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Injury
journal homepage: www.elsevier.com/locate/injury

Reverse neurocutaneous vs propeller perforator flaps in diabetic foot

reconstruction ✩
Efterpi Demiri∗, Antonios Tsimponis, Leonidas Pavlidis, Georgia-Alexandra Spyropoulou,
Periclis Foroglou, Dimitrios Dionyssiou
Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital,
Thessaloniki, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Introduction Reverse neurocutaneous and propeller perforator flaps are both used to reconstruct diabetic
Accepted 7 March 2020 distal lower limb defects. Our study aims to compare outcomes between these two groups of flaps with
Available online xxx
an emphasis on indications and complication rates.
Keywords: Method A retrospective analysis was conducted, reviewing data from 54 diabetic patients who underwent
Diabetic foot reconstruction of acute or chronic wounds of the foot and ankle between 2005-2018. Thirty-four patients
Skin defects (Group A) had a reverse neurocutaneous flap (NCF): nineteen sural and fifteen lateral supramalleolar
Reverse neurocutaneous flaps
flaps. Twenty patients (Group B) had a propeller flap (PF) based on peroneal (n = 13) or posterior tibial
Propeller flaps
artery perforators (n = 7). All patients had a preoperative Doppler examination to identify the nutrient
artery of the flap. In both groups, we recorded patients’ demographics, characteristics of the defect, post-
operative complications and time to heal. Follow-up ranged from 6 to 59 months. Student’s t-test and
chi-squared test were used for statistical analysis.
Results Mean patients’ age was 59.1 and 50.8 years for Group A and B, respectively. Defects were located
at the Achilles zone (n = 16), posterior heel (n = 14), foot dorsum (n = 9), lateral and medial malleolar
areas (n = 8), anterior ankle (n = 5) and lateral foot (n = 2). Mean size of the defect was 42.8 cm2 in
Group A and 23 cm2 in Group B. Uneventful healing was recorded in 20/34 neurocutaneous flaps and
in 12/20 propeller flaps; complications included two complete flap losses (one NCF, one PF), seventeen
distal flap necroses (10 NCFs, 7 PFs), fifteen delayed wound healing events over the donor or recipient
site (12 NCFs, 3 PFs). Secondary surgeries were required in 15 NCF and 8 PF patients. Mean healing time
was 48.1 and 40.7 days for Group A and B, respectively. All patients, except one NCF case, which resulted
in leg amputation, returned to previous levels of ambulation.
Conclusion Reverse neurocutaneous and propeller flaps may provide stable reconstruction of diabetic
lower limb defects; neurocutaneous flaps are specially indicated for larger and more distally located
defects, although they might be associated with longer healing time and additional revision surgeries.
Propeller flaps were more frequently used in younger patients for smaller and more proximally located
defects.
© 2020 Elsevier Ltd. All rights reserved.

Introduction fection susceptibility, combined with the limited availability of lo-

cal tissues in the proximity, are all negative predictive factors that
Reconstruction of soft tissue defects of the foot and ankle in di- should be seriously considered. Nonetheless, surgical management
abetic patients has always been a challenging problem. Increased of those patients has improved a lot, as a result of the introduc-
morbidity including angiopathy, neuropathy, immunopathy and in- tion and use of various regional flaps of the lower leg, based on
perforator or fasciocutaneous vascular axes [1–4].
The aim of the current study is to compare the results obtained
✩
from using the distally based neurocutaneous flaps, namely the re-
This paper is part of a Supplement supported by the European Federation of
verse sural and lateral supramalleolar flap [5], and the propeller-
Societies of Microsurgery (EFSM)
∗
Corresponding author. type perforator skin island flaps in reconstructing soft tissue de-
E-mail address: demirie@auth.gr (E. Demiri). fects of the ankle and foot in diabetic patients.

