The Reconstruction of the Mutilated Hand

ABSTRACT

The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.

Mutilated hand - hand reconstruction - free flaps - soft tissue

REFERENCES

• 1 Brenner P, Lassner F, Becker M, Berger A. Timing of free microsurgical tissue transfer for the acute phase of hand injuries.  Scand J Plast Reconstr Surg Hand Surg. 1997;  31 165-170
• 2 Neumeister M W, Brown R E. Mutilating hand injuries: principles and management.  Hand Clin. 2003;  19 1-15, v
• 3 Bueno Jr R A, Neumeister M W. Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment.  Hand Clin. 2003;  19 193-204
• 4 Medalie D A. Perforator-based forearm and hand adipofascial flaps for the coverage of difficult dorsal hand wounds.  Ann Plast Surg. 2002;  48 477-483
• 5 Koschnick M, Bruener S, Germann G. Free tissue transfer: an advanced strategy for postinfection soft-tissue defects in the upper extremity.  Ann Plast Surg. 2003;  51 147-154
• 6 Levin L S, Erdmann D. Primary and secondary microvascular reconstruction of the upper extremity.  Hand Clin. 2001;  17 447-455, ix
• 7 Talbot S G, Athanasian E A, Cordeiro P G, Mehrara B J. Soft tissue reconstruction following tumor resection in the hand.  Hand Clin. 2004;  20 vi, 181-202
• 8 O'Neill P J, Litts C. Hand and forearm reconstruction after skin cancer ablation.  Clin Plast Surg. 2004;  31 113-119
• 9 Chen H C, Buchman M T, Wei F C. Free flaps for soft tissue coverage in the hand and fingers.  Hand Clin. 1999;  15 541-554
• 10 Germann G, Bruener S. Free flap coverage of palmar hand wounds.  Tech Hand Up Extrem Surg. 2000;  4 272-281
• 11 Tsai F C, Yang J Y, Mardini S, Chuang S S, Wei F C. Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects.  Plast Reconstr Surg. 2004;  113 185-193; discussion 194–195
• 12 Kim J T, Kim S K. Hand resurfacing with the superthin latissimus dorsi perforator-based free flap.  Plast Reconstr Surg. 2003;  111 366-370
• 13 Li X J, Tong J, Wang Y. Combined free toe and free deep inferior epigastric perforator flap for reconstruction of the thumb and thumb web space.  J Reconstr Microsurg. 2000;  16 427-436
• 14 Sakai S. Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers.  Plast Reconstr Surg. 2003;  111 1412-1420; discussion 1421–1422
• 15 Brown D M, Upton J, Khouri R K. Free flap coverage of the hand.  Clin Plast Surg. 1997;  24 57-62
• 16 Pelzer M, Sauerbier M, Germann G, Tränkle M. Free “kite” flap: a new flap for reconstruction of small hand defects.  J Reconstr Microsurg. 2004;  20 367-372
• 17 Takeishi M, Ishida K, Kurihara K. Free dorsal middle phalangeal finger flap.  J Reconstr Microsurg. 2006;  22 493-498
• 18 Lee H B, Tark K C, Rah D K, Shin K S. Pulp reconstruction of fingers with very small sensate medial plantar free flap.  Plast Reconstr Surg. 1998;  101 999-1005
• 19 Işik S, Sezgin M, Oztürk S, Selmanpakoğlu N, Kütükçü Y. Free musculofasciocutaneous medial plantar flap for reconstruction of thenar defects.  Br J Plast Surg. 1997;  50 116-120
• 20 Okazaki M, Ueda K, Niu A, Momosawa A. Free lateral supramalleolar flap transfer as a small, thin flap.  Ann Plast Surg. 2002;  49 133-137
• 21 Hahn S B, Park H J, Kang H J, Kang E S. Finger reconstruction with a free neurovascular wrap-around flap from the big toe.  J Reconstr Microsurg. 2001;  17 319-323
• 22 Yang J W, Lee D C. Reconstruction of pulp defect using a free finger-pulp flap from an excised extra digit.  Br J Plast Surg. 2000;  53 703-704
• 23 Ninkovíc M M, Schwabegger A H, Wechselberger G, Anderl H. Reconstruction of large palmar defects of the hand using free flaps.  J Hand Surg [Br]. 1997;  22 623-630
