Updated: 5/16/2019

Extremity Flap Reconstruction

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Introduction
  • Definition of flap 
    • unit of tissue transferred from a donor site to a recipient site while maintaining its own vascular supply
  • Definition of pedicle
    • vascular portion of the transferred tissue
    • usually contains one artery and one or more veins
  • Indications for flap coverage
    • soft tissue injury with exposed
      • bone
      • tendons
      • cartilage
      • orthopaedic implants
  • Prognosis
    • free tissue transfer within 72 hours for severe trauma in the upper extremity has been shown to decrease complication rates
Classification
  • Blood supply classification
    • axial pattern local flaps
      • contain single arteriovenous pedicle (a "named vessel")
      • indications
        • primary/secondary closure not advisable and
        • area cannot support STSG or FTSG and
        • length-width ratio needed > 2:1
    • random pattern flaps
      • supported by numerous microcirculation with no single arteriovenous pedicle
      • indications
        • primary/secondary closure not advisable andarea cannot support STSG or FTSG and
        • length-width ratio needed < 2:1
    • venous flap
      • uses veins as inflow and outflow of arterial blood
  • Tissue type classification
    • cutaneous
      • include skin and subcutaneous tissue
    • fascial flap
      • include fascia with no overlying skin
      • example
        • temporoparietal flap
    • muscle flaps
      • usually requires additional transfer of a skin graft to cover muscle
      • alternatively, muscle can be transposed as part of a musculocutaneous flap (composite flap)
      • if motor nerve is not preserved the flap will atrophy to 50% of its original size
    • bone flaps
      • free fibula
        • based on peroneal artery pedicle
        • useful for diaphyseal reconstruction
      • free iliac crest
        • based on deep circumflex iliac vessels
        • useful for metaphyseal reconstuction
    • composite flaps
      • consists of multiple tissue types
        • examples
          • radial forearm flap (fasciocutaneous)
  • Mobilization type classification
    • local flap 
      • tissue transferred from an area adjacent to defect
    • distal random pattern flap
      • transfer of tissue to a noncontiguous anatomic site
      • indications
        • surrounding tissue will not support a local flap
        • length-width ratio needed < 2:1
    • distal axial pattern flap
      • indications
        • surrounding tissue will not support a local flap
        • length-width ratio needed > 2:1
    • free tissue transfer
      • indicatoins
        • local or distant tissue not sufficient for distal axial and random pattern flaps
Techniques

Fingertips & Hand
See Finger amputation and Flaps
Arm Flaps
Lateral arm flap • Lateral arm defects
• Blood supply by
posterior radial collateral artery (branch of profunda brachii)  
Leg Muscle Flaps
Medial Gastroc flap • Used for medial and midline defects over proximal third of tibia
• Pedicle supplied by
medial sural artery
Lateral Gastroc flap • Used for lateral defects over proximal third of tibia
Soleus Used for wounds over middle third of tibia
• Supplied by b
ranches of the popliteal artery trunk, the posterior tibial artery (medial), and the peroneal artery (proximal)
Gracilis • Most common donor for free muscle transfer
• Nerve is
anterior division of obturator nerve
• Artery is branch of
medial femoral circumflex artery
Free flaps • Used for wound coverage over distal third of tibia, or in the middle and proximal leg when soleus and gastrocnemius are damaged
Groin flap • Axial flap that has been a mainstay of providing soft-tissue coverage of the upper extremity
• Based on the
superficial circumflex iliac artery
• Risk of injury to lateral femoral cutaneous nerve
Bone Flaps
Free iliac crest Based on deep circumflex iliac vessels
Useful for metaphyseal reconstruction
Free fibula • Useful for diaphyseal reconstruction
• Based on
peroneal artery pedicle
Vascular bone graft from radius Gaining popularity osteonecrosis of scaphoid fractures
Harvested from dorsal aspect of distal radius
Based on 1-2 intercompartmental superretinacular artery (branch of radial artery)
Index metacarpal transposition    Indicated to reduce the space left between the index and ring finger following middle ray amputation. An alternative technique is deep transvers intermetacarpal ligament reconstruction.  
Little metacarpal transposition  
 Indicated to reduce the space left between the middle and little finger following ring ray amputation.

Technique
  • Ladder of reconstruction
    • in order of increasing complexity
      • primary closure
      • secondary closure
        • healing by secondary intention
      • skin graft
      • local flap
      • regional flap
      • free tissue transfer
Complications
  • Flap Failure
    • inadequate arterial flow
      • treatment
        • immediate return to operating room
    • inadequate venous outflow
      • treatment
        • loosen dressings, removal of selected sutures
        • return to operating room if not relieved by above measure
  • Donor site morbidity
    • may be cosmetically unacceptable
    • pain related to grafting
    • seroma
      • treatment
        • aspiration
        • excision if encapsulated
  • Nonunion for vascularized bone transfer
    • incidence
      • may be as high as 32% if no additional bone graft is used
 

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Questions (8)
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(OBQ13.240) A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness? Review Topic

QID: 4875
FIGURES:
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1

Moberg volar advancement flap

76%

(2771/3634)

2

Foucher first dorsal metacarpal artery flap

7%

(252/3634)

3

Littler neurovascular island flap

7%

(263/3634)

4

Free great toe pulp transfer

5%

(181/3634)

5

Holevich first dorsal metacarpal artery flap

4%

(136/3634)

L 2

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(OBQ12.158) A 58-year-old man presents with right middle finger swelling. Radiographs and an MRI of his hand are shown in Figure A and B. Tissue biopsy and staging investigations are performed. The tumor is then resected en bloc with the middle metacarpal, which is amputated 1.5cm from the carpometacarpal joint. The attached deep transverse intermetacarpal ligaments are sacrificed. To prevent scissoring of the remaining digits and small objects falling through the gap between index and ring fingers, which of the following procedures should be performed? Review Topic

QID: 4518
FIGURES:
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1

iliac crest bone grafting

4%

(168/4681)

2

ring metacarpal transposition

17%

(779/4681)

3

second toe transfer

3%

(144/4681)

4

index metacarpal transposition

52%

(2445/4681)

5

suture of deep transverse intermetacarpal ligaments

23%

(1092/4681)

L 4

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(OBQ06.1) A 32-year-old male sustains a type IIIb open proximal third tibia fracture. Four days after intramedullary nailing of the tibia, the wound is clean and ready for coverage with a medial gastrocnemius rotational flap. What is the dominant arterial blood supply to this flap? Review Topic

QID: 12
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1

Superior and inferior genicular arteries

4%

(73/1817)

2

Anterior tibial artery

2%

(31/1817)

3

Posterior tibal artery

28%

(503/1817)

4

Sural artery

55%

(1006/1817)

5

Saphenous artery

11%

(192/1817)

L 4

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(OBQ05.3) The sural artery provides the vascular supply to which musculocutaneous flap? Review Topic

QID: 40
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1

soleus

18%

(183/1022)

2

gastrocnemius

64%

(654/1022)

3

latissimus dorsi

1%

(6/1022)

4

tibialis anterior

1%

(7/1022)

5

peroneus longus

16%

(166/1022)

L 3

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