Clin Orthop Surg.  2018 Mar;10(1):74-79. 10.4055/cios.2018.10.1.74.

Fasciocutaneous Propeller Flap Based on Perforating Branch of Ulnar Artery for Soft Tissue Reconstruction of the Hand and Wrist

• Jang HS
• Lee YH
• Kim MB
• Chung JY
• Seok HS
• Baek GH

• KMID: 2405485
• DOI: http://doi.org/10.4055/cios.2018.10.1.74

Abstract

BACKGROUND
A skin defect of the hand and wrist is a common manifestation in industrial crushing injuries, traffic accidents or after excision of tumors. We reconstructed a skin defect in the ulnar aspect of the hand and wrist with a perforator-based propeller flap from the ulnar artery. The aims of our study are to evaluate the utility and effectiveness of this flap and to discuss the advantages and disadvantages of the flap in hand and wrist reconstruction with a review of the literature.
METHODS
Between April 2011 and November 2016, five cases of skin defect were reconstructed with a perforator-based propeller flap from the ulnar artery. There were four males and one female. The age of patients ranged from 36 to 73 years. Skin defect sites were on the dorso-ulnar side of the hand in three cases and palmar-ulnar side of the wrist in two cases. The size of the skin defect ranged from 4 × 3 cm to 8 × 5 cm. We evaluated the viability of the flap, postoperative complication and patient's satisfaction.
RESULTS
There was no failure of flap in all cases. The size of the flap ranged from 4 × 4 cm to 12 × 4 cm. One patient, who had a burn scar contracture, presented with limited active and passive motion of the wrist after the operation. The other patients had no complications postoperatively. Cosmetic results of the surgery were excellent in one patient, good in three patients, and fair in one patient.
CONCLUSIONS
The fasciocutaneous propeller flap based on a perforating branch of the ulnar artery is a reliable treatment option for the ulnar side skin defect of the hand and wrist.

Keyword

Ulnar artery; Perforator flap; Wrist

MeSH Terms

Accidents, Traffic
Burns
Cicatrix
Contracture
Female
Hand*
Humans
Male
Perforator Flap
Postoperative Complications
Skin
Ulnar Artery*
Wrist*

Figure

• 

  Fig. 1 A 73-year-old male presenting with recurrent squamous cell carcinoma at the wrist. (A) Photograph showing the full-thickness skin defect and exposure of the flexor digitorum superficialis tendon after wide excision of the carcinoma by a tumor surgeon. The flexor carpi ulnaris tendon and pisiform bone are removed and the ulnar artery and nerve are segmentally resected. (B) Design of the perforator-based fasciocutaneous flap with its vascular supply from a perforating branch of the ulnar artery. (C) The flap is dissected carefully and two perforating branches of ulnar artery are identified. (D) The flap is dissected totally and elevated from muscle fascia. (E) Of the two perforating branches, the proximal perforator is ligated and the fasciocutaneous flap is elevated carefully. (F) After 180° of flap rotation in clockwise direction, the flap size is matched to the skin defect. (G) Kinking or compression of the perforating branch is checked to allow 180° of rotation of the flap. (H) The site of perforator is confirmed to allow suture of the flap before nerve grafting. (I) After sural nerve harvesting, nerve grafting is performed to each site of sensory and motor branches of the ulnar nerve. (J) Key suture is performed to prevent ischemic damage of the remnant skin and compression of the perforator. (K, L) At 12 months after surgical treatment with full-thickness skin grafting of the donor site, no functional impairment of the hand motion is observed.

Reference

1. Miura T, Nakamura R. Use of paired flaps to simultaneously cover the dorsal and volar surfaces of a raw hand. Plast Reconstr Surg. 1974; 54(3):286–289. PMID: 4277753.

2. Zheng DW, Li ZC, Sun F, Shi RJ, Shou KS. Use of a distal ulnar artery perforator-based bilobed free flap for repairing complex digital defects. J Hand Surg Am. 2014; 39(11):2235–2242. PMID: 25267472.

3. Becker C, Gilbert A. The ulnar flap. Handchir Mikrochir Plast Chir. 1988; 20(4):180–183. PMID: 3169635.

4. Teo TC. The propeller flap concept. Clin Plast Surg. 2010; 37(4):615–626. PMID: 20816517.

5. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg. 1991; 44(1):53–54. PMID: 1993239.

6. Appleton SE, Morris SF. Anatomy and physiology of perforator flaps of the upper limb. Hand Clin. 2014; 30(2):123–135. PMID: 24731605.

7. Grobbelaar AO, Harrison DH. The distally based ulnar artery island flap in hand reconstruction. J Hand Surg Br. 1997; 22(2):204–211. PMID: 9149989.

8. Mathy JA, Moaveni Z, Tan ST. Perforator anatomy of the ulnar forearm fasciocutaneous flap. J Plast Reconstr Aesthet Surg. 2012; 65(8):1076–1082. PMID: 22507672.

9. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg. 2009; 124(6 Suppl):e419–e426. PMID: 19952709.

10. Gir P, Cheng A, Oni G, Mojallal A, Saint-Cyr M. Pedicled-perforator (propeller) flaps in lower extremity defects: a systematic review. J Reconstr Microsurg. 2012; 28(9):595–601. PMID: 22715046.

11. Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery. 2007; 27(5):384–394. PMID: 17557279.

12. Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg Am. 2006; 31(5):847–856. PMID: 16713853.

13. Ho AM, Chang J. Radial artery perforator flap. J Hand Surg Am. 2010; 35(2):308–311. PMID: 20141902.

14. 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(5):853–863. PMID: 21489723.

15. Pignatti M, Pasqualini M, Governa M, Bruti M, Rigotti G. Propeller flaps for leg reconstruction. J Plast Reconstr Aesthet Surg. 2008; 61(7):777–783. PMID: 18450531.

16. Koshima I, Iino T, Fukuda H, Soeda S. The free ulnar forearm flap. Ann Plast Surg. 1987; 18(1):24–29. PMID: 3827126.

17. Tan ST, James DW, Moaveni Z. Donor site morbidity of free ulnar forearm flap. Head Neck. 2012; 34(10):1434–1439. PMID: 22052605.

18. Chen SH, Xu DC, Tang ML, Ding HM, Sheng WC, Peng TH. Measurement and analysis of the perforator arteries in upper extremity for the flap design. Surg Radiol Anat. 2009; 31(9):687–693. PMID: 19390765.

19. Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and clinical implications. Plast Reconstr Surg. 1996; 98(2):195–210. PMID: 8764707.

20. Wong CH, Cui F, Tan BK, et al. Nonlinear finite element simulations to elucidate the determinants of perforator patency in propeller flaps. Ann Plast Surg. 2007; 59(6):672–678. PMID: 18046151.

21. Demirseren ME, Yenidunya MO, Yenidunya S. Island rat groin flaps with twisted pedicles. Plast Reconstr Surg. 2004; 114(5):1190–1194. PMID: 15457033.

22. Demir A, Acar M, Yldz L, Karacalar A. The effect of twisting on perforator flap viability: an experimental study in rats. Ann Plast Surg. 2006; 56(2):186–189. PMID: 16432329.

23. Masia J, Moscatiello F, Pons G, Fernandez M, Lopez S, Serret P. Our experience in lower limb reconstruction with perforator flaps. Ann Plast Surg. 2007; 58(5):507–512. PMID: 17452834.