Annales de chirurgie plastique esthétique (2011) 56, 90—98

ORIGINAL ARTICLE

Propeller flaps: Classification and clinical applications

Les lambeaux en hélice : classification et applications cliniques

B. Ayestaray *, R. Ogawa, S. Ono, H. Hyakusoku

Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku,
Tokyo 113-8603, Japan

Received 29 August 2010; accepted 15 November 2010

KEYWORDS Summary Propeller flaps feature a highly reliable reconstructive method, based on a perfo-
Propeller flap; rator vessel. Since their introduction in 1991, a great variety of propeller flaps have been
Perforator; described, according to their shape and their potential of coverage. Indeed, these flaps have
Central axis flap; progressively been refined and modified, concerning their vascularity and space design. The
Acentric axis flap; authors present a classification of propeller flaps. This anatomical classification is necessary to
Multilobed flap; understand the dissection procedure and the differences between the numerous types of
Perforator-supercharged propeller flaps nowadays described. It is the international classification, which should be used
flap; for the description and conception of these flaps.
Super-thin flap # 2010 Elsevier Masson SAS. All rights reserved.

Résumé Les lambeaux en hélice représentent une méthode de reconstruction, fiable et peu
MOTS CLÉS invasive, basée sur un pédicule perforant. Depuis leur introduction en 1991, une grande variété de
Lambeau en hélice ; lambeaux en hélice ont été décrits, en fonction de leur forme et de leur potentiel de couverture.
Perforante ; Ces lambeaux ont, en effet, fait l’objet de raffinements et de modifications importantes,
Lambeau centro-axial ; concernant leur vascularisation et leur représentation spatiale. Les auteurs présentent une
Lambeau acentro-axial ; classification des lambeaux en hélice. Cette classification anatomique des lambeaux en hélice
Lambeau multilobé ; est nécessaire pour comprendre les modalités de dissection et les différences entre les nombreux
Lambeau perforant types de lambeaux en hélice décrits à ce jour. Enfin, elle correspond à la classification inter-
superchargé ; nationale, devant être utilisée pour la description et la conception de ces lambeaux.
Lambeau super-fin # 2010 Elsevier Masson SAS. Tous droits réservés.

Introduction knowledge concerning skin vascularization, perforator ves-

Perforator flaps feature the last advance in the history of
reconstructive surgery. With the evolution of anatomical
* Corresponding author.
E-mail address: bayestaray@yahoo.fr (B. Ayestaray).
sels have been recognized as the main source of supply for
teguments. The history of skin flaps began in the 19th
century, with the anatomical works of Manchot [1] and
Spalteholz [2,3], describing different vascular skin terri-
tories. These works were completed by the radiographic
studies of Salmon [4] in 1936, who demonstrated the exis-
tence of other vascular skin territories. One century later,

