European Journal of Orthopaedic Surgery & Traumatology (2019) 29:357–366 https://doi.org/10.1007/s00590-018-2323-7 ORIGINAL ARTICLE • HAND - MICROSURGERY Propeller perforator faps in forearm and hand reconstruction Alexandru Valentin Georgescu1 · Ileana Rodica Matei1 Received: 13 October 2018 / Accepted: 19 October 2018 / Published online: 26 October 2018 © Springer-Verlag France SAS, part of Springer Nature 2018 Abstract After a long history in faps’ surgery, the perforator faps became the most used faps nowadays. From the beginning, their use as free faps diminished substantially the donor site morbidity. In the attempt to not only diminish the donor site morbid- ity, but also to achieve more similar reconstructions, a new concept appeared 20 years ago: local perforator faps. The local perforator faps ofer as main advantages the absence of microsurgical sutures (“microsurgical non-microvascular faps”), same surgical feld, the sparing of muscles and main vascular pedicles, and shorter hospitalization time. They can be used as V–Y advancement faps, transposition faps, propeller faps, and keystone faps (multiperforator faps). The present study will refer to the use of local perforator faps in forearm and hand reconstruction, and will point on the most important technical aspects of their harvesting, the main indications, advantages and disadvantages, and possible complications. Keywords Forearm defects · Hand defects · Perforator faps · Propeller perforator faps Introduction the most popular being the radial fap [1]. These faps ofer most of the advantages mentioned above, but have also the Various methods have been used over the time for recon- disadvantage of scarifying one of the main arteries of the struction of challenging tissue defects of the upper limb. forearm. That is why the new concept of perforator faps But, if for the arm and proximal half of the forearm, the use was developed in the last 30 years, which allowed also the of a free split thickness graft (FSTG) is generally adequate, diminish of donor site morbidity by sparing the main vessels the problem becomes more difcult for coverage of tissue and muscles. defects in the distal forearm and hand. The superfcial posi- After a long evolution in fap surgery, which included tioning of important anatomical structures (i.e. tendons, ves- random pattern faps, muscle and musculocutaneous faps, sels, nerves, and bones) in these regions imposes in the large and fasciocutaneous flaps, Taylor and Palmer [2] reap- majority of cases the use of local, regional, or free faps. praised the works of Manchot [3] and Salmon [4] regarding A good cosmetic and functional result can be obtained by skin blood supply. They developed the angiosome concept, customizing the reconstructive procedure to each specifc showing that this represents a block of tissue supplied by a defect. The use of local or regional faps seems to be the same source artery and vein through branches for all tissues more rational choice because of their main advantages, i.e. between skin and bone. Neighbouring angiosomes are linked short operation time, use of similar tissues for reconstruc- to each other via “choke vessels”. tion, and no need of microsurgical sutures. One of the meth- A step forward was represented by the work of Saint-Cyr ods largely used in the past is represented by the reverse et al. [5], which focused on the perforator vessels and not the fow faps based on one of the main arteries of the forearm, source vessel anymore. After conducting several anatomical studies, they defned the “perforasome” as the vascular ter- ritory of a single perforator and enunciated some clinically * Ileana Rodica Matei relevant principles: [email protected] Alexandru Valentin Georgescu 1. The perforasomes are interconnected with each other [email protected] by direct and indirect linking vessels. The direct linking 1 Clinical Hospital of Rehabilitation Cluj Napoca, University vessels are macroscopic vessels, and they establish a of Medicine Iuliu Hatieganu Cluj Napoca, Str. Viilor Nr. direct “bridge” between branches of adjacent perfora- 46‑50, 400347 Cluj Napoca, Cluj, Romania Vol.:(0123456789)1 3 358 European Journal of Orthopaedic Surgery & Traumatology (2019) 29:357–366 tors. The indirect linking vessels are microscopic vessels Chang et al. [15] described in 1988 a fasciocutaneous equivalent to the “choke vessels” described by Taylor forearm reverse fap by sparing the radial artery (RA), but and Palmer [2], and constitute the microscopic subder- the real interest in using local perforator faps appeared in mal network. 