Ultrasound-Assisted Thin Posteromedial Thigh Free Flap for Coverage of Hand and Upper-Extremity Wounds

Conventional workhorse free flaps can be too thick for hand and upper-extremity reconstruction. Additionally, donor site scarring is often visible and bothersome to patients. This study aims to describe the technique for preoperative perforator mapping with color doppler ultrasound (CDU) and surgical technique for elevation of a thin posteromedial thigh or profunda artery perforator (PAP) flap. Additionally, a case series of patients who underwent the PAP free flap for reconstruction in the hand and upper extremity is reviewed.

Fifteen consecutive patients had a thin PAP flap for upper-extremity reconstruction. Computed tomography angiogram (CTA) and CDU was used for preoperative perforator mapping. All flaps were single perforator flaps.

The mean age of patients was 31.1 ± 21.4 years. Mean BMI was 24.8 ± 5.0. The mean difference in the proximal-distal location of the perforator assessed through CTA and CDU was 1.3 ± 0.7 cm. Flap success rate was 93.3%. There was one flap failure because of an intraoperative flap artery spasm that could not be salvaged. Minor complications included superficial wound dehiscence at the flap donor site in two patients that was treated conservatively. All arterial anastomoses were performed end-to-side. Mean artery diameter was 1.5 ± 0.5mm. Mean venous diameter was 2.0 ± 0.4 mm. Mean pedicle length was 6.9 ± 1.2 cm. Mean flap thickness was 7 ± 2.4 mm.

The posteromedial thigh or PAP flap offers a new option for reconstruction in the hand and upper extremity. Elevation in the thin or superthin plane allows flap thickness and contour matching the surrounding skin. Preoperative perforator mapping with CTA and CDU facilitates rapid and precise flap harvest. The donor site scar of the vertical PAP flap is well hidden and provides a superior aesthetic outcome compared to other workhorse free flaps.

Therapeutic V.