Medial elbow reconstruction with perforator based medial arm propeller flap

Transcription

1 Case Report Hand Microsurg 2018;7:58-62 doi: /handmicrosurg Medial elbow reconstruction with perforator based medial arm propeller flap Asim Uslu 1, Abdullah Surucu 1, Mehmet Ali Korkmaz 1, Umran Muslu 1, Cihan Sahin 2 ABSTRACT A perforator-based medial arm propeller flap was planned from the medial arm region near the medial elbow soft tissue defect as an alternative flap. The flap was elevated and rotated by 180 to the defect based on the perforator. The perforator-based medial arm propeller flap should be considered as an option for reconstruction of medial elbow soft-tissue defects. The flap is easy to harvest, the operation is quick, the donor area scar is well-hidden, and the skin in this area is elastic. However, in the proximal forearm region, a flap may not be safe enough. Key words: Medial elbow soft tissue defect, medial elbow reconstruction, medial arm propeller flap, propeller flap, perforator based flap Introduction Soft-tissue defects of the elbow may result from trauma, tumor, infection, and excessive pressure. Elbow soft-tissue coverage can be achieved using skin grafts, local flaps, pedicled flaps, and free flaps [1-6]. Elbow injuries that include exposed bone, joint, nerve, tendon without paratenon and implants require durable soft tissue coverage. Medial arm skin flap is a great alternative for reconstruction of medial elbow soft-tissue defects. The vascular pedicle of the medial arm flap is supplied by the perforator arteries of the superior ulnar collateral artery and the brachial artery [7,8] (Figure1). Hyakusa et al. first named the propeller flap in 1991, when this flap was used as a subcutaneous pedicled flap [9]. Hallock used the propeller flap based on a skeletonized perforating vessel [10]. The propeller flap has been less used in upper extremity reconstruction [11,12]. This paper presents a case with reconstruction of a medial elbow defect using a perforator-based medial arm propeller flap. Case Report A 23-year-old male patient presented with a skin defect in the right elbow medial region with an exposed orthopedic plate. Previously, he underwent surgery at another center for an intra-articular comminuted frac- Author affiliations : Correspondence : Received / Accepted : Department of Plastic and Reconstructive Surgery, Antalya Training and Research Hospital, Antalya, Turkey 2 Department of Plastic and Reconstructive Surgery, Haydarpasa Sultan Abdülhamit Training and Research Hospital, Istanbul, Turkey Asım Uslu, MD, Department of Plastic and Reconstructive Surgery, Antalya Training and Research Hospital, Antalya, Turkey asimuslu78@hotmail.com December 06, 2016 / May 30, Turkish Society for Surgery of the Hand and Upper Exremity

2 Perforator based medial arm propeller flap Figure 1. Schematic drawing showing the vascular anatomy of the flap. rotate 180 on the perforator. The inferior border of the flap was planned to be at the superior border of defect and the superior border of the flap was planned as the distance of the pedicle to the inferior border of the defect, and the pedicle to the superior border of the flap to have the same length on the anterior axillary line. Thus, the flap was designed as the proximal site of the defect on the arm to close the entire defect and the scar area when rotated by 180. The flap width was based on the wound width. The wound was debrided and irrigated before the flap coverage. The scar tissue that had recovered before was excised from the proximal forearm for durable coverage. The dissection started from the anterior border of the flap and then proceeded to the posterior border of the flap at medial arm above the muscular fascia. Two perforators were identified and dissected with great care. All the skin margins of the flap were cut and the flap was separated from the muscle fascia. The minor of the two perforators was sacrificed to enable rotation of the flap (Figure 3). The major of the perforators which penetrated the triceps brachii muscle was not dissected until the basis of the perforator. The perforator was only skeletonized in the triceps brachii muscle to allow rotation of the flap without kinking and traction of the perforator. The flap was turned counter-clockwise by 180 to the defect. The flap was transposed to the defect with care to ensure a tension-free inset. The su- Figure 2. A 23-year-old man presented with a skin defect on the right elbow medial region with an exposed orthopedic plate. ture of distal humerus. However,skin necrosis occurred in the surgery area after the operation. After being admitted to the hospital, a flap from the medial arm region was designed to cover the wound. The skin defect diameter (wound size) was 2 X 2 cm. A line extending from the medial epicondyle to the anterior axillary line was drawn. A perforator was identified and marked on this line by using a handheld Doppler ultrasound (Figure 2). The flap was planned to Figure 3. All the skin margins of the flap were cut and the flap was separated from the muscle fascia. The major perforator which penetrated the triceps brachii muscle was not dissected until the basis of the perforator. Hand and Microsurgery 59

