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ORIGINAL ARTICLES
NUMBER 1 YEAR 2005
The use of Free Flap Transfer in Upper Extremity Reconstruction
1 Department of Psychiatry, Alba County Hospital

Correspondence to:
Department of Psychiatry, Alba County Hospital, 1-3 Unirii Street,
Tel: +40-258-811661; E-mail: obumbea@yahoo.co.uk

The authors present in this paper the problem of microsurgical reconstruction of upper limb using free flap transfer. Basing on 77 cases with large variety of defects covered with different types of free flaps, we draw useful conclusions for best fitting between the reconstructive need and the selected flap. In a very detailed discussion we try to point out the indications and contra-indications for each type of the flap, obviously according to the type of the defect. We point several important aspects regarding these problems.
INTRODUCTION

The problem of reconstruction after various types of injuries of the upper extremity is not new. Nevertheless the importance of this vast domain is still acute. Extensive trauma, chronic infections, electrical injuries and burns, tumors are the main etiological factors leading to complex and extensive defects or to functional losses. Despite the fact that a great number of local flaps help the plastic surgeon in these reconstruction challenges, free flaps enrich the armamentarium of reconstructive issues. Sometime the only solution for limb salvation is the free flap transfer. As in any domain of plastic surgery, free flaps are placed in top position of the reconstructive ladder according to the balance between the complexity of the surgery and the reconstructive needs. In this paper we attempt to treat the problem of free flap transfer in upper limb globally, relaying on our experience. In “Discussions”, we present our opinion regarding indications, flap selection and general principles, trying to establish a conduit in microsurgical free flap reconstruction of upper limb.

MATERIAL AND METHOD

The total number of the patients for this study was 77. The etiology of the defects was distributed as follows– extensive trauma with soft tissue loss – 21, bone defects combined with soft tissue defects – 6, electrical injuries - 11, chronic infections – 17, sequelae – 14, functional losses – 8.
The flaps used for reconstructions were muscular, musculocutaneous, fasciocutaneous, osteomiocutaneous. From these – latissimus dorsi free flap – 29, gracilis free flap – 8, serratus anterior free flap – 6, scapular and parascapular free flap – 12, lateral arm free flap – 14, radial forearm free flap – 3, fibula osteomiocutaneous free flap – 5.

CASE REPORTS

CASE 1
Male patient 26 y.o.
Severe sequela of the elbow with bone exposure after recent electrical injury (Fig. 1A). Latissimus dorsi free flap was used for defect coverage. (Fig. 1B) Anasthomoses were performed between toracodorsal vessels and brachial vessels in end-to-side session. Flap totally survived. (Fig. 1C) Good contour and satisfactory functional restoration after 1 year postoperatively. (Fig. 1D)
Figure 1. A
Figure 1. B

Figure 1. C
Figure 1. D

CASE 2

Male patient 45y.o.
Crush injury of the elbow with complete disruption of both vascular axes and acute ischemia of the limb. After debridement large volar defect resulted in a 7 cm defect between the vascular stumps requiring grafts for revascularization. (Fig. 2A) For combined reconstruction – of interrupted vascular axis and large defect coverage latissimus dorsi free flap was used. The anastomoses were performed between proximal stump of radial artery and toracodorsal artery, and serratus anterior branch with distal stump of the radial artery in end-to-end session. (Fig. 2B) Flap and revascularised elbow totally survived. (Fig. 2C) Complete functional recovery 5 years postoperatively. (Fig. 2D, E)
Figure 2. A
Figure 2. B

Figure 2. C
Figure 2. D

Figure 2. E

CASE 3
Male patient 47 y.o.
Chronic osteitis of the 1st web space after trauma. (Fig. 3A) Relatively large defect of the first web after debridement. (Fig. 3B) For good, stable coverage and infection control, free serratus anterior muscle flap was used. (Fig. 3C) Anastomoses performed between toracodorsal artery and radial artery end-to-side, toracodorsal vein and radial commitant vein end-to-end. The flap totally survived. No infection recurrence after 2 years postoperatively. (Fig. 3D)
Figure 3. A
Figure 3. B

