Composite Tissue Loss Research Articles

Microvascular soft tissue reconstruction of the digits

Composite tissue loss to digits following trauma may require flap coverage. Local reconstruction techniques are popular but can result in a functional limitation at the donor site. Small free flaps though complex, may provide a superior alternative. We retrospectively reviewed the case-notes of all patients who had a small free flap to a digit following trauma. The time period was 4 years (2000-2004). Sixteen patients with 18 digital free flaps were identified. These comprised of 10 venous flow-through flaps, one lateral arm flap, one great toe to thumb pulp transfer, three first web space flaps from the foot, one medial plantar flap and two free posterior interosseous flaps. All 16 patients were invited for clinical review at an out-patients clinic. Ten patients (11 flaps) attended follow-up. Standardised assessment of outcome in terms of scar quality at both the recipient and donor sites, sensibility, range of motion and function of the hand was completed. Overall the average follow-up period was 14 months, with 16 out of 18 flaps surviving. Of the patients that attended for clinical review, the majority recovered excellent function of the hand (quick-DASH--av. 5.7) with satisfactory aesthetics, minimal pain or limitations in range of motion. The flaps were all soft and durable. Ten flaps recovered protective but not discriminative sensation (only one flap was innervated). The three patients whose donor site was the first-web space of the foot developed significant hypertrophic scarring. Small free flaps provide an acceptable method of reconstructing digital defects. Venous flow-through flaps provided the best overall results in this series. The donor site for first-web space flaps is probably unacceptable.

Use of the Eponychial Flap to Restore the Length of a Short Nail: A Review of 30 Cases

Distal digital amputations may result in composite tissue loss, affecting both the fingertip and the nail complex. Most surgical procedures that are used for fingertip reconstruction do not restore the nail defect. The eponychial flap is a new technique where a backward plication of the nail wall is used to expose the nail root and lengthen the visible part of the nail of the amputated digit. The authors describe the anatomical basis and the operative technique of this flap and also review a series of 30 eponychial flaps that were performed in 28 patients. All patients presented fingertip defects treated with volar advancement flaps. This procedure was followed by an eponychial flap that restored the length of the short fingernail. The eponychial flap procedure is an easy and reliable technique that is indicated in distal transverse digital amputations to lengthen the short injured nail. It can be associated with any method used for repairing the fingertip defect, thus enhancing the final cosmetic result of the digital reconstruction.

La revascularisation digitale ectopique temporaire

We present two clinical cases with complete amputation of multiple digits that were salvaged after having been successfully implanted on ectopic sites. The first case concerns a 73-year-old patient, who suffered a severe crush injury of his right hand that resulted in amputation of all four long fingers and an extensive tissue loss of the palm and the dorsum of the hand. Two of the amputated digits, that were considered to be replantable, were implanted on the dorsum of the left foot. The hand defect was covered with a pedicle groin flap. After six weeks, the two ectopically implanted fingers were transferred to their proper anatomical site. Several reconstructive procedures were performed later, in order to lengthen the first ray of the injured hand, and to deepen the first web space. Satisfactory functional results were recorded after eighteen months of follow-up. The second patient concerns a 45-year-old male patient, who had a gun shot accident of his right hand. The injury resulted in a composite tissue loss of the hand with complete amputation of his four long fingers. All fingers were implanted on the left forearm, while the hand defect was reconstructed using an osteocutaneous free flap of the iliac crest. Six weeks after the initial procedure, the ectopically implanted digits were transferred — as a single free flap — to the hand. We described with details the local conditions of the injured hands in both cases, and discuss the reasons we decided to perform this sophisticated method in order to preserve the viability and function of those totally amputated fingers. The recipient sites were selected in a distance from the injured area, always considering the availability and size of appropriate recipient vessels, and the safety of the surgical procedure. We agree that the whole concept of this procedure is very demanding, and requires several microsurgical operations with high risk of complications. However, it does deserve special consideration in reconstructive microsurgery, since it offers the possibility to salvage multiple amputated digits, by preserving the anatomy and restoring the function of severely injured hands.

