Immediate emergency free anterolateral thigh flap transfer for the mutilated upper extremity

Single-staged revascularization and reconstruction after crush injury of the wrist and distal forearm: A protocolized approach

BACKGROUND

Amputation of the wrist or distal forearm after high-energy trauma due to a crushing mechanism is associated with complex tissue defects, making repair, and reconstruction challenging. Given the difficulty of this type of salvage, patients unfortunately experience a high revision amputation rate. However, a higher quality of life has been reported in patients with successful reconstructions. Herein, we described a protocolized approach for revascularization and reconstruction for functional hand salvage after traumatic amputation from a crushing mechanism using an anterolateral thigh flap (ALT).

METHODS

A retrospective review was performed between October 2016 and October 2023 for all patients who underwent single-stage emergent debridement, revascularization, and soft tissue coverage using the ALT after amputation at the level of the wrist or distal forearm secondary to high-energy crush injury. Charts were reviewed for the preoperative Mangled Extremity Salvage Score, intraoperative details including what structures were injured and the reconstructive method performed, and postoperative data such as follow-up duration, outcomes, and complications.

RESULTS

Eleven patients met the inclusion criteria with an average age of 35.5 (21-49) years old. The average size of the skin soft tissue defects was 17.3 × 8 cm (range, length: 13-25 cm, width: 6-13 cm), and all cases had associated injury to the underlying bone, nerves, and blood vessels. The average size of the ALT flap used for reconstruction was 19.2 × 9.8 cm (range, length: 14-27 cm, width: 7-15 cm). All patients had survival of the replanted limb. One patient experienced partial flap necrosis that required secondary debridement and skin graft. Nine patients healed without requiring any additional debridement procedures. Patient follow-up averaged 24.6 (12-38) months. All patients achieved satisfactory functional recovery with Grade II to III of Chen's criteria.

CONCLUSIONS

For patients with traumatic crush amputation to the wrist with surrounding soft tissue injury, thorough debridement, revascularization, and reconstruction of amputated limbs can be performed in a single stage using the ALT. A protocolized approach from two institutions is presented, demonstrating improved survival and reduced complications of the traumatized limb with improved long-term patient outcomes.

Simultaneous or Delayed Free Tissue Transfer in Combination with Replantation Surgery

In hand and upper extremity replantation surgery, simultaneous free flap reconstruction restores the physiologic circulation to the amputated part, ensuring its survival, and promotes wound healing through anatomic restoration. Especially in digit replantation, an arterialized venous flap serves to reconstruct both vessel and soft tissue defects simultaneously. Delayed free flap reconstruction aims to enhance both functional improvement and cosmetic acceptance in a successfully replanted part using flaps that include functioning muscle, bone, joint, nerve, and soft tissue.

Evolution and Diversity of Medial Sural Artery Perforator Flap for Hand Reconstruction

The free medial sural artery perforator (MSAP) flap is a recently popularized flap. It has evolved from a composite myocutaneous flap to a pedicled perforator flap for lower limb reconstruction. It is also a versatile free perforator flap for extremity and head and neck reconstruction. The diversity of the flap designs with options for harvest of non-vascularized grafts enhances the versatility for hand and upper limb reconstruction. The adjunctive use of endoscopy and indocyanine green fluorescence imaging studies can assist and demystify the flap anatomy. The authors present their experience using free MSAP flaps for complex mutilated hand and upper extremity reconstruction.

Reconstruction of Finger Soft Tissue Defects With a Thinned Free Anterolateral Thigh Flap

BACKGROUND

Reconstructing complex soft tissue defects of the finger requires both functional and aesthetic aspects. There are many free tissue transfers as suitable options for digital resurfacing. The anterolateral thigh (ALT) flap is not the first choice for reconstruction of this area because it has the disadvantage that the subcutaneous tissue is too thick; however, its use as a thinned form has yet to be described much. This study presents the flap thinning technique in the small-sized ALT flap for the finger soft tissue defect.

METHOD

From May 2009 to March 2018, 10 patients with complete circumferential or semicircumcision defects in the fingers underwent reconstructive procedures that included thinned ALT flap transfer. Finger soft tissue damage due to contusion trauma includes loss of skin and exposure of the bone and tendon. The flap is thinned in 2 different ways: peripheral thinning and total microsurgical thinning, which is selected based on the perforator vessel structure of the flap.

