Reconstruction Of Upper Extremity Research Articles

Trends in Utilization of Upper Extremity Reconstructive Surgery Following Traumatic Brain Injury and Stroke.

Background: Spasticity resulting from traumatic brain injury (TBI) or stroke can lead to debilitating sequelae, including deformities from joint subluxation and spasticity, causing a loss of functional independence. Despite the effectiveness of surgery to address these issues, it is unclear how often these procedures are performed. The objective of the study was to determine the rate of, and trends associated with, reconstructive upper extremity surgery in patients following TBI or stroke. Methods: The National Inpatient Sample was queried for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for TBI and stroke as well as procedural codes representing functional upper extremity reconstruction from 2001 to 2012. Temporal trends were assessed for case volume, patient demographics, financial considerations, and hospitalizations. Results: A total of 2132 reconstructive procedures were performed in patients with TBI or stroke during the study period, with fewer than 230 cases conducted in any given year and no appreciable increase in case volume over time. This represented less than 1% of eligible, appropriate candidates undergoing surgery. Middle-aged, white females were the most common patients to have such surgery. Medicare was the primary payer for reconstruction, and the cost of surgery increased substantially over time. There was a trend toward longer hospital stays, and the inpatient mortality was approximately 0.5%. Conclusions: There is a substantial underutilization of upper extremity reconstructive surgery for patients with spasticity following TBI or stroke. Increasing costs and limited access to appropriate care may be contributing to differences in use among specific patient subgroups.

Microsurgical Reconstruction of the Upper Extremity

The advent of free tissue transfer has revolutionized upper extremity reconstruction in the setting of trauma, infection, and oncologic resection. Current microsurgical techniques allow for soft tissue coverage, osseous reconstruction, and free functioning muscle transfer. This review highlights perioperative planning considerations in terms of the timing of reconstruction and flap choice, as well as indications and contraindications, for upper extremity microsurgical reconstruction. Many commonly used fasciocutaneous, muscle, and osseous free flap options are reviewed, with specific emphasis on surgically relevant anatomy, flap variations, and pearls and pitfalls. Many of these free flap options are illustrated using case examples. This review contains 15 figures, 3 tables and 109 references. Key words: bone defect, elbow, free flap, hand, microsurgery, reconstruction, upper extremity, wrist

Application of a Modified Pedicled Adipofascial Lateral Arm Flap in the Prevention and Treatment of Radial Nerve Injuries.

The fasciocutaneous lateral arm flap is a workhorse flap in upper extremity reconstruction. However, its adipofascial variant is not widely used. The technique can be used in various clinical scenarios. The adipofascial flap can be transposed to circumferentially wrap the radial nerve with a pliable, vascularized fat and fascial envelope, mimicking the natural fatty environment of peripheral nerves. This technique has the advantage of providing a scar tissue barrier, a barrier to hardware irritation and a milieu for vascular regeneration of the nerve. Suggested applications include nerve coverage in the setting of posterior humerus plating to prevent adhesions; anticipation of bone grafting in the setting of an open fractures with bone loss, infection, or with the use of the Masquelet technique; in revision total elbow arthroplasty or endoprosthetic humerus replacement; and in the setting of neurolysis, repair or nerve grafting. The technique is straightforward and does not require microvascular expertise.

Principles in Reconstruction after Resection of Extremity and Truncal Sarcomas

Reconstruction of sarcoma defects of the trunk or extremity requires detailed understanding of a variety of techniques for wound closure. Advances in reconstruction and oncologic treatment have led to higher rates of limb salvage in patients who would have previously undergone amputation. Such defects often require consideration of the reconstructive ladder, moving from the most simplistic closure to free flaps. As previous surgeries or radiation therapy can create a challenging wound environment with scar and fibrosed tissues, at times the more complex up-front option will be a better long-term solution for a patient following sarcoma resection. A multidisciplinary approach to the initial management, resection, and reconstruction is certainly warranted to attain the best overall outcome for the patient from the oncologic and aesthetic standpoint. This review provides an overview of the reconstructive techniques employed in addressing defects of the trunk and extremities following sarcoma resection. This review contains 20 Figures and 30 References. Key words: abdominal wall reconstruction, chest wall reconstruction, free flap, lower extremity reconstruction, pedicled flap, propeller flap, reconstructive elevator, reconstructive ladder, upper extremity reconstruction

