Accepted Manuscript Posterior interosseous artery perforator-free flap: Treating intermediate-size hand and foot defects Chi Sun Yoon, MD Hyung Joo Noh, MD Gerardo Malzone, MD Hyun Suk Suh, MD Dong Hoon Choi, MD Joon Pio (Jp) Hong, MD, PhD, MMM PII:
S1748-6815(14)00118-1
DOI:
10.1016/j.bjps.2014.03.007
Reference:
PRAS 4118
To appear in:
British Journal of Plastic Surgery
Received Date: 17 September 2013 Revised Date:
4 February 2014
Accepted Date: 8 March 2014
Please cite this article as: Yoon CS, Noh HJ, Malzone G, Suh HS, Choi DH, Hong JP(J), Posterior interosseous artery perforator-free flap: Treating intermediate-size hand and foot defects, British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.03.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Posterior interosseous artery perforator-free flap: Treating intermediate-size hand and foot defects
Hyung Joo Noh, MD1, Gerardo Malzone, MD1, Hyun Suk Suh,
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Chi Sun Yoon, MD2,
MD3, Dong Hoon Choi, MD1, Joon Pio (Jp) Hong, MD, PhD, MMM1,*
1
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Department of Plastic Surgery, Asan Medical Center, University of Ulsan;
2
Department of Plastic Surgery, Ulsan University Hospital, University of Ulsan;
3
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Department of Plastic Surgery, Ewha Womans University Hospital, Seoul, Korea
*Corresponding author: Joon Pio Hong, MD, PhD, MMM, Department of Plastic Surgery,
138-736,
Korea.
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Asan Medical Center University of Ulsan, Songpa-gu, Poongnap2-dong, 388-1, Seoul, Tel:
(822)
3010-3600;
Fax:
(822)
476-7471;
Email:
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[email protected]
The authors have no conflicts of interest to report regarding any of the materials used
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in this study.
1
ACCEPTED MANUSCRIPT Summary Ambiguous defects on the hand and foot, especially on the fingers and toes, are still challenging to treat despite achievements in reconstruction. The purpose of this study was to evaluate the use of the posterior interosseous artery perforator flap
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for resurfacing intermediate-sized defects and provide adequate coverage over tendons and bones. Between October 2008 and March 2013, a total of 19 patients with soft-tissue defects on the hand or foot were treated. Flap elevation, anatomy,
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and clinical progress were evaluated. All flaps survived and covered the defects, which ranged in area from 12 to 45 cm2. The freestyle approach was used to harvest
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the flaps. The average length of the pedicle was 2.5 cm, and the pedicle was harvested without affecting the source vessel. The average diameter of the artery was 0.8 mm, and the average thickness of the flap was 3.5 mm. Anastomosis was performed either end-to-end on the perforator, or end-to-side on deep vessels. No
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subsequent thinning or surgical flap correction was necessary. Ambulation was allowed at 3 days postsurgery. The donor site was closed primarily to leave an acceptable donor site. A posterior interosseous artery perforator-free flap is a suitable
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choice for intermediate-size defects that are too large to cover using a local flap or too small for a first-line perforator flap. Up to 45 cm2 of adequate coverage can be
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provided using a thin posterior interosseous artery perforator-free flap that does not require additional debulking. The disadvantages of a short pedicle can be overcome using perforator-to-perforator supermicrosurgery.
Keywords: posterior interosseous artery perforator flap; small soft-tissue defect; perforator flap; supermicrosurgery; hand and foot reconstruction.
2
ACCEPTED MANUSCRIPT Introduction Soft-tissue defects on the hand and foot, especially the fingers and toes, often present as a challenging reconstructive problem. Despite the many flaps available for hand and foot reconstruction, small defects ideally require a thin flap. In many cases,
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a local flap provides excellent coverage for small defects, such as those found on the finger tips.1 However, relatively larger defects may require the use of skin graft when the flap is unable to close properly. Furthermore, you may encounter partial loss over
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the region that you really need coverage due to overzealous design. The aim of any reconstruction that involves exposure of the tendons and bone is to regain function
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by providing adequate cover and early rehabilitation. Nowadays, in the era of care that considers not only function but also form, one must continue to seek options that will allow the best possible results. For small lesions that are too big to be covered with local flaps, various other types of flaps have been developed i.e. arterialized
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venous flap, pulp flap, toe-web-space flap, distant flap, and others. However, these flaps cannot be used when larger flaps are required, as donor-site morbidity increases and viability becomes uncertain. It is also obvious that distant flaps, such
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as the pocket flap and cross finger flap, causes prolonged discomfort as well as the increased need for rehabilitation. The goal of this study was to identify the ideal flap
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for intermediate-size defects (average = 19.0 cm2; range = 6 × 2 cm–5 × 9 cm) that can efficiently avoid further contour revisions and, thereby, minimize donor-site morbidity. Such flaps have to be thin and small. Posterior interosseous artery (PIA) flaps do not require the sacrifice of a major artery in the upper limb and results in minimal donor-site morbidity.2-4 The PIA is located in the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi muscles, and several anatomical studies confirm the rich 3
ACCEPTED MANUSCRIPT presence of cutaneous perforator vessels.5-7 The PIA is anatomically united by two main anastomoses: one proximal (at the level of the distal border of the supinator muscle) and one distal (at the most distal part of the interosseous space). The PIA joins the anterior interosseous artery to form the distal anastomosis. The posterior
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interosseous fasciocutaneous flap can be used as a reverse-flow island flap because it is perfused by anastomoses between the two arteries at the level of the wrist. However, local flaps may not be feasible if the defect is not in the proximal part of the
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hand.8,9 Furthermore, posterior interosseous fasciocutaneous flap complications reportedly cause arterial inflow problems in reverse-pedicled flaps.10,11 Use of the PIA
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flap as the free flap for reconstructing soft-tissue defects in the extremities is reportedly successful, especially for defects that require a thin flap in order to regain delicate hand functions.12,13
Despite the PIA flap being one of the thinnest perforator flaps, little has been
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reported regarding its application to intermediate-size defects on the hand and foot, especially the fingers and toes. Here, we evaluate the PIA perforator flap as an
Methods
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option for such defects, especially those on the distal foot and hand.
