Septocutaneous perforator mapping and clinical applications of the medial arm flap

Preexpanded Brachial Artery Perforator Propeller Flap: An Addition to the Armamentarium for Postburn Axillary Contracture Reconstruction

BACKGROUND

Postburn axillary contracture is a common complication that leads to functional impairment and unsatisfactory aesthetic outcomes. The authors present their experience with axillary contracture reconstruction using preexpanded brachial artery perforator propeller (BAPP) flaps and provide a systematic review of other regional or free flaps.

METHODS

This retrospective study included patients who underwent postburn axillary contracture reconstruction using preexpanded BAPP flaps from 2015 to 2022. Data on the flap characteristics and function of the affected shoulders were recorded. A systematic review was conducted by retrieving studies that assessed the outcomes of regional or free cutaneous/fasciocutaneous flaps for treating axillary contracture from PubMed, Web of Science, Embase, and Scopus published before October 1, 2023.

RESULTS

Twelve preexpanded BAPP flaps measuring up to 26 × 11 cm (mean, 116.9 cm 2 ) survived completely with no major complications, and the donor sites were closed primarily. The average range of shoulder abduction increased from 77.9 to 141.7 degrees ( P = 0.002). The systematic review included 34 articles, reporting 12 regional and 3 free flaps. The most commonly reported flaps were the thoracodorsal artery perforator flap, scapular flap, and parascapular flap. The overall complication rate ranged from 0 to 25%, and the average change in shoulder abduction ranged from 72.5 to 99.4 degrees.

CONCLUSIONS

Preexpanded BAPP flaps can be used effectively for reconstructing postburn anterior axillary fold contracture. Donor-site availability and the specific axillary contracture type should be considered when selecting a regional or free flap.

Anatomy, surgical techniques, and clinical outcomes for the medial arm flap: A systematic review

BACKGROUND

The medial arm flap (MAF) has been used as a pedicle flap and free flap to reconstruct various deformities, including those of the head and neck, axilla, elbow, chest, and hand. This study reviews the anatomy of the flap, the technique of flap harvest, its clinical applications, and a systematic review of the current published literature.

METHODS

An online systematic review of MEDLINE, EMBASE, PubMed, and The Cochrane Library from inception to September 30, 2023, was completed. Studies that investigate the anatomy, technique or clinical outcomes of medial arm flaps were included. Clinical data extracted includes patient, defect, flap characteristics, complications, and take-back procedures. Anatomic data extracted includes anatomical variations, and vascular characteristics and patterns.

RESULTS

Between 1980 and 2023, 50 papers were published outlining the medial arm flap. Anatomic studies detail the anatomy of 384 medial arms, and outcomes are reported for 283 MAFs (75 free flaps and 208 pedicle flaps). The superior ulnar collateral artery is most commonly cited as the dominant arterial supply to the middle third of the medial arm. The majority of patients required reconstruction post-burn (39.2%), trauma (17.7%), and tumor excision (12.4%). MAFs were mostly used to reconstruct defects of the head and neck (41.7%), the hand and wrist (21.9%), and the elbow (16.3%). Eleven flaps (4.1%) suffered partial flap failure, and two flaps (0.7%) suffered total flap failure.

CONCLUSION

This manuscript demonstrates that the MAF is a reliable and underutilized flap option with a well-hidden donor scar and a low complication rate.

Sizeable Facial and Cervical Defect Repair using a Medial Arm Flap Combined With the Tissue Expansion Technique: Clinical Applications and Fifteen-year Follow-up

BACKGROUND

The aim of this study was to present the 15-year clinical results using a preexpanded pedicle medial arm flap for repairing massive facial and cervical defects.

METHODS

The process of our method is divided into 3 stages. In the first stage, the rectangle-shaped tissue expander was implanted subcutaneously in the medial arm region and serially inflated for ~3 months. In the second stage, the distal portion of the flap was to cover the defects, the proximal portion was overlapped with the residual lesion flap. The pedicle was divided 3 weeks later, and the extra tissue was reinserted back to the donor site.

RESULTS

A total of 27 patients were retained. All donor sites were closed directly. Maximum and minimum sizes of preexpanded cervical flaps were 2015 cm2 to 5.54 cm2. In 2 cases, partial necrosis occurred at the distal end of the flap, while the remaining flap survived completely. The median duration of follow-up was 7.5 years. During follow-up, 24 patients (88.9%) had satisfactory outcomes and 3 patients (11.1%) had partially satisfactory results.

CONCLUSION

Using expanded pedicle medial arm flap for face or neck defects' reconstruction showed that it was safe and effective, and had satisfying results in the long-term follow-up. The flap based on the proximal pedicle has a more reliable blood supply.