Principles in Reconstruction after Resection of Extremity and Truncal Sarcomas

Reconstruction of sarcoma defects of the trunk or extremity requires detailed understanding of a variety of techniques for wound closure. Advances in reconstruction and oncologic treatment have led to higher rates of limb salvage in patients who would have previously undergone amputation. Such defects often require consideration of the reconstructive ladder, moving from the most simplistic closure to free flaps. As previous surgeries or radiation therapy can create a challenging wound environment with scar and fibrosed tissues, at times the more complex up-front option will be a better long-term solution for a patient following sarcoma resection. A multidisciplinary approach to the initial management, resection, and reconstruction is certainly warranted to attain the best overall outcome for the patient from the oncologic and aesthetic standpoint. This review provides an overview of the reconstructive techniques employed in addressing defects of the trunk and extremities following sarcoma resection. This review contains 20 Figures and 30 References. Key words: abdominal wall reconstruction, chest wall reconstruction, free flap, lower extremity reconstruction, pedicled flap, propeller flap, reconstructive elevator, reconstructive ladder, upper extremity reconstruction

Leveraging the Medical Context to Increase Upper Extremity Reconstruction Among Patients With Tetraplegia: A Qualitative Analysis

ObjectivesTo (1) characterize patients' medical experiences from initial injury until they become candidates for upper extremity reconstruction (UER); and (2) identify points in this medical context that may be most amenable to interventions designed to increase UER utilization. DesignA qualitative cross-sectional study using grounded theory methodology and constant comparative analysis of data collected through semistructured individual interviews. SettingCommunity. ParticipantsA sample of individuals with C4 to C8 cervical spinal injuries (N=19) who sustained injuries at least 1 year before interview. Nine patients had undergone reconstruction, and 10 had not. The study sample was predominantly male (79%) and white (89%), and American Spinal Injury Association grades A through D were represented (A, 42%; B, 32%; C, 16%; D, 10%). InterventionsNot applicable. Main Outcome MeasuresParticipants' self-report of their medical experiences from the time of injury through the early recovery period. ResultsWe identified 3 domains that formed patients' medical context before UER candidacy: (1) their ability to achieve and maintain health; (2) their relationship with health care providers; and (3) their expectations regarding clinicians' tetraplegia-specific expertise. Trust emerged as a major theme driving potential intervention targets. Patients transferred to referral centers had higher trust in tertiary providers relative to local physicians. In the outpatient setting, patients' trust correlated with the tetraplegia-specific expertise level they perceived the specialty to have (high for physical medicine and rehabilitation, intermediate for urology, low for primary care). ConclusionsIn appropriate candidates, UER produces substantial functional gains, but reconstruction remains underused in the tetraplegic population. By analyzing how patients achieve health and build trust in early recovery/injury, our study provides strategies to improve UER access. We propose that interventions targeting highly trusted points of care (transfer hospitals) and avoiding low-trust points (primary care physicians, home health) will be most effective. Urology may represent a novel entry point for UER interventions.

Comparison of perioperative complications of pedicled island flap in reconstruction of extremities

