Soft tissue coverage of the distal third of the tibia with fasciocutaneous propeller flaps

BACKGROUND: The distal third of the tibia is often only amenable to free tissue transfer to cover exposed bone, tendons and neurovascular structures. Using relatively constant perforators of the tibial and peroneal vessels, soft tissue coverage can be achieved with so-called propeller flaps. METHODS: 8 patients presenting with post-traumatic defects over the lateral malleolus and the Achilles tendon were included in this study. A propeller flap based on perforators from the peroneal or tibial artery was used to cover the defect. RESULTS: One case of partial flap necrosis was encountered in a diabetic patient. Transient venous congestion of the flap tip was witnessed in two instances, which resolved without further intervention. No other complications occurred. All patients were fully ambulatory within 8 weeks, except for 1 patient, who required a below-knee amputation. CONCLUSION: The propeller flap has proven to be a versatile and elegant method to obtain soft tissue coverage with local tissue. Contrary to conventional rotation flaps, direct closure of the donor site is possible. Patients are not impaired by bulky flaps and may wear normal shoes. Even in the elderly, this flap was successful.     

Reconstruction of soft tissue defects in the Achilles tendon region with perforator-based fasciocutaneous flaps

Background

Reconstruction of soft tissue defects in the Achilles tendon region can be technically demanding. Perforator-based flaps can be an effective local solution, replacing like-for-like skin. We report our experience with perforator-based flap reconstruction of the Achilles tendon region with or without rupture of the Achilles tendon.

Methods

Between January 1999 and 2011, 11 patients had perforator-based flaps based on peroneal and posterior tibial perforators. There were six V-Y advancement flaps, four propeller flaps and one peninsular flap. The mean defect size was 19.3 (range 9–36)?cm². One patient had reconstruction of a composite Achilles tendon defect.

Results

There were no flap failures. Mean follow-up was 26.4 (range 3–120)?months. Post-operative complications included haematoma in one patient and dehiscence of wound because of further sloughing of the tendon—at the distal edge of a V-Y advancement flap. This patient needed a second local flap. There were no wound breakdowns, painful sensitivity or difficulty with walking. All patients who had skin and soft tissue reconstruction only were partially weight bearing by 2 weeks and gradually increased weight bearing and fully weight bearing by 4 weeks.

Conclusions

Perforator-based flaps are a robust method of covering small- to medium-sized defects in the Achilles tendon region. Presence of multiple perforators on either side of the Achilles tendon invites a number of flap designs, tailored to the defect. Level of Evidence: Level IV, Therapeutic study.     

The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap

BACKGROUND: Traumatic and nontraumatic defects of the distal third of the tibia are challenging in regard to soft tissue coverage. While local, pedicled fasciocutaneous perforator flaps allow adequate coverage, the donor site often requires skin grafting. When a local perforator flap is designed as a 180-degree propeller flap, an excellent esthetic result and direct closure of the donor site can be achieved, with minimal morbidity. METHODS: Eight patients with defects in the malleolar region were treated with 180-degree propeller flaps based on perforators from the tibial and peroneal vessels. RESULTS: One partial flap loss was encountered in an insulin-dependent diabetic. Partial superficial epidermolysis was encountered in 2 cases and healed without further interventions. No other complications were encountered. All patients returned to full ambulation within 8 weeks. CONCLUSION: The 180-degree propeller flap is an elegant and versatile method to achieve soft tissue coverage with local tissue in defects of the distal tibia. Contrary to other local perforator flaps, this specific design facilitates direct closure of the donor site. As only local, thin tissue is used, no interference with normal shoe wear occurs. Even in older patients, this flap has proven to be a reliable option.     

Perforator Propeller Flap “Relay” for Distal Lower Extremity Soft Tissue Reconstruction

The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm² in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.     

Reconstruction of elbow region defects using radial collateral artery perforator (RCAP)-based propeller flaps

Perforator-based propeller flaps permit flap rotation up to 180°. This ability to transfer skin from one longitudinal axis to another has led to the increasing use of perforator-based propeller flaps in extremity reconstruction, especially lower-extremity reconstruction. However, the application of perforator-based propeller flaps to upper-extremity reconstruction is still limited. This article reports two cases of successful reconstruction of elbow region defects with radial collateral artery perforator (RCAP)-based propeller flaps. The elbow region has a variety of perforators available for perforator-based propeller flap reconstruction. Among them, the RCAP seems to be one of the most reliable options. This is because there are less anatomical variations of perforators' location on the lateral upper arm than on the medial upper arm. By using an RCAP perforator as a flap pedicle, the small-to-medium sized defects (<6?cm in diameter) around elbow regions can be closed primarily without skin grafts.     

