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RESURFACING OF A COMPLEX UPPER EXTREMITY INJURY: AN EXCELLENT INDICATION FOR THE DORSAL THORACIC FASCIAL FLAP RON HAZANI, M.D., 1 * DARRELL BROOKS, M.D., 2 and RUDOLF F. BUNTIC, M.D. 2 We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabi- lization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying struc- tures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months fol- low-up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use. V V C 2008 Wiley-Liss, Inc. Microsurgery 29:128–132, 2009. Mutilating injuries of the upper extremity can present as a challenge to the reconstructive surgeon. Complex wounds may involve open fractures, exposed vessels, transected nerves, and skeletonized tendons. Upper ex- tremity reconstruction requires durable tissue that is able to protect the underlying structures and withstand joint motion. Methods of reconstruction include skin grafting, local flaps, and free tissue transfer. Skin grafts have limited du- rability, and local flaps are usually found in the zone of injury. Free flap transplantation is an excellent alterna- tive; however, not all flaps offer the same advantage. Muscle flaps are bulky and large, and fasciocutaneous flaps do not easily conform to the contour of the forearm. Fascial flaps are an ideal choice for resurfacing upper extremity wounds. They are tough, thin, pliable, and pro- vide a surface for tendon gliding. We present the success- ful use of the dorsal thoracic fascial flap (DTFF) in resur- facing a severely crushed forearm injury and demonstrate its minimal donor-site morbidity. The DTFF can be par- ticularly useful in cases requiring flap transection for sec- ondary revision as illustrated in this report. The severity of this mutilating injury and the functional result after reconstruction have not been presented previously and are of great value to the readers. CASE REPORT A 24-year-old right-hand-dominant male sustained a significant crush injury to the left forearm after an all-ter- rain vehicle rollover collision. Initial survey of his inju- ries revealed open fractures of the radius and ulna, signif- icant bone loss, and transection of the ulnar artery and nerve. Operative management consisted of external fixa- tion, repair of the transected ulnar artery, and fasciotomy of the forearm compartments. The patient was then transferred to our tertiary care center for management of his soft tissue injuries. Physical examination revealed a circumferential wound with muscle and tendon avulsions, and skeletonized extensor tendons (see Fig. 1). Radio- graphic imaging confirmed comminuted shortening of the long bones. Angiography demonstrated good flow through the palmar arch, a patent radial artery, and a compro- mised ulnar artery anastomosis (see Fig. 2). We proceeded with serial debridements of the ne- crotic tissue and plate fixation of the radius and ulna (see Fig. 3). Internal skeletal fixation was particularly crucial for stabilization of the free-floating bony segment of the radius. Subsequently, a unique tissue was required to resurface the large circumferential wound, protect the underlying structures, obliterate the dead space between the tendons and the exposed plates, and provide a gliding surface for the skeletonized tendons. We chose the dorsal thoracic fascial flap as an ideal candidate. The patient was placed in a left lateral decubitus posi- tion to facilitate simultaneous harvesting of the flap and preparation of the recipient bed. An incision was made dorsally between the spine of the scapula and the inferior angle of the scapula. The apex of the incision was over the triangular space and extended posteriorly toward the midline. Skin flaps were elevated to expose the dorsal thoracic fascia. A fascial flap was then developed from the medial to the lateral aspect of the back. Prior to reaching the triangular space, care was taken to ligate several muscle perforators. The circumflex scapular artery Presented at: The American Society of Reconstructive Microsurgery Annual Meeting, Beverly Hills, California, January 15, 2008. 1 Division of Plastic Surgery, University of Louisville School of Medicine, Louisville, KY 2 Division of Microsurgical Transplantation and Replantation, The Buncke Clinic, San Francisco, CA *Correspondence to: Ron Hazani, M.D., Division of Plastic Surgery, Univer- sity of Louisville School of Medicine, ACB Building, 2nd Floor, 550 South Jackson Street, Louisville, KY 40292. E-mail: [email protected] Received 14 August 2008; Accepted 14 October 2008 Published online 18 December 2008 in Wiley InterScience (www.interscience. wiley.com). DOI 10.1002/micr.20603 V V C 2008 Wiley-Liss, Inc.

Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

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Page 1: Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

RESURFACING OF A COMPLEX UPPER EXTREMITY INJURY:AN EXCELLENT INDICATION FOR THE DORSAL THORACICFASCIAL FLAP

RON HAZANI, M.D.,1* DARRELL BROOKS, M.D.,2 and RUDOLF F. BUNTIC, M.D.2

We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabi-lization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying struc-tures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months fol-low-up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that isbased on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremityinjuries and highly recommend its use. VVC 2008 Wiley-Liss, Inc. Microsurgery 29:128–132, 2009.

Mutilating injuries of the upper extremity can present as

a challenge to the reconstructive surgeon. Complex

wounds may involve open fractures, exposed vessels,

transected nerves, and skeletonized tendons. Upper ex-

tremity reconstruction requires durable tissue that is able

to protect the underlying structures and withstand joint

motion.

Methods of reconstruction include skin grafting, local

flaps, and free tissue transfer. Skin grafts have limited du-

rability, and local flaps are usually found in the zone of

injury. Free flap transplantation is an excellent alterna-

tive; however, not all flaps offer the same advantage.

Muscle flaps are bulky and large, and fasciocutaneous

flaps do not easily conform to the contour of the forearm.

Fascial flaps are an ideal choice for resurfacing upper

extremity wounds. They are tough, thin, pliable, and pro-

vide a surface for tendon gliding. We present the success-

ful use of the dorsal thoracic fascial flap (DTFF) in resur-

facing a severely crushed forearm injury and demonstrate

its minimal donor-site morbidity. The DTFF can be par-

ticularly useful in cases requiring flap transection for sec-

ondary revision as illustrated in this report. The severity

of this mutilating injury and the functional result after

reconstruction have not been presented previously and are

of great value to the readers.

CASE REPORT

A 24-year-old right-hand-dominant male sustained a

significant crush injury to the left forearm after an all-ter-

rain vehicle rollover collision. Initial survey of his inju-

ries revealed open fractures of the radius and ulna, signif-

icant bone loss, and transection of the ulnar artery and

nerve. Operative management consisted of external fixa-

tion, repair of the transected ulnar artery, and fasciotomy

of the forearm compartments. The patient was then

transferred to our tertiary care center for management of

his soft tissue injuries. Physical examination revealed a

circumferential wound with muscle and tendon avulsions,

and skeletonized extensor tendons (see Fig. 1). Radio-

graphic imaging confirmed comminuted shortening of the

long bones. Angiography demonstrated good flow through

the palmar arch, a patent radial artery, and a compro-

mised ulnar artery anastomosis (see Fig. 2).

We proceeded with serial debridements of the ne-

crotic tissue and plate fixation of the radius and ulna (see

Fig. 3). Internal skeletal fixation was particularly crucial

for stabilization of the free-floating bony segment of the

radius. Subsequently, a unique tissue was required to

resurface the large circumferential wound, protect the

underlying structures, obliterate the dead space between

the tendons and the exposed plates, and provide a gliding

surface for the skeletonized tendons. We chose the dorsal

thoracic fascial flap as an ideal candidate.

The patient was placed in a left lateral decubitus posi-

tion to facilitate simultaneous harvesting of the flap and

preparation of the recipient bed. An incision was made

dorsally between the spine of the scapula and the inferior

angle of the scapula. The apex of the incision was over

the triangular space and extended posteriorly toward the

midline. Skin flaps were elevated to expose the dorsal

thoracic fascia. A fascial flap was then developed from

the medial to the lateral aspect of the back. Prior to

reaching the triangular space, care was taken to ligate

several muscle perforators. The circumflex scapular artery

Presented at: The American Society of Reconstructive Microsurgery AnnualMeeting, Beverly Hills, California, January 15, 2008.

1Division of Plastic Surgery, University of Louisville School of Medicine,Louisville, KY2Division of Microsurgical Transplantation and Replantation, The BunckeClinic, San Francisco, CA

*Correspondence to: Ron Hazani, M.D., Division of Plastic Surgery, Univer-sity of Louisville School of Medicine, ACB Building, 2nd Floor, 550 SouthJackson Street, Louisville, KY 40292. E-mail: [email protected]

Received 14 August 2008; Accepted 14 October 2008

Published online 18 December 2008 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20603

VVC 2008 Wiley-Liss, Inc.

