Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e211ee215

CASE REPORT

Free posterior interosseous artery perforator flapfor finger reconstruction*

Toshihiro Ishiko a,*, Norihiko Nakaima b, Shigehiko Suzuki a

a Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University,Sakyo-ku, Kyoto 606-8507, Japanb Department of Orthopedics, Sumiya Orthopedic Hospital, Wakayama, Japan

Received 23 March 2007; accepted 31 January 2009

KEYWORDSPerforator flap;Posterior interosseousartery;Finger reconstruction

* This case was presented at the 48thSociety of Plastic and Reconstructive2005.

* Corresponding author.E-mail address: ishiko@kuhp.kyoto

1748-6815/$-seefrontmatterª2009Britdoi:10.1016/j.bjps.2009.01.065

Summary We successfully transplanted two free posterior interosseous artery perforatorflaps that had been harvested simultaneously from a single posterior interosseous arterysystem to the index and middle fingers of a 19-year-old man. Our case suggests that multiplefree perforator flaps can be prepared from a single posterior interosseous artery system.ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

The posterior interosseous artery flap is a versatile flap thatcan be used to cover small- and medium-sized defects inthe forearm and hand, including the fingers. It was devel-oped for use as either a reverse-flow pedicled flap1e3 ora free flap.4 The original posterior interosseous artery flapwas based on the septum including the posterior inteross-eous artery vessels and their perforators. In 1999, a poste-rior interosseous flap based on a septal perforator wasreported as a pedicled flap.5 However, there have been noreports of a free perforator flap based on the posteriorinterosseous artery system. We report the simultaneoustransfer of two free posterior interosseous artery

annual meeting of JapaneseSurgery, Tokyo, 13e15 April

-u.ac.jp (T. Ishiko).

ishAssociationofPlastic,Reconstruc

perforator flaps from a single posterior interosseous arterysystem, to the index and middle fingers.

Case report

A 19-year-old man had his left index and middle fingerscaught in a heat press machine for 3 min. The wounds weredebrided 8 days after the injury (2 days after the firstexamination at our hospital). All the tissues distal to thedistal interphalangeal (DIP) joints of the index and middlefingers had become necrotic (Figure 1, above). After thedebridement, the extensor and flexor superficialis dig-itorum tendons were exposed in the proximal two-thirds ofthe middle phalanges of both fingers (Figure 1, below). Inorder to cover the skin defects two free posterior inter-osseous artery perforator flaps including parts of theposterior antebrachial cutaneous nerve, measuring3.5� 7.5 cm and 3.5� 9.5 cm, respectively, were outlined

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 1 (Above)Preoperative views of a 19-year-old man who had his left index and middle fingers caught in a heat pressmachine for 3 minutes. (Below) After debridement, the extensor and flexor tendons were exposed. The distal phalanx of the indexfinger was eventually excised.

e212 T. Ishiko et al.

on the posterior aspect of the left forearm (Figure 2).Suitable perforators had previously been located byDoppler sonography. The flap was dissected from the ulnarmargin until the septocutaneous perforating vessels wereobserved, following which the radial border of the flap wasincised. The cutaneous veins and the branch of the poste-rior antebrachial cutaneous nerve were dissected andincluded in the flap. The septal perforating vessels werecarefully dissected in the intermuscular septum. As one ofthe two perforating systems was very thin, the proximalflap was based on a single perforating system while thedistal flap was based on two perforating systems. Eachperforating system included a short segment of the poste-rior interosseous artery and its comitant veins. The prox-imal flap was transferred to the previously preparedrecipient defects of the index finger and the distal flap wastransferred to the defect of the middle fingers. The digitalartery of the index finger was anastomosed to the distalside of the posterior interosseous artery of the proximal

flap, whereas for the middle finger it was anastomosed tothe proximal side of the posterior interosseous artery of thedistal flap. The dorsal cutaneous vein of the index fingerwas anastomosed to the cutaneous vein of the proximal flapand that of the middle finger was anastomosed to theproximal side of the comitant vein of the posterior inter-osseous artery of the distal flap. Neural coaptation wasachieved between the branch of the posterior antebrachialcutaneous nerve of the flaps and the digital nerves of theindex and middle fingers. Most of the donor area was closeddirectly, but part of it was covered with a full-thickness skingraft harvested from the medial side of the upper arm.

The patient fell down in a corridor and hurt his left hand2 days post-operatively. Immediately after that, both theindex- and middle-finger flaps became congested(Figure 3). After the intravenous administration of heparin,the index flap recovered, but the flap on the middle fingerremained congested. Therefore, we immediately re-anas-tomosed its dorsal cutaneous. As a result, both flaps

Figure 2 Two free posterior interosseous artery perforatorflaps simultaneously prepared from one posterior interosseousartery system.

Free posterior interosseous artery perforator flap e213

survived completely. The patient returned to manual work3 months post-operatively.

At 8 months postoperatively, the middle phalanx of theindex finger was partially exposed because of flap ulcera-tion. It is supposed that the ulceration first developed onthe fragile seam of the flap, which was placed just over thestump of the phalanx and was injured by frequentmechanical stress during manual work. After shortening thephalanx a little, the ulceration healed. For 2 years post-operatively, there has not been any recurrence of theulceration (Figure 4). Regarding the sensory recovery ofthe flaps, the index finger was categorised as ‘blue’ and themiddle finger as ‘purple’ according to the SemmeseWeinstein test.

