A review and critical appraisal of central axis flaps in axillary and elbow contractures

Abstract

Contractures of the axilla and elbow can produce a significant impact on quality of life by reducing the ability to perform activities of daily living. Varieties of techniques are available for resurfacing defects following contracture release but graft or flap loss, donor-site morbidity, esthetics, and recurrences are still challenges for reconstructive surgeons. Central axis "propeller" flaps based on a random, subcutaneous pedicle were first described for axillary and elbow contractures to deploy the unburnt skin of axillary dome in type I and II contractures (Kurtzman and Stern) by moving them 90° to straddle the contracting bands. This strategy provided better esthetics and avoided prolonged splinting. Over more than two decades, there have been several design modifications of these flaps with extended applications to cubital fossa. A comprehensive review of published literature on the topic is presented to discuss classifications, design modifications, and applications of such flaps in managing axillary and elbow contractures.

Keywords: Axillary contracture; Central axis flap; Elbow contracture; Propeller flap; Subcutaneous pedicled flap.

Fig. 1

A schematic illustration of the “original” propeller flap design for right elbow contracture. a The flap is designed in the center of the cubital fossa along the axis of the arm. b After the release of the contracture, the flap is raised and rotated by 90°, like a propeller. The donor area is covered with a skin graft

Fig. 2

a, b A schematic illustration of a multilobed propeller flap. The quadrilobed flap, based on a central subcutaneous pedicle is rotated 90° after release of contracture. The donor areas are closed primarily as far as possible

Fig. 3

a A 32-year-old female with a post-burn, type II, left axillary contracture. The axillary dome is spared but surrounding skin is severely scarred. b A quadrilobed flap is raised in the axillary fossa, based on a subcutaneous pedicle. c The flap is propelled by 90° to straddle the anterior and posterior axillary contracting bands. The donor area is split skin grafted. d An excellent functional and esthetic result at 30 months follow-up. The axillary hairs are well preserved and the flap skin has fully stretched. (Reprinted with the permission from Wolters Kluwer Medknow Publications license no. 4074290918181 [24])

Fig. 4

a–c A schematic illustration of a pinwheel flap design and execution for type II axillary contracture. Flap can be designed with variable number of lobes. Skin flaps spread out like a pinwheel and are rotated into the adjacent defect. Donor areas can usually be closed primarily

Fig. 5

A scarred propeller flap for right elbow contracture. a Preoperative flap marking in a 5-year-old child with a 45° elbow contracture. b A flap is raised of the central scarred tissue along the axis of the extremity, on a subcutaneous pedicle. Note the zig-zag incisions at the flap margin. c The flap is rotated by 90°. A small area of the donor defect is being closed primarily, and the rest is covered with a split skin graft. d Full elbow extension at 1 year postoperative follow-up

Fig. 6

A schematic illustration of an eight-limb propeller flap design for right elbow contracture. a, b An eight-limb flap marked and elevated with a central axis pedicle. c A likely postoperative view with flaps rotated clockwise or anticlockwise. Donor defects closed in a V-Y manner or with a split skin graft

Fig. 7

A zig-zag modified propeller flap for type II left axillary contracture in a 29-year-old patient with severe scarring of the anterior chest wall. a Preoperative view of with 45° shoulder abduction. b A flap marked for central axis pedicle with zig-zag incisions. c Release of the axillary contracture and the flap dissected and elevated. d The flap has been rotated by 90° to straddle the anterior and posterior contracting bands. e Part of the donor area being sutured primarily and the rest covered with a split skin graft. f At 3 years follow-up, the patient is showing full shoulder abduction and an excellent esthetic result. a, b, e and f were reprinted with permission from Indian J Plast Surg., 2016 [25]

Fig. 8

A “Namaste” propeller flap for post-burn contracture of the right elbow. a A zig-zag flap outlined for the elbow contracture. b The islanded flap is elevated based on a subcutaneous pedicle. c Both limbs of the flap are rotated in the same direction by 90°. d Flap is inset and the donor sites are closed primarily. e A 2-year postoperative results showing full elbow extension

Fig. 9

A schematic illustration of planning for multiple rhomboid flaps. Multiple rhomboids with 600 and 1200 angles are designed along the line of contracture. The total length of the flaps should not be less than the half of the contracture length but should also not exceed the total length. It is possible to close the donor defects in V-Y advancement along the long axis