Flow-through anterolateral thigh flap for reconstruction inelectrical burns of the severely damaged upper extremity

Yen-Chang Hsiao, Jui-Yung Yang, Cheng-Jen Chang, Chih-Hung Lin, Shu-Yin Chang,Shiow-Shuh Chuang *

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine,

Chang Gung University, Taipei, Taiwan

b u r n s 3 9 ( 2 0 1 3 ) 5 1 5 – 5 2 1

a r t i c l e i n f o

Article history:

Accepted 3 August 2012

Keywords:

Anterolateral thigh flap

Electrical burn

Flow through

a b s t r a c t

Background: Many surgeons have to face the challenge of the sophisticated management of

catastrophic high-voltage injuries to upper extremities. These patients present with both

vast soft tissue defects and varied segmental main artery defects with compromised

circulation of the distal limb. This study is a first attempt to analyze the outcome of the

flow-through anterolateral thigh flap for reconstruction in acute electrical burns of the

severely traumatized upper extremity.

Method and patient: From March 2001 to February 2012, five men were enrolled in the study.

All in this series suffered from high voltage current (higher than 1000 V) electrical burn and

had the presence of wide segmental soft tissue defects, exposure of underlying vital

structures and segmental artery injury with compromised circulation. Flow-through ante-

rolateral thigh flaps were used for limb salvage.

Result: Follow up for all patients was present from 6 months to 7 years. The mean age was

37.8 years old. The mean timing of free flap transfer was 5.8 days after injury. The mean flap

sizes were 31.6 cm � 16.5 cm. The mean artery defect was 14.2 cm in length. Venous

thrombosis occurred 1 day post-operatively in one patient. No donor site morbidity was

noted. In the postoperative period, no infection, no hematoma, nor deaths were noted.

Successful limb salvage rate was 80% in this series.

Conclusion: In electrical injuries of the severely damaged upper extremity, flow through

anterolateral thigh flaps provide for reconstruction of both the vessels and soft tissue

simultaneously. Although the risk of flap failure is higher than with other etiologies of

burn, the data shows that the above reconstruction technique is useful for upper extremity

salvage.

# 2012 Elsevier Ltd and ISBI. All rights reserved.

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/burns

1. Introduction

High voltage electrical injuries to upper extremities inevitably

result in devastating damage to tissue, especially at the

location of the entry and exit of the passage of current. The

* Corresponding author at: Department of Plastic and Reconstructive SuGung University, 5, Fu-Hsing Street, Kweishan, Taoyuan 333, Taiwan

E-mail addresses: sschuang@ms1.hinet.net, nosehsiao@gmail.com

0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved.http://dx.doi.org/10.1016/j.burns.2012.08.007

real territory of injury is usually underestimated and uncer-

tain during the initial evaluation. Devitalization and severe

damage of vital structures such as tendons, vessels, bones,

and nerves is usually not reflected in superficial wounds [1].

Systematic involvement is also a big challenge to all surgeons

[2]. Early aggressive debridement is essential and removal of

rgery, Chang Gung Memorial Hospital, College of Medicine, Chang. Tel.: +886 3 3281200x3355; fax: +886 3 3287260.

(S.-S. Chuang).

b u r n s 3 9 ( 2 0 1 3 ) 5 1 5 – 5 2 1516

necrotic tissue results in exposure of vital structures. Such

wound conditions cannot support the skin grafts well.

Therefore, reconstruction has to shift to using either local

flaps or free flaps. However, the source of the local flaps is

limited to the upper extremities. As a result, free flaps are

relatively suitable for the reconstruction of upper limbs.

Early use of microvascular free tissue transfer in electrical

injuries has been researched extensively in the past. The

advantages of free tissue transfer are early wound closure,

preservation of vital structures, improvement of function,

reduced hospitalization, and possible salvage of limbs [3–8].

Sometimes, severe electrical injuries to upper extremities may

cause segmental defects of the main artery (radial and ulnar

artery). The circulation will be compromised gradually if

vascular reconstruction is not established adequately at the

acute stage and may ultimately result in the loss of limbs [9–

11]. In the most difficult circumstances of electrical injuries,

vast soft tissue defects and main artery destruction occur at

the same time. The aim of reconstruction is simultaneous soft

tissue coverage and main artery revascularization. Conse-

quently, the flow-through free flap transfer offers the best

solution for such situations.

