Subfascial-cutaneous propeller flap for reconstruction of chronic distal lower-limb wounds with exposed bone: two-case reports

Introduction and importance: Propeller perforator flaps provide a reliable reconstructive option for distal lower-limb soft-tissue defects, particularly in resource-limited settings where microsurgical free-flap reconstruction may not be readily available. These cases highlight the practical application of propeller perforator flaps in a low-resource setting, demonstrate key surgical decision-making processes, illustrate the management of flap-related complications, and report favorable functional outcomes following reconstruction of complex distal lower-limb wounds. Case presentation: We present two patients with distal lower-limb wounds and exposed bone: a 33-year-old man with a post-traumatic medial malleolar defect reconstructed using a posterior tibial artery perforator propeller flap, and a 13-year-old boy with a chronic distal anterior leg wound secondary to osteomyelitis reconstructed using a superficial peroneal artery perforator propeller flap. Both patients had no significant comorbidities. Minor complications, including partial flap necrosis and venous congestion, were successfully managed conservatively. At the 2-month follow-up, both patients achieved satisfactory wound coverage, preservation of limb function, and acceptable cosmetic outcomes. Clinical discussion: Propeller perforator flaps provide effective reconstruction for complex distal lower-limb defects. Compared with free flaps, they offer a reliable, low-morbidity reconstructive option, particularly in resource-limited settings. Complications such as venous congestion and partial flap necrosis may occur but can often be successfully managed with conservative measures. Conclusion: Propeller perforator flaps are a reliable and effective option for reconstruction of distal lower-extremity soft-tissue defects, providing durable coverage while preserving major vascular structures and minimizing donor-site morbidity. These flaps represent a valuable alternative to local rotational and microsurgical free flaps, particularly in resource-limited settings.