Correspondence and communications 125

Conflict of interest statement

None.

References

1. Chen YC, Chen CT, Lin CH, et al. A safe and effective way forreduction of temporomandibular joint dislocation. Ann PlastSurg 2007 Jan;58(1):105e8.

2. Kummoona R. Surgical managements of subluxation and dislo-cation of the temporomandibular joint: clinical and experi-mental studies. J Craniofac Surg 2010 Nov;21(6):1692e7.

3. Cascone P, Ungari C, Paparo F, et al. A new surgical approachfor the treatment of chronic recurrent temporomandibularjoint. J Craniofac Surg 2008 Mar;19(2):510e2.

4. Ardehali MM, Kouhi A, Meighani A, et al. Temporomandibularjoint dislocation reduction technique: a new external methodvs. the traditional. Ann Plast Surg 2009 Aug;63(2):176e8.

5. Shun TA, Wai WT, Chiu LC. A case series of closed reduction foracute temporomandibular joint dislocation by a new approach.Eur J Emerg Med 2006 Apr;13(2):72e5.

Nebil Yes‚ilo�gluMurat Sarici

Hakan S‚irino�gluGokhan TemizEmre Guvercin

Gaye Taylan FilinteDr. Lutfi Kırdar Kartal Training and Research Hospital,

Department of Plastic Reconstructive and AestheticSurgery, Turkey

E-mail address: drhakansirinoglu@gmail.com

ª 2014 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.bjps.2014.08.052

Reconstruction of forearmsoft tissue defects withradial artery perforator-pedicled propeller flaps

Figure 1 Preoperative view showing the location of thetumour and the design of the radial artery perforator-pedicledpropeller (RAPPP) flap.

Dear Sir,

The radial forearm flap is one of the most versatile flapsused in reconstructive surgery with many advantages, suchas reliable vascularity, pliable skin, hairlessness, potentialsensibility, and ease of dissection. However, it has twomajor drawbacks, including the sacrifice of the radial arteryand donor site scarring. With the advent of perforator sur-gery, the radial artery perforator flap may be raised withoutcompromising the main trunk of the radial artery. In 1991,Hykosoku et al.1 first described the propeller flap techniquethat has been proven to be a very useful reconstructivemodality. In this article, we present our experiences withforearm soft tissue defect reconstruction using the radialartery perforator-pedicled propeller (RAPPP) flap.

A 19-year-old patient was referred to us after anincomplete resection of an inflammatory myofibroblastictumour in his left forearm. Prior to the surgery, the loca-tions of the radial artery perforators were explored usingDoppler ultrasound. A perforator with a strong pulsatilesignal was identified approximately 2 cm from the proximalborder of the expected area of tumour resection (Figure 1).A complete resection resulted in a round defect measuring4.5 cm in diameter. An 11 � 4.5 cm RAPPP flap wasdesigned adjacent to the wound. One lateral side of theflap was first incised and the flap was raised above the deepfascia until sizable perforating vessels were identified. Theperforator emerged from the intermuscular fascial septumbetween the brachioradialis and the flexor carpi radialismuscles. The other side of the flap was then incised and thewhole flap was elevated. The perforating vessels werefurther dissected within the intermuscular septum to themain stems of the radial artery and veins. The flap wasrotated 180 degrees to reconstruct the defect. Care wastaken to avoid kinking or twisting of the vascular pedicle.The donor site was closed primarily and the flap healeduneventfully. The overall appearance of the forearm waswell preserved and the patient was satisfied with the finalaesthetic outcome (Figure 2).

Propeller flaps are innovative flaps for local defectreconstruction. In 1991, Hyakusoku et al.1 described an is-land flap that could be rotated 90 degrees, like a propeller,to reconstruct the axilla and antecubital fossa. In 2006,Hallock introduced the perforator-based propeller flappattern, which combined the perforator concept with apropeller design, and allowed the local flap to rotate up to180 degrees.2 This evolution expanded the indications forrepairs involving a local flap.