Page 2: Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

was then identified and traced into the triangular space.

The vein and artery were ligated and the flap was taken

off the operative field (see Fig. 4).

Concurrently, a second team was working on the

left arm. With the aid of microscope magnification, the

ulnar artery and nerve were explored. The ulnar artery

was prepared as the recipient vessel for our transplanta-

tion. The proximal and distal edges were freshened, and

good pulsatile flow was noted from both ends—consist-

ent with a patent palmar arch. The ulnar nerve was then

approached. To cable graft a 4 cm gap at the injury

site, a 16 cm superficial peroneal nerve was harvested.

The nerve was then transected into four segments and

inset with identification of like fascicular groups (see

Fig. 5).

The flap, measuring �15 3 25 cm in its largest

dimension, was brought to the field and anastomosed to

the proximal ulnar artery edge in an end-to-end fashion.

Good flow was noted in the flap and throughout the

venae comitantes. For our venous outflow, we used the

Figure 1. Mutilating injury of the upper extremity after skeletal fixa-

tion. (Above) circumferential wound with a small dorsal skin bridge.

(Below) skeletonized extensor tendons. [Color figure can be viewed in

the online issue, which is available at www.interscience.wiley.com.]

Figure 2. Angiography of the distal forearm. The arrow is pointing

to the partially compromised ulnar artery anastomosis at the zone

of injury. A free floating segment of the distal radius is also demon-

strated in this image. [Color figure can be viewed in the online

issue, which is available at www.interscience.wiley.com.]

Figure 3. Internal fixation of the radius and ulna. (Above) A view of

the injury site following plate-fixation and soft tissue debridement.

(Below) X-ray of the distal forearm demonstrating plate reduction of

the radius and ulna. [Color figure can be viewed in the online issue,

which is available at www.interscience.wiley.com.]

Dorsal Thoracic Fascial Flap 129

Microsurgery DOI 10.1002/micr

Page 3: Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

superficial veins of the forearm. An implantable venous

Doppler (Cook Vascular, Leechburg, PA) was placed for

postoperative monitoring. Inset of the flap allowed cover-

age of the nerve reconstruction, the arterial anastomosis,

and the exposed tendons on the volar aspect of the ex-

tremity extending onto the extensor side (see Fig. 6). The

flap was large enough to wrap around the skeletonized

extensor digitorum tendons in a ‘‘hotdog-in-a-bun’’ fash-

ion. At the conclusion of the case, a large meshed split-

thickness skin graft was harvested from the lateral thigh

and applied to the open wound.

RESULTS

Postoperatively, the patient did well, and all wounds

healed with no incident. The patient was placed in a

long-arm splint, which permitted limited, gentle passive

and active range-of-motion of the digits. At 2 weeks, the

patient demonstrated preservation of function and contour

of the dorsal thoracic silhouette (see Fig. 7). At four-

months, the patient returned to the operating room for re-

vision of the skeletal fixation. For optimal exposure, we

were able to transect the flap longitudinally without com-

promising blood flow to the distal part. Elevation and

reinsetting of the fascial flap proceeded uneventfully. Six-

months following the injury, the patient demonstrated an

Figure 4. Intraoperative view of the harvest site. The fascial flap is

elevated based on the circumflex scapular vessels. [Color figure

can be viewed in the online issue, which is available at www.

interscience.wiley.com.]

Figure 5. The recipient site is prepared for micro-anastomosis of

the dorsal thoracic fascial flap to the proximal end of the ulnar ar-

tery. Cable grafting of a 4-cm ulnar nerve gap is demonstrated.

[Color figure can be viewed in the online issue, which is available

at www.interscience.wiley.com.]

Figure 6. Flap inset. [Color figure can be viewed in the online

issue, which is available at www.interscience.wiley.com.]

Figure 7. Donor-site at 2 weeks follow-up displaying preservation

of function and contour of the dorsal thoracic silhouette. [Color

figure can be viewed in the online issue, which is available at

www.interscience.wiley.com.]

