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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 39-42

Reconstruction of hand and wrist soft-tissue defects using radial artery perforator flap


Department of Plastic, Reconstructive and Aesthetic Surgery, Kahramanmaraş Sütçü Aİmam University, Kahramanmaraş, Turkey

Date of Submission15-Mar-2020
Date of Acceptance19-Apr-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Alper Urals FEBOPRAS
Avşar Mah, Batı Çevreyolu Blv. No: 251/A 46040, Onikişubat, Kahramanmaraş
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_23_20

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  Abstract 


Aim: Soft-tissue defects in the hand and wrist are frequently encountered injuries that may occur due to trauma, burns, or other causes. We aimed to report our experiences in reconstruction of these defects using a radial artery perforator flap (RAPF). Materials and Methods: Eight patients who underwent surgery for reconstruction of the hand and wrist soft-tissue defects at our institution between December 2017 and December 2019 were included in the study. The patients were evaluated in terms of age, sex, etiology, flap size, defect region, and postoperative complications. Results: All defects were reconstructed by utilizing RAPF. The most common etiology of the defects was work-related accidents. The mean age of the patients was 40.4 (10–69) years. The mean flap size was 63.5 ± 14.76 cm2. Six patients healed uneventfully, while we observed partial necrosis of the RAPF flap in one of the cases and a marginal epidermolysis in another. The donor sites were skin grafted in each patient. The patient where partial necrosis observed was re-operated for debridement and skin grafting subsequentially. The duration of follow-up of the patients was 6 months. Conclusions: Radial forearm perforator flap is a reliable and effective reconstructive option to reconstruct small to moderately sized defects of the hand and wrist.

Keywords: Hand defects, perforator flap, upper extremity


How to cite this article:
FEBOPRAS AU, Bilgen F, Bekerecioğlu M. Reconstruction of hand and wrist soft-tissue defects using radial artery perforator flap. Turk J Plast Surg 2021;29:39-42

How to cite this URL:
FEBOPRAS AU, Bilgen F, Bekerecioğlu M. Reconstruction of hand and wrist soft-tissue defects using radial artery perforator flap. Turk J Plast Surg [serial online] 2021 [cited 2021 Jan 22];29:39-42. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/39/305906




  Introduction Top


Hand and wrist soft-tissue defects are among the most frequently encountered upper extremity defects that occur as a result of trauma, tumor resection, and burns for which there is an ongoing search for the best reconstructive method.[1] The main goal in reconstruction of upper extremity defects is to provide the best structural and functional repair with the minimum morbidity. In injuries or defects that occur by other causes in this region, as structures such as tendon, nerve, bone, and joints are frequently exposed, repair with a flap that has a pliable and reliable tissue is required in reconstruction. While several conventional flaps such as groin flap, abdominal flap, radial forearm flap, and posterior interosseous artery flap are still being commonly used, with the increase in the knowledge on perforasome anatomy and flap physiology, the concept of a perforator flap started a new era and changed the algorithms of soft-tissue reconstruction in extremities by creating a striking effect.[2],[3],[4] Repair of defects in upper extremities with cutaneous or fasciocutaneous perforator flaps has brought about highly significant advantages such as shortened surgery duration, repair with similar tissues (like with like) and in connection to this, a more aesthetical appearance, preservation of major arterial structures, and elimination of the necessity of a second surgery for division of the pedicle as in interpolation flaps.[5] A radial artery perforator flap (RAPF) is a useful flap that has a reliable perforator anatomy, does not cause morbidity in the patient, can be raised easily in a short time, and can be used in reconstruction of small- and medium-sized soft-tissue defects of the hand and wrist.[6] In this study, we aimed to evaluate the utility of radial artery perforator flap in soft-tissue reconstruction of hand and wrist defects.


  Materials and Methods Top


This study was carried out with the approval of the ethics committee (Protocol number: 258) and by obtaining written informed consent from all patients. A retrospective analysis was performed including 8 patients who underwent surgery by utilizing radial forearm perforator flaps in order to reconstruct hand and/or wrist soft-tissue defects between December 2017 and December 2019. Drug use, tobacco use, and other comorbid diseases that could compromise wound healing were investigated. The patients were evaluated in terms of flap size, etiology, sex, age, localization of the defect, and complications. The details are shown in [Table 1].
Table 1: Patient demographics, flap dimensions, and complications

