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Propeller Flap

The propeller flap is an island flap that reaches its recipient site through axial rotation (90–180°) around its nourishing pedicle.[1][2] The Tokyo consensus, reached at a 2009 meeting and published in 2011, classified subcutaneous-pedicled, perforator-pedicled and supercharged designs. The 2020 update also recognizes axial-pedicled, muscle and chimeric propeller flaps; not every propeller pivots on a single skeletonized perforator.[1][30] Rotation can bring local tissue to penoscrotal, perineal, vulvar and selected urethral defects without necessarily requiring free transfer. Donor morbidity and vascular risk depend on the particular design and site.

The variant-specific PMTP Propeller Flap page covers the deep-femoral-perforator flap in technique-level detail.

Geometric Principle​

The propeller flap is conceptually distinct from the geometric flaps in the rest of this section (Z-plasty, rhomboid (Limberg), bilobed). The steps below describe the perforator-pedicled subtype, designed in freestyle fashion around an identified perforator without a fixed geometric template; subcutaneous-pedicled propellers instead rotate on a broader tissue pedicle.[1][2][3]

StepDetail
Perforator identificationPreoperative handheld Doppler or multidetector-row CT angiography. MDCT provides high-resolution 3D images of the perforator's position and subcutaneous course[4]
Skin-island designMark an elliptical/lenticular island around a candidate perforator; after exploratory dissection, choose a usable perforator and redraw the island if needed. The perforator divides a larger "propeller blade" directed toward the defect from a smaller blade that may cover part of the donor site, which can otherwise be closed primarily if feasible. Adjust the blade ratio to defect size and confirm reach and tension-free donor closure.[2][3]
RotationThe flap is elevated as a complete island, the perforator is skeletonized, and the skin paddle is rotated 90–180° around the perforator axis — analogous to a propeller blade spinning on its shaft. A 180° rotation places the larger blade directly into the defect[1][5]

Tokyo Consensus classification[1]​

  • Subcutaneous-pedicled propeller flap. Rotates on a subcutaneous tissue pedicle
  • Perforator-pedicled propeller flap. Rotates on a skeletonized perforator vessel (most common in GU reconstruction)
  • Supercharged propeller flap. Adds a venous or arterial microvascular anastomosis to augment outflow or inflow, respectively.[30]

Why propeller differs from other local flaps​

Perforator-pedicled propeller flaps offer flexible local design around a suitable mapped vessel.[2] Unlike the rhomboid or bilobed geometric templates, the skin island can be tailored to the defect and the actual vascular territory.[2]

Urologic Applications​

Penoscrotal resurfacing — internal pudendal artery perforator (IPAP) propeller flap​

The most significant urologic application is the IPAP propeller flap from the gluteal fold for extensive penoscrotal reconstruction:[6]

  • 10 consecutive patients with extensive penoscrotal defects (Fournier's gangrene, foreign-body injection, trauma, cancer)
  • The IPAP was identified with handheld Doppler and served as the pivot. The flap was internally rotated > 90° in tension-free fashion, with the long axis centered on the gluteal fold
  • Mean flap dimensions 6.7 × 11.7 cm
  • No major complications over mean 19.7 mo follow-up; one case of partial distal necrosis healed spontaneously[6]
  • All 10 patients in Han’s series were satisfied with cosmetic and functional results.[6]
  • The gluteal-fold donor site provides a natural-appearing scrotal pouch with a hidden donor scar and optimal skin thickness and pliability

The gluteal-fold skin closely matches scrotal skin in thickness, texture, and color, which is an aesthetic advantage.

