Reconstruction of elbow region defects using radial collateral artery perforator (RCAP)-based propeller flaps

Perforator-based propeller flaps permit flap rotation up to 180°. This ability to transfer skin from one longitudinal axis to another has led to the increasing use of perforator-based propeller flaps in extremity reconstruction, especially lower-extremity reconstruction. However, the application of perforator-based propeller flaps to upper-extremity reconstruction is still limited. This article reports two cases of successful reconstruction of elbow region defects with radial collateral artery perforator (RCAP)-based propeller flaps. The elbow region has a variety of perforators available for perforator-based propeller flap reconstruction. Among them, the RCAP seems to be one of the most reliable options. This is because there are less anatomical variations of perforators' location on the lateral upper arm than on the medial upper arm. By using an RCAP perforator as a flap pedicle, the small-to-medium sized defects (<6?cm in diameter) around elbow regions can be closed primarily without skin grafts.     

The eight-limb modified propeller flap--a safer new technique

Introduction

Contracture deformities affecting the flexor aspect of the elbow joint and the 1st web space are not uncommon sequelae of burns. Surgical treatment is contemplated in those patients with established contractural deformities in whom non-surgical treatment is ineffective or functional integrity of the joint is at jeopardy. Surgical treatment consists of incising the scar tissue to release joint contracture and covering the defect that might result with skin grafting or various tissue flaps. In this work, we used a modification of the multilobed propeller flap to treat eight patients with contracture deformities.

Materials and methods

Eight patients with contracture deformities of the elbow (five patients) and 1st web space (three patients) were subjected to release and modified propeller flap coverage. The modification implies planning eight limbs based on a central axis so that rotation occurs in 45° instead of 90° in the original propeller flaps.

Results

All patients had acceptable results with complete range of movement regained in affected joints and no serious complications. Only a case of partial loss of skin graft and another case with congestion of one lobe were reported, and both were managed conservatively.

Conclusion

The new modification has the advantages of being flexible, can be tailored to best match the defect so that it can be closed primarily or needs smaller skin grafts, can be used even when there is much scarring and, finally, the resultant appearance is cosmetically acceptable with little donor morbidity, if any.     

A simple concept for covering pressure sores: wound edge‐based propeller perforator flap

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process. Between January 2009 and January 2017, 33 wound edge‐based propeller perforator flaps were used to cover pressure sores at various locations in 28 patients. In four cases more than one flap was used on the same patient. The patients comprised 18 males and 10 females with a mean age of 41·25 (range, 16–70) years. All patients underwent follow‐up for 0–12 months. The mean follow‐up duration was 5·03 months. Venous congestion was observed in three flaps that were rotated by 180° (9·1%). However, there was a significant difference between flaps rotated by 90° and 180° according to the complication rate (P = 0·034). Out of 33 flaps, 29 flaps healed uneventfully. Patients were able to sit and lie on their flaps three weeks after surgery. In our study, we were able to obtain satisfying final results using these novel flaps.     

同指固有动脉穿支血管螺旋桨皮瓣修复末节指体缺损

目的探讨同指固有动脉穿支血管螺旋桨皮瓣修复末节指体缺损的临床疗效。方法采用固有动脉穿支血管螺旋桨皮瓣修复术修复12例末节指体缺损患者(14指),切取面积1.5 cm×1.2 cm^2.8 cm×2.5 cm。结果患者均获得随访,时间2个月~1年。14指皮瓣全部成活,指端皮瓣饱满不臃肿,质地柔软,感觉恢复。结论同指固有动脉穿支血管螺旋桨皮瓣修复末节指体缺损手术操作简便,血供可靠,可一期修复手指末节组织缺失,手指功能恢复良好。     

Central axis flap methods

Extensively burned patients often lack ample healthy skin for autotransplantation. Scar contractures are then frequent. Here, we reconstructed contractures using flaps of remaining healthy skin around the recipient sites. In this report, we present four original scar contracture repair methods using subcutaneous pedicled flaps: (1) Propeller flap, (2) multilobed propeller flap, (3) scar-band rotation flap and (4) pin-wheel flap. The subcutaneous pedicle under the center of these various types of flaps allows these methods to be characterized as "central axis flap methods." We have employed these flaps to treat mild scar contractures in the axilla and cubital fossa. These methods are easily manipulated to restore function and improve aesthetics of scar contractures.     

Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects

BackgroundCovering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation.MethodsPatients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects.ResultsThe mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm² (range, 48–125 cm²). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation.ConclusionsThe propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.     

