“Optimizing Perforator-Based Propeller Flap Design for Distal Leg, Ankle and Hindfoot Reconstruction: A Systematic Review and Meta-Analysis”

BACKGROUND: Perforator-based propeller flaps (PPF) have emerged as an important reconstructive option for distal lower-extremity defects. While previous studies have reported outcomes, the optimal design parameters and their impact on complications remain unclear. This study aimed to establish evidence-based guidelines for PPF design through a systematic review and meta-analysis of individual patient data. METHODS: PubMed, Embase, and Cochrane Library were searched for studies published through March 2025. A total of 402 propeller flaps from 27 studies were included in the meta-analysis. Primary outcomes included target site complications (TSC), vascular complications, and flap necrosis. Design parameters, including perforator location, flap width, flap dimension, and rotational arc, were evaluated for their impact on outcomes. RESULTS: Among 402 flaps, TSC occurred in 22% (95% CI: 17%-27%), including venous congestion (4%) and flap necrosis (12%). Lower complication rates were associated with flap width >4.5 cm (22%; P = 0.02), flap dimension 40-80 cm² (18%; P = 0.04), and flap-to-defect ratio 4.5 cm, and flap-to-defect ratio < 2.5 preserves optimal outcomes, confirming PPF as dependable single-stage alternatives to free flaps for distal lower-extremity defects.Clinical Question/Level of Evidence: Therapeutic, Level III.