0294-1260/$ — see front matter # 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.anplas.2010.11.004
[()TD$FIG]
Propeller flaps: Classification and clinical applications
Figure 1 Classification of propeller flaps based on the type of pedicle. a: subcutaneous-pedicled propeller flap (SPP flap); b: muscle-
pedicled propeller flap (MPP flap); c: perforator-pedicled propeller flap (PPP flap); d: vascular-pedicled propeller flap (VPP flap).
Taylor and Palmer described in 1987 the angiosomes concept
[5], and proved in 2003 their implication in the physiology of
perforator flaps [6]. He also proved that vascular territories of
the skin are defined by perforator arteries, raising from source
vessels. In 1986, Nakajima et al. already distinguished, ana-
tomically, six types of skin arteries [7] and elaborated a
classification of skin flaps in six groups, which is fundamental
for the understanding of perforator flaps. In reality, right from
the first World War, Gino Pieri, an Italian military surgeon,
published in his atlas in 1918 a map of perforator flaps of the
human body [8]. Kroll and Rosenfield reworked the idea stated
by Pieri and was the first to use the term of ‘‘perforator flap’’
in 1988 [9]. One year later, Koshima and Soeda proved the
reliability of a skin flap vascularized by a perforator artery,
raising from the deep inferior epigastric artery (DIEP flap) [10].
In 1991, Hyakusoku et al. described an island flap, vascularized
by a perforator, and rotated from 908, for the reconstruction
of skin scar contractures of burn patients [11]. Its skin paddle
was designed with an oval helicoïdal and primary closing
shape, centered on the perforator. Its shape and mobilization
reminds these of a propeller; that is the reason why this flap is
called propeller flap. Initially, the supplying perforator was
included in a subcutaneous pedicle, located in the center of
the flap. During these 20 last years, propeller flaps have been
refined and modified, concerning their vascularity and space
design. A classification is necessary to understand the dissec-
tion procedure and the differences between the numerous
types of propeller flaps nowadays described. These flaps
feature a highly reliable reconstructive method, based on a
perforator. Their main interest is to respect major vascular
axis and to avoid the disadvantages of microvascular free
flaps.
Classification
The classification of propeller flaps is based on the perforator
vessel, supplying the flap vascularity. The perforator can be
musculocutaneous or septocutaneous [12—16]. The propeller
flaps follow this classification, but are also based on the type
and the position of the vascular pedicle in the flap. They are
defined as helicoïdal-shaped island skin flaps, with a rotation
axis centered on the supplying perforator. So far, perforator-
pedicled propeller flaps (PPP flaps) are considered as classi-
cal perforator flaps. But other flaps including perforators,
into the flap pedicle, enter also in this classification. This
pedicle can be subcutaneous (SPP flaps), muscular (MPP
flaps) or vascular axial (VPP flaps).
The propeller flaps respond to two classifications, which
are not antinomic but complementary.
91
Classification based on the type of pedicle
Perforator-pedicled propeller flaps (PPP flaps)
These flaps are skin flaps, vascularized by a perforator
pedicle, which is skeletonized on its complete length
(Fig. 1c). The dissection of perforator vessels has two advan-
tages: it permits a safe rotation of the flap up to 1808; the
flap can also be designed effectively and safely according to
the perforator course. In this way, larger skin paddle can be
harvested, and more distant defects can be covered [17]. It is
recommended to select a dominant perforator with a caliber
superior to 1 mm, but, in our experience, PPP flaps are
reliable even when they are based on a smaller perforator,
contained between 0.5 and 1 mm.
Non-perforator pedicled propeller flaps
These flaps, helicoidal-shaped and centered on a source
pedicle, are classified among propeller flaps. When their blood
supply is based on a dominant perforator included in the flap
pedicle, they are considered as perforator-based flaps.
Subcutaneous-pedicled propeller flaps (SPP flaps). SPP
flaps are skin flaps based on one or several perforators
included in the flap pedicle, which is dissected into the
underlying subcutaneous adipose tissue (Fig. 1a). If a domi-
nant perforator is skeletonized through the subcutaneous
pedicle, they become perforator pedicled propeller flaps
(PPP flaps). The main interest of these flaps is to reduce
the operative time, comparing to PPP flaps. But, they need a
perfect knowledge of the anatomy of perforator vessels. The
major problem of these flaps is a pedicle kinking for rotations
superior to 908. That is why they generally can not be
mobilized more than 908. Moreover, the inclusion of adipose
tissue around the perforator vessels reduce the vascularity of
the flap. In this way, the skin paddle is smaller than PPP flaps
and can not cover large defects. Thus, these disadvantages
limit the indications of SPP flaps in reconstructive surgery.
Nevertheless, we use SPP flaps for burned patients, if the
wound was deep. In this case, perforators may be damaged.
Donor sites are very limited in burned patients. SPP flaps can
be harvested, even if a dominant perforator has not been
found around the recipient site. The flap pedicle must
include small perforators.
Muscle-pedicled propeller flaps (MPP flaps). MPP flaps are
skin flaps based on one or several perforators included in the
flap pedicle, which is dissected through muscle tissue
(Fig. 1b). They become perforator pedicled propeller flaps,
if a dominant musculocutaneous perforator is skeletonized
through the muscular pedicle. We use MPP flaps if a dominant
92
musculocutaneous perforator has not been found. The mus-
cular pedicle must include small musculocutaneous perfora-
tors. These flaps are also interesting to cover tissues with a
weak vascularity or surgical material. In this case, the mus-
cular pedicle is rotated and advanced towards the defect.
Vascular-pedicled propeller flaps (VPP flaps). These flaps
are based on the direct cutaneous or septocutaneous perfora-
tors, raising from an axial arteriovenous pedicle. They are
defined by a skin paddle and a rotation around a pivot point,
which is the base of the axial vascular pedicle (Fig. 1d). If a
dominant perforator is skeletonized and used as a pivot point,
the flap becomes a perforator-pedicled propeller flap (PPP
flap). On the contrary, if it is not dissected but only included in
the pedicle, the flap can be considered as a perforator-based
flap. A typical example of VPP is the distally-based radial
artery flap. Very large skin paddles can be harvested compared
to perforator flaps. Venous return is very strong, so there is no
doubt of survival. We use VPP flaps, in association with a distal
propeller flap, to cover very distant defects from the donor
site (cf flap-in-flap propeller flaps).
Classification based on the pedicle position
Central axis propeller flaps
The pedicle is located at the center of the flap. These flaps
are highly reliable, because of an homogenous blood supply
of the skin paddle [11,20]. The main indication of central axis
propeller flaps is the coverage of two adjacent defects. In
this way, the flap must be raised between them and rotated
up to 908 (Fig. 2).
Acentric axis propeller flaps
The advantage to displace the rotation arc of the flap at its
periphery is to increase the distance between the defect and
the perforator, chosen as pivot point [17,21—23]. Then,
these flaps are very useful to cover defects, located in areas
distant from regions rich in perforators [24—28]. It is recom-
mended to analyse the perforator course by MultiDetector-
row Computed Tomography (MDCT) before designing the skin
paddle. Indeed, only perforators with a long course, and a
directionality parallel to the longitudinal axis of the flap, can
be selected for raising acentric axis propeller flaps (Fig. 2).
Technical refinements
Coverage area of the flap: multilobed propeller
flaps
Different types of multilobed propeller flaps can be
designed, in view to cover several defects at the same time.
They are very useful for the treatment of adjacent scar
[()TD$FIG]
Figure 2 Classification based on the pedicle position. a: central axis propeller flap; b: acentric axis propeller flap.
B. Ayestaray et al.
contractures. Then, different shapes have been described
[29]:
 the first shape consists in harvesting small triangular flaps,
on both sides of the propeller, which permits to close
directly the donor site in a V-Y design;
 the second shape consists in harvesting two lobes, of
equal area, pedicled on the same perforator;
 the third shape consists in harvesting non-symmetrical
bilobed flaps, i.e. with lobes of unequal area. The larger
lobe is useful to treat a scar contracture.
Length of rotation axis: flap-in-flap propeller flap
This concept is possible only with propeller flaps pedicled on
a dominant perforator and non-perforator pedicles (axial for
VPP flaps, muscular for MPP flaps). These flaps imply a double
rotation of the skin paddle, around two distinct vascular
pivot points [30]. The first rotation is performed with the
non-perforator pedicle of the flap; the second rotation is
performed around the dominant perforator. Then, the skin
paddle can be mobilized more distantly from the donor site,
and cover more distant defects from the supplying perfora-
tor.
Vascularity of the flap: perforator-supercharged
propeller flaps
Very long and large perforator flaps must be supercharged
with other vessels, in view to increase their survival area
(Fig. 3). These flaps are generally used as super-thin flaps,
which implies a supercharging with other perforators (‘‘per-
forator supercharging’’), but not axial pedicles [31,32]. The
skin paddle design of such flaps is not so easy. Indeed, it must
take into account the perforators anatomy, but also the
topography of recipient vessels.
Thickness of the skin paddle: super-thin
propeller flaps
The super-thin flap technique consists in ‘‘defatting a skin
flap, until the subdermal vascular network can be identified
through a minimal fat layer’’ [33—37]. This method suits
particularly well the perforator flaps concept. Indeed, it is
possible to remove easily the adipose tissue from a perfora-
tor which has been skeletonized. Then, their vascularity
depends on the perforator, which supplies the subdermal
vascular network. Concerning the terminology, ‘‘super-thin
flap’’ et ‘‘subdermal vascular network flap’’ are respectively
the generic and the anatomical names of the same clinical
entity. The main interest of this technique is to increase the
survival area of the flap, especially in its distal region [38].
[()TD$FIG]
Propeller flaps: Classification and clinical applications 93