Perineoscrotal and perineal reconstruction​

Several propeller configurations have been described:

  • Posteromedial thigh (PMT) propeller flap. Scaglioni 2015: a 9 × 23 cm PMT propeller flap based on two profunda-femoris perforators for a 10 × 12 cm scrotal defect after Fournier's gangrene in one patient, with complete flap survival at 3 months.[7]
  • Vertical posteromedial thigh (vPMT) propeller flap. Wishart 2021: 21 pedicled vPMT flaps in 12 patients (3 scrotal, 8 perianal, 5 vulvar defect cases, with some combined defects). 18/21 rotated in propeller fashion. Flap sizes 5–9 × 18–35 cm. All flaps survived; all donor sites primarily closed.[8]
  • Propeller PMTP flap. Kwon 2021: 8 patients with extensive perineal defects (infection and skin cancer) reconstructed with PMTP propeller flaps rotated 180°. Mean flap 256.5 cm². All flaps survived without major complications over mean 22.4 mo.[9] (See PMTP Propeller Flap for technique-level detail.)

A 2026 systematic review of 107 studies describing 619 patients and 625 mixed flap reconstructions after Fournier's gangrene reported flap loss in 1.6% of cases.[10] Medial-thigh, pudendal-thigh, ALT and gracilis designs were most commonly named.[10]

Perineal-urethrostomy revision​

Schulster et al. (2021) described a novel application, a posterior-thigh propeller flap for perineal urethrostomy (PU) revision in complex cases at high risk for stenosis:[11]

  • The stenotic PU was incised, and a propeller flap was designed around the posterior-thigh perforator closest to the defect
  • The flap was elevated and rotated on its pedicle; absorbable sutures partially tubularized its apex at the urethrotomy, which was calibrated to 30 Fr
  • At 17 months: patent PU, voiding well, low post-void residual

A local propeller flap can import tissue from outside the scarred field when its perforator, reach and tissue properties are suitable. The 17-month patency result comes from one patient.

Urogynecologic Applications​

Vulvar reconstruction — IPAP propeller and other perineal perforator flaps​

The IPAP propeller flap is one of the most extensively studied perforator flaps for vulvar reconstruction:

  • Hashimoto 2014. In 45 cases, 71 IPAP flaps covered vulvar skin (36 cases), buttock skin (10), vagina (9), anus (6), and pelvic cavity (6). Propeller transfer was used in 35 cases, transposition in 3, and V-Y advancement in 7. Of 71 flaps, 67 survived completely (94.4%) and 4 had partial necrosis; none failed completely.[12]
  • Han 2016 "gull-wing flap". In nine women with Cordeiro type I vaginal defects after vulvar tumor excision, bilateral IPAP-based flaps rotated 150–180° supplied sufficient volume for three-dimensional reconstruction of the labia and external vaginal wall. One patient had partial flap necrosis; follow-up ranged from 5 to 16 months.[13]
  • Shin 2022. Retrospectively described 16 patients/27 new PPSF flaps, and compared aesthetic ratings with an earlier PPPF group. All PPSF flaps survived and no major complications were observed. PPSF had better symmetry, labial-shape and total aesthetic scores than the earlier PPPF group in this nonrandom comparison.[14]

Vulvar reconstruction algorithms — location-based selection​

For vulvar cancer, the 2023 ESGO guideline requires reconstructive surgical skills within the multidisciplinary team in early and advanced disease and bases technique selection on patient and tumor characteristics and team experience (IV, B).[33] The Toulouse Algorithm (Ricotta et al., 2025) describes location-based perforator and musculocutaneous options for vulvar cancer reconstruction without establishing a first-line propeller preference.[15] Potential perforator sources include IPAP, deep femoral or PAP, medial circumflex femoral and external pudendal systems, with selection depending on defect and donor anatomy.

In a retrospective series of 47 patients, Han 2023 used the vulvo-thigh junctional crease and perforator location to guide flap selection: 31 patients (66%) received IPAP flaps and 16 (34%) received profunda-perforator or transverse-upper-gracilis flaps. Wound complications occurred in 12.9% of the IPAP group and 37.5% of the combined comparator group (p = 0.04); the groups had different defect locations and flap types.[16]

Huang 2015 reported 27 perforator flaps in 16 patients for vulvar reconstruction (4 IPAP flaps). All 27 flaps survived and donor sites were primarily closed; three of 16 patients required debridement and closure of small wounds, one developed temporary peroneal nerve palsy, and one underwent flap debulking at three months.[17]