• 24 Pederson W C. Upper extremity microsurgery.  Plast Reconstr Surg. 2001;  107 1524-1537; discussion 1538–1539, 1540–1543
• 25 Brandt K, Khouri R K, Upton J. Free flap as flow-through vascular conduits for simultaneous coverage and revascularization of the hand or digit.  Plast Reconstr Surg. 1996;  98 321-327
• 26 Shen Y M, Shen Z Y. Greater omentum in reconstruction of refractory wounds.  Chin J Traumatol. 2003;  6 81-85
• 27 Salgado C J, Orlando G S, Serletti J M. Clinical applications of the posterior rectus sheath-peritoneal free flap.  Plast Reconstr Surg. 2000;  106 321-326
• 28 Del Piñal F, Pisani D, García-Bernal F J, Regalado J, Del Pino F J, Ayala H. Massive hand crush: the role of a free muscle flap to obliterate the dead space and to clear deep infection.  J Hand Surg [Br]. 2006;  31 588-592
• 29 McGill D, Watson S. A novel use of the free gracilis muscle flap in hand trauma.  Plast Reconstr Surg. 2005;  115 1801-1802
• 30 Hwang K, Han J Y, Chung I H. Topographical anatomy of the anconeus muscle for use as a free flap.  J Reconstr Microsurg. 2004;  20 631-636
• 31 Kawamura K, Yajima H, Kobata Y, Shigematsu K, Takakura Y. Clinical applications of free soleus and peroneal perforator flaps.  Plast Reconstr Surg. 2005;  115 114-119
• 32 Hatoko M, Muramatsu T. The use of latissimus dorsi muscle flap in the aesthetical reconstruction of heat-press injury of the hand.  Burns. 2001;  27 75-80
• 33 Topalan M, Ozden B C, Aydin A, Erer M. Use of free serratus anterior muscle slips for the reconstruction of dorsal-side defects of the hand resulting from hot press injury.  J Burn Care Rehabil. 2004;  25 346-348
• 34 del Piñal F, Herrero F. Extensor digitorum brevis free flap: anatomic study and further clinical applications.  Plast Reconstr Surg. 2000;  105 1347-1356
• 35 Horch R E, Stark G B. The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft-tissue defects.  Plast Reconstr Surg. 1999;  103 1421-1427
• 36 Pan C H, Chuang S S, Yang J Y. Thirty-eight free fasciocutaneous flap transfers in acute burned-hand injuries.  Burns. 2007;  33 230-235
• 37 Yildirim S, Taylan G, Eker G, Aköz T. Free flap choice for soft tissue reconstruction of the severely damaged upper extremity.  J Reconstr Microsurg. 2006;  22 599-609
• 38 Ulkur E, Uygur F, Karagöz H, Celiköz B. Use of free dorsoulnar perforator flap in the treatment of postburn contractures of the fingers.  Burns. 2006;  32 770-775
• 39 Kim H H, Jeong J H, Seul J H, Cho B C. New design and identification of the medial sural perforator flap: an anatomical study and its clinical applications.  Plast Reconstr Surg. 2006;  117 1609-1618
• 40 Turner A, Ragowannsi R, Hanna J, Teo T C, Blair J W, Pickford M A. Microvascular soft tissue reconstruction of the digits.  J Plast Reconstr Aesthet Surg. 2006;  59 441-450
• 41 Woo S H, Seul J H. Optimizing the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers.  Plast Reconstr Surg. 2001;  107 1-8
• 42 Adani R, Tarallo L, Marcoccio I, Cipriani R, Gelati C, Innocenti M. Hand reconstruction using the thin anterolateral thigh flap.  Plast Reconstr Surg. 2005;  116 467-473; discussion 474–477
• 43 Wang H T, Fletcher J W, Erdmann D, Levin L S. Use of the anterolateral thigh free flap for upper-extremity reconstruction.  J Hand Surg [Am]. 2005;  30 859-864
• 44 Kim K S, Kim E S, Kim D Y, Lee S Y, Cho B H. Resurfacing of a totally degloved hand using thin perforator-based cutaneous free flaps.  Ann Plast Surg. 2003;  50 77-81
