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The eight-limb modified propeller flap—A safer newtechnique

Husam Hosny a,*, Wael El-Shaer b

a Plastic Surgery Unit, Faculty of Medicine (Kasr El-Eine Hospital), Cairo University, Cairo, Egyptb Plastic Surgery Unit, Bani Suif University, Beni Suef, Egypt

a r t i c l e i n f o

Article history:

Accepted 18 December 2010

Keywords:

Burn contracture

Propeller flap

Central axis flap

Flaps

a b s t r a c t

Introduction: Contracture deformities affecting the flexor aspect of the elbow joint and the

1st web space are not uncommon sequelae of burns. Surgical treatment is contemplated in

those patients with established contractural deformities in whom non-surgical treatment is

ineffective or functional integrity of the joint is at jeopardy. Surgical treatment consists of

incising the scar tissue to release joint contracture and covering the defect that might result

with skin grafting or various tissue flaps. In this work, we used a modification of the

multilobed propeller flap to treat eight patients with contracture deformities.

Materials and methods: Eight patients with contracture deformities of the elbow (five

patients) and 1st web space (three patients) were subjected to release and modified propeller

flap coverage. The modification implies planning eight limbs based on a central axis so that

rotation occurs in 458 instead of 908 in the original propeller flaps.

Results: All patients had acceptable results with complete range of movement regained in

affected joints and no serious complications. Only a case of partial loss of skin graft and

another case with congestion of one lobe were reported, and both were managed conser-

vatively.

Conclusion: The new modification has the advantages of being flexible, can be tailored to best

match the defect so that it can be closed primarily or needs smaller skin grafts, can be used

even when there is much scarring and, finally, the resultant appearance is cosmetically

acceptable with little donor morbidity, if any.

# 2011 Elsevier Ltd and ISBI. All rights reserved.

1. Introduction

The hand and upper extremity are commonly affected in

burns. They are affected in more than 50% of burn cases [1].

Contractural deformities affecting the elbow and hand are

common sequelae of burn injuries. Up to 39% of burns involve

some portion of the hand or upper extremity [2]. Joint

problems and contracture deformities are usually encoun-

tered in those patients, and are attributed to many factors

including acquiring the position of comfort during acute phase

* Corresponding author at: 21 El-Shorta Blds., Maadi Kornish, Cairo 11E-mail address: husamhosny@yahoo.com (H. Hosny).

0305-4179/$36.00 # 2011 Elsevier Ltd and ISBI. All rights reserved.doi:10.1016/j.burns.2010.12.015

of recovery and/or improper splinting and physiotherapy. The

deformity is then aggravated by soft-tissue contracture that

finally ensues [3].

Surgical treatment is contemplated in those patients with

established contractural deformities in whom non-surgical

treatment is ineffective and performed when the scar tissue

becomes fully mature.

For elbow contractures, surgical treatment comprises

release of the contracture by incising the scar tissue and then

covering the resultant defect with one or more of various types

of tissue coverage including skin grafts, Z plasty, V–Y flaps,

729, Egypt.

Table 1 – Criteria of patients and results.

Case # Site Age(years)

Gender Tissue deficiency(cm)

Length added(cm)

Grafting Follow-up(months)

Complication

1 Elbow 22 F 8 10 � 6 –

2 Elbow 34 F 9 12 � 13 Venous congestion

3 Elbow 18 M 15 10 + 14 –

4 Elbow 42 M 7 9 � 9 –

5 Elbow 28 F 11 12 + 10 Partial graft loss

6 1st web 23 M 4.2 5.6 � 14 –

7 1st web 44 F 3.8 5 � 18 –

8 1st web 19 F 3.6 4.8 � 16 –

b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9906

local or distant fasciocutanous flaps, muscle or myocutanous

flaps and free flaps, each of them having its advantages and

disadvantages. The choice between them depends on the

availability of healthy skin near to the affected area.

Thumb contractures remain a very difficult issue in the

reconstructed hand that may involve shortening of the

adductor muscle in severe cases, necessitating the release

of its transverse head. In less severe cases, release can be done

using simple Z-plasty or better four-flap or five-flap Z-plasty.