https://doi.org/10.1016/j.injury.2020.03.014
0020-1383/© 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic
foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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2 E. Demiri, A. Tsimponis and L. Pavlidis et al. / Injury xxx (xxxx) xxx
Table 1
Summarized demographic and clinical data of the two groups and statistical analysis results. BMI: Body Mass Index, ABI: Ankle Brachial Index
Group A Neurocutaneous flaps
34 patients 19 reverse sural flaps15 lateral
N supramalleolar flaps
Age (mean) 59.1 years
BMI (mean) 27.8
ABI (mean) 0.98
Defect size (mean) 42.8 cm2
Complications rate 14/34 (41,2%)
Revision surgeries 15/34 (44.1%)
Healing time (mean) 48.1 days
Patients and methods
We conducted a retrospective analysis of 54 diabetic patients,
who underwent reconstruction of acute or chronic wounds of the
ankle and foot, between 2005-2018, using regional vascularized
pedicle skin flaps from the leg. Thirty-four patients (Group A)
had a reverse neurocutaneous flap (NCF); in nineteen cases a re-
verse sural flap was used, while in fifteen patients a reverse lat-
eral supramalleolar flap. Twenty patients (Group B) underwent a
propeller-type skin flap reconstruction (PF) based on perforators of
the peroneal (n = 13) or posterior tibial artery (n = 7). All pro-
cedures were performed in a single institution by the same senior
surgeons.
The vascular status of the involved lower limb was assessed
clinically, by palpation of the posterior tibial and dorsalis pedis
pulsation, and confirmed by Doppler flowmeter; further radiolog-
ical investigation, i.e. CT angiography, was only performed when
needed. All patients underwent a preoperative Doppler examina-
tion to identify the nutrient artery of the flap.
In both groups, we recorded patients’ characteristics, i.e. age,
Body Mass Index (BMI) and Ankle-Brachial Index (ABI), aetiology,
size and location of the defect, postoperative complications, time
to heal and secondary revision surgeries.
Statistical analysis was conducted through SPSS (edition 26)
software package. Shapiro Wilk was used to test normality for the
quantitative variables (defect size, age, BMI, ABI and total heal-
ing time). Data was thoroughly examined and Student’s t test and
Mann-Whitney U test were used to elaborate the statistically sig-
nificant difference. Qualitative parameters were examined through
Chi-square test and Fishers exact test. The level of statistical signif-
icance was determined to pvalues < 0.05. Patients with large and
complex tissue losses requiring free tissue reconstruction and cases
with insufficient data were not included in the study.
Results
Our series of 54 diabetic patients included forty-four males
and ten females, aged between 42 and 83 years, with a follow-
Fig. 1. 69-year-old diabetic patient presenting an extensive chronic ulcer over the posterior heel (a); After wound debridement and reverse sural flap harvesting, the final
result 15 months after reconstruction was satisfactory (b)
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic
foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
[m5G;March 14, 2020;13:30]
Group B Propeller perforator flaps P value
20 patients 13 peroneal a. perforator flaps 7
posterior tibial a. perforator flaps
50.8 years 0.007
26.3 0.345
1.02 0.659
23 cm2 0.000
8/20 (40%) 0.322
8/20 (40%) 0.097
40.7 days 0.000
up ranging from 6 to 59 months. Regarding patients’ demograph-
ics, mean age in Group A was 59.1 years ± 8.329 and in Group B
50.8 years ± 8.97, difference which was found statistically signif-
icant (p = 0.007). Mean Body Mass Index (BMI) was 27.8 in the
NCF group and 26.3 in the PF group, while Ankle-Brachial Index
(ABI) was found 0.98 and 1.02 for Group A and B, respectively;
non-statistically significant difference was depicted in both param-
eters (p = 0.345 & p = 0.659) as shown in Table 1.
Aetiology of the defect included trauma in 21 cases (39%),
chronic ulcer in 26 cases (48%) and previous surgery in 7 cases
(13%), with equal distribution in both groups. Mean size of the de-
fect was 42.8 cm2 in Group A and 23 cm2 in Group B (p < 0.001).
Location of the defects concerned the Achilles zone in 16 cases, the
posterior heel in 14 patients, the foot dorsum in 9, the medial and
lateral malleolar areas in 8, the anterior ankle and lateral distal
foot in 5 and 2 cases, respectively.
Neurocutaneous flaps were used in 9 defects of the Achilles
area (26.47%), 10 defects over the posterior and plantar heel
(29.41%), 7 of the foot dorsum (20.59%), 3 defects over the lat-
eral aspects of the ankle (8.82%), 3 defects over the anterior an-
kle (8.82%) and 2 ulcers over the lateral distal foot area (5.88%), as
shown in Table 2. More specifically, reverse sural flaps were har-
vested to cover 10 defects over the posterior heel and plantar area,
6 wounds over the foot dorsum, one wound over the lateral an-
kle and 2 ulcers over the anterior ankle (Fig. 1). From those flaps,
three reverse sural flaps were used in a pure adipofascial fashion;
a skin graft was used to cover the flap (Fig. 2). Lateral supramalleo-
lar flaps were used to cover 9 wounds over the Achilles zone, 2 de-
fects of the lateral and medial malleolus, 2 defects over the lateral
distal foot, one defect over the foot dorsum and one over the an-
terior ankle. One of our lateral supramalleolar flaps was “delayed”
and transferred to the wound at a second stage, one week after the
primary procedure.
Propeller-type flaps were used to cover 7 tissue losses of the
Achilles zone (35%), 4 of the posterior heel (20%), 2 over the foot
dorsum (10%), 2 over the anterior ankle (10%) and 5 over the me-
dial or lateral malleolar areas of the foot (25%) (Fig. 3). Table 3
illustrates the distribution of Group B defects’ location.
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E. Demiri, A. Tsimponis and L. Pavlidis et al. / Injury xxx (xxxx) xxx 3

