Microsurgical reconstruction of the upper limb

2021 ◽  
pp. 385-392
Author(s):  
Alex E. Hamilton
Keyword(s):  
Soft Tissue ◽  
Upper Limb ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Bone Defects ◽  
Nerve Reconstruction ◽  
Microsurgical Reconstruction ◽  
Tissue Transfer ◽  
Toe Transfer

This chapter describes the microsurgical options for reconstruction of the hand, including replantation of amputated parts, nerve reconstruction, and free tissue transfer for reconstruction. The various free flap options for reconstruction of skin, soft tissue, and bone defects including the reconstruction of digits with toe transfer, are discussed.

Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review

2019 ◽  
Vol 36 (01) ◽  
pp. 032-040 ◽  
Author(s):  
Jacob R. Rinkinen ◽  
Shawn Diamond ◽  
Jonathan Lans ◽  
Curtis L. Cetrulo ◽  
Kyle R. Eberlin
Keyword(s):  
Systematic Review ◽  
Soft Tissue ◽  
Activities Of Daily Living ◽  
Free Flap ◽  
Daily Living ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Ulcer Formation ◽  
Soft Tissue Reconstruction ◽  
Tissue Transfer

Background Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. Methods A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. Results A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. Conclusion Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

scholarly journals Free Flap Reconstruction after Complications of Total Ankle Arthroplasty: Case Series and Review of the Literature

2018 ◽  
Vol 03 (01) ◽  
pp. e13-e20
Author(s):  
Jocelyn Lu ◽  
Tammer Elmarsafi ◽  
John Steinberg ◽  
Paul Kim ◽  
Christopher Attinger ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Free Flap ◽  
Case Series ◽  
Free Tissue Transfer ◽  
Total Ankle Arthroplasty ◽  
Anterior Tibial Artery ◽  
Ankle Arthroplasty ◽  
Tissue Transfer ◽  
Anterior Tibial

Background Postoperative complications of total ankle arthroplasty (TAA) include anterior surgical site dehiscence, hardware failure, infection, and amputation. Early intervention with free flap may provide TAA salvage. We report the largest series of failed TAA require microsurgical free tissue transfer, identify risk factors, and examine the long-term post-free flap outcomes. Materials and Methods This is a case series of consecutive patients from a single institution dedicated to limb salvage. Inclusion criteria included patients who underwent TAA with complications related to the index surgery and underwent microsurgical free tissue transfer. Nine patients were identified within the inclusion parameters. Results Patients presented with osteomyelitis 4 (44%), soft tissue infections 4 (44%), and wound dehiscence 1 (11%) following TAA. Three (33%) radial forearm free flaps and six (67%) anterolateral thigh flaps were used, with a 100% microsurgical success rate. Preoperative angiography revealed six (67%) patients with anterior tibial artery occlusion at the level of the ankle or below. Patients required an average of 2.7 ± 1 (range 1–4) operative débridements prior to free flap, with successful flap outcome and return to full weight bearing status in nine (100%) patients. The mean long-term lower extremity functional scale score was 62 out of 80 points. Conclusion Microsurgical free tissue transfer is an effective and favorable strategy to attain a stable soft tissue envelope for patients presenting with surgical site complications following TAA. We recommend early involvement with plastic surgery and endovascular angiography to evaluate the integrity of the anterior tibial artery.

scholarly journals Flap Decisions and Options in Soft Tissue Coverage of the Upper Limb

2014 ◽  
Vol 8 (1) ◽  
pp. 409-414 ◽  
Author(s):  
Michelle Griffin ◽  
Sandip Hindocha ◽  
Marco Malahias ◽  
Mohamed Saleh ◽  
Ali Juma
Keyword(s):  
Soft Tissue ◽  
Upper Limb ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Careful Consideration ◽  
Surrounding Tissue ◽  
Soft Tissue Coverage ◽  
Scapular Flap ◽  
Radial Forearm

Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.

scholarly journals Facial Nerve Reconstruction with Free Vascularized Composite Nerve Flap from Intrapetrous Portion to Terminal Branches—Case Report

2021 ◽  
Author(s):  
Pedro C. Cavadas ◽  
Magdalena Baklinska
Keyword(s):  
Case Report ◽  
Soft Tissue ◽  
Facial Nerve ◽  
Free Flap ◽  
Nerve Reconstruction ◽  
Nerve Stump ◽  
Stylomastoid Foramen ◽  
Facial Nerve Reconstruction ◽  
Delayed Reconstruction