• 45 Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients.  Plast Reconstr Surg. 2001;  108 1197-1208; discussion 1209–1210
• 46 Park J J, Kim J S, Chung J I. Posterior interosseous free flap: various types.  Plast Reconstr Surg. 1997;  100 1186-1197; discussion 1198–1199
• 47 Fan C Y, Jiang J, Zeng B F, Jiang P Z, Cai P H, Chung K C. Reconstruction of thumb loss complicated by skin defects in the thumb-index web space by combined transplantation of free tissues.  J Hand Surg [Am]. 2006;  31 236-241
• 48 Ho T, Couch M, Carson K, Schimberg A, Manley K, Byrne P J. Radial forearm free flap donor site outcomes comparison by closure methods.  Otolaryngol Head Neck Surg. 2006;  134 309-315
• 49 Ofer N, Baumeister S, Ohlbauer M, Germann G, Sauerbier M. [Microsurgical reconstruction of the burned upper extremity].  Handchir Mikrochir Plast Chir. 2005;  37 245-255
• 50 Kaufman M R, Jones N F. The reverse radial forearm flap for soft tissue reconstruction of the wrist and hand.  Tech Hand Up Extrem Surg. 2005;  9 47-51
• 51 Chen S L, Chen T M, Lee C H. Free medial sural artery perforator flap for resurfacing distal limb defects.  J Trauma. 2005;  58 323-327
• 52 Baumeister S, Köller M, Dragu A, Germann G, Sauerbier M. Principles of microvascular reconstruction in burn and electrical burn injuries.  Burns. 2005;  31 92-98
• 53 Hashmi P M. Free scapular flap for reconstruction of upper extremity defects.  J Coll Physicians Surg Pak. 2004;  14 485-488
• 54 Hough M, Fenn C, Kay S P. The use of free groin flaps in children.  Plast Reconstr Surg. 2004;  113 1161-1166
• 55 Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Kawai A. Vascularized femoral nerve graft with anterolateral thigh true perforator flap for massive defects after cancer ablation in the upper arm.  J Reconstr Microsurg. 2003;  19 299-302
• 56 Mardini S, Tsai F C, Wei F C. The thigh as a model for free style free flaps.  Clin Plast Surg. 2003;  30 473-480
• 57 Javaid M, Cormack G C. Anterolateral thigh free flap for complex soft tissue hand reconstructions.  J Hand Surg [Br]. 2003;  28 21-27
• 58 del Piñal F, Herrero F, Jado E, Oteo J A, Garcia-Bernal F. Salvage and functional rehabilitation of a massively crushed hand with two sequential free flaps.  J Trauma. 2002;  53 980-983
• 59 Cavadas P C. Posterior interosseous free flap with extended pedicle for hand reconstruction.  Plast Reconstr Surg. 2001;  108 897-901
• 60 Flügel A, Kehrer A, Heitmann C, Germann G, Sauerbier M. Coverage of soft-tissue defects of the hand with free fascial flaps.  Microsurgery. 2005;  25 47-53
• 61 Hallock G G. The utility of both muscle and fascia flaps in severe upper extremity trauma.  J Trauma. 2002;  53 61-65
• 62 Walton R L, Matory W E, Petry J J. The posterior calf fascial free flap.  Plast Reconstr Surg. 1985;  76 914-26
• 63 Wintsch K, Helaly P. Free flap of gliding tissue.  J Reconstr Microsurg. 1986;  2 143-151
• 64 Meland N B, Weimar R. Microsurgical reconstruction: experience with free fascia flaps.  Ann Plast Surg. 1991;  27 1-8
• 65 Millesi H. Free flap of gliding tissue.  J Reconstr Microsurg. 1986;  2 151
• 66 Rogachefsky R A, Ouellette E A, Mendietta C G, Galpin P. Free temporoparietal fascial flap for coverage of a large palmar forearm wound after hand replantation.  J Reconstr Microsurg. 2001;  17 421-423
• 67 Brent B, Upton J, Acland R D et al.. Experience with the temporoparietal fascial free flap.  Plast Reconstr Surg. 1985;  76 177-188