The lotus-petal flap — a propeller variant​

The lotus-petal flap is a gluteal-fold IPA-perforator fasciocutaneous flap that can be configured as a propeller (as well as a transposition or V-Y advancement). The Confalonieri 2017 V-Y versus LPF series, the Hellinga 2016 ELAPE series, and the Bodin 2015 supra-fascial-LPF series are covered in depth on the dedicated lotus-petal page.[18][19][20][21]

Perineal reconstruction after pelvic exenteration​

For large perineal defects after APR or pelvic exenteration, Witte's review included 1,988 patients across 58 mainly observational studies; among the 910 APR patients, 91% received a rectus-abdominis flap. Propeller perforator flaps are described as alternatives when their tissue volume, reach and perfusion suit the defect.[22]

The IPAP propeller was used in 1 of 11 perineal reconstructions after APR by Loreti 2023, alongside 8 rotation flaps and 2 advancement island flaps, all based on the internal pudendal perforator system. All 11 flaps survived with no immediate postoperative major complications, and 8 of the 11 reconstructions (73%) were in previously irradiated tissue.[23] In a randomized trial of 51 patients with IPAP V-Y advancement flaps after irradiated APR, an adapted mobilization program beginning postoperative day 1 increased day-5 independent 3-m ambulation versus five days of bed rest (17/25 versus 10/26; p = 0.035).[29] Postoperative complications occurred in 17/25 versus 21/26 patients (p = 0.296).[29]

Complications and Management​

The following review rates describe 1,315 propeller flaps in 1,242 patients across multiple body regions, limiting their application to GU or perineal reconstruction:[24]

  • Complications in 281/1,242 patients (22.6%)[24]
  • Most frequent: partial flap necrosis and venous congestion
  • Significantly higher complication rates in patients > 70 years and in infants under 10 years
  • Higher complication rates in the lower limbs (approximately 31.8%) than other regions[24]

Venous congestion — the Achilles heel​

Venous congestion can result from pedicle torsion or compression.[25][26][27][28]

  • Venous supercharging. Chaput 2018 compared consecutive groups of 30 standard and 30 venous-supercharged lower-limb propeller flaps. Congestion was 36.7% versus 6.7%, and distal necrosis 30% versus 3.3%, with longer operative time for supercharging. The comparison was nonrandom and mainly involved traumatic lower-limb flaps.[26]
  • Local subcutaneous LMWH injection. Pérez 2014 retrospectively described salvage attempts in 15 mixed free or regional congested flaps when venous outflow could not be restored surgically. Although all were at least partially salvaged, 13 patients required transfusion (mean 5 units of packed red cells per patient), and hematoma and anemia-related syncope occurred.[27]
  • Flap geometry. Huang's 2026 meta-analysis covered 402 distal-leg, ankle and hindfoot propeller flaps. Huang's 40–80 cm² area and width >4.5 cm associations concern distal-leg flaps; the flap-to-defect ratio <2.5 association was not statistically significant (p = 0.15), so none defines a validated perineal threshold.[28]

Comparison with Other Flap Techniques​

A gracilis muscle flap and VRAM have different reach, bulk and donor-site risks.

FeaturePropeller flapRhomboid (Limberg)Bilobed flapV-Y advancementMusculocutaneous (VRAM / gracilis)
VascularizationSubcutaneous or perforator pedicle; may be superchargedRandom patternRandom or perforatorSubcutaneous / perforatorNamed vessel (axial)
Arc of rotationUp to 90° with a subcutaneous pedicle; up to 180° with a perforator, axial or muscle pedicle[30]~60°90–100°None (linear)Variable
Tissue bulkThin, adjustableMinimalMinimalModerateSubstantial
Donor-site morbidityDepends on flap size and closureDepends on defect and closureDepends on defect and closureDepends on defect and closureDepends on muscle and donor site
Defect-size capacitySmall to largeSmall to moderateSmall to moderateSmall to moderateLarge
Example perineal / genital useSelected penoscrotal, vulvar or perineal defectsSelected small posterior vulvar defectsSelected multi-compartment defectsSelected vulvar or perineal defectsDeep-volume or pelvic-floor defects, neovagina
Key advantageFreestyle design; thin, pliable; hidden donor scarSimple geometryTissue relay from lax areaNo rotation neededBulk for dead-space obliteration
Key limitationVenous congestion with rotationSize-limited (random)Complex designLimited reachDonor-site morbidity