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Vascular anatomy

The radial artery courses between the brachioradialis and flexor carpi radialis muscles and toward the radial styloid, and in this course, it provides approximately 15–25 skin perforators, most of which are clustered in the proximal and distal.[6] Forty-nine percent of all perforators of the radial artery in the forearm emerge out of a 30% distal part of the forearm.[7] Among these perforators, whose calibration is 0.3–0.5 mm in diameter, it is known that about ten are localized in the distal forearm to the 2–4 cm proximal of the radial styloid, while it was shown that, within the 2-cm area to the most distal from the radial styloid boundary to the proximal, there are at least 2 skin perforators, and at least one of these is present as a major perforator at a calibration of >0.5 mm.[6],[8]

Surgical technique

All surgeries were carried out under general anesthesia and with a tourniquet. To make dissection easier, before the surgery, a handheld Doppler device was used to mark the trace of the radial artery and confirm the radial artery flow at the wrist. Allen test was not applied. The radial styloid was marked, and a mark was made with a marking pen at its 2-cm proximal. The flap was designed depending on the dimensions of the defect to be reconstructed. However, designed flap dimensions were at least 1 cm larger than the required dimensions in order to prevent any tension after flap is transposed in propeller fashion. Flap elevation was initiated from proximal to distal. While raising the flap, fascia was included in the flap in 6 of the patients, whereas it was not included in 2 patients. To the 2-cm proximal of the radial styloid, all perforators were either ligated or cauterized with a bipolar cautery. When the marked distal area was reached, dissection was carried on more meticulously. There was always one distal major perforator between the 2-cm proximal of the radial styloid and the marked boundary or 1 cm distal of it [Figure 1]. Following perforator identification, all margins of the flap was completely incised, and the flap was raised. The skin island between the flap pivot point and the defect was incised and a raw surface was created. Thereafter, the flap was transposed to the defect in a propeller fashion over this raw surface to avoid any possible compression. A Penrose drain was placed in each case following flap inset. The flap donor area was closed with a split-thickness skin graft (STSG) in all cases, and the arm was splinted for 1 or 2 weeks.
Figure 1: One major distal perforator of the radial artery is identified and shown with a purple background

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  Results Top


A total of 8 patients (7 males and 1 female) consulted from the department of orthopedics or emergency department who received hand or wrist soft-tissue reconstruction utilizing radial artery forearm perforator flaps were included in this retrospective study. The mean age of the patients was 40.4 (range between 10 and 69 years). The most frequent causes of hand and wrist defects were work-related accidents (n = 4). RAPF was applied to reconstruct defects caused by road traffic accidents in 3 other patients and a defect caused by burn contracture release. RAPF was performed for defects in the wrist (n = 3), hand dorsum (n = 3), hypothenar area (n = 1), and thenar area (n = 1). The largest RAPF flap dimension was 14 cm × 7 cm [Figure 2]a, [Figure 2]b and [Figure 2]c, while the smallest RAPF size was 8 cm × 4 cm, which was used to cover the exposed area following transfer from the extensor indicis proprius tendon to the extensor pollicis longus tendon [Figure 3]a and [Figure 3]b. The surface areas of the flaps ranged from 32 cm2 to 98 cm2, with a mean area of 63.5 ± 14.76 cm2. In all patients, the flap donor area was covered by STSG. In the early period, transient venous congestion was encountered in two patients. No intervention such as medical leech therapy or heparin injection was performed for venous congestion. Venous congestion resolved spontaneously in one patient by the fifth postoperative day. The flap recovered without any loss after marginal epidermolysis formation and healed with complete survival [Figure 4]a and [Figure 4]b. In the other patient, venous congestion resulted in partial necrosis in the distal one-third of the flap. For this reason, debridement to the necrotic part of the flap and secondary skin grafting were performed subsequently.
Figure 2: (a) Dorsal hand defect after mutilating hand injury. (b) Immediate postoperative photo after RAPF reconstruction performed. The area that appears to be bruised in the most distal of the flap developed partial necrosis afterward. (c) Partial necrosis at distal of the flap on the 7th postoperative day

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Figure 3: (a) Dorsal hand defect which tendons are exposed and RAPF is shown as raised. (b) Postoperative photograph in the 3rd postoperative month

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Figure 4: (a) Wound in the wrist extending from the thenar region to the wrist. (b) Postoperative 6th-month photograph with reasonable result