RESULT

The ALT flap sizes, averaging 4-9 cm wide and 6-12 cm long, were thinned to 4-7 mm. One perforator was included in the flaps with a pedicle length average of 6.1 cm. The flaps survived entirely in all patients except one with a 30% area in the distal part of the thinned ALT flap that became necrotic because of venous occlusion. Donor sites were closed primarily for all patients. No patients required secondary flap defatting.

CONCLUSIONS

The small thinned ALT perforator flap can be an excellent option for full circumferential or semicircumferential soft tissue defects of the finger. Follow-up showed this as an excellent alternative for finger reconstruction in terms of aesthetic appearance and functional outcome.

Twenty-minute harvesting of flow-through type vastus lateralis muscle flap significantly reduces the need for a temporary intravascular shunt in the treatment of severe upper extremity trauma in civilian patients

For the reconstruction of severe upper extremity trauma involving arterial injury in civilian patients, it is generally recommended that the revascularization time be shortened using a temporary intravascular shunt (TIVS). However, if a flow-through type vastus lateralis muscle (VLm) flap can be harvested in 20 minutes and bypassed at the obstructed ischemic zone within 30 minutes, blood flow can be restored as quickly or more quickly than when using a TIVS, eliminating the need for a TIVS. This procedure was applied in the reconstruction of 3 cases of severe extremity trauma with vascular injury. The mean age was 69.7 years. Surgery was started an average of 2.93 hours from the onset. The average flap harvest time was 0.33 hours. The average time to revascularization from flap harvest was 1.33 hours, the average total operation time was 6.43 hours, and all upper extremities were salvaged. No cases showed ischemia-reperfusion injury or severe muscle contracture. The flow-through-type VLm flap can be applicable as a bypass graft for a 20 cm defect at any region distal to the elbow. In addition, harvesting the flap attached to blood-rich muscle not only controls the infection of contaminated wounds through the filling of dead space, but also has the potential to replace damaged muscle or tendon tissue. Even though TIVS placement is currently used extensively in this field of treatment, its role could be significantly reduced if a flow-through-type VLm flap can be harvested within 20 minutes.

Management of Complex Upper Extremity Trauma with Associated Vascular Injury

Introduction Combined soft tissue and vascular injuries of the upper extremity pose several challenges at once to the plastic surgeon. Many decisions have to be taken urgently that will influence the salvage or amputation of the affected extremity. The aim of this article was to provide an evidence-based outline for the management of such injuries. Learning objectives of this article are as follows: (1) approach to a patient with upper extremity composite tissue and vascular injury presenting to the emergency, (2) decision-making as to when to salvage and when to go for amputation of the traumatized upper extremity, (3) role of imaging in emergency situation, (4) role of fasciotomy, (5) intraoperative sequencing of steps, and (6) options for vascular reconstruction and the flaps used for coverage. After reading this article, the reader should have a clear understanding of the management of vascular injury in a patient with composite defects of upper extremity.

Temporoparietal Fascial Free Flap: A Systematic Review

ABSTRACT

The temporoparietal fascial flap (TPFF) is a versatile tool used in head and neck reconstructive surgeries as well as distal upper and lower extremity reconstructions. Depending on the anatomical location and characteristics of the recipient site soft tissue defects, harvesting techniques for TPFF retrieval may include elevation as a pedicle or a free flap, inclusion of the temporalis muscle and/or adjacent calvarial bone as a composite flap. The TPFF as a free flap is not only used for soft tissue coverage of various defects, and it can be used as a joint gliding surface with coverage of nerve and tendons after repair or trauma. This article includes a systematic search of the medical literature for indications, historical background, techniques, current perspective, and complications along with the pros and cons of the free TPFF compared with other potential reconstructive options.

Large wounds reconstruction of the lower extremity with combined latissimus dorsi musculocutaneous flap and flow-through anterolateral thigh perforator flap transfer

BACKGROUND

Management of large wounds of the lower extremities remains a challenge for plastic and reconstructive surgeons. Herein, a surgical technique and clinical algorithm using the combined transfer of a latissimus dorsi (LD) musculocutaneous flap and flow-through anterolateral thigh (ALT) perforator flap for the treatment of extensive soft-tissue defects is described.