When to Reach for the Propeller Flap​

  • Extensive penoscrotal resurfacing where local advancement is insufficient and the gluteal-fold donor matches scrotal skin character (IPAP propeller).[6]
  • Vulvar oncologic reconstruction when a thin, pliable, potentially sensate fasciocutaneous flap suits the defect (IPAP propeller, gull-wing or lotus-petal design). The tunneled perineal-perforator switch flap is a separate perforator alternative rather than a propeller design.[12][13][14][19]
  • Extensive perineal defects after Fournier's, ELAPE, or pelvic exenteration when VRAM is unavailable or undesired (PMTP / vPMT propeller, lotus-petal, IPAP).[7][8][9][20][23]
  • Perineal urethrostomy revision in scarred, multiply-operated fields where a distant local propeller imports healthy tissue outside the injury zone.[11]

Reconsider the design when the defect requires more deep-space volume than a fasciocutaneous island supplies, or when donor perfusion, irradiation, prior surgery or venous outflow make rotation unsafe. A muscle-bearing or other flap may be preferable, but that decision is defect- and patient-specific. A 2024 synthesis of 49 studies (1,840 women after vulvoperineal cancer resection) did not find a statistically significant difference in short-term complication frequency between perforator (n = 276) and nonperforator (n = 1,564) flap groups (p > 0.05).[31]

Technical Pearls​

  • Plan the vascular pivot with examination and an appropriate mapping method; handheld Doppler, ultrasound or CT angiography can be useful depending on location and prior operations. Confirm the actual perforator and usable rotation arc at dissection.[4]
  • Preserve venous outflow during dissection. Perforator skeletonization and the need for a 2–3 cm soft-tissue cuff are design-specific.
  • Check perfusion and outflow during rotation. Compare clockwise and counterclockwise rotation, inspect the pedicle for twisting, buckling, compression or tension, and reassess flow before inset; change the arc or flap plan if perfusion is inadequate.[2]
  • Consider outflow options when the expected rotation or donor field increases venous risk.[25][26]
  • Inset without avoidable tension while preserving the pedicle and venous drainage. Apply dressings that permit serial visual checks of skin-paddle color and capillary refill. If venous congestion appears, first release external tension or remove tight sutures; derotation may be needed.[32]
  • Match donor tissue to the defect. Gluteal fold, posteromedial thigh and perineal perforator systems offer different reach, thickness and donor scars; choose according to actual vascular anatomy and reconstructive needs.

See Also​

References​

1. Pignatti M, Ogawa R, Hallock GG, et al. "The 'Tokyo' Consensus on Propeller Flaps." Plast Reconstr Surg. 2011;127(2):716–722. doi:10.1097/PRS.0b013e3181fed6b2

2. D'Arpa S, Toia F, Pirrello R, Moschella F, Cordova A. "Propeller Flaps: A Review of Indications, Technique, and Results." Biomed Res Int. 2014;2014:986829. doi:10.1155/2014/986829

3. Blough JT, Saint-Cyr MH. "Propeller Flaps in Lower Extremity Reconstruction." Clin Plast Surg. 2021;48(2):173–181. doi:10.1016/j.cps.2021.01.002

4. Ono S, Chung KC, Hayashi H, et al. "Application of Multidetector-Row Computed Tomography in Propeller Flap Planning." Plast Reconstr Surg. 2011;127(2):703–711. doi:10.1097/PRS.0b013e318200a99e

