Accepted Manuscript

Defect reconstruction over the olcreanon with the distally extended lateral arm flap

R. Wettstein , N. Helmy , D.F. Kalbermatten

PII: S1748-6815(14)00214-9

DOI: 10.1016/j.bjps.2014.04.036

Reference: PRAS 4181

To appear in: Journal of Plastic, Reconstructive & Aesthetic Surgery

Received Date: 13 March 2014

Accepted Date: 29 April 2014

Please cite this article as: Wettstein R, Helmy N, Kalbermatten DF, Defect reconstruction over theolcreanon with the distally extended lateral arm flap, Journal of Plastic, Reconstructive & AestheticSurgery (2014), doi: 10.1016/j.bjps.2014.04.036.

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Defect reconstruction over the olcreanon with the distally extended lateral arm

flap.

R. Wettstein1, 2, N. Helmy3, D.F. Kalbermatten1

1Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University

Hospital of Basel, Basel, Switzerland

2 Plastic, Reconstructive, Aesthetic and Hand Surgery, Solothurn Hospitals,

Solothurn-Olten-Dornach, Switzerland

2Department of Orthopaedic Surgery and Traumatology, Bürgerspital Solothurn,

Solothurn, Switzerland

Correspondence:

Reto Wettstein, MD

Department of Plastic, Reconstructive, Aesthetic and Hand Surgery

University Hospital Basel

Spitalstrasse 21, CH-4031 Basel, Switzerland

Fon +41 61 556 5482

Fax +41 61 265 7301

E-mail: drwette@yahoo.com

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Abstract

Defect reconstruction over the olecranon should be reliable, quick, relatively simple

and with minimal complications. More recently, perforator flaps have been described

with the benefit of minimal donor site morbidity when compared to muscle flaps or

flaps relying on the major arteries of the upper extremity. So far, most of these flaps

were harvested on the upper arm and rotated 180° in to the defect. The aim of the

present study was to analyse the results with the proximally based, distally extended

lateral arm flap for soft tissue reconstruction over the olecranon. The subcutaneous

tissue layer in this area is thinner than in the upper arm and less rotation of the

pedicle is necessary. The location of the perforator just proximal to the lateral

epicondyle and the precise territory of the flap are well known.

Nine consecutive male patients with a mean age of 57±27 years presenting with soft

tissue defects after surgical treatment of bursitis (8 cases) or a pressure sore (1

case) were operated on. The mean operation time was 60±15 minutes. In 8 of the 9

cases, the flap healed uneventfully or with a minor complication (fistula). One patient

underwent revision surgery due to marginal flap necrosis. The defect was closed with

a local advancement flap.

In conclusion, the flap was reliable, relatively simple and quick to harvest and yielded

acceptable aesthetic results with minimal bulging over the olecranon. Postoperative

recovery was relatively painless and short.

Keywords: perforator flap, propeller flap, posterior radial collateral artery, elbow

reconstruction

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Introduction Soft tissue defects over the elbow joint that require flap surgery are relatively rare

and frequently the result of complications after surgical treatment of bursitis. In these

cases the defect size is limited and reconstruction with loco-regional flaps is the first

choice.1 Several flaps have been used such as the anconeus muscle flap2, radial

forearm flap1, adipofascial turnover flaps3, and the extensor carpi radialis longus

muscle flap.4 More recently, perforator flaps have been described for elbow

reconstruction.5-9 Interestingly, these flaps were consistently harvested from the

upper arm and require 180° rotation to cover defect s over the olcreanon.

The aim of the present work was to analyse the outcome of a consecutive series of

defect reconstructions over the olecranon with the distally extended lateral arm flap.

The extended lateral arm flap has been described by Kuek10 and was used as a free

flap for lower extremity11 and head and neck reconstruction.12 So far, its use as a

pedicled flap for soft tissue reconstruction in the elbow has not been described.

Patients and Methods

General patient data

Nine male patients were operated for soft tissue reconstruction over the olecranon.

The mean age of the patients was 57±27 years (range 28 – 83 years). Two of the 9

patients suffered from diabetes mellitus type II, five were active smokers and one

was on immunosuppressive therapy after renal transplantation. All defects were

located over the olecranon with exposed bone. In 8 cases the defect resulted from

surgical treatment of bursitis, and in one cases it resulted from a pressure sore.

