The use of a free and pedicled lateral arm flap for coverage of an extensive degloving injury of the upper extremity

Classical skin free flaps are rarely used to cover large skin defects of the upper extremity because of the limited donor size. Muscle flaps with a skin graft are preferred because they provide a large amount of cover and a good blood supply. A case report is presented in which a double skin flap was used to cover a large defect (40×8 cm) extending from the lateral humeral condyle to the dorsal aspect of the hand. A free lateral arm flap from the contra–lateral arm was successfully used in conjunction with a pedicled reversed lateral arm flap from the injured limb. We suggest that skin flaps should be considered for cover of skin defects. The lateral arm flap, which is a versatile flap, offers thin, pliable and sensate skin with minimal donor site morbidity.     

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.     

上臂外侧骨皮瓣移植修复手部复合伤

目的 介绍应用游离上臂外侧骨皮瓣移植修复手部软组织并掌骨缺损的手术疗效。方法 对7例手部软组织及掌骨缺损的患者，设计带桡侧副动脉后支的肱骨下段骨皮瓣一期修复皮肤和骨缺损。结果 骨皮瓣全部存活，术后随访6～12个月，皮瓣质地优，移植骨块全部骨性愈合，手功能按手外科学会上肢功能评定标准，优6例，良1例。结论 本组骨皮瓣切取方便，血供可靠且不损伤主要血管，是修复手部软组织伴骨缺损的较好方法。     

带感觉的上臂外侧皮瓣游离移植修复手部皮肤缺损

目的游离上臂外侧穿支感觉皮瓣修复手部皮肤缺损。方法2008年7月-2010年5月．急诊或择期行同侧上臂外侧穿支感觉皮瓣修复手部皮肤缺损11例．其中单纯皮肤缺损5例．合并肌腱伤或骨折6例。皮瓣切取面积为6．5cm×4．5cm-11cm×6．5cm,皮瓣包括上臂外侧皮神经．移至受区重建皮瓣感觉。结果术后皮瓣全部成活。随访5～12个月．皮瓣外观及弹性良好,单纯皮肤缺损行皮瓣移植后手部各关节主被动活动正常者5例,合并肌腱伤或骨折行皮瓣移植后手部各关节主动活动有不同程度影响者6例。按中华医学会手外科学会断指再植功能评定标准评定：优7指,良4指。结论带感觉上臂外侧皮瓣游离移植是修复手部皮肤缺损的一种较好方法。     

游离上臂外侧皮瓣在手部皮肤缺损中的应用

目的 探讨应用游离上臂外侧皮瓣修复手部中小面积软组织缺损的方法和临床效果.方法 2007年10月-2008年4月,对14例手部皮肤缺损患者,应用游离上臂外侧皮瓣进行修复.以桡侧副血管为蒂重建皮瓣血供,以皮神经重建感觉,皮肤缺损面积为5.0 cm×4.0 cm～9.0 cm×5.5cm.血管采用端端或端侧吻合法.结果 术后皮瓣全部存活.无血管危象发生.术后随访时间为3～8个月,3例皮瓣略臃肿(2例手背皮瓣3个月后行整形手术),皮瓣外观及弹性良好,感觉恢复至S3～S4.结论 以桡侧副血管为蒂的上臂外侧皮瓣血管解剖恒定,皮肤穿支丰富,感觉重建满意,是修复手部中小面积皮肤缺损的有效方法.     

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。     

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.     

Reconstruction of soft tissue and bone defects in lower extremity with free flaps

This article reports our experiences treating soft tissue and bone defects in the lower extremity with free flaps. One of the most common causes for lower extremity wounds are high-energy injuries. These kinds of injuries contain soft tissue and bone defects beyond neurovascular complications. The rate of infection and nonunion is very high in these injuries. Between 1988 and 1996, we applied 33 flaps to 28 patients. The numbers and kinds of the free flaps are as follows: 12 latissimus dorsi, nine radial forearm, seven lateral arm, three vascularised fibula grafts with skin, one gracilis, and one medial plantar flap. Three free flaps were lost (12%). The success rate is 88%. The advantage of free flaps is that they allow the reconstruction of the large defects in one-session operations. Thus, they decrease the rate of infection and increase that of nonunion. The patient returns to his active life at an earlier stage. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:176–181 1998     

