Upper extremity resurfacing via an expanded latissimus dorsi musculocutaneus flap for large circumferential defects: the “spiral” reconstruction technique

We present an expanded latissimus dorsi musculocutaneus (LDMC) flap to treat circumferential upper extremity defects via resurfacing and “spiral reconstruction” in 5 patients during a 17-year period. Five patients with different indications for tissue expansion from burns to congenital hairy nevi were operated. The expansion was done in a longitudinal direction, and a rectangular tissue expander (TE) was inserted under the LD muscle to expand the flap in a longitudinal direction thereby forming a “long” flap rather than a “wide” one. After excising the circumferential lesion, the expanded “elongated” flap was wrapped spirally around the extremity to cover the defect; the donor site was closed as usual. The 5 patients we treated via LDMC flaps in a spiral fashion were free of complications, and all were satisfied with the outcome. All the flaps survived and the spiral reconstruction allowed for a tension-free donor site closure and near complete recipient coverage. This technique is indicated for large circumferential extremity skin defects and deformities. Application of expanded LDMC flaps in a spiral fashion can be used by the reconstructive surgeon to resurface large circumferential upper extremity lesions when indicated. The idea of a long and thinned expansion flap must be in a longitudinal direction and we need this long expanded and thin flap to “spiral” it around the extremity to cover a large defect. The “spiral” flap coverage introduced here for large circumferential extremity defects enables the surgeon to cover the defect with simultaneous donor site closure and good results.     

"Think nerve" in upper extremity reconstruction

Upper extremity reconstruction may be greatly facilitated by "thinking nerve" in the initial evaluation. Frequently, the obvious soft tissue deformity or bone or joint pathology distracts the reconstructive surgeon from an underlying nerve problem. When pain is a portion of the presenting complaints, thinking nerve becomes more obvious. This article attempts to direct the reconstructive surgeon approaching the upper extremity to look for underlying nerve injury in the region of a damaged wrist capsule, neuromas of the cutaneous nerve, and sites of nerve entrapment.     

Reconstructive treatment of soft tissue sarcoma of the upper extremity

Limb-sparing surgery is currently the cornerstone of treatment for most patients with soft-tissue sarcoma of the upper extremity. To achieve the best outcome, the reconstructive surgeon must be part of a multidisciplinary team and is required to have a thorough understanding of the whole treatment concept. This article provides an update for the current surgical management of patients with soft tissue sarcoma of the upper extremity. Relevant nonsurgical aspects are also highlighted.     

侧腹部扩张任意型皮瓣修复上肢皮肤软组织缺损

目的 提高上肢大面积皮肤软组织缺损的外科治疗效果。减少供皮区畸形,方法 于侧腹部埋置扩张器,经充分扩张后,取出扩张器,形成蒂在腹部的扩张皮瓣。修复扩张器取出创面后,将“额外”皮瓣远位直接移转至上肢修复皮肤软组织缺损。结果 1997年以来,应用该方法为6例患者修复上肢皮肤软组织缺损,移转扩张皮瓣全部成活,无血运障碍、皮瓣坏死等并发症发生。获得满意效果。结论 在上肢局部无可利用的正常皮肤软组织修复缺损时,远位扩张皮瓣带蒂直接移转是一种值得考虑且安全可靠的手术方法。     

Making the V-Y advancement flap safer in fingertip amputations

Amputation of the fingertip is a common injury of the upper extremity. Over the years, a variety of reconstructive techniques have been described. For dorsal oblique and transverse amputations, the Atasoy V-Y advancement flap is a popular choice because it preserves finger length, sensation and function. However, closure under tension remains a problem, putting the flap at risk of partial or full necrosis. To avoid this untoward complication, the classic V-Y advancement technique has been modified to allow for a tension-free closure.     

The current role of the vascularized‐fibular osteocutaneous graft in the treatment of segmental defects of the upper extremity

Large osseous defects of the upper extremity can be a challenging problem for the reconstructive surgeon. There are numerous treatment options reported in the literature with variable results. We review our experience with the vascularized‐fibular osteocutaneous graft for these complex defects with a focus on surgical techniques and outcomes. © 2009 Wiley‐Liss, Inc. Microsurgery, 2011.     

Use of "spare parts" in mutilated upper extremity injuries

Management and treatment of complex mutilated upper extremity injuries often can be challenging and at times seemingly formidable. A reconstructive surgeon's ability to mobilize, transpose, and transfer tissues has allowed not only closure of complex wounds but also restoration of function and form. Use of "spare parts" from an otherwise unsalvageable limb represents the ultimate form of reconstruction that probes the creative mind and challenges the reconstructive knowledge of the surgeon. In this article, the authors review and discuss the use of various "spare parts" in the treatment of mutilating hand injuries.     

