|Year : 2021 | Volume
| Issue : 1 | Page : 43-50
An algorithm for the reconstruction of nonfingertip upper extremity soft tissue defects
Soysal Bas, Mert Sizmaz, Alican Aydin, Selami Serhat Sirvan, Semra Karsidag
Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
|Date of Submission||13-Apr-2020|
|Date of Acceptance||28-Jun-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Soysal Bas
Sisli Hamidiye Etfal Training and Research Hospital, Halaskargazi Road, Etfal Street, 34371, Sisli
Source of Support: None, Conflict of Interest: None
Aims: The aim of this study was to evaluate the advantages and disadvantages of reconstructive methods used in the upper extremity soft tissue defects other than the fingertips, according to location. Materials and Methods: This retrospective study included 212 patients operated between January 2012 and January 2019 due to upper extremity soft tissue defects excluding the fingertip. Patients were evaluated in terms of age, gender, etiology, reconstruction area, method, and complications. Statistical Analysis Used: The relationship between the reconstructive method or location and the complication was evaluated by one-way analysis of variance test. The relationship between categorical variables was tested by Kruskal–Wallis test. The significance of multiple comparisons was adjusted using Bonferroni correction. Results: The average age of patients was 35.4 ± 19.12 years; 168 were male and 44 were female. 158 patients were operated for trauma, 34 for malignant tumor, 12 for infection, and 8 for extravasation. Complications were observed in 19 of the 220 reconstructive procedures (8.6%): two of the local flaps, three distant flaps, two regional flaps, five perforator flaps, and seven free flaps. 26% of these complications were seen in fingers, 15% in hands, 42% in wrists, 5.2% in forearms, 5.2% in elbows, and 5.5% in arms. Conclusions: There are many procedures for upper extremity reconstruction that can be selected according to defect location and character. It should be kept in mind that complex reconstructions that are preferred especially in complicated injuries may end up with challenging complications. In these types of complicated injuries, it would be better to prefer a reconstructive ladder instead of a reconstructive elevator.
Keywords: Distant flap, free flap, perforator flap, upper limb, venous flap
|How to cite this article:|
Bas S, Sizmaz M, Aydin A, Sirvan SS, Karsidag S. An algorithm for the reconstruction of nonfingertip upper extremity soft tissue defects. Turk J Plast Surg 2021;29:43-50
|How to cite this URL:|
Bas S, Sizmaz M, Aydin A, Sirvan SS, Karsidag S. An algorithm for the reconstruction of nonfingertip upper extremity soft tissue defects. Turk J Plast Surg [serial online] 2021 [cited 2021 Mar 6];29:43-50. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/43/305903
| Introduction|| |
The upper extremity plays an important role in reflexive self-defense against trauma and in independent daily motor function, especially of the hand. If the upper extremity suffers from trauma, infection, tumor excision, or burn, the restoration of critical structures such as bones, tendons, nerves, and vessels must be ensured. Functionality of the upper extremity must then be restored. Covering the site of injury or trauma with appropriate soft tissue is crucial for the improvement of motor, sensory, and aesthetic functions of the upper extremity.
One of the most important principles in reconstruction is the need for a clean wound bed. For this purpose, conventional methods, such as debridement and wound care in traumatic wounds, are used. In tumor patients, appropriate resection should be performed in such a way that a safe surgical margin is obtained through bypassing conventional methods.
In upper extremity soft tissue reconstruction, basic and simple procedures such as primary closure or secondary healing must be considered at first. Performing free flaps with reconstructive elevators might be the first choice of treatment in some selected cases. In fact, either the lower steps on the reconstructive ladder or more sophisticated procedures of reconstructive elevator may be the first choice. This preferred method is determined by defect size, location, degree of contamination, vascular exposure, nerve, joint, tendon and bone structures, functional needs, and aesthetic results. In addition, postoperative care and early rehabilitation are other factors affecting the choice of reconstruction.
