Propeller Flaps in the Upper Extremity: Arm and Forearm Reconstruction

Abstract

The propeller flap is an island of skin that is raised on its pedicle (most commonly a single perforator) and can rotate 180 degrees to cover a soft tissue defect. Thanks to these features, the propeller flap brings reliable tissue from outside of the zone of injury while sparing the main vessels of the upper extremity. This technique limits the donor site to the same limb, captures skin characterized by having the same color and texture, does not necessarily need a microvascular anastomosis, and overall reduces the operating time and surgical cost. Our intent here is to present 27 cases with different soft tissue defects of the upper arm and forearm that have been successfully reconstructed using propeller flaps. The surgical technique, with emphasis on the anatomy of the upper arm, is described. In particular, use of a freestyle approach to customize a perforator-based propeller flap to cover defects from small to medium size is detailed. In our experience, the use of a perforator propeller flap in the upper extremity for resurfacing represents both a very reliable and aesthetically pleasant option.

Reconstruction of the upper extremity is usually very challenging because joint, bone, nerve, and tendon may be exposed, and a simple skin graft can lead to an unstable wound or contracted scar.

Ideally, the coverage should be thin and pliable and match color and contour to improve the aesthetic outcome of the upper extremity. The procedure should be performed in one stage to allow early mobilization, thereby improving functional results and reducing hospitalization and therefore costs.

With the introduction of the perforator propeller flap, ¹ it is now possible to raise a flap on a single vessel close to the defect, with great freedom in flap planning. ² The great benefit of this technique is the advantages of a free flap and those of a local pedicle flap.

Like a free flap, the propeller flap is made of tissue taken out of the injury zone and is based on an identified and reliable vascular pedicle. But, as a local flap, it is harvested from the same anatomical region, therefore having the same skin texture and color and a faster operating time without the need of a microscope or vascular anastomosis. ³

The idea of perforator vessels piercing the subcutaneous tissue to vascularize the skin, coming from a principal vascular axis, was first reported by the Italian surgeon Pieri, who already in 1918 had drawn all the cutaneous perforator of the body and suggested a flap design according to the course of the main vessels. ⁴ Seventy years later, Kroll and Rosenfield introduced the term perforator flap . ⁵ In 1991, Hyakusoku et al described a flap based on a single pedicle and rotated 90 degrees to resurface a burn scar defect, calling it a propeller flap, because just like a ship's propeller it consisted of a central hub (the pedicle) with radiating blades. ¹ In the past 30 years, several anatomical studies and clinical experiences have refined the technique; however, today, using a freestyle approach based on the perforasome theory, ⁶ a flap can be harvested anywhere in the body, and by dissecting a perforator meticulously down to the main vessel the flap can be propelled about it up to180. ^{7 8}

Materials and Methods

Between March 2009 and September 2019, 18 men and 9 women with a mean age of 38 years (range: 11–68 years) in our experience had upper extremity soft tissue reconstruction with a perforator-based propeller flap of the arm and forearm. The defects resulted from extirpation of soft tissue sarcoma in 16 patients, trauma in 5 patients, debridement of an exposed olecranon implant in 3 patients, excision of an olecranon bursa in 2 patients, and release of postburn scar contracture in 1 patient. The parameters examined included the size and location of the defect, the perforator that was used, the flap size, the degree of rotation of the perforator, management of the donor site (direct closure vs. skin grafting), and flap survival rate. All flaps based on a perforator arising from the vascular system of the hand were excluded.

Relevant Anatomy

To become confident with any perforator flap of the arm, it is important to completely understand the vascular anatomy of the upper limb ( Figs. 1 and 2 ). ^{9 10 11} The main vessels originate from the brachial artery (BA), which divides in the forearm into the radial, ulnar, and common interosseous artery. Before reaching the cubital fossa, the BA during its course in the upper arm gives rise to the following important branches: profunda brachii artery (PBA), superior ulnar collateral artery (SUCA), and inferior ulnar collateral artery. The PBA runs toward the posterolateral region of the arm, and after crossing the medial intramuscular septum divides into two branches: the posterior descending branch and the radial collateral artery (RCA), which runs in the radial sulcus to supply the skin of the middle third of the upper arm overlying the biceps, the brachialis, and the lateral head of the triceps muscle.

Fig. 1.

Vascular anatomy of the upper extremity and perforator-based propeller flaps. BAP, brachial artery perforator; IUCAP, inferior ulnar collateral artery perforator; RAP, radial artery perforator; RRAP, radial recurrent artery perforator; SUCAP, superior ulnar collateral artery perforator; UAP, ulnar artery perforator.

Fig. 2.

Diagram illustrating the vascular territories of the upper arm: ( A ) anterior and ( B ) posterior. 1, brachial artery; 2, superior ulnar collateral artery; 3, radial collateral artery; 4, inferior ulnar collateral artery; 5, arterial network around the elbow joint; 6, radial artery; 7, ulnar artery; 8, posterior interosseous artery; 9, anterior interosseous artery.

Typically, in the upper limb, the perforators have an intermuscular or septocutaneous course, passing in the septum between the muscle bellies, although proximally in the forearm they often can have an intramuscular course.

In the upper arm, the BA provides circulation to the skin in the anteromedial region through three to four perforators arising in the medial intermuscular septum between the triceps and biceps. Perforators of the RCA, the terminal branch of the PBA, arise from the lateral septum between the triceps and brachialis muscles to supply the skin of the anterolateral and posterolateral regions of the upper arm.

The lower third of the anteromedial and posteromedial regions of the upper arm mainly is vascularized by perforators of the SUCA. The SUCA gives off anteriorly two indirect perforators to the medial region, one situated only 3 cm from the elbow joint, and posteriorly a direct cutaneous trunk, which supplies the posteromedial region to become part of the rete cubiti. The elbow and cubital fossa are nourished by perforators of the arterial network surrounding the elbow, with the latter derived from recurrent and collateral branches from the brachial and deep BAs.

Perforators from the radial artery are generally found in the septum between the brachioradialis and flexor carpi radialis muscles, and supply the skin of the volar and radial side of the forearm. Ulnar artery perforators (UAPs) course in the septum between the flexor carpi ulnaris and flexor digitorum superficialis muscles to vascularize the ulnar and contribute to the volar region of the forearm.

The posterior and anterior interosseous arteries participate in providing circulation to the posterior region of the forearm, respectively in turn the proximal two thirds and the distal third. The perforators from the posterior interosseous artery emerge between the extensor carpi ulnaris and extensor digiti minimi muscles. The perforators of the anterior interosseous artery emerge between the extensor digitorum communis and extensor digiti minimi to reach the skin of the posterior region of the more distal forearm.

Surgical Technique

Patient Selection

The main indications for perforator pedicled propeller flaps are small- to medium-sized defects of the upper limb, ranging from burn scar to cancer removal. Greater attention must be given during traumatic soft tissue loss restoration, ensuring to choose the perforator well out of the zone of injury and to commit to that perforator only after direct examination during the surgery.

Preoperative Study

The preoperative use of an audible Doppler when performing a freestyle perforator flap ¹² can be quite difficult because the main source vessels are more superficial than in the lower limbs, and the sound perceived can be quite confusing. To differentiate the signals, mark as the perforator that with a more consistent, loud, and high pitched Doppler sound. In actuality in our experience, we commit to a perforator only after direct exploration of the vessel. For this purpose, the initial skin incision is made in such a fashion to allow visualization of the perforator piercing the subcutaneous tissue, without compromising any further surgical backup plan such as a regional axial flap or even-free flap.

Flap Planning and Designing

Using a freestyle perforator-based propeller flap approach, ¹³ we initially mark a perforator not very far from the defect to avoid unnecessarily a long flap that would add a risk of inadequate distal perfusion. The perforator will be the pivot point of an ellipsoid shaped flap that will be rotated 180 degrees to cover the defect. ¹⁴ The flap itself is then designed by first measuring the distance from the perforator to the distal edge of the defect. This measured length is transferred in the opposite direction from the perforator on what will be the longitudinal axis of the flap. Often, making this a little longer will provide a safety factor, as sometimes some length is lost on rotation. The defect width is measured and marked on either side of the perforator to be the width also of the flap.

Operative Technique

A tourniquet is always used after arm elevation only for exsanguination to minimize any bleeding that could obscure the field while still insuring that visualization of any veins will be straightforward. In our experience, we prefer to raise the flap on the suprafascial plane to obtain a thinner flap and preserve the fascia.

In addition, if secondary tendon reconstruction is required, the suprafascial dissection leaves a better gliding plane. The perforator must be carefully identified using the planned exploratory incision and then cautiously dissected for a length that allows rotation without collapse obstructing the vein, usually achieved by releasing all fibrous strands and vascular branches encountered. The vessels are irrigated with lignocaine as a vasodilator. Rotation of the flap is chosen in the direction that results in the least kinking of the perforator.