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  Discussion Top


Soft-tissue defects of the wrist and the hand occur as a result of burn, infection, tumor resection, and especially trauma. Hand is a unique machine that is capable of using any kind of machines. Therefore, reconstruction of hand and wrist defects necessitates individualized treatment methods that will restore the best function and cosmesis with minimal morbidity. Local flaps, pedicled flaps, interpolation flaps, perforator flaps, or free flaps can be employed to cover defects of the hand and wrist depending on the individual characteristics of the patient, characteristics of the wound, and the defect size.[9] Since pedicled groin and abdominal flaps, once used to be workhorses for the reconstruction of hand and wrist defects, cause serious problems such as prolonged postoperative immobilization periods, discomfort, joint contractures, stiffness, and necessity for the second surgery, today, they are recommended only in certain indications such as complex hand defects in children, high-voltage electric burns with the hand surviving on collateral circulation, mutilating hand injuries, and multiple defects in the digits, hand, or forearm.[10]

Nonbulky reconstruction of the hand and wrist defects without major donor site morbidity can be achieved through the prevalently preferred microsurgical options such as anterolateral thigh flap, superficial circumflex iliac perforator (SCIP) flap, or free lateral arm flap.[11] The concept of pure skin perforator flaps has gained popularity recently. Pure skin perforator flaps whether pedicled or free seems like superior in upper extremity reconstruction to fasciocutaneous or musculocutaneous flap types since they provide thin and pliable tissue. Narushima et al. reported favorable outcomes in reconstruction of hand soft-tissue defects utilizing free SCIP flap harvested as super-thin up to 2-mm thickness.[12] Although satisfactory results can be achieved with a SCIP reconstruction, reconstructive surgeons must definitely have multiple backup plans because there are also some serious disadvantages of SCIP flap such as highly variable anatomy, short pedicle, and even sometimes confusing flap harvest.[13]

Despite the advantages of free flap reconstruction thanks to microsurgical methods, operative durations are quite long and an experienced microsurgical team is required. In addition, close monitoring of the patients is mandatory in the postoperative period.

Considering the pros and cons of the reconstruction methods mentioned above, RAPF provides significant advantages in reconstruction of small- and medium-sized soft-tissue defects in the hand and wrist with characteristics of easy flap harvest, shortened duration of surgery, and rapid learning curve. RAPF can be used either as a sensate flap or an adipofascial flap that allows primary closure of the flap donor site. More importantly, RAPF can be safely used, even the radial and ulnar artery connections are severed, or the radial artery is the single blood supply to the thumb since it does not lead to major artery sacrification. The radial artery's perforators have reliable and consistent anatomy such that RAPF can be raised as a free flap based on one or two adjacent perforators if desired.[14],[15]

Limitations of this method are that it cannot be used in defects that extent to the distal of the metacarpophalangeal joint or large defects wider than 20 cm × 10 cm, and there is a need for skin graft to cover the donor area of RAPF if harvested with a width more than 3 cm.[5],[9] Although the RAPF cutaneous territory had been shown to range from 104 to 333 cm2 by methylene blue injection on cadavers, Weinzweig et al. reported 50% loss of a 286-cm2-sized RAPF in their series.[6],[16] Similar to Weinzweig et al.'s results, while the largest flap with 100% survival was 12 cm × 8 cm sized in their case series, our largest flap with full survival was 13 cm × 7 cm in size.[16] Since the anatomy of radial artery perforators and perforasomes is well defined, searching for the exact emergence point of the perforator is not always a must for RAPF harvest. In addition, pursuit of the perforator sound by a handheld Doppler can be confusing during flap design due to the superficial localization and of the radial artery.[6] Therefore, in this study, we harvested RAPF as if we were raising a freestyle perforator flap without designating a precise perforator location preoperatively. We raised the flap based on the most distal perforator or two adjacent perforators. The flap with the largest dimensions in our series was 14 cm × 7 cm that we observed necrosis in almost one-third of the flap. The most important cause of this partial necrosis was thought to be the perforasome injury of the most proximal part of the flap that was previously crushed and bruised. Although capillary refill test was normal in bruised area before flap elevation, the choke vessels probably had already lost the capacity of dilation and remodeling. Moreover, comorbidities such as diabetes mellitus and acute renal failure, which usage of this flap is not recommended in their presence, may also have worsened the flap circulation and further increased flap necrosis at the most distal portion. On the other hand, in the pediatric patient on whom we performed RAPF to release burn contracture, although a part of the flap was old burnt tissue, no complication was observed, and the recovery of the patient was almost perfect. Previously, in the literature, Martin et al. reported that a successful reconstruction can be made in the upper extremity with an RAPF prepared from old burnt tissue.[17] Since perforator flaps are generally more prone to develop temporary venous congestion, we transposed the flap to defect not from a skin tunnel but by incising the skin between the flap and defect in each case knowing that a tunnel would be hazardous to flap circulation. Nevertheless, in case 2, we observed venous congestion, and secondarily to this, 1 cm margin partial epidermolysis occurred at the distalmost of the flap. The underlying cause of this was considered to be the perioperative consumption of Maras powder, a type of smokeless tobacco, which had been previously proven to increase oxidative stress and cause cellular damage by its active ingredient named Nicotiana rustica Linn.[18]