The aim of this study was to evaluate the advantages and disadvantages of reconstructive methods used in the upper extremity soft tissue defects other than the fingertips, according to location. Complications of these methods were also assessed.
| Subjects and Methods|| |
This study included 212 patients who were hospitalized and operated between January 2012 and January 2019 due to soft tissue defects of the upper limb, except for the fingertip. The data were obtained retrospectively from medical digital records. Patients treated in the emergency department, patients with superficial defects that did not require surgery, and patients who underwent reconstruction with primary repair were excluded from the study. Patients were evaluated in terms of age, gender, etiology, reconstruction area, method, and complications. In posttraumatic wounds, soft tissue reconstruction was performed after tendon, bone, vein, and nerve repairs completed. After serial debridement and wound care, a clean wound bed was obtained. In patients undergoing tumor excision, reconstruction was performed after resection with safe surgical margins in all dimensions. Reconstruction options were determined according to defect location and wound character [Figure 1].
|Figure 1: Reconstructive algorithm for nonfingertip upper extremity soft tissue reconstruction. (Piap: Posterior interosseous artery perforator flap, Prcap: Posterior radial collateral artery perforator flap, Dmap: Dorsal metatarsal artery perforator flap, Ld: Latissimus dorsi muscle-skin flap, Vf: Venous flap, V: Volar, D: Dorsal, M: Medial, L: Lateral)|
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SPSS version 15.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Descriptive statistic: The number and percentage for categorical variables were given. The relationship between the reconstructive method or location and the complication was evaluated by one-way analysis of variance test. The relationship between categorical variables was tested by Kruskal–Wallis test. The significance of multiple comparisons was adjusted using Bonferroni correction. Statistical significance level was accepted as P < 0.05.
| Results|| |
The average age of the patients was 35.4 ± 19.12 years (ranging from 2 to 93 years); 168 were male and 44 were female. Of the 212 patients, 179 (84.4%) were older than 18 years of age and 33 patients (15.5%) were under 18 years.
158 patients were operated for trauma, 34 for malignant tumor, 12 for infection, and 8 for extravasation. Of the patients operated for trauma, 56 were due to occupational accidents, 51 were due to traffic accidents, 25 were due to burns, 14 were due to gunshot wounds, and 12 were due to animal bites. In bite injuries, 7 patients were bitten by dogs, 3 by snakes, and 2 by spiders. Thirteen patients were operated for squamous cell carcinoma, 9 for malignant melanoma, 7 for basal cell carcinoma, 3 for Bowen's disease, and 2 for the cutaneous T-cell tumor of the skin [Table 1].
Reconstructive methods and complications according to upper extremity regions are shown in [Table 2]. Of the reconstruction methods, 64 (30%) were skin grafts, 28 (12.7%) were local flaps, 52 (23.6%) were distant flaps [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f, 24 (10.9%) were regional flaps, 4 (1.8%) were muscle flaps, 23 (10.4%) were perforator flaps [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e and [Figure 4]a, [Figure 4]b, [Figure 4]c, [Figure 4]d,, [Figure 4]e, and 25 (11.3%) were free flaps [Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d. Injuries of the fingers accounted for 74 (33.6%) of the cases, while 50 (22.7%) were injuries of the hand, 45 (20.4%) of the wrist, 24 (10.9%) of the forearm, 9 (4%) of the elbow, and 18 (8.1%) of the arm. Complications were observed in 19 of the 220 reconstructive procedures (8.6%). Although the complication rate due to reconstructive methods was statistically significant (P < 0.001), the location was not (P < 0.779). Two of the local flaps (7.1%), three distant flaps (5.7%), two regional flaps (8.3%), five perforator flaps (21.7%), and seven free flaps (28%) had complications. Five (26%) of these complications occurred in the fingers, 3 (15%) in the hand, 8 (42%) in the wrist, 1 (5.2%) in the forearm, 1 (5.2%) in the elbow, and 1 (5.5%) in the arm.