Figure 3. C
Figure 3. D

CASE 4
Female patient 23 y.o.
Compartment syndrome of the elbow. After excision of devitalized musculature, large volar defect of the elbow resulted with totally lost of flexor muscles, except flexor pollicis longus. (Fig. 4A) For defect coverage and functional restoration of digital flexion free gracilis myo-cutaneous flap was used. (Fig. 4B) Microvascular anasthomoses were performed between flap vessels and radial vessels in end-to-side arterial and end-to-end venous sessions. The motor nerve of the gracilis muscle was connected to one of the motor muscular branches of the median nerve. For sensory restoration in ulnar nerve territory the distal stump of ulnar nerve was anastomosed end-to-side to median nerve. Satisfactory sensory recovery occurred after 1 year (8 mm Weber test). Satisfactory flexion of fingers was achieved 3 years postoperatively. (Figs. 4C, D)
Figure 4. A
Figure 4. B

Figure 4. C
Figure 4. D

CASE 5
Male patient 17 y.o.
Electric injury of the dorsal aspect of the thumb ray. (Fig. 5A) After debridement, large defect with first web space involvement resulted. (Fig. 5B) Free lateral arm for defect coverage was chosen. (Fig. 5C) Anastomoses of deep h are used umeral vessels of the flap were performed with radial artery and commitant vein in end-to-end session. (Fig. 5D) Flap totally survived, good and stable coverage after 6 month postoperatively. (Fig. 5E, F)
Figure 5. A
Figure 5. B

Figure 5. C
Figure 5. D

Figure 5. E
Figure 5. F

CASE 6
Male patient 38 y.o.
Crush injury of the arm with large soft tissue and humeral bone defect. In the first stage humerus was stabilized with an external Hoffman fixator and the soft tissue defect covered with a rotated latissimus dorsi myo-cutaneous flap. (Fig. 6A, B) In the second stage humeral bone defect was reconstructed with free fibula osteo-myo-cutaneous flap. (Fig. 6C, D) Microvascular anastomoses were performed between peroneal vessels and brachial vessels in end-to-side session. External fixator was replaced with screwed plate. (Fig. 6E) Functional recovery was achieved 1 year postoperatively.
Figure 6. A
Figure 6. B

Figure 6. C
Figure 6. D

Figure 6. E
Figure 6. F


RESULTS

From 107 free flaps 105 completely survived (98%). Good and stable coverage was achieved in 90% of the cases. In all cases of chronic infections durable infection control resulted with no recurrences. From 5 functional gracilis transfers, 4 were successful with more than 60% of functional recovery, one gracilis muscle survived but functional recovery was not achieved because of nature of the trauma (avulsion amputation) and elongation of the nerves. All fibula flaps survived and satisfactory osseous reconstruction was obtained.

