Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocutaneous pedicle flap

This paper reports the authors' experience with latissimus dorsi island pedicle flaps in the acute treatment of massive arm injuries. Seven patients with upper arm injuries and four patients with forearm injuries were treated with latissimus dorsi pedicle flaps. All cases involved massive soft-tissue loss and open fractures. Primary healing of wounds occurred without complications in 10 of 11 patients; the eleventh developed a wound infection. There were no instances of flap loss or vascular complications. This report compares and discusses surgical management options and details the importance of robust, immediate soft-tissue coverage for optimal functional recovery. Contrary to traditional thought, delay in definitive wound closure may be unnecessary when aggressive debridement is followed by acute flap closure.     

Management of soft-tissue problems in leg trauma in conjunction with application of the Ilizarov fixator assembly

Forty-five patients presenting with high-energy open grade III tibial diaphyseal fractures were treated with the Ilizarov technique. Of these patients, 28 required plastic surgical intervention for achieving wound closure. Most of the injuries were complicated by initial neglect and inadequate primary soft-tissue coverage resulting in osteitis, sequestration, and segmental diaphyseal tibial defects, often in combination with skin-envelope deficits of various types in and around the fracture perimeter. The unique soft-tissue problems encountered while using the Ilizarov fixator have not been focused on in previous reports on the management of segmental bone defects. Four basic local flap procedures: the transposition flap, rotation flap, adipofascial turnover flap, and Z-plasty are useful and versatile for managing most types and grades of soft-tissue defects associated with a segmental bone loss with the Ilizarov technique.     

The role of local fasciocutaneous flaps in total burn wound management.

The majority of acute burn wounds or delayed reconstructions are best managed simply with a skin graft. However, if vascularized tissue is mandatory, the local fasciocutaneous flap may have an important role in providing a single-stage technique for obtaining tissue nearly identical in color, texture, and consistency to that of the defect being restored. This review of 182 consecutive burn patients needing surgery found that they underwent 233 separate episodes for skin grafting. Appropriately, only a fraction of this number required some form of vascularized flap, with 14 patients having 21 local fasciocutaneous flaps. Six were elevated in previously skin-grafted regions, which is an advantage peculiar to this flap type. Three flaps (14 percent) suffered major complications requiring a second surgical intervention. Only six of all flaps were used for acute burn wounds, but two of the three complications accrued in this subset, with one directly attributable to wound infection. Since most flaps were required for either coverage or release of contractures about joints, it has been recommended that the initial surgical approach for treatment of the acute wound in these regions be altered to preserve the fascial plexus whenever possible to permit the use of this simple and expedient alternative if it is needed later.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

Scalping injuries: new technique for stabilization of flaps to the skull

Extensive scalping injuries offer a unique challenge for tissue coverage because of the wide expanse of bone and lack of deep soft tissue or significant perforating vessels. For smaller injuries, pedicle flaps offer ideal coverage. Larger defects can be covered by omental flaps. Coverage with a free muscle flap followed by split-thickness skin grafting offers optimal long-term coverage. Two new techniques are introduced. The wire-button technique offers stabilization, and the halo frame provides good support and protection for a new free-flap graft and may increase the success rate of flaps in patients with scalping injuries.     

The effect of muscle flap transposition to the fracture site on TNFalpha levels during fracture healing

