Reverse Superficial Palmar branch of Radial artery pedicled flap for Palmar and Digital reconstruction: A systematic review of literature with a retrospective case review

Abstract

Background: Most studies on the superficial palmar branch of radial artery (SUPBRA) flap involve its use as a free flap with only few reports in literature regarding its use as a reverse pedicled flap. This systematic review presents a summary of the available literature on the indications, anatomy, technique, complications and outcomes of the reverse SUPBRA flap and also describes our experience.

Methods: A computer search was performed on the Embase, Medline and Pubmed databases for clinical studies describing the reverse SUPBRA flap in accordance with the standard principles for systematic review and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A retrospective review of cases performed by the senior author was also conducted.

Results: Seven studies qualified for the review with 50 flaps in 50 patients meeting the inclusion criteria. The senior author has performed nine reverse SUPBRA flaps from 2006 to 2015. The flap was found to be most useful for defects of the thumb, index, palm and first webspace. Variations in vascular anatomy may necessitate a change of operative strategy. Venous congestion was common but transient in the majority. Complications were rare and included minor tip necrosis, scar contracture, donor site sensitivity and numbness, thumb adduction contracture and cold intolerance.

Conclusions: The reverse SUPBRA flap is a versatile flap for reconstructing defects of the thumb, index, palm and first webspace. It is quick to raise, has a low donor site morbidity and complication rate and achieves very reasonable functional and aesthetic outcomes.

Keywords: Reverse SUPBRA; Superficial palmar branch of radial artery flap; distally based SUPBRA; finger defect reconstruction; glabrous skin cover; palm reconstruction.

Figure 1

Flow chart depicting the search strategy for the inclusion of articles in the systematic review as per the PRISMA guidelines.

Figure 2

Pre-operative and post-operative photographs of thumb reconstruction with a reverse SUPBRA flap. (A)Thumb amputation defect and an elevated reverse SUPBRA flap. (B) Flap inset into thumb defect with donor site closed. (C) Healed flap and donor site with well-concealed donor scar.

Figure 3

Pre-operative and post-operative photographs of resurfacing a pigmented thumb skin graft with a reverse SUPBRA flap. (A) Pigmented skin graft over volar aspect of the thumb from previous burn reconstruction. (B) Post-operative photo showing the healed flap with good colour and texture match and good functional outcome.

Figure 4

Reconstruction of post-infective wound of the index finger. (A) Flap markings for coverage of defects involving the volar and radial aspects of the index finger. (B) Healed flap at 6 months showing a bulky contracted flap causing flexion contracture of the finger. (C, D) Final result following flap thinning and contracture release showing excellent functional and aesthetic outcomes.

Figure 5

Diagrammatic representation of the arc of rotation and potential reach of the reverse SUPBRA flap. The flap is best suited for defects of the thumb, index and palm and flap reach rapidly reduces toward the ulnar digits with more of the flap lost in transport.

Figure 6

Use of a modified skin paddle for the reconstruction of index finger pulp defect following neurolysis for painful pencil-tip deformity. (A) Flap markings shown and neurolysis being performed (B) Flap elevated and inset into pulp. Note the use of a narrow skin bridge over the pedicle.