|Figure 2: A 38-year-old male patient's left hands finger ring avulsion injury (a). Postoperative 12th day after revascularization (b and c). Reconstruction with groin flap after debridement (d). The dorsal and palmar aspect of the final reconstruction (f)|
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|Figure 3: A 58-year-old female patient with malignant melanoma in the right arm. View after excisional biopsy (a). Preoperative view of posterior radial collateral artery perforator flap (b and c). Immediate postoperative view (d). Postoperative 6th month view (e)|
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|Figure 4: A 21-year-old male patient with first web contracture after burn injury (a). Posterior interosseous artery perforator flap elevation (b). Immediate postoperative view (c). Postoperative first month (d). Postoperative 4th month (e)|
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|Figure 5: A 35-year-old male patient, left metacarpal hand image one week after crush injury (a). Preoperative planning of anterolateral thigh flaps flap (b). Postoperative 2nd week view (c). Postoperative 1st month view (d)|
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The causes of the complications in patients undergoing reconstructions with flaps are shown in [Table 3]. Eight of the patients who developed complications had flap loss. In these patients, reconstruction was completed with skin grafts.
| Discussion|| |
Fingers and hands are wrapped with a specialized soft tissue envelope consisting of skin, subcutaneous adipose tissue, and fibrous septa. This soft tissue envelope, which allows restricted mobilization in these confined spaces, limits reconstruction with local flaps. In this study, distant flaps were the most used method for the reconstruction of finger and hand region. The main advantage of distant flaps is that their size can be planned according to the desired defect size of the upper extremity. The major disadvantage is that there is a need for a two-stage operation. To provide adequate local perfusion to interpolation flap, to establish vascularity between the wound bad and flap, two-stage surgery is inevitable. Goertz et al. reported in their study that only one flap loss was seen in 85 patients who underwent inguinal flap and the rate of delayed wound healing was 22%. In this study, inguinal flap was the most commonly used flap with lowest complication rates. No flap loss was detected and only two patients had wound detachment (4.3% of 43 patients). Cross finger and reverse cross finger flaps are interpolation flaps that harvested from the neighboring fingers for small defects. Although not seen in this study, the major disadvantage is donor site morbidity.
Heterodigital artery island flaps do not have the disadvantages of interpolation flaps, but they can cover only limited size of defects. These were used for sensory reconstruction, especially in patients with pulp defects. In this method, which was used in 12 patients, meticulous dissection and postoperative cortical learning are required. Two patients had flap loss (16.6%). Teoh et al. used this flap for nonpulp finger or pulp defects in 29 patients. Although they did not detect flap loss in their study, they found flexion contracture in 8 patients. Therefore, they recommended the use of the flap when other flap options were not indicated. Dorsal metacarpal artery perforator flaps harvested from the intermetacarpal spaces and rotated on the perforator., In this study, dorsal metacarpal artery perforator flaps were used in five patients, and no complications were observed. This flap generally has low complication rates. It allows primary closure of the donor area with the cutaneous tail design, and in particular, the flap is useful for the exposed proximal interphalangeal joint defects as a salvage procedure.
The advantages of venous flaps are that they have more potential donor areas such as forearm or medial plantar regions; these regions have more tissue compliance for the hand and finger, and they are easily elevated with the use of pneumatic tourniquet. Woo et al. reported a success rate of 98.1% in 154 venous flaps for small, medium, and large defects. They also found 5.4% partial necrosis and emphasized that the necrosis area decreased as the flap size increased. In this study, five patients underwent finger reconstruction, and two patients experienced flap loss (complication rate was 40%). The largest drawback of this method is that postoperative clinical monitoring differs from conventional flap follow-up. Because venous flaps are arterialized, the distinction between arterial insufficiency and venous congestion may not be clear. Furthermore, the flap requires detailed planning of the afferent and efferent veins to ensure maximum blood retention.
