Donor sites for emergency free flaps

The flaps most commonly used in the authors' unit for reconstruction have been the lateral arm flap, groin flap, scapular flap, latissimus dorsi flap, and first web space of the foot. Many other flaps have been used, but these are the workhorses of the authors' practice. It is not possible to discuss here all the flaps that can be used in upper extremity surgery for delayed and immediate reconstruction.

A prime consideration is the size of the defect and whether it requires a fasciocutaneous, mus-culocutaneous, or composite flap. Other factors to consider in selecting the donor site for a flap include the cosmetic match of the skin adjacent to the defect, the possibility of limiting donor site morbidity to one limb, and the ability for the flap to be harvested simultaneously as the patient undergoes surgery of the traumatized area.

Lateral arm flap

The lateral arm flap offers relative thinness and generally a good skin color match with the hand.

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Fig. 10. Contour of the forearm corresponds to the contour of the upper arm. Acceptable flexion (A) and full extension (B) are demonstrated. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Dissection may be done rapidly with the patient in the supine position, and the donor site allows immobility to be confined to a single limb when repairing hand defects. Because a study at the authors' institute found that female patients were twice as likely as male patients to complain about the appearance of the donor site [19,20], the authors now restrict the use of the lateral arm flap to men. Multiple small perforators along the posterior radial collateral artery supply this type C fasciocutaneous flap with innervation from the lower lateral cutaneous nerve. On average, the vascular pedicle is 6 cm in length, although it may range from 4 to 8 cm.

A lateral arm flap was used in a 56-year-old man who sustained a crushing injury to the dorsum of his hand (Fig. 11) with a machine used on the farm to break corn and other grains. The palmar aspect of the hand was not involved, but he sustained loss of soft tissue, extensor tendons, and bone (Fig. 12). Radiography indicated loss of bone of the second and third metacarpals and fractures of the fourth and fifth metacarpals (Fig. 13). After radical debridement, the extent of the defect of the dorsal right hand can be appreciated in Fig. 14. The extensor tendons to the small finger were present. Bone fixation required bone grafting and a stabilization plate for fixation of the other metacarpals (Fig. 15). After the bones were stabilized, the wound was ready to accept a large lateral arm flap (Fig. 16), with tendon grafts passed through the flap to reconstruct the extensor

Fig. 11. Injury in the dorsal hand shows exposed tendon on the ulnar side. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 12. As the skin flap is elevated, the problem looks more complicated, with not just total damage to the skin and tendon but to part of the bone. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 11. Injury in the dorsal hand shows exposed tendon on the ulnar side. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 12. As the skin flap is elevated, the problem looks more complicated, with not just total damage to the skin and tendon but to part of the bone. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 15. Differing types of osteosynthesis were required to stabilize the bone. The index and middle fingers needed a stabilization plate. The head of the index finger also required a cerclage of wire and two Kirschner wires to maintain the reconstruction of the intermetacarpal ligaments. The ring and small finger metacarpals required a Kirschner wire and cerclage. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 13. Radiograph demonstrates total loss of the second metacarpal and fractures of the third, fourth, and fifth metacarpals. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

mechanism. Once healed, the patient could flex and extend the hand (Fig. 17), and he returned to work within 3 months.

Groin flap

The groin flap is often a more agreeable alternative to the lateral arm flap in covering medium-sized defects, particularly in women, because the donor site is less noticeable. It has been used as a pedicle flap and as a free flap. The superficial circumflex iliac artery, a branch of the

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Fig. 14. After radical debridement, the gap in the fifth metacarpal is obvious, as is the lack of an extensor tendon. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

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Fig. 14. After radical debridement, the gap in the fifth metacarpal is obvious, as is the lack of an extensor tendon. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 15. Differing types of osteosynthesis were required to stabilize the bone. The index and middle fingers needed a stabilization plate. The head of the index finger also required a cerclage of wire and two Kirschner wires to maintain the reconstruction of the intermetacarpal ligaments. The ring and small finger metacarpals required a Kirschner wire and cerclage. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

femoral artery, supplies this flap. The vessel size can be quite small; however, it may be harvested with a cuff of the femoral artery, which makes anastomosis easier (Tsu-Min Tsai, MD, personal communication, 1982). The groin flap may have to be thinned to remove excess subcutaneous tissue.

The use of this flap may be illustrated in a 19-year-old woman who was involved in a motor vehicle accident that caused severe injury to the ulnar aspect of the hand (Fig. 18). The fifth metacarpophalangeal joint was damaged, with contamination of the metacarpal head by gravel and loss of cartilage. The extensor tendons to the ring and small fingers were lost. There was intrinsic muscle damage as well as a large skin defect (Fig. 19). After radical debridement, the extent of injury is more easily appreciated: a skin defect; the loss of extensor tendons; the loss of the dorsal cortex of the third, fourth, and fifth metacarpals; and the loss of the fifth meta-carpophalangeal joint (Fig. 20). Fig. 21 shows the defect after flap coverage with tendons threaded through the subcutaneous tissue. The donor defect is acceptable, and no scar can be seen (Fig. 22). Fig. 23 shows the result after reducing the size of the flap for cosmetic reasons.

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5 Common Skin Problems Answered

5 Common Skin Problems Answered

Our skin may just feel like a mere shield that protects us from the world outside. But, the fact is, its more than just the mask that keeps your insides in. It is a very unique and remarkable complex organ that reflects our general health.

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