Defektdeckung an der Hand mit dem freien Serratus-Faszien-Lappen

The reconstructive microsurgery ladder in orthopaedics

Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.

The free lateral arm flap-a reliable option for reconstruction of the forearm and hand

BACKGROUND

This retrospective study was performed to verify the advantages and disadvantages of the free lateral arm flap for defect reconstruction of the forearm and hand.

PATIENTS AND METHODS

Between 2001 and 2010, 21 patients underwent defect coverage of the forearm and hand with the free lateral arm flap. The mean patient age was 48 years (17-78). The results concerning defect origin, flap size, pedicle length, operative time, revisions of the anastomoses or other complications, donor site morbidity, and length of hospital stay were evaluated.

RESULTS

The majority of defects were caused by infections or chronic wounds. The defects were localized at the forearm in 6 cases and at the hand in 15 cases. The flap width ranged from 3 to 8 cm, and the length was from 5 to 20 cm. All flaps survived. Only in one case, a revision of the anastomosis was necessary. Primary closure of the donor site was possible in all patients. No complications occurred during the healing procedure. The majority of the patients were satisfied with the aesthetic result at the recipient site as well as at the donor site.

CONCLUSION

The free lateral arm flap is a very reliable option for defect coverage at the forearm and hand for small and medium size defects. A satisfactory aesthetic appearance, an excellent tissue quality, and frequent primary donor site closure are great advantages for selecting this flap.

Funktionelle und ästhetische Gesichtspunkte bei der Defektdeckung der Streckseite an Hand und distalem Unterarm mit freien Lappenplastiken

INTRODUCTION

Free coverage of exposed functional structures of the hand and distal forearm can be achieved using a variety of free flaps. However, there is a lack of data in the literature which tissue components are best used for defect coverage of this specific area regarding aspects such as tendon gliding and tissue elasticity. The purpose of this retrospective study was to compare and to evaluate the functional and aesthetical results using free cutaneous, fascial and muscle flaps.

PATIENTS AND METHODS

Between 1994 and 2002, a total of 56 patients underwent free flap coverage at the dorsal side of the hand and forearm at our institution. Of these patients, 20 with 21 free flaps met the study criteria and were available for follow-up examination. Depending on the tissue component used patients were allocated into three different groups. In group 1 eight patients received a fascial flap, in group 2 eight a cutaneous flap and in group 3 five a muscle flap. The mean follow-up was 50 months (range: 4-103 months). At follow-up examination the patients answered the Client Satisfaction Questionnaire (CSQ 8) and the DASH questionnaire.

RESULTS

Regarding range of motion of the wrist and fingers, fascial flaps clearly showed the best results. Concerning grip strength and pinch grip, fascial and cutaneous flaps demonstrated the same results. Patients with cutaneous flaps showed the best DASH score. Regarding the overall aesthetical outcome, fascial and cutaneous flaps were far better than muscle flaps. Donor site morbidity was lowest for fascial flaps followed by muscle flaps and was highest for cutaneous flaps.

CONCLUSION

Cutaneous and fascial flaps had the best functional and aesthetical results. Fascial flaps achieved the best aesthetical outcome of the donor site. We recommend free fascial flaps and cutaneous flaps as the first choice due to their advantages in the specific area of the dorsal site of the hand and distal forearm which requires pliable and thin tissue coverage.

[Burned palm reconstruction. Current concepts regarding grafting techniques, sensibility and hand function]

BACKGROUND

The purpose of this study was to evaluate the results of conservative and operative treatment for burn injuries in the palmar region of the hand. METHODS AND CLINICAL MATERIAL: One hundred ten patients from the severe burn center in Ludwigshafen, Germany were evaluated a mean of 28 months postoperatively. Sixty-one had been treated with split-thickness skin grafts (43 sheet and 18 mesh grafts). In addition to subjective evaluation (including pain assessment and aesthetic outcome rating by visual analog scale), objective outcome analysis included clinical tests, measurement of active range of motion and grip strength, and sensibility testing with the two-point discrimination and Semmes-Weinstein monofilament tests.

RESULTS

Of the patients, 90% were satisfied with the results, showing excellent pain relief with an average score under 13 on the visual analog scale. Aesthetic outcome was rated good with sheet grafts; in appearance, mesh grafts tended to be rated average or insufficient. Functional outcome tests demonstrated a significant correlation between depth of injury and range of motion. Grip strength analysis revealed superior results with sheet grafts. Sensibility in the injured areas was lower than on the contralateral hands. The Semmes-Weinstein test average was 3.4 degrees at the burned area vs 3.0 degrees in healthy hands, underscoring lower sensibility after burns.

CONCLUSION

Surgical treatment of burned palms leads to good subjective and objective results, if specialized burn units are involved. Overall sheet transplantation seems to be the better choice for surgical reconstruction of the palmar burned hand.