Foot and ankle reconstruction: An experience on the use of 14 different flaps in 226 cases

The aim of this report was to present our experience on the use of different flaps for soft tissue reconstruction of the foot and ankle. From 2007 to 2012, the soft tissue defects of traumatic injuries of the foot and ankle were reconstructed using 14 different flaps in 226 cases (162 male and 64 female). There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety‐four cases were combined with open fractures. One hundred and sixty‐two cases had tendon. Among 164 free flaps, 8 flaps were completely lost, in which the defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage (25 pedicled flaps and 32 free flaps), ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. The donor site complications were seen in 3 cases with the free anterolateral thigh perforator flap transfer. All of limbs were preserved and the patients regained walking and daily activities. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead spce, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice. © 2013 Wiley Periodicals, Inc. Microsurgery 33:600–604, 2013.     

腓动脉主穿支蒂腓肠神经营养血管皮瓣修复跟腱区创面

目的 探讨应用改良腓肠神经营养血管皮瓣修复跟腱区创面的方法及疗效.方法 设计切取以最低位腓动脉主穿支为蒂的矩形腓肠神经营养血管皮瓣,修复跟腱后皮瓣旋转180°,远、近端交换覆盖创面.供区一般直接缝合,个别病例需小面积全厚植皮.结果 2005年6月至2008年10月临床应用15例,皮瓣切取面积13 cm ×15 cm～ 18 cm ×9 cm,均全部成活.术后随访10～ 17个月,足踝功能良好,外形轮廓接近正常.结论 该皮瓣血供确切,修复后外形平整美观,利于正常穿鞋行走,适用于跟腱区创面缺损的修复.     

Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap

IntroductionAchilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue.Methods7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel.ResultsThe size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage.ConclusionDistally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.     

Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects

BackgroundCovering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation.MethodsPatients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects.ResultsThe mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm² (range, 48–125 cm²). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation.ConclusionsThe propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.     

Soft tissue coverage of a total gluteal defect with a combination of perforator-based flaps: A case report

Soft tissue defects in the buttock area are often related to decubitus ulcers, which are usually small to medium-large size and can be regularly treated with local flaps. However, when the defects have bigger size, such as those involving the whole gluteal region, the coverage can become more challenging, since this specific area needs both a good resistance to pressure and an acceptable functional result. The most common solution for similar cases is the use of multiple local flaps, or, in extreme situations, a free flap. In particular, local flaps based on perforator vessels are, in selected cases, a consolidated alternative to free flap allowing an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of “like with like” coverage. Here we present a case of a large mycosis fungoides nidus of the gluteal region measuring 25 cm × 18 cm reconstructed using two large perforator flaps adjacent to the defect combined with a remote one for coverage of the donor site. The cranial flap was designed based on a perforator arising from the superior gluteal artery and transferred into the defect by means of a V–Y advancement, while the two caudal propeller flaps in the posterior thigh were both based on perforators of the profunda femoris artery and rotated 180°, respectively. To obtain a tension-free cover of the donor site defect we applied the concept of “sequential” propeller flaps. Post-operative course was uneventful and the patient was ambulatory with assistive devices after 1 week. At 6 months follow-up, wounds were completely healed without complications and a good functional result was obtained. This report showed the great coverage potential of multiple perforator-based local flaps when properly combined allowing primary closure of the donor site. In particular, we managed to reconstruct a total gluteal defect using just ipsilateral side tissue, reducing morbidity, and obtaining a stable result.     

Propeller flaps for leg reconstruction.

Leg soft tissue defects with bone or tendon exposure need to be covered with a flap. Various local and free flaps with more or less consistent donor site defects have been described in the past. After the introduction of the perforator-based flap concept, new flaps have also been described for the leg. An evolution and simplification of the perforator flap concept, together with the 'free style' flap harvesting method, are the propeller flaps, i.e. local flaps, based on a perforator vessel, which becomes the pivot point for the skin island that can, therefore, be rotated up to 180 degrees . In this prospective study, six consecutive patients, having post-traumatic soft tissue defects of the leg or knee prosthesis infection, with bone or tendon exposure, were treated with propeller flaps. Complete and stable coverage of the soft tissue losses was obtained in all cases with an inconspicuous, only cosmetic, donor site defect. No flap necrosis was observed, with the exception of a small superficial necrosis of the tip of one flap, due to the inclusion in the design of scarred tissue. In two cases, transient venous congestion was observed and resolved spontaneously. Mean operative time was 2 h (ranging from 60 min to 6 h when an orthopaedic procedure was also needed) and mean hospital stay after surgery was 10 days. Propeller flaps allow the coverage of wide defects, can be raised with a relatively simple surgical technique, have a high success rate and good cosmetic results without functional impairment. In the light of this they can be considered among the first surgical choices to resurface complex soft tissue defects of the leg.     