METHODS

From January 2012 to September 2018, 12 patients (six men and six women) aged 6-37 years, sustained injuries in road traffic accidents with large soft-tissue defects in the lower extremities. Seven cases were Gustillo Anderson type IIIB open fractures and two cases were Gustillo Anderson type IIIC open fractures. Two wounds were located in the knee joint, four in the calf, and six in the ankle and foot. The skin defect size ranged from 25 × 20 cm² to 36 × 25 cm² . All patients in this series underwent reconstruction using combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap, wherein the LD was attached through its pedicle to the distal continuation of the ALT flap.

RESULTS

The size of the flow-through ALT perforator flaps ranged from 13.5 × 6.5 cm² to 31 × 8.5 cm² . The size of the LD musculocutaneous skin paddle ranged from 25 × 6 cm² to 34 × 7 cm² , and that of the muscle paddle ranged from 13 × 3.5 cm² to 30 × 11 cm² . One patient experienced postoperative thrombosis of the venous pedicle, and the flap was salvaged after emergency re-exploration and thrombectomy. No other complications were observed postoperatively. The mean follow-up period was 26.8 months. All patients were able to ambulate independently at the end of the follow-up period.

CONCLUSIONS

The combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap ensured adequate surface coverage, making it a feasible procedure for large soft-tissue defects.

The Anterolateral Thigh Perforator Flap: Its Expanding Role in Lower Extremity Reconstruction

The anterolateral thigh (ALT) flap is a popular flap for lower extremity reconstruction despite its varied pedicle anatomy. Beyond its use for soft tissue coverage, using the chimeric flap concept, the ALT flap is useful for tendon and ligament reconstruction and the creation of a gliding surface with the fascia lata component. The vastus lateralis muscle can be included for dead-space obliteration. The main pedicle is long and is a similar size match for major artery reconstruction. If several perforators are available, a split flap could be fashioned into a multitude of shapes all arising from the same pedicle.

Harvesting the anterolateral thigh flap with non-sizable perforators

BACKGROUND

The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present.

METHODS

A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival.

SURGICAL TECHNIQUE

Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle.

RESULTS

A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites.

CONCLUSIONS

It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps.

Microsurgical Tissue Transfer in Complex Upper Extremity Trauma

Microsurgical tissue transfer may provide reconstructive option for extensive loss of tissues due to upper extremity trauma or tumor resection. This article reviews the authors' experience in using microsurgical tissue transfers for reconstruction of upper extremity trauma.

Comparison of Fasciocutaneous and Muscle-based Free Flaps for Soft Tissue Reconstruction of the Upper Extremity

Soft tissue free flap reconstruction of upper extremities has proven to be reliable and essential for limb salvage and function. Nevertheless, comparative data regarding flap outcome are still lacking. The present study aimed to compare procedural features and individual complication rates of different free flaps used for upper extremity reconstruction.

Methods

The authors evaluated retrospectively the results of 164 free flaps in 149 patients with upper extremity defects. Chart reviews were performed from April 2000 to June 2014, analyzing flap choices, complication, and success rate assessment for patients >18 years old, with a soft tissue defect of the upper extremity. Chosen flap types were classified as fasciocutaneous (including adipocutaneous) and muscle-based, respectively. We comparatively analyzed total flap loss, flap survival after microsurgical revisions, and susceptibility rates for thromboses rates and partial flap necrosis.

Results

Defect size was larger when muscle-based flaps were used (231 ± 38.6 versus 164 ± 13.7 cm², P < 0.05). Outcome analysis revealed a tendency towards higher arterial thrombosis rates for muscle flaps (10.2% versus 4.3%) and venous thrombosis rates for fasciocutaneous flaps (2% versus 7%). Total flap loss (6.1% versus 7.8%) and flap survival after vascular revisions (75% versus 70.6%) showed comparable rates. Partial flap necrosis was generally higher in muscle-based flaps (22.4% versus 8.6%, P = 0.02) with impact on patients' hospital stay (37.2 ± 4.69 and 27.11 ± 1.62 days, n = 115, P = 0.01), while no differences in partial necrosis rates were noted in flaps larger than 300 cm² (25% versus 10%, P = 0.55). There was a trend over time towards using fasciocutaneous-based flaps more frequently with a final overall percentage of 83.7% between 2012 and 2014.