1994. Then, the use of local perforator faps in forearm and 2. The orientation of linking vessels dictates the design of hand reconstruction became increasingly extensive. They are a fap: axial in the extremities, and perpendicular to the mostly used as propeller faps. midline in the trunk. The term propeller fap was introduced by Hyakusoku 3. Perforators from a specifc source have perforasomes et al. [16] in 1991 after performing an adipocutaneous fap that will be preferentially flled before flling perforas- blood supplied through a random subcutaneous pedicle omes from adjacent source vessels and rotated through 90 degrees. In 2006, Hallock [17] used this term for the frst time to defne a perforator fap rotated Moreover, Rubino et al. [6] have shown that by harvest- through 180 degrees. The Advisory Panel of the First Tokyo ing a fap based on a single perforator, the perfusion in this Meeting on Perforator and Propeller Flaps defned in 2009 perforator will increase and contribute to the recruitment the term propeller perforator fap: a skin island with two of adjacent perforasome territories. That can explain the paddles demarcated by the perforator vessel, which has to large dimensions of some faps. rotate through at least 90–180° [18]. As a result of this evolution, the era of perforator faps Besides the advantages described above, there are also started with the harvesting of the frst faps sparing the some possible drawbacks in using these faps. The most source artery and underlying muscle performed by Kroll important complications are represented by complete or par- and Rosenfeld in 1988 [7] and Koshima and Soeda in tial fap loss due to venous problems, but the general com- 1989 [8], and the use of perforator faps became increas- plication rate is similar to that for free faps. In an attempt to ingly more extensive. Free perforator faps such as the minimize the complication rate, the venous supercharging of anterolateral thigh fap, thoracodorsal artery perforator a fap may be necessary. The careful planning and design of faps, lateral arm perforator fap, inferior epigastric artery the fap, and of the length of the perforator is of maximum perforator fap, and biceps femoris perforator fap are importance. Another important factor in diminishing the used successfully for reconstruction of tissue defects in complication rate is the appreciation of the real dimensions the upper limb. of such a fap blood supplied through a single perforator The distant donor site, the difficulties in obtaining a pedicle. Initially, it was considered that the dimensions of a similar reconstruction, and the technical high-demanding perforator fap are represented by the distance between two procedure are some of the factors that stimulated surgeons perforators, but later on Saint-Cyr et al. [5] demonstrated to fnd alternatives to free faps. Nowadays, the use of local that a single perforator is hyper-perfused after cutting the perforator faps gained a big popularity, especially in the other perforators, which increases its flling pressure and legs, due to some of their advantages: (1) replacing like with opens the linking vessels with adjacent territories (Fig. 1). like, (2) donor site in the same area, (3) possible complete or The establishing of the safer dimensions of a fap before partial donor site primary closure, (4) do not need microvas- or during surgery can dramatically ameliorate the success cular sutures (microsurgical non-microvascular faps), and rate. Hand-held Doppler, colour Doppler, duplex ultra- (5) shorter operating time [9–14]. sound, arteriography, magnetic resonance angiography, and Fig. 1 Cadaver specimen after latex injection showing two perforators (a and b) with their territories (the pointed quad- rangles); the red pointed circles represent the linking vessels between these two territories. If the perforator a is ligated, the pressure in the perforator B increases and opens the linking vessels (red arrow) with the adjacent territory of the perfora- tor a 1 3 European Journal of Orthopaedic Surgery & Traumatology (2019) 29:357–366 359 high-resolution computed tomography are methods routinely brachioradialis and pronator teres in the proximal third of the used to provide information about the perforator’s distribu- forearm and between brachioradialis and fexor carpi radia- tion and/or calibre [12], but not regarding fap viability. New lis in the distal two-thirds of the forearm. In the proximal methods able to asses the fap perfusion during surgery, but part, the perforators are both muscular and septocutaneous, not the dimensions of a fap, are represented by fuorescein but in the distal part, they are only septocutaneous. One of [12, 19, 20] or indocyanine green near-infrared angiography the septocutaneous perforators in the proximal part is repre- [12, 20–23]. sented by the inferior cubital artery described by Lamberty Due to the superfcial location of the main axial source and Cormack,