• 68 Biswas G, Lohani I, Chari P S. The sandwich temporoparietal free fascial flap for tendon gliding.  Plast Reconstr Surg. 2001;  108 1639-1645
• 69 Yano H, Fukui M, Yamada K, Nishimura G. Endoscopic harvest of free temporoparietal fascial flap to improve donor-site morbidity.  Plast Reconstr Surg. 2001;  107 1003-1009
• 70 Chung K C, Cederna P S. Endoscopic harvest of temporoparietal fascial free flaps for coverage of hand wounds.  J Hand Surg [Am]. 2002;  27 525-533
• 71 Kim P S, Gottlieb J R, Harris G D, Nagle D J, Lewis V L. The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery.  Plast Reconstr Surg. 1987;  79 72-80
• 72 Yano H, Nishimura G, Kaji S, Murakami R, Fujii T. A clinical and histologic comparison between free temporoparietal and scapular fascial flaps.  Plast Reconstr Surg. 1995;  95 452-462
• 73 Jin Y T, Cao H P, Chang T S. Clinical application of the free scapular fascial flap.  Ann Plast Surg. 1989;  23 170-177
• 74 Koshima I, Inagawa K, Jitsuiki Y, Tsuda K, Moriguchi T, Watanabe A. Scarpa's adipofascial flap for repair of wide scalp defects.  Ann Plast Surg. 1996;  36 88-92
• 75 Datiashvili R O, Shibaev EYu, Chichkin V G, Oganesian A R. Reconstruction of a complex defect of the hand with two distinct segments of the scapula and a scapular fascial flap transferred as a single transplant.  Plast Reconstr Surg. 1992;  90 687-694
• 76 Yildirim S, Taylan G, Aköz T. Use of fascia component of the anterolateral thigh flap for different reconstructive purposes.  Ann Plast Surg. 2005;  55 479-484
• 77 Hsieh C H, Yang C C, Kuo Y R, Tsai H H, Jeng S F. Free anterolateral thigh adipofascial perforator flap.  Plast Reconstr Surg. 2003;  112 976-982
• 78 Muneuchi G, Suzuki S, Ito O, Kawazoe T. Free anterolateral thigh fasciocutaneous flap with a fat/fascia extension for reconstruction of tendon gliding surface in severe bursitis of the dorsal hand.  Ann Plast Surg. 2002;  49 312-316
• 79 Fotopoulos P, Holmer P, Leicht P, Elberg J J. Dorsal hand coverage with free serratus fascia flap.  J Reconstr Microsurg. 2003;  19 555-559
• 80 Buehler M J, Pacelli L, Wilson K M. Serratus fascia “sandwich” free-tissue transfer for complex dorsal hand and wrist avulsion injuries.  J Reconstr Microsurg. 1999;  15 315-320
• 81 Fassio E, Laulan J, Aboumoussa J, Senyuva C, Goga D, Ballon G. Serratus anterior free fascial flap for dorsal hand coverage.  Ann Plast Surg. 1999;  43 77-82
• 82 Schwabegger A H, Hussl H, Rainer C, Anderl H, Ninković M M. Clinical experience and indications of the free serratus fascia flap: a report of 21 cases.  Plast Reconstr Surg. 1998;  102 1939-1946
• 83 Summers A N, Sanger J R, Matloub H S. Lateral arm fascial flap: microarterial anatomy and potential clinical applications.  J Reconstr Microsurg. 2000;  16 279-286
• 84 Chen H C, el-Gammal T A. The lateral arm fascial free flap for resurfacing of the hand and fingers.  Plast Reconstr Surg. 1997;  99 454-459
• 85 Yousif N J, Warren R, Matloub H S, Sanger J R. The lateral arm fascial free flap: its anatomy and use in reconstruction.  Plast Reconstr Surg. 1990;  86 1138-1145; discussion 1146–1147
• 86 Chen H C, el-Gammal T A. The lateral arm fascial free flap for resurfacing of the hand and fingers.  Plast Reconstr Surg. 1997;  99 454-459
• 87 Hyza P, Vesely J, Stupka I, Cigna E, Monni N. The bilobed arterialized venous free flap for simultaneous coverage of 2 separate defects of a digit.  Ann Plast Surg. 2005;  55 679-683
• 88 De Lorenzi F, van der Hulst R R, den Dunnen W F et al.. Arterialized venous free flaps for soft-tissue reconstruction of digits: a 40-case series.  J Reconstr Microsurg. 2002;  18 569-574; discussion 575–577