Conclusions

Microsurgical tissue transfer to the upper extremity is safe and reliable, but flap-type specific procedural and measures should be taken into consideration. Total flap loss as well as flap survival after microsurgical revisions are not altered between these flaps. They differ, however, in their susceptibilities for thromboses rates, partial flap necrosis and thus require individual risk stratification and flap placement.

Cross limb vessel transfer for salvage of the extremity with irreparable artery injury

PURPOSE

Complex injuries of the extremity can be very challenging to treat. In the setting of soft tissue infection and vascular defect, arterial reconstructions are at high risk of failure. Historically, there have not been good options to successfully salvage limbs with these serious injuries. We describe our experience of utilizing a cross limb vessel transfer to salvage the limb.

METHODS

Patients were identified retrospectively with complex vascular injuries of the extremity and wound infection, who were treated with a cross limb vessel transfer. Once the infection has successfully been cleared, flow-through flap transfer was performed for definitive reconstruction of the arterial injury. Data collated included patient demographics, injury and operation details, and post-operative outcomes including blood supply of the limb, wound infection and complications.

RESULTS

Between April 2014 and January 2017, 3 patients with an average age of 21 years (range, 16-29) were admitted. The median length of hospital stay was 62 days (range, 26-122). The average number of operation was 7.3 times (range, 6-10). Two patients' upper limb had survived with limited movement, relatively minor donor site morbidity and confirmed flow through the vessel reconstruction using CTA, while one patient had lower limb amputation due to severe infection and prolonged ischemia time.

CONCLUSIONS

This series of patients demonstrates that cross limb vessel transfer is an invaluable technique to salvage the limb in patients with complex vascular injury and wound infection. However, for lower limb with prolonged ischemia time and severe infection, limb salvage is not recommended.

Free Tissue Transfer for Upper Extremity Reconstruction

With 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.

Traumatic Wounds of the Upper Extremity: Coverage Strategies

Soft tissue coverage of traumatic wounds of the upper extremity is often required to restore adequate function and form. An optimal coverage should be stable, durable, and able to withstand heavy demands of work, should allow free joint mobility, and should have an aesthetically acceptable appearance. Reconstructive options for coverage include autologous tissue and dermal skin substitutes. Multiple factors, including wound characteristics and complexity, general condition of the patient, and surgeon comfort and expertise, help in selection of the reconstructive technique. This article summarizes commonly used soft tissue reconstructive options for traumatic wounds of the upper extremity.

USE of arterialized saphenous vein venous flow-through flaps as a temporizing measure for hand salvage in contaminated wounds presenting with limb ischemia: A case series

BACKGROUND

Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases.

METHODS

Spanning 2008 to 2015, four patients presenting with large contaminated crush/avulsion wounds with vascular injury underwent hand revascularization with S-VFTF, allowing the contaminated wounds to be serially debrided. Definitive soft tissue reconstruction was performed once the wound was considered clean. The S-VFTF skin paddle was de-epithelialized and the soft tissue defect covered with a free latissimus dorsi flap or a rectus abdominis myocutaneous flap.

RESULTS

All ischemic limbs were successfully reperfused and there were no take backs for perfusion issues. All S-VFTF remained patent at discharge and final follow-up. No partial or complete finger/hand amputations were required. All definitive coverage free flap survived with no complications.

CONCLUSION

The two-stage reconstruction presented may help reconstructive and vascular surgeons consider alternatives to traditional vascular reconstruction methods. This technique avoids an exposed vascular graft in an extensively contaminated open wound. It allows the surgeon to perform thorough and sufficient debridement of the wound, preventing definitive reconstruction in a not yet declared zone of injury.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

Perforator-based propeller flaps reliability in upper extremity soft tissue reconstruction: a systematic review

Current data on upper extremity propeller flaps are poor and do not allow the assessment of the safety of this technique. A systematic literature review was conducted searching PubMed, EMBASE, and the Cochrane Library electronic databases, and the selection process was adapted from the preferred reporting items for systematic reviews and meta-analysis statement. The final analysis included ten relevant articles involving 117 flaps. The majority of flaps were used for the hand, distal wrist, and elbow. The radial artery perforator and ulnar artery perforator were the most frequently used flaps. The were 7% flaps with venous congestion and 3% with complete necrosis. No difference in complications rate was found for different flaps sites. Perforator-based propeller flaps appear to be an interesting procedure for covering soft tissue defects involving the upper extremities, even for large defects, but the procedure requires experience and close monitoring.