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This retrospective study was performed after approval from the institutional
review board of Asan Medical Center. Between October 2008 and March 2013, a total of 19 patients were treated for soft-tissue defects in the upper or lower extremities due to various causes. All patients underwent reconstruction using short pedicled PIA perforator-free flaps. All flaps were anastomosed either end-to-end on the perforator (distal end of the vessel) or end-to-side on the deeper vessel. Multidetector-row computed tomographic angiograms of the upper or lower 4
ACCEPTED MANUSCRIPT extremities were obtained before surgery if the vascular status was questionable. Hand-held Doppler ultrasound was preoperatively used to mark potential recipient perforators around the soft-tissue defects and trace the perforator of the flap.
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Intensity was observed and marked during the tracing of the recipient perforator.
Surgical procedure
Surgeries were performed on all patients under general anesthesia by the
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same surgeon. In every case, the freestyle approach was used. The preoperative identification of the vessel was made using Doppler ultrasound. Complete
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debridement was performed before any reconstructive procedure. The recipient vessels were identified after debridement or tumor excision. If large peripheral vessels or small branches from the peripheral vessels were already exposed within the defect, we used those vessels as the recipient vessel if a good pulse was
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detected; if not, we searched for a recipient vessel that was subfascial and adjacent to the defect margin. After securing the pulsating recipient artery and viable veins, the required length for the pedicle was estimated. The PIA perforator flap was designed
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according to the size of the defect around the Doppler-traced perforator. Cutaneous perforators could be found along the line extending from the lateral epicondyle to the
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radial border of the head of ulna.14 Flap elevation began suprafascially from one margin, we prefer to start with the ulnar side, to confirm the location of the perforator under the designed area. If the perforator was not included in the original design, then a new design was made directly over the pedicle. The rest of the flap was elevated once the perforator was identified. The perforator was dissected until the proper length was obtained. Frequently, dissection extended beyond the deep fascia. We preferred to skeletonize the pedicle when entering the deep fascia and 5
ACCEPTED MANUSCRIPT intermuscular septum and dissect toward the deeper interosseous vessels. The posterior antebrachial cutaneous nerve was identified and included if an innervated flap was needed. The pedicle of the flap was divided and ligated before it met the posterior interosseous vessel. Usually, the obtained short pedicled flap was < 3–4 cm
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(video).
Anastomoses were performed in either an end-to-end or end-to-side fashion. The recipient arteries included the dorsal metatarsal artery (3 patients), dorsal digital
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artery (8 patients), proper plantar digital artery (3 patients), palmar branch of the radial artery (3 patients), or ulnar artery (2 patients). Venous drainage occurred
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through the accompanying vein of the PIA. The recipient vein was either the accompanying or superficial vein. One artery and one vein were anastomosed in all patients. Anastomoses were performed in an end-to-end fashion in 14 patients and end-to-side fashion in 5 patients using a 10-0 nylon suture. All donor sites were
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closed primarily.
Postoperative monitoring was performed every 2 hours for 2 days, and then every 8 hours until discharge. Arterial and venous patency were clinically monitored
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according to the color, refill, and temperature. If subjective findings were equivocal, duplex scanning was used to monitor vessel status. A vasodilator (10 µg lipo-
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prostaglandin E1; Eglandin; Welfide, Seoul, Korea) was mixed with 5% dextrose solution and infused over 4 hours per day for 5 days. In addition, 3800 IU lowmolecular-weight
heparin
(Fraxiparin;
Sanofi-Aventis,
Paris,
France)
was
subcutaneously injected over 5 days. Depending on flap status, ambulation was allowed on postoperative day 3. The patient was discharged from the hospital within 7 days if no other problems were noted. Supportive short-arm or short-leg splints were postoperatively used to immobilize all patients for 1 week. After the splint was 6
ACCEPTED MANUSCRIPT removed, the patients participated in an active and passive physical rehabilitation program in order to achieve maximum range of motion. Compressive garments were applied to all patients on postoperative day 5.
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Results
The study population included 8 female and 11 male patients. The average age of the patients was 38 years (range, 6–66 years). The causes of the soft-tissue
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defects included resection of malignant melanoma (subungual type; 5 patients), resection of neurogenic tumor (1 patient), electrical burn (1 patient), trauma (4
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patients), and diabetic ulcer (8 patients). Defects were located on the first toe in 11 patients, thumb in 3 patients, dorsum of the foot in 3 patients, and left palm in 2 patients. The average time required to raise the flaps was approximately 30 minutes. The average size of the flap was 19.0 cm2 (range = 6 × 2 cm–5 × 9 cm). The width of
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the flap averaged 3.1 cm (range = 2.3–5 cm), and the length averaged 5.94 cm (range = 4–10 cm). The average thickness of the flap was 3.5 mm (range = 2.5–5 mm). With the exception of 1 flap, all perforators were found according to markings
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obtained using Doppler ultrasound. In 1 flap, the perforator was 4 cm from the marking. All perforators originated from the PIA. The average length of the pedicle, as
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measured from the base of the flap, was 2.5 cm (range = 1–3.2 cm), and the average artery diameter was 0.8 mm (range = 0.5–1.0 mm.). Only a single perforator was required for all flaps.
All flaps were successful without anastomotic complications. One case of marginal necrosis occurred but healed with secondary intervention. Two patients developed postoperative hematoma and blisters but healed without further surgical intervention. The donor site for all cases was closed primarily. Minimal donor-site 7
ACCEPTED MANUSCRIPT morbidity developed. The average follow-up period was 18 months (range = 1–53 months). During the follow-up period, the flaps demonstrated good contours and no additional secondary contouring procedures were required.
