A review and critical appraisal of central axis flaps in axillary and elbow contractures
© The Author(s) 2017
Received: 21 December 2016
Accepted: 5 April 2017
Published: 4 May 2017
Contractures of the axilla and elbow can produce a significant impact on quality of life by reducing the ability to perform activities of daily living. Varieties of techniques are available for resurfacing defects following contracture release but graft or flap loss, donor-site morbidity, esthetics, and recurrences are still challenges for reconstructive surgeons. Central axis “propeller” flaps based on a random, subcutaneous pedicle were first described for axillary and elbow contractures to deploy the unburnt skin of axillary dome in type I and II contractures (Kurtzman and Stern) by moving them 90° to straddle the contracting bands. This strategy provided better esthetics and avoided prolonged splinting. Over more than two decades, there have been several design modifications of these flaps with extended applications to cubital fossa. A comprehensive review of published literature on the topic is presented to discuss classifications, design modifications, and applications of such flaps in managing axillary and elbow contractures.
Contractures of axilla and elbow are one of the most common functionally limiting sequelae of burn injury as they profoundly affect the hand function by influencing the strategic positioning of the hand . Therefore, these contractures can produce a significant impact on quality of life by reducing the ability to perform activities of daily living. A variety of techniques are available for release of contractures, including simple skin grafting, local flaps [2–7], regional flaps [8–16], central axis flaps [17–25], perforator flaps [26–29], and free-tissue transfers [30, 31]. However, graft or flap loss, donor-site morbidity, esthetics, and recurrences are still challenges for reconstructive surgeons.
Propeller flaps are an important addition to the armamentarium for management of soft tissue defects. The concept of propeller flap has evolved over the past few decades with increasing knowledge of the location and vascular territory perfused by perforators. Since central axis propeller flaps are eminently suitable in many cases of axillary and elbow contractures, this review discusses the definition, classification, design modifications, and indications of such flaps primarily for these applications.
Definitions and concept
As a subcutaneous pedicle is under the center of every flap, these methods are categorized as “central axis flaps.”
The term “Propeller” was introduced in 1991 by Hyakusoku et al. for reconstruction of contracture in cubital and axillary region . The central axis flap was introduced because of the observation that even extensively burned patients sometimes have healthy skin in axillary or cubital fossa because of joint flexion at the time of injury. The idea was to design flaps in the center of the axillary or cubital fossa, utilizing this unburnt skin, by elevating it as an island on a subcutaneous pedicle. The flap is designed and elevated as a “propeller,” and then rotated by 90° to straddle the area under the contracting bands after contracture release. The remaining donor site is covered with skin grafts. Since then, various modifications of the propeller flap design have been described [19–25].
The concept of “propeller flap” has been refined and modified over the past few years leading to the evolution of “perforator (based) propeller flap” by Hallock . The flap described by Hallock was similar in shape to the one described by Hyakusoku but was based on a skeletonized perforating vessel and was rotated 180°. In the same year, Teo  elaborated on the surgical technique and extended the applications of the perforator propeller flaps. The use of such flaps is now popular and features a highly reliable reconstructive method for soft tissue defects in different areas of the body [32–36, 37, 38].
The first meeting on perforator and propeller flaps was conducted in 2009 in Tokyo. The terminology consensus for propeller flaps accepted at this meeting was analogous to the “Gent” consensus on perforator flap terminology [39, 40].
A propeller flap can be defined as an island flap that reaches the recipient site through an axial rotation . Every skin flap can become a propeller flap, but an island flap that reaches the recipient site through an advancement movement or those that move through a rotation and are not completely islanded are excluded from this definition.
Classification of propeller flaps
Classification of propeller flaps
Type of flap
Subcutaneous pedicled propeller flap
The flap is based on a random subcutaneous pedicle. The perforators included in pedicle are not visualized or isolated. The flap rotates by 90°.
Perforator pedicled propeller flap
Skeletonized perforating vessel included
Flap is based on a perforator that decides the position of the skin island and is centered over it. The perforator is then skeletonized and freed from the fascial adhesions. The flap rotates between 90° and 180°. This type of flap is most commonly used in reconstructive surgery.
Supercharged propeller flap
Skeletonized perforating vessel with additional vein or artery, or both
If a long pedicled flap is required and the isolated perforator vessel is not providing sufficient arterial inflow or venous outflow, an extra pedicle can be anastomosed. The flap rotates between 90° and 180°.
