Serratus Fascia Research Articles

Prepectoral Prosthetic Breast Reconstruction Without ADM Using a Subfascial Approach.

Immediate prosthetic reconstruction has evolved to a prepectoral position. A technique is described where the pectoral and serratus fascia is raised from superiorly. Initially, Vicryl mesh was used to close the superior fascial defect, but later abandoned by using primary closure for tissue expanders, or creating a pocket in the infraclavicular pectoralis muscle after prosthesis (DTI) insertion. The inframammary fold is also reinforced. Patients with a BMI > 30 have axillary liposuction. Retrospective analysis over a 4-year period. Data included age, number of breasts having expanders or DTI. Prosthetic extrusion and follow-up were recorded. The percentage coverage by fascia was calculated. Forty-seven patients (80 breasts) had mean age of 42 years (range 32-62), twelve patients (19 breasts) had Vicryl mesh inserted, while 35 patients (61 breasts) had closure as noted above. Tissue expanders were inserted in 39 breasts (10 mesh, 29 without). DTI (direct to implant) performed in 41 breasts (32 no mesh, 9 with mesh). Three patients with mesh developed recalcitrant seromas. The mean size of prosthesis used was 353ml (range 200-500ml). Extrusion occurred in eight breasts (two with mesh, six without). Mean coverage of the prosthesis by fascia was 74% (range 50-100%), and nine patients also had bilateral axillary liposuction of the axillary roll. Mean follow-up was 13 months. Another technique for immediate prosthetic reconstruction providing an additional layer of prosthetic cover in prepectoral plane, without mesh. Applicable for all grades of ptosis. Extrusion rate is low. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes after elevation of serratus anterior fascia flap versus serratus muscle flap in direct-to-implant breast reconstruction following mastectomy: a prospective study.

The purpose of this study was to compare postoperative pain between SF flap and serratus anterior muscle (SM) in direct-to-implant breast reconstruction. This is a prospective cohort study that included 53 women diagnosed with breast cancer who underwent mastectomy and one-stage implant-based breast reconstruction from January 2020 to March 2021. Twenty-nine patients (54.7%) had SF elevation, and 24 patients (45.3%) underwent SM elevation. We evaluated patient-reported early postoperative pain on the first day after surgery. Also, it was reported that all surgical complications in the first month and patient reported outcomes (PROs) were measured with the BRECON 23 questionnaire. The serratus fascia group used implants with larger volumes, 407.6 ± 98.9 cc (p < 0.01). There was no significant difference between the fascial and muscular groups regarding the postoperative pain score reported by the patients (2 versus 3; p = 0.30). Also, there was no difference between the groups regarding early surgical complications and PROs after breast reconstruction. The use of SF seems to cause less morbidity, which makes the technique an alternative to be considered in breast reconstruction. Although there was no statistical difference in postoperative pain scores between the fascia and serratus muscle groups.

Fronto-Orbitary Arteriovenous Malformation Reconstruction with Latissimus Dorsi Free Flap and Anterior Serratus Fascia Anastomosed to the Nutrient Vessels of the Lesion.

Fronto-Orbitary Arteriovenous Malformation Reconstruction with Latissimus Dorsi Free Flap and Anterior Serratus Fascia Anastomosed to the Nutrient Vessels of the Lesion.

Reconstruction of Hand and Foot Defects with Free Serratus Carpaccio Flap and Free Serratus Fascia Flap: A Comparative Retrospective Study of Surgical Outcomes.