Perforator propeller flaps for lower extremity soft-tissue defect reconstruction: Shortening the learning curve

BackgroundThe perforator propeller flap is an advantageous option for soft tissue reconstruction in the lower limb as it ensures the preservation of the main artery and muscle, eliminates the need for microsurgical reconstruction as well as provides “like with like” resurfacing of the defects. Despite this, it remains a technically demanding reconstructive option for residents and surgeons with little experience in perforator dissection. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects were addressed with propeller flaps.MethodsA retrospective study of all propeller flap based reconstruction done on patients with soft tissue defects involving the distal third of the leg was undertaken from August 2018 to December 2020.Results28 patients were treated with propeller flaps for various lower extremity defects. The median defect size was 12 cm². The posterior tibial artery (PTA) was used in eleven cases (39.3%) and the peroneal artery (PA) in seventeen of the cases (60.7%). The complication rate was 28.6% (n = 8). The complete flap necrosis rate was 10.7% (n = 3) and partial flap necrosis rate was 7.1% (n = 2), The rate of venous congestion was 7.1% (n = 2) and wound dehiscence occurred in 3.5% (n = 1). There was a significant negative correlation between the number of cases performed by a resident and the operative time.ConclusionAlthough propeller flaps are a reliable option to address lower extremity defects, they have a long learning curve and require a good amount of experience and perforator dissection skills to reduce the probability of flap failure. We are of the opinion that residents should be adequately trained in this procedure to ensure optimal outcome delivery.     

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

Background:

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent.

Materials and Methods:

We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series.

Results:

63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.

Conclusion:

Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects.

Level of Evidence:

Therapeutic IV.KEY WORDS: Hand defects, perforator flaps, propeller flaps, perforator based propeller flaps, upper extremity, wrist defects     

The 'propeller' distal anteromedial thigh perforator flap. Anatomic study and clinical applications.

BACKGROUND: The leg and peripatellar region have always been known as a poor source of available flaps. One flap donor site that has proven to be adequate is the distal anteromedial half of the thigh. Due to the potential and plentiful vascular sources of this anatomic region we decided to study the distal anteromedial thigh and its clinical applications. ANATOMIC STUDY: Sixteen cryopreserved inferior limbs were latex-injected in the femoral artery and the skin perforators of the distal anteromedial thigh and their source vessels were studied. CLINICAL STUDY: In a period between December 2000 and June 2005, skin islands from the distal anteromedial aspect of the thigh of six patients were transferred, as local perforator flaps, to reconstruct the peripatellar region and upper leg soft tissue defects. Every flap was based on a single adequate perforator vessel. The tissue was rotated, as a 'propeller', through 180 degrees and the flap was named 'the propeller distal anteromedial thigh perforator flap'. RESULTS: In the distal anteromedial thigh the anatomic variability includes not only perforator vessels but also their source vessels. Skin perforators can come from each of the deep vessels. Our clinical results, with a follow up of 1-4 years, show no total flap losses. Partial necrosis > 20% happened in one diabetic patient. CONCLUSION: The propeller distal anteromedial thigh perforator flap can be reliably transferred based on only one adequate perforator vessel. It reduces the morbidity and improves the availability of the distal anteromedial thigh as a flap donor site and represents an additional reconstructive option for knee and upper leg defects.     

穿支皮瓣移植修复四肢软组织缺损108例

目的 探讨应用穿支皮瓣修复四肢皮肤软组织缺损的临床效果. 方法2007年7月至2009年5月,分别采用腹壁下动脉穿支皮瓣、股前外侧穿支皮瓣、胸背动脉穿支皮瓣、股外侧穿支皮瓣、骨间背侧动脉穿支皮瓣、桡侧副动脉穿支皮瓣、腓肠内侧动脉穿支皮瓣、胫后动脉穿支皮瓣、旋髂深动脉穿支皮瓣、腓动脉穿支皮瓣移植修复四肢皮肤软组织缺损108例(游离移植98例,带蒂转移10例),皮瓣切取面积最小4 cm×2 cm,最大44 cm×9 cm,皮瓣供区均直接缝合.结果 术后5例发生静脉危象,其中1例松解包扎后危象解除,4例再次手术探查,2例成活,2例坏死,其余103例顺利成活,皮瓣受区与供区创121愈合良好.术后随访6-24个月(平均10个月),皮瓣颜色、质地好,外形不臃肿;皮瓣供区遗留线性瘢痕,功能无影响. 结论穿支皮瓣不携带肌肉、深筋膜及运动神经,对皮瓣供区影响小,还具有血供可靠、质地薄、不需二期去脂整形的优点,是修复四肢浅表创面的首选方法.     