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Case 1
A 54-year-old male diabetic patient with first ray ulceration and osteomyelitis was referred to the plastic surgery department. Ulceration was first noted after
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wearing a poorly fitted shoe, which became increasingly and slowly aggravated over a 6-month period (Fig. 1A). After aggressive debridement, which included a piece of
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the proximal phalangeal bone and metatarsal bone, the first toe was still considered salvageable. Following endovascular angioplasty, angiography of the anterior tibial artery revealed sufficient flow, the dorsal digital artery demonstrated a good pulse, and the superficial vein was isolated adjacent to the defect. An 8 × 2.5 cm flap was
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raised using a 2-cm pedicle from the left forearm (Fig. 1B, C). The artery and vein had diameters of 0.7 mm and 0.8 mm, respectively, and anastomosis was performed in an end-to-end fashion. The donor site was closed primarily. Over the first 2 days,
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slight congestion was noted and 4 leeches were applied. Otherwise, postoperative progression was uneventful. The patient started ambulation on day 5 and was
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discharged on day 8 after achieving good control of blood sugar levels. Healing was uneventful, and the patient was discharged 3 weeks after surgery. Follow-up examination at 4 months demonstrated good contours and function of the first ray and acceptable donor scarring (Fig. 1D, E).
Case 2 A 6-year-old boy was diagnosed with malignant melanoma on the first left 8
ACCEPTED MANUSCRIPT toe. He had a small lesion on the toe nail for few months before biopsy confirmed the diagnosis. Wide excision was performed to remove the toe nail and shave off the distal phalanx (Fig. 2A). The dorsal digital artery was identified and demonstrated good pulsation that was sufficient for use as the recipient artery along with the
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superficial vein. The flap was elevated from the left forearm and measured 5 × 2.5 cm with a 1-cm pedicle (Fig. 2B). The diameters of the artery and vein were 0.6 mm. and 0.7 mm, respectively. End-to-end anastomosis was performed. The donor site
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was closed primarily. Healing was uneventful, and the patient was discharged 1 week after surgery. Follow-up examination at 15 months demonstrated good contours and
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function without recurrence (Fig. 2C).
Discussion
The objective of tissue reconstruction in the extremities is to regain function
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by providing adequate coverage and sensation, if possible. In our experience, the workhorse flaps for significant hand and foot reconstructions include the anterolateral thigh (ALT) perforator flap, thoracodorsal artery perforator (TDAP) flap, superficial
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circumflex iliac artery perforator (SCIP) flap, and various muscle flaps. However, for small lesions that are too big to be covered with local flaps, various flaps have been
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described including arterialized venous flap, pulp flap, toe-web-space flap, distant flap, and others.15-17 These flaps are limited in terms of size, as larger flaps are required, donor-site morbidity increases, and viability becomes uncertain. It is also obvious that distant flaps, such as the pocket flap and cross finger flap, cause prolonged discomfort and the increased need for rehabilitation. The goal of this study is to identify the ideal flap for small intermediate-size defects (average size = 19.0 cm2; range = 6 × 2 cm–5 × 9 cm) that can efficiently 9
ACCEPTED MANUSCRIPT avoid further contour revisions and, thereby, minimize donor-site morbidity. Such flaps have to be thin and small. Muscle flaps were ruled out because they cannot be appropriately harvested, and thus we ended up using other perforator flaps. All firstline perforator flaps required secondary revision procedures, such as contouring, due
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to the excessively fat and thick dermal layers. It was very difficult to close the flap due to its apparent thickness in comparison to the surrounding skin. Using the reconstruction elevator approach, we tried to find the best one-stage solution.18
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The anatomy of the posterior interosseous vascular system has been widely described and divided into three territories10-12,19-22: 1) the proximal region, which
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usually presents with small thin vessels; 2) the central area that has a few good septocutaneous perforators; and 3) the distal region that has several branches of suitable caliber.5,7 The freestyle approach usually involves the central region. However, if the perforator is unreliable without a strong pulse after suprafascial
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elevation of the flap, one can always dissect along this plane in order to locate a more reliable perforator. In our series, we identified 1 flap when we could not find a perforator in the Doppler-traced site. We had to explore and subsequently find a
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pulsatile perforator that was 4 cm from the initial marking. In these situations, we recommend approaching either distally or proximally along the muscular septum in
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order to locate perforators. One can overcome anatomical uncertainty by directly visualizing perforators. We located good pulsatile arteries (average diameter, 0.8 mm; range, 0.5–1.0 mm) that could be successfully used in microanastomosis. In this series, PIA perforator flaps demonstrated an average thickness of 3.5 mm (range, 2.5–5 mm). They demonstrated excellent harmony with the surrounding skin that was adjacent to the defect. Sufficiently sized flaps up to 5 × 9 cm were acquired. All flaps were closed primarily up to a width of 5 cm, resulting in a negligible 10
ACCEPTED MANUSCRIPT scarring. However, the biggest disadvantage was a short pedicle length (average, 2.5 cm; range, 1–3.2 cm; as measured from the base of the flap). Reconstruction of the hand or foot usually allows the recipient pedicle to be located superficially or adjacent to the defect. By using these superficially located recipient vessels, we were able to
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overcome the disadvantage of short pedicled flap. In our experience, it is much safer to first prepare the defect and then find the recipient vessel and start elevation. This sequence allows the determination of the required pedicle length and flap. The size
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of the flap artery and veins should demonstrate good agreement with the diameter of the recipient vessels in this region. Although some vessels may be as small as 0.5
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mm., advances in microscopy and technical skill allow anastomosis after a certain learning curve.23
Since its introduction by Masquelet and Angrigiani, use of the PIA flap has gained considerable recognition for use in reconstructive surgery.2,3 The cutaneous
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paddle of the flap demonstrates unique properties due to its thin, pliable, wellvascularized, relatively hairless, sensate skin and the possibility of primary closing with only a linear scar. In hand and finger reconstruction, the flap can be
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simultaneously raised along with preparation of the recipient site under a brachial plexus block, and a single tourniquet can be used to minimize blood loss. However,
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due the limited arc of rotation required to reach the hand, most studies discuss the reverse pattern as a viable option; however, partial and total necrosis is reportedly due to to anatomic variability, and inconsistency in the distal part of the extended reverse patterns flap.8-12,19 Therefore, microsurgical options should be considered in order to achieve reliable coverage of the fingers. When selecting a flap, we choose one that ensures safety and ideally accommodates the defect and provides normal physiology. The freestyle approach 11
ACCEPTED MANUSCRIPT allows the flap to be small and thin while still having an independent pedicle. Flap selection should be based on the predicted functional and aesthetic results, not only for the recipient but also the donor site. To reconstruct the hand and foot, especially the digits, small wounds should be covered with local flaps. Thin perforator flaps are
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available for large defects, such as ALT, TDAP, SCIP, and other fascial and muscle flaps. However, for intermediate-size defects, PIA perforator flaps that are placed using the freestyle approach need to be thin in order to provide efficient and
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Conflict of Interest/Funding: None
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adequate coverage.
