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CME

Upper Extremity MicrosurgeryWilliam C. Pederson, M.D.San Antonio, Texas

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the indications for freeflap coverage of the upper extremity. 2. Know the advantages and disadvantages of the flaps discussed. 3. Have a basicunderstanding of the anatomy of the flaps discussed. 4. Have a variety of options for free tissue transfer.

The application of microsurgical tissue transfer to re-construction of the upper extremity allows repair of sig-nificant bone and soft-tissue defects. Through the yearsthe approach has changed from one of simply getting thewound covered to primary reconstruction to preserve orregain function. A wide variety of free flaps offers thepotential to reconstruct nearly any defect of the arm andhand. Vascularized bone transfer can be utilized to repairlarge bony defects, while innervated free muscle transfercan replace missing muscle function. The total array offlaps and their indications is beyond the scope of a singlediscussion, but this article focuses on a few flaps that havefound application for coverage and functional restorationin the hand and upper extremity. (Plast. Reconstr. Surg.107: 1524, 2001.)

Since its inception, microsurgery has foundwide application in reconstructing the upperextremity. Digital replantation, which was firstperformed in 1968,1 probably represents thepinnacle of reconstruction in the hand, be-cause it allows exact replacement of the miss-ing part. The replacement of missing parts inkind was extrapolated in 1969, when Cobbett2

reported the first great toe transfer to replace amissing thumb. Although the first successfulfree flap reported in 19733 was to the lowerlimb, the technique of free tissue transfer rap-idly became incorporated into reconstructivesurgery of the hand and arm. Through thestudy of vascular anatomy of potential donorsites, the plastic surgical community has givenitself a wide variety of available tissues for re-constructive purposes.4 Almost any compositedefect of the upper limb can now be recon-structed with a free tissue transfer. This article

will discuss options for the reconstruction ofthe upper extremity with free tissue transfers.5,6

APPROACH

The topic of upper extremity microsurgery isa wide one, and for the purposes of this discus-sion, it will be divided into two areas: coverageand functional reconstruction. Although manysituations will be encountered in which soft-tissue coverage is the only requirement, itshould not be forgotten that coverage andfunctional reconstruction can be accomplishedin one step with the appropriate application ofmicrosurgical tissue transfer. In assessing awound of the upper extremity, the surgeonshould first decide on the ultimate goal of thereconstruction. This will be predicated onmany factors, not the least being the patient’sage, occupation, other injuries, and futureplans. The surgeon should have in mind a planin terms of how the initial procedure fits withwhat else may be necessary in the future. Al-though soft-tissue coverage may be the firstpriority in a patient with an avulsion injury tothe hand, the type of flap chosen not onlyshould allow later surgery but should be per-formed in a way that will maximize later efforts.

When a patient initially presents with awound of the upper extremity, the surgeonmust carefully assess the wound and make anumber of important decisions. The assess-ment of the injury should take into account thestatus of the wound (clean or dirty), the pres-ence or absence of fractures (and/or bony de-fects), and the status of neurovascular struc-

From the Hand Center of San Antonio and the Departments of Surgery and Orthopaedic Surgery, the University of Texas Health ScienceCenter at San Antonio. Received for publication April 20, 2000; revised August 25, 2000.

1524

tures (distal vascular supply and nervefunction). All of these considerations are im-portant in choosing the proper approach toreconstruction. Clean wounds with defects instructures other than soft-tissue coverageshould be considered for primary reconstruc-tion. Untidy wounds will usually require de-bridement and, although they may require freeflap soft-tissue reconstruction, repair of otherstructures may best be left until a closed woundis obtained.

PLANNING

Regardless of the type of flap chosen, preop-erative planning is essential for success. Theprimary issue in microvascular tissue transfer isvascular access for vessel anastomosis. Al-though the upper extremity has a rich vascularsupply, trauma or tumor extirpation may limitthe available choices for anastomosis. In mostpatients, the hand will maintain adequate per-fusion if only one of the major arteries (radialor ulnar) is open. If the hand is viable andeither one of these pulses is strong, I think thatarteriography is unnecessary. If there is anyquestion regarding the status of hand perfu-sion, an arteriogram should be performed, es-pecially if free flap transfer is contemplated. Inchoosing where to perform vascular anastomo-ses, a site out of the zone of injury should bechosen. If one is not sure, the vessels should beexplored and followed proximally until there isno blood staining in the vascular sheath. Forcoverage of the hand, anastomosis is usuallyperformed to either the radial or ulnar arter-ies. For the radial side of the hand and dorsum,the radial artery in the snuffbox may be usedfor end-to-end or end-to-side anastomosis. Ifboth the radial and ulnar arteries are patent,an end-to-end anastomosis at this level shouldnot compromise circulation to the hand. Inmost instances, however, it is probably safer toperform an end-to-side anastomosis. For cover-age of the forearm, anastomosis can be per-formed to either of these vessels or to thebrachial artery in the antecubital fossa. If thereis significant trauma to the forearm, a proximalend-to-side anastomosis to the brachial artery ispreferable. In the upper arm, most anastomo-ses will be to the brachial system. Venous anas-tomosis is usually best done to one of the su-perficial veins of the forearm, because thedeep venous system is small and anastomosismay be difficult. The surgeon must be sure that

there is no proximal injury to the chosen veinto avoid outflow obstruction and thrombosis.

For most free flaps, a two-team approach isthe most expeditious. The recipient site can bedebrided and vessels made ready for anastomo-sis while the flap is dissected. This may not befeasible in some settings, especially if the cho-sen flap is to come from the injured arm (i.e.,the lateral arm flap). If there is inadequatesurgical help for this approach, the wound isdebrided and measured, and then an appro-priate flap is harvested. Once the flap has beenharvested, it is left attached by its pedicle forperfusion while the vessels are dissected on therecipient limb. When the recipient vessels areready, the pedicle is divided and the flap istransferred.