Perforator propeller flaps for sacral and ischial soft tissue reconstruction

The perforator-based flaps in the sacral and ischial region is designed according to the localization of perforators that penetrate the gluteus maximus muscle, reach the intra-fascial and supra-fascial planes with the overlying skin forming a rich vascular plexus. The perforator-based flaps described in this article are highly vascularized, have minimal donor site morbidity, and do not require the sacrifice of the gluteus maximus muscle. In a period between April 2008 and March 2009, six patients with sacral pressure sore were reconstructed with propeller flap method based on superior gluteal and parasacral artery perforators. One flap loss was noted. Three cases of ischial pressure sore were reconstructed with longitudinal propeller flap cover, based on inferior gluteal artery perforator. One flap suffered wound infection and dehiscence. Two cases of pilonidal sinus were reconstructed with propeller flap based on parasacral perforators. Both the flaps survived without any complications. Donor sites were closed primarily. In the light of this, they can be considered among the first surgical choices to re-surface soft tissue defects of the sacral and ischial regions. In the series of 11 patients, two patients (18%) suffered complications.     

The neurovascular flap in finger injuries

Surgical Principles The finger tip with its protective nail on the dorsum and durable, yet highly sensitive, pulp on the volar aspect is a very important part of the digit. It is thus imperative, following an injury, to preserve as much as possible of this area. Numerous procedures, attempting to achieve this, have been described. These include simple split skin grafts, distant flaps and island pedicle flaps. The lateral advancement flap described by Kutler in 1947 [6] (Figure 1) and the volar flap described by Atasoy et al. in 1970 [1] (Figure 2) were important steps toward achieving skin cover by advancing local tissues. However, the mobility of their flaps was, of necessity, limited. The neurovascular flap, described here, utilizes the principle of distal advancement but entails the total mobilization of a triangular skin island on its own neurovascular pedicle. In this way distal mobility is greatly enhanced which allows for full thickness skin cover over the tip of the digit and yet preserves full sensation and durable skin.     

Aesthetic Penoscrotal Resurfacing: Creating Propeller Flaps from Gluteal Folds

Background

Reconstruction of extensive penoscrotal defects is a surgical challenge. Resurfacing defects in highly complex three-dimensional structures and restoring their function are an essential part of the reconstruction of penoscrotal regions.

Perforator propeller flaps for lower extremity soft-tissue defect reconstruction: Shortening the learning curve

BackgroundThe perforator propeller flap is an advantageous option for soft tissue reconstruction in the lower limb as it ensures the preservation of the main artery and muscle, eliminates the need for microsurgical reconstruction as well as provides “like with like” resurfacing of the defects. Despite this, it remains a technically demanding reconstructive option for residents and surgeons with little experience in perforator dissection. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects were addressed with propeller flaps.MethodsA retrospective study of all propeller flap based reconstruction done on patients with soft tissue defects involving the distal third of the leg was undertaken from August 2018 to December 2020.Results28 patients were treated with propeller flaps for various lower extremity defects. The median defect size was 12 cm². The posterior tibial artery (PTA) was used in eleven cases (39.3%) and the peroneal artery (PA) in seventeen of the cases (60.7%). The complication rate was 28.6% (n = 8). The complete flap necrosis rate was 10.7% (n = 3) and partial flap necrosis rate was 7.1% (n = 2), The rate of venous congestion was 7.1% (n = 2) and wound dehiscence occurred in 3.5% (n = 1). There was a significant negative correlation between the number of cases performed by a resident and the operative time.ConclusionAlthough propeller flaps are a reliable option to address lower extremity defects, they have a long learning curve and require a good amount of experience and perforator dissection skills to reduce the probability of flap failure. We are of the opinion that residents should be adequately trained in this procedure to ensure optimal outcome delivery.     

The propeller flap for postburn elbow contractures

Flexion contracture of the elbow is a common sequela of burn injury. Numerous methods have been suggested for release, including grafting, Z-plasty, Y-V flaps, local or distant fasciocutaneous flaps, muscle or myocutaneous flaps, free flaps, tissue expanders and non-surgical orthotics. In this article the authors present their experience with the propeller flap method in seven cases of elbow flexion contracture. Sufficient extension and an acceptable aesthetic outcome were obtained. Other benefits include easy design and rapid flap elevation that permits a single stage correction of the deformity without further sacrificing an artery or muscle. We think that the main disadvantage of the propeller flap is using the same skin that has suffered from the burn insult which has a poorer cosmetic result. Other than this and excluding deep burn injuries, we believe that the propeller flap is a useful alternative for elbow contracture release.     