5. Ono S, Sebastin SJ, Yazaki N, Hyakusoku H, Chung KC. "Clinical Applications of Perforator-Based Propeller Flaps in Upper Limb Soft Tissue Reconstruction." J Hand Surg Am. 2011;36(5):853–863. doi:10.1016/j.jhsa.2010.12.021

6. Han SE, Kim EJ, Sung HH, Pyon JK. "Aesthetic Penoscrotal Resurfacing: Creating Propeller Flaps From Gluteal Folds." Eur Urol. 2018;73(4):610–617. doi:10.1016/j.eururo.2016.09.033

7. Scaglioni MF, Chen YC, Yang JC. "Posteromedial Thigh (PMT) Propeller Flap for Perineoscrotal Reconstruction: A Case Report." Microsurgery. 2015;35(7):569–572. doi:10.1002/micr.22479

8. Wishart KT, Fritsche E, Scaglioni MF. "Pedicled Vertical Posteromedial Thigh (vPMT) Flap for the Reconstruction of Extensive Perianal-Genital Defects." J Plast Reconstr Aesthet Surg. 2021;74(1):123–129. doi:10.1016/j.bjps.2020.08.001

9. Kwon HJ, Seo JH, Choi JY, et al. "Propeller Posteromedial Thigh Perforator Flaps for Coverage of Extensive Perineal Defects." Microsurgery. 2021;41(4):335–340. doi:10.1002/micr.30726

10. Alammar A, Laing K, Somasundaram J, Wallace DL, Rogers AD. "Flap Reconstruction Following Fournier's Gangrene: A Systematic Review of Techniques and Outcomes." Burns. 2026;52(3):107888. doi:10.1016/j.burns.2026.107888

11. Schulster ML, Dy GW, Vranis NM, et al. "Propeller Flap Perineal Urethrostomy Revision." Urology. 2021;148:302–305. doi:10.1016/j.urology.2020.12.002

12. Hashimoto I, Abe Y, Nakanishi H. "The Internal Pudendal Artery Perforator Flap: Free-Style Pedicle Perforator Flaps for Vulva, Vagina, and Buttock Reconstruction." Plast Reconstr Surg. 2014;133(4):924–933. doi:10.1097/PRS.0000000000000008

13. Han HH, Jun D, Seo BF, et al. "Internal Pudendal Perforator Artery-Based Gull Wing Flap for Vulvovaginal 3D Reconstruction After Tumour Excision: A New Flap." Int Wound J. 2016;13(5):920–926. doi:10.1111/iwj.12410

14. Shin J, Kim SA, Rhie JW. "Perineal Perforator Switch Flap for Three-Dimensional Vulvovaginal Reconstruction." J Plast Reconstr Aesthet Surg. 2022;75(9):3208–3216. doi:10.1016/j.bjps.2022.04.052

15. Ricotta G, Russo SA, Ferron G, Meresse T, Martinez A. "The Toulouse Algorithm: Vulvar Cancer Location-Based Reconstruction." Int J Gynecol Cancer. 2025;35(4):100065. doi:10.1016/j.ijgc.2024.100065

16. Han WY, Kim Y, Han HH. "A Simplified Algorithmic Approach to Vulvar Reconstruction According to Various Types of Vulvar Defects." Ann Plast Surg. 2023;91(2):270–276. doi:10.1097/SAP.0000000000003597

17. Huang JJ, Chang NJ, Chou HH, et al. "Pedicle Perforator Flaps for Vulvar Reconstruction — New Generation of Less Invasive Vulvar Reconstruction With Favorable Results." Gynecol Oncol. 2015;137(1):66–72. doi:10.1016/j.ygyno.2015.01.526

18. Höckel M, Dornhöfer N. "Vulvovaginal Reconstruction for Neoplastic Disease." Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5

19. Confalonieri PL, Gilardi R, Rovati LC, et al. "Comparison of V-Y Advancement Flap Versus Lotus Petal Flap for Plastic Reconstruction After Surgery in Case of Vulvar Malignancies: A Retrospective Single Center Experience." Ann Plast Surg. 2017;79(2):186–191. doi:10.1097/SAP.0000000000001094