The trauma and sepsis that follow open fractures and wounds may lead to the production of various cytokines. Understanding wound healing requires a direct knowledge of the specific cytokines and the respective wound fluid levels that are present at the wound site. An animal model was designed that mimics the open fracture and the clinical repair of the human, high-energy open fracture. Canine right tibiae were fractured with a penetrating, captive-bolt device, then repaired in a standard clinical fashion using an interlocking intramedullary nail. Before primary wound closure, microdialysis probes were placed at the fracture site and in a muscle located at a contralateral site. Canines received one of the following experimental protocols: (1) tibial fracture (n = 5); (2) tibial fracture plus Staphylococcus aureus inoculation at the fracture site (n = 5); and (3) tibial fracture, S. aureus inoculation, and a rotational gastrocnemius muscle flap (n = 5). Microdialysis fluid samples were collected intermittently for 7 days. Tumor necrosis factor alpha (TNFalpha) levels at the fracture site were significantly elevated 3 to 34-fold (p<0.02), as compared with respective serum levels at all time points for all treatment groups. Fracture site TNFalpha levels were elevated (p<0.02) in days 1 through 6, as compared with the baseline and contralateral in all treatment groups. At days 1 through 6, the TNFalpha levels of the muscle flap group fracture site were significantly decreased by approximately 50 percent (p<0.05), as compared with the fractures without muscle flaps and regardless of additional S. aureus inoculation. On day 7, fracture site TNFalpha levels in all animal groups were similar, yet remained well above those of baseline TNFalpha. These results demonstrate that S. aureus does not further elevate TNFalpha levels in the presence of an open fracture and that a muscle flap reduces pro-inflammatory TNFalpha levels during early wound healing. This experimental model allows for the characterization of specific biological signals and cellular pathways that are influenced by bacterial infection and surgical closure. These data provide a scientific framework on which to judge or validate therapeutic regimens for open-fracture wound healing.     

The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity

From April of 2000 to May of 2003, 28 consecutive patients with chronic osteomyelitis of the lower extremity underwent surgical debridement and reconstruction with anterolateral thigh perforator flaps (six cases were combined with vastus lateralis muscle flaps). All wounds were open for a minimum period of 6 weeks (average, 24.7 months; range, 6 weeks to 52 months). The average patient age was 42.8 years (range, 18 to 71 years), there were 21 male and seven female patients, and the average follow-up period was 18.2 months (range, 5 to 41 months). The cause of injury was an open fracture in 10 cases, secondary wound complications after reduction in eight cases, and diabetic foot in 10 cases. The surface defects ranged from 50 to 153 cm. The wounds were debrided an average of 2.5 times and then reconstructed with flap and treated with antibiotics for 6 weeks. Antibiotic beads were used in six cases and secondary bone graft procedures were performed in seven cases 3 months after the flap coverage. All 28 flaps were successful without any signs of recurrences or persistent osteomyelitis, but partial wound dehiscence was observed during early rehabilitation in two cases suspected of delayed healing caused by diabetes. These wounds healed spontaneously. All patients achieved acceptable gait function after rehabilitation. No debulking procedure was necessary in any case. Although the muscle flap is known to provide superior vascular supply, the type of flap used for coverage seems to be less critical in the final outcome, provided that total debridement and obliteration of dead spaces are achieved. A well-vascularized anterolateral thigh perforator flap was successfully used to combat infection and bring stability to wounds with chronic osteomyelitis.     

Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction

An extensive series reviewing the benefits and drawbacks of use of the gracilis muscle in lower-extremity trauma has not previously been collected. In this series of 50 patients, the use of microvascular free transfer of the gracilis muscle for lower-extremity salvage in acute traumatic wounds and posttraumatic chronic wounds is reviewed. In addition, the wound size, injury patterns, problems, and results unique to the use of the gracilis as a donor muscle for lower-extremity reconstruction are identified. In a 7-year period from 1991 to 1998, 50 patients underwent lower-extremity reconstruction using microvascular free gracilis transfer at the University of Maryland Shock Trauma Center, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center. There were 22 patients who underwent reconstruction for coverage of acute lower-extremity traumatic soft-tissue defects associated with open fractures. The majority of patients were victims of high-energy injuries with 91 percent involving motor vehicle or motorcycle accidents, gunshot wounds, or pedestrians struck by vehicles. Ninety-one percent of the injuries were Gustilo type IIIb tibial fractures and 9 percent were Gustilo type IIIc. The mean soft-tissue defect size was 92.2 cm2. Successful limb salvage was achieved in 95 percent of patients. Twenty-eight patients with previous Gustilo type IIIb tibia-fibula fractures presented with posttraumatic chronic wounds characterized by osteomyelitis or deep soft-tissue infection. Successful free-tissue transfer was accomplished in 26 of 28 patients (93 percent). All but one of the patients in this group who underwent successful limb salvage (26 of 27, or 96 percent) are now free of infection. Use of the gracilis muscle as a free-tissue transfer has been shown to be a reliable and predictable tool in lower-extremity reconstruction, with a flap success and limb salvage rate comparable to those in other large studies.     

