Home Print this page Email this page Users Online: 148
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 27  |  Issue : 1  |  Page : 40-43

Reverse radial forearm perforator plus flaps for the reconstruction of postelectrical burn sequelae of hand and forearm defects


1 Department of Plastic Surgery and Burns, Jubilee Mission Medical College and Research Institute, Chennai, Tamil Nadu, India
2 Department of Plastic Surgery and Burns, Vijaya Hospital, Chennai, Tamil Nadu, India
3 Department of Computer Science, St. Thomas College, Thrissur, Kerala, India

Date of Web Publication17-Jan-2020

Correspondence Address:
Dr. Pradeoth Mukundan Korambayil
Department of Plastic Surgery and Burns, Jubilee Mission Medical College and Research Institute, Thrissur - 680 005, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_15_19

Rights and Permissions
  Abstract 


Background: The reverse radial forearm perforator flaps are useful in softtissue reconstruction of the hand and forearm. Certain modifications in the flap and usage of hyperbaric oxygen therapy as an adjunct in reconstruction could aid in better outcome of the surgical procedure. The conventional reverse radial artery forearm flap incorporates the radial artery along with its venae commitants along with the flap providing less chances of venous congestion. The per-foratoronly flap may cause a twist in a pedicle which may not affect the artery much, but a small increase in pressure may obstruct the tiny veins running along with the perforator resulting in chances of venous congestion which is a common problem in propeller or perforator flaps. This can be overcome by designing a flap with adequate venous outflow and reducing the postoperative inflammatory edema to prevent pressure to the tiny perforators with arterial and venous components.
Aims and Objectives: To focus on flap harvest in a perforator plus model to increase the venous outflow and use of hyperbaric oxygen therapy as an adjunct to prevent the inflammatory edema on the perforator vessels.
Materials and Methods: Reverse radial artery perforator plus flaps used for the reconstruction of hand and forearm soft-tissue loss in a series of patients due to electrical burns. We used hyperbaric oxygen therapy as an adjunct for reconstruction.
Results: No flap related complication in the series. One patient developed venous congestion at the distal tip region which settled without any further intervention.
Conclusion: Defects of the hand and forearm due to the electrical burns could be effectively managed with radial forearm perforator plus flap with allowing adequate venous outflow, and hyperbaric oxygen therapy as an adjunct in electrical burns.

Keywords: Electrical burns, hyperbaric oxygen therapy, radial artery perforator plus flap, soft-tissue reconstruction


How to cite this article:
Korambayil PM, Ambookan PV, Dilliraj VK, Karangath RR. Reverse radial forearm perforator plus flaps for the reconstruction of postelectrical burn sequelae of hand and forearm defects. Indian J Burns 2019;27:40-3

How to cite this URL:
Korambayil PM, Ambookan PV, Dilliraj VK, Karangath RR. Reverse radial forearm perforator plus flaps for the reconstruction of postelectrical burn sequelae of hand and forearm defects. Indian J Burns [serial online] 2019 [cited 2020 Oct 26];27:40-3. Available from: https://www.ijburns.com/text.asp?2019/27/1/40/275893




  Introduction Top


The reverse radial forearm flap with radial artery and its venae commitants has been used extensively for the distal soft-tissue reconstruction of the hand and forearm.[1],[2] The conventional reverse radial forearm flap provides adequate perfusion of the transferred tissue with less chances of venous congestion. The patency of the palmar arches is the key for the reverse flow flap. In case of electrical burns, as the injury travels through the neurovascular bundle, there are high chances of injury to the arches, and there are always possibilities for flap complications. For moderate-to-large defects, it is always better to relay on a flap which is not in close vicinity to the injured region. A groin flap is considered to be relatively safer than in flaps harvested from the injured zones. For small defects, a groin flap may cause more morbidity than the regional flaps. In this condition, a perforator flap may be reliable as it may not sacrifice the primary vessel.[3],[4] Complications such as venous congestion are not uncommon when we totally rely on the venous drainage by veins along the perforators. A flap with adequate venous outflow is necessary in perforator flaps. Venous outflow obstruction may be caused by the mechanical strain on the twist of the pedicle or due the surrounding impending inflammatory edema due to the surgery itself. A perforator plus flap may solve the issue by providing additional venous outflow channels, and hyperbaric oxygen therapy as an adjunct will resolve some of the inflammatory edemas due to the procedure and can be used for the prevention of morbidity.[5],[6]


