|Year : 2020 | Volume
| Issue : 3 | Page : 166-170
Use of propeller flaps for reconstruction of extensor side elbow defects
Daghan Dagdelen1, Alper Aksoy2
1 Department of Plastic, Reconstructive and Aesthetic Surgery, Trakya University School of Medicine, Edirne, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Konur Hospital, Bursa, Turkey
|Date of Submission||08-Jul-2019|
|Date of Acceptance||11-Sep-2019|
|Date of Web Publication||26-May-2020|
Dr. Daghan Dagdelen
Department of Plastic, Reconstructive and Aesthetic Surgery, Trakya University School of Medicine, General Hospital Block, 8th Floor, Balkan Campus, Edirne 22030
Source of Support: None, Conflict of Interest: None
Introduction: Extensor side elbow defects are difficult to repair among upper extremity injuries. The bulk of surrounding soft tissue is limited and often affected by the trauma, although seems to be ideal, propeller flaps are not being widely adopted for upper extremity soft-tissue reconstructions. In the present study, we set out to share the results of the perforator propeller flaps that are based on either the arm or the forearm, which we thought the perforator vessel anatomy is relatively constant. Patients and Methods: All patients who underwent elbow defect repair between June 2016 and June 2018 were evaluated retrospectively. Patients were evaluated in terms of the etiology and demographic parameters. Flaps were assessed by the artery system, on which they were based on the dimensions of skin island, the rotation angle of the skin paddle, and closure method of the donor site. Outcomes were noted during bimonthly follow-up visits. Results: In 11 patients, the dominant etiology was chronic bursitis. The mean flap skin paddle size was 48.8 ± 16.9 cm2. For defect repair, radial collateral artery (RCA) perforator flaps were used in six patients. Posterior interosseous artery (PIA) perforator flaps were used in remaining five patients. All the flaps were based on a single perforator artery. The mean rotation degree was measured as 165° ±11.6°. In nine cases, the flap donor site was closed primarily, whereas split-thickness skin grafts were used in two cases. The average follow-up period was 13 ± 5 months. No limitation in the range of motion of the elbow joint was noted. Distal marginal necrosis was observed in two flaps. Conclusion: We advocate that both PIA and RCA perforator flaps are very useful options for soft-tissue reconstruction of extensor side elbow defects.
Keywords: Elbow joint, perforator flap, surgical flaps
|How to cite this article:|
Dagdelen D, Aksoy A. Use of propeller flaps for reconstruction of extensor side elbow defects. Turk J Plast Surg 2020;28:166-70
| Introduction|| |
Extensor side elbow defects are difficult to repair among upper extremity injuries. Being at a very mobile zone and having thinner subcutaneous adipose tissue are the main causes that bring about difficulties to repair these defects. The bulk of surrounding soft tissue is limited and often affected by the same factors that cause defects (e.g., trauma, infection, and radiation).
The soft tissue used for the reconstruction of the mobile area defects should be compatible with the joint movement. Local flaps are not a durable option for the repair of elbow defects, because the surrounding tissues are also generally traumatized. Thus, regional and free flaps are more proper methods for the reconstruction of elbow defects.
However, propeller flaps are not being widely adopted for upper extremity soft-tissue reconstructions. One of the prominent reasons for this hesitation is the variations in the anatomy of perforator vessels.
In the present study, we set out to share the results of the perforator propeller flaps that are based from either the radial collateral or the posterior interosseous artery (PIA) systems, which we thought that the perforator vessel anatomy is relatively constant. We raised 11 flaps based on perforators from either of the arterial systems and used them for the reconstruction of extensor side elbow defects. We sought to share the results of two perforator propeller flaps that can be used for the elbow soft-tissue reconstruction.
| Patients and Methods|| |
The method of this retrospective study was approved by the local ethics review board. Informed consent for the surgery was obtained from all patients who underwent elbow defect repair between June 2016 and June 2018. The flaps used for elbow reconstruction were based on perforators using either radial collateral artery (RCA) system in the arm or PIA system in the forearm.
Selection of the flaps was based on the location of the defects using the elbow joint axis as a reference point. If the defect was located only distal to the elbow joint, while the elbow was held in 90 degrees of flexion, a PIA perforator flap was elevated. If the defect consists of a part that gets proximally beyond the joint axis, then RCA perforator (RCAP) flap was preferred.
Patients were evaluated in terms of the etiology and demographic parameters. Flaps were assessed by the artery system, on which they were based on the dimensions of skin island, the rotation angle of the skin paddle, and closure method of the donor site. Outcomes were noted during bimonthly follow-up visits.