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ACCEPTED MANUSCRIPT References
1.
Lister G. Local flaps to the hand. Hand Clin 1985;1:621-40.
2.
Masquelet AC, Penteado CV. The posterior interosseous flap. Ann Chir Main
3.
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1987;6:131-9.
Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg Br 1988;13:130-5.
Neuwirth M, Hubmer M, Koch H. The posterior interosseous artery flap:
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4.
Aesthet Surg 2013;66:623-8. 5.
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Clinical results with special emphasis on donor site morbidity. J Plast Reconstr
Pahl S, Schmidt HM. Clinical anatomy of the interosseous arteries of the forearm. Handchir Mikrochir Plast Chir 1994;26:246-50.
6.
Tonkin MA, Stern H. The posterior interosseous artery free flap. J Hand Surg
7.
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Br 1989;14:215-7.
Cavadas PC. Posterior interosseous free flap with extended pedicle for hand reconstruction. Plast Reconstr Surg 2001;108:897-901. Costa H, Soutar DS. The distally based island posterior interosseous flap. Br J
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8.
Plast Surg 1988;41:221-7. Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous
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9.
reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr Surg 1993;92:285-93.
10.
Chen HC, Cheng MH, Schneeberger AG, Cheng TJ, Wei FC, Tang YB. Posterior interosseous flap and its variations for coverage of hand wounds. J Trauma 1998;45:570-4.
11.
Chen HC, Tang YB, Chuang D, Wei FC, Noordhoff MS. Microvascular free 13
ACCEPTED MANUSCRIPT posterior interosseous flap and a comparison with the pedicled posterior interosseous flap. Ann Plast Surg 1996;36:542-50. 12.
Park JJ, Kim JS, Chung JI. Posterior interosseous free flap: various types. Plast Reconstr Surg 1997;100:1186-97; discussion 98-9. Lin CT, Chen SG, Chen TM, Dai NT, Chang SC. Free fasciocutaneous flaps for reconstruction
of
complete
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13.
circumferential degloving
Microsurgery 2013;33:191-7.
of
digits.
Mei J, Morris SF, Ji W, Li H, Zhou R, Tang M. An anatomic study of the dorsal
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14.
injury
forearm perforator flaps. Surg Radiol Anat 2013;35:695-700.
Lee DC, Kim JS, Ki SH, Roh SY, Yang JW, Chung KC. Partial second toe pulp
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15.
free flap for fingertip reconstruction. Plast Reconstr Surg 2008;121:899-907. 16.
Woo SH, Kim KC, Lee GJ, et al. A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: an 11-year experience. Plast Reconstr
17.
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Surg 2007;119:1823-38.
May JW, Jr., Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from
93. 18.
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the first web of the foot in hand reconstruction. J Hand Surg Am 1977;2:387-
Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive
19.
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elevator. Plast Reconstr Surg 1994;93:1503-4.
Shibata M, Iwabuchi Y, Kubota S, Matsuzaki H. Comparison of free and reversed pedicled posterior interosseous cutaneous flaps. Plast Reconstr Surg
1997;99:791-802. 20.
Chen HC, Buchman MT, Wei FC. Free flaps for soft tissue coverage in the hand and fingers. Hand Clin 1999;15:541-54.
21.
Giessler GA, Erdmann D, Germann G. Soft tissue coverage in devastating 14
ACCEPTED MANUSCRIPT hand injuries. Hand Clin 2003;19:63-71, vi. 22.
Davami B, Porkhamene G. Versatility of local fasciocutaneous flaps for coverage of soft tissue defects in upper extremity. J Hand Microsurg 2011;3:58-62.
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Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the
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next step in evolution. Plast Reconstr Surg 2009;123:230-5.
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23.
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ACCEPTED MANUSCRIPT Illustrations
Figure 1. a) A 54-year-old male diabetic patient with first ray ulceration and osteomyelitis was referred to the plastic surgery department. b) After aggressive
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debridement, an 8 × 2.5 cm flap was raised with a 2-cm pedicle from the left forearm. The artery and vein had diameters of 0.7 mm and 0.8 mm, respectively, and each anastomosis was performed in an end-to-end fashion. The donor site was closed
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function of the first ray and acceptable scarring.
SC
primarily. c, d) Follow-up examination at 4 months showed good contours and
Figure 2. A 6-year-old boy was diagnosed with malignant melanoma on the first left toe. a) A wide excision was performed to remove the toe nail and shave off the distal phalanx. The dorsal digital artery was identified and demonstrated good pulsation
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sufficient for use as a recipient artery along with the superficial vein. b) The flap was elevated from the left forearm (dimensions = 5 × 2.5 cm with a 1-cm pedicle). The diameters of the artery and vein were 0.6 mm and 0.7 mm, respectively. End-to-end
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anastomosis was performed. c) Follow-up examination at 15 months showed good
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contours and function without recurrence.