The optimum method for reconstruction of complex lateral oromandibular-cutaneous defects

BACKGROUND: Ablation of large intraoral cancers can create extensive through-and-through defects of the lateral face, resulting in loss of external facial skin, the lateral and anterior mandible, and the lateral mouth. Repair requires reconstruction of the lips, mandible, and full-thickness cheek defects. Ideal reconstruction with vascularized composite free flaps requires adequate bone and sufficiently large, yet versatile, skin flaps capable of resurfacing extensive intraoral and external defects. METHODS: A series of 12 patients with large lateral facial-mandibular defects is reviewed. All patients were treated for squamous cell carcinoma except for 1 patient with osteoblastic sarcoma of the mandible. All patients underwent primary reconstruction with various free flap techniques, including 6 scapular free flaps, 2 iliac crest free flaps, 3 free fibula flaps, and 1 radial forearm flap. Attainment of reconstructive goals, free flap survival, and complication rates were assessed. RESULTS: All defects were successfully reconstructed in the primary setting. No flap failures occurred. One venous occlusion was successfully salvaged. No orocutaneous fistulas or postoperative hematomas were noted. CONCLUSION: The reconstructive options for extensive defects of the lateral face and jaw are reviewed with attention to the complex three-dimensional soft tissue requirements. The superiority of the scapular composite flap is emphasized because this single free flap provides two independent and versatile skin paddles of optimal thickness in addition to adequate bone stock.     

游离小腿外侧腓动脉穿支皮瓣修复手前臂及足部皮肤缺损

目的介绍游离小腿外侧腓动脉穿支皮瓣修复手前臂及足部皮肤缺损的临床效果。方法以腓动脉应用解剖为基础,术前超声多普勒定位血管蒂,并以此为中心设计皮瓣。皮瓣面积：5cm×9cm-10cm×20cm。2009年10月-2012年5月,应用游离小腿外侧腓动脉穿支皮瓣修复手前臂及足部皮肤缺损17例。结果17例皮瓣及供区植皮全部成活,受区外形及功能满意,小腿功能无影响。结论游离小腿外侧腓动脉穿支皮瓣是修复手前臂及足部皮肤缺损的理想方法。     

旋股外侧动脉降支多叶组织瓣修复手部多部位软组织缺损

目的 探讨旋股外侧动脉降支多叶瓣修复手部多部位软组织缺损的手术方法和临床效果。方法对手部多部位软组织缺损15例,采用旋股外侧动脉降支多叶瓣修复,根据手部缺损情况设计股前外侧皮瓣,沿皮瓣穿支血管向远端继续解剖旋股外侧动脉降支,考虑好手部各缺损处间距,按需切取分叶穿支皮瓣、阔筋膜瓣、股直肌肌瓣、股外侧肌肌瓣、股中间肌肌瓣或旋股外侧动脉降支远端肌间隔瓣。形成以旋股外侧动脉降支为主干的一蒂多叶瓣,在肌瓣及阔筋膜瓣上植皮,一次修复手部多部位软组织缺损。 结果 术后无血管危象发生。修复各创面在肌瓣、阔筋膜瓣或旋股外侧动脉降支远端血管肌间隔上植皮均成活良好,外形无臃肿,植皮处恢复保护性感觉,供区创面愈合好,股四头肌肌力及膝关节屈、伸活动均正常。全部病例获得随访,随访时间6 ～ 20个月,平均8.7个月。按中华医学会手外科学会上肢部分功能评定标准：优3例,良9例,可3例,优良率80％。 结论 旋股外侧动脉降支多叶瓣能一次修复手部多部位软组织缺损,缩短手术时间及疗程,手部功能恢复良好,外形满意,是修复手部多部位软组织缺损的理想方法。     

Retrospective study of reverse dorsal metacarpal flap and compound flap： a review of 122 cases

SincethereversedorsalmetacarpalflapisreportedbyLUetalinChina,QuabaetalandMaruyamainBritainin1990,14thisflapanditscompoundflaphavebeenappliedtorepairsofttissuedefectson fingersuniversallyduetoitstextureandcolormatched withnormalfingers.Inordertogainbetterapplianceofthiskindo flap,weanalyzedrespectivelytheoperativeindications andtherangeofrepairingbasedonfollow upof122casesfor112years.METHODS ClinicaldataFrom1990to2003,weappliedthereversedorsa metacarpalflapanditscompoundflapin122cases,whic…     

