Middle and distal leg defects can be among the most challenging reconstructive problems in plastic surgery. But what if you could avoid microsurgery and still achieve reliable “like-with-like” coverage?

In this episode, we break down the principles, technique, and outcomes of perforator propeller flaps for lower extremity reconstruction. Drawing from the landmark PRS Global Open article by Mendieta et al. (2018), we discuss their series of 28 patients in Nicaragua and how local propeller flaps performed in small-to-medium defects of the mid and distal leg. These flaps preserve the major vascular axes, avoid the morbidity of muscle sacrifice, and eliminate the need for microsurgical anastomosis.

Key technical pearls include the two-centimeter pedicle dissection rule, use of handheld Doppler for flap planning, and ensuring tension-free inset. We’ll also cover complication rates (14% in this series, mostly partial necrosis), predictors of success, and when skin grafts for donor site closure may be necessary.

Takeaways:

• Preserve the main arteries and muscle—propeller flaps provide “like-with-like” coverage.

• Most are based on a single perforator (posterior tibial in 50% of cases).

• Up to 180° rotation is possible with careful dissection.

• Donor site can be closed primarily in most cases (85.7%).

• Complication rates are acceptable and comparable to free flaps.

References:Mendieta M, Cabrera R, Siu A, et al. Perforator Propeller Flaps for the Coverage of Middle and Distal Leg Soft-tissue Defects. Plast Reconstr Surg Glob Open. 2018;6:e1759. doi:10.1097/GOX.0000000000001759

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