Free fillet flap of the hand for elbow preservation in nonreplantable forearm amputation

The use of non-replantable amputated parts for reconstruction of the stump is a well-established technique. The use of a free fillet flap of the hand and forearm for elbow preservation in massive trauma of the upper extremity is reported in two cases. These free flaps allowed for covering and preserving a functional elbow and a more useful stump.     

Composite forearm free fillet flaps to preserve stump length following traumatic amputations of the upper extremity

BACKGROUND: Replantation of traumatic upper arm amputations are usually contraindicated due to patient age, comorbid diseases, ischemia time, and/or avulsion of proximal structures. Stable soft tissue coverage preserving proximal stump length and critical joints is required to prevent loss of limb function and aid in prosthetic fitting and comfort. The use of free fillet flaps from the amputated limb is well documented for lower-extremity amputations but has only recently been reported for upper-arm amputations involving distal humeral or elbow wounds or following radical upper-arm tumor resections. Furthermore, these described free fillet flaps were fasciocutaneous rather than composite flaps. Composite free fillet flaps from the amputated upper arm utilizing the flexor muscles adjacent to the vascular pedicles is not well described or documented. METHODS: Eight upper-extremity, composite, free fillet flaps were performed to cover proximal humeral and shoulder defects secondary to upper-arm traumatic amputation from July 1995 to May 2005 on 7 males and 1 female. A retrospective chart review was completed, and information collected included the age of patient, gender, date of injury and surgery, amputation site, mechanism of injury, ischemia time, type of fillet flap, donor and recipient vessels, flap sensation, flap survival, and number of complications. RESULTS: All upper-arm amputations were trauma related (100%) and secondary to industrial accidents (4), motor vehicle and motorcycle accidents (2), fall (1), and train (1). Patient age ranged from 16 to 62 years and polytrauma was noted in 50%. Procedures included 6 composite free fillet flaps and 2 radial forearm free fillet flaps, with 4 (50%) sensate. Sensory nerves included the medial (3) and lateral (2) antebrachial cutaneous nerves attached to median proximal nerve stumps. Ischemia time ranged from 280 to 630 minutes. All flaps survived and 2 (25%) complications occurred in 1 patient. Subjective and protective sensation was observed in each neurorrhaphy; however, no confirmatory tested was used. CONCLUSION: Immediate soft tissue coverage using composite free fillet flaps from amputated limbs can be successful, with few complications, and preserves limb length while maximizing available tissue. Furthermore, including flexor muscle belly adjacent to the vascular pedicles provides additional coverage and a well-vascularized composite flap to aid in prosthetic fitting and comfort.     

Free fillet flap application to cover forequarter or traumatic amputation of an upper extremity: A case report

Reusing tissue of amputated or unsalvageable limbs to reconstruct soft tissue defects is one aspect of the “spare parts concept.” Using a free fillet flap in such situations enables the successful formation of a proximal stump with the length needed to cover a large defect from forequarter amputation without risking additional donor‐site morbidity. The use of free fillet flaps for reconstruction after forequarter and traumatic upper extremity amputations is illustrated here in a case report. A 41‐year old patient required a forequarter amputation to resect a desmoid tumor, resulting in an extensive soft‐tissue defect of the upper extremity. A free fillet flap of the amputated arm and an additional local epaulette flap were used to reconstruct the defect. At 9 months after the procedure, a satisfactory result with a very well healed flap was attained. Free fillet flaps can be used successfully for reconstruction of large upper extremity defects, without risking additional donor‐site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:700–704, 2016.     

The free fillet flap after traumatic amputation: a review of literature and case report

Severe, mutilating hand injuries present difficult reconstructive scenarios. Often in these cases, portions of the amputated tissue may be used for reconstruction of the remaining digits and hand using the spare parts principle. The free fillet flap follows the spare parts concept. A literature review of free fillet flaps for hand and forearm coverage is provided. We also present a case report of a multi-digit and dorsal hand free fillet flap for coverage of a traumatic metacarpal hand. This flap demonstrates the value of ingenuity in planning during emergent trauma reconstruction.     