An anatomic study of the superficial peroneal nerve accessory artery and its perforators, and clinical application of superficial peroneal nerve accessory artery perforator flaps

In the 1990s, skin island flaps supplied by the vascular axis of sensitive superficial nerves, like the sural and saphenous nerves, were introduced. Flaps supplied by the superficial peroneal nerve accessory artery (SPNAA), however, are still not commonly used. The aim of this study is to understand the anatomic structure of the SPNAA and its perforators in the anterior intermuscular septum and to use SPNAA perforator flaps in the clinic. We dissected 16 cadavers and assessed the location and number of the SPNAA, its perforators, and the septocutaneous perforators originating from the anterior tibial artery. A SPNAA perforator flap was applied to 12 patients, the free flap was applied to 11 patients, and the pedicled flap was applied to 1 patient. SPNAA varied from 7 to 16 cm in length, with an average of 4.5 perforators to supply the lateral aspect. An average of 3.13 septocutaneous perforators originated from the anterior tibial artery. The mean size of the SPNAA perforator flaps was 65.5 cm. The complete follow-up period was 3-20 months. Although 1 flap was lost as a result of arterial thrombosis, the procedure was successful in the remaining 11 patients. In addition, reduced flap thickness made them more esthetically appealing. SPNAA perforator flaps could be an excellent alternative to perforator flaps that use the lower leg as a donor site.     

Perforator propeller flaps for sacral and ischial soft tissue reconstruction

The perforator-based flaps in the sacral and ischial region is designed according to the localization of perforators that penetrate the gluteus maximus muscle, reach the intra-fascial and supra-fascial planes with the overlying skin forming a rich vascular plexus. The perforator-based flaps described in this article are highly vascularized, have minimal donor site morbidity, and do not require the sacrifice of the gluteus maximus muscle. In a period between April 2008 and March 2009, six patients with sacral pressure sore were reconstructed with propeller flap method based on superior gluteal and parasacral artery perforators. One flap loss was noted. Three cases of ischial pressure sore were reconstructed with longitudinal propeller flap cover, based on inferior gluteal artery perforator. One flap suffered wound infection and dehiscence. Two cases of pilonidal sinus were reconstructed with propeller flap based on parasacral perforators. Both the flaps survived without any complications. Donor sites were closed primarily. In the light of this, they can be considered among the first surgical choices to re-surface soft tissue defects of the sacral and ischial regions. In the series of 11 patients, two patients (18%) suffered complications.     

Reconstruction of high voltage electric burn wound with exposed shoulder joint by thoracoacromial artery perforator propeller flap

We describe the reconstruction of high voltage electric burn injury with exposed shoulder joint by thoracoacromial artery perforator propeller flap based on the delto-pectoral perforators of thoracoacromial artery. The successful use of this propeller flap to cover the exposed shoulder joint in a case with limited local flap options demonstrates its use as an alternative technique.KEY WORDS: Exposed shoulder joint, perforator in deltopectoral groove, reconstruction, thoracoacromial artery perforator propeller flap     

The use of pedicled perforator flaps for reconstruction of lumbosacral defects

Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect.     

Ischial pressure sores: Reconstruction using the perforator‐based reverse flow musculocutaneous 180° propeller flap

The treatment of pressure sores requires soft tissue reconstruction with thick tissue to provide padding of bony prominences and obliterate dead space. Fasciocutaneous flaps may not provide adequate bulk. Propeller flaps (180°) based on perforators from the gluteal artery may be harvested as a reverse flow musculocutaneous flap including a muscle plug to reconstruct deep cavities. Three patients presenting with deep pressure sores required reconstruction of large cavities. In addition to a regular 180° propeller flap, a muscle plug based on a perforator found in the blade of the propeller was used to add bulk to the flap and obliterate the cavity with well‐vascularized tissue. One flap required secondary closure of the donor site due to dehiscence, one hematoma required drainage. All flaps survived completely. No recurrence of osteomyelitis or pressure sores was seen. The 180° propeller flap can be harvested as a reverse flow musculocutaneous flap including a muscle plug in the distal blade. This adds volume which is required to adequately obliterate large cavities in cases of osteomyelitis. This new technique may be useful in other areas as well. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.