LEVEL OF EVIDENCE

II.

Management of soft tissue defects of the hand

Soft tissue coverage of the hand remains a challenging problem to the hand surgeon, but advances in the field of microsurgery have provided improved thin, pliable, durable flaps that offer cosmetic reconstructive options. The reconstructive elevator is poised to replace the reconstructive ladder, thereby allowing early reconstruction by the best available option. This reviews focus on the variety of pedicled, free fasciocutaneous, and venous flaps available for successful soft tissue coverage of the hand.

Free tissue transfer to the traumatized upper extremity: Risk factors for postoperative complications in 282 cases

BACKGROUND

Complex traumatic upper extremity injuries frequently possess compromised local vasculature or extensive defects that are not amenable to local flap reconstruction. Free tissue transfer is required to provide adequate soft tissue coverage. The present study aimed to evaluate risk factors that contribute to postoperative complications and flap loss in complex upper extremity reconstruction.

METHODS

Retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographic characteristics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using χ(2) and Fisher exact tests.

RESULTS

In total, 238 patients underwent 285 free tissue transfers and met inclusion criteria, from which 3 were excluded because of inadequate information (n = 282). Extremities were repaired within 24 h (75 cases; 27%), in days 2-7 (32 cases; 12%), or after day 7 (172 cases; 62%). Timing of reconstruction did not significantly affect postoperative outcomes. Proximal location of injury was significantly associated with superficial (relative risk [RR], 6.5; P < .01) and deep infection (RR, 5.3; P < .01), and osteomyelitis (RR, 4.0; P < .01), although not with flap failure (P = .30). Presence of an open fracture was significantly associated with developing superficial (RR, 3.1; P = .01) and deep (RR, 1.9; P < .01) infection, as well as osteomyelitis (RR, 1.6; P < .01). Having a closed fracture did not negatively influence postoperative outcomes.

CONCLUSIONS

This study supports the safety of early free tissue transfer for reconstruction of traumatized upper extremities. Injuries proximal to the elbow and open fracture were associated with a significantly higher infection rate. Gustilo grade IIIC fractures, need for interpositional vein grafts, and anastomotic revision at index operation resulted in significantly higher risk of flap loss, whereas the presence of fracture, fracture fixation, and injury location were not predictors of flap failure.

Timing of traumatic upper extremity free flap reconstruction: a systematic review and progress report

BACKGROUND

The recommendations on the timing of microsurgical extremity reconstruction are as variable and numerous as the flaps described for such reconstruction. Original articles suggested that reconstruction should take place within 72 hours of injury. However, significant changes in perioperative and intraoperative management have occurred in this field, which may allow for more flexibility in the timing of reconstruction. This article aims to review current literature on timing of upper extremity reconstruction to provide the microsurgeon with up-to-date recommendations.

METHODS

A structured literature search including Spanish and English language articles published between January of 1995 and December of 2011 was performed using the MEDLINE and Scopus databases. The search strategy was conducted using groups of key words, and articles were subsequently reviewed for relevance. Bibliographies of selected articles were further reviewed for additional relevant publications. Rates of total flap loss, infection, hospital stay, and bony nonunion were recorded and analyzed according to emergent (<24 hours), early (<5 days), primary (6 to 21 days), or delayed (>21 days) reconstruction.

RESULTS

Fifteen articles met inclusion criteria. There was no significant association between timing of reconstruction and rates of flap loss, infection, or bony nonunion. Linear regression analysis displayed a significant association between length of hospital stay and timing of reconstruction.

CONCLUSIONS

No conclusive evidence exists to suggest that emergent, early, primary, or delayed reconstruction will eliminate or decrease complications associated with posttraumatic upper extremity reconstruction. Earlier reconstruction may decrease length of hospital stay and limit associated medical costs.

Anthropomorphic and perforator analysis of anterolateral thigh flap in Indian population

Background:

Anterolateral thigh (ALT) flap is one of the most common flaps in the reconstruction armamentarium of plastic surgeons, but there is no published data about the flap characteristics in the Indian population. The aim of this study is to analyse the anthropomorphic characteristics of the ALT flap and the perforator details in Indian population.