COVERAGE

The approach to wounds of the upper ex-tremity should follow the usual parameters ofsoft-tissue reconstruction. Many wounds can becovered with a split-thickness skin graft or withregional flaps, particularly in the hand. Theultimate morbidity of any local or regional flapmust be considered, however, especially in re-lation to later hand function. Because the handis highly visible, the cosmetic aspect of certainlocal and regional flaps must be considered aswell. Although certain wounds may be ade-quately covered with a flap from the same ex-tremity, one should consider what offers thebest coverage in terms of the overall recon-struction.7 This will often lead to the use of afree flap for many hand wounds. The followingdiscussion will cover the considerations regard-ing which flaps may be used for soft-tissue re-construction in the hand and arm.

The wound must be considered both interms of its tidiness and size. The first stepbefore flap coverage is always conversion of agrossly untidy wound to a clean one. Debride-ment should not be compromised to avoidmaking the wound larger, because almost anywound in the upper extremity can be coveredwith free tissue transfer. This concept was pro-moted by Godina, who coined the term“necrectomy”8 to describe the removal of allnonviable and contaminated tissue. In this ap-proach, intact neurovascular structures are leftin place and large bony fragments may becleaned and replaced in their anatomic posi-tion if adequate coverage can be obtained.Once the wound has been debrided, flap selec-tion should be considered. Dirty wounds are

Vol. 107, No. 6 / UPPER EXTREMITY MICROSURGERY 1525

usually best covered with muscle, because mus-cle manages infection better than skin only.8,9

Vascularized fascia also has advantages in termsof potential contamination,10 and it may beconsidered in some untidy wounds. The selec-tion of flap coverage for a clean wound allowsthe use of composite tissue in many cases. Par-ticularly in the case of tumor extirpation, thereconstructive surgeon may have the option ofreconstructing a complex defect with a singleflap. Although many smaller wounds in theupper extremity are amenable to local or re-gional flaps (i.e., the pedicled groin flap), thisdiscussion will center on the use of free flapsfor wound management.

Muscle Flaps for Coverage

The selection of which muscle to transfer isbased largely on the experience of the sur-geon, but the “workhorses” in large wounds ofthe upper extremity are the latissimus dorsiand rectus abdominis muscles. Smaller defectscan be covered with either a portion of one ofthese muscles or a smaller muscle flap, such asthe serratus anterior or gracilis muscle.

Latissimus dorsi. The latissimus dorsi muscle isa large muscle of the back and shoulder, and itsvascular supply for free transfer is based on thesubscapular-thoracodorsal system.11,12 The pedi-cle is lengthy (8 to 11 cm) and has a relatively largediameter proximally (up to 6 mm). This is thelargest single muscle available for transfer, and itsarea of coverage can be expanded by including aportion of the serratus anterior muscle throughits branch off the thoracodorsal artery.13 It can beused as an innervated muscle because of the sin-gle thoracodorsal nerve,14 but the latissimus isgenerally used to cover large, degloving-typewounds. Its advantages are that it has a totallyreliable vascular supply and is very large. Its pri-mary disadvantage is that the patient must beturned in the lateral decubitus position for muscleharvest. If the contralateral muscle is taken, thepatient can be turned on the side, and the injuredarm can be prepared simultaneously with muscleharvest (assuming that appropriate surgical assis-tance is available). It can be taken as a myocuta-neous flap, but for most indications in the upperextremity, only the muscle is taken; it is then cov-ered with a split-thickness skin graft. The donorsite is easily closed, but seroma formation is acommon sequelae of this donor site. The func-tional morbidity from the loss of muscle is mini-mal in most patients, but its use should be avoided

in patients who must adduct the arm strongly(crutch-walkers and paraplegics).

Rectus abdominis. The rectus abdominis is amuscle widely used in microsurgery, primarilyas part of the TRAM (transverse rectus abdo-minis musculocutaneous) flap for breast recon-struction. This muscle is on the anterior ab-dominal wall and runs from the medial lowerribs to the pubis. It lies in a sheath composedanteriorly of continuations of the external andinternal oblique muscle layers. The posteriorsheath is a continuation of the transversus ab-dominis, but in the lower abdomen, it is quitethin (below the linea semicircularis). This is afairly large muscle, and it has a reliable vascularpedicle based on the deep inferior epigastricsystem. The pedicle is fairly long (5 to 7 cm),and its diameter is fairly large (2.5 to 3 mm).The rectus abdominis muscle will cover mostdefects of the hand and forearm,15,16 and it willcover large defects of the forearm if most of themuscle is harvested and it is placed “barberpole” fashion around the arm.17 The advantagesof this muscle are that it has a reliable vascularpedicle and may be taken with the patient su-pine. The disadvantage of this muscle is that ahernia can result from its harvest if fascia istaken (for a myocutaneous flap) or if the an-terior sheath is weak. For coverage of the upperextremity, this muscle is usually harvested with-out a skin paddle and covered with a split-thick-ness skin graft.

Serratus anterior. This muscle is very usefulfor covering smaller hand defects.13,18 It consistsof nine slips of muscle that connect from theribs at the anterior axillary line to the tip of thescapula. The lower slips are vascularized by abranch coming off the thoracodorsal artery,and the upper slips are vascularized by a branchof the lateral thoracic artery. The lower threeslips may be taken individually or together as afree muscle flap based on the thoracodorsalpedicle. This dissection is tedious becausebranches of the long thoracic nerve may beintertwined with the vessels, and damage to thenerve supplying the remaining slips of musclecan lead to winging the scapula.19 The branchto the serratus is usually taken with the proximalthoracodorsal vessels, both to lengthen thepedicle and because of the larger diameter ofthe proximal vessel. This can give a very lengthypedicle (15 to 17 cm) with a large diameter (3to 6 mm). The primary advantage of this muscleis its small size and lengthy vascular pedicle. Thedisadvantages of this muscle are the potential

1526 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001

for long thoracic nerve injury and the decubitusposition necessary for harvest. This flap can beused to cover the dorsal or palmar hand andfirst webspace. It has the potential for innerva-tion with a branch of the long thoracic nerve,but this application would be limited in theupper extremity.

Although there are certainly other musclesavailable for use in the upper extremity, thesethree will afford coverage for almost any wound.The gracilis muscle will be discussed below in thesection on functional reconstruction.