Defects of the hand and foot often require an individualized reconstructive approach, due to their unique functional and aesthetic characteristics. Transferred tissues should be thin, pliable, and durable, with free fascial flaps meeting these requirements. This study aimed to evaluate the serratus fascia flap and the serratus carpaccio flap, which is a modification of the fascia flap, by including a thin muscle layer, with the goal of enhancing flap resilience and lowering morbidity rates. Between January 2000 and December 2017, 31 patients underwent microsurgical reconstruction of the hand or foot either by serratus fascia flap (fascia group) or serratus carpaccio flap (carpaccio group). The serratus fascia flaps were mainly harvested between 2000 and 2012, and the serratus carpaccio flaps between 2013 and 2017. Patient records were reviewed retrospectively, regarding demographics, complications, overall flap survival, additional revision surgeries, and surgical outcome. Categorical variables were compared using Fisher's exact test and continuous data with the Mann-Whitney tests. Logistic regression was used to examine the correlation between comorbidities and postoperative complication rates. Differences were considered significant when p < 0.05. The fascia group consisted of 17 patients and the carpaccio group of 14 patients. The average patient age in the fascia group was 39.2 ± 10.5 years, and it was 39.1 ± 14.7 years in the carpaccio group. Overall complication rates were significantly lower in the carpaccio group than in the fascia group (28.6% vs. 70.6%, p = 0.03). The rates of overall flap survival (85.7% in the carpaccio group vs. 74.5% in the fascia group, p = 0.66) and partial flap loss (14.3% in the carpaccio group vs. 47.1% in the fascia group, p = 0.07) did not differ significantly among both groups. One postoperative hematoma of the donor site requiring revision surgery was reported in the carpaccio group (7.1%, p = 0.45) while no donor-site morbidity was reported in the fascia group. Our findings indicate that the serratus carpaccio flap presents a promising alternative to the serratus fascia flap. This modification has proven to be effective in substantially reducing postoperative complications requiring additional surgical interventions. Therefore, the serratus carpaccio flap can be considered a dependable reconstructive option for addressing complex soft tissue defects of the hand and foot, with complication rates that are within an acceptable range.

Correction of Rippling in Implant-based Breast Reconstruction with Serratus Fascia Flap.

Implant-based breast reconstruction represents the most popular procedure for the treatment of women undergoing skin-sparing mastectomy. In selected patients, it allows for obtaining an excellent appearance of the reconstructed breast with great satisfaction to the patient. However, aesthetic and functional results can be affected by complications requiring reoperation. Among them, rippling is an undesired occurrence associated with implant-based reconstruction. It consists of a cutaneous manifestation, visible and/or palpable, of the implant wrinkles and edge which appear mostly when the patient leans forward. To treat this contour deformity, several techniques have been described such as acellular dermal matrices and autologous tissues. In this study, we intend to add the serratus anterior fascial flap within the autologous options in the treatment of implant rippling, reporting our experience.

Incorporation of the Vascularized Serratus Fascia Flap during Latissimus Dorsi Flap Harvest to Minimize Morbidity after Axillary Clearance

Incorporation of the Vascularized Serratus Fascia Flap during Latissimus Dorsi Flap Harvest to Minimize Morbidity after Axillary Clearance

Breast Reconstruction after Mastectomy with the Use of an Implant and Serratus Anterior Fascia Flap-Initial Clinical Evaluation.

Prosthesis-based techniques are the predominant form of breast reconstruction worldwide. The most performed surgical technique involves the placement of the expander in a partial submuscular plane. The coverage of the implant remains a difficult management problem that can lead to complications and poor outcomes. The use of the serratus fascia flap may be the best choice to create a subpectoral pocket for the placement of a tissue expander, with excellent results in terms of morbidity and cost-effectiveness. A total of 20 breast reconstructions with the inferolateral coverage with the serratus fascia were performed. Patients demonstrated a low overall complication rate (9.5%), such as seroma and infection, with complete resolution during the follow-up and no major complications. The US examination of the soft tissues over the implant reported thickness measurements that demonstrated a good coverage over the inferolateral area. Our study shows that using the serratus fascia flap to create a pocket with the pectoralis major for the placement of the tissue expander is an effective technique during two-stage breast reconstruction. The resulting low rate of morbidity and the US findings collected reveal the safety of this procedure. Its success relies on appropriate patient selection and specific intraoperative technique principles.

The free serratus carpaccio flap: indications and technique

Soft tissue reconstructions of the hand require a thin and resistant flap palmarly as well as sliding abilities between the extensor tendons and the flap on the dorsum of the hand. Elasticity is required to maintain the normal wrist range of motion. One option in these cases is the free serratus fascia flap that sometimes shows limitations regarding resistance as well as reliability. Here, we describe an easy modification including a thin muscle cuff in the serratus fascia flap - the serratus carpaccio flap - that improves the ease of flap harvest and morbidity rates. The indications for the serratus carpaccio flap, the technique of flap harvest and contouring as well as flap inset are described in detail. Clinical examples are given. The main advantage of the serratus carpaccio flap is the ability of the surgeon to adapt the flap thickness to the recipient site requirements. This allows excellent results regarding contour and function. Split thickness skin grafting fromthe instep region of the foot additionally allows optimal results for palmar as well as plantar defect reconstruction. Eighteen flaps for soft tissue defects of the hand (n = 5), foot (n = 10), and lower leg (n = 3) were performed. Complications included one flap loss, one venous re-anastomosis, two partial wound dehiscences and one postoperative hematoma at the donor site. Seventeen flaps survived completely. Secondary thinning procedures were not required. The serratus carpaccio flap is an excellent option for the reconstruction of medium-sized skin and soft tissue defects of the dorsum of the hand or foot, the palm, and the distal forearm.

Reconstruction of complex shallow defects of the extremities with musculofascial serratus anterior free flap

Background/aim Thin and flexible flaps are needed for the repair of extremity tissue defects. Serratus fascia flaps are the most suitable options. There are only a few case reports and case series in the literature. We have aimed to increase the success rate by taking the serratus fascia flaps together with some muscle tissue for the repair of extremity tissue defects. Materials and methodsBetween 2006 and 2015, 12 free serratus musculofascial flaps (FSMFFs) were transferred to 11 patients (8 males, 3 females) who had tissue shallow defects of the extremities due to different etiologic factors. The mean age was 24.6 years. Hospital records and patient photographs were reviewed and age, sex, etiologic cause, follow-up period, complication, flap success, cosmetic appearance, and functional results of the extremity were examined.Results The mean follow-up period was 29.5 months (7–109 months). All of the flaps survived fully and no partial or full necrosis was observed. Partial graft loss was encountered in one patient and it was recovered secondarily with wound dressing. A major deficiency was not experienced postoperatively in the functions and movements of the extremities retained. The cosmetic appearance of the operation area was acceptable or fine. The donor areas healed in all the patients without any problems, and the scars were hidden and inconspicuous.Conclusion In reconstruction of complex shallow defects of the extremities in which a gliding effect is desired, FSMFF may be an ideal option with its advantages as it does not sacrifice a major vessel, does not leave a hidden and short scar, can be harvested in wide dimensions, and allows the use of the surrounding tissues such as the latissimus dorsi muscle and scapular bone.

Free Serratus Fascia Flap for Reconstruction of Soft Tissue Defects Involving the Distal Upper and Lower Extremity.

Free fascial flaps are widely used for the reconstruction of defects located on the distal extremities as they provide thin yet durable soft tissue coverage. The serratus anterior fascia flap stands out from other fascial flap alternatives as it has optimal anatomical properties that can provide ideal coverage in a wide range of reconstructive challenges. The purpose of this study was to present our experience with the serratus anterior fascia flap in a variety of complex soft tissue defects. A retrospective review was conducted on patients who underwent reconstruction with the free serratus anterior fascia flap for complex soft tissue defects involving the distal extremities. Complex soft tissue defects of 13 patients were reconstructed using the free serratus fascia flap. No major postoperative complications such as flap loss, dehiscence, infection, or hematoma were encountered in any of the patients. All of the patients demonstrated durable and harmonious long-term flap coverage that facilitated movement without any signs of scar contractures and tendon adhesions at the site of reconstruction. The serratus anterior fascia flap demonstrates versatility and stability for the closure of complex distal extremity defects. It creates thin yet durable coverage that facilitates underlying tendon gliding while providing harmony with the natural contours of these anatomic areas and has low donor site morbidity, making it a primary choice in the reconstruction complex soft tissue defects involving the hands and feet.