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S1748-6815(14)00118-1
DOI:
10.1016/j.bjps.2014.03.007
Reference:
PRAS 4118
To appear in:
British Journal of Plastic Surgery
Received Date: 17 September 2013 Revised Date:
4 February 2014
Accepted Date: 8 March 2014
Please cite this article as: Yoon CS, Noh HJ, Malzone G, Suh HS, Choi DH, Hong JP(J), Posterior interosseous artery perforator-free flap: Treating intermediate-size hand and foot defects, British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.03.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Posterior interosseous artery perforator-free flap: Treating intermediate-size hand and foot defects
Hyung Joo Noh, MD1, Gerardo Malzone, MD1, Hyun Suk Suh,
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Chi Sun Yoon, MD2,
MD3, Dong Hoon Choi, MD1, Joon Pio (Jp) Hong, MD, PhD, MMM1,*
1
SC
Department of Plastic Surgery, Asan Medical Center, University of Ulsan;
2
Department of Plastic Surgery, Ulsan University Hospital, University of Ulsan;
3
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Department of Plastic Surgery, Ewha Womans University Hospital, Seoul, Korea
*Corresponding author: Joon Pio Hong, MD, PhD, MMM, Department of Plastic Surgery,
138-736,
Korea.
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Asan Medical Center University of Ulsan, Songpa-gu, Poongnap2-dong, 388-1, Seoul, Tel:
(822)
3010-3600;
Fax:
(822)
476-7471;
Email:
EP
[email protected]
The authors have no conflicts of interest to report regarding any of the materials used
AC C
in this study.
1
ACCEPTED MANUSCRIPT Summary Ambiguous defects on the hand and foot, especially on the fingers and toes, are still challenging to treat despite achievements in reconstruction. The purpose of this study was to evaluate the use of the posterior interosseous artery perforator flap
RI PT
for resurfacing intermediate-sized defects and provide adequate coverage over tendons and bones. Between October 2008 and March 2013, a total of 19 patients with soft-tissue defects on the hand or foot were treated. Flap elevation, anatomy,
SC
and clinical progress were evaluated. All flaps survived and covered the defects, which ranged in area from 12 to 45 cm2. The freestyle approach was used to harvest
M AN U
the flaps. The average length of the pedicle was 2.5 cm, and the pedicle was harvested without affecting the source vessel. The average diameter of the artery was 0.8 mm, and the average thickness of the flap was 3.5 mm. Anastomosis was performed either end-to-end on the perforator, or end-to-side on deep vessels. No
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subsequent thinning or surgical flap correction was necessary. Ambulation was allowed at 3 days postsurgery. The donor site was closed primarily to leave an acceptable donor site. A posterior interosseous artery perforator-free flap is a suitable
EP
choice for intermediate-size defects that are too large to cover using a local flap or too small for a first-line perforator flap. Up to 45 cm2 of adequate coverage can be
AC C
provided using a thin posterior interosseous artery perforator-free flap that does not require additional debulking. The disadvantages of a short pedicle can be overcome using perforator-to-perforator supermicrosurgery.
Keywords: posterior interosseous artery perforator flap; small soft-tissue defect; perforator flap; supermicrosurgery; hand and foot reconstruction.
2
ACCEPTED MANUSCRIPT Introduction Soft-tissue defects on the hand and foot, especially the fingers and toes, often present as a challenging reconstructive problem. Despite the many flaps available for hand and foot reconstruction, small defects ideally require a thin flap. In many cases,
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a local flap provides excellent coverage for small defects, such as those found on the finger tips.1 However, relatively larger defects may require the use of skin graft when the flap is unable to close properly. Furthermore, you may encounter partial loss over
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the region that you really need coverage due to overzealous design. The aim of any reconstruction that involves exposure of the tendons and bone is to regain function
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by providing adequate cover and early rehabilitation. Nowadays, in the era of care that considers not only function but also form, one must continue to seek options that will allow the best possible results. For small lesions that are too big to be covered with local flaps, various other types of flaps have been developed i.e. arterialized
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venous flap, pulp flap, toe-web-space flap, distant flap, and others. However, these flaps cannot be used when larger flaps are required, as donor-site morbidity increases and viability becomes uncertain. It is also obvious that distant flaps, such
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as the pocket flap and cross finger flap, causes prolonged discomfort as well as the increased need for rehabilitation. The goal of this study was to identify the ideal flap
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for intermediate-size defects (average = 19.0 cm2; range = 6 × 2 cm–5 × 9 cm) that can efficiently avoid further contour revisions and, thereby, minimize donor-site morbidity. Such flaps have to be thin and small. Posterior interosseous artery (PIA) flaps do not require the sacrifice of a major artery in the upper limb and results in minimal donor-site morbidity.2-4 The PIA is located in the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi muscles, and several anatomical studies confirm the rich 3
ACCEPTED MANUSCRIPT presence of cutaneous perforator vessels.5-7 The PIA is anatomically united by two main anastomoses: one proximal (at the level of the distal border of the supinator muscle) and one distal (at the most distal part of the interosseous space). The PIA joins the anterior interosseous artery to form the distal anastomosis. The posterior
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interosseous fasciocutaneous flap can be used as a reverse-flow island flap because it is perfused by anastomoses between the two arteries at the level of the wrist. However, local flaps may not be feasible if the defect is not in the proximal part of the
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hand.8,9 Furthermore, posterior interosseous fasciocutaneous flap complications reportedly cause arterial inflow problems in reverse-pedicled flaps.10,11 Use of the PIA
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flap as the free flap for reconstructing soft-tissue defects in the extremities is reportedly successful, especially for defects that require a thin flap in order to regain delicate hand functions.12,13
Despite the PIA flap being one of the thinnest perforator flaps, little has been
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reported regarding its application to intermediate-size defects on the hand and foot, especially the fingers and toes. Here, we evaluate the PIA perforator flap as an
Methods
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option for such defects, especially those on the distal foot and hand.
