Free Tissue Transfer for Upper Extremity Reconstruction

Abstract

With the advent of the Industrial Revolution, traumatic injuries of the upper extremity increased exponentially. As a result, surgeons began to reevaluate amputation as the standard of care. Following the Second World War, local and regional pedicled flaps became common forms of traumatic upper extremity reconstruction. Today, microsurgery offers an alternative when options lower on the reconstructive ladder have been exhausted or will not produce a desirable result. In this article, the authors review the use of free tissue transfer for upper extremity reconstruction. Flaps are categorized as fasciocutaneous, muscle, and functional tissue transfers. The thin pliable nature of fasciocutaneous flaps makes them ideal for aesthetically sensitive areas, such as the hand. The radial forearm, lateral arm, scapula, parascapular, anterolateral thigh, and temporoparietal fascia flaps are highlighted in this article. Muscle flaps are utilized for their bulk and size; the latissimus dorsi flap serves as a “workhorse” free muscle flap for upper extremity reconstruction. Other muscle flaps include the rectus abdominis and serratus anterior. Lastly, functional tissue transfers are used to restore active range of motion or bony integrity to the upper extremity. The innervated gracilis can be utilized in the forearm to restore finger flexion or extension. Transfer of vascularized bone such as the fibula may be used to correct large defects of the radius or ulna. Finally, replacement of “like with like” is embodied in toe-to-thumb transfers for reconstruction of digital amputations.

Functional Forearm Reconstruction With a Latissimus Dorsi Free Flap and Tendon Transfer After Congenital Soft-Tissue Sarcoma Resection in a 29-Week-Old Girl: A Case Report

“…Unfortunately, there is still a general unjustified reticence toward the use of microsurgical techniques in infants [5,13], for whom surgeons tend to prefer less risky but mutilating procedures to ensure radical resection margins. Functional muscle transfer for restoration of upper limb flexion/extension of fingers, wrist, or elbow can be obtained by transfer of an innervated LD or gracilis [3,9]. The use of several types of LD flap is well established for reconstruction and resurfacing of soft-tissue defects in the upper extremity, including for defects after tumor extirpation.…”

Advances in microsurgery for upper and lower extremity reconstruction and limb preservation

“…Pedicled flaps are inevitably limited by restricted tissue accessibility and characteristics [48] . On the other hand, free flaps can be chosen and custom designed according to the defect [1] . Characteristics of an ideal free flap are similarity with defect area and tissue reliability to allow secondary surgeries.…”

“…The gracilis muscle has similar characteristics to the muscles of the forearm and a tendinous portion suitable for digits tendon attachment. For these reasons, gracilis flap is a very useful flap in finger function restoration with very little donor site morbidity [1] .…”

“…Nowadays, the development of both trauma care and oncological treatments increased the number of situations in which plastic surgeons are called to perform difficult limb salvage and complex, tridimensional reconstructions. Fortunately, sophistication of microsurgical techniques and improvements in the comprehension of the blood supply to tissues in different areas of the body allow the ongoing evolution of reconstructive tissue transfer [1] . This enables surgeons, not only to extend the indication for limb preservation but also to obtain better results, in terms of both aesthetic and function recovery.…”

A Retrospective Comparative Functional and Aesthetic Outcome Study of Muscle versus Cutaneous Free Flaps for Distal Upper Extremity Reconstruction

“…[5][6][7] To date, a multitude of local, distant, and free flaps to the hand, wrist, and forearm have been introduced, but clinical evidence for choosing the right flap type for optimal functional and aesthetic outcomes is scarce. 8,9 In this context, it is often hypothesized that fasciocutaneous flaps are beneficial because the transferred fascia may function as potential gliding surface for underlying tendons. [10][11][12][13][14] Muscle flaps, on the other hand, albeit stimulating fracture healing and displaying antiinfectious properties, are regarded as susceptible to developing disabling adhesions when transferred for coverage of exposed tendons.…”