Elbow interposition arthroplasty

End-stage elbow arthritis in young, active patients presents a challenging problem to the upper extremity surgeon. Total elbow arthroplasty is not a viable option in this population because of functional restrictions, limited implant survivorship, and the lack of an adequate salvage option. With the appropriate surgical indication, interposition arthroplasty can relieve severe pain, affording a functional elbow without severely proscribing permitted activities. In addition, bone stock is preserved, as are other reconstructive options for the future.     

Pedicled radial forearm flaps for recalcitrant defects about the elbow

Chronic, open wounds about the elbow frequently require flap coverage. Skin grafts, local transposition flaps, muscle transposition flaps, and two-staged pedicled flaps from the chest and abdomen as well as free tissue transfers have all been reported. Recalcitrant elbow defects in patients in whom these previous flaps have failed are especially challenging to the upper extremity reconstructive surgeon. We have successfully employed pedicled radial forearm flaps in three patients in whom one or more previous flaps have failed.     

Perceived outcomes and utilization of upper extremity surgical reconstruction in individuals with tetraplegia at model spinal cord injury systems

STUDY DESIGN: Survey. OBJECTIVE: To measure the utilization of upper extremity reconstructive surgery and the clinicians' perceptions of the outcomes provided for persons with tetraplegia across the Model Spinal Cord (SCI) Injury Systems. SETTING: Model SCI Systems. METHODS: Participants: A clinician from each of the Model Centers. Main outcome measure: A mailed survey eliciting responses with respect to: (1) utilization of upper extremity reconstructive procedures and (2) the clinicians' perceived outcomes of these procedures. RESULTS: In all, 76% responded positively about the availability and appropriateness of upper extremity surgical reconstruction at their center. Of the respondents, 75% felt that surgery recipients were generally satisfied with their surgeries, 80% felt that the surgery made a positive impact on recipients' lives, 81% felt that recipients showed increased independence, and 70% reported a positive impact on recipients' occupation. In all, 93% felt insurance companies should pay for the procedures. Compared to the satisfaction of surgery recipients using a similar instrument, clinicians anticipated slightly greater improvements in all areas except occupation. CONCLUSIONS: There is a positive perception of the benefits of reconstructive surgery for tetraplegia; however, procedures are not routinely offered at all centers. The primary reasons reported for this include the misconception that insurance does not remit payment, that a surgeon is not available, and that surgical candidates are referred to another center.     

Sensory mapping.

The primary aim in reconstructive surgery of the upper extremity is to provide tactile gnosis to sensory depleted areas. It is essential for restoration of function and successful rehabilitation of the injured hand. Neurovascular free flaps may provide the answer to this catastrophic problem and transform a useless appendage into a functional gripping hand. Sensory mapping techniques can greatly assist the surgeon in precisely defining new donor sites for these transfers. Cutaneous sensibility, cutaneous sensation, and hand function are subjects of great complexity. Much more investigative and clinical work is needed in this challenging field to improve our evaluation of the sensory injury to the hand and to provide new avenues for restoring functional sensibility in the upper extremity.     

Revascularization of the chronically ischemic hand

Chronic ischemia of the upper extremity can pose challenging problems for the reconstructive hand surgeon. With a combined macro- and microvascular approach, many patients can be offered limb salvage rather than amputation. Direct revascularization probably offers the best approach when it can be attempted. The indirect approaches do offer improvement in most patients and are fairly straightforward. Arterialization of the venous system and free omental transfer should be used with caution by surgeons with little experience in microsurgery, however.     

Expanding horizons of reconstructive microsurgery in Lebanon: Reconstruction of complex traumatic wounds with anterolateral thigh perforator flaps in paediatrics patients less than 10 years of age

Paediatric complex wounds pose a challenge to the reconstructive surgeon due to the intricacy of reconstructive options required. Developments in microsurgery and microsurgical technique have brought free tissue transfer ever closer to the comfort zone of the reconstructive surgeon for reconstruction of paediatric traumatic complex wounds. We present our experience of microsurgical reconstruction in Lebanon for complex traumatic wounds in paediatric patients under the age of 10 years using the free anterolateral thigh (ALT) flap. The ALT flap has proven its value as a safe, adaptable, and aesthetically acceptable reconstructive option in paediatric complex trauma.     

