Background Single free flaps are a commonly used reconstructive method for multiple soft tissue defects in digits. We analyzed the flap size, division timing, and degree of necrosis in cases with various types of flap division.Methods We conducted a retrospective review of the medical charts of patients who had undergone single free flap reconstruction for multiple soft tissue defects across their digits from 2011 to 2020. The flap types included were the lateral arm free flap, venous forearm free flap, thenar free flap, hypothenar free flap, anterolateral thigh free flap, medial plantar free flap, and second toe pulp free flap. Flap size, anastomosed vessels, division timing, and occurrence of flap necrosis were retrospectively investigated and then analyzed using the t-test.Results In total, 75 patients were included in the analysis. The success rate of the free flaps was 97.3%. All flaps were successfully divided after at least 17 days, with a mean of 47.17 days (range, 17–243 days) for large flaps and 42.81 days (range, 20–130 days) for the medium and small flaps (P=0.596). The mean area of flap necrosis was 2.38% in the large flaps and 2.58% in the medium and small flaps (P=0.935). Severe necrosis of the divided flap developed in two patients who had undergone flap division at week 6 and week 34.Conclusions In cases where blood flow to the flap has been stable for more than 3 weeks, flap division can be safely attempted regardless of the flap size.

Background Fingertip injuries are very common; however, the reconstruction of volar pulp defects with nail bed defects is challenging in the absence of the amputated segment. We reconstructed fingertip amputations with nail bed defects using a new surgical approach: a subcutaneous flap and composite graft.Methods We treated 10 fingertip amputation patients without an amputated segment, with exposed distal phalangeal bone and full-thickness nail bed defects between February 2018 and December 2020. All patients underwent two-stage surgery: in the first stage, a subcutaneous flap was performed to cover the exposed distal phalanx, and in the second stage, a composite graft, consisting of nail bed, hyponychium, and volar pulp skin, was applied over the subcutaneous flap.Results All flaps survived and all composite grafts were successful. The wounds healed without any significant complications, including the donor site. The average follow-up duration was 11.2 months (range, 3–27 months). The new nail and the shape of the volar pulp were evaluated during follow-up. All patients were satisfied with their natural fingertip shapes and the new nails did not have any serious deformities.Conclusions A subcutaneous flap in combination with a composite graft fitting the shape of the defect could be another option for fingertip injuries without amputated segments.

In traumatic amputations in the upper extremities, replantation has been commonly attempted with high success rates. However, successful replantation implies both the maintenance of length and good functional outcomes of the restored hand. Since the thumb accounts for 40% to 50% of hand function, the utmost priority is on the salvage of the thumb. In cases when replantation is not feasible, various efforts have been made to replace the thumb, including pollicization of the index finger, toe transfer, lengthening of the thumb stump, and deepening of the first web space. Alternatively, heterotopic thumb-to-thumb replantation has been suggested as a rescue plan in rare circumstances of bilateral amputation in the upper extremities. However, even if heterotopic replantation is successful, there are situations in which a severe crushing injury to the thenar muscles of the recipient’s thumb causes opposition failure of the reconstructed thumb. We report a case of functional reconstruction of the thumb in a rare case of bilateral mangling amputations in the upper extremities, by a heterotopic thumb-to-thumb replantation combined with secondary opponensplasty to compensate for the opposition failure.

Purpose: Microsurgery in pediatric patients remains challenging because of technical difficulties in small-vessel anastomosis and flap dissection. Few reports have focused exclusively on the microsurgical reconstruction of traumatic hand defects in children. Herein, we share our experience of posttraumatic hand reconstruction with free tissue transfer in pediatric patients and compare the treatment outcomes with adults.Methods: A single-institution retrospective review of trauma-induced microsurgical hand reconstruction cases was performed. Pediatric patients below 17 years old and adults who underwent microsurgical reconstruction of traumatic hand defects between 2011 and 2021 were included. Patient demographics, flap type, use of vein grafts, operative time, flap survival, and postoperative complications were documented. A subgroup analysis of patients younger than 8 years was also performed. Data of pediatric patients were statistically compared with those of adults who underwent free flap surgery using nearly identical surgical procedures by four senior surgeons at our medical center.Results: Forty-one flaps in 39 pediatric patients and 184 flaps in 184 adult patients were analyzed. Fasciocutaneous flaps were predominantly used in both groups. In pediatric patients, all flaps survived, while 170 adults (92.4%) survived. No statistically significant between-group differences in treatment outcomes were found. However, pediatric patients (22.0%) had significantly fewer secondary operations than adults (67.4%, p<0.001).Conclusion: Microsurgical reconstruction for trauma-induced hand defects in pediatric patients has a high success rate and low complication rate, just as with adults. Pediatric patients may be more resistant to partial necrotic flap changes, thereby requiring fewer secondary operations than adults.

Purpose: This study compared the surgical outcomes and quality of life of patients who underwent fasciocutaneous and fascial anterolateral thigh (ALT) free flaps for the reconstruction of traumatic soft tissue defects in the foot.Methods: A single-institution retrospective review of medical data from 2008 to 2021 was conducted on 20 patients who underwent a fasciocutaneous ALT free flap or fascial ALT free flap in the foot. Information was collected on patients’ baseline information, preoperative characteristics, and postoperative courses. Quality of life was measured through the Foot and Ankle Disability Index (FADI) score. A questionnaire survey was administered to evaluate aesthetic satisfaction and subjective improvement of dryness and sensory function at the surgical site.Results: The mean flap dimensions were 13.96×4.58 cm and 10.75×3.50 cm in the fasciocutaneous and fascial groups, respectively. The overall flap failure and complication rates were higher in the fasciocutaneous group (total necrosis in one case, partial flap loss in two cases, and vascular complications in three cases). While aesthetic satisfaction and functional outcomes (FADI Sports) showed better outcomes in the fascial group, subjective improvement of dryness and sensory recovery showed better results in the fasciocutaneous group.Conclusion: In comparison to fasciocutaneous flaps, fascial free flaps demonstrated lower rates of wound complications, higher aesthetic satisfaction, and better functional outcomes, but less improvement in dryness and sensory recovery at the flap site. Therefore, the choice of a flap for foot reconstruction should depend on the plastic surgeon’s discretion and a thorough discussion with the patient.