Extensor side elbow soft tissue defects that could not be covered primarily, that are containing exposed vital structures (such as the tendon, bone, and joint) and exposed instrumentation formed the inclusion criteria. We excluded patients having a history of operation in the planned flap donor area or having a traumatic scar in the flap donor area.
Following the extensive debridement of the defect, the template of the defect was taken. Then, the planning of the flap was started.
Radial collateral artery perforator flap
After the arm was placed on the patient's chest, the humeral lateral epicondyle and the deltoid insertion were marked. A straight line interconnecting these two points was drawn on the arm. This line corresponds to the lateral intermuscular septum. Skin perforators were marked with a handheld Doppler device along the line. Elevation of the flap was initiated with a lateral incision, and the dissection was performed in a plane above the deep fascia, heading medially. Previously marked perforator arteries were sought. After the presence of the perforators was confirmed, the skin island was designed, based on the eligible perforator vessel. Afterward, the media incision was performed and the incision of skin island was completed. The flap was freed from the deep fascia and was rotated clockwise/counterclockwise and adapted to the defect.
Posterior interosseous artery perforator flap
The lateral epicondyle of the humerus and the ulnar head was marked, as the forearm was held in supination. The line drawn between two points marks the trajectory of the PIA. Within the proximal one-third of the forearm, the perforators were marked with aid of a handheld Doppler. The skin island was formed according to the defect, and a dissection through the lateral incision was commenced. A meticulous dissection was performed above the deep fascia of extensor compartment to locate the marked perforators. Afterward, the flap was designed based on the appropriate perforators, and the incision of the skin island was finalized. Flap elevation and adaptation to the defect were performed similar to RCAP flap.
Intravenous low-molecular-weight dextran with a dose of 30 cc/h (maximum 300 cc) was administered to the patients for the first 3 days following the surgery. During the hospitalization period, the patients were also treated with enoxaparin sodium with a dose of 60 mg/day, and 100 mg acetylsalicylic acid was administered orally for 14 days following discharge. The operated upper extremity was immobilized with a cast-splint for 2 weeks.
| Results|| |
In 11 patients, the dominant etiology was chronic bursitis. The mean flap skin paddle size was 48.8 ± 16.9 cm2. For defect repair, RCAP flaps were used in six patients. All the flaps were based on a single perforator artery. The mean rotation degree was measured as 165° ±11.6°. In nine cases, the flap donor site was closed primarily, while split-thickness skin grafts (STSG) were used in two cases. The average follow-up period was 13 ± 5 months. No limitation in the range of motion of the elbow joint was noted. Distal marginal necrosis was observed in two flaps, and they were followed with local wound care. The data are presented in detail in [Table 1].
After encountering marginal necrosis in two cases, operation technique was revised to include a superficial venous anastomosis performed on the distal end to prophylactically augment venous drainage.
A 48-year-old male patient with an elbow defect secondary to chronic bursitis was consulted. The patient had a history of debridement to olecranon bursa and an attempt of secondary saturation. He had an anamnesis of 48 pack/year cigarette consumption. He did not have any comorbid diseases. After debridement, the right elbow defect was measured as 4 cm × 5.5 cm. The major part of the defect was located proximal to the elbow joint axis, thus an RCAP flap was planned. Two perforators were marked with the Doppler along the lateral intermuscular septum, and elevation of the flap was initiated through the lateral incision. It was decided to elevate the flap based on proximal perforator after seeing the distal perforator to be of inadequate caliber. The flap was redesigned according to the new pivot point. The flap size was measured as 11.5 cm × 6 cm and was adapted to defect by turning 170° clockwise. The flap donor site was closed primarily. A 1 cm × 0.7 cm marginal necrosis distal to the flap was observed after discharge from the hospital. A complete wound healing was achieved with local wound care. There was no limitation in the elbow movements of the patient. A satisfying outcome was achieved [Figure 1].
|Figure 1: Reconstruction with radial collateral artery perforator flap. (a) Defect and outlines of the planned flap and marking of perforators. (b) Elevation of the flap and visualization of perforators. (c) Defect closure. (d) Early marginal necrosis. (e) Postoperative 6th-month view, elbow in full extension|
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A 37-year-old male patient was referred for an elbow defect. He had undergone a previous surgery of debridement of the posterior elbow bursa followed by reconstruction with a random local flap for closure which failed, eventually. Defect was measured as 4 cm × 5 cm and was limited distal to the elbow joint axis. For closure, a PIA perforator propeller flap was drawn. The perforators, which were located on the line drawn from the lateral epicondyle over the ulnar styloid, were marked with a handheld Doppler. It was decided to raise the flap based on the perforator closest to the defect. The elevated flap size was measured as 7 cm × 6 cm and adapted to the defect by turning 160° clockwise. The flap donor site was closed with an STSG. The follow-up visits of the patient were uneventful. There were no limitations in the patient's elbow movements [Figure 2].