Salvage of functional elbow range of motion in complex open injuries using a sensate transposition lateral arm flap

Complex open posterior elbow injuries pose three principal challenges to the reconstructive surgeon. First, the surgeon must provide stable soft-tissue closure over the joint/skeletal reconstruction. Second, the coverage must be thin and supple and promote the free gliding of the underlying structures. Finally, secondary and tertiary procedures must be anticipated beneath the flap, because a stiff, scarred, and adherent flap will only compromise these procedures. The results of 10 consecutive fasciocutaneous transposition lateral arm flaps for coverage of posterior elbow wounds are reported. This flap provides coverage that is thin and supple and that allows subsequent elevation for secondary procedures. Functionally, these flaps allowed for the development of an average arc of motion of 20 to 114 degrees and an average pronation-supination motion of 119 degrees.     

The groin flap in reparative surgery of the hand

The historical literature of the use of axial vascular pattern flaps from the hypogastric and iliofemoral regions in reparative surgery of the hand is concisely reviewed. Thirty-six iliofemoral (groin) flaps were utilized for delayed primary resurfacing and secondary reconstruction of defects of the hand and forearm. Two flaps (6 percent) were complicated by partial necrosis. We caution against the immediate resurfacing (within 24 hours of injury) of acute crushed hand wounds by distant flaps. The immediate application of a healthy flap on a soiled or crushed wound invites complications of local tissue necrosis, infection, and subsequent loss of the flap. When distant flaps are indicated for coverage of acute hand wounds, delayed primary coverage following complete removal of all nonviable tissue is a safe and reliable regimen. It is advantageous to design the serviceable portion of the flap on the distal area of the vascular territory of the groin flap. Thoughtful yet "radical" defatting can be performed on the lateral portion of the groin flap territory. Constructed in this way, the long medial base of the groin flap allows freedom for movement at the wrist and metacarpophalangeal and interphalangeal joints, thus decreasing edema and stiffness. In the management of soft-tissue defects in the hand requiring distant flap coverage, we choose to utilize the conventional groin flap in preference to the microvascular free flap when both techniques will deliver equal results.     

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.     

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept.By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps).Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery.Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients.On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.     

Treatment of finger avulsion injuries with innervated arterialized venous flaps

Complete degloving injury of the digits not amenable to revascularization may leave poor cosmetic and functional results. We used innervated venous flaps from the dorsum of the foot in two patients with traumatic finger degloving injuries. All the flaps successfully provided coverage over the denuded fingers. Good sensation and nearly full rage of motion of the fingers were obtained. There were no donor-site problems. The advantages of this flap are preservation of a major artery of the donor site, easy elevation without deep dissection, and providing a thin, nonbulky tissue and good sensation. The innervated arterialized venous flap is a useful method that provides functional and cosmetic coverage to the severe avulsion injury of the finger.     

Immediate and long-term management of gunshot wounds to the lower face

The steadily increasing level of urban violence and attempted suicides in the recent past has resulted in large numbers of gunshot injuries to the face from small-caliber weapons. Our experience with 35 consecutive cases of civilian gunshot wounds involving primarily the lower face is presented. Initial management included securing of the airway, control of bleeding, and treatment of coexisting injuries. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the mandibular fractures were reduced and stabilized appropriately. Large bony defects were treated by stabilization of the mandibular segments followed by secondary bone grafting. Intraoral soft tissues were then repaired with local mucosal flaps or tongue flaps when necessary. Finally, the soft tissues were repaired by primary closure or local flaps. Distant flaps were used only as a secondary procedure. Our results are presented, the differences between civilian and military injuries are discussed, and the principles of gunshot ballistics are described. We conclude that most of these wounds can be treated in a relatively conservative manner immediately after the injury with good functional and cosmetic results.     