  Materials and Methods Top


Surgical technique

Radial artery perforators were identified and marked with a handheld Doppler device. After placing a tourniquet control, wound debrided and the soft tissue defect is calculated. Reverse radial forearm perforator plus flap is performed with a magnifying loupe for clarity in dissection. When a patient in the supine position, the incision starts at the proximal forearm, radial aspect, and then down to the deep fascia. Deep fascia and skin are tagged to prevent shearing force. The flap is raised carefully not to injure the radial artery including as much of veins inside the flap. The distal perforator is preserved along with available veins into the flap. Once the flap is raised, the flap is rotated accordingly to reach the soft-tissue defect in the hand or forearm. The suturing starts by securing the pedicle region first and then to the peripheral regions of the flap. The donor site can be closed either primarily or with a skin graft. Hyperbaric therapy is either started before surgery as preconditioning or after the surgery. Pressure used is around 1.8–2.4 atmosphere absolute (ATA) with a minimum of six sessions.


  Results Top


Case 1

A 27-year-male had an electrical injury to the left hand while operating an inverter. The wound was conservatively managed in local hospital. After 6 months, the patient presented with the first webspace contracture of the left hand with the thumb in complete adduction [Figure 1]a. Contracture release was done [Figure 1]b,[Figure 1]c,[Figure 1]d, and radial artery forearm perforator plus flap was designed for the reconstruction [Figure 1]e. Flap was elevated and inset was completed [Figure 1]f and [Figure 1]g. Postoperatively, The patient developed venous congestion at the distal tip region which settled without any further intervention [Figure 1]h,[Figure 1]i,[Figure 1]j,[Figure 1]k. Twelve sessions of hyperbaric oxygen therapy were administered to the patient. The late postoperative period showed adequate restoration of thumb movement [Figure 1]l and [Figure 1]m.
Figure 1: (a) Left first webspace contracture due to electrical burns. (b) Surgical release of contracture – volar view. (c) Surgical release of contracture– end on webspace view. (d) Surgical release of contracture – dorsal view. (e) Radial artery perforator plus flap harvest. (f) Radial artery perforator plus flap inset – dorsal view. (g) Radial artery perforator plus flap – volar aspect. (h) Postoperative congested flap at tip region – dorsal view. (i) Postoperative congested flap at tip region – volar view. (j) Healed radial artery perforator plus flap – volar view. (k) Healed radial artery perforator plus flap – dorsal view. (l) Late postoperative picture – dorsal view. (m) Late postoperative picture – volar aspect

Click here to view


Case 2

A 32-year-old male sustained an injury to the left forearm and hand due to a high-voltage electrical shock. The patient developed compartment syndrome within 6 h of injury which was relieved by fasciotomy of the hand and forearm region. Later, the patient developed tissue necrosis at the distal third ulnar aspect of the left forearm measuring approximately 4 cm × 3 cm × 1 cm [Figure 2]a. The wound was debrided which resulted in an exposure of the flexor carpi ulnaris tendon in the distal region [Figure 2]b. Radial artery forearm perforator plus flap was designed including as much of venous flow [Figure 2]c. Flap was rotated around 90°, and the inset was completed [Figure 2]d. The donor area was covered with skin graft harvested from medial aspect upper arm region [Figure 2]e. Twelve sessions of hyperbaric oxygen therapy were administered to the patient. Flap settled well without any further intervention [Figure 2]f.
Figure 2: (a) Postelectrical burns necrotic tissue left forearm distal third ulnar aspect. (b) Postwound debridement picture showing exposure of flexor carpi ulnaris in the distal aspect. (c) Radial artery perforator plus flap harvest including as much of distal veins into the flap. (d) Flap inset completed by 90° rotation. (e) Donor area covered with a skin graft. (f) Late postoperative picture of the healed flap

Click here to view



  Discussion Top


Electric current preferentially passes through the least resistance regions of the body, particularly traveling through the neurovascular bundles. Soft-tissue reconstruction of the electrical burns defects poses with problems of lack of proper delineation of vascularity. Complications associated with the flaps are common when the flaps are harvested in and around the zone of injury. Moderate-to-large defects due to electrical burns of the hand and forearm are addressed commonly by groin or abdominal flaps as this flap vascularity is away from the zones of injury. For small defects, a groin or abdominal flap may cause more morbidity than the regional or local flaps. Smaller soft-tissue reconstruction with local or regional flaps for electrical burn injury may require proper planning to achieve adequate coverage.