|Figure 2: Reconstruction with posterior interosseous artery perforator flap. (a) Defect after debridement. (b) Elevation of the flap and the perforator. (c) Early postoperative view, elbow in full extension. (d) Postoperative 12th month|
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| Discussion|| |
Elbow defects are problematic to reconstruct owing to the joint mobility and to the paucity of the neighboring soft tissue. Successful examples of reconstruction with axial fasciocutaneous flaps, such as the radial forearm and reverse lateral arm flap, abdominal interpolation flaps, pedicled latissimus dorsi musculocutaneous flap, and various free flaps, were reported in the literature.,,,
Perforator flaps are frequently utilized in lower extremity soft-tissue reconstruction. However, there is a reluctance for using them in the upper limb. Variations in the anatomical localization of perforators are presumably the main reason that limits the widespread use of such flaps. In their study, Hwang et al. showed that anatomic variations are rare in the lateral side perforators, especially in the arm region. A posterior branch of RCA, which is the vessel feeding the classical lateral arm flap, sends perforators on which the RCAP flap is based on. Three distinct studies have further revealed that posterior radial collateral artery has three skin perforators.,, Although the reference points were given diversely in each study, to be practical, locations of the perforators can be defined along the projection of the lateral intermuscular septum, at 5th, 8th, and 11th cm proximal to the lateral epicondyle. In the first case, we shared the flap based on the second perforator artery.
The PIA flap is commonly used as a reverse-flow pedicled flap for closure of the finger and dorsal side of the hand defects as a reverse-flow pedicled flap. After its division from the common interosseous artery, PIA enters the deep extensor muscle compartment at the inferior border of the supinator muscle. From this point, it gives many septocutaneous perforators along its trace up to the anastomosis with the anterior interosseous artery at the proximal wrist.
These skin perforators of the PIA are branched in three different patterns. In the first pattern, the perforators are scattered mostly at the proximal and the distal ends of the PIA. In the second pattern, the perforators are branched along the arterial trace at 1–2 cm intervals; whereas in the third pattern, many small perforators are arborized from a single branch at the proximal end of the PIA. The constant location of the proximal perforators is common in all three patterns.
Along its course to the distal forearm, variations such as a decrease of the arterial diameter in the middle one-third segment or abrupt ending of the PIA are not uncommon. Therefore, the recommended method for the elevation of the traditional reverse-flow flap is that the dissection is performed from distal to proximal. This approach may warrant a change in the operation plan if such an anomaly is encountered. However, elevation of a propeller or free flap from the proximal segment of PIA is safe and less inconvenient as opposed to reverse-flow flap, owing to the rather constant and superficial location of the perforator arteries.
In this study, of all the flaps, elevated from either of the arterial systems, were based on a single perforator artery. We could not find anyin vivo study measuring the exact size of the skin island supplied by a single perforator from either of the arterial systems. However, Ayestaray et al. reported that they elevated a 15 cm × 6 cm skin island on a single perforator of RCA in a patient with ulnar defect. It is possible to include more than one perforator artery in flaps, but in such case, the rotation arcs will be restricted. In our series, the average arc of rotation was 165° for RCAP flaps and 160° for PIA perforator-based flaps, which we wound adequate for a defect closure.
The donor site could be closed primarily in widths of up to 7.5 cm for the lateral arm flap. For RCAP flaps, the flap width was 6 cm on average. The donor site was sutured primarily without the requirement of graft in all the flaps elevated from this system. STSGs were applied for the donor site closure in two of the five PIA perforator flaps. In a large series of 102 cases, in which solely reverse pedicled PIA flaps were used; Costa et al. reported that the donor site could be sutured primarily in all cases where the flap size was <7 cm. However, in our series, STSG was used to close the donor sites with widths exceeding 5 cm. We argue that primary closure of a 7 cm width defect in forearm may hinder the local skin perfusion and may increase the compartment pressures.
