|Year : 2014 | Volume
| Issue : 1 | Page : 77-84
Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!
Nikhil Panse, Parag Sahasrabudhe
Department of Plastic Surgery, B.J.Government Medical College & Sassoon Hospital, Pune, Maharashtra, India
|Date of Web Publication||31-Mar-2014|
Vimal Niwas, Sudarshan Society, Near Model Colony Post Office, Shivajinagar, Pune - 16
Source of Support: None, Conflict of Interest: None
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.
Keywords: Hand defects; perforator flaps; propeller flaps; perforator based propeller flaps; upper extremity; wrist defects
|How to cite this article:|
Panse N, Sahasrabudhe P. Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!. Indian J Plast Surg 2014;47:77-84
|How to cite this URL:|
Panse N, Sahasrabudhe P. Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!. Indian J Plast Surg [serial online] 2014 [cited 2019 May 20];47:77-84. Available from: http://www.ijps.org/text.asp?2014/47/1/77/129628
| » Introduction|| |
In spite of the early reluctance of the plastic surgery community to accept regular use of perforator based propeller flaps in clinical practice, these flaps are gradually looked upon as a safe and reliable option in reconstructive plastic surgery.
A propeller flap is an island flap that moves around a stationary vascular axis, and reorients itself from one axis to the other.  Early description of propeller flaps mentioned of a thick subcutaneous pedicle which restricted the arc of rotation of these flaps. With increasing knowledge and awareness of the location and the vascular territory perfused by cutaneous perforators, it is now possible to design propeller flaps based on a single perforator, so-called "perforator based propeller flaps." These flaps permit flap rotation up to 180°. The concept of free styling of perforator flaps offers greater degree of freedom and intra operative maneuverability in flap planning since flap harvest can be carried out in any anatomical area where a sizable perforator can be detected. 
Although there are a large number of reports of using perforator based propeller flaps in lower limb reconstruction, the application of this technique in the upper extremity is infrequently reported. , We present our experience of free style perforator-based propeller flaps for upper limb soft tissue reconstruction.
| » 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 March 2013. All the flaps were performed by the first author for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcomes are evaluated and presented as an uncontrolled case series.
63 flaps were performed in 62 patients. 60 flaps were islanded on a single perforator, and three flaps were islanded on two perforators. All flaps were rotated around the axis of the perforator through various degrees ranging from 90 degrees to 180 degrees. The three perforator flaps which were islanded on two perforators were rotated up to 90 degrees. It was done after ascertaining intra operatively that the two perforators do not impinge on each other.
Generally most of the perforators in the upper extremity follow the intermuscular septum distally, but proximally they often pierce the muscle bellies. , In the upper arm, they arise from the lateral septum between triceps and brachialis muscles and from medial intermuscular septum between triceps and biceps. , Perforators of radial artery are generally found between the septum between brachioradialis and flexor carpi radialis. , The ulnar artery perforator arises in the septum between flexor carpi ulnaris and flexor digitorum superficialis. , The perforators from the posterior interosseus artery emerge between extensor carpi ulnaris and extensor digitiminimi. The perforators of the anterior interosseus artery emerge between extensor digitorum communis and extensor digiti minimi to reach the skin. ,
Patient selection: Small to moderate sized defects, post electric burn defects and resurfacing after post burn contracture release can be effectively managed by perforator based propeller flaps. We generally tend to avoid performing perforator flaps for those extremities, where in there is extensive trauma zone, associated multiple fractures of the extremity above the level of the defect. This is to ensure that the perforator is free of the trauma zone. However, final decision regarding utility of perforator is determined intra-operatively.
We consider preoperative Doppler as desirable and not mandatory prerequisite for performing a free style perforator flap. The Doppler study is made with a hand held Doppler with an 8 Hz frequency probe around the axis of the major vessel adjoining the defect. The perforator with a consistent, audibly loud and high pitched Doppler signal is marked.  In our clinical practice, we have noticed that it is a bit more difficult to differentiate a perforator from the main vessel in the upper extremity than in the lower extremity, probably because the shorter length and proximity of the perforators to the main vessel in the upper extremity.
We prefer a partially exsanguinated extremity as it eases the identification of the perforators.
