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

PPF show a low total flap necrosis rate (2%), with most partial losses closed by skin grafting. Keeping flap dimension within 40-80 cm², width > 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.