Microvascular Reconstruction of Serious Frontal Sinusitis and Osteomyelitis after Frontal Craniotomy

Frontal craniotomy complicated with sinusitis and cutaneous fistula may lead to a great challenge of plastic surgeons due to large defect of composite tissue loss with erosion of frontal bone. Frontal osteomyelitis induced by sinusitis is the most frequent clinical presentation. To treat the complication, adequate antibiotics and surgical intervention should be performed at the same time. The purposes of reconstructive surgery are removal of all infection sources, separation of cranial content from nasal cavity and composite tissue repair. To reach these goals, free flap is the best choice because of the following advantages: one stage procedure including debridement and reconstruction, more resistant to recurrent infection due to rich of blood supply, available composite tissue for transposition, bulky effect of replacement for volume loss, easy way to design the size and shape of the flap for matching the defect.

Innervated dorsal adipofascial turnover flap for fingertip amputations.

Traumatic or thermal injury to the fingertip may result in composite tissue loss. Exposed tendon, bone, or joint surface is best treated by flap coverage. The authors present their experience with a new technique that provides coverage for fingertip defects using the innervated dorsal adipofascial turnover flap, which consists of adipofascial tissue only and relies on the arterial anastomotic network of this tissue layer to sustain its vascularization. Eight digital amputations between the distal phalanx proximal to the nail matrix and midportion of the middle phalanx were resurfaced successfully with the innervated dorsal adipofascial turnover flap. The flaps survived completely; the mean follow-up was 9 months. This technique seems to be a relatively simple way of achieving early recovery. It does not require the use of distant flap immobilization of adjacent digits, nor does it require the use of homodigital flaps, which may jeopardize an already injured finger. The main advantages of the innervated dorsal adipofascial turnover flap are its ready availability from the local tissue, its sensation, and the absence of functional and aesthetic disturbance at the donor site.

TREATMENT OF COMPOSITE TISSUE LOSS FOLLOWING HAND AND FOREARM TRAUMA

Restoration of satisfactory function following composite tissue loss in the hand and forearm requires reconstruction of soft tissue defect, nerve and tendon injury, and skeletal fixation when fracture occurs. Microsurgical techniques often are required, but single-donor composite tissue transfers seldom are necessary. Reconstructive strategy requires careful planning. Decision-making principles and surgical alternatives are discussed at the end of the article.

The blood supply of the osteocutaneous free fibular graft

The use of an osteocutaneous free fibular graft as a single-stage reconstructive procedure for composite tissue loss is increasingly common. Detailed anatomical study in cadavers of the blood supply to the graft demonstrates cutaneous arteries arising from the peroneal artery and then passing along the posterior surface of the lateral intermuscular septum. These vessels pierce the crural fascia and then ramify to supply the skin. Knowledge of the vascular anatomy of the skin overlying the fibula is essential to the success of the graft.

Microsurgery for macrodefects: Microvascular free-tissue transfer for massive defects of the head and neck

Despite defect location and the fear of creating complex massive defects, coverage of large areas of soft tissue loss, with or without exposed calvaria, dura, and brain, can be reconstructed reliably with microvascular free tissue transfer. This technique permits separation of the oronasopharynyx from the intracranial contents, coverage of dural grafts, restoration of composite tissue loss, and achievement of superior aesthetic results in a single stage. When choosing vascular anastomotic sites, free-flap transfer permits a greater latitude in flap orientation, tailoring, and inset than is possible when using fixed pedicled rotation flaps. When confronted with a deeply invasive or gigantic malignancy, a multidisciplinary team approach is optimal. The risk associated with sophisticated ablative and reconstructive operative procedures is justified when dealing with potentially curable lesions. The success of these extensive procedures is related not only to the functional result and the aesthetic appearance, but most importantly to the resultant quality of life they allow.

Alternative hand flaps for amputations and digital defects

Traumatic or thermal injury to the hand may result in a composite tissue loss. Exposed tendon, bone, or joint surface is best treated by flap coverage. This paper will discuss four types of alternative hand flaps that can be used to treat difficult areas and/or minimize complications. (1) A thumb flap elevated from the metacarpophalangeal joint flexion crease covers a fingertip injury and the donor site is closed primarily. (2) A proximally based side-finger flap, preferably from the ulnar side of the donor finger, can be used to cover a fingertip defect in a young person or a thumb tip in any age. (3) A deepithelized cross-finger flap, flipped 180 degrees upside-down, can cover a defect on an adjacent finger. The under side of the flap and the donor area are skin grafted. (4) A proximally based arterialized side-finger flap, including the digital artery but sparing the digital nerve, is rotated dorsally to cover a secondarily exposed proximal interphalangeal joint in burn patients where adjacent fingers are not available as donor sites.