Figure 3 Perforator-supercharged propeller flap. The flap is rotated around the first perforator pedicle at the proximal part of the
flap. A second perforator pedicle is raised at the distal extremity of the flap. This second pedicle is cut and anastomosed to recipient
vessels. This technique increases the flap survival area and avoid a venous congestion in the distal part of the flap.

Clinical cases Case 3: collateral radial artery perforator-

Case 1: superior gluteal artery perforator-
pedicled propeller flap
A 37-year-old male suffered from pilonidal cysts on the sacral
region for several years. Cysts were completely resected and
the defect was reconstructed using 12 cm  5 cm of a super-
ior gluteal artery perforator (SGAP) pedicled propeller flap
(Fig. 4). The musculocutaneous superior gluteal artery per-
forator was confirmed preoperatively using MDCT and intrao-
peratively (Fig. 5). Two months after the surgery, the flap
survived completely and no recurrence of pilonidal cysts
were observed (Fig. 6).
pedicled propeller flap
A 53-year-old man presented an open fracture of the right
elbow. His right elbow had struck the door during a car
accident. There was a 6 cm  4 cm skin defect. A bone
tip harvested from ilium was grafted to the right olecranon
using stainless steel wire. The skin defect over the fracture
was covered with a rotated PPP flap based on a septocuta-
neous perforator of the collateral radial artery, raising from
the deep brachial artery (Fig. 11). The perforator pedicle was
located on an acentric portion of the flap (Fig. 12). After 1808
rotation, no kinking of the perforator was observed. 1 month
after the surgery, the flap survived completely (Fig. 13).