130 Hazani et al.

Microsurgery DOI 10.1002/micr

Page 4: Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

excellent functional and esthetic outcome. The patient

was able to actively flex and extend all digits as illus-

trated in Figure 8. A positive Tinel’s sign was appreci-

ated 12 cm distal to the proximal repair of the ulnar

nerve. In addition, intrinsic muscle atrophy was noted in

the palm of the injured extremity.

DISCUSSION

Free flap transplantation allows for rapid closure of

difficult wounds, provides a robust blood supply to the

zone of injury, and facilitates clearing of infected

wounds. Coverage of an upper extremity wound can be

very challenging as it requires a tissue that easily con-

forms to the contour of the forearm and hand, protects

the underling structures, and provides a surface for ten-

don gliding. Fascial flaps possess the properties of such

tissue as a thin, pliable, and durable flap.1

As with other types of free flaps, fascial flaps have

their limitations inherent to the tissue with regard to tex-

ture, location, size, and pedicle length. The radial forearm

fascial flap requires the sacrifice of a major artery to the

hand,2 and patients with thin subcutaneous tissues may

experience delayed healing of the donor site.1 The lateral

arm flap is limited by the pedicle length and flap size.3

Temporoparietal fascial flaps are limited by their short

vascular pedicle, unpredictable venous anatomy, and

small dimension of �100 cm2.4

The dorsal thoracic fascial flap can be harvested

based on a long vascular leash and provide a significant

amount of tissue as its vascular territory encompass more

than 350 cm2.1 Its minimal donor-site morbidity makes

the DTFF a great option for young and active patients; it

maintains the dorsal thoracic silhouette while its absence

does not give rise to a functional disability.5

The dorsal thoracic fascia is defined as the anatomic

layer that provides blood supply to the scapular and para-

scapular fasciocutaneous flaps (see Fig. 9). In 1987, the

DTFF was identified as a free flap, an axial-patterned flap

based on the circumflex scapular vessels, which could be

transferred without the overlying skin and subcutaneous

tissue.6 Colen et al.1 have used the DTFF in reconstruc-

tion of the upper and lower extremities and demonstrated

its ability to resist shear forces in troublesome locations

such as the palm of the hand and the sole of the foot.

This case shows the versatility of the DTFF in upper

extremity reconstruction as it also permits for adjunctive

procedures and late secondary revisions. There is no

consensus in terms of how one should determine the

timing of flap division, and there is only limited clinical

literature on the topic.7 Serel et al.8 reported the use of

a free anterolateral thigh perforator flap for a cross-

bridge microvascular anastomosis. After a four-week

neovascularization period, the pedicle was cut, and the

flap demonstrated complete viability. Lau et al.7 demon-

strated the viability of a transected free rectus abdominis

muscle flap for reconstruction of the lower extremity af-

ter dividing the main pedicle at 6 weeks postoperatively.

In our experience, the DTFF was safely divided at 4

months follow-up, while not compromising the viability

of the transected part. We hypothesize that early neovas-

cularization of the distal aspect makes this fascial flap

an excellent candidate for upper extremity injuries

Figure 8. The patient demonstrating excellent active range-of-

motion at six-months follow-up. [Color figure can be viewed in the

online issue, which is available at www.interscience.wiley.com.]

Figure 9. The dorsal thoracic fascia and the vascular territory of

the circumflex scapular artery. [Color figure can be viewed in the

online issue, which is available at www.interscience.wiley.com.]

Dorsal Thoracic Fascial Flap 131

Microsurgery DOI 10.1002/micr

Page 5: Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

requiring secondary procedures without causing signifi-

cant morbidity.

Another advantage of the DTFF is its ability to oblit-

erate potential dead spaces while conforming to the con-

tour of the distal aspect of the extremity. In this case, the

fascial flap was wrapped around the extensor tendons and

eliminated a considerable amount of dead space between

the tendons and the plated radius. The ‘‘hotdog-in-a-bun’’

configuration did not distract from the ability of the ten-

dons to glide freely during the postoperative period as

demonstrated in our 6 months follow-up.

