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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.
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
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
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
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
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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.
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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.
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