Objective The lower trapezius musculocutaneous flap (LTMF) is a workhorse flap for the reconstruction of soft-tissue defects of the head and neck. However, when harvesting a large LTMF to repair massive defects, primary closure of the donor site may be challenging. This study aimed to evaluate the feasibility and safety of using a perforator propeller flap (PPF) for primary closure of LTMF donor sites and to analyze the buddy flap donor-site closure strategies through a comprehensive literature review.
Methods We retrospectively reviewed data from patients who underwent LTMF donor-site defect reconstruction using PPF between January 2015 and October 2025. Data on patient demographics, defect features, flap characteristics, postoperative complications, and outcomes were collected and analyzed. In addition, a comprehensive literature search was conducted in PubMed, Embase, Scopus, and Web of Science to identify studies published before October 9, 2025, describing the use of an additional flap to close the donor site of a primary flap.
Results Seventeen patients underwent donor-site reconstruction of LTMFs using PPFs. The harvested LTMFs measured an average of 29.8 × 11.5 cm. The PPFs measured an average of 15.7 cm in length and 5.9 cm in width. All donor sites were closed primarily, and all PPFs survived completely. Complications occurred in three cases, including two cases of distal partial necrosis of the LTMF and one wound dehiscence at the LTMF donor site. The distal necroses were managed with debridement followed by secondary local flap reconstruction, whereas the wound dehiscence healed after conservative treatment. In the literature review, 43 studies comprising 547 cases were identified. Three reconstructive categories were established: Type 1 (locoregional flap), Type 2 (distant pedicled flap), and Type 3 (free flap) donor-site closures. Primary closure was achieved in 97.1% of patients, with an overall complication rate of 15.4%. Commonly adopted donor-site closure techniques for harvesting large flaps from different anatomical regions were summarized, providing a comprehensive overview of region-specific reconstructive strategies and their clinical outcomes.
Conclusions The PPF provides a safe and effective option for achieving primary closure of large LTMF donor sites. Using one flap to reconstruct the donor site of another large flap represents a reliable and versatile approach that facilitates primary closure while minimizing donor-site morbidity and adhering to the “like-with-like reconstruction” principle.
| [1] |
Baek SM, Biller HF, Krespi YP, et al. . The lower trapezius island myocutaneous flap. Ann Plast Surg., 1980, 5: 108-114
|
| [2] |
Haas F, Weiglein A, Schwarzl F, et al. . The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconstr Surg., 2004, 113: 1580-1590
|
| [3] |
Raguse JD, Czabanka M, Voss JO, et al. . The lower trapezius island myocutaneous flap in tunnelled technique to cover complicated tissue defects located between the craniocervical and cervicothoracic junction following spinal surgery. J Craniomaxillofac Surg., 2016, 44: 969-972
|
| [4] |
Ou KL, Dai YH, Wang HJ, et al. . The lower trapezius musculocutaneous flap for head and neck reconstruction: two decades of clinical experience. Ann Plast Surg., 2013, 71(Suppl 1): S48-54
|
| [5] |
Xie T, Liu Y, Han T, et al. . Flap design and preliminary clinical experience of the lower trapezius musculocu-taneous flap carrying a portion of the latissimus dorsi muscle. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi (Chinese)., 2021, 35(3): 349-355
|
| [6] |
Ratner D. Skin grafting. Semin Cutan Med Surg., 2003, 22: 295-305
|
| [7] |
Marble K, Fudem G. First web space release with the dorsal hand rotation flap: closing the donor site. Ann Plast Surg., 1995, 35: 83-85
