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

J Reconstr Microsurg. 2020 Nov;36(9):634-644. doi: 10.1055/s-0040-1713598. Epub 2020 Jun 24.


Background: Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity.

Methods: PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used.

Results: Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01).

Conclusion: Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.

Publication types

  • Systematic Review

MeSH terms

  • Ankle / surgery
  • Humans
  • Lower Extremity* / surgery
  • Microsurgery
  • Perforator Flap*
  • Plastic Surgery Procedures*