Breast Reconstruction Utilizing Buried Dermato-cutaneous Skin Flaps and Immediate Adipocyte Transfer: A Minimally Invasive Autologous Breast Reconstruction Technique.

Background:Autologous breast reconstruction historically required flaps that were invasive, required prolonged operative times and recoveries, and resulted in varying degrees of donor site morbidity. We present our early results with a minimally invasive completely autologous breast reconstruction technique utilizing buried dermato-cutaneous (DMC) flaps and immediate fat grafting. A 25-patient, 43-breast consecutive case series is presented.Methods:Select patients desiring autologous breast reconstruction who had sufficient breast ptosis and fat donor tissue were offered breast reconstruction with buried folded over DMC flaps with adipocyte transfer (DCAT). A Wise pattern mastectomy was performed, and fat was transferred into an inferiorly based, buried and folded DMC flap. Fat was also immediately grafted into the pectoralis, subpectoral space, and below pectoralis and serratus fascia. Most patients underwent additional fat grafting at 3-month intervals to complete the reconstruction.Results:Twenty-five consecutive patients (43 breasts) underwent the DCAT procedure with 18 (42%) free nipple grafts. Eight patients (8 breasts) had prior breast radiation, and 2 patients (2 breasts) required postmastectomy radiation. Average fat grafted at initial mastectomy was 70 mL per breast (range 50–103 mL). Nineteen patients (76%) underwent additional outpatient fat grafting. Two additional outpatient fat graft sessions (range 0–3) at 3-month intervals completed the reconstruction. Average fat grafted at the second stage was 217 mL (range 50–320 mL). Average follow-up was 20 months from DCAT and 12 months from last fat graft.Conclusion:The DCAT procedure appears to provide a minimally invasive, autologous breast reconstruction alternative in select patients.

Improving Cost-efficiency in Bilateral Direct-to-Implant Reconstructions with Acellular Dermal Matrix.

Summary:The use of acellular dermal matrix (ADM) for bilateral breast reconstruction has increased in recent years. Detection of BCRA mutation and therefore bilateral risk-reduction mastectomy is one of the main reasons for this increase. High cost of ADM is considered a major drawback for its use. The authors present a new technique which allows the use of only one unit of ADM for both breasts. After assessing the viability of the skin of mastectomy flaps, a musculofascial pocket formed superiorly by pectoralis major, laterally by serratus fascia and inferiorly by rectus fascia, is performed. Then, the ADM is divided in two halves. We propose two different ways to divide the matrix, cutting it vertically or diagonally in two. The way in which the matrix should be cut depends on the distensibility of the pocket. Afterwards, the implant is inserted and the exposed area of the implant is covered by the ADM sutured to the edges of the musculofascial pocket. Using only one ADM unit for bilateral reconstruction, the procedure becomes not only more cost-effective but also can reduce complications such as seroma, rippling, wrinkling, and visibility by means of a better coverage with lesser foreign body load. Furthermore, the lesser the matrix used, the faster the integration is achieved.

A Limited Submuscular Direct-to-Implant Technique Utilizing AlloMax.