PurposeThe aim of this study was to analyze the differences in perioperative complications for pedicled island flaps in the reconstruction of extremities and to identify the factors contributing to pedicled island flap necrosis. Furthermore, the flap indications based on these outcomes are summarized. MethodsBased on the inclusion criteria, 228 skin flaps were included in this study. Univariate and multivariate analyses were used to identify the risk factors for pedicled island flap necrosis. Differences in perioperative complications between upper and lower extremities were analyzed using the chi-square test or Fisher's exact test. ResultsThe average age of the patients was 38 years. The overall complication rate was 21.93%, including partial flap necrosis (10.09%) and total flap necrosis (5.70%). The overall complication rate and flap necrosis rate in upper extremity reconstruction were significantly lower than the rates in lower extremity reconstruction. Flap area and postoperative wound infection were statistically significant risk factors for pedicled island flap necrosis in extremity reconstruction. Preoperative contamination of the wound bed was a statistically significant risk factor for postoperative wound infection. ConclusionsThe flap area and postoperative wound infection were both independent risk factors for pedicled island flap necrosis in extremity reconstruction. The causes contributing to the differences in perioperative complications between upper and lower extremities reconstruction included preoperative contamination of the wound bed, postoperative wound infection, and the flap area but were also related to anatomical factors of the skin flap. Pedicled island flaps are more suitable for small- and medium-sized soft tissue defects.

Checkpoints to Progression: Qualitative Analysis of the Personal and Contextual Factors That Influence Selection of Upper Extremity Reconstruction Among Patients With Tetraplegia

Patients with tetraplegia consistently rank better use of the upper extremity as their top functional priority. Multiple case series have demonstrated that upper extremity reconstruction (UER) is well-tolerated and can produce substantial functional improvements for appropriate candidates; however, UER remains critically underutilized. The mechanisms that drive differences in provider practice and referral patterns have been studied, but comprehensive examination of the patient factors that influence UER decisions has not been performed for American patients. Nineteen patients with C4-8 cervical spinal injuries were selected using purposive sampling: 9 patients had undergone UER, 10 had not undergone UER. Semistructured interviews were conducted and transcripts evaluated using grounded theory methodology. Our study yielded a conceptual model that describes the characteristics common to all patients who undergo UER. Patients who selected reconstruction proceeded stepwise through a shared sequence of steps: (1) functional dissatisfaction, (2) awareness of UER, and (3) acceptance of surgery. Patients' ability to meet these criteria was determined by 3 checkpoints: how well they coped, their access to information, and the acceptability of surgery. Extremely positive or negative coping prevented patients from moving from the Coping to the Information Checkpoint; thus, they remained unaware of UER and did not undergo surgery. A lack of knowledge regarding reconstruction was the strongest barrier to surgery among our participants. We built a conceptual model that outlines how patients' personal and contextual factors drive their progression to UER. Moving from functional dissatisfaction to understanding that they were candidates for UER was a substantial barrier for participants, particularly those with very high and very low coping skills. To improve utilization for all patients, interventions are needed to increase UER awareness. Standardizing introduction to UER during the rehabilitation process or improving e-content may represent key awareness access points.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

Skin Perfusion Changes within 12 h after Axillary Plexus Block

Background/Purpose: An improvement of the blood flow would be beneficial in microvascular upper-extremity reconstruction and in digit replantation. In the present work, skin perfusion changes and their duration due to axillary plexus block were quantified. Methods: The peripheral blood flow of the upper extremities in 20 patients undergoing trapeziectomy under axillary plexus block was analyzed. Results: Laser Doppler spectrophotometry was used to measure perfusion factors over a 12-h period, with the contralateral hand acting as the control. Axillary plexus block produced a significant increase of peripheral oxygen saturation (117 ± 35% vs. control 93 ± 22%, p = 0.019), peripheral blood flow (220 ± 166% vs. 130 ± 77%, p = 0.037), and velocity (164 ± 58% vs. 117 ± 45%, p = 0.011). Conclusion: Axillary plexus block produces an improvement of peripheral tissue oxygen saturation of the upper extremities over the first 6 h after the inception of anesthesia. This suggests a potential benefit especially for critically perfused tissues.

Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting.

