title: Freestyle multiple propeller flap reconstruction (jigsaw puzzle approach) for complicated back defects.
abstract: BACKGROUND
  The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk.
  
  
  METHODS
  From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance.
  
  
  RESULTS
  The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery.
  
  
  CONCLUSIONS
  Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the tension to multiple flaps, supplying sufficient volume to obliterate dead space, and have reliable vascularity as the flaps do not need to be oversized. This can be a viable approach to reconstruct extensive defects on the posterior trunk.
authors.affiliation: Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Sung Woo
authors.initials: SW
authors.lastname: Park
authors.affiliation: Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Tae Suk
authors.initials: TS
authors.lastname: Oh
authors.affiliation: Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Jin Sup
authors.initials: JS
authors.lastname: Eom
authors.affiliation: Department of Plastic Surgery, Ulsan University Hospital, University of Ulsan, Seoul, Korea.
authors.forename: Yoon Chi
authors.initials: YC
authors.lastname: Sun
authors.affiliation: Department of Plastic Surgery, Ewha Womans University Hospital, Seoul, Korea.
authors.forename: Hyun Suk
authors.initials: HS
authors.lastname: Suh
authors.affiliation: Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors.forename: Joon Pio
authors.initials: JP
authors.lastname: Hong
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001415:Back / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply*; D011183:Postoperative Complications; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome