Versatile clinical application of radial artery perforator flap for hand and wrist reconstruction

Mladen Jovanović; Jelena Nikolić; Aleksandar Komarčević; Vesna Mijatović-Jovanović; Milan Stojičić; Sveto Bjelan

doi:10.2298/VSP220721093J

Mladen Jovanović University of Novi Sad, Faculty of Medicine Novi Sad, Novi Sad, Serbia
Jelena Nikolić University of Novi Sad, Faculty of Medicine Novi Sad, Novi Sad, Serbia
Aleksandar Komarčević University of Novi Sad, Faculty of Medicine Novi Sad, Novi Sad, Serbia
Vesna Mijatović-Jovanović University of Novi Sad, Faculty of Medicine Novi Sad, Novi Sad, Serbia
Milan Stojičić University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Sveto Bjelan University Clinical Center of Vojvodina, Clinic for Plastic and Reconstructive Surgery, Novi Sad, Serbia

DOI: https://doi.org/10.2298/VSP220721093J

Keywords: hand, radial artery, surgical flaps, surgical procedures, reconstructive, wrist joint

Abstract

Background/Aim. Radial artery perforator flap (RAPF) is a type of fasciocutaneous or adipofascial reverse pedicle flap, which proved to be a versatile flap for the reconstruction of small and moderate size soft tissue defects of the forearm, wrist, and hand. RAPF provides suitable skin coverage with elastic subcutaneous tissue thus enabling the protection of exposed or damaged functional structures and their simultaneous repair. The aim of this study was to summarize and analyze the results of the treatment of patients with upper extremity soft tissue defects caused by trauma, infection, burn, or tumor removal, which were reconstructed with RAPF. Methods. This retrospective study included 20 consecutive patients with skin and soft tissue defects of the hand and wrist, treated at the University Clinical Center of Vojvodina from 2012 to 2022. The design of the flaps and length of the pedicles were determined by the recipient site. Tourniquet-induced exsanguination was used during surgery for better visualization. The flaps were elevated and placed at the site of the defect. Data on patients and flaps were summarized upon their collection. Results. Distally based fasciocutaneous RAPF was used in all cases. The average age of the patients was 48 years, predominantly (64%) males. Defects were most often localized on the dorsal part of the hand (60%) and wrist (20%). The most common indications for surgery were trauma (45%) and tumor resection (25%). A satisfactory coverage of the defect was achieved in all 20 patients with no flap loss. Venous congestion was noted in 4 (20%) patients, which resulted in partial necrosis of the flap in 3 (15%) patients. Wound healing was achieved upon conservative treatment by secondary intention in two patients and with a secondary suture in the last one. A surgical site infection occurred in 2 (10%) patients who withdrew after proper local and systemic therapy. Conclusion. RAPF proved to be a workhorse flap for soft tissue reconstruction of the upper limb. This surgical solution led to an excellent functional and aesthetic outcome in the majority of patients. Complex surgical procedures could be done simultaneously, together with the reconstruction of tendons, joints, or fracture stabilization. The reliability and safety of these flaps are confirmed through our clinical data.

References

1. Benanti E, De Santis G, Leti Acciaro A, Colzani G, Baccarani A, Starnoni M. Soft tissue coverage of the upper limb: A flap reconstruction overview. Ann Med Surg (Lond) 2020; 60: 338‒43.

2. Yang GF, Chen PJ, Gao YZ, Liu XY, Li J, Jiang SX, et al. Forearm free skin flap transplantation: a report of 56 cases. Br J Plast Surg 1997; 50(3): 162‒5.

3. Lu KH. The forearm radial arterial turnover flap and its clinical applications. Zhonghua Wai Ke Za Zhi 1982; 20(11): 695‒7, 704. (Chinese)

4. Chang YT, Wang XF, Zhou ZF, Di SY, Sun YC, Chang J. The reversed forearm island fasciocutaneous flap in hand reconstruction: 10 successful cases. Chin J Plast Surg Burns 1988; 4: 41–2.

5. Appleton SE, Morris SF. Anatomy and physiology of perforator flaps of the upper limb. Hand Clin 2014; 30(2): 123‒35, v.

6. Zheng HP, Xu YQ, Lin J. Radial forearm perforator flap. In: Zheng HP, editor. Atlas of perforator flap and wound healing. Singapore: Springer; 2019. p. 135‒60.

7. Das De S, Sebastin SJ. Considerations in Flap Selection for Soft Tissue Defects of the Hand Clin Plast Surg 2019; 46(3): 393‒406.

8. Saint-Cyr M, Mujadzic M, Wong C, Hatef D, Lajoie AS, Rohrich RJ. The Radial Artery Pedicle Perforator Flap: Vascular Analysis and Clinical Implications. Plast Reconstr Surg 2010; 125(5): 1469‒78.

9. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T. Accompanying arteries of the cutaneous veins and cutaneous nerves in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr Surg 1998; 102(3): 779‒91.

10. Homsy C, McCarthy ME, Lim S, Lindsey JT Jr, Sands TT, Lindsey JT Sr. Portable Color-Flow Ultrasound Facilitates Precision Flap Planning and Perforator Selection in Reconstructive Plastic Surgery. Ann Plast Surg 2020; 84(6S Suppl 5): S424‒30.

11. Yamakawa S, Hayashida K. Dorsal hand reconstruction with radial artery perforator-based adipofascial flap. Plast Aesthet Res 2020; 7: 24.

12. Jovanovic M, Janjic Z, Komarcevic A, Mijatovic-Jovanovic V, Marinkovic M, Tomic M. Neurocutaneous flaps for soft tissue reconstruction of the knee, lower leg, ankle and foot: Clinical experience with 32 patients. Vojnosanit Pregl 2019; 76(6): 620–7.