Utilization of two methods assisting perforator identification for brachial artery perforator propeller flap application

The brachial artery perforator propeller (BAPP) flap has the advantages of both local and perforator propeller flaps, and it remains relatively underused partly because of the anatomical variations of perforators in the medial arm. We aimed to review our preliminary experience using two different methods for perforator localization of a BAPP flap, including the application of a refined coordinate system (the ABC system) in the medial arm and indocyanine green angiography (ICGA). We evaluated the advantages and disadvantages of these methods and selected the optimal examination mode depending on detailed clinical settings. The perforator was identified for each patient using the ABC system and/or ICGA, depending on the clinical setting. Twenty-two patients underwent soft-tissue reconstructions with 22 BAPP flaps, and perforator localization for all the flaps was performed before surgery using the ABC system. Thirty-one perforators were localized before surgery and marked accordingly, all of which were visualized during surgery, except two, which were not found during the surgery. ICGA was used in six pre-expanded flaps at both stages of surgeries. Twenty-seven perforators were detected before surgery, and all of them were identified during surgery; the previously localized perforators found using the ABC system in the six patients were all reidentified using ICGA. Both the ABC system and ICGA were found to be useful for preoperative perforator localization in BAPP flap transfers. Each method has its unique downsides; however, they can supplement each other to facilitate safe and effective flap elevation. Therefore, selection of the optimal method based on the clinical settings is recommended.

Cutaneous perforators of the arm and anatomical landmarks for defining the flap donor sites

PURPOSE

There are few studies searching for possible perforator flap donor sites on the arm. This study aimed to identify the locations of cutaneous perforators of the arm according to anatomical landmarks.

METHODS

Thirteen Thiel-fixed and latex-filled upper extremities of bodies donated to science were used. The distance between the acromion and medial or lateral epicondyle of the humerus was defined as the Y-axis, and the axis that cut the Y-axis perpendicularly through the epicondyles of the humerus was identified as the X-axis. The Y-axis was then divided into three parts Cutaneous arterial perforators were found using surgical dissection. The locations of the perforators were determined according to the defined lines and regions.

RESULTS

On the lateral side, there were 6.00 ± 2.08 perforators per arm, of which 56.4% were septocutaneous and 43.6% muscular. In all extremities, with in the distal 1/3 of the lateral arm, there were 1-4 radial collateral artery-based perforators. The mean distance of these perforators to the Y-axis was 1.16 ± 0.53 cm. On the medial side, there were 5.05 ± 1.44 perforators per arm, which were all septocutaneous perforators. In 85% of the extremities, within the middle 1/3 of the medial arms, there were 1-2 superior ulnar collateral artery-based perforators. The mean distance of these perforators to the Y-axis was 1.53 ± 0.61 cm.

CONCLUSION

There are always perforators from the radial collateral artery with in the distal third of the lateral arm. Within the middle third of the medial arm, it is usually possible to find a perforator from the superior ulnar collateral artery.

Clinical Effectiveness of Free Upper Arm Medial Flap in Repairing Skin and Soft Tissue Defects of the Dorsum of the Hand

Objective

To study the effectiveness of medial upper arm free flap in repairing skin and soft tissue (SST) defects of the dorsum of the hand.

Methods

10 patients with SST defects on the dorsum of the hand who underwent free upper arm medial flap repair in our hospital from March 2017 to August 2018 were included in the study. Hand function, flap survival rate, wound healing, donor wound recovery, and the level of pain in the injured area were recorded before the operation, 1 month, and 6 months postoperatively.

Results

The highest score in hand function was seen at the 6-month postoperative interval, followed by that at the 1-month postoperative interval. The lowest score in hand function was the preoperative score (P < 0.05). All flaps were still surviving 6 months postoperatively. Recovery of the function of the donor muscle, the elbow joint, as well as wound healing, all progressed well. 6 months postoperatively, 3 patients developed numbness and stiffness of the hand, but the symptoms were relieved following treatment. Compared to the preoperative scores, the visual analogue scale (VAS) scores at the injured site 1 month and 6 months postoperatively were significantly decreased, with the 6-month postoperative score being lower than the 1-month postoperative score (P < 0.05).

Conclusion

The free upper arm medial flap is a good alternative for repairing skin and soft tissue defects of the dorsum of the hand with exposed phalanges, an approach that merits widespread promotion and clinical application.

Facial and Neck Reconstruction With Pre-expanded Medial Upper Arm Flap: An Alternative method and 20-Year Experience

PURPOSE

To present our experience with pre-expanded medial upper arm flap in facial and neck reconstruction.

PATIENTS AND METHODS

This was a retrospective study operated between January 1st, 2001 and January 1st, 2021, at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College. Staged face and/or neck reconstruction was performed.