The wrist contains the most complex bone and ligamentous structures in the body, with the tendon, nerve, and vascular structures just beneath the thin soft tissue envelope. In this study, in cases where graft and local flaps options could not use in wrist reconstruction, inguinal flaps, posterior interosseous artery flaps, and free flaps were preferred. Reverse radial forearm flaps were used for the reconstruction of the first web and dorsal wrist defects in two patients each, and no complications were observed. Jones et al. achieved 100% success in 57 patients with pedicle radial forearm flaps. They found partial flap loss in a patient with a history of upper extremity necrotizing fasciitis in reverse flow flap. There was no complication in antegrade flow flaps performed in elbow defects. Radial forearm flaps require sacrifice of the radial artery; thus, patients must demonstrate adequate flow through the ulnar artery with Allen's test.
The posterior interosseous artery flap is another option used for dorsal wrist and first web reconstruction. High tissue compliance, no need to sacrifice major vessels, and low donor area morbidity are advantages of this method. The difficulty of dissection, increased potential for venous congestion, and anatomical variations of the pedicle are disadvantages. In this study, 10 patients underwent reconstruction with posterior interosseous artery flap. The flap has the highest complication rates among another pedicled flaps. Two patients had flap loss due to hematoma and venous insufficiency. In one patient, the flap put back into its original place due to pedicle discontinuity in the middle part of the forearm. Sönmez et al. described venous supercharge technique in 17 patients to prevent venous insufficiency. Costa et al. reported 1% pedicle variation in their 202 cadaveric and clinical cases. They recommended to transfer the flap as free flap when there is pedicle discontinuity in the middle of the forearm.
Free flaps are often the first choice in covering important structures in complicated hand and upper extremity injuries.,, Anterolateral thigh flaps (ALT) were performed in 12 patients for hand, wrist, and forearm reconstruction, and one patient had flap loss due to venous insufficiency. The biggest disadvantage of the ALT flap in distal upper extremity reconstruction is the limitation of joint movement owing to bulkiness of the flap. For this reason, defatting operations are often required. In this study, six patients were operated for debulking of ALT flap. Seth and Iorio used super-thin and supra-facial ALT flaps in six patients for upper extremity reconstruction, eliminating the need for defatting. Superthin or suprafacial ALT reconstruction completed in one session. In the last years, profunda artery perforator flap that is elevated from the thigh area has been considered as a good alternative to the ALT flap. The most important advantages include presence of a less vascular variation compared to the ALT flap, more medially placed and less visible donor area scar, and possibility of a less hair-bearing reconstruction, especially in men. In addition, lateral cutaneous paresthesia that can be seen in a quarter of the cases after ALT flap elevation is not observed.
In this study, mostly used free flap option in wrist reconstruction was the dorsalis pedis flap. The most important advantage of this method is tissue pliability. The thickness of the flap is suitable for wrist. Dorsalis pedis flap is technically easy to harvest. Eo et al., in their series of 20 cases, successfully used dorsalis pedis flaps in complicated hand defects as composite, chimeric, or sequential flaps, including the second toe. However, donor site morbidity creates a drawback in the use of this flap. Samson et al. emphasized that other flap options should be considered before free dorsalis pedis flap. When these other options are not suitable, free dorsalis pedis flap can be used. During harvesting of the flap, paratenon of the toe extensors should be preserved by gentle dissection. Donor area should be covered by thick unmeshed split-thickness skin grafts. The surgeon must pay special attention to protect distal 2 cm of dorsum of the foot to ensure wound healing. In this study, dorsalis pedis flaps were used in six cases. As complications, one patient had venous insufficiency and two patients had wound healing problems in the flap donor areas. There was no flap loss in any patient.
In recent years, with the understanding of the perforator flap concept, many alternatives to conventional flaps have been defined. The superficial circumflex iliac artery perforator flap has advantages such as lower donor area morbidity, less vascular variation than the free groin flap, and having a longer pedicle. It also has the possibility of bone reconstruction and lymph node transfer with chimeric planning., The most important advantage of the medial sural artery perforator flap is that it has a long pedicle, a well-hidden donor area compared to the radial forearm flap and the dorsalis pedis flap, and it does not cause tendon exposure in the donor area. These flaps eliminate the need for defatting operation, especially in the distal upper extremity due to their thin structures. The most important disadvantage of these flaps is that they require microsurgery, meaning a meticulous dissection technique. The learning curves of these flaps are relatively long.