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Endpoints

The type of anaesthesia, duration of the operation, size of the defect, flap and

postoperative complications were assessed. Postoperative complications were

classified as major if a surgical revision was necessary. Time to complete healing

and full range of elbow motion exercises was also assessed.

Anatomic basis, preoperative planning, surgical technique and postoperative care

The lateral arm flap has a reliable anatomy with predictable location of the

septocutaneous perforators arising from the posterior branch of the radial collateral

artery (PRCA).13 The most distal perforator is located in the area of the lateral

epicondylus and has to be included in the distally extended lateral arm flap.10 The

dimensions of the distally extended flap can reach approximately 14x5 cm. Clinically,

the lateral intermuscular septum, which contains the PRCA, lies slightly posterior to a

line drawn from the deltoid insertion to the lateral epicondyle.

For the proximally pedicled, extended lateral arm flap, the preoperative planning

relied solely on clinical examination for scars that may compromise the feeding

vessel. No angiography or other investigations were performed.

After debridement of the wound and harvest of biopsies for bacteriological and

histological analysis if necessary, the size of the defect was measured and the flap

outline designed with the proximal part of the flap lying over the lateral epcicondylus.

Flap raisal started from distal to proximal. The muscle fascia was left intact in the

distal part. Just proximal to the lateral epicondylus, the dissection was deeper and

included the periosteum in order to include the perforator. At this point, the

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preparation was bloody since there exists an well-developped anastomotic network,

the so-called lateral epicondyle plexus, with the recurrent radial artery. If necessary

for flap inset, the dissection continued proximally to mobilize the septum and the

PRCA, respectively.

In most cases, the flap was islanded and tunnelled subcutaneously, but the defect

size was bigger and in continuity with the site of flap harvest, the flap may include a

skin bridge. If the flap was not larger than 5-6 cm, direct donor site closure was

possible. One drain was inserted under the flap and removed after 5-7 days. All

patients received prophylactic antibiotic therapy that was adapted to the

bacteriological analysis if necessary. Postoperative care included cast immobilization

of the elbow for 2 weeks.

Results

Three of the patients had general anaesthesia, 4 brachial plexus anaesthesia and 2

were operated under local anaesthesia. Tourniquet was not used for flap surgery.

The mean duration of the operation (including debridement) was 60±15 minutes.

One of the patients developed a marginal partial flap necrosis that required surgical

revision. Secondary closure was obtained with a local advancement flap. Another

patient developed a fistula after removal of the suture material that was managed

conservatively and healed within 2 weeks. The remaining 7 patients had no

complication and range of motion exercises were started at 2 weeks, i.e. after suture

removal and full mobilisation was allowed depending on tension in full elbow flexion

after 2-3 weeks. A typical presentation before and after surgery is presented in Fig. 1.

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In the patient that had a secondary surgery, guided range of motion exercises were

started after suture removal.

Discussion

In this consecutive series of 9 patients presenting with a soft tissue defect over the

olecranon, the distally extended lateral arm flap was a reliable option for soft tissue

reconstruction. Seven of the patients had uneventful healing and were able to

mobilize their elbow without restrictions after 3 weeks. In one patient full mobilisation

was delayed by one week by the presence of a fistula, which healed spontaneously.

In one case, a reoperation was necessary since a marginal flap necrosis resulted in

wound dehiscence.

Advantages of the distally extended lateral arm flap over alternative flaps are that it is

thin, pliable, and can be used as a sensate flap. The anatomy is consistent in regard

to perforator location and presence, and the precise flap territory is well known.

Since the defect size over the olecranon is usually limited to a few centimeters, the

donor site can be closed directly. Muscle tissue is spared as are major vessels.

Surgical preparation of the flap is straightforward and relatively quick. If needed, the

pedicle can be mobilized more proximally to increase the arc of rotation and ease

with flap inset.

The classical lateral arm flap donor area more proximal to the elbow yields a thicker

subcutaneous tissue layer that may result in cushioning over the olecranon which is

only minimal with the distal donor site. In terms of safety of blood perfusion, reversed

flow flaps seem to be reliable, but require a 180° of rotation whereas the distally

extended lateral arm flap can reach the defect with a rotation of 90° only.