Liposuction-assisted revision and recontouring of free microvascular tissue transfers

Liposuction has become a widely accepted and utilized technique that allows the aesthetic surgeon to improve regional definition and contour. Although the techniques of liposuction have now been extended to a variety of noncosmetic procedures as well, the application of this technique in the area of reconstructive surgery has lagged. To ascertain the applicability and effectiveness of liposuction for the revision of free microvascular tissue transfers we undertook a retrospective analysis of our free flap reconstruction cases that were revised and recontoured using liposuction. From this review of 12 cases we found liposuction to be a safe and effective technique for the delayed revision of free flap reconstructions of the head and neck region and lower extremity.Presented at the Annual Meeting of the Lipoplasty Society of North America, Seattle, Washington, September 1991; and the Robert H. Ivy Society Meeting, Pittsburgh, Pennsylvania, April 1992     

Rational flap selection and timing for coverage of complex upper extremity trauma.

Reconstruction of complex extremity trauma continues to be a challenging task for plastic surgeons. Characteristics of such injuries include destruction of functional structures, often due to high energy trauma that causes significant invalidity. Before the era of free flaps, pedicled fasciocutaneous and muscle flaps were the only option for reconstruction of the severely injured upper extremity. The management of complex injuries of the upper extremity has changed with the development of reconstructive microsurgery. Nowadays, we have a great variety of different free flaps to cover defects of the upper extremity and restore function by innervated free flaps. Sensibility, skin thickness, texture, colour, durability, binding of the flap to the underlying structures, donor site morbidity, possibility of secondary reconstructive procedures, the surgeon's experience and operative facilities must all be taken into consideration for choosing the optimal reconstructive procedure. Not only the reconstructive und functional requirements but the timing of reconstruction is extremely important for final result. The purpose of this paper is to define the principles of flap selection and timing of flap reconstruction, according to the assessment of trauma in the upper limb.     

Optimizing functional upper extremity reconstruction—Simultaneous free anterolateral thigh flap and tendon transfers—A case report

Composite upper extremity defects involving muscle–tendon units are amongst the most formidable reconstructive challenges and mandate functional restoration in addition to stable soft‐tissue coverage. Here, the authors present a case of a composite defect involving the extensor muscle–tendon units of the forearm resulting from surgical resection of a recurrent Merkel cell cancer. Functional restoration was achieved via multiple tendon transfers followed by soft tissue coverage with a free anterolateral thigh (ALT) flap. No donor‐ or recipient‐site complications were encountered and complete flap survival was noted. Following a 6‐week period of immobilization, physical therapy and range of motion exercises were initiated. Excellent functional outcome and high patient satisfaction were noted at 8 weeks postoperatively. In summary, simultaneous tendon transfers and microsurgical tissue transfer may provide a potentially superior approach for upper extremity reconstruction in complex composite defects. © 2014 Wiley Periodicals, Inc. Microsurgery 37:71–74, 2017.     

The evolution of the surgical management of severe lower extremity trauma

A hundred years ago, the question of whether to amputate a severely injured extremity could be answered rather easily and did not pose a serious dilemma. However, the increasing reconstructive capabilities have permitted the retreat to amputation to be made less frequently and occasionally create a dilemma concerning the best means of securing optimal function for the traumatized extremity. The surgeon must carefully balance the extent of trauma with the likelihood that his or her reconstructive efforts would surpass the functional results afforded by prompt amputation and prosthetic fitting. Although the mechanisms of limb destruction have changed in the past 2 centuries, the fundamental dilemma confronting the trauma surgeon has remained unchanged. In the words of Samuel D. Gross: "The cases which may reasonably require and those which may not require interference with the knife are not always so clearly and distinctly defined as not to give rise, in very many instances, to the most serious apprehension ... that, while the surgeon endeavors to avoid Scylla, he may not unwittingly run into Charybdis, mutilating a limb that might have been saved, and endangering life by the retention of one that should have been promptly amputated."     

A case report of cross-leg free latissimus dorsi myocutaneous flap transplantation

One of the significant reconstructive challenges is closure of large soft tissue defects of the lower extremity. A patient with a large traumatic defect in the lower extremity was treated with a cross-leg free latissimus dorsi myocutaneous flap. The size of the flap was 32×12 cm. The pedicle was divided 22 days after the initial operation. The result was satisfactory after a 2-year follow-up. This technique allows the transfer of large flaps to cover compromised wounds, with the advantage of using suitable recipient vessels. Received: 4 March 1998 / Accepted: 25 March 1999