Background:This study evaluates a novel limited submuscular direct-to-implant technique utilizing AlloMax where only the upper few centimeters of the implant is covered by the pectoralis, whereas the majority of the implant including the middle and lower poles are covered by acellular dermal matrix.Methods:The pectoralis muscle is released off its inferior and inferior-medial origins and allowed to retract superiorly. Two sheets of AlloMax (6 × 16 cm) are sutured together and secured to the inframammary fold, serratus fascia, and the superiorly retracted pectoralis. Thirty-seven breasts in 19 consecutive patients with follow-up at 6 months were reviewed.Results:Nineteen consecutive patients with 37 reconstructed breasts were studied. Average age was 50 years, average BMI was 24.3. Ptosis ranged from grade 0–III, and average cup size was B (range, A–DDD). Early minor complications included 1 seroma, 3 minor postoperative hematomas managed conservatively, and 3 minor wound healing problems. Three breasts experienced mastectomy skin flap necrosis and were managed with local excision. There were no cases of postoperative infection, red breast, grade III/IV capsular contractures, or implant loss. A single patient complained of animation postoperatively. One patient desired fat grafting for rippling.Conclusions:The limited submuscular direct-to-implant technique utilizing AlloMax appears to be safe with a low complication rate at 6 months. This technique minimizes the action of the pectoralis on the implant, reducing animation deformities but still providing muscle coverage of the upper limit of the implant. Visible rippling is reduced, and a vascularized bed remains for fat grafting of the upper pole if required.

Extended Submuscular Implant-Based Breast Reconstruction with Pectoralis-Serratus Sling and Acellular Dermal Matrix.

Partial muscle coverage with the use of acellular dermal matrix (ADM) has become commonplace in implant-based breast reconstruction.1-8 Compared with total submuscular coverage,9-12 the advantages of partial muscle coverage and ADM have included greater primary implant fill volumes, quicker expansion, increased lower pole expansion, and improved breast aesthetics.5,8,13-15 Since Breuing and Warren’s 2005 description,1 ADM has been widely used as a “pectoralis extender” and “inferolateral sling.” Having amassed experience and largely favorable results with this classical technique,1 we have nevertheless found several limitations with this approach, primarily related to the incision of the lateral margin of the pectoralis major muscle and the requisite lateral inset of the allograft. First, the lateral ADM inset requires two suture lines, along both the incised pectoralis major muscle lateral margin and serratus fascia, which can be time intensive. Second, lateral allograft inset can be technically arduous, particularly through increasingly limited-length or inframammary mastectomy incisions. Finally, we had commonly noted lateralization of the breast pocket throughout the expansion process, with varying degrees of lateral breast prosthesis displacement, that have necessitated onerous and additional time-intensive lateral capsulorrhaphy maneuvers to re-define the lateral pocket at the second stage. The authors’ current implant-based breast reconstruction technique was devised to establish more robust definition of the lateral breast pocket, limiting potential implant displacement and minimizing the need for capsular modification at a second procedure. The technique, described below and demonstrated in Figure 1, is a hybrid approach that combines the advantages of ADM inferiorly with extended submuscular coverage laterally by elevating the pectoralis major muscle in continuity with the serratus anterior muscle and fascia. This technique provides more vascularized autogenous implant coverage, improves support and maintenance of breast shape and implant position, facilitates control of the lateral pocket through …

Abstract P2-12-18: Outpatient mastectomy with reconstruction in a freestanding surgery center using multimodality opiod-sparing perioperative analgesia including liposomal bupivacaine