A non-committal generous exploratory incision is made. Incision is made in such a fashion that if need arises, tissue on both sides of the incision could be used for harvesting a flap. Due care is taken to make maximum use of the available tissue on both sides of the incision. Due care must also be taken while making the incision so that, if appropriate perforator is not identified or if found to be in trauma zone, the same incision can be used to delay a fasciocutaneoous flap or harvest a regional axial flap or as a gateway to dissect the recipient vessel for micoanastomosis.
Subfascial or suprafascial identification of perforator
Although there are no fixed rules, our choice of using a suprafascial or a subfascial perforator flap depends on the defect. For defects like amputation stumps, or defects where secondary procedures are not anticipated, we generally prefer subfascial incision to identify the perforator and raise the flap [Figure 1]. This is helpful as we have noticed that, if the skin part of the flap is lost, the fascia may still be intact and graftable in due course of time.
|Figure 1: The subfascial distal radial artery perforator flap: (a) Crush hand, (b) Defect identified after debridement and fixation, (c) Flap islanded on distal radial artery perforato, (d) Well settled flap|
Click here to view
We have realized that; in those cases with associated nerve injuries or tendon injuries, which might need tendon transfers or tendon grafts at a later date, it is better to go for a suprafascial flap harvest. This ensures a smooth subfascial tract for tendon transfer/tendon graft if need arises [Figure 2].
|Figure 2: The suprafascial distal radial artery perforator flap: (a) Distal ulnar defect, (b) Flap islanded on distal radial artery perforator, (c, d) Flap in situ with donor area skin grafted|
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Flap planning and designing
In a free style concept, the planning of the flap dimensions is intraoperative. After a non-committal exploratory incision is made, the perforators are identified. In general we tend to avoid any perforator which is excessively close to the edge of the wound as the perforator might be fragile because of post traumatic vascular disease. We also prefer not to choose a perforator which is too far from the defect as it increases the length of the flap unnecessarily.
After an appropriate, reliable perforator is identified, the distance of the perforator to the distal edge of the defect is measured. Planning is made in reverse, considering the degree of rotation involved, and distal edge of the flap is marked along the long axis of the upper extremity. Due care is taken to add 1-1.5 cms to the long axis of the flap. The width of the defect is noted and marked on either side of the perforator.
The flap is then harvested, and islanded on the perforator. All fibrous strands are dissected to prevent compression on the perforator after rotation. Throughout the procedure, a lignocaine soaked small piece of gauze is kept over the perforator. The perforator/guaze is irrigated by lignocaine solution to prevent drying and spasm of the perforator. , Once the flap is islanded, tourniquet is released and flap is permitted to perfuse for a while before rotation. Whenever possible, a subcutaneous vein is kept at the base of the flap. It is possible to anastomose this vein to a local vein to augment the venous outflow if a venous compromise is anticipated. Cautery is used judiciously as and when needed away from the perforator to achieve absolute hemostasis.
The flap is then propelled as necessary to cover the defect. In case where 180 degrees rotation is needed, it is advisable to turn the flap from the side which causes the least degree of torsion on the perforator. This is decided on visual inspection. The initial sutures are taken along the sides of the perforator to prevent traction to the perforator. , Due care is taken to inset the flap without any tension. The flaps appear a bit congested in the initial few days, but gradually settle down with time. Few clinical images demonstrating the distal ulnar atery perforator flap, recurrent radial artery perforator flap, proximal ulnar artery perforator flap and proximal radial artery perforator flap are shown [Figure 3],[Figure 4] and [Figure 5].
|Figure 3: Distal ulnar artery perforator flap for dorsum hand defect. (a) Defect on dorsum of hand, (b) Flap islanded, (c, d) Well settled flap and graft|
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|Figure 4: Recurrent radial artery perforator flap & Proximal ulnar artery perforator flap. (a) Elbow defect, (b) Recurrent radial artery perforator flap harvested, (c) Proximal ulnar defect & proximal ulnar artery perforator flap harvested, (d, e) Well settled flaps|
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|Figure 5: Proximal radial artery perforator flap. (a, b) Elbow contractures; (c) Harvested proximal radial artery perforator flap, (d) Flap islanded on perforator, (e) WEll settled flap|
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Post operative care
Splintage and strict limb elevation is maintained for a period of 10 days. Arm slings are generally avoided for the initial couple of days. If they are applied, they are applied in a fashion that does not cause compression over the perforator. Crepe bandage is initiated on day 7. Sutures are removed on 10-12th day, and physiotherapy as and where necessary is initiated.