Salvage of major amputation stumps of the lower extremity with latissimus dorsi free flaps

In some severe lower limb injuries, the level of bone trauma enables preservation of the knee joint or adequate length of the femoral stump only if the soft tissues can be reconstructed over the exposed bone. The options for soft-tissue reconstruction of an amputation stump are to use a flap from the amputated distal part, a local flap possibly after tissue expansion or a free flap. To preserve an adequate length of stump we reconstructed 10 stumps with latissimus dorsi free flaps: above the knee in one patient and below the knee in nine. The reconstructions were done during an acute post-traumatic phase in five and for late problems with the stump in four patients. In one patient the reconstruction was done nine weeks after a below-knee amputation for ischaemic necrosis after septicaemia. All flaps survived, but the venous anastomosis had to be revised in three patients in the early postoperative period. All patients regained adequate ambulation for their daily activities. The flap was secondarily debulked in three patients. Every effort should be made to preserve an adequate stump length, particularly in young patients with crushing injuries of the extremities and when there is severe or recurrent late stump ulceration. A latissimus dorsi musculocutaneous soft-tissue reconstruction is a reliable and durable option for stump defects.     

Salvage of major amputation stumps of the lower extremity with latissimus dorsi free flaps.

In some severe lower limb injuries, the level of bone trauma enables preservation of the knee joint or adequate length of the femoral stump only if the soft tissues can be reconstructed over the exposed bone. The options for soft-tissue reconstruction of an amputation stump are to use a flap from the amputated distal part, a local flap possibly after tissue expansion or a free flap. To preserve an adequate length of stump we reconstructed 10 stumps with latissimus dorsi free flaps: above the knee in one patient and below the knee in nine. The reconstructions were done during an acute post-traumatic phase in five and for late problems with the stump in four patients. In one patient the reconstruction was done nine weeks after a below-knee amputation for ischaemic necrosis after septicaemia. All flaps survived, but the venous anastomosis had to be revised in three patients in the early postoperative period. All patients regained adequate ambulation for their daily activities. The flap was secondarily debulked in three patients. Every effort should be made to preserve an adequate stump length, particularly in young patients with crushing injuries of the extremities and when there is severe or recurrent late stump ulceration. A latissimus dorsi musculocutaneous soft-tissue reconstruction is a reliable and durable option for stump defects.     

Die Filetlappenplastik zur Rekonstruktion ausgedehnter Defekte der oberen Extremität einschließlich Schulterregion

Extensive soft tissue defects of the upper extremities were reconstructed with major fillet flaps in nine patients over a 5-year period at two institutions. Etiologies included trauma and tumor resection. Defect locations were the shoulder ( n=3), combined defects of the shoulder plus neck, arm or chest wall ( n=4) as well as one upper arm and one forearm defect. Seven of nine flaps required microsurgical free tissue transfer. Fillet flaps harvested from amputated parts represent the "spare part" concept, providing coverage of defects without additional donor site morbidity. Unlike the classic "spare part" fillet flap concept, the partial or complete conversion of an anatomically intact arm was performed for the coverage of large defects, especially for tumor reconstruction, in this series. Fillets flaps facilitate reconstruction in difficult and complex cases. Major fillet flaps represent a valuable option for reconstruction in the upper extremities with either pedicled or free tissue transfers involving extensive tissue defects.     

Double flap from amputated opposite lower limb for cover of plantar and dorsal surfaces of a crushed foot

Bilateral limb trauma poses many possibilities for management. In a situation of bilateral amputation, if the amputated limb is not salvageable or replantation is not advisable, the amputated limb can be used to harvest tissue for free tissue transfer to cover the amputation stump. We describe a case here in which we have used these principles.KEY WORDS: Double free flap, free tissue transfer, microsurgery, non-replantable amputation, spare parts surgery     

Microsurgical free flap transfer to amputation sites: indications and results

A series of microsurgical free flap reconstructions to amputation stumps of the upper as well as the lower extremities was reviewed in 7 male and 2 female patients. Indications included preservation of length after trauma in 6 patients and cure of local infection in 2 patients. In 1 patient an extensive defect after resection of a recurrent shoulder sarcoma required use of a complete arm fillet free flap for tumor reconstruction. Microvascular free flaps used included four scapular flaps, two fillet flaps from the amputated extremity, one anterolateral thigh flap, and one lateral arm flap. Seven of 9 patients were fitted with a prosthesis and underwent occupational therapy resulting in ambulatory and improved functional status. Microvascular reconstruction is indicated in emergency settings as well as for elective reconstruction of amputation sites. Using uninjured "spare parts" of the amputated extremity should be considered. Elective reconstruction is performed preferably with free flaps based on the subscapular vascular system.     

Amputation stump salvage using a "banked" free-tissue transfer.

A free radical forearm flap was salvaged from a nonreplantable amputated extremity and banked on the ipsilateral chest wall. Later, the flap was simply rotated to provide coverage of the proximal humeral stump, eliminating the need for a second microvascular procedure.     