Abstract HYPOTHESIS: The introduction of effective non-narcotic analgesics and the long-acting local anesthetic bupivacaine liposome (Exparel) has resulted in improved postoperative pain control and decreased reliance on opioid analgesics that often have the undesirable adverse effects of sedation, nausea, respiratory depression, and dysphoria or confusion. This has resulted in shorter postoperative care unit stays, earlier return to normal activity, and improved patient satisfaction without sacrificing appropriate pain control. Based on a positive experience with these agents in the inpatient setting, we hypothesized that mastectomy with immediate implant-based reconstruction could be performed safely in a freestanding outpatient surgery center using a multimodality opioid-sparing analgesic regimen. METHOD: Over a 6 month period we performed unilateral or bilateral mastectomy with concurrent implant-based reconstruction on 20 patients. One patient had a unilateral mastectomy and 19 patients had bilateral mastectomy performed. Sixteen of the patients had nipple sparing mastectomy procedures. Reconstruction was performed with tissue expanders in 6 patients and as a single stage procedure with silicone gel implants in 14 patients. Acellular dermal matrix was used to support the implant in all but 1 patient. All patients were given gabapentin 600mg on the evening prior to and morning of surgery. Acetaminophen 1gm IV was given prior to induction of anesthesia in the preoperative area and again 6 hours later in the post anesthesia care unit. Ketorolac 30mg IV was given during the last half of the surgical procedure. All patients had general anesthesia with standard inhalational agents and IV fentanyl as needed. The retropectoral and serratus fascia were infiltrated with liposomal bupivacaine after surgical removal of the breast tissue, before reconstruction was started. The drain sites were also infiltrated with liposomal bupivacaine. Patients were discharged with prescriptions for gabapentin 300mg twice daily for 7 days followed by 300mg nightly for 7 days, carisoprodol 350mg every 6 hours as needed for muscle spasms, ibuprofen 800 mg every 8 hours for 5 days, hydrocodone/acetaminophen every 4 hours as needed for pain, and oral antibiotics of the surgeon's choice. RESULTS: All 20 patients completed their surgery and were discharged home after a brief stay in the postoperative care unit. No patient required readmission for pain control or any other complication in the perioperative period. No patient reported inadequate pain control. All patients were highly satisfied with their perioperative care as reported during postoperative follow-up phone calls the day after surgery and during their post-operative follow up visit. CONCLUSION: In our experience, outpatient mastectomy with reconstruction in a freestanding surgery center is safe and has a high degree of patient satisfaction when using a multimodality opioid-sparing analgesia regimen including liposomal bupivacaine. By avoiding opioid-related adverse effects, patients have a more rapid recovery, earlier return to activities of daily living, and therefore improved quality of life. Proper patient selection requires a multidisciplinary team approach for success. Citation Format: Rock DT, Jandik AL, Wittenborn WS, Fairfax K, Sandadi S. Outpatient mastectomy with reconstruction in a freestanding surgery center using multimodality opiod-sparing perioperative analgesia including liposomal bupivacaine. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-18.

Local Infiltration of Liposomal Bupivacaine for Pain Control in Patients Undergoing Mastectomy with Immediate Tissue Expander Reconstruction.

Mastectomy with immediate tissue expander reconstruction is associated with postoperative pain, nausea, and vomiting. Various techniques of perioperative and postoperative pain control have been described. Our standard of care for postsurgical pain management in patients undergoing mastectomy with immediate tissue expander reconstruction has been preoperative ultrasound-guided paravertebral block. Recent literature demonstrating the opioid-sparing benefits of liposomal bupivacaine has directed two of our plastic surgeons to pilot its use in immediate tissue expander reconstruction. In the accompanying video, we present our technique of intraoperative local infiltration of liposomal bupivacaine into the base of mastectomy skin flaps, serratus fascia, and periaxillary tissue aftercompletion of the mastectomy and before tissue expander placement into the reconstruction pocket.

Immediate Definitive Prosthetic Reconstruction in Patients With Ptotic Breasts

Immediate reconstruction of medium/large ptotic breasts can be performed by using expanders, definitive implants, or autologous flaps. If a skin-sparing mastectomy is feasible, excellent results can be achieved by planning Wise pattern incisions, using definitive implants. The authors suggest the use of a dermal-adipose flap, harvested from the ptotic part of the breast, rotated laterally, and interposed between the serratus fascia and the pectoralis muscle to close the inferolateral part of the pocket. We performed 23 immediate unilateral single-stage breast reconstructions, with simultaneous contralateral reduction. Preoperatively, all breasts showed grade II or III ptosis. There was no case of implant infection or failure of the reconstruction. The median follow-up was 21 months; however, some patients followed up for >4 years; in this period, no case of capsular contracture was observed. This technique has provided good shape, acceptable ptosis consistent with the healthy breast and symmetric scars.

