We read with interest the recently published article by Stevanovic and Sharpe.1 In their work, the authors provide a comprehensive review of techniques currently indicated for elbow reconstruction. This region is constantly exposed to tension and motion. Consequently, tissue with adequate texture, elasticity, and strength must be provided to achieve bone and joint coverage as well as soft-tissue replacement. In the last decade, the perforator-based propeller flap has gained extreme popularity as a valid alternative to microsurgical transfers to the lower extremity, but the application of this technique to the upper limb is rarely reported in the literature. Therefore, we congratulate Stevanovic and Sharpe on their article, and we would like to complement their review by sharing our experience with the use of perforator-based propeller flaps in elbow reconstruction.
Between July of 2011 and April of 2013, two male patients and one female patient underwent elbow and supra-elbow defect reconstruction with two posterior radial collateral artery flaps and one brachial artery perforator-based propeller flap, respectively. The flaps were designed along the vertical axis of the extremity, using the lateral and medial intermuscular septa as an anatomical reference. The two posterior radial collateral artery perforator flaps, measuring 13 × 5 (Figs. 1 and 2) and 11 × 4.5 cm, were based on the most distal perforator of the lateral arm flap, constantly reported to emerge about 4 to 5 cm proximal to the lateral epicondyle.2 The flaps were rotated 180 degrees to resurface two lateral elbow defects consequent to melanoma excision. The brachial artery perforator flap, measuring 16 × 6 cm, was raised in a free-style fashion on two brachial artery myocutaneous perforators and rotated 90 degrees to reconstruct a lateral supra-elbow defect following removal of a Marjolin ulcer. The mean operative time was 115 minutes. The flap donor sites were always closed primarily. Venous congestion with partial necrosis was observed in the distal tip of the brachial artery perforator-based propeller flap, leading to delayed healing by secondary intention. Nevertheless, all the flaps achieved a satisfactory functional and aesthetic outcome, with complete restoration of the operated site.
Elbow reconstruction is undoubtedly a challenging procedure. All the classically described reconstructive options present several drawbacks. Use of the proximally pedicled radial forearm flap is associated with significant donor-site morbidity and with the violation of a main vascular source to the hand. Local rotational muscle flaps are reserved for small to moderate-size defects, need to be skin grafted, and are associated with sacrifice of muscular units. Distant myocutaneous flaps, such as the latissimus dorsi flap, are indicated only in cases of massive traumatic defects with bone, joint, or fixation device exposure.
The pedicled thoracodorsal artery perforator flap represents a valid alternative to myocutaneous transfer,3 but it requires extensive dissection as well as creation of a subcutaneous tunnel, thus exposing the pedicle to the risk of compression. In this scenario, use of perforator-based propeller flaps based on lateral or medial arm perforators represents a reliable option to achieve an excellent morphofunctional reconstruction with minimal donor-site morbidity.4,5 We strongly support this surgical option in cases of small to moderate-size defects (maximum of 6 to 7 cm wide) resulting from oncological resection or low-energy traumatic accidents, provided that the presence and patency of perforator vessels have been confirmed preoperatively.
The authors have no financial interest to declare in relation to the content of this communication. No funding was received for this work.
Beniamino Brunetti, M.D.
Stefania Tenna, M.D., Ph.D.
Achille Aveta, M.D.
Igor Poccia, M.D.
Francesco Segreto, M.D.
Paolo Persichetti, M.D., Ph.D.
Department of Plastic, Reconstructive, and
“Campus Bio-Medico di Roma” University
1. Stevanovic M, Sharpe F. Soft-tissue coverage of the elbow. Plast Reconstr Surg. 2013;132:387e–402e
2. Tan BK, Lim BH. The lateral forearm flap as a modification of the lateral arm flap: Vascular anatomy and clinical implications. Plast Reconstr Surg. 2000;105:2400–2404
3. Oksüz S, Ulkür E, Tuncer S, Sever C, Karagöz H. Elbow reconstruction with a pedicled thoracodorsal artery perforator flap after excision of an upper-extremity giant hairy nevus. J Plast Reconstr Aesthet Surg. 2013;66:566–569
4. 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;36:853–863
5. 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;65:1418–1421
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