The forearm consists of subcutaneous muscle bodies in the proximal region. At the distal portion of the forearm, nerves, tendons, and vessels get more superficial. Although proximal forearm wounds can be reconstructed with a skin graft, free or distant flaps are first choice of treatment in distal wounds. ALT free flaps were used in five patients, and posterior interosseous artery flaps were preferred in two patients for the purpose of covering important structures in the distal forearm. Compartment syndrome which is most commonly seen in forearm in upper extremity occurs as a result of burn, extravasation, blunt, or penetrating trauma. The fasciotomy defects are usually reconstructed with primary closures or skin grafts.
Olecranon is situated in proximity to skin at the elbow. As olecranon is just beneath the skin, bone-exposed elbow defects are very common. High rates of bone exposition and limitation of the joint motion due to secondary contraction limit the use of skin grafts in the elbow region. Although reconstruction with pedicled latissimus dorsi muscle flaps and radial forearm flaps is frequently performed in elbow defects, they have not been used in this study., Small defects were reconstructed using rotation flaps in two cases, and the larger defects in four cases were reconstructed with thoracolumbar flap which has common disadvantages of interpolation flaps. Anyway, it has advantages such as no need for microsurgery and muscle sacrifice. Although it has been demonstrated that fasciocutaneous flaps are as successful as muscle flaps for the prevention of infection, muscle flaps are frequently used cover plates and screws for the purpose of filling dead spaces., In this study, two patients underwent successful reconstruction with a pedicled latissimus dorsi muscle skin flap to reconstruct exposed plate and screws after a traumatic humerus fracture. In addition, two patients who underwent elbow arthrodesis with plate-screws were covered with biceps brachii muscle flaps. In biceps brachii muscle flap, lateral head is rotated for the reconstruction. As arthrodesis was applied to the elbow joint, no morbidity was observed due to the rotation of the lateral head of biceps brachii muscle.
First, Brunetti et al. used the posterior radial collateral artery perforator flap as V-Y advancement flap in the upper arm defects. In this study, the flap was used as a propeller in the upper lateral region defects in seven patients. Venous insufficiency was observed in one patient, but venous insufficiency disappeared during follow-up. A radial collateral artery perforator flap can be used as local flap for elbow defects and as free chimeric flap in composite defects, including bone and soft tissue., These flaps originate from the same source vessel, but the radial collateral artery perforator flap is elevated on the distal perforators despite the posterior radial collateral artery perforator flap is elevated on the proximal perforators.
Skin grafts require appropriate wound beds and immobilization. According to this study, the most common used method among all reconstructive options was skin grafts. The major advantage of skin grafts is that it is the only option in cases where other reconstructive methods are not suitable, when flap reconstruction fails, and in patients with comorbidities. In addition, it can be the first choice in appropriate wound bed and location.
The reconstructive ladder and reconstructive elevator can be used in the upper extremity reconstruction depending on the etiology and defect location. In this study, although there was no significant difference between the complication rates according to the locations, the complication rate is higher in the upper steps of the reconstructive ladder. The need for more invasive or complex reconstruction is associated with a more complex injury or comorbidity, with a higher potential for complications. Therefore, considering complication rates, the lower steps of the reconstructive ladder, such as skin grafts or groin flaps, should be considered to make reconstruction less complicated in complicated injuries.
The main limitation of the study is its retrospective nature. The data are obtained from medical records. Furthermore, fingertip reconstructions were not included in the study. Although a new surgical technique has not been defined in the study, frequently applied reconstructive options in the upper extremity defects of different locations have been presented in an algorithmic approach.
| Conclusion|| |
There are many procedures in the upper extremity reconstruction excluding the fingertip, from skin grafts to free flaps, that were used according to defect location and character. It should be kept in mind that complex reconstructions that will be preferred especially in complicated injuries can cause complications with high morbidity. For this type of injury, it would be better to prefer a reconstructive ladder instead of a reconstructive elevator.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]