The perforator flaps performed in our series were:
- Axillary Artery Perforator flap. (AxAP)
- Brachial artery perforator flaps.( BrAP)
- Recurrent radial artery perforator flaps. (RRAP)
- Recurrent ulnar artery perforator flaps. (RUAP)
- Proximal radial artery perforator flaps. (PRAP)
- Proximal ulnar artery perforator flaps. (PUAP)
- Distal radial artery perforator flaps. (DRAP)
- Distal ulnar artery perforator flaps. (DUAP)
- Posterior interosseus artery perforator flaps. (PIAP)
- Anterior interosseus artery perforator flaps. (AIAP)
- Ulnar digital artery perforator flaps. (UDAP)
| » Results|| |
63 free style perforator flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013.The follow up ranged from 3 weeks to six months. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn reconstruction including electric burns, and two for post snake bite defects [Figure 6].
The age group varied from 9 years to 51 years with the average age of 34 years. Of the 62 patients, 38 were male and 24 were female. Most of the patients of trauma injury were male, and most of the patients with burn injuries were females.
In case of use of free style perforator based propeller flaps for post burn resurfacing, the flaps were used in 7 cases of little finger contracture, 6 in case of wrist contracture, 4 in electrical burns, 8 in elbow contractures, 4 for axillary contractures, and one for adduction contracture of the thumb. Both post snake bite defects were on the dorsum of the hand and forearm respectively. Of the trauma cases, two defects were on the arm region, six were in the elbow and proximal forearm region, and 23 defects were in the distal wrist, palm and dorsum of hand. Two flaps were performed in one patient of post traumatic defect over the elbow, and the proximal forearm.
The defect sizes ranged from 3 × 4 cm 2 to 6 × 10 cm 2 . The largest defect in our series was a 6 × 10 defect on the palm involving almost the entire palmar surface, which was resurfaced by the distal ulnar artery perforator flap. The choice of perforator was commonly decided on the area near the perforator. Axillary artery perforator flap was performed in 4 cases of post burn axillary contractures. Brachial artery perforator flaps were performed in 3 patients, of which 2 were post traumatic defects, and one was post burn elbow contracture. Recurrent radial artery perforator flaps were done in two post traumatic defects. Recurrent ulnar artery perforator flaps were done for 3 post-traumatic defects. Proximal radial artery perforator flaps were done for 4 cases of post burn elbow contractures.
Distal radial artery perforator flaps were performed in 16 patients, of which 9 were for post traumatic defects, 7 were for post burn resurfacing.
Proximal ulnar artery perforator flap was performed for one case of trauma, and two cases of post burn contractures. Distal ulnar artery perforator flap was performed in 8 cases of trauma and 3 cases of post burn resurfacing and one case of snake bite.
Posterior interosseus artery perforator flap was done for one case of post snake bite defect. Anterior interosseus artery perforator flap was done in 6 cases of trauma, and two cases of post-burn resurfacing. Ulnar digital artery perforator flap  was performed in 7 cases of post-burn little finger contractures [Figure 7].
We were able to achieve primary closure in all the seven cases of ulnar digital artery perforator flaps. Apart from that, we were able to achieve primary closure in three cases only. That was because of the larger size of our defects. However, the graft requirement was significantly reduced due to the propeller design of the flap.
Of the 63 flaps, there was necrosis in 8 flaps. Of the 8 flaps, four flaps underwent complete necrosis. One of them was for post-burn axilla defect. It was managed by a graft after debriding the flap. The other three were post traumatic defects, which were managed by a second flap cover by either an abdominal or groin flap. There was partial necrosis in four flaps. One of them was managed by another perforator plus flap for the distal forearm [Figure 8]. Two defects were skin grafted and one healed secondarily. There was no significant correlation of smoking and diabetes to flap failure.
