Re-Vision of Geometric Flap Design in Lower Limb Reconstruction: A Comparative Analysis on Perforator Enhancement

<b>Background:</b> Perforator flaps improved the reconstruction paradigm in the lower extremity, increasing coverage possibilities. This study aims to quantify how added perforators could enhance standard geometrical patterns (compared to random flaps). <b>Methods:</b> A total of 29 cases of lower limb soft tissue reconstruction (STR)-52% trauma, 21% osteomyelitis with skin fistulas, 21% healing disorders with unstable scarring and 6% cancer-related surgery-were performed in our institution between 2012 to 2023 with geometric random (GR) local flaps (34%), geometric perforator-enhanced (GP) flaps (32%) or pure propeller perforator (PP) flaps (34%), were retrospectively analysed. Patients with proximal thigh defects, a follow up of less than 3 months and those who received an axial, muscle or free flap were excluded. Geometric patterns (as length:width ratio (L:W)) were compared among groups, analysing healing outcomes and complications. <b>Results:</b> Leg defects were categorized into 62% distal, 14% middle, 14% proximal third and 10% distal thigh. No significant difference in defect size was detected among groups. Mean flap size was significantly larger for GP (70.5 cm², (<i>p</i> < 0.05)) and PP (74.4 cm², (<i>p</i> < 0.01)) than GR (53.7 cm²). The L:W ratio was significantly higher in GP (L:W 2.2:1, (<i>p</i> < 0.05)) and PP (L:W 2.8:1, (<i>p</i> < 0.01)) than in GR (1.5:1), but no significant difference was found between GP and PP. A reduced complications rate (partial flap loss, infection, healing, revision surgery, etc.) was observed in the GP group, when compared to GR. <b>Conclusions:</b> Flap geometric design can be significantly improved by the inclusion of perforators, maintaining spatial advantages with larger ductility and improved vascular solidity.