|
| [8] |
Potet P, De Bonnecaze G, Chabrillac E, et al. . Closure of radial forearm free flap donor site: A comparative study between keystone flap and skin graft. Head Neck., 2020, 42: 217-223
|
| [9] |
Lane JC, Swan MC, Cassell OC. Closure of the radial forearm donor site using a local hatchet flap: analysis of 45 consecutive cases. Ann Plast Surg., 2013, 70: 308-312
|
| [10] |
Elliot D, Bardsley AF, Batchelor AG, et al. . Direct closure of the radial forearm flap donor defect. Br J Plast Surg., 1988, 41: 358-360
|
| [11] |
Yamamoto T, Daniel BW, Kageyama T, et al. . Expanding indication of free hypothenar flap transfer: Sequential pedicled ulnar palm flap transfer to a relatively large hypothenar flap donor site. J Plast Reconstr Aesthet Surg., 2022, 75: 332-339
|
| [12] |
Franchi A, Fritsche E, Scaglioni MF. Sequential propeller flaps in the treatment of post-traumatic soft tissue defects of the lower limb - a case series. Injury., 2020, 51: 2922-2929
|
| [13] |
Onuma H, Fuse Y, Karakawa R, et al. . The pedicled anterolateral thigh flap for donor site closure after a large superficial circumflex iliac artery perforator flap harvest. Plast Reconstr Surg Glob Open., 2023, 11 e5115
|
| [14] |
Chi Z, Lin D, Chen Y, et al. . Routine closure of the donor site with a second dorsal metacarpal artery flap to avoid the use of a skin graft after harvest of a first dorsal metacarpal artery flap. J Plast Reconstr Aesthet Surg., 2018, 71: 870-875
|
| [15] |
Tong D, Liu Y, Wu LW, et al. . Free groin flap for aesthetic and functional donor-site closure of the anterolateral thigh flap. J Plast Reconstr Aesthet Surg., 2016, 69: 1116-1120
|
| [16] |
St-Laurent JY, Lanzetta M. Resurfacing of the donor defect after wrap-around toe transfer with a free lateral forearm flap. J Hand Surg Am., 1997, 22: 913-917
|
| [17] |
Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg., 2006, 56: 540-542
|
| [18] |
Pignatti M, Ogawa R, Hallock GG, et al. . The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg., 2011, 127: 716-722
|
| [19] |
Liu Y, Zang M, Song B, et al. . The “buddy flap” concept of soft-tissue-defect reconstruction. J Plast Reconstr Aesthet Surg., 2011, 64: 1475-1482
|
| [20] |
Han T, Khavanin N, Zang M, et al. . Utilizing perforator propeller flaps for donor site closure: harvesting large workhorse flaps without lingering concerns. J Reconstr Microsurg., 2025, 41: 709-718
|
| [21] |
Wang M, Zang M, Zhu S, et al. . Lower trapezius myocutaneous propeller flap based on dorsal scapular artery. Ann Plast Surg., 2022, 89: 502-509
|
| [22] |
Gohil D, Mandlik D, Mistry YA, et al. . A technique for primary closure of the free radial artery forearm flap donor site-Early results. J Head Neck Physicians Surg., 2022, 10: 75-79
|
| [23] |
Galazka A, Stawarz K, Bienkowska-Pluta K, et al. . Optimizing wound healing in radial forearm donor sites: a comparative study of ulnar-basedflap and split-thickness skin grafting. Biomedicines., 2025, 13(5): 1131
|
| [24] |
Marchesi A, Gatto A, Cavalli EM, et al. . Free-style propeller ulnar artery perforator flaps for radial forearm flap donor site repair. Microsurgery., 2024, 44 e31074
|
| [25] |
Visconti G, Salgarello M. Anteromedial thigh perforator-assisted closure of the anterolateral thigh free flap donor site. J Plast Reconstr Aesthet Surg., 2013, 66: e189-192
|
| [26] |
Pagliara D, Mangialardi ML, Vitagliano S, et al. . Improving outcomes in anterolateral thigh flap donor-site reconstruction using propeller flaps: a retrospective comparative study with skin grafting. J Reconstr Microsurg., 2021, 37: 436-444
|
| [27] |
Iida T, Yoshimatsu H, Koshima I. Reconstruction of anterolateral thigh defects using perforator-based propeller flaps. Ann Plast Surg., 2017, 79: 385-389
|
| [28] |
Hudson CS, Huang AT. Perforator-based propeller flaps for reconstruction of massive anterolateral thigh donor site wounds. Head Neck., 2020, 42: E49-e52
|
| [29] |
Zhao Y, Qiao Q, Liu Z, et al. . Alternative method to improve the repair of the donor site of the anterolateral thigh flap. Ann Plast Surg., 2002, 49: 593-598
|
| [30] |
Kumbla PA, Thorburn AQ, Makwana S, et al. . Use of the keystone perforator flap closure for the anterolateral thigh free flap donor site. Craniomaxillofacial Trauma Reconstr., 2021, 14(1): 47-52
|
| [31] |
Turin SY, Spitz JA, Alexander K, et al. . Decreasing ALT donor site morbidity with the keystone flap. Microsurgery., 2018, 38: 621-626
|
| [32] |
Scaglioni MF, Barth AA, Chen YC. Perforator flap based on the third perforator of the profunda femoris artery (PFA)-assisted closure of the free vertical posteromedial thigh (vPMT) flap donor site. Microsurgery., 2018, 38: 758-762
|
| [33] |
Chi Z, Chen Y, Chu T, et al. . Distally based sural neuro-fasciocutaneous perforator flap for foot and ankle reconstruction: Surgical modifications for flap pedicle and donor site closure without skin graft. J Plast Reconstr Aesthet Surg., 2018, 71: 224-231
|
| [34] |
Morgan PF, Hornig JD, Momin SR, et al. . Perforator-based propeller flap for fibula free flap donor site repair: A novel surgical technique. Laryngoscope., 2020, 130: 1233-1235
|
| [35] |
Sharma M, Balasubramanian D, Thankappan K, et al. . Propeller flaps in the closure of free fibula flap donor site skin defects. Annals of Plastic Surgery., 2013, 71: 76-79
|
| [36] |
Kaleem A, Patel N, Schubert E, et al. . Use of soleus musculocutaneous perforator-based propeller flap for lower extremity wound coverage after osteocutaneous fibula free flap harvest. Microsurgery., 2021, 41: 233-239
|
| [37] |
Lee ZH, Ha AY, Shuck JW, et al. . Closure of the osteocutaneous fibula flap donor site with a tonearm (propeller) flap: Anatomic considerations and surgical indications. J Plast Reconstr Aesthet Surg., 2025, 100: 240-247
|
| [38] |
Scaglioni MF, Franchi A, Fritsche E. Propeller flap donor site closure by means of another propeller flap: A case report and literature review. Microsurgery., 2020, 40: 252-257
|
| [39] |
Franchi A, Fritsche E, Scaglioni MF. Sequential propeller flaps in the treatment of post-traumatic soft tissue defects of the lower limb – a case series. Injury., 2020, 51: 2922-2929
|
| [40] |
Wang C, Yang W, Zhang F, et al. . Superficial peroneal neurocutaneous flap for coverage of donor site defect after the combined transfer of toe and dorsal foot flap. Ann Plast Surg., 2021, 86: 440-443
|
| [41] |
Dong JS, Peng YP, Zhang YX, et al. . Reverse anterior tibial artery flap for reconstruction of foot donor site - Utilizing the same vessel system. Plast Reconstr Surg., 2003, 112(6): 1604-1612
|
| [42] |
Wang Y, Yuan C, Gu J, et al. . Coverage of big toe defects after wraparound flap transfer with a second-toe medial-side adjacent toe flap. Ann Plast Surg., 2022, 89: 191-195
|
| [43] |
Hattori Y, Tamemoto T, Niu A. Partial second toe pulp flap transfer for the coverage of great toe hemipulp flap donor site. Plast Reconstr Surg Glob Open., 2022, 10 e4152
|
| [44] |
Montgomery J, Mace AT, Cotter C, et al. . Frontalis muscle flap: a novel method for donor site closure of an interpolated paramedian forehead flap. J Laryngol Otol., 2010, 124: 453-455
|
| [45] |
Liu Y, Zang M, Wu L, et al. . Improving the versatility of the latissimus dorsi myocutaneous flap using the perforator propeller flap concept. Ann Plast Surg., 2020, 84: 689-696
|
| [46] |