The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft-tissue defects

Stable wound coverage after extensive soft-tissue loss of the upper extremity remains a difficult problem in the management of large defects of the upper limb. To prevent further tissue loss owing to infection or inadequate cover when important structures such as vessels, tendons, nerves, joints, and bones are exposed, various free flaps have been introduced into the therapeutic armamentarium of acute plastic surgical management options. Emergency or delayed early reconstruction has been proposed to prevent chronic infection and further tissue loss. We report a series of 12 emergency and delayed early reconstructions of the forearm, wrist, carpus, metacarpus, and hand using the free rectus abdominis muscle flap with split-skin coverage, demonstrating the versatility of this flap within this special context. Emergency free rectus muscle flap transfer is safe, technically easy, and expandable.     

Free medial plantar perforator flaps for the resurfacing of finger and foot defects

In this article, three cases in which free medial plantar perforator flaps were successfully transferred for coverage of soft-tissue defects in the fingers and foot are described. This perforator flap has no fascial component and is nourished only by perforators of the medial plantar vessel and a cutaneous vein or with a small segment of the medial plantar vessel. The advantages of this flap are minimal donor-site morbidity, minimal damage to both the posterior tibial and medial plantar systems, no need for deep dissection, the ability to thin the flap by primary removal of excess fatty tissue, the use of a large cutaneous vein as a venous drainage system, a good color and texture match for finger pulp repair, short time for flap elevation, possible application as a flow-through flap, and a concealed donor scar.     

The expanded supraclavicular flap, prefabricated with thoracoacromial vessels, for reconstruction of postburn anterior cervical contractures

Mentosternal contractures are well-known complications after burns, scald injuries, and injuries with acid or lye. These contractures may cause severe deformities that are both functionally and aesthetically crippling. Reconstruction of the neck requires the transfer of large flaps of thin, pliable skin to optimally match the texture and color of the recipient region. With the introduction of free tissue transfer, the availability of flaps for reconstruction of large neck defects has greatly increased. Unfortunately, many of these flaps are bulky and are not well matched to the thin and pliable skin of the neck. This article introduces the expanded supraclavicular flap prefabricated with the thoracoacromial vessels for reconstruction of anterior cervical contractures. Their anatomic location, length, and arc of rotation make the thoracoacromial vessels an excellent choice for prefabricating the supraclavicular skin for its subsequent interpolation into the anterior neck. Skin expansion in the donor region not only allows coverage of the larger unit of the anterior neck but also modifies the morphologic characteristics of the transferred flap through capsule formation and fatty tissue atrophy, which is beneficial for obtaining an optimal neck reconstruction.     

The medial adiposofascial flap of the leg: anatomical basis and clinical applications

Despite recent advances in microsurgical techniques, coverage of lower leg defects by locoregional flaps remains indicated in selected cases. The interest in these types of flaps has improved because recent clinical work advocates that fascial and fasciocutaneous flaps can be well indicated for bone coverage. The anatomical study of the medial adiposofascial flap is presented in this article. The flap is based on the rich vascular network supplied by the saphenous artery and the posterior tibial artery perforators. This flap can be harvested on the anteromedial aspect of the leg and can be mobilized to cover defects located between the patella and the heel. This multiple blood supply makes it possible to harvest this flap in various ways, so various defects can be covered. To confirm and prove the versatility and clinical value of this flap, the authors have studied a series of 22 cases in which this flap was used for coverage of lower leg defects. For these defects, especially when situated in the lower third or around the heel and ankle, coverage by a free flap is most often the only proposed solution. However, the authors have obtained excellent results in the majority of these cases, avoiding a free flap procedure. Moreover, in this way, the option of using a free flap remains possible if needed. There is minimal donor-site morbidity and a high functional and aesthetic outcome, making this flap a first-choice flap in selected cases of lower leg defects.     

Free-style free flaps

Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.