The propeller flap was first introduced by Hyakusoku et al. in

1991 [4] to release burn contracture of the elbow, using the

scarred tissue. Shortly afterwards, some modifications to avoid

its shortcomings were added such as the multilobed propeller

flap [5], scar band rotation flap [6] and the pin-wheel flaps [7].

In this work, a new modification of the propeller flap is

proposed aimingat resolvingthe shortcomings of thepreviously

mentioned propeller flaps by decreasing their axis of rotation.

[()TD$FIG]

Fig. 1 – Preoperative planning showing: (a) the calculation of the

plane of the arm (A) and forearm (F). In this case it is estimated

approximately 11 cm. (b and c) Anterior and lateral views of th

that the distance between the summits of the two lobes that wil

2. Patients and methods

This work involved eight patients, three males and five

females, with a mean age of 28.75 years (18–44 years) with

burn scar contracture deformities affecting the elbow (five

cases) and the hand 1st web space (three cases) (Table 1). The

scars were stable and mature with almost no healthy skin in

the vicinity. On the other hand, cases with joint disease,

immature scars or previously operated upon were excluded.

2.1. Preoperative planning

The flap design consists of a central subcutaneous pedicle and

eight triangular lobes based on a mathematically integrated

way. The length that needs to be added to compensate for the

shortening is calculated from the contralateral limb or along

amount of shortening by measuring through the midaxial

that after release of contracture; the defect will be

e 8-limbs of the modified propeller flap are then drawn so

l lie along the contracture should be 11 cm or slightly more.

[()TD$FIG]

Fig. 2 – (a) Preoperative calculations. (b) Planning for release of postburn thumb adduction deformity.

[()TD$FIG]

Fig. 4 – 10 days postoperative picture; some of the donor

areas of the triangular lobes have been closed in a V–Y

technique – 6 o’clock position – and others may need split

thickness skin grafting.

b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9 907

the mid-axial plain of the affected joint; thus the amount of

lengthening can be predetermined (Figs. 1 and 2). Then, the

flap is drawn so that the distance between the summits of the

triangular lobes that will fit along the axis of contracture

should be slightly longer than calculated lengthening to

compensate for any shortening that may occur to the flap

with rotation. The rotation of the flap is then carried out in 458

manner in either a clockwise or a counter-clockwise direction.

It is worth mentioning that the triangular lobes are random

flaps; hence, the height of the lobes should not exceed their

bases (ratio 1:1).

2.2. Technique

Incisions and release are then carried out, making sure that

dissection of the triangular flaps should include the subcuta-

neous tissue to insure maximum vascularity, taking into

consideration the fact that dissection should not go beneath

the central pedicle (Fig. 3). Then, the flap is rotated in the

planned direction, starting with the lobes adjacent to the

longitudinal axis of the contracture, followed by the rest of

the lobes. In some cases, when the tissues are lax, the

resultant V-shaped defects after release can be closed partly in

[()TD$FIG]

Fig. 3 – Release of the contracture by incising deep down to

the deep fascia, the triangular lobes are elevated with the

subcutaneous tissue but avoiding the central pedicle.

a V–Y manner. This will facilitate closure of the donor sites by

the rotating lobes, obviating the need for skin grafts. On the

other hand, when the soft-tissue defect is extensive and

cannot be compensated for by the previous step, split-

thickness skin grafts are used to close the remaining defects

(Fig. 4). However, achieving full range of movement in the

affected joint is of utmost importance and should not be

compromised for not using skin grafts.

Postoperative care includes inspection of the flap in the

next day to insure its vascularity, followed by daily dressing

with an antiseptic solution. Stitches were removed after 10

days.

3. Results

In all cases, stable and supple tissue coverage was obtained

(Figs. 5 and 6) with a mean follow-up period of 12.5 months

(range 6–18 months). In the early postoperative period, no total

or partial losses of the flap had occurred. Only congestion at

the tip of one of the lobes was encountered in one flap that

might be attributed to decreased amount of its underlying

[()TD$FIG]

Fig. 5 – A case of postburn thumb adduction deformity: (a) preoperative view and (b) postoperative view.