3 Uslu A et al. Figure 4. The flap was transposed to the defect with care to ensure a tension free inset. The superior donor site of flap was primarily closed and the remaining area was split thickness skin grafted. Figure 6. Radiographs of bone at the elbow. There was extension restriction of in the elbow joint. The flap and grafts applied have no effect on the restriction of joint movement. Figure 5. A Perforator Based Medial Arm Propeller Flap was used for soft-tissue coverage. Postoperative results at 6 months. perior donor site of the flap was primarily closed and the remaining area was grafted with split-thickness skin (Figure 4). The operation lasted an hour. In the early postoperative period, venous congestion was observed in the distal part of the flap. On postoperative day one, the sutures in the distal part of the flap were removed to reduce the venous congestion. However, there was flap loss in the distal part of the flap. Debridement was applied to the necrotic area of the flap which covered the excised scar tissue area and it was closed with split-thickness skin graft. The arm and forearm were splinted posteriorly to immobilize the elbow joint for seven days. At six months postoperatively no complications have developed (Figure 5). There was extension restriction of in the elbow joint. The restriction was related to the fracture of the joint and to the elbow joint being held at 90 in the splint applied before the patient was admitted hospital for two months (Figure 6). The flap and grafts applied have no effect on the restriction of joint movement. Discussion There are various methods for reconstruction of elbow soft-tissue defects. Skin grafting is the most simple method but it requires a vascularized bed and has the disadvantage of prolonged splinting and a patchy appearance. Closure of an elbow soft-tissue defect with a flap is the more preferred technique rather than skin grafting. A pedicelled radial forearm flap (RFF) can be used for elbow reconstruction [13-15]. However, having to sacrifice the radial artery, which is one of the two major arteries of the arm, is the main disadvantage of RFF, and a second disadvantage is the donor-site morbidity. The latissimus dorsi flap can reach up to 6 to 8 cm distal to the olecranon and can be used as a pedicelled flap for elbow reconstruction [16,17]. But the pedicelled latissimus dorsi flap was reported to have the highest complication rate when it is used as the soft tissue coverage of elbow defects [18]. Free tissue transfer is the last resort for elbow reconstruction, which can be used when there is insufficient tissue in the region, for example in cases of 60 Hand and Microsurgery Year 2018 Volume 7 Issue

4 Perforator based medial arm propeller flap crush injuries [19]. Single-stage reconstruction with a free tissue transfer can provide excellent functional and cosmetic results, but it requires microsurgery skill and instruments. Patients with pre-existing morbidities cannot tolerate long lasting operations. Blood supply to the medial arm skin comes from the superior ulnar collateral artery (65%), direct cutaneous branches from the brachial artery (20%), or both (15%) [20]. Matlobut et al. studied vascular supply to the medial side of the arm and found that the superior ulnar collateral artery was the most important blood supply to the medial arm flap [8]. The perforator fasciocutaneous flap of distal brachial artery was described as the new perforator flap and the center of the flap was measured as 11.5 cm above and 1.3 cm medial to the medial epicondyle of the humerus [21]. Another study determined that the medial arm skin blood supply originates from the superior ulnar collateral artery, direct cutaneous artery, brachial artery and the superficial brachial artery [22]. An anatomic study determined that there are two areas, 7.5 and 8.2 cm, proximal to the medial epicondyle in the medial arm. These areas always contain at least one perforator [23]. Based on this anatomic information, we planned a perforator-based medial arm propeller flap for reconstruction of the medial elbow defect in the presented patient. Perforators of the flap arise from the superior ulnar collateral artery and the brachial artery [8,20-22]. The propeller flap was designed on a perforator with the greatest pulsation. The flap was planned to cover the scar tissue on the dorsomedial surface of the proximal forearm area. Coverage with a robust flap was planned particularly as this area is exposed to trauma and weight-bearing depending on position. However, necrosis was observed in the distal part of the flap which was close to the excised scar tissue. Zang et al. used freestyle perforator-based propeller flaps for medial elbow reconstruction in 2 patients. The perforators were found to be 12 cm and 7 cm proximal to the medial epicondyle. In a patient in that study venous congestion which developed in the distal flap was associated with excessive tension over the pedicle and this was corrected by removing tension over the pedicle [24]. In the presented patient there was no tension over the pedicle, but venous congestion developed in the distal part of the flap in the early period and over time. As the flap was planned to be narrow and this section was far from the perforator, skin necrosis occured. The medial elbow soft tissue defect was successfully reconstructed with this flap in our case as in the cases described by Zang et al [24]. Elbow region defects often require flap coverage, and this flap can be a good option for medial and posterior elbow reconstruction. The operation is easy and quick, the donor area scar is well-hidden, and the skin in this area is elastic. The operation can be done under regional anesthesia as the same anatomic area is being worked on. As the flap donor site is adjacent to the defect, color matching is good. The most significant disadvantage of the flap is that no tourniquet is used in the operation because of the anatomic area of the flap location. If careful hemostasis is not done while raising the flap bleeding can occur in the surgical site. This makes it more difficult to locate perforators and increases the possibility of perforator injuries. Anatomic studies have been made related to define the localization of the flap perforators [8,20-22]. However, it is still not known exactly how much tissue can be supplied proximally with these perforators. Therefore, further anatomic and clinical studies are required. Conflict of interest statement The authors have no conflicts of interest to declare. References 1. Lai CS, Tsai CC, Liao KB, Lin SD. The reverse lateral arm adipofascial flap for elbow- coverage. Ann Plast Surg 1997;39: Coessens B, Vico P, de Mey A. Clinical experience with the reverse lateral arm flap in soft- tis- Hand and Microsurgery 61