• 89 Kantarci U, Cepel S, Gürbüz C. Venous free flaps for reconstruction of skin defects of the hand.  Microsurgery. 1998;  18 166-169
• 90 Inada Y, Fukui A, Tamai S, Mizumoto S. The arterialised venous flap: experimental studies and a clinical case.  Br J Plast Surg. 1993;  46 61-67
• 91 Nichter L S, Jazayeri M A. The physiologic basis for nonconventional vascular perfusion.  Plast Reconstr Surg. 1995;  95 406-412
• 92 Thatte M R, Thatte R L. Venous flaps.  Plast Reconstr Surg. 1993;  91 747-751
• 93 Alagoz M S, Uysal A C, Sensoz O. Staged and late-period reconstruction of the crushed hand: prefabricated osseous flap.  Ann Plast Surg. 2007;  58 84-90
• 94 Rui Y, Shou K, Zhang Q, Xu Y, Sun Z, Xu L. Combined free-tissue transfer for primary reconstruction of radial part of the hand.  Microsurgery. 2004;  24 59-62
• 95 Ozçelik D, Uğurlu K, Turan T. Reconstruction of the replanted hand with latissimus dorsi muscle and serratus anterior fascia combined flap.  J Reconstr Microsurg. 2003;  19 153-156
• 96 Jenkins N L, Lalikos J F, Wooden W A, Benacci J C, Meadows Jr W M. Innovative techniques in bony reconstruction to facilitate hand salvage.  Ann Plast Surg. 2002;  48 484-488
• 97 Chung K C, Tong L. Use of three free flaps based on a single vascular pedicle for complex hand reconstruction in an electrical burn injury: a case report.  J Hand Surg [Am]. 2001;  26 956-61
• 98 Akin S. Microvascular free on-top plasty in a mutilated hand.  Ann Plast Surg. 2001;  47 183-186 discussion 186-187
• 99 Lee H B, Tark K C, Kang S Y, Kim S W, Chung Y K. Reconstruction of composite metacarpal defects using a fibula free flap.  Plast Reconstr Surg. 2000;  105 1448-1452
• 100 Chen H C, Tang Y B, Mardini S, Tsai B W. Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators.  Microsurgery. 2004;  24 270-280
• 101 Hriscu M, Mojallal A, Breton P, Bouletreau P, Carret J P. Limb salvage in proximal humerus malignant tumors: the place of free vascularized fibular graft.  J Reconstr Microsurg. 2006;  22 415-421
• 102 Kremer T, Bickert B, Germann G, Heitmann C, Sauerbier M. Outcome assessment after reconstruction of complex defects of the forearm and hand with osteocutaneous free flaps.  Plast Reconstr Surg. 2006;  118 443-454 discussion 455-456
• 103 Momeni A, Stark G B. The free fibular flap: a useful flap for reconstruction following composite hand injuries.  J Hand Surg [Br]. 2006;  31 304-305
• 104 Hui K C, Zhang F, Lineaweaver W C, Moon W, Buncke G M, Buncke H J. Serratus anterior-rib composite flap: anatomic studies and clinical application to hand reconstruction.  Ann Plast Surg. 1999;  42 132-136
• 105 Adani R, Marcoccio I, Tarallo L. Flap coverage of dorsum of hand associated with extensor tendons injuries: a completely vascularized single-stage reconstruction.  Microsurgery. 2003;  23 32-39
• 106 Cavadas P C, Raimondi P. Free fillet flap of the hand for elbow preservation in nonreplantable forearm amputation.  J Reconstr Microsurg. 2004;  20 363-366
• 107 Terán P, Araya E, Casado C. Reconstruction of a pulp defect using a free finger-pulp flap from a non-replantable digit.  Br J Plast Surg. 2002;  55 158-159
• 108 Küntscher M V, Erdmann D, Homann H H, Steinau H U, Levin S L, Germann G. The concept of fillet flaps: classification, indications, and analysis of their clinical value.  Plast Reconstr Surg. 2001;  108 885-896
• 109 Brown R E, Wu T Y. Use of “spare parts” in mutilated upper extremity injuries.  Hand Clin. 2003;  19 73-87, vi