DISCUSSIONS - FREE FLAPS IN THE UPPER EXTREMITY

The use of the free flaps in upper extremity coverage is a wide topic and has a lot of indications based upon numerous criteria. The first successful free tissue transfer to the upper extremity was reported by Harii in 1974.1 In the upper extremity the microsurgical transplantation is used for precise purposes: good and stable coverage and functional restoration.
Free flaps can provide good and stable coverage providing healthy tissue for further reconstructive procedures as tendon grafting or tendon transfer, nerve and bone grafting. The functional repair could be achieved in one stage by free flap as in flexion or extension restoration of the elbow or digits. Also, the free flaps can be used as flow-through flaps to restore vascular continuity. In those cases the procedure achieves two purposes: coverage and vessel gap bridging. This is the case of major replantations or crush injuries with damage of the arterial axes of the limb.
The indications of free flap transfer are in accordance with various general and local factors. The most important factors are the patient, the nature of the defects, the limb condition, the options for local reconstructive resources and the aesthetic appearance.
The patient candidate for microsurgical procedures must be in good health condition and seriously motivated for regaining the functional use of his upper limb and to be rapidly reinserted socially and at work. Relative contraindications include systemic disease such as end-stage diabetes mellitus, severe arteriosclerosis, chronic obstructive pulmonary disease and psychiatric disturbances. Age alone should not be a deterrent.2 Patient management corresponds to the nature of the clinical situation (acute or chronic).
The defects can be situated at any site of the upper extremity – hand, forearm and arm. The defects are small, medium and large, simple and complex. In serious trauma situations or after large tumor excision, the defects involve tendons, muscle, nerve, vessels and bone, these defects being called composite. Etiologically, the defects are from extensive trauma, crush and avulsion, electrical injury, tumor resection, chronic sequelae and soft tissue and bone infections.
The limb condition is also a very important prerequisite of the microsurgical procedures. Free tissue transfer should not be selected to cover a limb that has no potential for functional recovery. This requires a sensate hand, mobile joints and a sufficient number of tendons and muscles.3 The surgeon must assess the condition of the recipient vessels and carefully select the site of anastomosis: the radial and ulnar arteries in hand reconstruction, the brachial artery for forearm and arm arm reconstruction. The arterial anastomoses are done in an end-to-side fashion to avoid impairment of the vascular condition of an already injured limb. The recipient veins selected for the anastomoses are usually from the superficial system.4
Usually, in the upper extremity reconstruction there are many options available. The surgeon must consider the reconstructive ladder and select appropriately the indication for free flap transfer. One should consider what offers the best coverage in terms of the overall reconstruction.5 Lister has advocated considerations that may influence the choice of the free flaps: 1) general health of the patient, 2) position requirements, 3) aesthetic demands of the patient, 4) the size of the wound, 5) thickness, 6) special needs of the defect, 7) surgeon’s skill, 8) team experience.6
The wound care should follow the principles of surgical management. The debridement should be adequate and should not be limited, since any defect of the upper extremity can be covered with a free flap.4 Any dead tissue must be meticulously removed. If present under the free flap, it can lead to uncontrolled infection and failure. The skeleton must be stabilized and in case of major bony defects the segments must be debrided and aligned.
The choice of free flaps in upper extremity reconstruction is very large. Cutaneous, fascial and fasciocutaneous, muscular and musculocutaneous, osseus and osteo-cutaneous flaps are available in the surgeon’s armamentarium; some of those flaps are mentioned and are frequently used in upper limb reconstruction.