There are a number of perforators originating from theradial artery.3 A reliable perforator flap may be raisedbased on any of the perforating vessels. The closest,proximal perforator is preferred for the vascular pedicle.For adult patients, if the width of the defect is limited to5 cm, the propeller flap donor site can be closed primarily.Otherwise, free skin grafting may be needed to aid donorsite closure. In the case presented, the width of the donorsite defect was less than 5 cm, allowing direct donor siteclosure in the patient.

Figure 2 The RAPPP flap is rotated 180� and used to recon-struct the defect, which resulted from tumour resection. Thedonor site is closed primarily.

* This work has been accepted for E-Poster presentation at The12th Congress of the European Society of Plastic, Reconstructiveand Aesthetic Surgery (ESPRAS) Edinburgh, 8th July 2014.

126 Correspondence and communications

Exploration of the location of the perforator usingDoppler ultrasound should be conducted prior to surgery.Because the radial artery is usually relatively superficial,the signals from the perforator and its source vessel may beconfused. Thus, a pulsatile signal from the source arterymight be misdiagnosed as that of the perforating vessel.Ono et al.4 described two methods for differentiatingDoppler signals between the main vessel and the perfora-tors. First, the sound from the main vessel will continue tobe heard when the probe moves proximally or distally,whereas the perforator sound is only heard at one location.Second, the sound originating from the main vessel islouder than that from the perforator. According to our ex-periences, these sounds may not always guarantee accu-rate differentiation between source artery and perforatorDoppler signals. To overcome this disadvantage, only onelateral border of the flap was incised before finally identi-fying an appropriate perforator.

The lengths of the radial artery perforating vessels aregenerally shorter than those of other regions of the body.The pedicle of the flap should be dissected retrograde aslong as possible, even to its origin from the radial vessel.Generally speaking, a 3 cm pedicle length is desirable for a180 degrees rotation of the propeller flap, and will notcompromise the flap vascularity.5

The RAPPP flap is a good option for the reconstruction ofsmall-to moderate-sized forearm defects. The flap dissec-tion is easy and straightforward, and primary donor siteclosure can be achieved when the width of the flap is lessthan 5 cm. The overall aesthetic appearance of the forearmcan also be preserved using this modality.

Ethical approval

N/A.

Funding

None.

Conflict of interest statement

None.

Acknowledgements

None.

References

1. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flapmethod. Br J Plast Surg 1991;44:53e4.

2. Hallock GG. The propeller flap version of the adductor muscleperforator flap for coverage of ischial or trochanteric pressuresores. Ann Plast Surg 2006;56:540e2.

3. Saint-Cyr M, Mujadzic M, Wong C, Hatef D, Lajoie AS,Rohrich RJ. The radial artery pedicle perforator flap: vascularanalysis and clinical implications. Plast Reconstr Surg 2010;125:1469e78.

4. Ono S, Sebastin SJ, Yazaki N, Hyakusoku H, Chung KC.Clinical applications of perforator-based propeller flaps inupper limb soft tissue reconstruction. J Hand Surg 2011;36:853e63.

5. Wong CH, Cui F, Tan BK, et al. Nonlinear finite element simu-lations to elucidate the determinants of perforator patency inpropeller flaps. Ann Plast Surg 2007;59:672e8.

Jianhua ZhangMengqing Zang

Department of Plastic and Reconstructive Surgery,Plastic Surgery Hospital, Peking Union Medical College,

Beijing, China

Shengji YuLibin Xu

Cancer Hospital, Peking Union Medical College,Beijing, China

Yuanbo LiuDepartment of Plastic and Reconstructive Surgery,

Plastic Surgery Hospital, Peking Union Medical College,Beijing, China

E-mail address: ybpumc@sina.com

ª 2014 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.bjps.2014.08.057

Utilising the MTP plantarfat: A novel approach inSyme’s amputation*

Dear Sir,

We present a patient with a significant heel injury requiringsoft tissue padding for a Syme’s amputation. During aSyme’s procedure, the tibia and fibula are cut just above