Upper extremity salvage procedure with flow-through free flap transfer taken from the amputated part

Flow-Through Free Fibula Osteocutaneous Flap in Reconstruction of Tibial Bone, Soft Tissue, and Main Artery Segmental Defects

OBJECTIVE

The aim of this report was to present the use of flow-through free fibula osteocutaneous flap for the repair of complex tibial bone, soft tissue, and main artery segmental defects.

PATIENTS AND METHODS

Five patients with bone, soft tissue, and segmental anterior tibial artery defects were included. The lengths of injured tibial bones ranged from 4 to 7 cm. The sizes of impaired soft tissues were between 9 × 4 and 15 × 6 cm. The lengths of defect of anterior tibial artery segments ranged from 6 to 10 cm. Two patients had distal limb perfusion problems. Flow-through free fibula osteocutaneous flap was performed for all 5 patients.

RESULTS

Patients were followed for 12 to 18 months. All wounds healed after 1-stage operation, and all flow-through flaps survived. The distal perfusion after vascular repair was normal in all patients. Superficial necrosis of flap edge was noted in 1 case. After the local debridement and partial thickness skin graft, the flap healed uneventfully, and the surgical operation did not increase injury to the donor site. Satisfactory bone union was achieved in all patients in 2 to 4 months postoperation. Enlargement of fibula graft was observed during follow-up from 12 to 18 months. The functions of adjacent joints were recovered, and all patients were able to walk normally.

CONCLUSIONS

Flow-through free fibula osteocutaneous flap was shown to be an effective and efficient technique for repairing composite tibial bone, soft tissue, and main artery segmental defects. This 1-stage operation should be useful in clinical practice for the treatment of complex bone, soft tissue, and vessel defects.

Upper Extremity Salvage With a Flow-Through Free Flap

In complex extremity injuries, which include composite tissue lost with devascularization caused by segmental vascular damage, simultaneous coverage of the defects with revascularizations should be required. One-stage reconstruction of both soft tissue coverage and vascular damage can be performed by a flow-through-type free flap. In this series, 5 patients between 13 and 36 years of age with wide composite tissue defects in the cubital region and segmental defects in brachial arteries were operated at our clinic between 1996 and 2003. With the aim of reconstructing the wide tissue defects in the cubital region as well as that of the brachial artery, a radial arterial flow-through flap was applied. The radial artery of the flow-through flap was anastomosed to the proximal ends of the brachial and ulnar arteries in an end-to-end fashion. In 4 of the patients, the radial arterial flow-through flap was prepared from the distal aspect of the wounded forearm and in 1 patient from the contralateral forearm. In the postoperative period, no complications related to the anastomosis were encountered in the flap with all anastomoses found to be patent, and distal circulation was restored. The radial arterial flow-through flap is very useful in the clinical field of major trauma of the cubital region with brachial artery damage with numerous advantages that include the opportunity to work in one single surgical area, shorter dissection times resulting from simple and fixed anatomy, perfect color and tissue adaptation, and the suitability of the vessel caliber and length.

Flow-through flaps: A review of current knowledge and a novel classification system

Flaps have long been recognized as an essential tool for soft-tissue reconstruction. Flaps range in complexity from local to free and perforator flaps and can include a variety of composite tissues. The concept of a flow-through flap, in which both the proximal and the distal ends of the vascular pedicle of a free flap are anastamosed to provide blood flow to distal tissues, was first described by Soutar et al. in 1983. An uninterrupted arterial flow was established by Soutar et al. between the external carotid and distal facial artery via a radial forearm flap for head and neck reconstruction (Soutar et al., Br J Plast Surg 1983;36:1-8). Shortly thereafter, Foucher et al. were the first to report the reconstruction of an extremity with a simultaneous vascular defect by utilizing a radial forearm flow-through flap (Foucher et al., Br J Plast Surg 1984;37:139-148). The utility of the flow-through flap is now well established, and its indications for use continue to grow. The principle advantage of this flap is that it provides the opportunity for a single stage composite reconstruction of both soft tissue and vascular defects, making it particularly useful in the reconstruction of ischemic extremities and defects from oncologic ablations. Improvements in microsurgical equipment and techniques are making early difficulties with these flaps irrelevant, giving plastic surgeons opportunities to become more creative in the choices and uses of flow-through flaps. The literature consists mostly of case reports and series. The nomenclature used to describe the types of flow-through flaps is confusing and inconsistent. The purpose of this article is to provide an organized review of flow-through flaps and to classify these flaps based on their inflow, outflow, and the nature of their vascular conduit. Additionally, we have included a discussion on the physiology of these flaps, reviewed the current literature, and summarized the various types of flow-through flaps in a reference guide that can aid in flap selection.

Use of a venous flap from an amputated part for salvage of an upper extremity injury

The authors describe a patient in whom a large arterialized venous flap was harvested from a nonreplantable part after partial hand amputation. A 9 x 6-cm segment of dorsal hand skin was transplanted acutely in an artery-vein-vein fashion to cover exposed bone, joints, and reconstructed tendons. The flap provided durable coverage, and at 1 year the patient regained 94% total active motion at the index finger and 99% total active motion at the long finger. Salvage of component parts such as a venous flap and extensor tendons avoided additional procedures for coverage and staged tendon reconstructions.

Upper limb free flap reconstruction after tumor resection

Free tissue transfer is the autologous transplantation of composite tissue and its arterial and venous blood supply to a distant site. Free tissue transfers, also called free flaps, may include skin, fascia, muscle, or bone. Free flaps were once considered highly complex procedures; now they are frequently used as the reconstructive option of choice. While several variables must be considered when one plans a free tissue transfer, the most important consideration is the size and location of the defect created by the tumor resection. Free tissue transfer is a multistep procedure, including preparation of the recipient site, harvesting of the flap, and transfer and revascularization of the flap. For upper extremity reconstruction, the gracilis muscle flap has been particularly useful, as has the lateral arm fasciocutaneous flap. Semin. Surg. Oncol. 19:246-254, 2000.