Park SY, Lee KT. Usefulness of dorsal scapular artery perforator flap for donor site closure after harvesting latissimus dorsi flap/thoracodorsal artery perforator flap: A report of three cases. Microsurgery., 2025, 45 e70033
|
| [47] |
Wu L, Tong D, Zhu S, et al. . Consecutive flap transfer for repairing massive soft tissue defects in the opisthenar with improved donor site closure. Chin J Traumatol., 2014, 17: 256-260
|
| [48] |
Azizeddin A, Choong PFM, Grinsell D. Reconstructive options for large back free flap donor sites. ANZ J Surg., 2018, 88: 1066-1070
|
| [49] |
Liu Y, Song B, Jin J, et al. . A freestyle pedicled thoracodorsal artery perforator flap aiding the donor-site closure of a parascapular flap. J Plast Reconstr Aesthet Surg., 2010, 63: e280-282
|
| [50] |
Chan YW, Ng RW, Yuen AP. Lateral thoracic flap for donor site repair of pectoralis major myocutaneous flap. J Plast Reconstr Aesthet Surg., 2009, 62: 1004-1007
|
| [51] |
Chaturvedi G, Kushwaha AK, Jha R, et al. . Evaluating pedicled pectoralis major myocutaneous flap reconstructions for oral malignancy and the influence of laterally based rotational advancement flap on donor site integrity and nipple position in male patients. Cureus., 2024, 16e58022
|
| [52] |
Kaul P, Tiwari AR, Kumar R, et al. . Thoracoabdominal flap closure for large post pectoralis major myocutaneous flap donor site in advanced oral cancer: An innovative approach in resource constraint setting. Indian J Otolaryngol Head Neck Surg., 2024, 76: 5682-5686
|
| [53] |
Zang MQ, Zhu S, Chen B, et al. . Use of serial flap transfer technique in en bloc reconstruction of extensive soft tissue defects in the head and neck. Journal of Craniofacial Surgery., 2022, 33: 809-813
|
| [54] |
Liu Y, Song B, Zhu S, et al. . Reconstruction of the burned hand using a super-thin abdominal flap, with donor-site closure by an island deep inferior epigastric perforator flap. J Plast Reconstr Aesthet Surg., 2010, 63: e265-268
|
| [55] |
Zhang YX, Hallock GG, Song D, et al. . Synchronous closure of a large medial perforator-based superficial circumflex iliac artery perforator free flap donor site using an ipsilateral lateral perforator-based superficial circumflex iliac artery perforator propeller flap. Ann Plast Surg., 2020, 85: 146-148
|
| [56] |
Hsieh CH, Kuo YR, Yao SF, et al. . Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plast Reconstr Surg., 2004, 113: 1355-1360
|
| [57] |
Zhang YX, Hayakawa TJ, Levin LS, et al. . The economy in autologous tissue transfer: Part 1. The kiss flap technique. Plast Reconstr Surg., 2016, 137: 1018-1030
|
| [58] |
Chang NJ, Waughlock N, Kao D, et al. . Efficient design of split anterolateral thigh flap in extremity reconstruction. Plast Reconstr Surg., 2011, 128: 1242-1249
|
| [59] |
Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg., 2004, 114: 910-916
|
| [60] |
Kedar DJ, Pak CJ, Suh HP, et al. . Propeller flaps in the posterior trunk. Semin Plast Surg., 2020, 34: 176-183
|
| [61] |
Khan UD, Miller JG. Reliability of handheld Doppler in planning local perforator-based flaps for extremities. Aesthetic Plast Surg., 2007, 31: 521-525
|
| [62] |
Bristol DG. The effect of tension on perfusion of axial and random pattern flaps in foals. Vet Surg., 1992, 21: 223-227
|
| [63] |
Chao AH, Yu P, Skoracki RJ, et al. . Microsurgical reconstruction of composite scalp and calvarial defects in patients with cancer: a 10-year experience. Head Neck., 2012, 34: 1759-1764
|
| [64] |
Innocenti A, Menichini G, Innocenti M. Six-years experience in major scalp defect reconstruction with free flap: analysis of the results. Acta Biomed., 2022, 92e2021301
|
Funding
the Capital’s Funds for Health Improvement and Research (CFH)(2022-1-4041)
RIGHTS & PERMISSIONS
The Author(s), under exclusive licence to the Huazhong University of Science and Technology
PDF