5 Uslu A et al. sue coverage of the elbow. Plast Reconstr Surg 1993;92: Bunkis J, Ryu RK, Walton RL, Epstein LI, Vasconez LO. Fasciocutaneous flap coverage for periolecranon defects. Ann Plast Surg 1985;14: Culbertson JH, Mutimer K. The reverse lateral upper arm flap for elbow coverage. Ann Plast Surg 1987;18: Lazarou SA, Kaplan IB. The lateral armflap for elbow coverage. Plast Reconstr Surg 1993;91: Lai CS, Lin SD, Chou CK, Tsai CC. The reverse lateral arm flap, based on the interosseous recurrent artery, for cubital fossa burn. Br J Plast Surg 1994;47: Perignon D, Havet E, Sinna R. Perforator arteries of the medial upper arm: anatomical basis of a new flap donor site. Surg Radiol Anat 2013;35: Matloub HS, Ye Z, Yousif NJ, Sanger JR. The medial arm flap. Ann Plast Surg 1992;29: Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991;44: Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg 2006;56: 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: Uchida R, Matsumura H, Imai R, Tanaka K, Watanabe K. Anatomical study of the perforators from the ulnar palmar digital artery of the little finger and clinical uses of digital artery perforator flaps. Scand J Plast Reconstr Surg Hand Surg 2009;43;2: Jones NF, Jarrahy R, Kaufman MR. Pedicled and Free Radial Forearm Flaps for Reconstruction of the Elbow, Wrist, and Hand. Plast Reconstr Surg 2008;121;3: Tizian C, Sanner F, Berger A. The proximally pedicled arteria radialis forearm flap in the treatment of soft tissue defects of the dorsal elbow. Ann Plast Surg 1991;26: Govila A, Sharma D. The radial forearm flap for reconstruction of the upper extremity. Plast Reconstr Surg 1990;86: Jutte DL, Rees R, Nanney L, Bueno R, Lynch JB. Latissimus dorsi flap: A valuable resource in lower arm reconstruction. South Med J 1987;80: Stevanovic M, Sharpe F, Thommen VD, Itamura J, Schnall SB. Latissimus dorsi pedicle flap for coverage of soft tissue defects about the elbow. J Shoulder Elbow Surg 1999;8: Choudry UH, Moran SL, Li S, Khan S. Soft-tissue coverage of the elbow: an outcome analysis and reconstructive algorithm. Plast Reconstr Surg 2007;119: Carriquiry CE. Versatile fasciocutaneous flaps based on medial septocutaneous vessels of the arm. Plast Reconstr Surg 1990;89; Breidenbach WC, Adanson W, Terzis JK. Medial arm flap revisited. Ann Plast Surg 1987;18: Cil Y, Kocabiyik N, Ozturk S, Isik S, Ozan H. A New Perforator Flap Distal Medial Arm: A Cadaveric Study. Eplasty 2010;10:e Karamursel S, Bağdatlı D, Demir Z, Eray T, Selim C. Use of Medial Arm Skin as a Free Flap. Plast Reconstr Surg 2005;115: Perignon D, Havet E, Sinna R. Perforator arteries of the medial upper arm: anatomical basis of a new flap donor site. Surg Radiol Anat 2013;35: Zang M, Yu s, Xu L, Zhao Z, Ding Q, Guo L, et al. Freestyle perforator- based propeller flap of medial arm for medial elbow reconstruction. Microsurgery 2015;35: Hand and Microsurgery Year 2018 Volume 7 Issue