At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries. However, long-term outcomes of complex reconstruction performed in the resource-limited setting are not known. This hinders understanding of outcomes and disability from these injuries and prevents systematically addressing care delivery around upper extremity trauma in the developing world. This project aims to analyze the details of the unique Ganga Hospital reconstruction experience and use patient-reported outcome measures for the first time in this patient population to evaluate post-injury recovery and disability . Forty-six patients were evaluated 6months or more after massive proximal upper extremity reconstruction at Ganga Hospital. Patients completed functional tests, Jebsen-Taylor test (JTT), and patient-reported outcomes (PROs)-Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between metrics were assessed with Pearson's correlation coefficients. Linear regression modeling evaluated associations between severity, reconstruction, and outcomes. MHQ and DASH results correlated with functional test performance, JTT performance, and SF-36 scores (Pearson's coefficients all ≥0.33, p≤0.05). In this cohort, mean MHQ score was 79±15 and mean DASH score was 13±15, which are not significantly different than scores for long-term outcomes after other complex upper extremity procedures. The following factors predicted PROs and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their job after injury. Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes. PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing and may be used to assess post-traumatic disability.

Single stage soft tissue and extensor tendon reconstruction of upper extremity with antero-lateral thigh free flap- A case report

Soft tissue coverage for traumatic soft tissue loss of upper extremity is challenging with limited local tissues availability. Hence, free tissue transfer is indicated. A patient presented to us with degloving injury of the right dorsum hand and forearm following a road traffic accident. There was large soft tissue defect on the dorsal lateral aspect of the hand and forearm, open comminuted fracture of distal end radius with segmental loss of extensor tendons. After adequate debridement and fracture stabilization with external fixator, soft tissue and extensor tendon reconstruction were performed with conjoined flow-through anterior-lateral thigh and tensor fascia lata free flap. At postoperative three months, there was non union of the distal end of right radius. Flap was re-elevated and non union was corrected with osteotomy, non vascularized bone graft and locking plate. Subsequently, at 1 year follow up revealed limited range of movement at wrist joint (flexion-extension 15 degree), acceptable at metacarpophalangeal of all fingers (hyperextension 15 degree, flexion 60 degree) and interphalangeal joints (PIP joint extension- flexion 0-45 degree, DIP joint extension-flexion 0-15 degree). Hand grip was weak and requires further hand therapy. Anterior lateral thigh flap is a versatile and reliable option for reconstruction of large soft tissue and composite defects of upper extremity with favourable outcome.

An Anatomical Feasibility Study on the Use of the Hypoglossal and Hemi–Hypoglossal Nerve as a Donor Motor Nerve for Free Functioning Muscle Transfer in Upper Extremity Reconstruction

Objective/Hypothesis: Reconstruction of adult brachial plexus injuries remains a clinical challenge. The advent of nerve transfers and free functioning muscle transfers has increased the available reconstructive options in particular when there have been root avulsions. The accessory, intercostals, and phrenic nerves have been the most common donor nerves used to reanimate free muscle transfers. However, it is not uncommon for these patients to have sustained multiple rib fractures or a phrenic nerve avulsion precluding the use of either nerve as a donor. The paucity of currently available donor motor nerves for transfer led us to investigate the hypoglossal and hemi–hypoglossal nerve as a potential donor nerve for a free functioning muscle transfer. The hypoglossal and hemi–hypoglossal nerve have been used successfully as a nerve transfer for the facial nerve and with some success as a nerve transfer with nerve grafts to the musculocutaneous nerve in obstetrical brachial plexus palsy. We postulated that the hypoglossal and hemi–hypoglossal nerve could be used for nerve transfer without nerve grafts for innervation of a gracilis or latissimus dorsi muscle for elbow flexion in upper extremity reconstruction. To our knowledge, this has not been studied before. Materials and Methods: In 12 formalin-embalmed cadavers (6 males and 6 females), the hypoglossal, thoracodorsal, and obturator nerve branch to gracilis was dissected bilaterally and their respective lengths from their origin to the muscle measured. The distance from the lowest point of the hypoglossal nerve in the neck to the lateral third of the clavicle was measured. Results: The average distance from the lowest point of the hypoglossal to the lateral clavicle was 8.4 ± 1.3 cm in males and 7.7 ± 0.8 cm in females. When the hypoglossal was transected distally and brought down, the average distance to the clavicle was 4.5 ± 1.6 cm in males and 3.8 ± 1.5 cm in females. The average length of the nerve to the gracilis was 13.1 ± 1.6 cm in males and 12.4 ± 11 cm in females and of the thoracodorsal nerve 14.9 ± 1.5 cm in males and 14.0 ± 1.0 cm in females. Conclusion: This cadaveric study demonstrates that the hypoglossal and hemi–hypoglossal nerves may be used as potential motor donor nerves by direct nerve transfer without the need for nerve grafting to innervate a free functioning gracilis or latissimus dorsi muscle for upper extremity reconstruction.