Materials and Methods:

ALT flap details were studied in 65 patients of Indian origin comprising 45 males and 20 females. The study period is from August 2011 to July 2012. A prospective database of the Doppler findings, perforator and pedicle details and the flap morphology were maintained. The variables are analysed by using the SPSS, PASW statistics 18 software IBM^®.

Results:

In nearly 75% of cases, the perforator was found within 4 cm of the pre-operative Doppler markings. The percentage of musculocutaneous and septocutaneous perforators was 61.8% and 38.2% respectively. The pedicle variation was found in 6 cases (9.23%). The average thickness of the thigh skin in Indians is similar to the western people, but thicker than the other Asian people. Flap thinning was performed in nine patients without any major complications.

Conclusion:

The perforator details and type in the Indian population are similar to the published reports from other parts of the world. We advise pre-operative Doppler examination in possible cases. The variation in pedicle anatomy should not be overlooked to avoid complications. The thickness of subcutaneous tissue of the flap is higher in Indians, but still can be safely thinned. The data of this study will serve as a guide for the ALT flap characteristics in Indian patients.

Composite anterolateral thigh perforator flaps in the management of complex hand injuries

The anterolateral thigh (ALT) fasciocutaneous flap has been well described for hand skin cover, however its use in its composite (multiple tissue) form incorporating bone, muscle and/or fascia has been less well described. We report the usefulness of the composite ALT flap in six complex hand trauma cases, four male and two female (age range 14-46 years). The palm of the hand was affected by injury in three cases, the dorsum in two cases, and the radial side in one case. The first web formed part of the injury in three cases. There was variable involvement of the tendons, nerves and bones. Fascia lata was included in the flap to provide a gliding surface in four cases, part of the vastus lateralis muscle was included to obliterate dead space in two cases and to create a first web in one case, and a bone block from the iliac crest was included to reconstruct the lost metacarpals in one case. All flaps survived with minimal complications. This work shows that the anterolateral thigh composite flap is a reliable option when multiple tissue types are required in hand reconstruction.

The clinical application of anterolateral thigh flap

The anterolateral thigh flap can provide a large skin paddle nourished by a long and large-caliber pedicle and can be harvested by two-team work. Most importantly, the donor-site morbidity is minimal. However, the anatomic variations decreased its popularity. By adapting free-style flap concepts, such as preoperative mapping of the perforators and being familiar with retrograde perforator dissection, this disadvantage had been overcome gradually. Furthermore, several modifications widen its clinical applications: the fascia lata can be included for sling or tendon reconstruction, the bulkiness could be created by including vastus lateralis muscle or deepithelization of skin flap, the pliability could be increased by suprafascial dissection or primary thinning, the pedicle length could be lengthening by proximally eccentric placement of the perforator, and so forth. Combined with these technical and conceptual advancements, the anterolateral thigh flap has become the workhorse flap for soft-tissue reconstructions from head to toe.

Microsurgical coverage reconstruction in upper and lower extremities

Trauma is one of the main causes of upper- and lower-limb defects. Limb injuries frequently result in complex defects, hence reconstruction can be demanding. The basic principles of trauma management and methods of reconstruction are analyzed. Then, the evolution of free tissue transfer is reviewed with particular attention to the use of anterolateral thigh flap in reconstruction of upper- and lower-limb trauma cases. The anterolateral thigh flap is the workhorse flap in our department due to its versatility in the reconstruction of complex defects. Finally, the concept of free-style perforator flaps is presented. Microsurgery has supplied the armamentarium of the plastic surgeon with a very powerful tool. Essentially, microsurgery may almost always provide a solution in cases of complex defects that cannot be covered with the simpler options of the reconstructive ladder. The recently acquired perforator flap concept will gradually become the most popular method of microsurgical reconstruction, as it minimizes donor-site morbidity and replaces "like tissue with like tissue."

Microsurgery of the upper extremity

In the past 50 years, hand surgeons have made considerable contributions to microsurgery. The unique demands of complex upper extremity care have driven many of the technical and scientific advances of this discipline, including functional muscle transfers, nerve transfers, and composite tissue allotransplantation. The purpose of this article was to review the current applications of microsurgery to the upper extremity.