The muscular and musculocutaneous flaps are used mostly in debrided infected wounds.7 The “workhorse” for large defects is the latissimus dorsi flap. For small and medium defects, portions of latissimus or other flaps like serratus anterior and gracilis are used.
The latissimus dorsi flap (type V) is a large flap based on the subscapular-thoracodorsal system.8,9 The length of the pedicle is 10-15 cm, the diameter of the thoracodorsal vessels is 1 to 2,5 mm for the artery and 2-3 mm for the vein. It can be used as a muscular flap and also with the inclusion of a skin paddle. Its reliable perfusion and its consistence allow the coverage of extensive wounds. The deep defects can be successfully filled, since the muscular tissue is draping easily in a complex convoluted wound.6 The donor site can be closed directly. The flap can be used in combination with the scapular flap or the serratus anterior flap.10,11 This large flap covers reliably large wounds on the forearm. Many authors have used this flap for double purpose: coverage and restoration of the arterial integrity.3 Based upon the vascular architecture of the subscapular and thoracodorsal system (including the serratus branch), the “T” segment can also be used as a double end-to-end anastomosis in an atherosclerotic damaged recipient vessel.12 The harvest of the latissimus dorsi flap leaves no functional loss.
The serratus anterior flap (type III) (8), described by Takayanagi in 1982 was popularized by Brody and Buncke as the free muscle flap of choice in the coverage of small and moderate soft-tissue defects in the upper extremity. It has a long vascular pedicle up to 15 cm (the serratus branch of the thoracodorsal artery, which can be traced to the axilary vessels), large diameter vessels and the donor site has a minimal morbidity.13,14 Only the three-four inferior slips can be harvested on the thoracodorsal artery. It can be used for coverage of the dorsal hand, palm and first web space. As the latissimus dorsi flap it has the disadvantage of turning the patient for flap harvest. The long thoracic nerve must be protected during the dissection since its lesion leads to severe functional impairment (winging of the scapula).
The gracilis is a type II muscle located in the medial thigh. It has a dominant pedicle that arises from the medial circumflex femoral artery with the main length of 5-6 cm and the vessels diameter of about 2 mm.8 It can cover small and medium-sized defects but its strong indication is in the functional reconstruction of the upper extremity. The flap has a single nerve, the obturator, which can be used for a reinnervated transfer. Muscle transplantation is used when tendon transfers are no longer available. The indications are severe Volkmann ischemic paralysis, major muscle trauma with crush and avulsion, electrical injuries, long standing nerve injury and compartmental muscle excision for tumor.15 The prerequisites for successful innervated muscular transfer are: adequate passive excursion of the distal joints, intact sensation in the hand, available neurovascular structures for anastomosis, adequate distal soft-tissue coverage of the tendons repairs and lack of simpler solutions as tendon transfers.16
The most used cutaneous flap for coverage of the upper extremity is the scapular flap. Based on the circumflex scapular artery, branch of the subscapular artery, this flap has a great potential of coverage. It can be harvested on the horizontal branch of the subscapular artery as a scapular flap or on the descending branch as a parascapular flap.17,18 The groin flap is nowadays rarely used because of the short pedicle from the superficial circumflex iliac artery. Even if it has a strong indication in the composite reconstruction of the dorsum of the hand with tendons included, the dorsalis pedis is also rarely used because of the high morbidity of the donor site.
The fasciocutaneous flaps strongly used in upper extremity reconstruction are the forearm radial and the lateral arm flap.