Table 2
Distribution of defects’ location in Group A (neurocutaneous flaps)

Fig. 2. 80-year-old man presenting a post-traumatic complex tissue loss (a); coverage with an adipofascial reverse sural flap, primarily grafted with stable final result after
uneventful healing, one year post-operatively (b)

Fig. 3. Design of the peroneal artery perforator propeller flap in a 77-year-old man with a chronic ulcer over the lateral malleolus (a); 6-month-postoperative result with
the donor site covered with a skin graft (b)

Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic
foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
JID: JINJ
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4 E. Demiri, A. Tsimponis and L. Pavlidis et al. / Injury xxx (xxxx) xxx

Table 3
Distribution of defects’ location in Group B (propeller flaps)

Fig. 4. 65-year-old diabetic patient with a chronic ulcer over the Achilles tendon, planned to be covered with a lateral supramalleolar flap (a); Although there were initial
signs of partial flap ischemia, post-operative result was stable three years post-operatively (b)

Fig. 5. Post-traumatic soft tissue defect over the medial malleolus in a 54-year-old patient and design of a posterior tibial artery perforator propeller flap (a); immediate
result after reconstruction (b); distal flap necrosis (c); final result after skin grafting (d)

Uneventful primary healing was recorded in 20 out of 34 neu-
rocutaneous flaps (58,8%) and in 12 out of 20 propeller flaps
(60%). In Group A, complications occurred in 14 out of 34 oper-
ated wounds (41,2%) and included one complete loss of a lateral
supramalleolar flap and ten partial flap necroses, due to venous
insufficiency, that required secondary skin grafting (Fig. 4); de-
layed healing was recorded in three recipient sites and nine donor
sites of the flaps. Overall, secondary surgeries (surgical debride-
ment, skin grafting) were performed in 15 NCF patients (44.1%).
In Group B, complications occurred in 8 flaps (40%) including
one complete propeller flap necrosis and seven distal skin is-
land necroses; six cases were managed surgically with secondary
skin grafting (Fig. 5) and one patient was treated conservatively
with dressings. Delayed wound healing was recorded in three flap
donor sites. Revisional surgeries were required in 8 PF patients
(40%).
The overall success rate including the revisional surgeries was
at 97% for Group A and 95% for Group B, with a mean time to heal
48.1 and 40.7 days for Group A and B, respectively. The case that
presented complete loss of the propeller flap, although re-operated
and successfully reconstructed with a free ALT flap, was not con-
sidered successful regarding the original reconstructive procedure.
Statistical analysis did not show any significant difference re-
garding occurrence of complications and revision surgeries be-
tween the two groups (p = 0.322); however, mean healing time
was significantly higher in Group A (p < 0.001). Table 1 summa-
rizes mean values of recorded parameters and statistical analysis
results. All patients, except one NCF case, which resulted in leg

Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic
foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
JID: JINJ
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E. Demiri, A. Tsimponis and L. Pavlidis et al. / Injury xxx (xxxx) xxx
amputation following the flap loss, returned to previous levels of
ambulation. None of our patients had a recurrence of the recon-
structed ulcer during the follow-up period.
Discussion
Development of foot ulcers in patients suffering from diabetes
mellitus is considerably high. It is estimated that 12 percent of
diabetic patients may develop some foot ulceration during their
lifetime [6,7]. Glucose control, management of co-morbidities, as
well as successful reconstruction of diabetic foot defects have been
shown to decrease lower limb amputation rates and prolong sur-
vival in this multi-morbid population [7].
Several reconstructive modalities are being used including skin
grafting, loco-regional or free flaps. For complex wounds, selection
of the right technique should be based on the safer flap according
to the vascularity of the limb and patient’s comorbidities [4]. Free
tissue transfer is extensively used during the recent years, mainly
for large and/or more complicated tissue defects; despite the high
success rates of free flaps even in diabetic patients, careful case
selection and pronounced microsurgical skills are required for per-
forming those demanding procedures [6,8,9].
Among loco-regional flaps, the distally based neurocutaneous
flaps have been successfully used for soft tissue reconstruction in
diabetic foot ulcers during the last two decades [1,10–12]. Salmon
first reported that the superficial nerves of the leg (sural, saphe-
nous and superficial peroneal nerves) are accompanied by arterial
axes delivering multiple vascular branches to the overlying skin
and anastomotic vessels to the suprafascial and deep vascular net-
works of the leg [13]. In 1992, Masquelet et al, based on their
anatomical studies, confirmed these observations and pointed out
similar characteristics in the vascular supply of these “neurocuta-
neous” skin island flaps, namely the sural artery and the lateral
supramalleolar flap, both supplied by vascular axes of sensitive su-
perficial nerves [5]. Advantages of these distally based cutaneous
flaps include the avoidance of microsurgical procedures and the
preservation of major arterial axes of the extremities, the latter be-
ing extremely important in lower limbs with insufficient blood cir-
culation [12]. Indications of those flaps in reconstructing foot and
ankle wounds are quite similar, with the lateral supramalleolar flap
being mostly indicated for covering the medial malleolar area, the
Achilles zone and the distal areas of the foot; [10,14] the reverse
sural flap is more frequently used for covering the posterior and
weight-bearing heel and the lateral malleolar areas [1,15].
Parallel advanced studies on the vascular anatomy of the lower
leg, resulted in the description and harvesting of new pedicled skin
island flaps supplied by perforator vessels, emerging from the ma-
jor arterial axes of the leg, i.e. the anterior and posterior tibial, and
the peroneal arteries [16]. Even in diabetic patients with compro-
mised circulation, a major vascular axis -most commonly the per-
oneal artery- remains patent with viable perforators to supply a
perforator flap [17]. Georgescu et al, published a series of 25 dia-
betic lower limb wounds that were successfully reconstructed with
propeller-type skin flaps mainly based on perforators of the per-
oneal and posterior tibial artery [3].
Interestingly, results of our retrospective study showed high and
comparable success rates in both groups of reconstructive meth-
ods, with 97% and 95% for neurocutaneous and propeller flaps, re-
spectively. Although our analysis did not show any significant dif-
ference regarding overall success or complication rates between
the two groups, mean time to heal was significantly higher in
Group A. Need for revision surgeries was also found higher in the
NCF patients, but without statistically significant difference. An ex-
planation to these findings might be the fact that neurocutaneous