20. Hellinga J, Khoe PC, van Etten B, et al. "Fasciocutaneous Lotus Petal Flap for Perineal Wound Reconstruction After Extralevator Abdominoperineal Excision." Ann Surg Oncol. 2016;23(12):4073–4079. doi:10.1245/s10434-016-5332-y

21. Bodin F, Dissaux C, Seigle-Murandi F, et al. "Posterior Perineal Reconstructions With 'Supra-Fascial' Lotus Petal Flaps." J Plast Reconstr Aesthet Surg. 2015;68(1):e7–e12. doi:10.1016/j.bjps.2014.10.028

22. Witte DYS, van Ramshorst GH, Lapid O, Bouman MB, Tuynman JB. "Flap Reconstruction of Perineal Defects After Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods." Plast Reconstr Surg. 2021;147(6):1420–1435. doi:10.1097/PRS.0000000000007976

23. Loreti A, Arelli F, Spallone D, Bruno E, Abate O. "The Use of the Internal Pudendal Artery Perforator Flap After Abdominoperineal Reconstruction: A Single Center Study." J Plast Reconstr Aesthet Surg. 2023;84:87–92. doi:10.1016/j.bjps.2023.05.015

24. Sisti A, D'Aniello C, Fortezza L, et al. "Propeller Flaps: A Literature Review." In Vivo. 2016;30(4):351–373. PMID 27381596

25. Brunetti B, Salzillo R, De Bernardis R, et al. "Conjoined Thoracodorsal Perforator-Supercharged Dorsal Intercostal Artery Perforator Propeller Flap for Reconstruction of a Complex Upper Back Defect." Microsurgery. 2024;44(1):e31129. doi:10.1002/micr.31129

26. Chaput B, Bertheuil N, Grolleau JL, et al. "Comparison of Propeller Perforator Flap and Venous Supercharged Propeller Perforator Flap in Reconstruction of Lower Limb Soft Tissue Defect: A Prospective Study." Microsurgery. 2018;38(2):177–184. doi:10.1002/micr.30162

27. Pérez M, Sancho J, Ferrer C, García O, Barret JP. "Management of Flap Venous Congestion: The Role of Heparin Local Subcutaneous Injection." J Plast Reconstr Aesthet Surg. 2014;67(1):48–55. doi:10.1016/j.bjps.2013.09.003

28. Huang SC, Yeh YS, Chen WH, et al. "Optimizing Perforator-Based Propeller Flap Design for Distal Leg, Ankle and Hindfoot Reconstruction: A Systematic Review and Meta-Analysis." Plast Reconstr Surg. 2026. doi:10.1097/PRS.0000000000012993

29. Lima de Araujo CA, de Freitas Busnardo F, Thome Grillo VA, et al. "Effect of Early Postoperative Mobilization on Functional Recovery, Hospital Length of Stay, and Postoperative Complications After Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects: A Prospective, Randomized Controlled Trial." Ann Surg Oncol. 2025;32(2):993–1004. doi:10.1245/s10434-024-16497-x

30. Pignatti M, Ogawa R, Mateev M, et al. "Our Definition of Propeller Flaps and Their Classification." Semin Plast Surg. 2020;34(3):139–144. doi:10.1055/s-0040-1715158

31. Wendelspiess S, Kouba L, Stoffel J, et al. "Perforator versus Non-Perforator Flap-Based Vulvoperineal Reconstruction—A Systematic Review and Meta-Analysis." Cancers (Basel). 2024;16(12):2213. doi:10.3390/cancers16122213

32. Pignatti M, Pinto V, Docherty Skogh AC, et al. "How to Design and Harvest a Propeller Flap." Semin Plast Surg. 2020;34(3):152–160. doi:10.1055/s-0040-1714271

33. Oonk MHM, Planchamp F, Baldwin P, et al. "European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023." Int J Gynecol Cancer. 2023;33(7):1023–1043. doi:10.1136/ijgc-2023-004486