Free lateral arm flap for 1-stage reconstruction of soft tissue and composite defects of the hand: A retrospective analysis of 118 cases

In this article, the long-term outcomes of hand defects after 1-stage reconstruction with lateral arm flap were retrospectively analyzed in a large series. Between the years 1990 and 2004, 118 traumatic hand defects were reconstructed using lateral arm fasciocutaneous flap (n = 104), lateral arm fascial flap (n = 6), and composite lateral arm flap (n = 8) in Chang Gung Memorial Hospital. There were 22 females and 96 males with an average age of 32.5 +/- 13.3 years.The mean follow-up period was 17 +/- 6.2 months. The overall success rate was 97.5%. The cosmetic outcomes were satisfactory and only 16.1% of the patients required debulking. The functional recovery of the hand contractures secondary to crush injury were generally associated with poor results. In the composite flap group, reconstruction of the extensor tendons with triceps tendon yielded limitation in tendon excursion and poor functional results. However, complete bone healing without complication was uniformly detected in all cases. Lateral arm fasciocutaneous flap endured secondary interventions well and no complications regarding wound healing was encountered.     

Reconstruction of complex parotidectomy defects using the lateral arm free tissue transfer.

OBJECTIVES: The study goal was to show that the lateral arm flap is a viable reconstructive option for complex parotidectomy defects.Study design and setting We studied a case series at a tertiary care medical center from March 1997 to March 2002. The lateral arm flap was used to reconstruct parotidectomy defects that included a composite resection of adjacent tissue in 30 patients. There were 19 men and 11 women (mean age, 62 years; mean follow-up, 19 months). The mean flap area was 114 cm(2), and the mean flap volume was 172 cm(3). The posterior cutaneous nerve of the forearm (PCNF) was used as a facial nerve cable graft in 14 patients. Facial disability outcomes were measured using the Facial Clinimetric Evaluation scale. RESULTS: The major and minor complication rates with use of this reconstructive approach were low: 16.7% (5 of 30) and 26.7% (8 of 30), respectively. Donor site morbidity was minimal, with no patient having a major donor site complication and 23.3% (7 of 30) having minor complications. Functional recovery of the facial nerve occurred in 6 of 8 evaluable patients who underwent facial nerve grafting using the PCNF. Controlling for degree of facial nerve paralysis, Facial Clinimetric Evaluation scale scores of our patients were not statistically different than those of a historic population with a facial paralysis and no surgical defect. CONCLUSIONS: The lateral arm free flap effectively restores facial appearance when used for reconstruction of complex parotidectomy defects. The PCNF, a nerve harvested with the lateral arm flap, can be used as a facial nerve cable graft with a high rate of success. SIGNIFICANCE: The lateral arm flap is successful as a single donor site for reconstructing facial contour and the facial nerve after major ablative defects in the parotid region.     

A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects.

The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.     

上臂远端外侧肱骨骨皮瓣修复手部复合组织缺损

目的 探讨上臂远端外侧肱骨骨皮瓣在手外科的临床应用效果.方法 对8例手部复合组织缺损的患者,根据掌指骨缺损的情况,先设计骨瓣的切取位置和大小(骨瓣远端止于肱骨外上髁的上缘),然后再根据皮肤缺损的面积和骨缺损的相对位置设计皮瓣的大小.前臂后皮神经位于皮瓣的中轴线上,可以保留或一并切取使用,恢复受区感觉.皮瓣切取面积为4.0cm×8.0cm～6.0cm×8.0cm,骨瓣切取大小为4.0cm×1.5cm×1.0cm～6.0cm×1.5cm×1.0cm.结果 术后8例骨皮瓣全部存活,上臂供区创面直接闭合,愈合好,上臂功能无影响.术后随访4～24个月,皮瓣感觉恢复良好,移植骨完全愈合,手部外形满意.结论 上臂远端外侧肱骨骨皮瓣是修复手部创面和掌、指骨复合组织缺损的理想选择.     