|Figure 8: Necrosed radial artery perforator flap. (a) Distal radial defect, (b, c) Distal radial artery perforator flap harvested, (d) Necrosed flap, (e, f, g) Defect covered by perforator plus flap|
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One flap of brachial artery perforator flap for mid-humeral defect had settled well, but the fixator was loosened, and the proximal fracture fragment penetrated through the flap, puncturing the flap [Figure 9]. The fixator was realigned, and the rent in the flap was sutured.
|Figure 9: Brachial artery perforator flap. (a) Humerus exposed, (b) Flap islanded on perforator, (c) Identification of perforator, (d) Well settled flap, (e) Proximal fracture segment piercing through the flap|
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All the flaps were lost because of congestion; as is commonly encountered with perforator flaps. Amongst the four flaps which were completely lost, 3 had hematoma formation and one had compression of overlying muscle over the perforator.
Failure of 8 flaps out of 63 flaps almost amounts to a 12-13% failure rate. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we have a significant failure rate, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.
| » Discussion|| |
Pedicle local flaps, regional flaps, distant flaps and free flaps can be used to resurface defects over the upper extremity. Each of them has its own set of advantages and disadvantages.
Pedicle local flaps (transposition or rotation) are simple and rapid to execute and bring local skin with a good color and texture match. However, their arc of rotation is generally restricted to 90°, and their utility is limited to areas of skin laxity. These flaps almost always lead to dog ear formation necessitating further revisions. 
Pedicle distant flaps like abdominal and groin flaps are reliable and safe. But it requires prolonged immobilization which may result in stiffness of uninvolved joints. The bulk can be excessive and repeated debulking surgeries might be necessary. Pedicle regional flaps (radial and ulnar artery forearm flaps and posterior interosseus artery flaps) have all the advantages of local flaps and also have a greater arc of rotation.  Radial and ulnar artery flaps necessitate division of a major vessel of the upper extremity. The posterior interosseus artery flap needs considerable dissection, and at times may be complicated because of aberrant anatomy.
Free flaps are a good option for medium to large defects with a variety of donor options to suit the requirements of the particular patient. However they are infrastructure dependent, have a significant learning curve and have a potential for total flap loss. Moreover, facilities are not universally available.
A perforator-based propeller flap for the upper limb combines the advantages of pedicled local flaps (good tissue match), pedicled regional flap (180° arc of rotation), pedicled distant flap (reliable), and free flap (tissue away from zone of injury). 
In addition, literature review suggests that it allows linear closure of the donor defect in smaller defects.  This is made possible by the propeller design of the flap, which on rotation brings the bridge segment of the flap into the donor defect, making closure easier.
In our series however, we were able to achieve primary closure of the donor defect in only three cases. This was because of our larger defect size. The requirement of skin graft was definitely reduced due to the propeller design of the flap.
The upper extremity is generally exposed, and therefore skin graft over the exposed upper extremity is not an aesthetically pleasing sight. This might be one of the reasons why the perforator based propeller flaps are not so popular in the upper extremity reconstruction.
However, most of the patients coming to our unit are from the poor socioeconomic strata and daily wages workers. Their main concern is going back to work as early as possible and aesthetic outcomes are the least of their concerns. Free style perforator based propeller flaps offer a safe, reliable and single stage option for these patients with minimal functional morbidity and without sacrifice of a major vessel. These flaps are neither time consuming, nor infrastructure dependent. They have a significant disadvantage of poor donor site aesthetics. In a resource poor country like India; these flaps have a definite role to play in soft tissue reconstruction of the upper extremity.
The major drawback of a perforator-based propeller flap is that the perforator must be intentionally twisted to allow the flap to rotate. The perforators of the upper extremity are generally shorter in length as compared to those of the lower extremity. TC Teo  feels that one of the potential limitations to the wider application of the propeller flaps, especially in the distal forearm is the relatively short pedicle, which does not tend to withstand extreme (180°) rotation so well.
Even though the pedicle length and diameter of the upper extremity perforators is less as compared to those of the lower extremity, so is the thickness of the skin and fascia which is transferred on the perforator. Few previous experimental studies have studied the effect of pedicle twisting on flap survival. ,,,,
Based on these studies and reports in the literature, perforator-based propeller flaps with a rotation up to 180° have shown to be viable and versatile. ,,,,,,,
More often, it is obvious as to rotation in which direction will cause less pedicle twisting. In those cases, which need 180° twist, flap rotation is attempted from both sides, and rotation resulting in minimal twist is selected.