  Conclusion Top


Consequently, in the light of the findings of this study, in small and medium-size defects of the hand and wrist, in patients without comorbidities who does not smoke or use smokeless cigarette derivatives, a radial artery forearm perforator flap may be used as a reliable and versatile reconstruction method.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery 2007;27:384-94.  Back to cited text no. 1
    
2.
Morris SF, Tang M, Almutari K, Geddes C, Yang D. The anatomic basis of perforator flaps. Clin Plast Surg 2010;37:553-70, xi.  Back to cited text no. 2
    
3.
Yilmaz S, Saydam M, Seven E, Ercocen AR. Para-umbilical perforator based pedicled abdominal flap for extensive soft-tissue deficiencies of the forearm and hand. Ann Plast Surg 2005;54:365-8.  Back to cited text no. 3
    
4.
Akdağ O, Yıldıran G, Sütçü M, Karameşe M. Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects. Ulus Travma Acil Cerrahi Derg 2018;24:43-8.  Back to cited text no. 4
    
5.
Ho AM, Chang J. Radial artery perforator flap. J Hand Surg Am 2010;35:308-11.  Back to cited text no. 5
    
6.
Saint-Cyr M, Mujadzic M, Wong C, Hatef D, Lajoie AS, Rohrich RJ. The radial artery pedicle perforator flap: Vascular analysis and clinical implications. Plast Reconstr Surg 2010;125:1469-78.  Back to cited text no. 6
    
7.
Kimura T, Ebisudani S, Osugi I, Inagawa K. Anatomical analysis of cutaneous perforator distribution in the forearm. Plast Reconstr Surg Glob Open 2017;5:e1550.  Back to cited text no. 7
    
8.
Chang SM, Hou CL, Zhang F, Lineaweaver WC, Chen ZW, Gu YD. Distally based radial forearm flap with preservation of the radial artery: Anatomic, experimental, and clinical studies. Microsurgery 2003;23:328-37.  Back to cited text no. 8
    
9.
Ono S, Sebastin SJ, Ohi H, Chung KC. Microsurgical flaps in repair and reconstruction of the hand. Hand Clin 2017;33:425-41.  Back to cited text no. 9
    
10.
Al-Qattan MM, Al-Qattan AM. Defining the indications of pedicled groin and abdominal flaps in hand reconstruction in the current microsurgery era. J Hand Surg Am 2016;41:917-27.  Back to cited text no. 10
    
11.
Wink JD, Gandhi RA, Ashley B, Levin LS. Flap reconstruction of the hand. Plast Reconstr Surg 2020;145:172e-83e.  Back to cited text no. 11
    
12.
Narushima M, Iida T, Kaji N, Yamamoto T, Yoshimatsu H, Hara H, et al. Superficial circumflex iliac artery pure skin perforator-based superthin flap for hand and finger reconstruction. J Plast Reconstr Aesthet Surg 2016;69:827-34.  Back to cited text no. 12
    
13.
Feng S, Xi W, Zhang Z, Tremp M, Schaefer DJ, Sadigh PL, et al. A reappraisal of the surgical planning of the superficial circumflex iliac artery perforator flap. J Plast Reconstr Aesthet Surg 2017;70:469-77.  Back to cited text no. 13
    
14.
Ozkan O, Akyürek M, Coşkunfirat OK, Safak T, Ozgentaş HE. The free radial artery septal perforator vessel-based flap. Plast Reconstr Surg 2005;115:2062-9.  Back to cited text no. 14
    
15.
Safak T, Akyürek M. Free transfer of the radial forearm flap with preservation of the radial artery. Ann Plast Surg 2000;45:97-9.  Back to cited text no. 15
    
16.
Weinzweig N, Chen L, Chen ZW. The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery: An anatomic and clinical approach. Plast Reconstr Surg 1994;94:675-84.  Back to cited text no. 16
    
17.
Martin JP, Chambers JA, Long JN. Use of radial artery perforator flap from burn-injured tissues. J Burn Care Res 2008;29:1009-11.  Back to cited text no. 17
    
18.
Kılınç M, Okur E, Kurutas EB, Güler FI, Yıldırım I. The effects of maras powder (smokeless tobacco) on oxidative stres in users. Cell Biochem Funct. 2004;22:233-6.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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