Although not exhibited in this case, we had consid-

ered designing the flap such that the branch of the serra-

tus anterior would connect as a T-shaped flow-through

flap to reconstruct the ulnar artery. A flow-through flap

can provide continuity to the ulnar aspect of the palmar

arch while perfusing the transplanted tissue. Free flaps as

flow-through vascular conduits for simultaneous coverage

and revascularization of the forearm,9 hand, and digits10

had been described previously. However, the flow-

through model did not allow for perfect inset of the fas-

cial flap in this case.

Use of the superficial peroneal nerve for grafting

motor and sensory defects of the ulnar nerve is based on

our previous experience with this donor site.11 Given the

limited number of donor sites and their topographic varia-

tions, Sunderland12 noted that the most valuable nerves

for grafting are the superficial radial and the sural nerves.

The superficial peroneal sensory nerve has several qual-

ities that make it an excellent autograft. Nonetheless, it

has generally been overlooked. Its length can be as long

as 40 cm, a comparable length to the sural nerve; the

anatomic pattern is relatively consistent, making the sur-

gical harvesting straightforward; harvest of the superficial

peroneal does not leave an anesthetic area on the plantar

aspect of the foot; and, intraoperative positioning are

greatly simplified in comparison with the sural nerve.11

The nerve can be harvested while the patient is in the

supine or the lateral decubitus position as demonstrated

in this case.

In conclusion, the dorsal thoracic fascia is a reliable

flap with consistent vascular anatomy and low donor-site

morbidity. Its thin and durable texture allows for inset of

this pliable tissue in locations that are usually difficult to

achieve contour. Our case underscores the utility of the

DTFF in the management of complex upper extremity

injuries. We highly recommend its use and believe that it

should be part of the armamentarium of the reconstruc-

tive surgeon.

REFERENCES

1. Colen LB, Pessa JE, Potparic Z, Reus WF. Reconstruction of the ex-tremity with the dorsal thoracic fascia free flap. Plast Reconstr Surg1998;101:738–744.

2. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Op-erative Approaches. New York: Thieme Medical Publishers; 1993.

3. Katsaros J, Tan E, Zoltie N, Barton M, Venugopalsrinivasan D, Ven-kataramakrishnan D. Further experience with the lateral arm freeflap. Plast Reconstr Surg 1991;87:902.

4. Buncke HJ. Microsurgery: Transplantation-Replantation. Philadel-phia: Lea and Feibiger; 1991.

5. Ugurlu K, Ozer K, Huthut I, Ozcelik D, Tatlidede S, Egemen O, BaL. Experimental fascial flap model in the dog: free flap of the dorsalthoracic fascia. J Reconstr Microsurg 2003;19:477–482.

6. Kim PS, Gottlieb JR, Harris GD, Nagle DJ, Lewis VL. The dorsalthoracic fascia: anatomic significance with clinical applications inreconstructive microsurgery. Plast Reconstr Surg 1987;79:72–80.

7. Lau KN, Park D, Dagum AB, Bui DT. Two for one: Salvage ofbilateral lower extremities with a single free flap. Ann Plast Surg2008;60:498–501.

8. Serel S, Kaya B, Demiralp O, Can Z. Cross-leg free anterolateralthigh perforator flap: A case report. Microsurgery 2006;26:190–192.

9. Costa H, Guimaraes I, Cardoso A, Malta A, Amarante J, GuimaraesF. One-staged coverage and revascularisation of traumatized limbsby a flow-through radial mid-forearm free flap. Br J Plast Surg1991;44:533–537.

10. Brandt K, Khouri RK, Upton J. Free flaps as flow-through vascularconduits for simultaneous coverage and revascularization of the handor digit. Plast Reconstr Surg 1996;98:321–327.

11. Buntic RF, Buncke HJ, Kind GM, Chin BT, Ruebeck D, BunckeGM. The harvest and clinical application of the superficial peronealsensory nerve for grafting motor and sensory nerve defects. PlastReconstr Surg 2002;109:145.

12. Sunderland S. Nerves and Nerve Injuries. Edingburgh. ChurchillLivingstone;1978.

132 Hazani et al.

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