Fascia and Fasciocutaneous Flaps

In the case of clean traumatic wounds or tu-mor excision, a cutaneous free flap may offer thebest option for reconstruction. These flaps usu-ally offer a better cosmetic result than a musclecovered with a skin graft, and they are probablybetter in terms of performing later surgerythrough or under the flap. This is particularlytrue in the case of later tendon surgery, wherethe fascia contained in these flaps may offer abetter gliding surface for tendons. In a hand withmultiple digital amputations, a cutaneous flap isbetter in terms of providing coverage for later toetransfer as well. There are any number of fascial/fasciocutaneous flaps available, but the primaryflaps are the radial forearm, lateral arm, scapular,and temporoparietal fascial free flaps. Althoughthe groin flap is used in some centers as a freeflap and has some definite advantages (primarilydonor-site cosmetics), the variability and limitedlength/size of its vascular pedicle make it a sec-ond level choice for free transfer in most centers.

Radial forearm free flap. This flap offers al-most ideal characteristics for hand reconstruc-tion.20 Its primary application is as a pedicledflap based on reversed flow through the distalradial artery and venae comitantes.21 Nonethe-less, it may be used as a free flap in certaininstances, and it affords excellent hand cover-age. This flap can be raised anywhere along thecourse of the radial artery, and a skin islandfrom very small to quite large may be taken. Theradial artery provides a large caliber vessel foranastomosis, and it may be used for revascular-ization of the distal limb if necessary as a “flow-through” free flap. The venous drainage isthrough the dual concomitant veins of the ra-dial artery, but larger flaps can be drained usingcutaneous veins. There has been some contro-versy regarding the primary venous drainage ofthese flaps, but the venae comitantes offer re-liable drainage, even in the absence of super-

ficial veins. This flap may be innervated by anas-tomosis of the lateral antebrachial cutaneousnerve, part of which is invariably in the flap. Thequality of sensation in such reinnervated flaps isnot great, but it may be useful. If the patient hasa palmaris longus tendon, it may be taken in theflap as well, and this provides an excellent op-tion for tendon reconstruction, especially onthe dorsal hand. Because the tendon is takenwith its surrounding tissue, it has excellent glid-ing when transferred as part of the flap. A por-tion of the volar radius may be harvested withthe flap as well, and this is particularly useful inthe reconstruction of missing segments of meta-carpal.22,23 The radial artery can be taken withthe fascia only; this provides a thin flap that isparticularly useful in reconstructing the palm.

The advantages of using this flap as a free flapare its thinness, its reliability (based on the radialartery), and the multitude of other tissues thatmay be harvested with it. The main disadvantageof this flap is the resulting donor site, which mustusually be covered with a skin graft. The donorsite is usually aesthetically unpleasant, but itcauses few functional problems. Another relativecontraindication to this flap is the loss of theradial artery, but studies have shown that signifi-cant problems are unusual. Cold sensitivity isseen, but this may be related to other factors.Although the radial forearm flap is an excellentfree flap, it can usually be used as a distally pedi-cled island flap for hand reconstruction. If thisflap is not available for some reason as a pedicledflap, I usually select a skin flap from another areaand do not take a radial forearm flap from thecontralateral uninjured arm.

Lateral arm free flap. This cutaneous flapfrom the lateral distal upper arm is based on theradial collateral artery, a branch of the profun-dus brachii.24 This vessel runs with the radialnerve in the spiral groove and comes to lie inthe intermuscular septum between the brachia-lis and lateral head of the triceps. It gives arterialsupply to the skin overlying the septum and tothe underlying humerus. Distal to the intermus-cular septum, the posterior radial collateral ar-tery has a rich system of anastomoses with ves-sels in the proximal lateral forearm, which willallow extension of the flap onto the proximalforearm. The pedicle for this flap is relativelyshort (5 to 7 cm), and the proximal artery hasa small diameter (1.5 to 2 mm) when comparedwith the flaps previously discussed. The lengthof the pedicle is limited by the fact that it exitsthe spiral groove with the radial nerve, and dam-


age to this nerve must be avoided in dissection.The skin paddle can be based directly over theintermuscular septum for a smaller flap or ex-tended distally for a larger one. Donor sites upto 7 cm in width can be closed primarily, butlarger ones will require a skin graft.25 Whenclosed primarily, the donor site can be verycosmetic, but in some patients, the scar willwiden significantly. The lateral cutaneous nerveof the arm is in the flap, and thus the skin canbe innervated if necessary.26 A portion of thelateral humerus can be taken with the flap forbony reconstruction, based on its vascular sup-ply from the overlying pedicle.27

The lateral arm flap is purported to be a“thin” flap, but because of the tissue in theintermuscular septum, it is a bit bulky whenplaced on a flat recipient site (i.e., the back ofthe hand). This problem can be avoided byusing the fascia only, which also decreases do-nor-site problems.25,28 The primary advantagesof this flap are that it can be taken from theipsilateral arm (of injury),29 it avoids the sacri-fice of a major vessel, and the donor site canoften be closed primarily. The primary disad-vantages of the lateral arm flap are its some-what limited size and the short and small-diameter pedicle. It is very useful in coveringsmall defects of the hand and works very well inthe first webspace. In thin patients, it can beused to cover a degloving injury of the thumb,with the added benefit of reinnervation by thecutaneous nerve (Fig. 1).

Scapular flap. The scapular and parascapu-lar flaps offer a versatile large skin flap tocover defects in the upper extremity (Fig.2).30 The vascular supply is based on thecircumflex scapular vessels, which branchfrom the subscapular system.31 The pediclefor this flap is long (4 to 6 cm) because thesubscapular vessels can be taken if necessary,and this provides vessels of large diameter atthe takeoff from the axillary artery. The ves-sels lie in the fascia with branches to theoverlying skin. There are two primarybranches, thus giving rise to the “transverse”scapular flap, which is sited transverselyacross the back, and the “parascapular” flap,which is sited obliquely down the back. Basedon this vascular supply, a very large skin flapcan be designed that will cover most defectsof the forearm and/or arm.32 Although anumber of cutaneous nerves enter the skin,there is not a dominant nerve to this area,and thus this flap has poor potential for in-

nervation. Branches from the primary pedi-cle feed the lateral surface of the scapula,and a portion of this bone can be taken torepair bony defects. This bone is quite flat,however, and its primary indication is in thereconstruction of smaller defects in thehand. Donor sites in the 8-cm range canusually be closed primarily, but this is usuallylimited to the parascapular design of theflap.