The distally planned lateral arm flap in hand reconstruction

The lateral arm flap is a versatile free flap with straightforward dissection and low donor site morbidity. However, it presents some drawbacks: the vascular pedicle is relatively short (2-6 cm), and the flap is rather thick. Further surgery is often needed to decrease flap volume. An anastomotic network between the posterior collateral radial artery and the recurrent radial artery allows the skin paddle to be safety located over the epicondylar region and proximal forearm. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of eight consecutive distally planned lateral arm flaps used for hand reconstruction is presented. The medical records and operative notes were reviewed. Six patients were reviewed. The minimum follow-up was six months. Flap size ranged from 11 x 5.5 cm to 23 x 7 cm (average 15 x 6 cm), pedicle length ranged from 8 to 10 cm (average 9 cm), no venous grafts were needed for the microanastomosis. The mean flap harvesting time was 50 minutes. All donor sites were closed primarily. All flaps survived totally despite postoperative arterial thrombosis in one case that was salvaged by a skin graft over the surviving fascia. To date, no further surgery was needed to debulk the flaps. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self-assessment of appearance of both reconstruction and donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle than the classical lateral arm flap with no added technical difficulties.     

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.     

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.

     

Defektdeckung durch freie Lappenplastiken am Fußrücken

Background

Large complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.

Patients and methods

Evaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.

Results

On average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.

Conclusion

Free muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.     

游离肘外侧皮瓣修复手部皮肤缺损

目的 探讨以桡侧副动脉后支供血的游离肘外侧皮瓣的设计和应用技术。方法 以肱骨外上髁后缘与三角肌止点后缘连线为轴,在肘外侧部设计包含前臂后皮神经的皮瓣,以桡侧副动静脉为蒂,蒂长可达５～８ｃｍ。临床应用游离肘外侧皮瓣修复手部皮肤缺损７例。结果７例皮瓣均完全存活,效果良好,结论 肘外侧皮瓣血管蒂较长,皮瓣薄且质地佳,手术操作较方便,适合修复中等面积手部皮肤缺损。     

游离上臂外侧皮瓣在头颈肿瘤术后缺损修复的临床应用

目的 探讨以桡侧副动脉后支供血的游离上臂外侧皮瓣的设计和应用技术.方法 临床应用游离上臂外侧皮瓣修复头颈肿瘤术后缺损9例.结果 9例皮瓣均完全存活,效果良好.结论 上臂外侧皮瓣血管蒂恒定,皮瓣薄且质地佳,手术操作方便,供区隐蔽,适合修复头颈肿瘤尤其口腔术后缺损.     

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.     

Microvascular flap reconstruction of the mandible: a comparison of bone grafts and bridging plates for restoration of mandibular continuity.

OBJECTIVE: To compare the efficacy of vascularized bone grafts and bridging mandibular reconstruction plates for restoration of mandibular continuity in patients who undergo free flap reconstruction after segmental mandibulectomy.Study design and setting A total of 210 patients underwent microvascular flap reconstruction after segmental mandibulectomy. The rate of successful restoration of mandibular continuity in 151 patients with vascularized bone grafts was compared to 59 patients with soft tissue free flaps combined with bridging plates. RESULTS: Mandibular continuity was restored successfully for the duration of the follow-up period in 94% of patients who received bone grafts compared with 92% of patients with bridging mandibular reconstruction plates. This difference was not statistically significant. In patients who received bone grafts, most cases of reconstructive failure occurred during the perioperative period and were due to patient death or free flap thrombosis. In patients who received bridging plates, all instances of reconstructive failure were delayed for several months and were due to hardware extrusion or plate fracture. CONCLUSIONS: Vascularized bone-containing free flaps are preferred for reconstruction of most segmental mandibulectomy defects in patients undergoing microvascular flap reconstruction. However, use of a soft tissue flap with a bridging mandibular reconstruction plate is a reasonable alternative in patients with lateral oromandibular defects when the nature of the defect favors use of a soft tissue free flap. SIGNIFICANCE: Both bone grafts and bridging plates represent effective methods of restoring mandibular continuity following segmental mandibulectomy, with the former being the preferred technique for patients undergoing microvascular reconstruction.