The reverse radial forearm flap with radial artery along with its venae commitants has been used extensively for the distal soft-tissue reconstruction of the hand and forearm.[1],[2] The conventional reverse radial forearm flap provides adequate perfusion of the transferred tissue with less chances of venous congestion. The patency of the palmar arches is the key for the reverse flow flap. In case of electrical injury, to sacrifice, a major artery of the compromised limb can be prevented using a reliable perforator flap.[3],[4] Perforator anatomy of the radial forearm has been described extensively by Chang.[7] Complications such as venous congestion are not uncommon when we totally rely on the venous drainage by veins along the perforators.[8] A flap with adequate venous outflow is necessary in perforator flaps. Supercharging of vein is advised by some authors to prevent complications due to venous congestion.[8] Venous outflow obstruction may be caused by the mechanical strain on the twist of the pedicle or due the surrounding impending inflammatory edema due to the surgery itself.[6] A perforator plus flap may solve the issue by providing additional venous outflow channels, and hyperbaric oxygen therapy as an adjunct will resolve some of the inflammatory edemas due to the procedure and can be used for the prevention of morbidity.[5],[6]

Hyperbaric oxygen therapy certainly helps to combat impending compartment syndrome; soft-tissue injury associated with burns which resembles almost a crush injury and the burnt tissue.[9] In our institution, we deliver hyperbaric oxygen through monoplace chamber, wherein 100% oxygen is delivered in 1.8–2.4 ATA for a period of 90 min. A minimum of six sessions is required. The sessions can be extended according to the condition of the wound healing. Patients who require intensive care unit management may be better treated with multiplace chamber where medical assistance can be provided easily. Hyperbaric oxygen therapy reduces the inflammatory edema and prevents the primary and secondary ischemia cycle which results in the effective survival of compromised tissue [Figure 3].
Figure 3: Primary and secondary ischemia cycle

Click here to view



  Conclusion Top


Small defects of the hand and forearm due to the electrical burns could be effectively managed with radial forearm perforator plus flap with allowing adequate venous outflow, and hyperbaric oxygen therapy as an adjunct in electrical burns can salvage the otherwise compromised remnant tissues or flaps.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Soutar DS, Tanner NS. The radial forearm flap in the management of soft tissue injuries of the hand. Br J Plast Surg 1984;37:18-26.  Back to cited text no. 1
    
2.
Martin D, Bakhach J, Casoli V, Pellisier P, Ciria-Llorens G, Khouri RK, et al. Reconstruction of the hand with forearm island flaps. Clin Plast Surg 1997;24:33-48.  Back to cited text no. 2
    
3.
Jeng SF, Wei FC. The distally based forearm island flap in hand reconstruction. Plast Reconstr Surg 1998;102:400-6.  Back to cited text no. 3
    
4.
Koshima I, Moriguchi T, Etoh H, Tsuda K, Tanaka H. The radial artery perforator-based adipofascial flap for dorsal hand coverage. Ann Plast Surg 1995;35:474-9.  Back to cited text no. 4
    
5.
Korambayil PM, Ambookan PV, Dilliraj VK. Superiorly based perforator plus flap for inguinal defects. Plast Aesthet Res 2014;1:89-93, 128.  Back to cited text no. 5
  [Full text]  
6.
Korambayil PM, Ambookan PV, Dilliraj VK. Options for thumb revascularization: Our experience and literature review. Plast Aesthet Res 2014;1:37-40.  Back to cited text no. 6
  [Full text]  
7.
Chang SM. The pedicle of neurocutaneous Island flaps. Plast Reconstr Surg 1996;98:374-6.  Back to cited text no. 7
    
8.
D'Arpa S, Toia F, Pirrello R, Moschella F, Cordova A. Propeller flaps: A review of indications, technique, and results. Biomed Res Int 2014;2014:986829.  Back to cited text no. 8
    
9.
Bhutani S, Vishwanath G. Hyperbaric oxygen and wound healing. Indian J Plast Surg 2012;45:316-24.  Back to cited text no. 9
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed528    
    Printed66    
    Emailed0    
    PDF Downloaded35    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]