Abstract: Functional Latissimus Transfer for Upper Extremity Reconstruction: A Case Report and Review of the Literature

BACKGROUND: Upper extremity reconstruction often utilizes the Latissimus Dorsi (LD) muscle flap for its width, length, and ample blood supply. Variant flaps and techniques have been described that support the uses of this flap to suit a wide range of reconstructive needs.

Outcomes of Massive Proximal Upper Extremity Reconstruction in the Resource-Poor Setting: Level 4 Evidence

There is no financial information to disclose. Considering current limitations in prosthetics and hand transplantation, limb salvage remains the dominant reconstructive option for proximal upper extremity trauma. This is especially true in countries where social services are not available to support the disabled. At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries.1Sabapathy S.R. Venkatramani H. Bharathi R.R. Dheenadhayalan J. Bhat V.R. Rajasekaran S. Technical considerations and functional outcome of 22 major replantations (The BSSH Douglas Lamb Lecture, 2005).J Hand Surg Eur Vol. 2007; 32: 488-501Crossref PubMed Scopus (41) Google Scholar However, long-term outcomes of complex reconstruction performed in this resource-limited setting are not known. We hypothesize that patient-reported outcome questionnaires (PROs) can measure functional and health-related quality-of-life (QoL) outcomes after upper extremity salvage, and determine what injury components and outcomes predict long-term success. Forty-six patients were evaluated 6 months or more after massive upper extremity reconstruction at Ganga Hospital. Demographic and employment data were collected. Patients completed isolated functional tests, Jebsen-Taylor composite functional test (JTT), and PROs – Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between outcomes metrics were assessed with Pearson’s correlation coefficients. Linear regression modeling evaluated associations between injury severity, reconstruction required, and outcomes. MHQ and DASH had significant correlations with functional tests, JTT, and SF-36 (Figure 1). Mean MHQ score was 79 +/- 15 and mean DASH score was 13 +/- 15, not significantly different than long-term outcomes after other upper extremity procedures.2Shauver M.J. Chung K.C. The Michigan Hand Outcomes Questionnaire after 15 Years of field trial.Plast Reconstr Surg. 2013; 131: 779e-787eCrossref PubMed Scopus (70) Google Scholar Injury severity score, as well as most fractures and vessel injuries, did not predict outcomes; however, the following factors did predict patient-reported outcomes and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their current job after injury (Table 1). •Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes.•PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing.•Extent of soft tissue reconstruction and need for median nerve repair are more predictive of outcomes and satisfaction than other elements of reconstruction.•Facilitating return to work is critical in improving outcomes and satisfaction for patients in the developing world.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Rehabilitation After Surgical Reconstruction to Restore Function to the Upper Limb in Tetraplegia: A Changing Landscape

Upper limb reconstructive surgical procedures for individuals with tetraplegia are performed in many centers internationally. Most recipients of surgery return to local communities and nonsurgical centers for postoperative rehabilitation and long-term follow-up. This supplement focuses on the clinical significance of upper extremity reconstruction, addressing issues related to the availability and choice for surgery, preoperative assessments, postoperative training paradigms, and appropriate outcome measures. Comprehensive intervention protocols are described in terms of dose, timing, specific activities, modalities, and related outcomes. Shared knowledge of current rehabilitation practice, as it relates to reconstructive surgery, can expand treatment options communicated to patients, increase the availability of postoperative muscle reeducation programs, and motivate long-term follow-up assessments.