Case 2: circumflex scapular artery perforator- Discussion

pedicled bilobed propeller flap
A 42-year-old male suffered from severe axillary contracture
caused by burn (Fig. 7). A bilobed flap consisted of 17 cm 
10 cm flap and 12 cm  6 cm flap was harvested (Fig. 8). The
flap was based on one septocutaneous perforator of the
circumflex scapular artery. It was elevated from the periph-
ery and the circumflex scapular vessels were identified. The
large flap was rotated 908 and covered the defect after
contracture removal. The small flap was also rotated 908
and covered the recipient site of the large donor flap (Fig. 9).
Two weeks after the operation, the flap survived completely
[()TD$FIG]and the axilla was recovered functionally (Fig. 10).
Advantages of propeller flaps
Propeller flaps represent a new reconstructive technique,
having many advantages. First, they permit to cover very
large defects, because of their vascular reliability. More-
over, their vascularity can be supplied by perforators located
distantly from the anatomical regions to reconstruct, which
is particularly interesting when they are functional regions.
Indeed, it is better to limit the morbidity at the donor site,
when it is a functional area, and to use a skin paddle located
distantly, in a non-functional region. As every perforator
flap, propeller flaps do not sacrifice major vascular axis, and

Figure 4 Case 1. a: design of the superior gluteal artery perforator flap based on a musculocutaneous perforator. b: the acentric axis
of the flap is the dominant musculocutaneous perforator, raising from the right superior gluteal artery.
[()TD$FIG]
94 [()TD$FIG] B. Ayestaray et al.

Figure 5 Case 1. Intraoperative view of the musculocutaneous

perforator.

then limit the donor site morbidity, in terms of muscular

force, sensibility and trophicity. Eventually, the surgical
technique is based on the flap rotation, around an axis
represented by the perforator. There is no need of micro-
vascular anastomoses, which reduces the operative time and
postoperative failure risks. In our clinical experience, PPP
flaps, raised as acentric axis propeller flaps, are the most
useful propeller flaps. The main interest of SPP flaps is when
perforators of the donor area are damaged, especially in
burned patients. We use MPP flaps if a dominant musculo- Figure 7 Case 2. Preoperative view of the axillary scar con-
cutaneous perforator has not been found, or for the coverage tracture.
of implants. VPP flaps are interesting to perform flap-in-flap
propeller flaps for very distant defects.
mental to determinate the survival area of propeller flaps
Preoperative analysis [18,19]. That is why we always perform preoperatively a
MDCT before designing a propeller flap.
Because of the variability of the perforators course and
vascular territory in human beings, it is recommended to Microvascular patency
perform a preoperative analysis by color Doppler ultrasono-
graphy or MultiDetector-row Computed Tomography (MDCT). The vascularity of propeller flaps is based on perforator
This analysis permits to evaluate the size and to adapt the vessels, undergoing a torsion between 0 to 1808. Despite
shape of the skin paddle, reducing the operative time and the the important torsion of the pedicle, the skin paddle has
postoperative necrosis risk [16]. Moreover, the analysis of clinically no suffering or necrosis area. Wong advocates to
the suprafascial perforator directionality (Fig. 14) is funda- select a perforator having a caliber superior to 1 mm and a
[()TD$FIG]

Figure 6 Case 1. a: clinical result 3 months postoperatively; b: after rotation of the flap, donor site is closed primarily.
[()TD$FIG]
Propeller flaps: Classification and clinical applications 95

Figure 8 Case 2. a: design of the circumflex scapular artery perforator bilobed flap, based on a septocutaneous perforator. b: the
axis of the flap is the dominant septocutaneous perforator, raising from the left circumflex scapular artery. This perforator is located
between the 2 lobes of the flap.

[()TD$FIG]

Figure 9 Case 2. a: intraoperative view. After releasing the scar contracture, coverage of the axillary defect by the large lobe of the
flap. b: intraoperative view. Donor site is closed by the small lobe of the flap. c: rotation is made around the septocutaneous perforator
of the left circumflex scapular artery.
[()TD$FIG]
96 B. Ayestaray et al.

