Floor plan - 2013 Annual Meeting - American Association for Hand ...

Resurfacing of a Complex Upper Extremity Injury: An Excellent Indication for the Dorsal
Thoracic Fascial Flap
Institution where the work was prepared: The Buncke Clinic, San Francisco, CA, USA
Ron Hazani, MD; Darrell Brooks, MD; Rudolf F. Buntic, MD; The Buncke Clinic
INTRODUCTION:
Resurfacing of complex injuries of the upper extremity can pose a challenge to the reconstructive surgeon. Injuries characterized by
skeletonization of structures such as bone or tendon can require circumferential wrap by the transplanted tissue. Skin graft and fasciocutaneous
flaps are not appropriate and muscle flaps can be excessively bulky. Fascial flaps are an ideal solution but most are small.
We present a case in which the dorsal thoracic fascia was harvested, transplanted for forearm coverage, and its distal extent wrapped
around skeletonized extensor tendons.
CASE REPORT:
A 35 year-old right-hand-dominant man sustained a left forearm crush injury in an all-terrain-vehicle rollover accident. The patient had
open radius and ulna fractures, with significant muscle loss at the muscle-tendon junction. The resultant defect involved a large circumferential
wound with skeletonized extensor tendons. After serial debridement, ORIF of the comminuted radius and ulna, and cable graft
reconstruction of the ulnar nerve, the contralateral dorsal thoracic fascia was harvested. The flap was thin and well vascularized measuring
8X15 cm in dimension. It was successfully transplanted to provide vascular cover of the ulnar nerve reconstruction, flexor tendons,
plated fracture sites, and its distal extent was wrapped around the extensor tendons. There were no complications.
CONCLUSION:
The dorsal thoracic fascial flap is an excellent option for reconstructing large complex wounds requiring thin, supple, vascular tissue,
which is completely or partially buried. It can be utilized for many applications, but is especially suited for circumferential wrap of tendons
and/or obliteration of complex dead space. It is one of the largest sources of vascular fascia, its harvest is associated with little
morbidity and its transplantation does not result in a bulky reconstruction.
The Pedicled FHL Flap: A Good Option When Options Aren't Good
Institution where the work was prepared: New York University School of Medicine, New York, NY, USA
Otway Louie1; Evan Garfein1; Jamie P. Levine2; Pierre Saadeh1; (1)NYU Medical Center, (2)New York University School
of Medicine
INTRODUCTION:
Lower extremity wounds remain challenging problems for even the most experienced reconstructive surgeon. Wounds of the distal
third of the tibia and ankle, in particular, frequently require free flap reconstruction, given the paucity of described local flap options.
Additionally, free flaps around the knee are represent difficulty with regard to recipient vessels. We present an anatomical study of the
pedicled flexor hallicus longus (FHL) flap (proximally or distally based) and clinical examples of its use.
METHODS:
The anatomic approach and arc of rotation of the FHL flap was defined in 8 cadavers. The distally and proximally based FHL flaps were
used in lower extremity reconstruction.
RESULTS:
Optimal approach to the FHL was prone, through an incision over the fibula with dissection between the lateral and posterior compartments.
The FHL was dissected off the fibula with its peroneal artery to the tibioperonal bifurcation. Distally, flap dissection proceeded
to just below maleolar level. The flap could be proximally or distally based allowing for coverage of defects up to 8x12cm of the distal
tibia and ankle. Anterior defects could be directly accessed via a local opening in the interosseous septum. A distally based FHL flap
was used to reconstruct a 6x8cm distal posterior tibial/calcaneal sarcoma resection defect. The patient had 3 vessel runoff into the foot
and adequate foot /retrograde flap perfusion (tested by peroneal artery occlusion). There was no flap loss and the patient went on to
receive XRT at 6wks post op. A patient with injuries including a posterior knee dislocation required coverage of an open knee wound
for which local flap options were precluded due to disruption of local vasculature. A proximally based FHL flap was used to provide a
covered vascular leash with excellent vessel size match for reconstruction with a free rectus flap.
CONCLUSIONS:
The pedicled FHL flap is a useful option in lower extremity reconstruction. Caveats for its use include the need for adequate leg inflow
and foot outflow. Additionally, the distally based flap requires adequate collateral circulation from the posterior/anterior tibial systems.
Supercharging to these vessels may extend the use of this flap in situations of compromised vasculature. Additionally, the flap may be
proximally based effectively allowing for an "insulated extension cord" to which donor vessels may be attached.
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