AbstractThe case presented here is a delayed reconstruction of a facial nerve defect after radical parotidectomy without a useful nerve stump at the stylomastoid foramen. A composite free flap was used to reconnect the nerve’s intrapetrous portion to the peripheral branches and reconstruct the soft-tissue deficit.

scholarly journals Extended reverse sural artery pedicle flap: a versatile and reproducible option for coverage of ankle and foot defects

2019 ◽  
Vol 7 (3) ◽  
pp. 866
Author(s):  
Bhushan R. Patil ◽  
Chandrashekhar Wahegaonkar ◽  
Nikhil Agarkhedkar ◽  
Bharat Bhushan Dogra
Keyword(s):  
Soft Tissue ◽  
Weight Bearing ◽  
Free Tissue Transfer ◽  
Soft Tissue Defects ◽  
Pedicle Flap ◽  
Tissue Transfer ◽  
Major Vessel ◽  
Sural Artery ◽  
Tissue Defects ◽  
Ankle And Foot

Background: Coverage of soft tissue defects around distal third of the leg, particularly ankle and foot is a common situation faced by a plastic and reconstructive surgeon. Options available for such defects are limited due to scarcity of additional soft tissue that can be used without exposing tendons or bone. Associated conditions such as major vascular compromise, comorbidities and lack of facilities or expertise make free tissue transfer less preferred. Distally based sural artery flap has been a frequently used flap in such conditions, easy to perform and has reproducible results. We extended the reach of the flap and reproduced the results.Methods: We performed extended reverse sural artery pedicled flaps in 19 patients who presented to us between 2015 to 2017 with soft tissue defects around ankle and foot. Patients included 15 post RTA, 2 diabetic foot, 1 post resection defect and 1 post burn contracture release defect. Size of the defect ranged between 8x6cm to 14x10cm. Average follow up period was ranging from 8 months to 2.5 years.Results: All the flaps healed well without any obvious complications except one patient in whom marginal necrosis (2 cm margin of distal most flap) was observed and was secondarily treated with skin grafting.Conclusions: We observed that extended reverse sural pedicle flap is a rapid, reliable option for coverage of soft tissue defects around ankle and heel, sparing major vessel compromise and lengthy surgical procedure during free tissue transfer. This flap should be the first option for the patients with trauma and defects over weight bearing foot in whom peroneal axis vessels are preserved.

Free Flap Head and Neck Reconstruction with an Emphasis on Postoperative Care

2018 ◽  
Vol 34 (06) ◽  
pp. 597-604 ◽  
Author(s):  
Jacob D'Souza ◽  
Wendy King ◽  
Michael Bater ◽  
Daniel van Gijn
Keyword(s):  
Free Flap ◽  
Microvascular Complications ◽  
Free Tissue Transfer ◽  
Congenital Defects ◽  
Head And Neck Reconstruction ◽  
Functional Rehabilitation ◽  
Immediate Reconstruction ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Free Flap Monitoring

AbstractMicrosurgical free tissue transfer represents the mainstay of care in both ablative locoregional management and the simultaneous reconstruction of a defect. Advances in microsurgical techniques have helped balance the restoration of both form and function—decreasing the significant morbidity once associated with large ablative, traumatic, or congenital defects—while providing immediate reconstruction enabling early aesthetic and functional rehabilitation. There are a multitude of perioperative measures and considerations that aim to maximize the success of free tissue transfer. These include nutritional support, tight glycemic control, acknowledgment of psychological and psychiatric factors, intraoperative surgical technique, and close postoperative monitoring of the patients' hemodynamic physiology. While the success rates of free tissue transfer in experienced hands are comparable to alternative options, the consequences of flap failure are catastrophic—with the potential for significant patient morbidity, prolonged hospital stay (and associated increased financial implications), and increasingly limited options for further reconstruction. Success is entirely dependent on a continuous arterial inflow and venous outflow until neovascularization occurs. Flap failure is multifactorial and represents a dynamic process from the potentially reversible failing flap to the necrotic irreversibly failed flap—necessitating debridement, prolonged wound care, and ultimately decisions concerned with future reconstruction. The overriding goal of free flap monitoring is therefore the detection of microvascular complications prior to permanent injury occurring—identifying and intervening within that critical period between the failing flap and the failed flap—maximizing the potential for salvage. With continued technique refinement, microvascular free flap reconstruction offers patients the chance for both reliable functional and aesthetic restoration in the face of significant ablative defects. The caveat to this optimism is the requirement for considered perioperative care and the optimization of those factors that may offer the difference between success and failure.

scholarly journals Computed tomography angiographic study of internal mammary perforators and their use as recipient vessels for free tissue transfer in breast reconstruction

