Superficial lateral arm flap for post-burn antecubital contractures

This paper presents a new variant of the distally based lateral arm fasciocutaneous flap that involves a straightforward and easy dissection as no specific vessel identification or inclusion is needed. Ten fresh cadavers were dissected to study the vascular supply. All three recurrent arteries-radial, ulnar, and interosseus-nourish the flap. The study also identified muscular perforators from the radial recurrent artery, piercing brachioradialis, and, in addition, septocutaneous perforators from the ulnar and interosseous recurrent arteries entering the base of the flap. Clinical application in 12 patients with upper limb burns including antecubital fossa contracture is also reported. This is a reliable and reproducible flap. The clinical dissection is straightforward and easy, with no need to identify or include a specific vessel at the base of the flap. Harvest requires neither the microscope nor loupes and can be done without a tourniquet, so it can be used in even the most modest surgical settings.

Thumb reconstruction after radical tumor resection using free osteocutaneous lateral arm flap with secondary humerus fracture-a case report

INTRODUCTION

Malignant diseases with infiltration of bony structures in the area of the phalanges or metacarpals require either amputation or complex reconstruction. The decision for reconstruction means to restore length, mobility, sensibility, stability as well as aesthetics.

METHODS

We present a case of complex first ray reconstruction of the left hand using a free osteocutaneous lateral arm flap from the ipsilateral side. The reconstruction was performed after radical resection of an exulcerated squamous cell carcinoma, including the first metacarpal bone, trapezium, partial trapezoid and distal scaphoid as well as partial resection of the extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus and flexor carpi radialis tendons. The osteosynthetic restoration was achieved distally by a double wire cerclage and a proximally by temporary K-wire suspension. Moreover, to reconstruct the extensor pollicis longus tendon the ipsilateral palmaris longus tendon was harvested and used. Postoperatively, a secondary humerus fracture occurred, which was initially attended by plate osteosynthesis. The fracture showed delayed healing, which was treated by re-plating and autologous cancellous bone.

RESULTS

12 months postoperatively, the patient showed an excellent outcome with length preservation and good range of motion, sensibility, stability and aesthetic of the thumb. Furthermore, the quarterly tumor aftercare showed no evidence of recurrence.

CONCLUSION

This case report showed that the free osteocutaneous lateral arm flap is a reliable solution for the reconstruction of the first ray with a great functional and aesthetic outcome. To prevent a secondary humerus fracture, a preventive plate osteosynthesis simultaneous with the osteocutaneous flap elevation should be considered.

Lateral arm flap: indications and techniques

The lateral arm flap (LAF) is a popular flap transfer, which can be applied in many procedures. It was first described in 1982, and till then, even more clinical applications are suggested. It can be used as a free fasciocutaneous or fascial flap to cover small- to medium-sized soft tissue defects in head and neck but also in upper and lower extremity reconstruction, or as an osteocutaneous flap when vascularized bone graft is needed. We present the indications and contraindications, the advantages and disadvantages, as well as the step-by-step technique of harvesting a fasciocutaneous and an osteocutaneous flap and its complications. We conclude that the LAF is a reliable and versatile tool for reconstructive surgery, due to its anatomical characteristics and the low complication rate.

Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction

INTRODUCTION

Tissue loss accompanied by bone defects in the thumb is a challenging reconstruction problem. Traditional repair methods are unsatisfactory.

METHODS

Microsurgical thumb reconstruction was performed using 13 thinned chimeric radial collateral artery (RCA) perforator flaps. The flap was created with a thinned skin paddle and humeral bone segments using independent perforators. Primary defatting was completed when the thickness of the perforator entry was approximately similar to that in the periphery. The posterior cutaneous nerve of the arm was carried to make a sensory flap. Defects were 8.5 × 4.5 cm(2) on average (ranging in size from 4.5 × 1.5 to 15.0 × 6.0 cm(2)), and flap size was 9.0 × 5.5 cm(2) on average (ranging in size from 5.0 × 2.0 to 16.0 × 7.0 cm(2)), whereas the humeral fragments were 2.0 × 1.0 cm(2) on average (ranging in size from 1.5 × 0.5 to 4.0 × 1.5 cm(2)). All data were expressed as mean ± SD. The cosmetic appearance of the donor and recipient sites, Kapandji opposition score and static two-point discrimination of the operated thumb were evaluated during a follow-up visit.

RESULTS

Follow-up time was 16.6 months (ranging from 14 to 28 months). Flap thickness before defatting, measured immediately after flap elevation was 14.5 mm (ranging from 10.0 to 25.0 mm). Average flap thickness after defatting was 3.5 mm (ranging from 3.0 to 6.0 mm). Venous congestion occurred in two cases. Successful microsurgical revision was achieved in both cases. All flaps survived. Bone components achieved union in all cases at an average period of 4.8 months (ranging from 3 to 6 months). Based on Kapandji opposition score, the mean thumb opposition score was 6. The mean sensation of flap was 7.5 mm (ranging from 6 to 11 mm). No further flap revision or defatting procedures were required in all cases. Cosmetically acceptable results were achieved for all patients.

CONCLUSIONS

Findings proved that thinned chimeric RCA perforator flap is a beneficial microsurgical alternative for reconstructing complex bone and soft tissue defects in thumb.

Anatomy and physiology of perforator flaps of the upper limb

Perforator flaps are an excellent reconstructive option for a functional upper limb reconstruction. This article explores the physiology and general principles of perforator flaps and their indications for use in reconstruction of the upper extremity. Workhorse perforator flaps of the upper extremity, such as the radial artery perforator, ulnar artery perforator, lateral arm perforator, posterior interosseous artery, first dorsal metacarpal artery perforator and perforator-based propeller flaps, are discussed in greater detail.