Reverse Bipaddle Posterior Interosseous Artery Perforator Flap

Background: The reverse posterior interosseous artery perforator flap is useful for covering defects over the distal forearm, wrist, and hand, but some of its major limitations include short vascular pedicle, inadequate distal reach, difficult pedicle dissection, and risk of venous congestion. Some of these drawbacks have been overcome with refinements over the years, but the problems of donor-site morbidity and inability to reconstruct multiple subunits of the hand in a single stage remain. The authors developed a variant of the original distally based flap to extend its applications and minimize donor-site morbidity. Methods: Eleven cases of reverse bipaddle posterior interosseous artery perforator flap reconstruction were reviewed. Defect locations included the first web space, proximal thumb, dorsum of the hand, palm, wrist, and the radial or ulnar half of the hand. Results: Eleven patients were successfully treated with the bipaddle posterior interosseous artery perforator flap with no major complications. In seven cases, the type A chain-like variant was used to cover defects involving two different units of the hand. In four patients, the type B “kiss” pattern was required to resurface a large defect of a single unit of the hand. In all type B cases, the donor site was closed directly. All patients were satisfied with their outcomes. Conclusions: The reverse bipaddle posterior interosseous artery perforator flap is an excellent method of covering large defects of the hand involving multiple subunits. The authors confirm its vascular reliability and highlight several recommendations for skin island location, pedicle dissection, and flap raising and insetting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.