The primary advantages of this flap are thelength and diameter of its pedicle, along with itspotential large size. The primary disadvantage ofthis flap is the need for turning the patient toharvest it. The scapular flap is an excellent choiceto cover large wounds of the forearm, and it canbe used in place of a pedicled groin flap for handcoverage. It can be combined with the latissimusdorsi and serratus anterior muscle flaps on asingle pedicle to provide a huge amount of tissueand to cover different surfaces of the hand andarm (Fig. 3).33,34

Temporoparietal fascia flap. The temporopa-rietal fascia offers a flap of specialized tissue thathas great utility in hand reconstruction.35 Thisflap is supplied by the superficial temporal ar-tery and vein, and it has a pedicle in the 2- to3-cm range that is about 1.5 to 2.5 mm in di-ameter.36 The temporal fascia lies on the tem-poral region of the skull, beginning on the zy-goma and running superiorly. There is asuperficial and deep layer, and both may betaken with this flap. The use of both layers offascia has been promoted for use in wrappingadherent tendons on the dorsum of the handafter tenolysis in a scarred bed. The deep fasciacan also provide tissue for reconstructing smalltendons on the dorsal hand as well. A flap ofmoderate dimensions may be taken (in therange of 8 to 10 cm). The potential for harvest-ing vascularized bone with this flap exists, butthe thin, outer table bone available has few (orno) indications in the hand. Although the do-nor scar is one of the best in terms of cosmesis,the problem of alopecia exists because the su-perficial fascia must be dissected from just be-neath the hair follicles of the scalp.

The primary advantages of this flap are itspotential to provide a gliding surface and itsgood donor site (one of the best in terms ofcosmesis). The primary disadvantage of thisflap is that it is very thin and must be coveredwith a skin graft. Temporoparietal fascia offersvery nice coverage for defects of the fingersand hand, but the size of the flap is limited.37


This tissue does seem to improve the glidingability of tendons, particularly on the dorsum.When covered with a split-thickness skin graft,the temporoparietal fascia flap offers the thin-nest coverage available (excluding other fascialflaps). It is probably not the best choice whenlater surgery through the flap is contemplated,however.

FUNCTIONAL RECONSTRUCTION

Composite tissue transfer offers the ability toreconstruct functional deficits with flaps con-taining skin, bone, joint, and reinnervatedmuscle. Detailed discussion of each of theseareas is beyond the scope of this article, but abrief outline of procedures to deal with signif-

FIG. 1. (Above, left) Degloving injury to the thumb in a 23-year-old man. (Above, right) A piece of cloth is used for a templatefor a lateral arm flap. (Center, left) The flap is marked on the lateral upper arm. (Center, right) The flap is placed. Note that the“seam” was placed dorsally, with anastomosis of the lateral cutaneous nerve of the arm to the ulnar digital nerve of the thumb.(Below, left) Results at 8 months. Protective sensation had returned. (Below, right) Flexion at 8 months.


icant bone loss, muscle necrosis, and digitalloss will be covered.

Free Fibula

Most bony defects in the upper extremitycan be managed with standard bone grafts;however, long defects (. 6 cm) and those

associated with recurrent failure to heal may becandidates for microvascular bone transfer.38

Although there are several flaps available thatcan include a portion of vascularized bone (il-iac crest, lateral arm, radial forearm, dorsalispedis), the fibula osseocutaneous flap offersthe best piece of bone for reconstructing sig-nificant defects of the long bones of the upperextremity.39,40 Smaller defects, such as those inthe hand, can be managed by one of the pre-viously discussed flaps, with inclusion of a seg-ment of bone. Larger defects of the radius,ulna, or humerus will usually require a piece ofbone such as the fibula.41 The vascular supplyof the free fibula is based on the peronealvessels of the leg. These vessels run along thedeep surface of the fibula from just below thetibioperoneal trunk to the level of the ankle.Although the peroneal vessels provide a nutri-ent artery to the medullary canal of the fibula,they also provide a rich periosteal blood supplyto the cortical surface. The proximal portion ofthe fibula can be taken to reconstruct the ra-diocarpal joint, but this segment of bone getsits primary blood supply from a branch of theanterior tibial artery,42 which must be taken toassure viability of this segment.

A portion of the skin overlying the fibula canbe taken with the bone, and thus compounddefects can be managed with this flap (Figs. 4and 5). The perforators to the skin run aroundthe posterior aspect of the bone, and thus it isbest to include a cuff of muscle along theposterior surface of the bone if a skin paddle isto be included. If a skin paddle is taken, mostdonor sites will require a skin graft on theoverlying muscles. The primary advantage ofthis donor site is the large amount of bone thatcan be taken. In adults, a total of up to 24 to 26cm of bone may be harvested. The fibular headshould be left in place at the knee level, and 6cm of the distal fibula should remain to avoidproblems with the ankle. In children, a screwshould be placed across the fibular-tibial jointto avoid proximal migration of the fibula. Thedisadvantages of this donor site are few: thepedicle is relatively short (2 to 4 cm) and thereis some morbidity from harvesting, but thesedo not usually present functional problems.

Innervated Gracilis Transfer

In some instances, there is a need to replacedamaged or excised muscle in the forearm orupper arm. Although many losses can be ade-quately reconstructed with standard tendon

FIG. 2. (Above) The hand of a baby with dorsal wrist con-tracture after a burn. (Below) The hand after scar excision,wrist release, and scapular flap.