The tourniquet is then released and flap perfusion assessed. We prefer to leave the flap for 15 minutes in the original position before starting the closure, as if there is any sign of congestion, we may decide to perform a venous microanastomosis for supercharging. Although, usually, the propeller flap may appear a bit congested during the first few days, most often this is an autoresolving phenomenon that will gradually disappear. When direct closure of the donor site is not possible, a traditional split-thickness skin graft is used to cover the defect—a far superior option than risking a compartment syndrome.

Postoperative Care

The arm is splinted for 2 weeks and strict limb elevation is maintained. Arm slings are generally avoided for the initial couple of days to avoid any risk of dependency. A crepe bandage is initiated on day 7 with progressive compression. Sutures are removed on the 10th to 12th day if healing appears adequate, and then arm mobilization and physiotherapy are started as needed.

Clinical Examples

Case 1: Brachial Artery Perforator Propeller Flap

A 16-year-old woman presented with a high-grade fibromyxoid sarcoma of the elbow. Wide local excision produced a 12 × 8 cm soft tissue defect ( Fig. 3 ). With elbow flexion, the wound was seen to increase in surface area, and underlying nervous structures were made more vulnerable. A freestyle perforator-based propeller flap reconstruction was planned. Using a Doppler ultrasound probe, three perforators were identified about the defect ( Fig. 3 ). The perforator with the most visible pulsation upon direct exploration was coming from the BA and chosen as the pedicle of a 16 × 6 cm flap ( Fig. 4 ). The pedicle vessels were dissected for 3 cm in the septum between the triceps and biceps muscles to allow flap rotation without pedicle kinking ( Fig. 5 ). The donor site was closed directly ( Fig. 6 ).

Fig. 3.

Soft tissue defect over the elbow after sarcoma excision. Preoperative marking of the brachial artery perforators around the defect.

Fig. 4.

Propeller flap islanded eccentrically on the perforator coming from the brachial artery. This operative picture clearly shows the classic propeller design with the long blade proximal to the perforator pivot and the short blade more distal.

Fig. 5.

Counterclockwise 180-degree rotation of the flap into the defect.

Fig. 6.

Postoperative picture at 1 year.

Case 2: Radial Collateral Artery Perforator Propeller Flap

A 44-year-old woman presented with an elbow soft tissue defect following olecranon bursitis. An RCAP-based propeller flap, measuring 10 × 4 cm, was planned to cover the defect, measuring 7 × 5 cm. The location of perforators was confirmed preoperatively using acoustic Doppler ( Fig. 7 ). A perforator that arose from the lateral intermuscular septum of the arm was included ( Fig. 8 ). The flap was rotated 180 degrees to cover the defect. The donor site was closed primarily without the need for a skin graft ( Fig. 9 ). The patient retained full range of elbow motion, and the flap provided stable wound coverage without adherence to underlying structures.

Fig. 7.

Preoperative 7 × 5 cm elbow defect, with identification of the radial collateral artery perforators.

Fig. 8.

Intraoperative picture showing the perforating vessel pedicle coming from the lateral intermuscular septum.

Fig. 9.

Immediate postoperative picture with inset flap.

Case 3: Posterior Interosseous Artery Perforator Propeller Flap

A 43-year-old man with a soft tissue sarcoma of the elbow underwent wide excision and reconstruction with a posterior interosseous perforator flap. The flap measuring 16 × 6 cm was raised from the posterior aspect of the forearm, where a highly visible perforator was found piercing the fascia between the extensor carpi ulnaris and extensor digiti minimi muscle ( Fig. 10 ). After flap rotation ( Fig. 11 ), the donor site was closed with a skin graft ( Fig. 12 ) and arm splinted for 2 weeks.

Fig. 10.

Intraoperative picture showing a posterior interosseous perforator coming from the septum between the extensor carpi ulnaris and the extensor digiti minimi muscles.

Fig. 11.

Clockwise 180-degree rotation of the flap to cover the exposed elbow joint.

Fig. 12.

One year postoperative appearance of the reconstruction.