Circumferential forearm fasciocutaneous free flap reconstruction of forequarter amputation/chest wall resection using simultaneous extra-anatomic revascularization (SEAR)

Background: This report describes a technique in which temporary extra-anatomic revascularization of an amputated part was used to preserve a free flap while tumor resection and chest wall reconstruction were performed. Methods: A patient with multiple local recurrences of basosquamous carcinoma of the shoulder underwent forequarter amputation with en bloc resection of the upper chest wall. During the resection, an elbow disarticulation of the amputated limb was performed. The vascular pedicle of the amputated forearm was joined to the dorsalis pedis vessels of the foot. Following completion of tumor resection and chest wall reconstruction, the forearm was disconnected from the foot and re-anastomosed to thoracic vessels, and a circumferential fasciocutaneous free flap was then harvested and inset. Results: No ischemic flap complications occurred, and the patient recovered well. Ample time was afforded for complete tumor resection with negative margins and prosthetic reconstruction of the chest wall. Conclusions: The technique of temporary, simultaneous extra-anatomic revascularization of an amputated part for later free flap harvest may be helpful in avoiding potentially long flap ischemia times in selected complex oncologic resections. Presented at the Cine Clinic, 50th Annual Cancer Symposium, Society of Surgical Oncology, March 21, 1997, Chicago, Illinois. The opinions expressed in this article are those of the authors alone, and are not the opinions of the United States Air Force or the Department of Defense.     

Comparative Evaluation in Pharyngo-oesophageal Reconstruction: Radial Forearm Flap compared with Jejunal Flap. A 10-year experience

We reviewed 109 consecutive patients with cancer of the hypopharynx or cervical oesophagus who underwent free flap transfer for immediate reconstruction after total pharyngolaryngo-oesophag-ectomy. The free flaps used were either free jejunal (n = 70) or radial forearm flaps (n = 39). Significantly more fistulas (3/70 compared with 15/39, p < 0.0001) and strictures (6/64 compared with 13/33, p = 0.0008) developed in the radial forearm than the jejunal flap group. However, functional donor site morbidity was minimal and there were no cases of total flap necrosis in the forearm flap group. We consider that the free jejunal flap should be the first choice for total reconstruction of pharyngo-oesophageal defects. However, the forearm flap is suitable for elderly, high risk patients, because it is less invasive and has minimal donor site morbidity, which facilitates early recovery.     

Indications and outcomes of double free flaps in head and neck reconstruction

Objective. This study describes the clinical setting and operative outcomes for simultaneous double free flap treatment of extensive composite head and neck cancers. Methods. A retrospective review at two tertiary referral centers was performed. Patient demographics, cancer characteristics, reconstruction methods, and postoperative course were recorded. All patients were assessed for diet, speech, esthetics, socialization, and satisfaction using specific evaluation scales. Results. A total of 30 patients underwent double free flap reconstruction between 2001 and 2007. There were 19 men and 11 women, mean age of 62 years (range, 42–79). Comorbidities were present in 67% of the cases and 70% smoked. Most frequently the cancer was a squamous cell carcinoma (90%), in advanced stage (87%), and recurrent (67%), affecting the oral cavity (43%), larynx (23%) or pharynx (20%). The fibula osteoseptocutaneous/radial forearm fasciocutaneous flap combination was most commonly used (n = 13), followed by the jejunum‐radial forearm flap (n = 10). Three flaps required early anastomosis revision and only two partial flap losses were observed. In 11 cases, there was a severe recipient site complication: wound dehiscence (n = 3), oral incompetence (n = 4), fistula (n = 2), and stenosis (n = 2). Two patients died in the postoperative period due to medical problems (7%). The mean follow up was 15.3 months. Patient satisfaction was poor to moderate and the overall functional evaluation score was low. Conclusions. Double free flaps for one‐stage reconstruction of extensive head and neck defects should be used in selected cases. Although a reliable procedure, immediate postoperative morbidity and mortality is high, and the long‐term functional and esthetic results are modest. Realistic outcomes should be discussed with patients during planning and consent. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

Reconstruction of a massive lower limb soft-tissue defect by giant free DIEAP flap

Treatment of high-velocity trauma of the lower limb is often challenging in its nature, especially when dealing with extensive soft-tissue loss, underlying bone fractures and vascular lesions. The main goal in this surgery is the preservation of a functional and sensitive limb, or maximal functional length of the stump when dealing with limb amputations. We present a case report of a reconstruction of a complex massive soft-tissue defect of a lower limb by a giant free deep inferior epigastric artery perforator (DIEAP) flap. Classification and treatment options for massive lower limb defects are discussed. The free DIEAP flap is another valuable option for massive soft-tissue lower limb reconstructions and limb salvage procedures. It provides massive amounts of soft tissue with minimal donor-site morbidity, which is easily amenable for secondary corrections.     

Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo‐radiotherapy. Forty‐two free flaps were used in these patients. The predominant combination was that of free fibula osteo‐cutaneous flap with free anterolateral thigh (ALT) fascio‐cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro‐mandibular bone and soft tissue defects (n = 13), (b) large oro‐mandibular soft tissue defects (n = 4), (c) complex skull‐base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow‐up period was 11 months. Twelve patients were alive and free of disease at the end of the follow‐up. Eighteen of 19 patients with oro‐mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro‐mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Reconstruction of large head and neck deformities: Experience with free gracilis muscle and myocutaneous flaps

Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. The authors describe their experience with the gracilis free flap and the myocutaneous gracilis free flap with reconstruction of head and neck defects. Eleven patients underwent 12 free tissue transfer to the head and neck region. The reconstruction was performed with the transverse myocutaneous gracilis (TMG) flap (n = 7) and the gracilis muscle flap with skin graft (n = 5). The average patient age was 63.4 years (range, 17–82 years). The indications for this procedure were tumor and haemangioma resections. The average patient follow‐up was 20.7 months (range, 1 month–5.7 years). Total flap survival was 100%. There were no partial flap losses. Primary wound healing occurred in all cases. Recipient site morbidities included one hematoma. In our experience for reconstruction of moderate volume and surface area defects, muscle flaps with skin graft provide a better color match and skin texture relative to myocutaneous or fasciocutaneous flaps. The gracilis muscle free flap is not widely used for head and neck reconstruction but has the potential to give good results. As a filling substance for large cavities, the transverse myocutaneus gracilis flap has many advantages including reliable vascular anatomy, relatively great plasticity and a concealed donor area. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

An anterior‐lateral thigh perforator flap on a recipient brachial‐radial vein graft for complex wound reconstruction: A case report

A case of challenging microsurgical reconstruction of a difficult defect in a radiated upper limb is reported. A difficult wound, with tendon and bone exposition, developed on the dorsum of the forearm in a 76‐year‐old patient; she had been radiated since almost 50 years and her left hand had also been revascularized twice with venous grafts between the humeral artery and the superficial palmar arch. After failure of a local flap, an anterior‐lateral thigh perforator flap was successfully transferred with end‐to‐side anastomoses on the arterialized venous graft. Up to date follow‐up shows a good outcome. The Authors discuss the case and review the indications for microsurgical reconstruction in difficult wounds after radiation and ischemic limb conditions. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Salvage of amputated thumbs by temporary ectopic implantation

Purpose: To determine the indications and benefits of ectopic implantation in the salvage of amputated thumb. Basic procedures: Two cases of avulsed amputated thumbs were temporarily ectopically implanted onto the forearm and foot, with microvascular anastomoses. When the stump condition allowed, and the soft‐tissue defects were repaired, the ectopic implanted thumbs were replanted to their anatomic positions. Results: Both thumbs survived the temporary ectopic implantation and second‐stage replantation. The length of the thumbs was maintained, and the thumbs regained their function in 16‐ and 10‐week follow‐ups. Conclusions: Temporary ectopic implantation of amputated parts provides an innovative procedure for the salvage of amputated thumbs under special circumstances. Although this procedure is very demanding, it does deserve special consideration in reconstructive microsurgery, since it offers the possibility to salvage amputated thumbs with extensive soft tissue loss of the hand, by preserving the anatomy and restoring the function of severely injured hands. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.     

Latissimus dorsi musculocutaneous free flap transplantation to salvage below-elbow amputation in an emergency operation: A case report

We used a free latissimus dorsi musculocutaneous flap (LD m-c flap) to cover a large skin defect at the stump of a forearm in an emergency operation. The patient we discuss is a 52-year-old man. Amputation at the distal one third of the left forearm occurred after catching his hand and wrist in a machine. The amputated left hand was severely damaged and there were wide skin defects. The function of the elbow joint was well preserved. Both the radius and ulna were cut 7 cm distal from the elbow joint. A 20 × 8 cm square of LD m-c flap was transplanted to the stump of the forearm. The flap survived without incident. The range of motion of the elbow joint was from 20° to 85°. The prosthesis was well fitted to the stump, and the patient returned to his workshop 9 months after injury. © 1996 Wiley-Liss, Inc.