Combined multi-lobed flaps: A series of 39 extensive hand and multi-digit injuries one-staged reconstructions using modified designs of ALT,DPA and chimeric linking flaps

IntroductionThe use of multiple small flaps linked in a “chain-linked” flap microanastomosed chimeric system is recommended in distal hand and digital defects reconstruction. The aim of this study is to demonstrates our experience utilizing microsurgical fabrication, multi-lobed and linking combined flaps for the reconstruction of hand degloving injuries with complex multidigit soft tissue defects.MethodsMicroanastomosed chimeric flap systems using ALT and DPA modified designed flaps were combined in five selections to cover extensive soft tissue defects involving the hands and multiple digits of 39 patients (M:F − 36:3) from October 2009 to February 2013. Five different microsurgical combined chimeric flap systems utilised in extensive hand and multidigit injuries; innervated ALT flaps, multilobed DPA flaps, innervated ALT flap with multilobed DPA flap, innervated ALT flap with sensate ALT flap and bilobed ALT flap with multilobed DPA flap. All DPA donor sites were reconstructed using free ALT flap and anterior tibial artery propeller flap.ResultsThirty-nine combined free flap extremities reconstructions on 39 patients (M:F − 36:3) with average age 28.5 (18–45) years sustained traumatic degloving injuries, 24 from road traffic accidents and 15 from industrial devices. Five different designs of combined multi-lobed flaps have be successfully used without any peri-operative complications. Average follow-up of 12 months, all flaps survived without complications. Operated extremities showed favorable functional recovery with restoration of the diminished protective sensation on the flap through reinnervation. All flaps survived uneventfully with coverage matching the texture and color of the recipients. Donor sites healed without complication.ConclusionThe microsurgical fabrication of chimeric ALT flaps and multilobed DPA flaps is a valuable alternative for the reconstruction of hand degloving injury with complex multidigit soft tissue defects.Level of evidence: Level IV, therapeutic study.     

Application of the free-style brachial artery perforator based propellar flap in the management of axillary hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic and recurrent inflammatory disease often requiring surgical intervention in extensive lesions. Total of seven axillary lesion with HS was treated with free-style perforator based propeller flaps (innominate perforator originating from the brachial artery) after complete excision. The flap design mimicked the axis and design of the brachioplasty surgery. The flaps were elevated and after obliterating the defect, the remnant flap was discarded and donor site was primarily closed. All flaps were performed successfully and HS did not recur in any of the patients. In addition, the operated limb also showed a reduction of arm circumference of more than 5 cm. This is the first report using the free-style perforator based propeller flap to reconstruct the axillary HS. It is a simple and a reliable approach yielding good functional and aesthetic outcome with additional advantages of providing a brachioplasty.     

Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction

BACKGROUND: Although the anterolateral thigh flap has been extensively used for head and neck reconstruction in Asia, reported variations of vascular anatomy seem confusing and may have contributed to the unpopularity of this flap in the United States. The purposes of this study are to classify the vascular anatomy and to assess the suitability of this flap for head and neck reconstruction in a Western population. METHODS: Seventy-two consecutive anterolateral thigh flaps for head and neck reconstruction was retrospectively reviewed. RESULTS: The number of cutaneous perforators for the anterolateral thigh flap ranged from one to three. On the basis of their location and origin, a simple classification system is introduced to assist flap dissection. Of the 72 thighs explored, 68 flaps (94%) were raised successfully. CONCLUSIONS: The vascular anatomy of the flap follows predictable patterns. The anterolateral thigh flap is well suited for head and neck reconstruction in Westerners.     

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

Background:

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent.

Materials and Methods:

We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series.

Results:

63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.

Conclusion:

Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects.

Level of Evidence:

Therapeutic IV.KEY WORDS: Hand defects, perforator flaps, propeller flaps, perforator based propeller flaps, upper extremity, wrist defects     

Propeller TAP flap: Is it usable for breast reconstruction?