Case 4: Ulnar Artery Perforator Propeller Flap

A 49-year-old right-hand dominant woman presented with a recurrence of a synovial sarcoma of the left wrist, which had been treated in another hospital with an unplanned excision. The patient had received repeated marginal excisions including the third and fourth sensory palmar branches of the median nerve, and the flexor digitorum profundus (FDP) and superficialis tendons of the ring and long fingers ( Fig. 13 ). Silastic tendon rods were placed to allow secondary reconstruction of the excised FDP tendons. An elliptical propeller flap measuring 20 × 7 cm based on a UAP was designed to cover the defect ( Fig. 13 ). The flap was raised, and the pedicle was isolated to allow 180-degree clockwise rotation ( Fig. 14 ). To reach comfortably the center of the wrist, the flap was passed beneath the flexor carpi ulnaris tendon. This maneuver further lengthened the reach of the pedicle that now was 3 to 4 cm in length to allow insetting while carefully avoiding any stretching or kinking of the perforator ( Fig. 15 ). Following early healing ( Fig. 16 ), urgent treatment was completed with radiation therapy.

Fig. 13.

Excision of recurrent synovial sarcoma of the palm with placement of flexor tendon rods that will require secondary tendon grafts. Dorsal ulnar artery perforator flap intended to cover the palmar defect rests on the ulnar side of the forearm.

Fig. 14.

The dorsal ulnar artery perforator propeller flap was harvested.

Fig. 15.

The flap is passed beneath the flexor carpi ulnaris tendon. This maneuver facilitated tension–free insetting of the flap in the palm.

Fig. 16.

Result 2 weeks after surgery, with well-healing flap and primary donor-site closure.

Discussion

Since their introduction, propeller flaps have gained great popularity among the reconstructive surgery community. Although the routine practice of this technique is largely accepted for lower limb soft tissue defect restoration, ^{15 16 17} in the upper limb the freestyle perforator propeller flaps can also play a very important role. ^{18 19 20} This is because they allow the resurfacing of reasonably sized defects using a commiserate sized skin paddle that can be harvested on a single vessel outside of the zone of injury, limit the donor-site morbidity to the same limb, and will not sacrifice any major blood vessel of the upper limb. ²¹ As an added bonus, since the tissue comes from the same anatomical region, it respects the “like with like” principle to ensure a better cosmetic outcome, which may be very important in a socially exposed part of the body like the upper extremity. ²²

Since rotation of the propeller flap is based on a single vascular pivot point, the perforator, there is no need for a microvascular anastomosis, thereby reducing both operating time and surgical risks. ²³ In complex cases where secondary procedures are needed, like for staged tendon reconstruction, the use of a perforator flap will have a faster and more reliable neovascularization compared with a skin grafted muscle flap, which avoids the risk of delayed partial flap loss or wound breakdown following any flap reelevation.

Regardless of these advantages, the use of propeller flap in the upper arm can be quite challenging mainly due to the shorter length of the perforator pedicle when compared with that of the lower limb. Thus, it is very important to dissect the perforator down to the main vessel and then check that when the flap is rotated the vein does not collapse. Because the pedicle vessels do not withstand any twist when empty, ²⁴ we do release the tourniquet before flap rotation to allow blood to completely perfuse the flap for a good 15 minutes. This is especially true for the distal forearm where a perforator coming from the radial or anterior interosseous artery tend to be quite short.

As shown by the anatomical study of Chen at al, ²⁵ the upper extremity has more than 100 perforators that can be used to raise a flap. If the skin is divided according to source vessel, there are 16 distinct territories. ²⁵ In Fig. 2, the main vascular supply of the upper arm and forearm can be seen. The rich vascular net so created allows harvest of a flap anywhere around a defect, as long as the design is kept along the longitudinal axis of the limb to include the preferable linking vessels between perforasomes and to facilitate primary closure of the donor site.

As a rough guideline by region, axillary defects can be resurfaced using a propeller flap from the medial side of the upper arm based on perforators that arise from the BA or SUCA, as the major laxity there will allow direct closure of the donor site and a hidden scar as routine in a brachioplasty. The elbow must be covered realizing the need for surface area extension of the defect to allow unimpeded flexion. The closest perforator in this series had great variability, as a flap could be harvested on perforators of the BA, RRA, SUCA, or PIA. Although better overviewed in another part of this issue, the wrist and the hand can be covered using a perforator from any of all four main vessels of the forearm.

Conclusion

A perforator-based propeller flap provides a comparatively simple and rapid solution for complex skin deficits of the arm and forearm, albeit maintaining the charm and challenge while requiring the sophistication of a microsurgical technique. As demonstrated in this large series, this concept provides a reliable and aesthetically pleasing technique for upper extremity reconstruction.