The free lateral arm flap in reconstructive hand surgery

Microsurgical tissue transplantation has provided a great advance in reconstructive surgery, especially regarding upper limb defects. Compared to conventional pedicled flaps, mobilisation can occur earlier, hospital stay is shorter and no additional interventions for pedicle detachment and flap inset are needed. The lateral arm flap is an exceptionally versatile free flap with straightforward dissection and low donor site morbidity. End-to-side anastomosis preserves blood flow through the main arteries to the hand and reduces the risk of vascular compromise of the hand, which is especially important in case of severe hand injuries. Sixteen patients who underwent hand reconstruction using the lateral arm free flap are reviewed. All arterial anastomoses were conducted in end-to-side-technique either to the radial or the ulnar artery. There was no total- or partial-flap failure and only one revisional procedure due to a haematoma under the anastomosis. Eight flaps required secondary defatting, combined with removal of osteosynthesis material or tenolysis. From our point of view the free lateral arm flap is a very reliable and versatile method to resurface small and medium sized hand defects.     

Multilayer reconstructions for defects overlying the Achilles tendon with the lateral-arm flap: Long-term follow-up of 16 cases

Defects of the Achilles tendon and the overlying soft tissue are challenging to reconstruct. The lateral‐arm flap has our preference in this region as it provides thin pliable skin, in addition, the fascia and tendon can be included in the flap as well. The aim of this report is to share the experience the authors gained with this type of reconstruction. The authors report the largest series in the published reports today. Patients and methods: A retrospective review was performed of all patients treated between January 2000 and January 2009 with a lateral‐arm flap for a soft‐tissue defect overlying the Achilles tendon. Results: In the reviewed period, 16 soft‐tissue defects overlying the Achilles tendon were reconstructed, with a mean follow‐up of 63 months. In three cases, tendon was included into the flap and in two, a sensory nerve was coapted. Fifteen cases (94%) were successful, one failed. In seven cases, a secondary procedure was necessary for thinning of the flap. Conclusion: The lateral‐arm flap is a good and safe option for the reconstruction of defects overlying the Achilles tendon. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Function-Preserving Neurotized Lateral Arm Free Flap in the Reconstruction of Hemiglossectomy Defects

Introduction and Methods  The glabrous, thin, and pliable texture of lateral arm flap with no loss of any axial vessel of the limb renders it a good choice for hemiglossectomy defect reconstruction. The main caveat of this flap harvest is the loss of sensation in the distribution of posterior antebrachial cutaneous nerve (PABCN). In this article, we present two strategic sites and techniques to preserve the integrity of PABCN and at the same time harvesting lateral arm flap with a lengthy lower lateral cutaneous nerve of arm for the neurotization. The outcome of this function-preserving neurotized lateral arm free flap in the reconstruction of hemiglossectomy defects is analyzed and presented in this article. Results  Ninety percent of the patients attained grade 3 score in objective assessment, leading to a significant p -value of 0.02 with this technique. All had preservation of sensation in the distribution of PABCN. Conclusion  Our technique of harvest and neurotization has brought good functional recovery of the oral cavity with preservation of PABCN.     

Use of anterolateral thigh and lateral arm fasciocutaneous free flaps in lateral skull base reconstruction

Lateral skull base defects following tumor ablation are ideally reconstructed with microvascular free tissue transfer. Although the rectus abdominis free flap is the workhorse in skull base reconstruction, it has a number of drawbacks. Anecdotal reports have indicated that fasciocutaneous free flaps may be useful alternatives in selected cases. Patients undergoing lateral arm (4 cases) or anterolateral thigh (8 cases) fasciocutaneous free flap reconstruction of lateral skull base defects between 1999 and 2005 were therefore reviewed. Twelve consecutive patients (4 males, 8 females) with a mean age of 63 years (range, 39 to 74) underwent such reconstruction following resection of lateral (11 cases) and anterolateral (1 case) skull base lesions. Eight patients had squamous cell carcinoma, 3 had infection or osteoradionecrosis, and 1 had adenoid cystic carcinoma. The duration of surgery (from induction of anesthesia to exit from the operating room) averaged 14.5 hours (range, 10 to 19.5 hours). All donor sites were closed directly. All the flap transfers were successful, with minimal reconstructive and donor site morbidity. During the follow-up period (average, 18 months; range, 2-48 months), 2 patients died of metastatic disease, and another 2 died of other unrelated causes. The remaining 8 patients are alive and disease free. It is concluded that lateral arm and anterolateral thigh fasciocutaneous free flaps should be considered as viable reconstructive options for lateral skull base ablative defects.     