Use of the Serratus Anterior Fascia Flap for Expander Coverage in Breast Reconstruction

Postmastectomy partial submuscular tissue expander placement can prevent the upper pole fullness commonly seen with complete submuscular prosthesis placement. The resultant inferior and lateral margins require coverage to prevent prosthesis exposure. The fascial layer overlying the serratus anterior muscle can be used as an alternative to previously defined techniques to provide composite lateral coverage. This method offers adequate coverage, prevents expander lateralization, and minimizes use of allogenic material. This study reports the anatomy, surgical procedure, clinical outcomes, and aesthetics following use of the serratus anterior fascial flap for lateral expander coverage in postmastectomy expander-based breast reconstruction. Twenty-two patients (31 breasts) who underwent breast reconstruction with serratus fascia were included in a retrospective case-note analysis after approval by the institutional review board. Demographics, perioperative factors, postoperative complications, patient satisfaction, and aesthetics were recorded as relevant endpoints. Ten fresh cadaver hemichests were dissected, and the serratus fascia for each was measured for length and width. At a mean follow-up of 197 days (range, 71 to 370 days), seroma occurred in two breasts, wound infection occurred in one breast, partial mastectomy skin flap necrosis occurred in four breasts, and minor wound dehiscence occurred in one breast. There were no incidences of capsular contracture or hematoma. Four patients (five breasts) reported very mild tightness or banding in the lateral chest wall. The mean length of cadaver serratus fascia was 164.3 mm and the mean width was 122.8 mm. The serratus anterior fascia flap is a versatile and safe alternative for providing vascularized composite lateral prosthesis coverage in expander-based breast reconstruction.

Treatment of avulsion injury of three fingers with a compound thoracodorsal artery perforator flap including serratus anterior fascia

Complete degloving injury of three digits not amenable to revascularization may leave poor cosmetic and functional results. We used a compound thoracodorsal artery perforator (TDAP) flap in a 34-year-old, right-handed, male worker with traumatic degloving injury. The flap consisted of a thin nonbulky skin component isolated on two perforators in combination with serratus fascia, both pedicled on the thoracodorsal vessels. The mobility of the two flap components allowed the palmar and dorsal part of the fingers to be reconstructed without relying on multiple flaps or anastomoses. The skin component of the TDAP flap was transferred to the palmar defect, the serratus fascia flap to the dorsal part of the fingers and sutured loosely. Coverage of the serratus anterior fascia was done with split-thickness skin graft. Both components of the flap survived completely. One month after the first operation, the surgical syndactyly between middle and ring finger was separated, one month later the syndactyly between the ring and little finger. Good coverage of the soft tissue defects with good function could be achieved. There were no donor-site problems. Therefore, we consider the compound TDAP flap as a useful method that provides functional and cosmeticcoverage of severe avulsion injury of multiple digits. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.

Weichteilrekonstruktion am Hand- und Fingerrücken über dem Streckapparat

Small defects of extensor tendons can mostly be covered by local flaps. For larger defects the groin flaps, pedicled flaps from the forearm and free flaps are indicated. Between January 2001 and December 2005, we performed the following pedicled and free flaps to reconstruct the soft tissue defects of the hand or distal forearm: 23 pedicled flaps: 15 posterior interosseus artery or perforator flaps, 8 radial forearm flaps; 26 free flaps: 4 radial forearm flaps, 12 lateral upper arm flaps, 10 latissimus, serratus fascia or scapula flaps. With this study we want to illustrate the different procedures, compare their surgical techniques and outcomes and finally to rate the results. In the context of security, morbidity of the donor site and functional outcomes, our favourite flap is the lateral upper arm flap.