal artery perforator (TAP) 12perforator free flaps. In composite-tissue loss, it is possible to harvest a compound flap, for example, by inclusion 01'the fascia lata in the ALT to reconstruct a tendon of one of the main joints, or a "chimeric" flap,13 where each component 01'the flap can be separately placed because each is supplied by a distinct branch 01'the common source vessel. This review, derived from ollr experience in reconstruc- tion of oncologic and orthopaedic lower limb defects, could suggest the use of local or free perforator tissue transfers in 10wer limb soft tissue reconstruction and further propose an easy algorithm regarding which would be the most effective for patient rehabilitation. 507 Copyriqt,t~:;j LippincottWílliams&Wilkins.Unauthorizedreproductionofthisartide isprohiblted.