Free Flap Choice for Soft Tissue Reconstruction of the Severely Damaged Upper Extremity

ABSTRACT

Reconstruction of complex wounds of the hand associated with severe bone, tendon, nerve and soft-tissue injuries has been a major problem in hand surgery. Early definitive soft-tissue coverage of this kind of extensive wound with well-vascularized tissue is one of the most important stages of reconstruction for salvage of the extremity and restoration of function. Although multiple free flap donor sites have been described for complex upper extremity wounds, the authors think that anterolateral thigh (ALT) and lateral arm (LA) flaps are good choices for soft-tissue reconstruction in the upper extremity because of their reconstructive characteristics. These flaps can be used as flow-through and also sensate flaps. There is no need for position change intraoperatively and two teams may work simultaneously. Donor sites can be hidden and there is no required sacrifice of major artery or muscle.

KEYWORDS

Complex upper extremity defects - soft tissue coverage

REFERENCES

• 1 Mandrekas A D, Zambacos G J. Reverse flow radial forearm flap for reconstruction of the hand.  Ann Plast Surg. 1994;  33 536-543
• 2 Kostakoglu N, Kecik A. Upper limb reconstruction with reverse flaps. A review of 52 patients with emphasis on flap selection.  Ann Plast Surg. 1997;  39 381-389
• 3 Buchler V, Frey H. Retrograde posterior interosseus flap.  J Hand Surg Am. 1991;  16 283-292
• 4 Masquelet A C, Penteado C V. The posterior interosseus flap. In: Gilbert A, Masquelet A, Hertz V Pedicle Flaps of the Upper Limb. Boston, MA; Little Brown 1992: 11-18
• 5 Levin L C, Condit D P. Combined injuries-soft tissue management.  Clin Orthop Rel Res. 1996;  327 172-181
• 6 Pederson W C. Upper extremity microsurgery.  Plast Reconstr Surg. 2001;  107 1524-37
• 7 Chen Z W, Meyer V E, Kleinert H E, Beasley R W. Present indications and contraindications for replantation as reflected by long-term functional results.  Orthop Clin North Am. 1981;  12 849-870
• 8 Horch R E, Stark G B. The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft tissue defects.  Plast Reconstr Surg. 1999;  103 1421-1427
• 9 Favero K J, Wood M B, Meland N B. Transfer of innervated latissimus dorsi free musculocutaneous flap for the restoration of finger flexion.  J Hand Surg Am. 1993;  18 535-540
• 10 Whitney T M, Buncke H J, Alpert B S, Buncke G M, Lineaweaver W C. The serratus anterior free muscle flap. Experience with 100 consecutive cases.  Plast Reconstr Surg. 1990;  86 481-490
• 11 Germann G, Bickert B, Steinau H U, Wagner H, Sauerbier M. Versatility and reliability of combined flaps of the subscapular system.  Plast Reconstr Surg. 1999;  103 1386-1399
• 12 Soutar D S, Tanner N S. The radial forearm flap in the management of soft tissue injuries of the hand.  Br J Plast Surg. 1984;  37 18-26
• 13 Buehler M J, Pacelli L, Wilson K M. Serratus fascia sandwich free tissue transfer for complex dorsal hand and wrist avulsion injuries.  J Reconstr Microsurg. 1999;  15 315-320
• 14 Upton J, Rogers C, Durham-Smith G, Swartz W M. Clinical applications of free temporoparietal flaps in hand reconstruction.  J Hand Surgery Am. 1986;  11 475-483
• 15 Ninkovic M M, Schwabegger A H, Wechselberger G, Anderl H. Reconstruction of large palmar defects of the hand using free flaps.  J Hand Surg Br. 1997;  22 623-630
• 16 Song R, Song Y, Yu Y, Song Y. The upper arm free flap.  Clin Plast Surg. 1982;  9 27-35
