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Updated: Jun 30 2021

Extremity Flap Reconstruction

Images
https://upload.orthobullets.com/topic/6059/images/key image.jpg
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https://upload.orthobullets.com/topic/6059/images/gracilis.jpg
https://upload.orthobullets.com/topic/6059/images/groin flap.jpg
  • Introduction
    • Definition of flap
      • unit of tissue transferred from a donor site to a recipient site while maintaining its own vascular supply
    • Definition of pedicle
      • vascular portion of the transferred tissue
      • usually contains one artery and one or more veins
    • Indications for flap coverage
      • soft tissue injury with exposed
        • bone
        • tendons
        • cartilage
        • orthopaedic implants
  • Classification
    • Blood supply classification
      • axial pattern local flaps
        • contain single arteriovenous pedicle (a "named vessel")
        • indications
          • primary/secondary closure not advisable and
          • area cannot support STSG or FTSG and
          • length-width ratio needed > 2:1
      • random pattern flaps
        • supported by numerous microcirculation with no single arteriovenous pedicle
        • indications
          • primary/secondary closure not advisable andarea cannot support STSG or FTSG and
          • length-width ratio needed < 2:1
      • venous flap
        • uses veins as inflow and outflow of arterial blood
    • Tissue type classification
      • cutaneous
        • include skin and subcutaneous tissue
      • fascial flap
        • include fascia with no overlying skin
        • example
          • temporoparietal flap
      • muscle flaps
        • usually requires additional transfer of a skin graft to cover muscle
        • alternatively, muscle can be transposed as part of a musculocutaneous flap (composite flap)
        • if motor nerve is not preserved the flap will atrophy to 50% of its original size
      • bone flaps
        • free fibula
          • based on peroneal artery pedicle
          • useful for diaphyseal reconstruction
        • free iliac crest
          • based on deep circumflex iliac vessels
          • useful for metaphyseal reconstuction
      • composite flaps
        • consists of multiple tissue types
          • examples
            • radial forearm flap (fasciocutaneous)
    • Mobilization type classification
      • local flap
        • tissue transferred from an area adjacent to defect
      • distal random pattern flap
        • transfer of tissue to a noncontiguous anatomic site
        • indications
          • surrounding tissue will not support a local flap
          • length-width ratio needed < 2:1
      • distal axial pattern flap
        • indications
          • surrounding tissue will not support a local flap
          • length-width ratio needed > 2:1
      • free tissue transfer
        • indicatoins
          • local or distant tissue not sufficient for distal axial and random pattern flaps
  • Techniques
      • Flap Techniques
      • Fingertips & Hand
      • See Finger amputation and Flaps
      • Arm Flaps
      • Lateral arm flap
      • Lateral arm defects
      • Blood supply by posterior radial collateral artery (branch of profunda brachii)
      • Latissimus Dorsi myocutaneous flap
      • For large defects around the elbow
      • Blood supply provided by perforators off of the thoracodorsal artery
      • Leg Muscle Flaps
      • Medial Gastroc flap
      • Used for medial and midline defects over proximal third of tibia
      • Pedicle supplied by medial sural artery
      • Lateral Gastroc flap 
      • Used for lateral defects over the proximal third of tibia
      • Pedicle supplied by lateral sural artery
      • Soleus
      • Used for wounds over the middle third of tibia
      • Supplied by branches of the popliteal artery trunk, the posterior tibial artery (medial), and the peroneal artery (proximal)
      • Gracilis
      • Most common donor for free muscle transfer
      • Nerve is anterior division of obturator nerve
      • Artery is branch of medial femoral circumflex artery
      • Free flap
      • Used for wound coverage over distal third of tibia, or in the middle and proximal leg when soleus and gastrocnemius are damaged
      • Groin flap
      • Axial flap that has been a mainstay of providing soft-tissue coverage of the upper extremity
      • Based on the superficial circumflex iliac artery
      • Risk of injury to lateral femoral cutaneous nerve
      • Bone Flaps
      • Free iliac crest
      • Based on deep circumflex iliac vessels
      • Useful for metaphyseal reconstruction
      • Useful for diaphyseal reconstruction
      • Based on peroneal artery pedicle
      • Vascular bone graft from radius
      • Gaining popularity for osteonecrosis of scaphoid fractures
      • Harvested from dorsal aspect of distal radius
      • Based on 1-2 intercompartmental superretinacular artery (branch of radial artery)
      • Index metacarpal transposition
      • Indicated to reduce the space left between the index and ring finger following middle ray amputation.
      •  An alternative technique is deep transverse intermetacarpal ligament reconstruction.
      • Little metacarpal transposition
      • Indicated to reduce the space left between the middle and little finger following ring ray amputation.
  • Technique
    • Ladder of reconstruction
      • in order of increasing complexity
        • primary closure
        • secondary closure
          • healing by secondary intention
        • skin graft
        • local flap
        • regional flap
        • free tissue transfer
  • Complications
    • Flap Failure
      • inadequate arterial flow
        • treatment
          • immediate return to operating room
      • inadequate venous outflow
        • treatment
          • loosen dressings, removal of selected sutures
          • return to operating room if not relieved by above measure
      • strongest predictor of wound infection (second is time from definitive fixation to flap coverage)
    • Donor site morbidity
      • may be cosmetically unacceptable
      • pain related to grafting
      • seroma
        • treatment
          • aspiration
          • excision if encapsulated
    • Nonunion for vascularized bone transfer
      • incidence
        • may be as high as 32% if no additional bone graft is used
  • Prognosis
    • Free tissue transfer within 7 days for severe trauma in the upper extremity has been shown to decrease complication rates
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