2017 ◽  
Vol 50 (01) ◽  
pp. 050-055
Author(s):  
Aditya V. Kanoi ◽  
Karnav B. Panchal ◽  
Saugata Sen ◽  
Gautam Biswas
Keyword(s):  
Computed Tomography ◽  
Breast Reconstruction ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Tissue Transfer ◽  
Free Flap Transfer ◽  
Internal Mammary ◽  
Multiple Variables ◽  
The Right ◽  
Artery Perforator

ABSTRACT Context: The internal mammary artery perforator vessels (IMPV) as a recipient in free flap breast reconstruction offer advantages over the more commonly used thoracodorsal vessels and the internal mammary vessels (IMV). Aims: This study was designed to assess the anatomical consistency of the IMPV and the suitability of these vessels for use as recipients in free flap breast reconstruction. Patients and Methods: Data from ten randomly selected female patients who did not have any chest wall or breast pathology but had undergone a computed tomography angiography (CTA) for unrelated diagnostic reasons from April 2013 to October 2013 were analysed. Retrospective data of seven patients who had undergone mastectomy for breast cancer and had been primarily reconstructed with a deep inferior epigastric artery perforator free flap transfer using the IMPV as recipient vessels were studied. Results: The CTA findings showed that the internal mammary perforator was consistently present in all cases bilaterally. In all cases, the dominant perforator arose from the upper four intercostal spaces (ICS) with the majority (55%) arising from the 2nd ICS. The mean distance of the perforators from the sternal border at the level of pectoralis muscle surface on the right side was 1.86 cm (range: 0.9–2.5 cm) with a mode value of 1.9 cm. On the left side, a mean of 1.77 cm (range: 1.5–2.1 cm) and a mode value of 1.7 cm were observed. Mean perforator artery diameters on the right and left sides were 2.2 mm and 2.4 mm, respectively. Conclusions: Though the internal mammary perforators are anatomically consistent, their use as recipients in free tissue transfer for breast reconstruction eventually rests on multiple variables.

Evolution of a paradigm for free tissue transfer reconstruction of lateral temporal bone defects

Head & Neck ◽  
2008 ◽  
Vol 30 (5) ◽  
pp. 589-594 ◽  
Author(s):  
Eben L. Rosenthal ◽  
Teresa King ◽  
Benjamin M. McGrew ◽  
William Carroll ◽  
J. Scott Magnuson ◽  
...  
Keyword(s):  
Temporal Bone ◽  
Free Tissue Transfer ◽  
Bone Defects ◽  
Tissue Transfer

Third Place — Resident Basic Science Award 1994: Prefabricated Microvascular Autograft in Tracheal Reconstruction

1994 ◽  
Vol 111 (4) ◽  
pp. 396-406 ◽  
Author(s):  
Jose Fayad ◽  
Daniel B. Kuriloff
Keyword(s):  
Soft Tissue ◽  
Head And Neck ◽  
Bone Morphogenetic Protein ◽  
Free Tissue Transfer ◽  
Bone Induction ◽  
Tracheal Reconstruction ◽  
Composite Grafts ◽  
Tissue Transfer ◽  
Morphogenetic Protein ◽  
Femoral Vessels

Tracheal reconstruction continues to be a challenge in head and neck surgery. Numerous techniques, Including the use of alloplasts, composite grafts, and staged laryngotracheal troughs, have met with limited success because of Implant exposure, Infection, persistent granulation tissue, and eventual restenosis. With recently introduced techniques for soft-tissue molding, bone induction with bone morphogenetic protein, and microvascular free tissue transfer, a rodent model was developed to create a well-vascularized tracheal autograft. In this model, a rigid tube having the same dimensions and flexibility as the native trachea was created by wrapping a cylindrical silicone tracheal mold with a layer of vascularized adductor thigh muscle pedicled on the femoral vessels in the groin. Tracheal rings were created by filling transverse troughs in the muscle bed with bone morphogenetic protein—primed demineralized bone matrix before wrapping around the silicone mold. Grafts harvested at 2 weeks demonstrated rigid skeletal support provided by heterotopic bone formation in the form of rings and a smooth inner lining produced by fibroplasia. Bone transformation was controlled and restricted to the muscle troughs, allowing intervening regions of soft tissue and thus producing a flexible neotrachia. With this model, a homologous, vascularized tracheal autograft capable of microvascular free tissue transfer was fabricated based on the femoral vessels. Prefabrication of composite grafts, through the use of soft-tissue molding, bone Induction, and subsequent free tissue transfer, has an unlimited potential for use in head and neck reconstruction.

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