A Modified Vascular Delay Technique to Keep a Congested Perforator-Based Propeller Flap Afloat

Background: The perforator-based propeller flap is a versatile technique that has proven utility in complex lower extremity and lumbar reconstructions. Yet, this flap is prone to venous congestion due to its single-perforator design. In the setting of a congested propeller flap, it is often abandoned and a secondary flap option is utilized. The vascular delay technique has been successfully used to augment perfusion in other types of flaps; however, it has not been described for the propeller flap. We present our experience of salvaging a congested lumbar artery-based propeller flap using a modified technique. Method: A seven year old female with scoliosis, who previously underwent lumbar spine fusion, developed a non-healing lumbar wound with hardware exposure (Figure 1A). The wound was debrided (Figure 1B). We then located a lumbar artery perforator by Doppler ultrasound and raised a propeller flap. However, the flap became congested immediately upon transposition (Figure 1C). After ruling out mechanical obstruction, observing patiently, treating vasospasm with papaverine, and returning the flap to its anatomic position the congestion persisted. The flap was de-epithelialized, to treat congestion and decrease metabolic demand, and the congestion promptly resolved (Figure 1D). After a two week delay (Figure 2A), successful definitive flap transposition was performed (Figure 2B). No congestion was observed (Figure 2C). A split thickness skin graft was placed to cover the de-epithelized flap (Figure 2D). The patient had an uneventful hospital and recovery course. Results: At six months postoperatively, the patient demonstrated healthy and durable coverage of the spinal hardware (Figure 3). Discussion: To our knowledge, this is the first described use of vascular delay to salvage a congested propeller flap. We propose a flowchart (Figure 4) to assist with intraoperative decision making after observing flap congestion upon initial transposition. If necessary, vascular delay may be applied to prevent abandonment of an otherwise viable flap.