Versatility of the lateral arm free flap in various anatomic defect reconstructions

The free lateral arm flap may be harvested as a fascial, fasciocutaneous, or osteofasciocutaneous flap. Simultaneous flap elevation with preparation of the recipient site, easy dissection, minimal donor-site morbidity, and a constant vascular anatomy with long pedicle are advantages of the flap. In this study, the authors present 18 patients operated on between January, 2002 and August, 2003 in whom 18 free lateral arm flaps were utilized. There were four women and 14 men, and the mean patient age was 40 years. Thirteen fasciocutaneous, three fascial, and two osteofasciocutaneous flaps were used. Flaps were employed for the reconstruction of the lower extremity in five patients, upper extremity in nine patients, and head and neck in four patients. Thirteen flaps were elevated under axillary block and five flaps under general anesthesia. Aspirin, dipirydamol, dextran, and chlorpromazine were administered postoperatively. Venous insufficiency developed in two lower-extremity reconstructions on postoperative day 1. Venous thromboses were detected, anastomoses were re-done, and flaps healed uneventfully. No other postoperative complication was observed in the other patients. The free lateral arm flap may be used in various anatomic defects with various indications. It may be elevated under axillary block for extremity reconstructions.     

Versatility of lateral arm flap for hand reconstruction—a clinical experience

Background

The lateral arm free flap (LAFF) has several advantages in hand reconstruction due to multiple factors. We aimed to show the versatility of LAFF in treating hand defects.

Methods

A retrospective analysis of all LAAF for hand reconstruction carried out at our institutions between August 2006 and August 2012 was undertaken. Clinical records were reviewed with respect to patients’ age and gender, size and location of defect, type and size of flaps, and complications.

Results

Twenty-four hand defects were reconstructed using LAFF. These included 15 cutaneous flaps, 8 fascial flaps, and 1 osteocutaneous flap. All flaps survived well except for one case that developed arterial insufficiency and required anastomotic revision. Primary closure of the donor site was possible in all patients. No complications occurred during the healing procedure.

Conclusions

The free lateral arm flap is a versatile and reliable option for defect coverage at the hand for small- and medium-size defects. It can be raised as a cutaneous, fascial, or osteocutaneous flap. Several advantages favor the use of lateral arm flap in hand reconstruction. These include preservation of major arm blood vessels, its constant vascular anatomy, long pedicle, and low donor site morbidity.Level of Evidence: Level IV, therapeutic study.

     

Free osteocutaneous lateral arm flap: anatomy and clinical applications

For many surgeons, the potential to reconstruct skin, fascia, tendon, or bone in a single-stage procedure has made the lateral arm flap the technique of choice for reconstruction of complex defects. The aim of this study was to examine more closely how the humeral bone is supplied by the posterior collateral radial artery. To this end, we dissected 30 cadaver arms to determine the vascular relationship of the lateral arm flap to the humerus. The number of directly supplying vessels, and height to the lateral epicondyle of the humerus, were examined. The reconstructive potential of the osteocutaneous flap in different indications is analyzed in a series of five clinical cases. In all dissected extremities, we found one or two branches of the posterior collateral artery directly and constantly supplying the bone between 2-7 cm proximal to the lateral epicondyle. In five cases, combined defects, including bone, were successfully reconstructed with lateral arm flaps, including vascularized bone.     

Evolution of a paradigm for free tissue transfer reconstruction of lateral temporal bone defects

BACKGROUND: Tumors of the lateral skull base are best treated with surgery plus or minus radiation therapy. Surgical ablation may involve cutaneous structures, the auricle, the parotid, and the lateral temporal bone. These composite soft tissue defects are best reconstructed with composite tissue. Multiple pedicled flaps have been used to reconstruct these defects. Free flaps have been shown to provide the best tissue for these reconstructions. We review our experience and present an algorithm for their reconstruction. METHODS: A case series of consecutive patients treated between 1999 and 2006 at 2 tertiary care institutions, Oregon Health and Science University and University of Alabama at Birmingham were reviewed. There were 73 patients who had periauricular defects requiring 74 free tissue transfers in this retrospective chart review. All defects had extensive cutaneous loss and underwent some form of parotidectomy. There were 57 lateral temporal bone defects and 16 periauricular defects where the external auditory canal was preserved. The majority of patients had nonmelanoma skin malignancies (65%). Eighty percent of patients had undergone previous treatment (radiation therapy, surgery, or a combination therof). RESULTS: Early on, reconstruction was performed using a radial forearm (RFFF, n=29), evolving to lateral arm (n=6), rectus (n=11), and finally an anterolateral thigh (ALT, n=28) free flap. The average hospital stay was 6 days, and the overall complication rate was 22%. The rectus flap needed debulking in 34% of patients, and the anterolateral thigh in 9%. Periauricular defects were classified based on preservation of the external auditory canal (class I), lateral temporal bone resection with preservation of the auricle (class II), or lateral temporal bone with total auriculectomy (class III). CONCLUSION: Class I defects were best managed by RFFF reconstruction, class II defects were managed well with the ALT flap, and class III defects required the ALT or rectus flap.     