Shimpei Ono et al. feel that an empty vessel is more susceptible to kinking as compared to a vessel with flow, and they attempt clockwise and counterclockwise rotation of flap to select the direction of rotation before release of the tourniquet. When a rotation has been selected, they put the flap back in its native position. They do the actual rotation after release of the tourniquet. We, however feel that when a rotation is performed, one of the veins accompanying the perforator gets kinked, and the other one opens up; and unless the veins are filled it is difficult to determine the proper direction of rotation.
Contradictory to Shimpei Ono et al., after the flap is harvested, we release the tourniquet and flap is allowed to perfuse. To select the actual rotation, we rotate the flap clockwise and counterclockwise after the release of tourniquet with a couple of minute's interval between the two rotations to prevent spasm to the perforator. The direction causing the least torsional effects is selected. It is also important to isolate the pedicle and obtain as much length as is safely possible when a 180° rotation is planned. This minimizes the tortional effects on the pedicle. 
Saint-Cyr et al. have mapped out the territory perfused by a single perforator by carrying out static and dynamic dye injection studies in fresh cadavers.  They studied the radial artery, ulnar artery, and dorsal metacarpal artery perforator flaps in the upper limb. They introduced the concept of a perforasome (unique vascular territory supplied by a single perforator) and determined that the vascular axis of perforator flaps should follow the axial alignment of the linking vessels, which in turn follows the axial anatomy of the limb. When a flap includes two perforasomes, the link vessels open up to perfuse the flap from a single perforator. This is analogous to the choke vessel concept proposed by Taylor et al. 
To the best of our knowledge, how much flap can be safely harvested on a single perforator in upper limbs is unknown. It has been suggested that flaps up to one-third of limb length can be safely harvested in lower limb.  Until the exact territories can be determined, it is best to raise flaps that fall within the static territories. 
To the best of our knowledge and literature search, ours is the largest series of free style perforator based propeller flaps used for upper extremity reconstruction, wherein we have included various flaps for varied indications in the upper extremity. We used past clinical and anatomical studies of upper limb perforator flaps and our clinical experience to determine the size of our perforator-based propeller flaps. Although we have rarely used these flaps to resurface defects as large as the entire palm, we suggest these flaps are ideal for defects where the donor sites can be closed primarily or with minimal amount of skin graft over the donor site.
The upper limb has more than 100 cutaneous perforators (_0.5 mm diameter). , Chen et al. divided the skin of the upper extremity into 16 vascular territories based on the deep trunk vessels from which these perforators arise.  A perforator-based propeller flap can be designed on any of these perforators.
The axilla, elbow, forearm, wrist, and hand represent the major anatomical areas that usually require flap reconstruction.
In our series, we have used various perforators depending upon the area to be covered. Perforators from the medial aspect of the arm are generally selected for resurfacing the axilla, and midhumeral defects. This is mainly because of hidden donor site, and greater laxity of the tissues there. Recurrent radial or ulnar artery flaps are decided depending on the location of the defects. Generally radial sided wrist and hand defects are covered by radial artery perforator flaps, ulnar defects are covered by ulnar artery perforator flaps. Defects over dorsum are managed by anterior interosseus artery perforator flaps or the posterior interosseus artery flaps.
A perforator-based propeller flap is designed in the long axis of the limb because there is greater skin laxity in the long axis when compared to the transverse axis.  In addition; flaps designed along the long axis include the linking vessels (that follow the axis of the limb). 
| » Conclusion|| |
The availability of free style perforator flaps in our armamentarium for management upper extremity soft tissue reconstruction has increased our choices greatly. It has often given simple options to complex reconstructions. This technique provides us with a rapid and reliable reconstruction with acceptable aesthetic outcomes, especially when donor site is closed primarily. Proper patient selection, atraumatic handling of the perforator during flap harvest, complete isolation of the perforator to minimize the tortional effects, absolute hemostasis will give us good outcomes in free style perforator based propeller flaps for upper extremity reconstruction. They can be the first choice option in selected group of patients for upper extremity soft tissue reconstruction.
| » References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]