flaps were more frequently used in a significantly older patients’
population and for covering significantly larger tissues defects.
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic
foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
[m5G;March 14, 2020;13:30]
5
Regarding location of the defects, our results showed that pro-
peller flaps were used in 14 out of 20 cases (70%), for covering
more proximally located wounds, i.e. the Achilles tendon, the me-
dial, lateral and anterior aspect of the ankle. In contrary, neuro-
cutaneous flaps were used in 19 out of 34 cases for reconstruct-
ing more distal defects, i.e. the posterior heel and plantar area, the
dorsum and lateral side of the foot (55.9%). Obviously, the large
rotation arc of both types of neurocutaneous flaps allowed for cov-
ering more distal areas of the foot; the lateral supramalleolar flap
reached, not only the Achilles zone, but also the distal dorsum and
lateral aspect of the foot, while the reverse sural flap was a better
indication for covering the posterior heel and plantar defects.
Delaying the transfer of neurocutaneous flaps has also been re-
ported in order to improve the chances of flap transfer success,
especially in more complex cases of diabetic foot wounds [10,15].
Delay phenomenon is well known to increase functional blood flow
to the flap and, therefore, to enhance the survival of critically vas-
cularized skin islands. In our series, one patient who presented a
composite tissue loss over the distal lateral side of the foot, was
treated with a delayed lateral supramalleolar flap that successfully
reconstructed the defect in a two-staged procedure.
One of the major disadvantages of using the reverse neurocu-
taneous flaps comparing to the propeller perforator flaps, is the
donor site morbidity including sensory disturbances over the lat-
eral aspect of the foot and unpleasant scarring over the flap’s
donor site which is usually skin grafted. Healing of the donor site
was problematic in nine NCF cases of our series, due to “non-
take” of primary skin grafts, resulting in even poorer cosmetic out-
come. In only three cases of adipofascial reverse sural flaps, donor
site was directly closed and a skin graft was primarily applied to
cover the flap. As already reported, pure adipofascial neurocuta-
neous flaps provide thin reconstruction and fine contour over the
recipient zone with minor aesthetic alterations of the donor site,
that does not need to be grafted [18,19]. None of our Group A pa-
tients reported any functional troubles resulting from harvesting a
superficial sensitive nerve.
Considering these parameters and in order to reduce donor site
morbidity, we selected a propeller-type reconstruction when fea-
sible, especially in our younger patients and for limited sized de-
fects. In all but three of our PF patients, donor site was primar-
ily sutured, leading to inconspicuous scarring and better lower leg
contour.
Limitations of the study
This study has potential limitations. The location and the size of
the defect has played an important role in selecting the appropri-
ate flap; therefore, a selection bias may have influenced our study.
This could not have been avoided, since it is generally accepted
that neurocutaneous flaps can cover more extended defects, espe-
cially when located in more distal areas of the foot.
Conclusions
Results of our study showed that reverse neurocutaneous and
propeller-type skin flaps are safe and reliable alternative recon-
structive options for diabetic lower limb defects; both methods
provided successful coverage of various tissue losses over dia-
betic feet and ankles, reducing the need for microsurgical proce-
dures. Neurocutaneous flaps, although associated with more revi-
sion surgeries and significantly longer healing times, were consid-
ered better indications when facing large and distally located de-
fects of the foot and ankle. Propeller flaps were most frequently
used in younger patients for smaller and more proximal defects.
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Declaration of Competing Interest
None
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