Different designs for central axis flaps
The “original” propeller flap
Multilobed propeller flap
Scarred propeller flap
Eight-limb propeller flap
Zig-zag modified propeller flap
“Namaste” propeller flap
Multiple rhomboid flaps
Critical appraisal of central axis flaps
Today, there are multiple options available for reconstruction of post-burn contracture of the axilla and cubital fossa. Traditionally, surgeons have employed Z-plasty [2, 3] or another local flap modification [5–7] to lengthen linear contractures but relied on skin grafting for resurfacing of moderate to severe contractures. Need for prolonged splinting with skin grafting, breadth of scarring in a linear contracture, availability of unburnt skin in the axillary/cubital fossa, and desire for superior esthetics have motivated surgeons to develop innovative local/regional flaps. Good results can be obtained by many techniques. In this regard, the skin graft donor-site morbidity, tolerance for splinting, and complications related to graft or flap failure have dictated individual choices.
The simplest, time-tested reconstructive option has been skin grafting, but the need for prolonged splinting and a potential to recurrence have seen some disenchantment with the procedure. Moreover, skin grafting has limited success in children who are less compliant with postoperative splintage and physiotherapy. However, it seems an ideal choice for resurfacing a type III Kurtzman and Stern  axillary contracture or a severe elbow contracture.
Use of local flaps for axillary and elbow contractures has been popular for a longtime. Various local flap options in axilla for type I contracture include random pattern flaps , Z-plasty [2, 3], Y-V plasty , and a square flap , but most of the regional flaps like parascapular flap , scapular flap , latissimus dorsi flap [8, 9], and thoracodorsal artery perforator (TDAP)-based flap [27–29] are executed in type III contractures, to resurface the dome of the axilla. In 1986, Hyakusoku had also described the use of local fasciocutaneous and musculocutaneous flaps from the surrounding scarred tissue in patients of axilla contracture who did not have unscarred donor sites available . The decision to use scarred skin, as a flap, should be made keeping in mind the depth of the burn scar and previous surgical excisions .
However, when the axillary dome is spared, the use of local flaps mentioned above or a local flap rearrangement advanced by Z-plasty, or its likes, can either mar the esthetics of the axilla by sacrificing healthy hairy skin or destroy the potential to employ the unburnt skin in reconstruction. Quite akin are the circumstances with the presence of unburnt skin in the cubital fossa in elbow contractures.
The introduction of the central axis flap, for axillary contractures by Hyakusoku et al., added another option of reconstruction to address type II contractures. The attraction of the technique lies in utilizing the spared axillary fossa skin and propelling it by 90° to straddle the anterior and posterior axillary folds. The flap is based on a subcutaneous pedicle, is extremely simple to raise, and requires no microsurgical skills. Although, the donor area is still covered with skin grafts, it provides excellent functional recovery within 6 months, without splinting. The subcutaneous pedicle is very reliable, and minimal complications have been reported subsequently with this technique.
Perforator-based propeller flaps have overshadowed the application of central axis subcutaneous pedicled propeller flaps. Thoracodorsal artery perforator flap (TDAP flaps) is based on a septocutaneous perforator of circumflex scapular artery. It is increasingly used in axillary contractures to resurface the dome in type III contracture. It provides superior esthetics; less need for prolonged splinting and the donor site can be closed primarily [27–29].
There are several other options in reconstruction besides the central axis flaps, including a square flap , a trapeze-flap plasty [6, 7], or a free flap [40, 41]. A square flap has been described for a type I axillary contracture [13, 24]; a trapeze-flap plasty [6, 7] may be applicable in both axillary or elbow contractures; and a free flap [40, 41] is obviously employed in the absence of local tissue and the need to do away with splinting.
Reconstruction of axilla and elbow is difficult in patients with extensive burn because of skin paucity. Various designs for local flaps or central axis flaps offer an option to use any amount of unburnt skin centrally or in the vicinity. Many broad-based or multiple linear contractures can be managed effectively with the use of these flaps, besides these flaps offer better esthetics with superior and stable skin. The central axis flaps also do not dislocate the hair-bearing skin of the axilla. However, because of inherent limitations, many of these flaps are applicable only in mild contractures because if used in moderate contractures, they lead to incomplete release in the first stage. At the same time, these flaps are known to stretch over a period of time improving the functional outcome. There are no defined criteria for dimensions of these flaps that can be safely raised but very long flaps have been elevated and rotated by 90° without significant complications.
Central axis subcutaneous pedicled flaps are a reliable method of reconstruction in axillary and elbow contractures. They are eminently applicable in mild to moderate contractures but may not permit full contracture release in severe contractures. Better esthetic result, fewer complications, and the possibility to do away with splinting make these flaps a very attractive option.
The authors would like to thank Dr. Suvashis Dash for providing schematic diagrams.
None of the authors received any funding for this manuscript.
Availability of data and materials
The data is made available from personal research and personal records of authors.
DK contributed to the initial draft of the manuscript, patient pictures, and literature review. RBA contributed to the final manuscript, review of illustrations, and literature review. Both authors read and approved the final manuscript.
The authors declare that they have no competing interest.
Consent for publication
Both the authors provide their consent for publication. Written informed consent of publication of the photos of the patients were obtained from the patient or the guardian.
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