Microsurgical Reconstruction of the Upper Extremity

2018 ◽  
Author(s):  
Nikolas H Kazmers ◽  
Stephanie Thibaudeau ◽  
Zvi Steinberger ◽  
L. Scott Levin
Keyword(s):  
Upper Extremity ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Soft Tissue Coverage ◽  
Microsurgical Reconstruction ◽  
Case Examples ◽  
Extremity Reconstruction ◽  
Key Words Bone ◽  
Microsurgical Techniques ◽  
Perioperative Planning

The advent of free tissue transfer has revolutionized upper extremity reconstruction in the setting of trauma, infection, and oncologic resection. Current microsurgical techniques allow for soft tissue coverage, osseous reconstruction, and free functioning muscle transfer. This review highlights perioperative planning considerations in terms of the timing of reconstruction and flap choice, as well as indications and contraindications, for upper extremity microsurgical reconstruction. Many commonly used fasciocutaneous, muscle, and osseous free flap options are reviewed, with specific emphasis on surgically relevant anatomy, flap variations, and pearls and pitfalls. Many of these free flap options are illustrated using case examples. This review contains 15 figures, 3 tables and 109 references. Key words: bone defect, elbow, free flap, hand, microsurgery, reconstruction, upper extremity, wrist

scholarly journals Long-Term Quality of Life after Free Flap Upper Extremity Reconstruction for Traumatic Injuries

2019 ◽  
Vol 36 (03) ◽  
pp. 213-222 ◽  
Author(s):  
Sara van Bekkum ◽  
Tim de Jong ◽  
Michiel Zuidam ◽  
Marc A. M. Mureau
Keyword(s):  
Upper Extremity ◽  
Free Flap ◽  
Extremity Function ◽  
Sf 36 ◽  
Patient Reported ◽  
Extremity Reconstruction ◽  
Upper Extremity Function

Abstract Background Microsurgical reconstruction of upper extremity injuries is often challenging, and the resulting impact on the quality of life (QoL) may be significant. However, there is a lack of knowledge on long-term patient-reported QoL. Methods In a retrospective long-term follow-up study, all consecutive patients with an upper extremity injury who had undergone a free flap reconstruction were identified and categorized into three groups based on the type of injury. Patient-reported upper extremity function and QoL were assessed using three validated questionnaires: the 36-item Short Form Health Survey (SF-36), the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the Michigan Hand Outcomes Questionnaire (MHQ). Results A total of 61 patients were identified, of whom 10% had undergone a free flap reconstruction for soft tissue loss only, 62% for an injury accompanied by a fracture, and 28% for a (sub) total amputation. Twenty-one (44%) patients responded to the questionnaires, with a mean follow-up time of 9.7 ± 6.2 years. Patients, on average, reported poorer SF-36 “physical component score” and “role limitations due to physical health” scores compared with Dutch norms. Also, they reported poorer mean DASH scores compared with the general population, indicating worse upper extremity function. Mean MQH scores were lower for the injured side compared with the noninjured side. Pain correlated negatively with the total scores of DASH, MHQ, and SF-36. Conclusion Free flap upper extremity reconstruction is challenging. At 10 years of follow-up, the injury and its treatment continued to have a significant impact on the upper extremity function and daily QoL, with chronic pain being an important factor negatively affecting these outcomes.

scholarly journals 1106 Timing of Free Flap Reconstruction in Sarcoma Patients

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
A T Misky ◽  
S Williams ◽  
A Woollard
Keyword(s):  
Free Flap ◽  
Negative Impact ◽  
Trauma Surgery ◽  
Surgical Reconstruction ◽  
Complication Rates ◽  
Tissue Destruction ◽  
Microsurgical Reconstruction ◽  
Operative Complications ◽  
Extremity Reconstruction ◽  
Post Operative Complications

Abstract Aim In 1986 Godina reported that microsurgical reconstruction of traumatic wounds in the extremities undertaken with >72-hour delay caused significant tissue damage, hampering the microsurgical reconstruction and significantly increasing complication rates. It is our opinion that surgical treatment of sarcoma in the extremity is comparable to trauma surgery, given the extent of tissue destruction. The nature of sarcoma management often means that performing definitive reconstruction within 72 hours is not possible. We analyse the outcomes of our ‘delayed’ extremity reconstruction. Method We performed a retrospective analysis of 52 consecutive cases of free flap extremity reconstruction following sarcoma excision. Data was analysed for time from resection to reconstruction, significant patient demographics, details of the flap and post-operative complications. Results Between March 2017 and December 2020, we performed 52 free flaps for sarcoma reconstruction in the extremities. Mean time to reconstruction was 28 days (Median 15 days, Range: 0-316 days), with two reconstructions within 72 hours of excision. 9 patients had neoadjuvant chemo- or radiotherapy. Three patients had significant post-operative complications; two flaps failed intra-operatively (3.8%) and one patient (1.9%) experienced wound infection. Conclusions Godina’s study demonstrated the negative impact of delaying surgical reconstruction in the traumatised extremity, with a 12% failure and 17.5% infection rate in delayed reconstruction (72 hours to 3 weeks). Our results show that with advancements in microsurgical techniques and physiological optimization, it is possible to safely and successfully undertake delayed (>72 hours) microsurgical extremity reconstruction in sarcoma patients and achieve low flap failure and infection rates.