Versatility and donor site morbidity of the lateral upper arm flap in intraoral reconstruction.

OBJECTIVE: The lateral upper arm flap is not widely used yet for intraoral defect reconstruction. Investigation of its morphologic and functional outcome was the objective of this study. STUDY DESIGN: The morphologic and functional results of recipient (swallowing, flap survival, dehiscence of margins, cutaneous fistulas, intraoral hairs) and donor sites (wound healing, scar width and length, sensory and motor disturbance) (n = 44) were checked clinically. Postoperative swallowing was investigated via videofluorography (n = 11). RESULTS: The lateral upper arm flap showed low donor site morbidity, primary closure was achieved in all but one case. Sensory deficit at the proximal forearm (n = 27) occurred without any case of compromise of radial nerve function. Videofluorography allows for objective evaluation of swallowing function. CONCLUSIONS: The lateral upper arm flap is the reconstruction of first choice for intraoral defects due to its low donor site morbidity.     

The use of the lateral arm flap in upper limb surgery

Twenty patients who had had upper limb reconstruction using the lateral arm free microvascular flap are reviewed. The size of the flap, modifications to the flap, and complications were documented. There was one flap failure, and nine flaps required surgical thinning at a second procedure. This sole disadvantage was outweighed in clinical usage by the advantages and versatility of the lateral arm flap.     

Combined free fibular osteocutaneous-lateral calcaneal fasciocutaneous flap for reconstruction of composite oromandibular defects

The free fibular osteocutaneous flap is often used in the reconstruction of composite oromandibular defects. In contrast, the lateral calcaneal flap has never been used in oromandibular reconstruction. On the basis of their anatomic continuity, the authors combined the free fibular osteocutaneous flap with the lateral calcaneal skin paddle to obtain 2 adjoining flaps in different anatomic areas with the same vascular axis. The authors report their experience in 3 patients with composite oromandibular defects. In 1 patient without an outer skin defect, only a sensory lateral calcaneal skin paddle with a fibular osseus flap was harvested. The lateral calcaneal flap carried the sural nerve as a sensory flap in 2 patients, and the result was passable. Only 1 patient encountered superficial flap tip necrosis at the lateral calcaneal skin paddle, and recovered well after wound care. In conclusion, a flap with many specific features is a feasible choice for reconstruction of composite oromandibular defects.     

Reconstruction of elbow region defects using radial collateral artery perforator (RCAP)-based propeller flaps

Perforator-based propeller flaps permit flap rotation up to 180°. This ability to transfer skin from one longitudinal axis to another has led to the increasing use of perforator-based propeller flaps in extremity reconstruction, especially lower-extremity reconstruction. However, the application of perforator-based propeller flaps to upper-extremity reconstruction is still limited. This article reports two cases of successful reconstruction of elbow region defects with radial collateral artery perforator (RCAP)-based propeller flaps. The elbow region has a variety of perforators available for perforator-based propeller flap reconstruction. Among them, the RCAP seems to be one of the most reliable options. This is because there are less anatomical variations of perforators' location on the lateral upper arm than on the medial upper arm. By using an RCAP perforator as a flap pedicle, the small-to-medium sized defects (<6?cm in diameter) around elbow regions can be closed primarily without skin grafts.     