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This retrospective study was performed after approval from the institutional
review board of Asan Medical Center. Between October 2008 and March 2013, a total of 19 patients were treated for soft-tissue defects in the upper or lower extremities due to various causes. All patients underwent reconstruction using short pedicled PIA perforator-free flaps. All flaps were anastomosed either end-to-end on the perforator (distal end of the vessel) or end-to-side on the deeper vessel. Multidetector-row computed tomographic angiograms of the upper or lower 4
ACCEPTED MANUSCRIPT extremities were obtained before surgery if the vascular status was questionable. Hand-held Doppler ultrasound was preoperatively used to mark potential recipient perforators around the soft-tissue defects and trace the perforator of the flap.
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Intensity was observed and marked during the tracing of the recipient perforator.
Surgical procedure
Surgeries were performed on all patients under general anesthesia by the
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same surgeon. In every case, the freestyle approach was used. The preoperative identification of the vessel was made using Doppler ultrasound. Complete
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debridement was performed before any reconstructive procedure. The recipient vessels were identified after debridement or tumor excision. If large peripheral vessels or small branches from the peripheral vessels were already exposed within the defect, we used those vessels as the recipient vessel if a good pulse was
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detected; if not, we searched for a recipient vessel that was subfascial and adjacent to the defect margin. After securing the pulsating recipient artery and viable veins, the required length for the pedicle was estimated. The PIA perforator flap was designed
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according to the size of the defect around the Doppler-traced perforator. Cutaneous perforators could be found along the line extending from the lateral epicondyle to the
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radial border of the head of ulna.14 Flap elevation began suprafascially from one margin, we prefer to start with the ulnar side, to confirm the location of the perforator under the designed area. If the perforator was not included in the original design, then a new design was made directly over the pedicle. The rest of the flap was elevated once the perforator was identified. The perforator was dissected until the proper length was obtained. Frequently, dissection extended beyond the deep fascia. We preferred to skeletonize the pedicle when entering the deep fascia and 5
ACCEPTED MANUSCRIPT intermuscular septum and dissect toward the deeper interosseous vessels. The posterior antebrachial cutaneous nerve was identified and included if an innervated flap was needed. The pedicle of the flap was divided and ligated before it met the posterior interosseous vessel. Usually, the obtained short pedicled flap was < 3–4 cm
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(video).
Anastomoses were performed in either an end-to-end or end-to-side fashion. The recipient arteries included the dorsal metatarsal artery (3 patients), dorsal digital
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artery (8 patients), proper plantar digital artery (3 patients), palmar branch of the radial artery (3 patients), or ulnar artery (2 patients). Venous drainage occurred
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through the accompanying vein of the PIA. The recipient vein was either the accompanying or superficial vein. One artery and one vein were anastomosed in all patients. Anastomoses were performed in an end-to-end fashion in 14 patients and end-to-side fashion in 5 patients using a 10-0 nylon suture. All donor sites were
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closed primarily.
Postoperative monitoring was performed every 2 hours for 2 days, and then every 8 hours until discharge. Arterial and venous patency were clinically monitored
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according to the color, refill, and temperature. If subjective findings were equivocal, duplex scanning was used to monitor vessel status. A vasodilator (10 µg lipo-
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prostaglandin E1; Eglandin; Welfide, Seoul, Korea) was mixed with 5% dextrose solution and infused over 4 hours per day for 5 days. In addition, 3800 IU lowmolecular-weight
heparin
(Fraxiparin;
Sanofi-Aventis,
Paris,
France)
was
subcutaneously injected over 5 days. Depending on flap status, ambulation was allowed on postoperative day 3. The patient was discharged from the hospital within 7 days if no other problems were noted. Supportive short-arm or short-leg splints were postoperatively used to immobilize all patients for 1 week. After the splint was 6
ACCEPTED MANUSCRIPT removed, the patients participated in an active and passive physical rehabilitation program in order to achieve maximum range of motion. Compressive garments were applied to all patients on postoperative day 5.
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Results
The study population included 8 female and 11 male patients. The average age of the patients was 38 years (range, 6–66 years). The causes of the soft-tissue
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defects included resection of malignant melanoma (subungual type; 5 patients), resection of neurogenic tumor (1 patient), electrical burn (1 patient), trauma (4
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patients), and diabetic ulcer (8 patients). Defects were located on the first toe in 11 patients, thumb in 3 patients, dorsum of the foot in 3 patients, and left palm in 2 patients. The average time required to raise the flaps was approximately 30 minutes. The average size of the flap was 19.0 cm2 (range = 6 × 2 cm–5 × 9 cm). The width of
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the flap averaged 3.1 cm (range = 2.3–5 cm), and the length averaged 5.94 cm (range = 4–10 cm). The average thickness of the flap was 3.5 mm (range = 2.5–5 mm). With the exception of 1 flap, all perforators were found according to markings
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obtained using Doppler ultrasound. In 1 flap, the perforator was 4 cm from the marking. All perforators originated from the PIA. The average length of the pedicle, as
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measured from the base of the flap, was 2.5 cm (range = 1–3.2 cm), and the average artery diameter was 0.8 mm (range = 0.5–1.0 mm.). Only a single perforator was required for all flaps.
All flaps were successful without anastomotic complications. One case of marginal necrosis occurred but healed with secondary intervention. Two patients developed postoperative hematoma and blisters but healed without further surgical intervention. The donor site for all cases was closed primarily. Minimal donor-site 7
ACCEPTED MANUSCRIPT morbidity developed. The average follow-up period was 18 months (range = 1–53 months). During the follow-up period, the flaps demonstrated good contours and no additional secondary contouring procedures were required.