Postoperative period was uneventful with the initial flaps based on either of the arterial systems; however, after experiencing a distal necrosis in two flaps (based on both arterial systems), we modified the technique to have an additional venous anastomosis, to enhance the flap viability. For the five consequent perforator flaps (two RCA flaps and three PIA flaps), we performed a superficial vein anastomosis located distal from the perforating artery. The follow-up period for the latter flaps was uneventful. Chen et al. recommended addition of a similar venous anastomosis for pedicled PIA flaps. However, the anastomosis performed in this study was different considering to the flow patterns of pedicled reverse flow flaps. We can agree that addition of a prophylactic distal venous anastomosis may be a safeguard for distal necrosis.
For closure of the extensor side elbow defects, we selected the flap type by the orientation of the defect relative to the joint axis. If the defect was limited to the distal of the joint axis when the elbow was held in 90 degrees of flexion, a PIA perforator flap was used. However, if the defect passes beyond the axis proximally by any means, then the RCAP flap was preferred. This simple algorithm was based on the observations that, the perforators of the PIA system are located more distally to the elbow joint axis, compared with the RCA system. Furthermore, the aforementioned middle segment anatomic variations of the PIA may render distally based PIA perforators treacherous.
| Conclusion|| |
We advocate that both PIA and RCAP flaps are very useful options for soft-tissue reconstruction of extensor side elbow defects. The locations of the defect with its relevance to elbow joint axis and the choice of perforators are factors that must be considered if these flaps are to be used. We suggest that both flaps should be included among regional alternatives for soft-tissue reconstruction of the elbow defects.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872-7.
Pederson W. Nonmicrosurgical coverage of the upper extremity. In: Wolfe S, Pederson W, Hotchkiss R, Kozin S, editors. Green's Operative Hand Surgery. Vol. 2. 6th
ed. London: Churchill Livingstone; 2010. p. 1645-720.
Lazarou SA, Kaplan IB. The lateral arm flap for elbow coverage. Plast Reconstr Surg 1993;91:1349-54.
Lewis VL Jr., Cook JQ. The nondelayed thoracoepigastric flap: Coverage of an extensive electric burn defect of the upper extremity. Plast Reconstr Surg 1980;65:492-3.
Mordick TG 2nd
, Britton EN, Brantigan C. Pedicled latissimus dorsi transfer for immediate soft-tissue coverage and elbow flexion. Plast Reconstr Surg 1997;99:1742-4.
Ono S, Sebastin SJ, Yazaki N, Hyakusoku H, Chung KC. Clinical applications of perforator-based propeller flaps in upper limb soft tissue reconstruction. J Hand Surg Am 2011;36:853-63.
Hwang K, Lee WJ, Jung CY, Chung IH. Cutaneous perforators of the upper arm and clinical applications. J Reconstr Microsurg 2005;21:463-9.
Hennerbichler A, Etzer C, Gruber S, Brenner E, Papp C, Gaber O. Lateral arm flap: Analysis of its anatomy and modification using a vascularized fragment of the distal humerus. Clin Anat 2003;16:204-14.
Chang EI, Ibrahim A, Papazian N, Jurgus A, Nguyen AT, Suami H, et al.
Perforator mapping and optimizing design of the lateral arm flap: Anatomy revisited and clinical experience. Plast Reconstr Surg 2016;138:300e-6e.
Ayestaray B, Ogawa R, Ono S, Hyakusoku H. Propeller flaps: Classification and clinical applications. Ann Chir Plast Esthet 2011;56:90-8.
Murakami M, Ono S, Ishii N, Hyakusoku H. Reconstruction of elbow region defects using radial collateral artery perforator (RCAP)-based propeller flaps. J Plast Reconstr Aesthet Surg 2012;65:1418-21.
Morrison CS, Sullivan SR, Bhatt RA, Chang JT, Taylor HO. The pedicled reverse-flow lateral arm flap for coverage of complex traumatic elbow injuries. Ann Plast Surg 2013;71:37-9.
Costa H, Pinto A, Zenha H. The posterior interosseous flap – A prime technique in hand reconstruction. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstr Aesthet Surg 2007;60:740-7.
Chen HC, Cheng MH, Schneeberger AG, Cheng TJ, Wei FC, Tang YB. Posterior interosseous flap and its variations for coverage of hand wounds. J Trauma 1998;45:570-4.
Tung TC, Wang KC, Fang CM, Lee CM. Reverse pedicled lateral arm flap for reconstruction of posterior soft-tissue defects of the elbow. Ann Plast Surg 1997;38:635-41.
[Figure 1], [Figure 2]