FIG. 3. Multiple flaps are available on single pedicle. Herea portion of serratus anterior, latissimus dorsi, and a scapularcutaneous flap have been harvested on a single subscapularpedicle.


transfers, patients with significant loss of mus-cle substance (such as those with Volkmann’sischemic contracture) may benefit from recon-struction of function with a microvascular mus-cle transfer (Fig. 6).43 The muscles available forthis include the gracilis, latissimus dorsi, andrectus femoris. This latissimus dorsi can beused in the forearm as a free functional trans-fer,44 but it is not ideal. The rectus femoris hasbeen used for this in the past, but again it is notthe optimal muscle. The gracilis muscle, how-ever, is nearly ideal for reconstruction of themuscles of the forearm. It has adequate excur-sion to provide finger flexion or extension, it is

of the appropriate size (both length andwidth), and it has an excellent neurovascularpedicle. The gracilis is a muscle in the medialthigh that runs from the pubis to the medialtibia. It has a primary vascular pedicle (abranch of the profundus femoris) and entersthe muscle at its undersurface about 6 to 12 cmbelow its origin. The pedicle is rather short (5to 6 cm) and of relatively small diameter (1 to2 mm). There are usually two or three second-ary pedicles that enter the muscle distally, butthe muscle is well-perfused by its primary pedi-cle alone after microvascular transfer. The gra-cilis is powered by a single nerve, the anterior

FIG. 4. (Above, left) Humeral nonunion in a patient who had undergone seven prior proce-dures to attempt union. (Above, right) Intraoperative x-ray. Note that the fibula is held in placewith only two screws, while the plate spans the defect at the site of resection of nonunion. (Below)Arm after vascularized fibular transfer to nonunion. Hemostat points to plate over fibula.


branch of the obturator nerve, which entersthe muscle at the level of the vascular pedicleproximally. The distal third of the muscle istendinous, and this tendon is ideal for attach-ment to the distal flexors or extensors of thedigits. The primary advantage of this muscle asan innervated free transfer is that its size andexcursion closely match those of the muscles ofthe forearm. The primary disadvantage of thismuscle for free transfers is its relatively shortand small pedicle.

The primary indication for innervated mus-cle transfer to the forearm is loss of musclemass, as in Volkmann’s ischemic contractureor traumatic avulsion of the muscles. The pre-requisites for successful innervated muscletransfer include adequate passive excursion ofthe distal joints, intact sensation in the hand,available neurovascular structures for anasto-mosis, adequate distal soft-tissue for coverageof the tendon repairs, and lack of a simplersolution for the problem.43 In certain in-stances, some of these requirements can bemodified if the others are present. In general,however, this procedure should be reserved forthose patients with a severe problem that is notamenable to more standard solutions.

Toe Transfer

Microvascular toe transfer represents one ofthe pinnacles of reconstructive surgery. The

ability to replace in kind a missing digit with amobile, sensate toe offers the best type of re-construction available. Although this is a com-plex microsurgical procedure that should notbe undertaken without experience,45 it remainsthe benchmark for thumb and most digitalreconstructions. There are a number of varia-tions of toe transfer, and almost any tissueneeded for digital reconstruction can be trans-ferred. These range from pulp-only transfers todouble second and third toe transfers to recon-struct the metacarpal hand. Because this is anoverview, the discussion here will be limited toanatomy and a few technical points.

All great and second toe transfers ideallyhave their vascular basis on the dorsalis pedis–first dorsal metatarsal system. This anatomy ishighly variable, however, and a thoroughknowledge of it is the basis for safe harvestingof these flaps. The venous drainage is based onthe dorsal superficial veins of the foot, becausethe deep system that accompanies the arterialsupply is usually very small. The flaps can beinnervated by the proper plantar digital nervesto the toe(s) and by the deep peroneal nerve,which accompanies the dorsalis pedis/dorsalmetatarsal vessels.

Joint reconstruction. Destruction of the prox-imal interphalangeal or metacarpophalangealjoint in a finger remains a formidable recon-structive problem. Although arthroplasty withartificial joints continues to be an option inthese patients, results are poor in young, activepatients. The possibility of reconstructing amissing finger joint with a joint from a toewould seemingly obviate the problems associ-ated with artificial joint replacement.

There have been a number of reports ofjoint replacement in the hand with toejoints.46–50 The metatarsophalangeal joint andproximal interphalangeal joints of the secondtoe are used most often to reconstruct theanalogous joints in the hand. Despite earlyenthusiasm for this procedure, it remains prob-lematic. Extensor lag at the transferred joint iscommon,49–52 and complication rates are fairlyhigh and include vascular failure, infection,and late joint destruction.50,52 Active range ofmotion for transferred metatarsophalangealjoints is in the 30-degree range, with less intransferred interphalangeal joints.50–52 In chil-dren, transferred toe joints provide some po-tential for growth, but reports vary on theamount of growth obtained from the trans-ferred epiphyses.52–54 Although this procedure

FIG. 5. Results from the patient shown in Figure 4 at 2years postoperatively. Note incorporation and hypertrophy ofthe fibula.


certainly has advantages over implant arthro-plasty and fusion, it is a complex undertakingand should be used selectively by surgeons withexperience.

Thumb reconstruction. Toe transfer in one ofits forms offers many of the best ways to recon-struct defects of the thumb.55 For reconstruc-tion of the pulp of the thumb alone, only thelateral pulp of the great toe is taken; this may beinnervated by the lateral digital and deep per-oneal nerves. This flap provides excellent re-construction for the thumb and leaves littlemorbidity at the foot. For partial thumb ampu-tations (those from the mid-proximal phalanxlevel), a great toe “wrap-around” flap may beused (Fig. 7). This modification takes only thedistal phalanx and surrounding soft tissue,which is trimmed to approximate the circum-ference of the missing thumb.56,57 This tech-nique requires the use of an intercalated bonegraft segment between the proximal phalanx ofthe thumb and distal phalanx of the toe. Al-though this is arguably the most cosmetic typeof thumb reconstruction, it does not recon-

struct missing joints. Because it leaves the prox-imal phalanx intact, it has the potential to im-part less morbidity at the foot than whole greattoe transfer. Wei et al58 advocate the “trimmedtoe” technique to circumvent the lack of motionof the wrap-around flap. In this technique, theentire great toe is trimmed, including both thesoft-tissue and bony structures, to give a recon-

FIG. 6. (Above, left) Intraoperative view of the forearm of a 12-year-old boy after a propeller injury. Note the disrupted mediannerve (over background). (Above, right) Intraoperative view after innervated gracilis transfer. The skin paddle for monitoringis over the proximal muscle. (Below) Extension (left) and flexion (right) at 8 months postoperatively.