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Case 1
A 54-year-old male diabetic patient with first ray ulceration and osteomyelitis was referred to the plastic surgery department. Ulceration was first noted after
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wearing a poorly fitted shoe, which became increasingly and slowly aggravated over a 6-month period (Fig. 1A). After aggressive debridement, which included a piece of
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the proximal phalangeal bone and metatarsal bone, the first toe was still considered salvageable. Following endovascular angioplasty, angiography of the anterior tibial artery revealed sufficient flow, the dorsal digital artery demonstrated a good pulse, and the superficial vein was isolated adjacent to the defect. An 8 × 2.5 cm flap was
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raised using a 2-cm pedicle from the left forearm (Fig. 1B, C). The artery and vein had diameters of 0.7 mm and 0.8 mm, respectively, and anastomosis was performed in an end-to-end fashion. The donor site was closed primarily. Over the first 2 days,
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slight congestion was noted and 4 leeches were applied. Otherwise, postoperative progression was uneventful. The patient started ambulation on day 5 and was
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discharged on day 8 after achieving good control of blood sugar levels. Healing was uneventful, and the patient was discharged 3 weeks after surgery. Follow-up examination at 4 months demonstrated good contours and function of the first ray and acceptable donor scarring (Fig. 1D, E).
Case 2 A 6-year-old boy was diagnosed with malignant melanoma on the first left 8
ACCEPTED MANUSCRIPT toe. He had a small lesion on the toe nail for few months before biopsy confirmed the diagnosis. Wide excision was performed to remove the toe nail and shave off the distal phalanx (Fig. 2A). The dorsal digital artery was identified and demonstrated good pulsation that was sufficient for use as the recipient artery along with the
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superficial vein. The flap was elevated from the left forearm and measured 5 × 2.5 cm with a 1-cm pedicle (Fig. 2B). The diameters of the artery and vein were 0.6 mm. and 0.7 mm, respectively. End-to-end anastomosis was performed. The donor site
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was closed primarily. Healing was uneventful, and the patient was discharged 1 week after surgery. Follow-up examination at 15 months demonstrated good contours and
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function without recurrence (Fig. 2C).
Discussion
The objective of tissue reconstruction in the extremities is to regain function
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by providing adequate coverage and sensation, if possible. In our experience, the workhorse flaps for significant hand and foot reconstructions include the anterolateral thigh (ALT) perforator flap, thoracodorsal artery perforator (TDAP) flap, superficial
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circumflex iliac artery perforator (SCIP) flap, and various muscle flaps. However, for small lesions that are too big to be covered with local flaps, various flaps have been
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described including arterialized venous flap, pulp flap, toe-web-space flap, distant flap, and others.15-17 These flaps are limited in terms of size, as larger flaps are required, donor-site morbidity increases, and viability becomes uncertain. It is also obvious that distant flaps, such as the pocket flap and cross finger flap, cause prolonged discomfort and the increased need for rehabilitation. The goal of this study is to identify the ideal flap for small intermediate-size defects (average size = 19.0 cm2; range = 6 × 2 cm–5 × 9 cm) that can efficiently 9
ACCEPTED MANUSCRIPT avoid further contour revisions and, thereby, minimize donor-site morbidity. Such flaps have to be thin and small. Muscle flaps were ruled out because they cannot be appropriately harvested, and thus we ended up using other perforator flaps. All firstline perforator flaps required secondary revision procedures, such as contouring, due
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to the excessively fat and thick dermal layers. It was very difficult to close the flap due to its apparent thickness in comparison to the surrounding skin. Using the reconstruction elevator approach, we tried to find the best one-stage solution.18
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The anatomy of the posterior interosseous vascular system has been widely described and divided into three territories10-12,19-22: 1) the proximal region, which
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usually presents with small thin vessels; 2) the central area that has a few good septocutaneous perforators; and 3) the distal region that has several branches of suitable caliber.5,7 The freestyle approach usually involves the central region. However, if the perforator is unreliable without a strong pulse after suprafascial
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elevation of the flap, one can always dissect along this plane in order to locate a more reliable perforator. In our series, we identified 1 flap when we could not find a perforator in the Doppler-traced site. We had to explore and subsequently find a
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pulsatile perforator that was 4 cm from the initial marking. In these situations, we recommend approaching either distally or proximally along the muscular septum in
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order to locate perforators. One can overcome anatomical uncertainty by directly visualizing perforators. We located good pulsatile arteries (average diameter, 0.8 mm; range, 0.5–1.0 mm) that could be successfully used in microanastomosis. In this series, PIA perforator flaps demonstrated an average thickness of 3.5 mm (range, 2.5–5 mm). They demonstrated excellent harmony with the surrounding skin that was adjacent to the defect. Sufficiently sized flaps up to 5 × 9 cm were acquired. All flaps were closed primarily up to a width of 5 cm, resulting in a negligible 10
ACCEPTED MANUSCRIPT scarring. However, the biggest disadvantage was a short pedicle length (average, 2.5 cm; range, 1–3.2 cm; as measured from the base of the flap). Reconstruction of the hand or foot usually allows the recipient pedicle to be located superficially or adjacent to the defect. By using these superficially located recipient vessels, we were able to
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overcome the disadvantage of short pedicled flap. In our experience, it is much safer to first prepare the defect and then find the recipient vessel and start elevation. This sequence allows the determination of the required pedicle length and flap. The size
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of the flap artery and veins should demonstrate good agreement with the diameter of the recipient vessels in this region. Although some vessels may be as small as 0.5
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mm., advances in microscopy and technical skill allow anastomosis after a certain learning curve.23
Since its introduction by Masquelet and Angrigiani, use of the PIA flap has gained considerable recognition for use in reconstructive surgery.2,3 The cutaneous
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paddle of the flap demonstrates unique properties due to its thin, pliable, wellvascularized, relatively hairless, sensate skin and the possibility of primary closing with only a linear scar. In hand and finger reconstruction, the flap can be
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simultaneously raised along with preparation of the recipient site under a brachial plexus block, and a single tourniquet can be used to minimize blood loss. However,
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due the limited arc of rotation required to reach the hand, most studies discuss the reverse pattern as a viable option; however, partial and total necrosis is reportedly due to to anatomic variability, and inconsistency in the distal part of the extended reverse patterns flap.8-12,19 Therefore, microsurgical options should be considered in order to achieve reliable coverage of the fingers. When selecting a flap, we choose one that ensures safety and ideally accommodates the defect and provides normal physiology. The freestyle approach 11
ACCEPTED MANUSCRIPT allows the flap to be small and thin while still having an independent pedicle. Flap selection should be based on the predicted functional and aesthetic results, not only for the recipient but also the donor site. To reconstruct the hand and foot, especially the digits, small wounds should be covered with local flaps. Thin perforator flaps are
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available for large defects, such as ALT, TDAP, SCIP, and other fascial and muscle flaps. However, for intermediate-size defects, PIA perforator flaps that are placed using the freestyle approach need to be thin in order to provide efficient and
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Conflict of Interest/Funding: None
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adequate coverage.
