Two Perforators Improve the Extent and Reliability of Paraumbilical Flaps for Upper Limb Reconstruction

Abstract

Background: Complex defects of the forearm and arm are best reconstructed with free flaps. Free flaps are however not universally available. They require long operative time and may be contraindicated in patients with extensive injuries due to a lack of good recipient vessels. The alternatives to free flaps are distant flaps such as groin flaps, random abdominal flaps, thoracoepigastric flaps and paraumbilical perforator flaps. These are axial flaps that are limited by the angiosomes supplied by a given perforator or blood vessel. To improve the extent and reliabilities of the paraumbilical flaps, we incorporated two perforators in the flap.

Methods: A total of 17 patients with extensive forearm defects were managed by two vessel paraumbilical perforator flaps between January 2013 and December 2018. The perforators were identified by a hand-held Doppler and the flap was fashioned with the perforators at the base.

Results: The mean length of the flap raised was 19.5 cm and width was 8.3 cm. The median age was 39 years. All the flaps were successful with no incidence of flap necrosis and no dehiscence.

Conclusion: Two vessel perforator flaps improved the reliability of the paraumbilical perforator flap, allowing for a bigger flap to be harvested and thus ensuring a cover of larger defects. The flaps were easy to raise and were easily tolerated by the patients.

Keywords: Forearm; Limb; Paraumbilical flap; Perforator; Reconstruction.

Fig. 1

Two perforators identified about 3 cm from the umbilicus at the base of the flap

Fig. 2

Patient with extensive arm defect that required free nerve grafts to reconstruct both the median and ulnar nerve with two perforators of paraumbilical flap planned to cover the wounds. The flap dimensions were determined by the size of the wound to be covered. Note the two perforators marked by arrows

Fig. 3

A. Two vessel perforator flaps raised in a subfascial plane from distal to proximal, with the donor site primarily closed. B. Paraumbilical flap raised: The donor site was closed primarily. Note the arrows pointing at the 2 perforators

Fig. 4

A. Patients with exposed tendons and neurovascular structures ready to be covered with paraumbilical flap of dimensions 24×10 cm. B. Perforator paraumbilical flap successfully anchored to the recipient site

Fig. 5

A. Left volar arm defect fully covered with the two vessel paraumbilical flap immediately after separation. B. Left arm wound fully covered with the paraumbilical flap at 2 months of follow up. Note that the defects had extended between the wrist and the elbow

Fig. 6

Note the scar on one of the patients who had paraumbilical perforator flaps. The flap extended to just about 4 cm from the spinal cord