scholarly journals Lower Extremity Reconstruction with Vascularized Free-Tissue Transfer: 20 Years of Experience in the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

2021 ◽  
Vol 73 (7) ◽  
pp. 462-470
Author(s):  
Nutthawut Akaranuchat
Keyword(s):  
Survival Rate ◽  
Lower Extremity ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Flap Surgery ◽  
Free Flap Surgery ◽  
Anterolateral Thigh ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
The Mean

Objective: The reconstruction of extensive soft-tissue defects in the lower extremity still poses a great challenge to plastic and reconstructive surgeons. The ideal approach is to achieve a proper soft-tissue coverage with a well-vascularized flap, which results in a durable weight-bearing surface and permits normal joint motion. This study aims to retrospectively analyze the outcomes of lower-extremity reconstruction with vascularized free-tissue transfer performed at our plastic surgery division. Materials and Methods: A retrospective chart review was performed regarding 58 patients with defects in the lower extremity which were reconstructed with vascularized free-tissue transfers between 2000 and 2019. Forty-four of the patients were male, and 14 were female. The mean age was 44.4 years (range: 6-89 years). The most common indication for free-flap surgery was a secondary reconstruction after tumor eradication (23 cases, 39.7%), and 84.8% of the defects were exposed bare bones, tendons, or joints.Results: In our 58 reviewed cases, the foot was the most common area requiring reconstruction with a free flap (68.9%), and the mean defect size was 12.5 x 8.1 cm. The most commonly used free flap was the Anterolateral thigh free flap (39.7%), followed by the Gracilis free flap (29.3%), and the Superficial circumflex iliac artery-perforator free flap (10.4%). The recipient vessels most frequently used were posterior tibialis vessels (53.4%). The overall flap-survival rate was 75.9%, though there was an increased survival rate of up to 85.7% in the last five years of the period studied. The flap-salvage rate was 40.9%, and arterial thrombosis was the major cause of flap loss (50%). Factors associated with free-flap failure were re-exploration and free flap surgery after tumor or cancer eradication. The most common post-operative complication was flap-wound dehiscence (10.3%). Two patients received a flap correction due to bulkiness, and three had recurrence of ulceration. Conclusion: Microvascular free-tissue transfers for lower- extremity-defect reconstructions are reliable and valuable as a surgical technique. In over 20 years of experience in our division, we’ve had an overall flap-survival rate of 75.9%. Our flap of choice was the Anterolateral thigh free flap.

Microsurgical reconstruction of the upper limb

2021 ◽  
pp. 385-392
Author(s):  
Alex E. Hamilton
Keyword(s):  
Soft Tissue ◽  
Upper Limb ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Bone Defects ◽  
Nerve Reconstruction ◽  
Microsurgical Reconstruction ◽  
Tissue Transfer ◽  
Toe Transfer

This chapter describes the microsurgical options for reconstruction of the hand, including replantation of amputated parts, nerve reconstruction, and free tissue transfer for reconstruction. The various free flap options for reconstruction of skin, soft tissue, and bone defects including the reconstruction of digits with toe transfer, are discussed.

scholarly journals Free Tissue Transfer for Upper Extremity Reconstruction

2019 ◽  
Vol 33 (01) ◽  
pp. 017-023 ◽  
Author(s):  
Rami Dibbs ◽  
Luke Grome ◽  
William Pederson
Keyword(s):  
Upper Extremity ◽  
Muscle Flap ◽  
Free Tissue Transfer ◽  
Serratus Anterior ◽  
Muscle Flaps ◽  
Functional Tissue ◽  
Tissue Transfer ◽  
Free Muscle Flap ◽  
Reconstructive Ladder ◽  
Extremity Reconstruction

AbstractWith the advent of the Industrial Revolution, traumatic injuries of the upper extremity increased exponentially. As a result, surgeons began to reevaluate amputation as the standard of care. Following the Second World War, local and regional pedicled flaps became common forms of traumatic upper extremity reconstruction. Today, microsurgery offers an alternative when options lower on the reconstructive ladder have been exhausted or will not produce a desirable result. In this article, the authors review the use of free tissue transfer for upper extremity reconstruction. Flaps are categorized as fasciocutaneous, muscle, and functional tissue transfers. The thin pliable nature of fasciocutaneous flaps makes them ideal for aesthetically sensitive areas, such as the hand. The radial forearm, lateral arm, scapula, parascapular, anterolateral thigh, and temporoparietal fascia flaps are highlighted in this article. Muscle flaps are utilized for their bulk and size; the latissimus dorsi flap serves as a “workhorse” free muscle flap for upper extremity reconstruction. Other muscle flaps include the rectus abdominis and serratus anterior. Lastly, functional tissue transfers are used to restore active range of motion or bony integrity to the upper extremity. The innervated gracilis can be utilized in the forearm to restore finger flexion or extension. Transfer of vascularized bone such as the fibula may be used to correct large defects of the radius or ulna. Finally, replacement of “like with like” is embodied in toe-to-thumb transfers for reconstruction of digital amputations.

