Commentary on "Comparative analysis of propeller flaps vs. modified perforator-based flaps in foot and ankle reconstruct
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LETTER TO THE EDITOR
Commentary on "Comparative analysis of propeller flaps vs. modified perforator-based flaps in foot and ankle reconstruction" by Rajkumar R, Sharma HK, Dash S & Babu VS. Pawan Agarwal 1
&
Dhananjaya Sharma 2
Received: 15 October 2020 / Accepted: 17 November 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Sir, We read with interest the article ‘Comparative analysis of propeller flaps vs. modified perforator-based flaps in foot and ankle reconstruction’ by Rajkumar et al. [1]. Authors have modified perforator flaps (MPF) by retaining a thin continuity of subcutaneous tissue to the minor blade of the perforator flap, which helps in avoiding the complications of venous congestion. They concluded that the MPF has a lesser complication rate in comparison with traditional propeller flaps. However, we have certain concerns regarding this modification of perforator flaps. 1 In their MPFs, authors have retained the subcutaneous pedicle with minor blade with a hope that subcutaneous vascular plexus and its veins will reduce the venous congestion in the flap. However, inclusion of veins in subcutaneous pedicle is a matter of presumption. Moreover, even if one get venous plexus in the subcutaneous tissue pedicle, it will mainly drain the minor blade, and how much it will contribute to venous drainage of major blade is questionable. 2 Additionally, the minor blade of their MPFs is located in the distal leg near the defect where the availability/ mobility of pliable subcutaneous tissue, which authors have used as second pedicle, is very limited. 3 This design of flap is against the principle of perforator flap as the use of more than one pedicle is a potential hazard because the two pedicles could kink each other. [2]
* Pawan Agarwal [email protected] 1
Department of Surgery, NSCB Government Medical College, 292/ 293, Napier Town, Jabalpur, MP 482003, India
2
Department of Surgery, NSCB Government Medical College, Jabalpur, MP 482003, India
4 Island propeller flap based on a subcutaneous pedicle can be rotated up to a maximum of 90° because the restraint imposed by the thick pedicle tends to limit its rotation. [3] In their study, authors have a mean rotation of MPF 155° as compared to 137.6° for propeller flap which seems very odd as propeller flap have a better arc of rotation. 5 As the authors have themselves accepted that in this MPF modification the resurfacing of donor site by minor blade which is one major advantage of propeller flap is lost as in order to have a supposedly kink-free rotation, authors have kept minor blade very small. 6 In this study, complication rate for propeller flap is shown to be very high (overall 33.3% with flap loss of 18.5%). In many studies, including one systematic review, the complete flap necrosis for propeller flap is rare and the partial flap loss rate is only ~ 11%. [4, 5] In fact, the complication rate for distally based perforator flap is much more as compared to propeller flap and it is in the range of 22– 30%. [6] We feel that
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