FIG. 7. Patient 1 year after great toe wrap-around recon-struction of the left thumb.


structed thumb of appropriate circumference.Their report showed a reasonable return of mo-tion in the trimmed joints.

In cases of loss of the entire thumb, theentire great toe may be transferred. It shouldbe noted that the metatarsophalangeal jointsact primarily in the extension arc. To avoidhyperextension of this joint when transferredto the hand, a dorsal oblique osteotomy is usedto place the toe in the proper position on thehand. The flexor and extensor tendons aretaken with a total great toe transfer, and anas-tomosis is ideally performed at the wrist level todecrease the incidence of tendon adhesions.The flexor tendon may be harvested through aseparate incision in the non–weight-bearingsurface of the arch of the foot and, if morelength is needed, another incision may bemade at the level of the tarsal tunnel. Theextensor tendon (extensor hallucis longus)is usually taken through the dorsal incisionmade for dissection of the neurovascularstructures.

Transfer of all parts of the great toe impartssome morbidity to the foot, but the effect whenevaluated with gait studies is generally mini-mal. Certainly, the tradeoff of a thumb for theloss of the great toe is usually well-accepted bythe patient. The primary disadvantage of thesetechniques is their inherent complexity and,although they offer superb reconstructive op-tions in patients with loss of all or part of thethumb, their application should probably belimited to those practitioners with experience.

Digital reconstruction. The second or secondand third toes may be transferred in a mannersimilar to that used with the great toe to recon-struct missing digits. A single toe transfer for asingle missing digit is generally not indicated,and the application of this technique is gener-ally reserved for those patients who have suf-fered a transmetatarsal amputation (metacar-pal hand).59 Smaller portions of the second toecan be used for pulp and/or nail losses, but thistype of procedure is usually less necessary in thedigits than in the thumb. In the case of multipledigital loss, two fingers may be reconstructedwith either a double toe (second and third com-bined) from one foot60 or a second toe transferfrom each foot. The loss of the second toe onlyimparts very minimal morbidity, but the loss oftwo toes from one foot leaves a significantdeficit.61

CONCLUSIONS

This has been a brief overview of microsur-gical reconstruction of the upper extremity.The number of flaps available for hand andarm reconstruction is large, and only a fewhave been discussed here. There are a numberof flaps other than those discussed that haveapplication in the upper extremity, but I hopethis overview has given the reader a number ofoptions that offer a solution for most recon-structive problems. For further reading, oneshould seek out one of the many texts availableon the subject.12,62,63

William C. Pederson, M.D.The Hand Center of San Antonio9150 Huebner Road, Suite 290San Antonio, Texas [email protected]

REFERENCES

1. Komatsu, S., and Tamai, S. Successful replantation of acompletely cut-off thumb. Plast. Reconstr. Surg. 42: 374,1968.

2. Cobbett, J. R. Free digital transfer: Report of a case oftransfer of a great toe to replace an amputated thumb.J. Bone Joint Surg. (Br.) 51: 677, 1969.

3. Daniel, R. K., and Taylor, G. I. Distant transfer of anisland flap by microvascular anastomoses: A clinicaltechnique. Plast. Reconstr. Surg. 52: 111, 1973.

4. Cormack, G. C., and Lamberty, B. G. Fasciocutaneousvessels in the upper arm: Application to the design ofnew fasciocutaneous flaps. Plast. Reconstr. Surg. 74: 244,1984.

5. Chen, H. C., Buchman, M. T., and Wei, F. C. Free flapsfor soft tissue coverage in the hand and fingers. HandClin. 15: 541, 1999.

6. Brown, D. M., Upton, J., and Khouri, R. K. Free flapcoverage of the hand. Clin. Plast. Surg. 24: 57, 1997.

7. Upton, J., Havlik, R. J., and Khouri, R. K. Refinementsin hand coverage with microvascular free flaps. Clin.Plast. Surg. 19: 841, 1992.

8. Godina, M. Wound care and timing of microvascularflap transfer to the lower leg. In A Thesis on the Man-agement of Injuries to the Lower Extremity. Ljubljana: Pre-sernova Druzba, 1991. Pp. 77–84.

9. Chang, N., and Mathes, S. J. Comparison of the effectof bacterial inoculation in musculocutaneous and ran-dom-pattern flaps. Plast. Reconstr. Surg. 70: 1, 1982.

10. Calderon, W., Chang, N., and Mathes, S. J. Comparisonof the effect of bacterial inoculation in musculocuta-neous and fasciocutaneous flaps. Plast. Reconstr. Surg.77: 785, 1986.

11. Bailey, B. N., and Godfrey, A. M. Latissimus dorsi mus-cle free flaps. Br. J. Plast. Surg. 35: 47, 1982.

12. Jones, N. F., and Lister, G. D. Free skin and compositeflaps. In D. P. Green, R. N. Hotchkiss, and W. C.Pederson (Eds.), Operative Hand Surgery, 4th Ed. Phil-adelphia: Churchill Livingstone, 1999.

13. Whitney, T. M., Buncke, H. J., Alpert, B. S., Buncke,G. M., and Lineaweaver, W. C. The serratus anteriorfree-muscle flap: Experience with 100 consecutivecases. Plast. Reconstr. Surg. 86: 481, 1990.


14. Favero, K. J., Wood, M. B., and Meland, N. B. Transferof innervated latissimus dorsi free musculocutaneousflap for the restoration of finger flexion. J. Hand Surg.(Am.) 18: 535, 1993.

15. Horch, R. E., and Stark, G. B. The rectus abdominis freeflap as an emergency procedure in extensive upperextremity soft-tissue defects. Plast. Reconstr. Surg. 103:1421, 1999.

