J Reconstr Microsurg 2021; 37(03): 201-207
DOI: 10.1055/s-0040-1716321
Original Article

Anatomical Study and Clinical Application of Ulnar Artery Proximal Perforator Flaps

Mario Cherubino
1   Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
,
2   Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, University of Sassari, Sassari, Italy
,
Tommaso Baroni
1   Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
,
3   Department of Plastic and Reconstructive Surgery, Sapienza University of Rome, Umberto I University Hospital, Rome, Italy
,
Luigi Losco
4   Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
,
Corrado Rubino
2   Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, University of Sassari, Sassari, Italy
,
Luigi Valdatta
1   Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
› Institutsangaben
Funding None.

Abstract

Background The purpose of this study is to document the vascular anatomy of the free ulnar artery proximal perforator flap and to highlight the possibility of harvesting it based on the perforators originating from the posterior ulnar recurrent artery (PURA), to spare both the main axis of vascular supply to the hand. In addition, we present a case series of five patients treated for soft tissue defects of the hand with free ulnar artery proximal perforator flaps.

Methods Ten specimens of anterior forearm were dissected in this study to register number and characteristics of ulnar perforators. The dissection was focused on the perforators originating from the larger branch of the ulnar artery, the PURA, at the proximal third of anteromedial forearm. The anatomical dissections were evaluated in relationship with clinical dissections performed during flap harvesting in five patients.

Results In three of the specimens dissected, the proximal perforator originated from the PURA, and in the other seven specimens, it originated directly from the ulnar artery. Five cases of reconstruction of the hand were performed with success using the free ulnar artery proximal perforator flap, and in two cases, the perforator from the PURA was found and it was possible to raise the flap based on this branch of the ulnar artery.

Conclusion The free ulnar artery proximal perforator flap can be harvested in two different manners for the same skin island of the forearm. When possible, harvesting it form the PURA allows lengthening of the pedicle. In our experience, this flap presents many advantages such as thinness and hairlessness; it allows preservation of the ulnar neurovascular bundle with an acceptable donor site morbidity. Level of evidence: IV.

Authors' Contributions

M.C. supported in study design, data collection, performance of surgery, manuscript preparation, and critical review. A.B. dedicated in study design, data collection, data analysis, manuscript preparation, and critical review. T.B. focused in study design, data collection, and critical review. G.D.T. performed study design, manuscript preparation, and critical review. L.L. contributed in study design, manuscript preparation, and critical review. C.R. helped in study design, data analysis, and critical review. L.V. cooperated in study design, data analysis, manuscript preparation, and critical review.


Note

This study was performed with respect to the ethical standards of the Declaration of Helsinki, as revised in Tokyo 2004. Informed consent to participate was obtained from patients. Consent for publication was obtained from the patients.




