Flap Resurfacing of Postinfection Soft-Tissue Defects of the Hand:

Soft Tissue Coverage for Severe Infections

Coverage of soft tissue defects in the upper extremity caused by infection and debridement of infected tissue is a challenging problem. Treatment starts with prompt identification and eradication of infection, including antibiotics and extensive debridement. Optimizing the patient's medical and nutritional status can facilitate eradication of infection and wound healing. Coverage of soft tissue defects caused by infection and debridement demands consideration of many factors. Options include healing by primary or secondary intention, skin grafts, local flaps, and distant flaps. Negative pressure wound therapy and acellular dermal matrices can also aid in coverage.

Systematic Review and Meta-Analysis of Unconventional Perfusion Flaps in Clinical Practice

BACKGROUND

Although unconventional perfusion flaps have been in clinical use since 1975, many surgeons are still deterred from using them, because of some reports of high necrosis rates.

METHODS

The authors performed a systematic review and meta-analysis of all articles written in English, French, German, Spanish, and Portuguese on the clinical use of unconventional perfusion flaps and indexed to PubMed from 1975 until July 15, 2015.

RESULTS

A total of 134 studies and 1445 patients were analyzed. The estimated survival rate of unconventional perfusion flaps was 89.5 percent (95 percent CI, 87.3 to 91.3 percent; p < 0.001). Ninety-two percent of unconventional perfusion flaps (95 percent CI, 89.9 to 93.7 percent; p < 0.001) presented complete or nearly complete survival. Most defects mandating unconventional perfusion flap reconstruction were caused by trauma (63.6 percent), especially of the hand and fingers (75.1 percent). The main complication of all types of flaps was a variable degree of necrosis (7.5 percent of all unconventional perfusion flaps presented marginal necrosis; 9.2 percent and 5.5 percent had significant and complete necrosis, respectively). There was a positive correlation between the rate of postoperative infection and the need for a new flap (Pearson coefficient, 0.405; p = 0.001). Flaps used to reconstruct the upper limb showed better survival than those transferred to the head and neck or to the lower limb (p < 0.001).

CONCLUSION

Unconventional perfusion flaps show high survival rates and should probably be used more liberally, particularly in the realm of upper limb reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Multiple-digit resurfacing using a thin latissimus dorsi perforator flap

Traumatic digit defects of high complexity and with inadequate local tissue represent challenging surgical problems. Recently, perforator flaps have been proposed for reconstructing large defects of the hand because of their thinness and pliability and minimal donor site morbidity. Here, we illustrate the use of thin latissimus dorsi perforator flaps for resurfacing multiple defects of distal digits. We describe the cases of seven patients with large defects, including digits, circumferential defects and multiple-digit defects, who underwent reconstruction with thin latissimus dorsi perforator flaps between January 2008 and March 2012. Single-digit resurfacing procedures were excluded. The mean age was 56.3 years and the mean flap size was 160.4 cm(2). All the flaps survived completely. Two patients had minor complications including partial flap loss and scar contracture. The mean follow-up period was 11.7 months. The ideal flap for digit resurfacing should be thin and amenable to moulding, have a long pedicle for microanastomosis and have minimal donor site morbidity. Thin flaps can be harvested by excluding the deep adipose layer, and their high pliability enables resurfacing without multiple debulking procedures. The latissimus dorsi perforator flap may be the best flap for reconstructing complex defects of the digits, such as large, multiple-digit or circumferential defects, which require complete wrapping of volar and dorsal surfaces.