多指背侧皮肤和指骨复合缺损的修复与功能重建

目的探讨多指外伤近端背侧皮肤和指骨复合缺损的修复方法与疗效。方法1996年6月～2005年3月收治6例多指近端背侧皮肤和指骨复合缺损患者,累及2指者3例,3指者2例,4指者1例。一期采用游离髂骨移植分别重建各指骨缺损,然后行游离皮瓣移植修复,其中采用足背皮瓣4例,上臂外侧皮瓣1例,胸外侧皮瓣1例。二期行分指术同时做皮瓣部分修薄整形,3例患者另行伸指功能重建术。结果6例患者术后获6个月～9年(平均2年8个月)随访,移植皮瓣全部成活,经二期皮瓣修薄整形后指背修复、外形美观,随访手部X线片示游离髂骨移植成活良好、具有正常指骨形态特征。3例患者肌腱移植重建指伸肌腱功能后远节指间关节仲直功能恢复。结论髂骨移植修复多指指骨缺损和游离皮瓣移植覆盖是修复多指外伤背侧皮肤和指骨复合缺损的有效方法,后期皮瓣整形能他伤指恢复美观,伸指功能重建有助于恢复远节指间关节的功能。     

Utility of the lateral arm flap in head and neck reconstruction

Soft-tissue defects of the head and neck are often reconstructed with fasciocutaneous free flaps. The radial forearm flap is used most commonly, however the lateral arm flap may be the flap of choice in certain situations. Advantages include flap elevation with simultaneous tumor ablation, avoidance of intraoperative patient position changes, and primary closure of the donor site. After extirpative procedures of the head and neck region, 4 patients were reconstructed with the lateral arm flap. Flap survival was 100%, a vein graft to supplement the short pedicle length was necessary in 1 patient, all donor sites were closed primarily, and secondary procedures to reduce flap bulk were necessary in 2 patients. The lateral arm flap is an excellent alternative to the radial forearm flap and should be included in the armamentarium of the reconstructive head and neck surgeon.     

The free lateral arm flap—a reliable option for reconstruction of the forearm and hand

Background

This retrospective study was performed to verify the advantages and disadvantages of the free lateral arm flap for defect reconstruction of the forearm and hand.

Patients and Methods

Between 2001 and 2010, 21 patients underwent defect coverage of the forearm and hand with the free lateral arm flap. The mean patient age was 48 years (17–78). The results concerning defect origin, flap size, pedicle length, operative time, revisions of the anastomoses or other complications, donor site morbidity, and length of hospital stay were evaluated.

Results

The majority of defects were caused by infections or chronic wounds. The defects were localized at the forearm in 6 cases and at the hand in 15 cases. The flap width ranged from 3 to 8 cm, and the length was from 5 to 20 cm. All flaps survived. Only in one case, a revision of the anastomosis was necessary. Primary closure of the donor site was possible in all patients. No complications occurred during the healing procedure. The majority of the patients were satisfied with the aesthetic result at the recipient site as well as at the donor site.

Conclusion

The free lateral arm flap is a very reliable option for defect coverage at the forearm and hand for small and medium size defects. A satisfactory aesthetic appearance, an excellent tissue quality, and frequent primary donor site closure are great advantages for selecting this flap.     

Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction of tumor-related scalp defects

Eleven patients underwent free-flap reconstruction of tumor-related defects of the scalp, forehead, and temporal region. Flap selection aimed at achieving acceptable functional and aesthetic results combined with negligible donor-site morbidity. Ten males and one female, aged 61.3 +/- 14.3 years, were included in this study. Eight patients presented with tumor recurrences after previous surgery, irradiation, and/or chemotherapy. The average extension of defects was 169.5 (range, 30-600) qcm. Free flaps employed for reconstruction included antero-lateral thigh flaps (8), suprafascial radial forearm flap (1), lateral arm flap (1), latissimus dorsi muscle flap (1), and myocutaneous vertical rectus abdominis flap (1). Other procedures included nerve grafts to the facial nerve (2), ectropion correction (2), and fascia lata slings for static procedure in facial palsy (2). There was no pedicle revision and no flap failure. Donor-site morbidity was negligible. Hospitalization averaged 9.2 +/- 1.7 days. The anterolateral thigh perforator flap offers excellent coverage of tumor-related defects of the scalp, which require a thin flap for adequate contouring. The customized harvested myocutaneous anterolateral thigh flap is regarded as an elegant option for covering defects which consist of both deep and superficial areas. Fascia lata and nerve grafts are available at the same donor site. This easily allows additional procedures for cosmetic and functional improvement that are of high benefit for patients.