Recent Smoking History Is Not Associated With Adverse 30-Day Standardized Postoperative Outcomes Following Microsurgical Reconstructive Procedures of the Upper Extremity: Un Antécédent de Tabagisme Récent n’est Pas Associé à des Événements Indésirables Postopératoires Standardisés 30 Jours après des Procédures Microchirurgicales de Reconstruction du Membre Supérieur

2021 ◽  
pp. 229255032110247
Author(s):  
Olachi O. Oleru ◽  
Neil V. Shah ◽  
Peter L. Zhou ◽  
Dillon Sedaghatpour ◽  
Jaydev B. Mistry ◽  
...  
Keyword(s):  
Wound Healing ◽  
Upper Extremity ◽  
Free Flap ◽  
Postoperative Outcomes ◽  
Smoking History ◽  
Improvement Program ◽  
Reconstructive Procedures ◽  
Microsurgical Reconstruction ◽  
Flap Transfer ◽  
Free Flap Transfer

Background: Upper extremity (UE) microsurgical reconstruction relies upon proper wound healing for optimal outcomes. Cigarette smoking is associated with wound healing complications, yet conclusions vary regarding impact on microsurgical outcomes (replantation, revascularization, and free tissue transfer). We investigated how smoking impacted 30-day standardized postoperative outcomes following UE microsurgical reconstruction. Methods: Utilizing the National Surgical Quality Improvement Program, all patients who underwent (1) UE free flap transfer (n = 70) and (2) replantation/revascularization (n = 270) were identified. For each procedure, patients were stratified by recent smoking history (current smoker ≤1-year preoperatively). Baseline demographics and standardized 30-day complications, reoperations, and readmissions were compared between smokers and nonsmokers. Results: Replantation/revascularization patients had no differences in sex, race, or body mass index between smokers (n = 77) and nonsmokers. Smokers had a higher prevalence of congestive heart failure (5.2% vs 1.0%, P = .036) and nonsmokers were more often on hemodialysis (15.6% vs 10.4%, P = .030). Free flap transfer patients had no differences in age, sex, or race between smokers (n = 14) and nonsmokers. Smokers had a longer length of stay (6.6 vs 4.2 days, P = .001) and a greater prevalence of chronic obstructive pulmonary disorder (COPD; 7.1% vs 0%, P = .044). Recent smoking was not associated with increased odds of any 30-day minor and major standardized surgical complications, readmissions, or reoperations following UE microsurgical reconstruction via free flap transfer or replantation/revascularization. Baseline diagnosis of COPD was also not a predictor of adverse 30-day outcomes following free flap transfer. Conclusion: Recent smoking history was not associated with any 30-day adverse outcomes following UE microsurgical reconstruction via replantation/revascularization or free flap transfer. In light of these findings, further investigation is warranted, with particular focus on adverse events specific to free flaps and replantation/revascularization.

Use of the Anterolateral Thigh Free Flap for Upper-Extremity Reconstruction

2005 ◽  
Vol 30 (4) ◽  
pp. 859-864 ◽  
Author(s):  
Howard T. Wang ◽  
James W. Fletcher ◽  
Detlev Erdmann ◽  
L. Scott Levin
Keyword(s):  
Upper Extremity ◽  
Free Flap ◽  
Anterolateral Thigh ◽  
Extremity Reconstruction

scholarly journals Flap Decisions and Options in Soft Tissue Coverage of the Upper Limb

2014 ◽  
Vol 8 (1) ◽  
pp. 409-414 ◽  
Author(s):  
Michelle Griffin ◽  
Sandip Hindocha ◽  
Marco Malahias ◽  
Mohamed Saleh ◽  
Ali Juma
Keyword(s):  
Soft Tissue ◽  
Upper Limb ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Careful Consideration ◽  
Surrounding Tissue ◽  
Soft Tissue Coverage ◽  
Scapular Flap ◽  
Radial Forearm

Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.

Biceps Femoris Perforator Free Flap for Upper Extremity Reconstruction: Anatomical Study and Clinical Series

2005 ◽  
Vol 116 (1) ◽  
pp. 145-152 ◽  
Author(s):  
Pedro C. Cavadas ◽  
Juan Ram??n Sanz-Jim??nez-Rico ◽  
Luis Landin ◽  
Jes??s Correa
Keyword(s):  
Upper Extremity ◽  
Free Flap ◽  
Anatomical Study ◽  
Biceps Femoris ◽  
Clinical Series ◽  
Extremity Reconstruction
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