Distally based subcutaneous veins for venous insufficiency of the reverse posterior interosseous artery flap.

The reverse posterior interosseous artery flap (PIAF) provides soft, thin, and pliable tissue for upper extremity reconstruction without sacrificing any major arteries of the hand. The authors performed a new technique that included one extra distally based subcutaneous vein within the pedicle to diminish venous insufficiency and they aimed to present the results of reconstruction with this technique. Twelve patients with a mean age of 30years (range 5-52years) underwent reverse PIAF surgery. The defects were located on the hand and wrist, with a mean area of 57.8cm2 (range 20-99cm2) . After the skin between the distal edge and the pivot point of the flap was elevated, the most reliable subcutaneous vein was chosen, chased, and included within the flap. The average size of the PIAF was 6×5cm to 12×9cm (mean area: 64.4cm2 ) and the median follow-up time was 13months (range 4-16months). The mean quick Disabilities of the Arm, Shoulder and Hand (DASH) score was 21.4, indicating a low degree of disability. Of the 12 patients, ten were very satisfied and two were satisfied with the result of the reconstruction. All but one flap survived completely. One flap was nearly totally lost due to arterial insufficiency after hemodialysis. We observed no venous congestion or insufficiency in the patients. Subcutaneous veins may be reliable and useful for overcoming major drawbacks associated with reverse flow posterior interosseous artery flap and for diminishing flap loss due to venous insufficiency. © 2016 Wiley Periodicals, Inc. Microsurgery 36:384-390, 2016.

The therapy of upper extremity orthosis : upper extremity reconstruction, activity, participation and support

The therapy of upper extremity orthosis : upper extremity reconstruction, activity, participation and support

Review of Pedicled Groin and Thoracoepigastric Flaps in War-Related Extremity Trauma

BACKGROUND: War-related trauma can present substantial reconstructive challenges. The use of local tissue for extremity reconstruction is often impossible secondary to the large zone of injury associated with blast injuries. However, the torso is general protected by modern body armor. The purpose of this study is to investigate our experiences and outcomes of two stage pedicle flap procedures for complex upper extremity reconstruction in the war wounded. METHODS: This is a multi-institution retrospective consecutive case series review of all injured military personnel treated with flap coverage for complex extremity trauma from 2003 through 2012 within the National Capital Area (NCC). Data collected includes injury severity score (ISS), concomitant injuries, and treatment course. Outcomes measured includes flap and extremity complications such as infection, hematoma, and flap failure. RESULTS: From 2003 through 2012, 28 delayed pedicle groin and thoracoepigastric flaps were performed for upper extremity reconstruction after war-related injuries. All of the patients were male, age 19–35, with an average injury severity score of 20.1. Thirty percent of patients had a proximal vascular injury in the extremity reconstructed. Patients had a median of 6 (range 2–29) procedures performed on the affected extremity prior to flap transfer and 4 (range 1–27) performed after flap transfer. The total flap complication rate was 39%. The most common complication was partial necrosis (14%), followed by flap infection (11%). The flap failure rate was 7% (n=2), requiring additional flap transfer (free anterolateral thigh and pedicled lateral arm). There were no amputations in the group. The flap complication and failure rate were similar to the entire war-wounded extremity reconstruction cohort previously reported, 39 versus 27% and 7 versus 10%, respectively.1 Patients were followed for an average of 741 days. CONCULSION: Soft tissue coverage for complex extremity war-related trauma results has been highly successful with relatively low complication rates. In the critically injured war wounded patient, pedicle and free flaps have similar outcomes.2 However, when local tissue for pedicle flaps is not available, delayed reconstruction with groin or epigastric flaps is a good option that offers tissue from a protected region of the body and reliable blood supply with a low risk of failure.

Gigantic LCFA-SCIP Mosaic Flap for Upper Extremity Reconstruction

Gigantic LCFA-SCIP Mosaic Flap for Upper Extremity Reconstruction