Abstract

The aim of this study was to examine if a propeller thoracodorsal artery perforator (TAP) flap can be used for breast reconstruction. Fifteen women were reconstructed using a propeller TAP flap, an implant, and an ADM. Preoperative colour Doppler ultrasonography was used for patient selection to identify the dominant perforator in all cases. A total of 16 TAP flaps were performed; 12 flaps were based on one perforator and four were based on two. A permanent silicone implant was used in 14 cases and an expander implant in two. Minor complications were registered in three patients. Two cases had major complications needing additional surgery. One flap was lost due to a vascular problem. Breast reconstruction can be performed by a propeller TAP flap without cutting the descending branch of the thoracodorsal vessels. However, the authors would recommend that a small cuff of muscle is left around the perforator to ensure a sufficient venous return.     

Propeller flaps for leg reconstruction.

Leg soft tissue defects with bone or tendon exposure need to be covered with a flap. Various local and free flaps with more or less consistent donor site defects have been described in the past. After the introduction of the perforator-based flap concept, new flaps have also been described for the leg. An evolution and simplification of the perforator flap concept, together with the 'free style' flap harvesting method, are the propeller flaps, i.e. local flaps, based on a perforator vessel, which becomes the pivot point for the skin island that can, therefore, be rotated up to 180 degrees . In this prospective study, six consecutive patients, having post-traumatic soft tissue defects of the leg or knee prosthesis infection, with bone or tendon exposure, were treated with propeller flaps. Complete and stable coverage of the soft tissue losses was obtained in all cases with an inconspicuous, only cosmetic, donor site defect. No flap necrosis was observed, with the exception of a small superficial necrosis of the tip of one flap, due to the inclusion in the design of scarred tissue. In two cases, transient venous congestion was observed and resolved spontaneously. Mean operative time was 2 h (ranging from 60 min to 6 h when an orthopaedic procedure was also needed) and mean hospital stay after surgery was 10 days. Propeller flaps allow the coverage of wide defects, can be raised with a relatively simple surgical technique, have a high success rate and good cosmetic results without functional impairment. In the light of this they can be considered among the first surgical choices to resurface complex soft tissue defects of the leg.     

Prelaminated forearm flap for nose reconstruction

Various different procedures for partial or total reconstruction of the nose have been described, the methods of residual nasal tissue, and of buccal, frontal and temporal flaps being most widely used. Reconstruction of the nose with free vascular transplants is rarely used. Reconstruction of a nasal defect due to war injury of the nose with the use of prelaminated fasciocutaneous forearm flap with preserved allogeneic cartilage is described.     

A review of propeller flaps for distal lower extremity soft tissue reconstruction: Is flap loss too high?

Soft tissue coverage in the distal lower extremity remains a significant challenge. While free flaps are often utilized for larger defects, local perforator‐based propeller flaps may be ideal for smaller wounds requiring coverage. Propeller flaps can provide excellent form and function for both traumatic and atraumatic defects with minimal donor site morbidity but can have concerning rates of flap loss. We reviewed the literature, identifying 21 studies presenting 310 propeller flaps for distal lower extremity reconstruction. Total flap necrosis was noted in 5.5% of flaps, with partial necrosis in 11.6%. While these flaps do enable transfer of local, healthy tissue to the defect site without the need for a microsurgical anastomosis, this rate of flap loss is concerning and appropriate patient selection is crucial. This review provides a brief history and overview of the clinical application and research into distal lower extremity perforator propeller flaps to place this technique into a clinical context. © 2013 Wiley Periodicals, Inc. Microsurgery 33:578–586, 2013.     

Reconstruction of pressure sores with perforator-based propeller flaps

Perforator flaps have been successfully used for reconstruction of pressure sores. Although V-Y advancement flaps approximate debrided wound edges, perforator-based propeller flaps allow rotation of healthy tissue into the defect. Perforator-based propeller flaps were planned in 13 patients. Seven pressure sores were over the sacrum, five over the ischial tuberosity, and one on the tip of the scapula. Three patients were paraplegic, six were bedridden, and five were ambulatory. In three patients, no perforators were found. In 10 patients, propeller flaps were transferred. In two patients, total flap necrosis occurred, which was reconstructed with local advancement flaps. In two cases, a wound dehiscence occurred and had to be revised. One hematoma required evacuation. No further complications were noted. No recurrence at the flap site occurred. Local perforator flaps allow closure of pressure sores without harvesting muscle. The propeller version has the added benefit of transferring tissue from a distant site, avoiding reapproximation of original wound edges. Twisting of the pedicle may cause torsion and venous obstruction. This can be avoided by dissecting a pedicle of at least 3 cm. Propeller flaps are a safe option for soft tissue reconstruction of pressure sores.