Previous studies only reported on either primary or

secondary reconstruction of damaged upper extremity caused

by varied etiologies by different type of flow-through free flaps

[9,10,12,13]. This study is a first attempt to analyze the

outcome of the single flap, the flow-through anterolateral

thigh flap for reconstruction in acute electrical burns of the

severely traumatized upper extremity.

2. Patient and methods

From March 2001 to February 2012, 6273 patients were admitted

to the burn unit at Linkou Chang Gung Memorial Hospital. Five

male patients were enrolled in the study. All patients in this

series suffered from high voltage current (higher than 1000 V)

electrical burn and had the presence of wide segmental soft

tissue defects, exposure of underlying vital structures including

vessels, nerves, bones and tendons, and segmental artery

injured with compromised circulation at severely traumatized

upper extremities (Table 1). Relatively cold temperature and

either weak or no distal pulses in the affected distal extremities

were noted. All patients received initial resuscitation including

fluid resuscitation, evaluation of risk of rhabdomyolysis

evaluation, close cardiac monitor, analgesia management,

Table 1 – Patient demographics.

Patient no. Age/gender Localization Timing(days)

Flap size(cm)

1 36/M Right wrist and forearm 8 33 � 15

2 51/M Right wrist and forearm 5 33 � 21.5

3 34/M Left wrist and forearm 7 28 � 15

4 30/M Right wrist and forearm 5 30 � 18

5 38/M Right wrist and forearm 4 30 � 13

Timing: the timing of free flap transfer after injury.

PR: proximal radial artery, PU: proximal ulnar artery, DR: distal radial ar

initial wound dressing, and escharotomies if needed. In order

to reconstruct the wide soft tissue defects as well as reestablish

adequate blood supply for the distal limb, flow-through

anterolateral thigh flaps were proposed.

Fasciocutaneous anterolateral thigh flaps were designed in

all patients. Free flap transfer was delayed until the patients’

general condition had become stable in order to ensure that

the patients were able to bear the long-term microvascular

reconstructive surgery. A two-team approach was carried out

involving one team performing the flap harvesting at the leg’s

donor site and one team preparing the recipient site at the

upper extremities. All devitalized tissues were debrided

radically until healthy tissues were visualized. Segmental

injured nerves were removed, and meanwhile, their proximal

and distal ends were identified and marked. In addition, the

blind ends of the injured tendons were marked for the

following reconstruction. The flap’s size was designed

depending on the size of the defect. The perforators were

identified by the hand-held Doppler preoperatively. All

recipient vessels were assessed microscopically for their

quality and sizable matching. All recipient arteries should

appear to have good pulsating flow when cut. Once the vessel’s

quality was not suitable for anastomosis, further dissection

proximally and distally from the zone of trauma was carried

out [14]. The vessels’ anastomosis was done by 9-0 Nylon

sutures under microscopic magnificent in the end-to-end

fashion without vein grafts. Suction drain tubes were inserted

routinely. The donor area was covered by the split-thickness

skin grafts. Heparinization was implemented according to the

formula (5000 u heparin in 500 cm3 normal saline run 20 cm3

per hour) for all patients postoperatively. Immobilization of

the upper limbs for 2 weeks was applied by customized splints.

The patients were transferred to the burn ICU for close

monitoring postoperatively. Each patient’s profile was docu-

mented including: age, gender, percentage of the burned area

to total body surface area (TBSA), the length of the vessel’s

defect, flap type, flap size, number of perforators, recipient

vessel, location of recipient area, timing of surgery after injury,

operative time, duration of hospital stay, donor-site morbidity,

complications and follow-up period.

3. Result

Follow up for all patients was done from 6 months to 7 years

(48 months on average). The mean age was 37.8 years old

Perforatornumber

Arterialdefect (cm)

Flow-throughfashion

Complication

4 12 PR to DR No

3 14 PU to DU Right thumb amputation

2 16 PR to DR Flap failure, below-

elbow amputation

2 10 PR to DR No

3 19 PU to DR 4th, 5th digits amputation

tery, DU: distal ulnar artery.