Discussion

In hand and finger reconstruction, the forearm is a usefulsource of flaps. The advantages of flaps harvested from theforearm are as follows: (1) the flaps can be harvestedsimultaneously with the preparation of the recipient siteunder upper-arm anaesthesia; (2) the flaps can be har-vested while a tourniquet is applied to the arm; (3) theflaps can be transferred in a single-stage procedure that

Figure 3 Two days postoperatively, both the ind

enables post-operative elevation and early mobilisation ofthe treated hand to reduce oedema and fibrosis; (4) theflaps are thin and pliable; (5) the colour and texture matchthose of the hands and fingers and (6) the flaps can be usedas sensory flaps.

The radial forearm flap is very well known to recon-structive surgeons worldwide. However, it has a majordisadvantage, which is the sacrifice of a major artery tothe hand. To overcome this serious drawback, severalperforator flaps have been reported to that preserve thecontinuity of the radial artery.6e11 The free ‘radial arteryseptal perforator vessel’-based flap reported by Oskanet al. is particularly useful for small skin defects of fingersbecause of its minimal donor-site morbidity and the factthat it preserves the entire radial artery.11 However, itrequires advanced techniques for microsurgical anasto-mosis. Safak and Akyurek reported a perforator flap thatcontains a short segment of the radial artery included in aninverted-T-shaped arterial pedicle.10 Advanced skills arenot necessary to anastomose the radial artery, and thedonor artery can be anastomosed directly. However, whena relatively long segment of the radial artery is harvestedin order to prepare plural flaps for multiple finger injuriesor when a long vascular pedicle is needed even in a singleflap, a venous graft is required to preserve the vascularcirculation of the radial artery. In addition, as the diam-eter of the radial artery is larger than that of the digitalartery, it is somewhat troublesome to anastomose the twovessels.

Arterialised venous flaps have been used to re-surfaceskin defects of the hand and fingers.12,13 However, thesurvival mechanism of the flap remains unclear, although ithas been investigated.14 When arterialised venous flapswere applied to relatively large skin defects, severe post-operative swelling, discolouration, bullae formation andunpredictable partial necrosis of the flaps were reported asmajor problems.15

The free posterior interosseous artery perforator flap,which contains an inverted T-shaped pedicle that includesthe posterior interosseous artery and its comitant veins, hasthe following advantages over the previously describedflaps (which were harvested from the forearm). As theposterior interosseous artery is not the main artery of theforearm, it is not necessary to repair it. The posteriorinterosseous artery has an average external calibre of

ex and middle finger flaps became congestive.

Figure 4 Two years postoperatively, the patient returned to manual work.

e214 T. Ishiko et al.

1.6 mm (range 0.9e2.7 mm), which is in the permissiblerange for anastomosis to the proper or common digitalartery.1 In our case, it was possible to cover the skin defectsof two fingers simultaneously with a conventional freeposterior interosseous artery flap. However, when it isused, the resulting temporary surgical syndactyly should beseparated later. An anatomical study demonstrated thatthe posterior interosseous artery has 7e13 septocutaneousperforators.1 Theoretically, it may be possible to preparemultiple free perforator flaps from a single posteriorinterosseous artery system. In addition to the versatility ofthe conventional free posterior interosseous artery flap,the free posterior interosseous artery perforator flap hasplural productivity. The flap is useful for the repair ofdefects involving multiple fingers as was shown in our case.Such a perforator flap is relatively easy to prepare becausethe shorter the segment of the posterior interosseous arteryis, the easier and quicker the dissection of the pediclebecomes. Of course, when a longer pedicle with largediameter is necessary, dissection should proceed proxi-mally. Dissection along the pedicle should be performedvery carefully under magnification with a loupe to preventdamage to the perforating vessels. When the flap is widerthan 4 cm, a skin graft is necessary for closure of the donorsite. However, if the patient prefers, the skin graft can beexcised later.

Hubmer et al. reported that the posterior interosseousartery is narrowest in the mid forearm, where it is joined bya recurrent branch from the anterior interosseous artery,forming a choke anastomosis.16 It is possible that the

comitant veins of the posterior interosseous artery alsofollow a similar pattern. The comitant veins of the flapsthat we harvested could be narrower proximally thandistally. Hence, in the middle finger, the congestion of theflap had not been improved when a cutaneous vein wasanastomosed at the time of re-exploration. This suggeststhat the cutaneous vein is necessary to augment the venousreturn of the free posterior interosseous artery perforatorflap, especially in the mid forearm.

In our case, the toe-to-hand transfer technique wouldprovide functioning digits with an acceptable appearanceand sensibility, but the patient preferred not to lose histoe; therefore, we planned finger reconstructions usingflaps.

References

1. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis ofthe fascio-cutaneous flap of the posterior interosseous artery.Surg Radiol Anat 1986;8:209e15.

2. Zancolli EA, Angrigiani C. Dorsal forearm island flap. In:Abstracts of the 3rd Congress of the International Federationof Societies for Surgery of the Hand, Tokyo, Japan, 1986November 3e8. Tokyo; 1986. p. 201.

3. Zancolli EA, Angrigiani C. Posterior interosseous island forearmflap. J Hand Surg [Br] 1988;13:130e5.

4. Tonkin MA, Stern H. The posterior interosseous artery free flap.J Hand Surg [Br] 1989;14:215e7.

5. Cavadas PC. Posterior interosseous flap based on a septalperforator, in the absence of the distal artery. Plast ReconstrSurg 1999;104:592.

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11. Ozkan O, Akyurek M, Coskunfirat OK, et al. The free radialartery septal perforator vessel-based flap. Plast Reconstr Surg2005;115:2062e9.

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