RESULTS

Forty-one patients were treated in our institution and thirty-eight patients (forty-three flaps) were included in this cohort as. They ranged from 6 to 44 years old. There was no total flap loss in the cohort. Partial flap necrosis was observed in the earlier patients (4 cases).

CONCLUSION

Pre-expanded medial upper arm flap is well matched to the facial and neck skin in color, texture, and thickness. Considering the excellent aesthetic outcomes, this flap is a good alternative for selected patients with soft tissue defects of the head and neck.

Periorbital and Perioral Defect Reconstruction Using the Split Pre-Expanded Medial Arm Flap Aided by Using Indocyanine Green Angiography

ABSTRACT

The pre-expanded medial arm flap provides suitable skin for the resurfacing of a periorbital or perioral defect. However, the flap must be intraoperatively split to imitate the appearance of the oral or ophthalmic fissure, which can compromise flap perfusion. This study aimed to evaluate the safety and effectiveness of splitting pre-expanded medial arm flaps with the aid of indocyanine green angiography. All 8 patients underwent periorbital or perioral soft tissue reconstruction using a split pre-expanded medial arm flap. Flap splitting was aided by indocyanine green angiography. It was used during 2 stages of the procedure, tissue expander placement and flap transfer. The pedicle was divided 3 weeks later, and the flaps were used to resurface the defect. The distal portion of the flap was split into a fishmouth pattern in 5 patients and a window pattern in 3 patients. The donor sites were closed directly or by using a latissimus dorsi myocutaneous flap. There were no perioperative complications or flap necrosis. A pre-expanded split medial arm flap could be an option for the reconstruction of periorbital and perioral defects. With the assistance of indocyanine green angiography, vessel distribution and distal flap perfusion can be reliably evaluated, facilitating the safe splitting of the flap for the reconstruction of defects.

Cervicofacial Defect Reconstruction Using the Pre-Expanded Medial Arm Flap Without Immobilization of the Upper Extremity

SUMMARY

The medial arm flap has multiple advantages when used for cervicofacial defect reconstruction but remains underused. The main drawback of the medial arm flap is that the patient must maintain the passive immobilized posture before the pedicle division. This clinical study aims to introduce a reconstructive method for cervicofacial defects using the medial arm flap without the immobilization of the upper extremity. This retrospective study was performed with data from 14 patients requiring pre-expanded medial arm flaps to reconstruct cervicofacial defects. Indocyanine green (ICG) angiography was used to detect perforators and evaluate the flap perfusion; all the flaps underwent pre-transfer tissue expansion. A total of 15 full-length medial arm flaps were used. All the perforators identified by ICG angiography were directly visualized during flap elevation. In four cases, poor perfusion areas in the flaps were noted by intraoperative ICG angiography. Combined with the clinical observation, parts with poor perfusion were resected. The average flap size was 203.9 ± 75.2 cm2 and ranged 20 to 28 cm in length after tissue expansion. The medial arm donor sites were closed directly or using another flap. All flaps survived completely. The patients were followed-up for 1 to 22 months. All patients and their family members were satisfied with the outcomes. Cervicofacial defect reconstruction using a medial arm flap with the aid of tissue expansion and ICG angiography can provide sufficient tissue for defect resurfacing and also eliminate the necessity of the immobilization of the upper extremity during surgery.

Use of Indocyanine Green Imaging for Perforator Identification in Preexpanded Brachial Artery Perforator Flaps

The tissues of the medial arm as a donor site for perforator flap design have several advantages. However, they are relatively underused with limited reports, partly due to unreliable perforator anatomy. Therefore, we aimed to review our preliminary experience using indocyanine green (ICG) angiography to design and elevate preexpanded pedicled brachial artery perforator (BAP) flaps for regional reconstruction. All patients underwent soft tissue reconstructions using a preexpanded BAP flap in two or three stages. ICG angiography was used to localize perforators during both expander insertion and flap elevation. The pedicle was divided at the third stage 3 weeks following flap elevation for head and neck cases. Sixteen patients underwent reconstructions of the head and neck (n = 13) or shoulder/trunk (n = 3) using 14 perforator-plus and 2 propeller BAP flaps. In total, 50 perforators were identified using ICG imaging, all of which were appreciable during both expander placement and flap elevation. Thirty-five perforators were directly visualized during flap elevation, and an additional 15 perforators were not explored but incorporated into the flap. All flaps survived without necrosis, and the donor sites healed uneventfully without complications. The medial arm provides thin and pliable skin for the resurfacing of regional defects with relatively minimal donor-site morbidity. With the assistance of ICG angiography, perforators of the brachial artery can be reliably identified, facilitating the preexpansion and elevation of pedicled BAP flaps for use in head-neck and trunk reconstruction.