[()TD$FIG]

Fig. 6 – Postoperative result showing supple coverage after

release of the contracture deformity.

b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9908

subcutaneous tissue. However, it resolved spontaneously after

few days. Partial loss of less than 20% of the skin graft in

another case of elbow contracture occurred, and was managed

conservatively (Table 1). All the cases ran a smooth postoper-

ative period and achieved full range of movement of the

affected joints. Physiotherapy was not needed, and no

recurrence has occurred in any of our patients during the

period of this work.

4. Discussion

In spite of modern advances in burn care in the acute stage and

use of early physiotherapy and splints, contractural deformi-

ties affecting the upper extremity still present to plastic

surgeons due to improper physiotherapy and/or acquiring the

position of comfort. These deformities represent a challenge

to reconstructive surgeons as they may significantly alter the

quality of patient’s life.

Surgical management of contractural deformities involves

incisional release of the scar tissue and subsequent coverage

of the resultant defect. Regarding the elbow, flap coverage is

preferred over skin graft, as the latter has the tendency to

contract and there is always the risk that the graft may not

take partially or totally. Moreover, flap coverage brings in well-

vascularised, elastic, often uninjured, tissue that will not

contract and provides an aesthetic and durable coverage.

To reconstruct a burn elbow contracture, numerous local

and distant flaps have been employed, such as V–Y and Z-

plasty techniques for linear band contractures [8], local

fasciocutaneous flaps that may or may not include previously

burned skin territories, radial, ulnar and posterior inteross-

eous fasciocutaneous proximally based flaps and reversed

flow flaps such as the lateral arm and the ulnar recurrent

upper-arm flap. In addition, distant pedicled and microvascu-

lar transfer flaps are being used [9]. In all these flaps, the

functional losses, cosmetic results and compromise of future

reconstructive options should be taken into consideration

when planning these surgeries.

The use of subcutaneous pedicled flaps for burn contrac-

tures has been employed with encouraging results [10,11], and

also it was the case when incorporating scarred tissue for

reconstructive surgery of extensive burns [12]. In 1991,

Hyakusoku et al. introduced the concept of propeller flap

consisting of two lobes. Later, it was followed by some

modifications to include more limbs, for example, the

multilobed propeller flap [4], and pin-wheel flap [6].

The previously mentionedpropeller flaps share the common

propertyof rotation ina908 fashion.Asa result, thismay include

the risk of twisting the pedicle and causing some vascular

compromise of the flap. Further, the flaps are confronted by the

anatomical boundaries that limit the length of the flap lobes to

maximallyhalf thecircumference of the limb, as the filling lobes

are always perpendicular to contracture axis.

The modification in this work is the design of eight lobes in

a mathematically calculated pattern that makes the rotation

in a 458 instead of 908. This has the benefit of making the filling

lobes – that will fit along the contracture axis – to be along an

axis that lies away from the joint axis. Further, decreasing the

size of the remaining V-shaped defects, so that some of them

may be closed as V–Y technique reducing the amount of skin

grafts if needed. Moreover, the rotation in a 458 reduces the

risk of twisting the central pedicle and reduces the inevitable

shortening that occurs with flap mobilization.

b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9 909

In this work, neither flap loss nor recurrence was

encountered. Only venous congestion of one of the lobes

was seen, probably because of deficient subcutaneous tissue

underneath, which resolved spontaneously, and partial loss of

skin graft that was managed conservatively.

Hence, the eight limb – 458 rotation – propeller flap has the

benefits of flexible easy design tailored to the magnitude of

contracture, less twist of the central pedicle because of less

rotation, not limited by anatomical or pathological restrains as

it is away from joint axis and can include scar tissue and, finally,

it is a one-stage procedure with minimal, if any, added donor-

site morbidity. Hence, we find it very useful in managing severe

burn contractures of the elbow and 1st web space, especially

when the surrounding skin is unhealthy with much scars.

Conflict of interest statement

The article, including related data, figures and tables has not

been previously published and the article is not under

consideration elsewhere.

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