The radial flap is the only flap that provides skin similar in texture, color and mobility for hand reconstruction.19,20 In most clinical situations it is used as a reversed flap for coverage of the hand.21,22 In some cases, according to the requirements of the defect, it can be used as a free flap, harvested from the contralateral forearm. The flap is a type C fasciocutaneous flap, based on the arterial supply of the radial artery and drained by a dual venous system (superficial and radial commitants).23 The skin paddle can be raised anywhere on the axis of the radial artery, which includes the flap. The flap can be reinnervated by means of the lateral cutaneous antebrachial nerve, can include the palmaris longus or flexor carpis radialis for tendon reconstruction and a 10 cm segment of the radius can be included with the flap for metacarpal reconstruction.24 Since the flap includes the radial artery (the axis of the flap and a constant diameter) it can be used as a flow-through flap.25 The main disadvantages of this flaps are the appearance of the donor site which must be skin grafted, the rare possibility of acute ischemia of the hand and cold intolerance, since it sacrifices a major vessel of the limb.26,27 Some authors recommend the reconstruction of the radial artery by a venous graft.21 More recent studies consider this step unnecessary, since the radial artery harvesting causes no significant damage to hand viability.28,29 The Allen test is a simple but mandatory step before flap harvest.
The lateral arm flap is harvested from the lateral distal upper arm and is based on the radial collateral artery, branch of the profunda brachii artery.30 This vessel lies in the intermuscular septum between the brachialis and the lateral head of triceps. Distal to the intermuscular septum the radial collateral artery has vascular connections with the vascular elbow network and it can be harvested distally to the elbow. The pedicle is short (5 cm) and the proximal vessel diameter is 1,5-2 mm. The flap can be reinnervated by the lateral cutaneous nerve of the arm.31 If the flap is larger than 8 cm, the donor site cannot be closed directly. Theoretically, the whole skin of the lateral arm centered on the intermuscular septum and the proximal forearm can be included in the flap. A small portion of the humerus can be included with the flap for bony reconstruction.32 The flap, like the radial flap, can be harvested only fascial, thus decreasing donor site problems.33 It can be used as a flow-through flap, since it is also a type C fasciocutaneous flap. The main advantages of this flap are the possibility of harvest from the same limb (no change of the patient’s position during the procedure) and no sacrifice of a major vessel of the limb. It is used for first web, dorsum of the hand and thumb reconstruction. It is thicker than the radial flap and donor site problems are encountered. During the dissection, the radial nerve is at risk of damage because of its close relationship to the flap pedicle.
The fasciocutaneous flaps can be raised as pure fascial flaps. The temporoparietal fascial flap and the serratus anterior fascial flaps can also be used for coverage of plane surfaces where bulk is unnecessary, as the palm or the dorsum of the hand.34-36 The unique characteristics of the fascial flaps are the rich vascularity and the thin structure. The fascia is very useful as a “gliding tissue” in areas with great tendon excursion over joints.35
The bony defects, especially gaps larger than 6 cm are filled with vascularized bone transfers. Many flaps can include bone segments. Smaller defects of the metacarpals can be covered with portions of radius, rib included in the serratus anterior flap or metatarsal included in the dorsalis pedis flap. Larger gaps of the radius, ulna and humerus are reconstructed with vascularized fibula.37-39 The fibular flap based on the peroneal vessels (large diameter, pedicle length for about 5 cm) can be harvested as bone alone, or with a cuff of soleus muscle and a skin paddle for soft-tissue coverage. A large amount of bone can be harvested up to 24-26 cm in adults. The fibula has some morbidity but the functional consequences are minimal.
Postoperative monitoring of the free flaps is part of the procedure. One should assess flap color, capillary refill, Doppler flow and other monitoring techniques more sophisticated but with similar practical significance. The operated extremity is elevated and immobilized. The mobilization of the reconstructed limb should be started as early as possible without harming the flap procedure.
The advantages of the free flaps are: flap’s own blood supply, simultaneous transfer of composite tissue and precise tailoring to the defect.40,41 The disadvantages include the need of microsurgical expertise, time consuming and the requirement of further revision procedures.