Fig. 1 – (Above) High-voltage electrical burn on right wrist

and right forearm with vital structure exposure and

vascular compromise on the hand. (Middle) Flow-through

anterolateral thigh flap for wound coverage and

revascularization. (Below) Postoperative view after 2

months.

b u r n s 3 9 ( 2 0 1 3 ) 5 1 5 – 5 2 1 517

(minimum 36, maximum 51). The mean size of the involved

area was 10.6%TBSA (minimum 7%TBSA, maximum

20%TBSA). The location of the free flap coverage in five

patients was right wrist and forearm. One patient was at left

side. The mean timing of free flap transfer was 5.8 days after

injury (minimum 4 days, maximum 8 days). Mean operative

time of surgery was 8.2 hours (minimum 7 hours, maximum

10 hours). The flap sizes were 28 cm � 15 cm to 3 cm � 1.5 cm

(average, 31.6 cm � 16.5 cm). The mean perforator of the

anterolateral thigh flaps was 2.8 (2–4). The mean artery defect

was 14.2 cm in length (12–19 cm). In three patients, the

proximal end of the radial artery was anastomosed to the

proximal end of the descending branch of LCFA of the flow-

through anterolateral thigh flap, and the distal end of the LCFA

was anastomosed to the distal end of the radial artery. In one

patient, the ulnar artery was used in the above fashion. In one

patient, the proximal end of the descending branch of the

LCFA was anastomosed to the ulnar artery, and the distal end

of it was anastomosed to the radial artery. Two concomitant

veins of the descending branch of LCFA were anastomosed to

either the radial or ulnar artery’s concomitant veins respec-

tively for the free flaps’ venous drain. Superficial veins were

only used at the salvage procedure if it was needed. No

superficial vein anastomosis was needed for limb’s drain

because the defects were not circumferential in all patients

and the distal limbs’ venous drain was patent from the non-

injured aspect. Venous thrombosis occurred 1 day post-

operatively in one patient. Even though salvage explorations

were performed twice, the flap failure was noted finally. The

patient received below-elbow amputation 10 days after free

flap transfer. No debridement was performed before the free

flap transfer. The mean hospitalization was 52.8 days

(minimum 31, maximum 72). No donor site morbidity was

noted. In the postoperative period, no infection, no hemato-

ma, nor patient’s mortality were noted. The successful limbs

salvage rate was 80% in this series.

4. Case report

4.1. Case no. 5

A 38-year-old male patient sustained a high-voltage (11,000 V)

electrical burn (Fig. 1) that caused third- to fourth-degree

burns on his right forearm, right upper arm, and left palm

(8%TBSA). Exposure of multiple flexor tendons and large

devitalized tissue were noted. During the initial examination,

no pulsation was noted at the distal part of the limb. Capillary

refill >2 sec was checked. The hand appeared pale and cold.

CTA was arranged immediately. It revealed complete occlu-

sion of the volar main artery including radial, ulnar and

anterior interosseous artery. The hand’s blood supply only

was nourished by the posterior interosseous artery (Fig. 2).

Initial resuscitation was performed at admission. Four days

following the injury, aggressive debridement was carried out.

All devitalized flexor tendons, nerves, ligaments, muscles and

vessels were removed radically. The severe injured 4th and 5th

digits were amputated at Metacarpal-phalanx-joint level.

Segmental arterial defect, 23 cm and median nervous defect,

20 cm in length were noted after debridement. A flow-through

free anterolateral thigh fasciocutaneous flap, 3 cm � 3 cm in

size including partial tensor fascia lata was harvested from the

left leg for wound coverage which was nourished by the

transverse branch of LCFA. The flap was composed of 3

perforators. All of the vessels’ quality for anastomosis were

checked under microscopic magnificent. The proximal end of

the radial artery was anastomosed to the transverse branch of

LCFA. The proximal end of the ulnar artery was anastomosed

to the descending branch of LCFA. The distal end of the

descending branch of the LCFA was anastomosed to the distal

end of the radial artery. In addition, each of the concomitant

veins of the radial and ulnar arteries were anastomosed to the

concomitant veins of the transverse and descending branch of

LCFA respectively for the flap’s venous drain. No superficial

vein was used for the distal limb’s venous drain because the

venous structures in the dorsal aspect of the forearm were

Fig. 2 – (Left) Preoperative CTA revealed compete occlusion

of main arteries on right forearm except posterior

interosseous artery. (Right) Postoperative CTA showed

well establishment of the flow-through system from

proximal ulnar artery to distal radial artery.