16. Rao, V. K., and Baertsch, A. Microvascular reconstruc-tion of the upper extremity with the rectus abdominismuscle. Microsurgery 15: 746, 1994.

17. Press, B. H., Chiu, D. T., and Cunningham, B. L. Therectus abdominis muscle in difficult problems of handsoft tissue reconstruction. Br. J. Plast. Surg. 43: 419,1990.

18. Gordon, L., Levinsohn, D. G., Finkemeier, C., Angeles,A., and Deutch, H. The serratus anterior free-muscletransplant for reconstruction of the injured hand: Ananalysis of the donor and recipient sites. Plast. Reconstr.Surg. 92: 97, 1993.

19. Derby, L. D., Bartlett, S. P., and Low, D. W. Serratusanterior free-tissue transfer: Harvest-related morbidityin 34 consecutive cases and a review of the literature.J. Reconstr. Microsurg. 13: 397, 1997.

20. Braun, F. M., Hoang, P., Merle, M., Van Genechten, F.,and Foucher, G. Technique and indications of theforearm flap in hand surgery: A report of thirty-threecases. Ann. Chir. Main 4: 85, 1985.

21. Soutar, D. S., and Tanner, N. S. B. The radial forearmflap in the management of soft tissue injuries of thehand. Br. J. Plast. Surg. 37: 18, 1984.

22. Yajima, H., Tamai, S., Yamauchi, T., and Mizumoto,S. Osteocutaneous radial forearm flap for hand re-construction. J. Hand Surg. (Am.) 24: 594, 1999.

23. Foucher, G., Van Genechten, F., Merle, M., and Michon,J. A compound radial artery forearm flap in handsurgery: An original modification of the Chinese fore-arm flap. Br. J. Plast. Surg. 37: 139, 1984.

24. Katsaros, J., Schusterman, M., Beppu, M., Banis, J. C., Jr.,and Acland, R. D. The lateral upper arm flap: Anat-omy and clinical applications. Ann. Plast. Surg. 12: 489,1984.

25. Chen, H. C., and el-Gammal, T. A. The lateral armfascial free flap for resurfacing of the hand and fin-gers. Plast. Reconstr. Surg. 99: 454, 1997.

26. Harpf, C., Papp, C., Ninkovic, M., Anderl, H., and Hussl,H. The lateral arm flap: Review of 72 cases and tech-nical refinements. J. Reconstr. Microsurg. 14: 39, 1998.

27. Arnez, Z. M., Kersnic, M., Smith, R. W., and Godina,M. Free lateral arm osteocutaneous neurosensoryflap for thumb reconstruction. J. Hand Surg. (Br.) 16:395, 1991.

28. Yousif, N. J., Warren, R., Matloub, H. S., and Sanger,J. R. The lateral arm fascial free flap: Its anatomy anduse in reconstruction. Plast. Reconstr. Surg. 86: 1138,1990.

29. Scheker, L. R., Kleinert, H. E., and Hanel, D. P. Lateralarm composite tissue transfer to ipsilateral hand de-fects. J. Hand Surg. (Am.) 12: 665, 1987.

30. Burns, J. T., and Schlafly, B. Use of the parascapularflap in hand reconstruction. J. Hand Surg. (Am.) 11:872, 1986.

31. Barwick, W. J., Goodkind, D. J., and Serafin, D. The freescapular flap. Plast. Reconstr. Surg. 69: 779, 1982.

32. Thoma, A., and Heddle, S. The extended free scapularflap. Br. J. Plast. Surg. 43: 709, 1990.

33. Germann, G., Bickert, B., Steinau, H. U., Wagner, H., andSauerbier, M. Versatility and reliability of combinedflaps of the subscapular system. Plast. Reconstr. Surg.103: 1386, 1999.

34. Evans, G. R., and Luethke, R. W. A latissimus/scapulacombined myo-osseous free flap based on the sub-scapular artery used for elbow reconstruction. Ann.Plast. Surg. 30: 175, 1993.

35. Hing, D. N., Buncke, H. J., and Alpert, B. S. Use of thetemporoparietal free fascial flap. Plast. Reconstr. Surg.81: 534, 1988.

36. Abul-Hassan, H. S., von Drasek Ascher, G., and Acland,R. D. Surgical anatomy and blood supply of the fas-cial layers of the temporal region. Plast. Reconstr. Surg.77: 17, 1986.

37. Upton, J., Rogers, C., Durham-Smith, G., and Swartz,W. M. Clinical applications of free temporoparietalflaps in hand reconstruction. J. Hand Surg. (Am.) 11:475, 1986.

38. Weiland, A. J., Kleinert, H. E., Kutz, J. E., and Daniel,R. K. Free vascularized bone grafts in surgery of theupper extremity. J. Hand Surg. (Am.) 4: 129, 1979.

39. Yajima, H., Tamai, S., Ono, H., Kizaki, K., and Yamauchi,T. Free vascularized fibula grafts in surgery of theupper limb. J. Reconstr. Microsurg. 15: 515, 1999.

40. Ihara, K., Doi, K., Yamamoto, M., and Kawai, S. Freevascularized fibular grafts for large bone defects in theextremities after tumor excision. J. Reconstr. Microsurg.14: 371, 1998.

41. Gerwin, M., and Weiland, A. J. Vascularized bone graftsto the upper extremity: Indications and technique.Hand Clin. 8: 509, 1992.

42. Tang, C. H. Reconstruction of the bones and joints ofthe upper extremity by vascularized free fibular graft:Report of 46 cases. J. Reconstr. Microsurg. 8: 285, 1992.

43. Manktelow, R. T., and Anastakis, D. J. Functioning freemuscle transfers. In D. P. Green, R. N. Hotchkiss, andW. C. Pederson (Eds.), Operative Hand Surgery, 4th Ed.Philadelphia: Churchill Livingstone, 1999.

44. Park, C., and Shin, K. S. Functioning free latissimusdorsi muscle transplantation: Anterogradely posi-tioned usage in reconstruction of extensive forearmdefect. Ann. Plast Surg. 27: 87, 1991.