Figure 10 Case 2. Postoperative view. The function of the shoulder has been recovered, 2 weeks after the surgery.

[()TD$FIG]

Figure 11 Case 3. a: design of the collateral radial artery perforator flap, based on a septocutaneous perforator. b: the axis of the
flap is the dominant septocutaneous perforator, raising from the collateral radial artery.

[()TD$FIG]
length superior to 30 mm, and to rotate the flap with a
rotation angle inferior to 1808 [39]; in other words, if this
angle exceeds 1808, it is recommended to change the rota-
tion direction for keeping an angle inferior to 1808 [40].
Different experimental studies on animals were performed,
in view to study the microvascular patency, after a pedicle
torsion more or less important and a microsurgical anasto-
mosis. All these studies demonstrate that the torsion of a
microvascular pedicle leads to a significant reduction of the
vascular patency rate [41—46]. This reduction is more impor-
tant for the veins than the arteries. Experimentally, in rats,
the microvascular patency is around 80% for the femoral
artery and vein after a torsion of 908; 70% for a femoral artery
after a torsion of 1808; 25% for a femoral vein after a torsion
of 1808 [41]. Veins are more sensitive to a torsion, because of
a weaker wall, a lower intraluminal pressure and a bigger
elasticity [39,41,45,46]. The odds ratio concerning the
Figure 12 Case 3. Intraoperative view of the septocutaneous thrombotic risk is around 2 for an artery and 6 for a vein,
perforator. with a torsion of 908; it becomes 4 for an artery and 37 for a
[()TD$FIG]
Propeller flaps: Classification and clinical applications
Figure 13 Case 3. a: clinical result 6 months after the surgery. b: after rotation of the flap, donor site is closed primarily.
[()TD$FIG]
Figure 14 MDCT analysis of the Suprafascial perforator direc-
tionality (SPD) of the second musculocutaneous perforator,
raising from the left internal mammary artery.
vein, with a torsion of 1808 [41]. Selvaggi et al. demonstrate,
mathematically, that the buckling phenomenon, favouring
thrombosis, begins with torsions of 5218 for arteries, and
1058 for veins [44]. Nevertheless, these datas tally with
measurements taken either immediately, either 1 hour after
performing the torsion of microvascular pedicles. Topalan
et al. [45] and Bilgin et al. [46] demonstrate that, 1 week
after performing the pedicle torsion, the microvascular
patency rate is 100% with torsions of 908 and 1808, for
arteries and veins respectively. There is, in reality, a critical
phase during 72 h, while thrombotic risk is high for veins, if
the torsion is superior to 908. After this delay, the micro-
vascular patency rate returns at a normal level, and the risk
of venous thrombosis is almost non-existent. In this way, a
preventive anticoagulation during 72 h could be justified, for
propeller flaps with a rotation superior to 908. Nevertheless,
in our clinical experience, propeller flaps, with a rotation
superior to 908, do not suffer from any venous congestion and
do not have a superior necrosis rate. That is why no pre-
ventive anticoagulation is needed, in clinical practice, in
view to limit the venous thrombosis risk of propeller flaps.
Conclusion
Since more than 20 years, perforator flaps have proved their
reliability and their great interest in reconstructive surgery.
Perforator vessels can be used to cover local or regional
97
defects, through rotation flaps, without necessity of any
microvascular anastomosis. Perforator-pedicled propeller
flaps (PPP flaps) can be considered as one of ‘‘the most
sophisticated method to raise a perforator flap’’ [47]. These
flaps have many advantages, comparing to classical axial
flaps, because they do not sacrifice source arteries and
respect the vascularity of nearby anatomical elements
(i.e. muscle, fascia, nerve, bone and fat tissue). Perfora-
tor-pedicled propeller flaps are, in this way, a new step in the
era of less-invasive reconstructive surgery. The evolution of
ideas and surgical techniques has progressively followed the
anatomical knowledges of the skin vascularization. From the
Indian forehead flap to the studies of Spalteholz, Pieri and
Salmon, more than 1500 years have passed. More than 50
years after these anatomical studies, perforator flaps were
concretely used in clinical practice. Among perforator flaps,
propeller flaps mark a decisive step in the history of plastic
surgery.
Conflicts of interest
None.
Acknowledgments
Figures 1, 2 and 3 were drawn by Kazuyuki Sugiu. Figures 4, 6,
8, 9, 11 and 13 were conceived by Benoit Ayestaray, MD.
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