Fig. 3 – (Above) High-voltage electrical burn on left wrist

and left forearm. (Above-middle) After radial debridement,

injured extremity presented with vital structure exposure,

large soft tissue defect and distal compromised

circulation. (Below-middle) Reconstructed by the flow-

through free anterolateral thigh flap followed by venous

congestion postoperatively. (Below) Post below-elbow

amputation view.

b u r n s 3 9 ( 2 0 1 3 ) 5 1 5 – 5 2 1518

intact. The distal hand immediately turned warm and pink

after revascularization through the flow-through arterial

anastomosis. The donor site was covered with a split-

thickness skin graft from the medial thigh. Heparinization

formula was administrated for the first postoperative week.

The flap’s circulation was satisfactory postoperatively. CTA

study was arranged 3 weeks after surgery. The stable flow-

through arterial system was established from proximal ulnar

artery to distal radial artery (Fig. 2). The limb was salvaged.

Neither donor nor recipient site morbidity was noted during

the follow-up period.

4.2. Case no. 3

A 34-year-old male patient suffered from high-voltage

electrical injures, 20%TBSA and presented third- to fourth-

degree burns over his left forearm and wrist (Fig. 3). Poor

circulation of the distal limb was noted. In addition, right

parietal epidural hemorrhage was diagnosed and treated by

the neurosurgeon immediately. Seven days following the

injury, radical debridement leaving a 2 cm � 5 cm defect was

covered by a flow-through anterolateral thigh flap. His hand’s

circulation improved immediately after revascularization. No

heparinization administration was applied in order to prevent

risk of recurrent intracranial hemorrhage. Unfortunately, 1

day after surgery, the flap turned congestive. Therefore,

emergent exploration was arranged. Venous thrombus was

removed immediately and venous anastomosis was repaired

again. One day after the first exploration, the second salvage

exploration was arranged because the flap showed congestion

again. Superficial vein anastomosis with vein grafts was

carried out. In the following days, the flap’s circulation was

compromised gradually. Ten days after free flap transfer,

below-elbow amputation was performed. The patient was

discharged after 73 days of hospitalization.

b u r n s 3 9 ( 2 0 1 3 ) 5 1 5 – 5 2 1 519

5. Discussion

All surgeons have to face the challenge of the sophisticated

management of catastrophic high-voltage injuries to upper

extremities. To do so, they should immediately evaluate the

patient’s systematic condition, the patency of vascularity, and

the area of damaged tissue at the acute stage. Limb salvage,

functional recovery, and aesthetic appearance can be

achieved if primary reconstruction can be performed reason-

ably. Any delay in wound closure which results in desiccation

can increase morbidity because of tissue edema, inflamma-

tion, and infection [5]. Therefore, early debriding of the wound

and free tissue transfer can protect underlying healthy vital

structures, allow limbs salvage, and improve functional and

aesthetic results [1,4,6,15–17].

All five patients in this series had the presence of both vast

soft tissue defects and varied segmental main artery defects

with compromised circulation at distal limb. The advantage of

the flow-through free flap transfer is that it provides vascular

conduit and soft tissue coverage simultaneously. In addition,

artery-to-artery anastomoses are more conformable than vein

grafts as the bridge, and reducing the number of anastomosis

lowers the possible risk. In 1983, Soutar et al. first introduced

the flow-through concept, which involved using a radial

arterial flap in the reconstruction of the head and neck [18].

Then, Cormack and Lamberty used a fascio-cutaneous

forearm pedicled flap in flow-through fashion [19]. In 1984,

Foucher et al. first reported a flow-through compound radial

artery forearm flap in reconstruction of the extremities [20].

Brandt et al. reported their series of flow-through tempor-

oparietal fascia free flaps for hand and digit reconstruction at

primary and secondary reconstruction [9]. Kesiktas et al.

reported utilization of flow-through forearm flaps in upper

extremity salvage [13]. The concept of the flow-through flaps

can be applied into varied flaps with axial vascular pattern and

appropriate distal vessel size including free forearm flaps [11],

free fibular flaps [12], and anterolateral thigh flaps [10,21]. The

technique has been demonstrated to be safe and versatile.

In our series, we used the anterolateral thigh flap in the

flow-through fashion. The anterolateral thigh flap was first

proposed by Song et al. [22]. Koshima et al. first reported the

application of the anterolateral thigh flap as a flow-through

flap for reconstruction of defects in the upper extremities [23].

