Objective <p>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.</p> Methods <p>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.</p> Results <p>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.</p> Conclusions <p>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.</p>