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ACCEPTED MANUSCRIPT References
1.
Lister G. Local flaps to the hand. Hand Clin 1985;1:621-40.
2.
Masquelet AC, Penteado CV. The posterior interosseous flap. Ann Chir Main
3.
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1987;6:131-9.
Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg Br 1988;13:130-5.
Neuwirth M, Hubmer M, Koch H. The posterior interosseous artery flap:
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4.
Aesthet Surg 2013;66:623-8. 5.
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Clinical results with special emphasis on donor site morbidity. J Plast Reconstr
Pahl S, Schmidt HM. Clinical anatomy of the interosseous arteries of the forearm. Handchir Mikrochir Plast Chir 1994;26:246-50.
6.
Tonkin MA, Stern H. The posterior interosseous artery free flap. J Hand Surg
7.
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Br 1989;14:215-7.
Cavadas PC. Posterior interosseous free flap with extended pedicle for hand reconstruction. Plast Reconstr Surg 2001;108:897-901. Costa H, Soutar DS. The distally based island posterior interosseous flap. Br J
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8.
Plast Surg 1988;41:221-7. Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous
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9.
reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr Surg 1993;92:285-93.
10.
Chen HC, Cheng MH, Schneeberger AG, Cheng TJ, Wei FC, Tang YB. Posterior interosseous flap and its variations for coverage of hand wounds. J Trauma 1998;45:570-4.
11.
Chen HC, Tang YB, Chuang D, Wei FC, Noordhoff MS. Microvascular free 13
ACCEPTED MANUSCRIPT posterior interosseous flap and a comparison with the pedicled posterior interosseous flap. Ann Plast Surg 1996;36:542-50. 12.
Park JJ, Kim JS, Chung JI. Posterior interosseous free flap: various types. Plast Reconstr Surg 1997;100:1186-97; discussion 98-9. Lin CT, Chen SG, Chen TM, Dai NT, Chang SC. Free fasciocutaneous flaps for reconstruction
of
complete
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13.
circumferential degloving
Microsurgery 2013;33:191-7.
of
digits.
Mei J, Morris SF, Ji W, Li H, Zhou R, Tang M. An anatomic study of the dorsal
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14.
injury
forearm perforator flaps. Surg Radiol Anat 2013;35:695-700.
Lee DC, Kim JS, Ki SH, Roh SY, Yang JW, Chung KC. Partial second toe pulp
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15.
free flap for fingertip reconstruction. Plast Reconstr Surg 2008;121:899-907. 16.
Woo SH, Kim KC, Lee GJ, et al. A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: an 11-year experience. Plast Reconstr
17.
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Surg 2007;119:1823-38.
May JW, Jr., Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from
93. 18.
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the first web of the foot in hand reconstruction. J Hand Surg Am 1977;2:387-
Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive
19.
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elevator. Plast Reconstr Surg 1994;93:1503-4.
Shibata M, Iwabuchi Y, Kubota S, Matsuzaki H. Comparison of free and reversed pedicled posterior interosseous cutaneous flaps. Plast Reconstr Surg
1997;99:791-802. 20.
Chen HC, Buchman MT, Wei FC. Free flaps for soft tissue coverage in the hand and fingers. Hand Clin 1999;15:541-54.
21.
Giessler GA, Erdmann D, Germann G. Soft tissue coverage in devastating 14
ACCEPTED MANUSCRIPT hand injuries. Hand Clin 2003;19:63-71, vi. 22.
Davami B, Porkhamene G. Versatility of local fasciocutaneous flaps for coverage of soft tissue defects in upper extremity. J Hand Microsurg 2011;3:58-62.
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Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the
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next step in evolution. Plast Reconstr Surg 2009;123:230-5.
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23.
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ACCEPTED MANUSCRIPT Illustrations
Figure 1. a) A 54-year-old male diabetic patient with first ray ulceration and osteomyelitis was referred to the plastic surgery department. b) After aggressive
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debridement, an 8 × 2.5 cm flap was raised with a 2-cm pedicle from the left forearm. The artery and vein had diameters of 0.7 mm and 0.8 mm, respectively, and each anastomosis was performed in an end-to-end fashion. The donor site was closed
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function of the first ray and acceptable scarring.
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primarily. c, d) Follow-up examination at 4 months showed good contours and
Figure 2. A 6-year-old boy was diagnosed with malignant melanoma on the first left toe. a) A wide excision was performed to remove the toe nail and shave off the distal phalanx. The dorsal digital artery was identified and demonstrated good pulsation
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sufficient for use as a recipient artery along with the superficial vein. b) The flap was elevated from the left forearm (dimensions = 5 × 2.5 cm with a 1-cm pedicle). The diameters of the artery and vein were 0.6 mm and 0.7 mm, respectively. End-to-end
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anastomosis was performed. c) Follow-up examination at 15 months showed good
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contours and function without recurrence.
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