13. White CP, Steve AK Jr, Buchel EW, Hayakawa TE, Morris SF. Reverse radial artery flap perforator anatomy and clinical applications. Ann Plast Surg 2016; 77(3): 345‒9.

14. El-Mahy MM, Atiyya AN, Diab RA. Reconstruction of forearm, wrist and hand skin defects with local perforator flaps. Ain Shams Med J 2019; 70: 335‒46.

15. Wink JD, Gandhi RA, Ashley B, Levin LS. Flap reconstruction of the hand. Plast Reconstr Surg 2020; 145(1): 172e‒83e.

16. Boissiere F, Gandolfi S, Riot S, Kerfant N, Jenzeri A, Hendriks S, et al. Flap Venous Congestion and Salvage Techniques: A Systematic Literature Review. Plast Reconstr Surg Glob Open 2021; 9(1): e3327.

17. Efanov JI, ElHawary H, Chollet A, Mottard S, Borsuk DE. The pediatric arterialized venous flow-through flap. Plast Reconstr Surg Glob Open 2021; 9(3): e3488.

18. Luo X, Zhao B, Chu T, Chen H, Li B, Li Z, et al. Improvement of multiterritory perforator flap survival supported by a hybrid perfusion mode: A novel strategy and literature review. J Tissue Viability 2021; 30(2): 276‒81.

19. Roberts JM, Carr LW, Haley CT, Hauck RM, Michelotti BF. Venous flaps for revascularization and soft-tissue coverage in traumatic hand injuries: A systematic review of the literature. J Reconstr Microsurg 2020; 36(2): 104‒9.

20. Lucchina S, Fusetti C, Lazzaro L, Nistor A, Guidi M. End-to-side innervated sensate radial forearm flap in the hand: A 5-year follow-up. Hand Surg Rehab 2019; 38(3): 207‒10.

21. Raspanti A, Delcroix L, Ghezzi S, Innocenti M. Study of the tendinous vascularization for the compound radial forearm flap plus flexor carpi radialis tendon. Surg Radiol Anat 2016; 38(4): 409‒14.

22. Lahiri A. Managing Mutilating Hand Injuries. Clin Plast Surg 2019; 46(3): 351‒7.

23. Yoon AP, Chung KC. Management of Acute Extensor Tendon Injuries. Clin Plast Surg 2019; 46(3): 383‒91.

24. Starnoni M, Pinelli M, De Santis G. Surgical wound infections in plastic surgery: simplified, practical, and standardized selection of high-risk patients. Plast Reconstr Surg Glob Open 2019; 7(4): e2202.

25. Wang Q, Zhang H, Sun W, Li H. Clinical study on vacuum assisted closure combined with multiple flaps in the treatment of severe hand trauma. Pak J Med Sci 2022; 38(1): 248‒53.

26. Unglaub F, Sauerbier M. Management of soft tissue defects of the hand. Oper Orthop Traumatol 2020; 32(6): 475‒6. (German)

27. Wilson IF, Schubert W, Benjamin CI. The distally based radial forearm fascia-fat flap for treatment of recurrent de Quervain's tendonitis. J Hand Surg Am 2001; 26(3): 506‒9.

28. Uemura T, Takamatsu K, Okada M, Yokoi T, Onode E, Miyashima Y, et al. A case series of seven patients with recurrent median nerve neuropathy treated by the revision surgery of median nerve neurolysis and wrapping with radial artery perforator adipose flap. J Plast Reconstr Aesthet Surg 2020; 73(3): 453‒9.

29. Tiengo C, Macchi V, Porzionato A, Stecco C, Parenti A, Bassetto F, et al. The proximal radial artery perforator flap (PRAP-flap): an anatomical study for its use in elbow reconstruction. Surg Radiol Anat 2007; 29(3): 245‒51.

30. Georgescu AV, Matei IR. Propeller perforator flaps in forearm and hand reconstruction. Eur J Orthop Surg Traumatol 2019; 29(2): 357‒66.

31. Ettyreddy AR, Chen CL, Zenga J, Simon LE, Pipkorn P. Complications and outcomes of chimeric free flaps: A systematic review. Otolaryngol Head Neck Surg 2019; 161(4): 568‒75.

32. Jang HS, Lee YH, Kim MB, Chung JY, Seok HS, Baek GH. Fasciocutaneous propeller flap based on perforating branch of ulnar artery for soft tissue reconstruction of the hand and wrist. Clin Orthop Surg 2018; 10(1): 74‒9.

33. Kelada MN, Salem RR, Eltohfa YA, Ghozlan NA, Kholosy HM. Posterior interosseus artery flap for hand reconstruction: anatomical basis and clinical application. BMC Musculoskelet Disord 2022; 23(1): 662.

34. Bordianu A, Leoveanu FI. Hand soft tissue reconstruction with dorsal metacarpal artery perforator (Quaba) flap. J Med Life 2021; 14(5): 731‒6.

35. Prasetyono TOH, Menna C. Cutaneous Perforators and Their Clinical Implications on Intrinsic Hand Flaps: A Systematic Review. Plast Reconstr Surg Glob Open 2022; 10(4): e4154.

36. Zhang G, Su H, Ju J, Li X, Fu Y, Hou R. Reconstruction of dorsal and palmar defects of hand with anterolateral thigh flaps from one donor site. J Plast Reconstr Aesthet Surg 2019; 72(12): 1917‒22.

37. Shashaa MN, Swed S, Albahhah T, Alloush H. Newly repairing technique of deformed hand by a posterior interosseous flap in an infant: A case report. Int J Surg Case Rep 2022; 95: 107207.