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The scar location on the dorso-lateral side of the arm is one of the major drawbacks

of this technique. This could be prevented by the use of a flap from the medial aspect

of the arm.14 Also direct closure can lead to some degree of decrease of the

circumference of the arm. Despite the fact that the flap is very thin, there might some

degree of excess flap tissue if the elbow is in extension. This may partly be

prevented by tight flap inset with the arm in extension, which has to be balanced with

the risk of wound dehiscence after elbow mobilisation. In pressure sores, the

disadvantage of islanded flaps is that they usually do not allow secondary

mobilisation for defect coverage in case of a recurrence.

After the first positive results with this flap, the surgery was performed under local

anaesthesia in an outpatient setting, which is beneficial for patient comfort and leads

to decreased health care costs. Also it may be possible to start elbow mobilization

earlier, as suggested previously.7

In conclusion, the distally extended lateral arm flap is a reliable option for soft tissue

reconstruction over the olecranon. Flap harvest is relatively simple and quick. No

problems of venous congestion were observed after flap rotation of 90° and

subcutaneous tunnelling of the pedicle. Postoperative recovery is relatively painless

and short. The aesthetic outcome is acceptable with only limited cushioning over the

olecranon but an easily visible scar on the dorso-lateral aspect of the arm.

Ethical Approval: Not required.

Conflict of interest: The authors have no conflict of interest.

Funding: No funding was obtained for this study.

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References

1. Choudry UH, Moran SL, Li S, Khan S. Soft-Tissue Coverage of the Elbow: An Outcome Analysis and Reconstructive Algorithm. Plast Reconstr Surg 2007;119:1852–7.

2. Kuek LB, Chuan TL. The extended lateral arm flap: a new modification. Microsurg 1991;7:167–73.

3. Lai CS, Lin SD, Yang CC, Chou CK. The adipofascial turnover flap for elbow coverage. Ann Plast Surg 1992;28:190–4.

4. Janevicius RV, Greager JA. The extensor carpi radialis longus muscle flap for anterior elbow coverage. J Hand Surg Am 1992;17:102–6.

5. Okada M, Ikeda M, Uemura T, et al. A propeller flap based on the thoracoacromial artery for reconstruction of a skin defect in the cervical region: A case report. J Plast Reconstr Aesth Surg 2013;66:720–2.

6. Boucher F, La Marca S, Delay E, Mojallal A. Reconstruction des pertes de substance du coude par lambeau perforant en hélice de la région brachiale – Observation clinique. Ann Chir Plast Esthet 2013;58:277–82.

7. 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 Aesth Surg 2008;61:546–51.

8. Frost-Arner L, Björgell O. Local perforator flap for reconstruction of deep tissue defects in the elbow area. Ann Plast Surg 2003;50:491–7.

9. Murakami M, Ono S, Ishii N, Hyakusoku H. Reconstruction of elbow region defects using radial collateral artery perforator (RCAP)-based propeller flaps. J Plast Reconstr Aesth Surg 2012;65:1418–21.

10. Kuek LB, Chuan TL. The extended lateral arm flap: a new modification. Microsurgery 1991;7:167–73.

11. Kalbermatten DF, Wettstein R, vonKanel O, et al. Sensate Lateral Arm Flap for Defects of the Lower Leg. Ann Plast Surg 2008;61:40–6.

12. Vico PG, Coessens BC. The distally based lateral arm flap for intraoral soft tissue reconstruction. Head Neck 1997;19:33–6.

13. Hennerbichler A, Etzer C, Gruber S, et al. Lateral arm flap: Analysis of its anatomy and modification using a vascularized fragment of the distal humerus. Clin Anat 2003;16:204–14.

14. Cil Y, Kocabιyιk N, Ozturk S, et al. A new perforator flap from distal medial arm: a cadaveric study. Eplasty 2010;10:e65.

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Figure legend

Fig. 1. Typical presentation of a non-healing ulcer over the olecranon after surgical treatment of acute bursitis (left). Presentation 2 weeks after soft tissue coverage with an islanded distally extended lateral arm flap (right).

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