• 17 Katsaros J, Schusterman M, Beppu M, Banis Jr J C, Acland R D. The lateral upper arm flap: anatomy and clinical applications.  Ann Plast Surg. 1984;  12 489-500
• 18 Yousif N J, Warren R, Matloub H S, Sanger J R. The lateral arm fascial free flap: its anatomy and use in reconstruction.  Plast Reconstr Surg. 1990;  86 1138-1145
• 19 Gosain A, Matloub H S, Yousif N J, Sanger J R. The composite lateral arm free flap: vascular relationship to triceps tendon and muscle.  Ann Plast Surg. 1992;  29 496-507
• 20 Chen H C, El Gammal T A. The lateral arm fascial free flap for resurfacing of the hand and fingers.  Plast Reconstr Surg. 1997;  99 454-459
• 21 Berthe J V, Toussaint D, Coessens B C. One stage reconstruction of an infected skin and Achilles tendon defect with a composite distally planned lateral arm flap.  Plast Reconstr Surg. 1998;  102 1618-1622
• 22 Kuek L B, Chuan T L. The extended lateral arm flap: a new modification.  J Reconstr Microsurg. 1991;  7 167-173
• 23 Fogdestam I, Tarnow P, Kalaaji A. Extended free lateral arm flap with preservation of the posterior cutaneous nerve of the forearm.  Scand J Plast Reconstr Surg. 1996;  30 49-55
• 24 Lanzetta M, Bernier M, Chollet A, St Laurent J Y. The lateral forearm flap: an anatomic study.  Plast Reconstr Surg. 1997;  99 460-464
• 25 Hamdi M, Coessens B C. Evaluation of the donor site morbidity after lateral arm flap with skin paddle extending over the elbow joint.  Br J Plast Surg. 2000;  53 215-219
• 26 Song Y G, Chen G Z, Song Y L. The free thigh flap: a new free flap concept based on the septocutaneous artery.  Br J Plast Surg. 1984;  37 149-159
• 27 Ao M, Nagase Y, Mae O, Namba Y. Reconstruction of posttraumatic defects of the foot by flow through anterolateral or anteromedial thigh flaps with preservation of posterior tibial vessels.  Ann Plast Surg. 1997;  38 598-603
• 28 Kuo Y R, Jeng S F, Kuo M H et al.. Free anterolateral thigh flap for extremity reconstruction. Clinical experience and functional assessment of donor site.  Plast Reconstr Surg. 2001;  107 1766-1771
• 29 Rajajic N, Gang R J, Krishnan J, Bang R L. Thin anterolateral thigh flap.  Ann Plast Surg. 2002;  48 252-257
• 30 Muneuchi G, Suzuki S, Ito O, Kawazoe T. Free anterolateral thigh fasciocutaneous flap with a fat/fascia extension for reconstruction of tendon gliding surface in severe bursitis of the dorsal hand.  Ann Plast Surg. 2002;  49 312-316
• 31 Yildirim S, Avci A, Akan M, Misirlioglu A, Akoz T. Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee.  Plast Reconstr Surg. 2003;  15 1630-1637
• 32 Yildirim S, Avci G, Akoz T. Soft tissue reconstruction using free anterolateral thigh flap: experience with 28 patients.  Ann Plast Surg. 2003;  51 37-44
• 33 Yildirim S, Gideroglu K, Akoz T. Anterolateral thigh flap: ideal free flap choice for lower extremity soft tissue reconstruction.  J Reconstr Microsurg. 2003;  19 225-233
• 34 Koshima I, Nanba Y, Tsutsui T, Takahashi Y. New anterolateral thigh perforator flap with a short pedicle for reconstruction of defects in the upper extremities.  Ann Plast Surg. 2003;  51 30-36
• 35 Kuo Y R, Kuo M H, Chou W C, Liu Y T, Lutz B S, Jeng S F. One stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: clinical experience and functional assessment.  Ann Plast Surg. 2003;  50 149-155
• 36 Yildirim S, Taylan G, Akoz T. Use of fascia component of the anterolateral thigh flap for different reconstructive purposes.  Ann Plast Surg. 2005;  55 479-484