Yokota et al. also reported on the use of the short interposed

pedicle of flow-through anterolateral thigh flap for recon-

struction of damaged upper extremity [24]. Our series was the

first report that utilized early flow-through anterolateral thigh

flap transfer for primary upper extremity reconstruction

following severe high-voltage electrical burns. The anterolat-

eral thigh flap is reliable and suitable for flow-through fashion.

The advantages are as follows: (1) a large caliber and long

pedicle, (2) a large area of skin, (3) facilitates two-team

approach without changing patient’s position, (4) the versatile

application of chimeric composite flaps, (5) the fascial

component is an optimal gliding surface for the following

tendons reconstruction, (6) uses as sensate flaps, and (7) low

donor site morbidity [25–27]. The long pedicle length meets the

requirement if there is a need to establish the vascular

continuity by flow-through fashion in the scenario of the long

vascular segmental loss. Meanwhile, characteristics of vast

soft tissue coverage ensure the anastomosis site can be

covered safely and outside the zone of trauma. The anatomic

variation and steep learning curve is considered as its

disadvantage [28]. In our series, flow through anterolateral

thigh flaps provided optimal solution for simultaneous large

soft tissue coverage and vascular integrity reestablishment.

The selection of the recipient vessels, either radial or ulnar

artery, depends on the position of the flap and its vessel’s

anatomy. The recipient vessels should be sizable, in good

quality, and far from the zone of trauma.

The successful rate of 80% in our series is relatively lower

than in other studies (87–100%) [3–5,7,29,30]. In other reports,

the enrolled patients sustained either all kinds of etiology of

burns not specific to electrical burns or those specific to

electrical burns but without compromised circulation at the

distal limb. The territory of injury is thus more obscure and

more difficult to evaluate as electrical burn than in other

etiology of burns. The abnormalities in electrically injured

vessels include damage to endothelium and media, aneurysm

formations, vascular occlusions, and segmental narrowing

[29,31]. As a result, the healthy vessels can be used, which are

usually located 3 cm beyond the wound [14]. In the case of a

patient who had flap failure in our series, even though

intraoperative microscopic inspection of the patency of

vessels was performed precisely, the accurate zone of trauma

was still difficult to be evaluated initially in the electrical burn.

In addition, the lack of heparinization for this patient also

jeopardized the flap’s survival rate. The adequate periopera-

tive management after free tissue transfer may increase

successful rate including maintaining adequate perfusion of

the patient, anticoagulation agent [32] and prostaglandin

E1(PGE1) [33] administration. However, Dextran was not

routinely used due to its lack of an effect on overall flap

survival and because of the development of systematic

complications [34].

Mean operative time of surgery was 8.2 hours in this series.

Prolonged anesthesia time (>10 hours) may lead to the

development of significant systematic complications [35]. A

two-team approach may reduce surgical time. With burned

patients, regularly changing the patient’s position to prevent

pressure sore and rhabdomyolysis, monitor blood pressure

and urine output, keep adequate temperature and checking

blood gas during surgery combined with aggressive post-

operative chest care may reduce systematic complications.

The timing of free flap coverage has been classified into

three categories: immediate (<5 days), early (5–21 days), and

late (>21 days). The highest flap failure rate is at the early stage

[3]. For the patients with compromised circulation, early

establishment of adequate blood supply for limb salvage is

also a priority. However, early flap coverage is not always

possible in certain situations. The electrical burn patients

usually had comorbid problems, such as cardiovascular,

neurosurgical, renal functional, and hemodynamic problems,

which may delay the intention of the early flap coverage. If

burned patients sustained any unsolved systematic problems,

the free tissue transfer should be halted. Therefore, once all

comorbid problems are corrected, the flow through ante-

rolateral thigh flaps can provide reliable salvage in severe

electrical burn of the upper extremities at the early stage.

b u r n s 3 9 ( 2 0 1 3 ) 5 1 5 – 5 2 1520

However, if it is possible, performing free tissue transfer at

immediate stage can achieve optimal result because the blood

supply for distal limbs can be established early and the

survival rate of free flaps is higher at this stage.

6. Conclusion

In electrical injuries of the severely damaged upper

extremity, flow through anterolateral thigh flaps provide

for reconstruction of both the revascularization and soft

tissue coverage simultaneously. Although the risk of flap

failure is higher than with other etiology of burns, the data

shows that the above reconstruction is worthwhile for upper

extremity salvage.

Conflict of interest statement

None declared.

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