45. Lister, G. D., Kaisman, M., and Tsai, T. M. Reconstruc-tion of the hand with free microneurovascular toe-to-hand transfer: Experience with 54 toe transfers. Plast.Reconstr. Surg. 71: 372, 1983.

46. O’Brien, B., Gould, J. S., Morrison, W. A., Russell, R. C.,MacLeod, A. M., and Pribaz, J. J. Free vascularizedsmall joint transfer to the hand. J. Hand Surg. (Am.) 9:634, 1984.

47. Foucher, G., Sammut, D., and Citron, N. Free vascu-larized toe-joint transfer in hand reconstruction: Aseries of 25 patients. J. Reconstr. Microsurg. 6: 201, 1990.

48. Tsai, T. M., and Lim, B. H. Free vascularized transfer ofthe metatarsophalangeal and proximal interphalan-geal joints of the second toe for reconstruction of themetacarpophalangeal joints of the thumb and indexfinger using a single vascular pedicle. Plast. Reconstr.Surg. 98: 1080, 1996.

49. Chen, S. H., Wei, F. C., and Chen, H. C. Vascularizedtoe joint transplantation. Hand Clin. 15: 613, 1999.

50. Imamura, K., Nagatani, Y., and Hirano, E. Vascularizedtoe-to-finger joint transplantation: 11 patients fol-lowed for 4 years. Acta Orthop. Scand. 63: 457, 1992.

51. Chen, S. H., Wei, F. C., Chen, H. C., Hentz, V. R., Chuang,


D. C., and Yeh, M. C. Vascularized toe joint transferto the hand. Plast. Reconstr. Surg. 98: 1275, 1996.

52. Ellis, P. R., Hanna, D., and Tsai, T. M. Vascularizedsingle toe joint transfer to the hand. J. Hand Surg.(Am.) 16: 160, 1991.

53. Ishida, O., and Tsai, T. M. Free vascularized whole jointtransfer in children. Microsurgery 12: 196, 1991.

54. Singer, D. I., O’Brien, B. M., McLeod, A. M., Morrison,W. A., and Angel, M. F. Long-term follow-up of freevascularized joint transfers to the hand in children.J. Hand Surg. (Am.) 13: 776, 1988.

55. Lister, G. The choice of procedure following thumbamputation. Clin. Orthop. 195: 45, 1985.

56. Morrison, W. A., O’Brien, B. M., and MacLeod,A. M. Thumb reconstruction with a free neurovas-cular wrap-around flap from the big toe. J. Hand Surg.(Am.) 5: 575, 1980.

57. Doi, K. Microsurgical thumb reconstruction: Report ofsix cases with a wrap-around free flap from the big toeand an iliac bone graft. Ann. Acad. Med. Singap.11: 225,1982.

58. Wei, F. C., Chen, H. C., Chuang, C. C., and Chen,S. H. Microsurgical thumb reconstruction with toetransfer: Selection of various techniques. Plast. Recon-str. Surg. 93: 345, 1994.

59. Wei, F. C., el-Gammal, T. A., Lin, C. H., Chuang, C. C.,Chen, H. C., and Chen, S. H. Metacarpal hand: Clas-sification and guidelines for microsurgical reconstruc-tion with toe transfers. Plast. Reconstr. Surg. 99: 122,1997.

60. Wei, F. C., Chen, H. C., Chuang, C. C., and Noordhoff,M. S. Reconstruction of the hand, amputated at themetacarpophalangeal level, by means of combinedsecond and third toes from each foot: A case report.J. Hand Surg. (Am.) 11: 340, 1986.

61. Barca, F., Santi, A., Tartoni, P. L., and Landi, A. Gaitanalysis of the donor foot in microsurgical reconstruc-tion of the thumb. Foot Ankle Int. 16: 201, 1995.

62. Foucher, G. Reconstructive Surgery in Hand Mutilation. St.Louis: Mosby, 1997.

63. Serafin, D. Atlas of Microsurgical Composite Tissue Trans-plantation. Philadelphia: Saunders, 1996.


Self-Assessment Examination

Upper Extremity Microsurgeryby William C. Pederson, M.D.

1. THE LARGEST SINGLE MUSCLE AVAILABLE FOR MICROSURGICAL TRANSFER IS THE:A) Rectus abdominisB) Pectoralis majorC) Gluteus maximusD) Latissimus dorsiE) Trapezius

2. HARVEST OF THE SERRATUS ANTERIOR MUSCLE CARRIES THE RISK OF DAMAGE TO:A) The thoracodorsal nerveB) The pleuraC) The long thoracic nerveD) The medial pectoral nerveE) The axillary artery

3. THE MOST COMMON DONOR-SITE COMPLICATION OF TEMPOROPARIETAL FASCIA HARVEST IS:A) Facial nerve injuryB) Temporal wastingC) Temporomandibular joint malfunctionD) AlopeciaE) Necrosis of the scalp

4. A DEFINITE INDICATION FOR INNERVATED GRACILIS TRANSFER TO THE FOREARM WOULD BE:A) Volkmann’s ischemic contractureB) Electrical burn to the forearmC) High median nerve injuryD) Degloving injury to the forearmE) Radial nerve paralysis

5. THE TYPE OF GREAT TOE TRANSFER OFFERING THE BEST POTENTIAL FOR MOTION WOULD BE:A) Great toe wrap-aroundB) Whole great toe transferC) Trimmed great toe transferD) Great toe pulp transferE) Great toe interphalangeal joint transfer

6. THE TERM “NECRECTOMY” AS APPLIED TO WOUND DEBRIDEMENT IMPLIES THAT:A) Only the margins of the wounds are excisedB) All tissues that may have been damaged, including nerves and vessels, are excisedC) All contaminated or nonviable tissue is excised with the exception of major neurovascular structuresD) All deep structures are left intact, regardless of contamination, because coverage with a free flap will take care of any residualnecrotic tissue or contaminationE) Only obviously necrotic tissue is excised

To complete the examination for CME credit, turn to page 1635 for instructions and the response form.

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