CONCLUSIONS

In conclusion we can firmly affirm that the use of free flaps in upper limb reconstruction provide a very good solution for almost any reconstructive need. Using judiciously selected patients, respecting Lister’s principles, after passing the reconstructive ladder, we can achieve good, stable results even in extremely puzzling cases. In the hands of a determined and experienced surgeon free flap transfer is a top gun in his reconstructive armamentarium.
REFERENCES

1. Harii K, Ohmori K, Ohmori S. Successful clinical transfer of ten free flaps by microvascular anastomoses. Plast Reconstr Surg 1974; 53:259.
2. Bonawitz SC, Schnarrs RH, Rosenthal AI, et al. Free tissue transfer in elderly patients. Plast Reconstr Surg 1991; 87:1074-9.
3. Grotting JC, Askren CC. Forearm coverage with free latissimus muscle flap and skin graft; In Flaps: Decision Making in Clinical Practice, editor Elliot FL – The Members of the Oneiro Travel Club, Springer-Verlag, New-York, 1997
4. Pederson WC, Oishi S. Upper extremity microsurgery. Plast Reconstr Surg 2001,107(6):1540-3.
5. Upton J, Havlik RJ, Khouri RK. Refinements in hand coverage with microvascular free flaps. Clin Plast Surg 1992;19:841.
6. Lister GD. Emergency free flaps. In: Green DP editor. Operative Hand Surgery 1988; p. 1127-49
7. Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plast Reconstr Surg 1982;70:1.
8. Mathes SJ, Nahai F. Clinical Atlas of Muscle and Musculocutaneous Flaps. St. Louis, C.V. Mosby, 1982
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10. Evans GRD, Luethke RW. A latissimus/scapula myo-osseus combined free flap based on the subscapular artery used for elbow reconstruction. Ann Plast Surg 1003;30:175.
11. Harii K, Yamanda A, Ishibara K, et al. A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomoses. Plast Reconstr Surg 1982;70:620-9.
12. Lister GD, Arnez AO. The anterior T and Y grafts. Plast Reconstr Surg 1991;88:319-22.
13. Takayanagi S, Tsukie T. Free serratus anterior muscle and myocutaneous flaps. Ann Plast Surg 1982;8:277-83.
14. Brody GA, Buncke HJ, Alpert BS, et al. Serratus anterior muscle transplantation for treatment of soft-tissue defects in the hand. J Hand Surg 1990;15:322-7.
15. Manktelow RT, McKee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg 1978;3:416.
16. Manktelow RT, Zuker RM, McKee NH. Functioning free muscle transplantation. J Surg Hand 1984;9A:32.
17. Dos Santos LF. The vascular anatomy and dissection of the free scapular flap. Plast Reconstr Surg 1982;73:59.
18. Nassif TM, Vidal L, Povet JL, et al. The parascapular flap: a new cutaneous microsurgical free flap. Plast Reconstr Surg 1982;69:591.
19. Soutar DS, Tanner NSB. The radial forearm flap in the management of sof tissue injuries of the hand. Br J Plast Surg 1984;37:18.
20. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg 1982;91:21-6.
21. Biemer E, Stock W. Total thumb reconstruction: A one stage reconstruction using an osteocutaneous forearm flap. Br J Plast Surg 1983;36:52.
22. Foucher G, Van Genechten F, Merle M, et al. A compound radial artery forearm flap in hand surgery: An original modification of the Chinese forearm flap. Br J Plast Surg 1984;37:139.
23. Cormack GC, Lamberty BGH. A classification of fasciocutaneous flaps according to their patterns of vascularization. Br J Plast Surg 1984;37:80.
24. Yajima H, Tamai S, Yamauchi T, et al. Osteocutaneous radial forearm flap for hand reconstruction. Br J Plast Surg 1988;44:217-9.
25. Brandt K, Khouri RK, Upton J. Free flaps as flow-through vascular conduits for simultaneous coverage and revascularization of the hand or digit. Plast Reconstr Surg 1996;98:321-7.
26. Jones BM, O’Brien CJ. Acute ischaemia of th hand resulting from elevation of a radial forearm flap. Br J Plast Surg 1985;38:396.
27. Braun FM, Hoang PH, Merle M, et al. Technique and indications of the forearm flap in hand surgery. A report of thirty-three cases. Ann Chir Main 1985;4:85-97.
28. Dunet E, Leyder P, Devauchelle B, et al. Neurovascular complications at the donor site of radial pedicle fasciocutaneous free forearm flaps: Preliminary study. Ann Chir Plast Esthet 1990;35:307.
29. Kleinman W, O’Connell S. Effects of the fasciocutaneous radial forearm flap on vascularity of the hand. J Hand Surg 1993;18:953-8.
30. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 1984;12:489.
31. Harpf C, Papp C, Ninkovic M, et al. The lateral arm flap: Review of 72 cases and technical refinements. J Reconstr Microsurg 14: 39, 1998
32. Arnez ZM, Kersnic M, Smith RW, et al. Free lateral arm osteocutaneous neurosensory flap for thumb reconstruction. J Hand Surg 1991;16:395.
33. Chen HC, El-Gammal TA. The lateral arm fascial free flap for resurfacing of the hand and fingers. Plast Reconstr Surg 1997;99:454.
34. Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal fascial free flap. Plast Reconstr Surg 1985;76:177.
35. Wintsch K, Helaly P. Free flap of gliding tissue. J Reconstr Microsurg 1986;2:143.
36. Antohi N, Hodarnescu G, Stingu C, et al. Use of the free serratus anterior fascia flap in the coverage of the complex palm defects. Rom J Plast Surg 2001;1(IX):321.
37. Gilbert A. Vascularized transfer of the fibular shaft. Int J Microsurg 1979;1:100.
38. Taylor GI. The free vascularized bone graft. Plast Reconstr Surg 1975;55:533.
39. Gerwin M, Weiland AJ. Vascularized bone grafts to the upper extremity: Indications and technique. Hand Clin 1992;8:509.
40. Godina M. The tailored latissimus dorsi free flap. Plast Reconstr Surg 1987;80:304-6.
41. Coleman JJ, Sultan MR. The bipedicled osteocutaneous scapula flap. A new subscapular system free flap. Plast Reconstr Surg 1991;87:682.



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