Publikationsverlauf

Eingereicht: 29. April 2020

Angenommen: 15. Juli 2020

Artikel online veröffentlicht:
01. September 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Lovie MJ, Duncan GM, Glasson DW. The ulnar artery forearm free flap. Br J Plast Surg 1984; 37 (04) 486-492
  • 2 Tan ST, James DW, Moaveni Z. Donor site morbidity of free ulnar forearm flap. Head Neck 2012; 34 (10) 1434-1439
  • 3 Mathy JA, Moaveni Z, Tan ST. Perforator anatomy of the ulnar forearm fasciocutaneous flap. J Plast Reconstr Aesthet Surg 2012; 65 (08) 1076-1082
  • 4 Cherubino M, Corno M, Valdatta L, Adani R. Thumb reconstruction with thin proximal ulnar perforator free flap. J Hand Surg Am 2017; 42 (02) e133-e138
  • 5 Sun C, Hou ZD, Wang B, Ding ZH. An anatomical study on the characteristics of cutaneous branches-chain perforator flap with ulnar artery pedicle. Plast Reconstr Surg 2013; 131 (02) 329-336
  • 6 Yu P, Chang EI, Selber JC, Hanasono MM. Perforator patterns of the ulnar artery perforator flap. Plast Reconstr Surg 2012; 129 (01) 213-220
  • 7 Yang D, Morris SF. Ulnar artery perforator flap. In: Perforator Flaps. St Louis, MO: Quality Medical Publishing Inc; 2006: 283
  • 8 El-Khatib HA, Mahboub TA, Ali TA. Use of an adipofascial flap based on the proximal perforators of the ulnar artery to correct contracture of elbow burn scars: an anatomic and clinical approach. Plast Reconstr Surg 2002; 109 (01) 130-136
  • 9 Hayashi A, Maruyama Y. Anatomical study of the recurrent flaps of the upper arm. Br J Plast Surg 1990; 43 (03) 300-306
  • 10 Maruyama Y, Onishi K, Iwahira Y. The ulnar recurrent fasciocutaneous island flap: reverse medial arm flap. Plast Reconstr Surg 1987; 79 (03) 381-388
  • 11 Bhattacharya S, Bhagia SP, Bhatnagar SK, Pandey SD, Chandra R. The medial upper arm fasciocutaneous flap. An alternative flap to cover palmar defects of hand and distal forearm. J Hand Surg [Br] 1991; 16 (03) 342-345
  • 12 Hayashi A, Maruyama Y, Saze M, Okada E. Ulnar recurrent adipofascial flap for reconstruction of massive defects around the elbow and forearm. Br J Plast Surg 2004; 57 (07) 632-637
  • 13 Nakao J, Umezawa H, Ogawa R, Mateev MA. Reconstruction of elbow skin and soft tissue defects using perforator-pedicled propeller flaps. Microsurgery 2018; 38 (05) 473-478
  • 14 Prantl L, Schreml S, Schwarze H. et al. A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects. J Plast Reconstr Aesthet Surg 2008; 61 (05) 546-551
  • 15 Mateev MA, Trunov L, Hyakusoku H, Ogawa R. Analysis of 22 posterior ulnar recurrent artery perforator flaps: a type of proximal ulnar perforator flap. Eplasty 2009; 10: e2
  • 16 Wei Y, Shi X, Yu Y, Zhong G, Tang M, Mei J. Vascular anatomy and clinical application of the free proximal ulnar artery perforator flaps. Plast Reconstr Surg Glob Open 2014; 2 (07) e179
  • 17 Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 1961; 113: 409-424
  • 18 Doscher W, Viswanathan B, Stein T, Margolis IB. Hemodynamic assessment of the circulation in 200 normal hands. Ann Surg 1983; 198 (06) 776-779
  • 19 Haerle M, Häfner HM, Dietz K, Schaller HE, Brunelli F. Vascular dominance in the forearm. Plast Reconstr Surg 2003; 111 (06) 1891-1898
  • 20 Fazan VP, Borges CT, Da Silva JH, Caetano AG, Filho OA. Superficial palmar arch: an arterial diameter study. J Anat 2004; 204 (04) 307-311
  • 21 Tonks AM, Lawrence J, Lovie MJ. Comparison of ulnar and radial arterial blood-flow at the wrist. J Hand Surg [Br] 1995; 20 (02) 240-242
  • 22 Kleinert JM, Fleming SG, Abel CS, Firrell J. Radial and ulnar artery dominance in normal digits. J Hand Surg Am 1989; 14 (03) 504-508
  • 23 Dumanian GA, Segalman K, Buehner JW, Koontz CL, Hendrickson MF, Wilgis EF. Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg 1998; 102 (06) 1993-1998
  • 24 Khan AS, Henton JM, Adams TS, Dwivedi RC, Harris PA. Evaluation of hand circulation before radial forearm free flap surgery. Laryngoscope 2009; 119 (09) 1679-1681
  • 25 Saint-Cyr M, Mujadzic M, Wong C, Hatef D, Lajoie AS, Rohrich RJ. The radial artery pedicle perforator flap: vascular analysis and clinical implications. Plast Reconstr Surg 2010; 125 (05) 1469-1478
  • 26 Kimura T, Ebisudani S, Osugi I, Inagawa K. Anatomical analysis of cutaneous perforator distribution in the forearm. Plast Reconstr Surg Glob Open 2017; 5 (10) e1550
  • 27 Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 40th edition. London: Churchill Livingstone; 2009
  • 28 Moore KL. Clinically Oriented Anatomy. 6th edition. Baltimore: Lippincott, Williams and Wilkins; 2010
  • 29 Cho MJ, Kwon JG, Pak CJ, Suh HP, Hong JP. The role of duplex ultrasound in microsurgical reconstruction: review and technical considerations. J Reconstr Microsurg 2020; 36 (07) 514-521
  • 30 Kehrer A, Heidekrueger PI, Lonic D. et al. High-resolution ultrasound-guided perforator mapping and characterization by the microsurgeon in lower limb reconstruction. J Reconstr Microsurg 2020 DOI: 10.1055/s-0040-1702162
  • 31 Sieg P, Bierwolf S. Ulnar versus radial forearm flap in head and neck reconstruction: an experimental and clinical study. Head Neck 2001; 23 (11) 967-971
  • 32 Cherubino M, Berli J, Turri-Zanoni M. et al. Sandwich fascial anterolateral thigh flap in head and neck reconstruction: evolution or revolution?. Plast Reconstr Surg Glob Open 2017; 5 (01) e1197
  • 33 Jeong HH, Hong JP, Suh HS. Thin elevation: a technique for achieving thin perforator flaps. Arch Plast Surg 2018; 45 (04) 304-313
  • 34 Cherubino M, Stocco C, Ronga M. et al. Comparisons of fascio-cutaneous anterolateral thigh and sandwich fascial ALT free flap in the distal extremity reconstruction. Microsurgery 2019 DOI: 10.1002/micr.30515