Indications, Selection, and Useof Distant Pedicled Flap forUpper Limb Reconstruction

S. Raja Sabapathy, MS, MCh, DNB, FRCS Ed, MAMS*,Babu Bajantri, MS, MCh

KEYWORDS

� Pedicled flap � Soft tissue cover upper limb � Groin flap � Abdominal flap� Hand injury reconstruction

KEY POINTS

� Pedicled flaps are easy to raise, are reliable, and do not need microsurgical expertise.

� Many of the disadvantages of pedicled flaps can be offset by properly planning the flap.

� Narrowing the base of the flap around the axial vessels, keeping just adequate length to allowcomfortable mobility and primary thinning of the critical end of the flap are important steps.

� Good radical debridement before insetting of the flap facilitates primary reconstruction of tendonsand bones.

� Secondary thinning can be aggressively performed in pedicled flaps.

� When vessels are not available for free flaps, or when free flaps fail, pedicled flaps can be a lifeboat.

� Pedicled flaps can also be used in preparation for a major microsurgical procedure, such as toetransfer or microsurgical bone reconstruction.

INTRODUCTION

The description of the pedicled groin flap byMcGregor and Jackson1 was a milestone in thejourney of reconstruction of soft tissue defects ofthe hand. Understanding of the axial pattern ofblood supply in that flap led to further identificationof flaps based on various cutaneous vessels. Sub-sequent introduction of microsurgical free flapsenormously extended the reconstructive capa-bility, to an extent that the option of a pedicledflap to cover soft tissue defects in the hand wasoften relegated to the background. Free flapshave the advantage of being a single-stage proce-dure, involve fewer hospital inpatient days,encourage the primary reconstruction of otherinjured structures, and patients do not have to go

No disclosures for any of the authors.Department of Plastic Surgery, Hand and Reconstructivepalayam Road, Coimbatore 641 043, India* Corresponding author.E-mail addresses: rajahand@vsnl.com; srs@gangahospital

Hand Clin 30 (2014) 185–199http://dx.doi.org/10.1016/j.hcl.2014.01.0020749-0712/14/$ – see front matter � 2014 Elsevier Inc. All

through the discomfort and the period of “attach-ment” to the abdomen.2

Despite these advantages, pedicled flaps havesurvived as a valuable part of the reconstructivesurgeon’s armamentarium. Furthermore, refine-ments in techniques can offset most of the pre-sumed disadvantages associated with pedicledflaps.3 When well done, the outcome of pedicledflaps can be as good as and in certain aspectseven better than what a free flap can achieve inthe long term. In circumstances when free flapscannot be done because of paucity of recipientvessels or infrastructural inadequacies or whenthey fail, pedicled flaps serve as lifeboats.4

In the reconstruction of complex defects, pedi-cled flaps can serve as a foundation for the subse-quent microsurgical procedure. Groin flaps are

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used to cover the amputation stumps of the fingersand thumb before toe transfers.5 In major injuriesand single vessel limbs, pedicled flaps are usedto cover the soft tissue defect and subsequentlythe bone defect can be reconstructed with a freefibula transfer. In this way pedicled flaps arecomplementary to the success of microsurgery.Hence, it is mandatory on the part of an upperlimb reconstructive surgeon to be well versed inthe techniques of performing pedicled flaps. Inmost parts of the world they still serve as the work-horse in the management of upper limb injuriesand will likely never be entirely supplanted byfree tissue transfer.6

The anatomic basis of the commonly performedflaps, general principles that govern their use, site-specific technical considerations that influence theoutcome, and complications and their avoidanceare discussed in this article.

ANATOMIC CONSIDERATIONS

The infraumblical part of the abdomen and thelateral aspect of the trunk serve as common do-nors of pedicled flaps. The lower part of theabdomen is supplied by three vessel branchesthat arise from the femoral artery and the para-umblical perforators (Fig. 1).The superficial circumflex iliac artery (SCIA)

arises from the femoral artery 2 cm below the

Fig. 1. A schematic diagram showing the commonlyused flaps from the lower part of the abdomen forupper limb reconstruction and the vessels on whichthey are based. ASIS, anterior superior iliac spine;PUP, para umbilical perforators; SCIA, superficialcircumflex iliac artery; SEPA, superficial external pu-dental artery; SIEA, superficial inferior epigastricartery.

inguinal ligament or from a common trunk alongwith the superficial inferior epigastric artery(SIEA). It then passes laterally and gives a deepbranch at the medial border of Sartorius. The cuta-neous branch becomes superficial at the lateralborder of the Sartorius and runs into the tissuethat is raised as the groin flap. The vessel runs par-allel to the inguinal ligament, about 2 cm below ittoward the anterior superior iliac spine. A simple“rule of two finger widths” has been recommendedby Chuang and colleagues.7

The SIEA arises from the femoral artery 1 cmdistal to the inguinal ligament and passes verticallyupward superficial to the inguinal ligament within2.5 cm of the midinguinal point. It soon becomessuperficial by piercing the Scarpa fascia and runssuperolaterally with the final branches traced upto the umbilicus.8

The superficial external pudental artery (SEPA)arises from the femoral artery close to the preced-ing branches and passes medially deep to thegreat saphenous vein toward the pubic tubercle.9

It gives off branches at this point, and one of thebranches ascends toward the umbilicus.The deep inferior epigastric artery arises from the

external iliac artery just proximal to the inguinal lig-ament, passes beneath the rectus abdominis mus-cle, and anastomoses with the superior epigastricartery within the rectus sheath. They give rise toperforators along their course that pierce the ante-rior rectus sheath to supply the skin. The highestconcentration of these perforators is near the um-bilicus and they feed into a subcutaneous vascularnetwork that radiates like the spokes of a wheel.10

These paraumbilical perforators are useful to raiseflaps that are used for the reconstruction of thevolar defects of the forearm.11

These are the main vessels on which pedicledflaps used for the upper limb are based. Thebranches of these vessels anastomose freelywith each other in the anterior abdominal wall.Choke vessels exist between the territories andmost often the dimensions exceeding the primaryterritory of a particular vessel can be raised byincorporating an adjacent territory. A flap of largedimension can be raised by incorporating thesevessels in the base. The distance between thesite of emergence of the SCIA and the SIEA intothe subcutaneous tissue is only 6 to 8 cm in anadult, irrespective of the thickness of the abdom-inal wall (Fig. 2). By planning the base to includeboth the vessels, a flap of large dimensionsinvolving the entire infraumbilical part of the lowerabdominal wall up to the midline can be raised.This could also be raised as a bilobed flap to simul-taneously cover the volar and the dorsal defects ofthe hand.12,13

Fig. 2. Diagram illustrating the proximity of the sitesof entry of the axial vessels of the groin flap andthe hypogastric flap into the superficial plane. ASIS,anterior superior iliac spine. A, superficial externaliliac artery; B, superficial inferior epigastric artery.

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The lateral aspect of the chest and abdominalwall has a rich blood supply by perforatorsarising from the intercostal vessels and lumbararteries. Flaps from the lateral part of the abdom-inal wall and trunk can be raised based on thesevessels to cover the elbow and the proximalforearm.

GENERAL PRINCIPLESPreparation of the Bed

Good debridement of the wound is the key to suc-cess. The basic plastic surgical principles, such asradical debridement and stable skeletal stabiliza-tion, must not be compromised. Attention to detailin the preparation of the bed must be the samewhether one does a pedicled flap or an emergencyfree flap. Quality debridement should be per-formed even when a pedicled flap is planned. Aflap on a good bed leads to a soft and suppleflap, whereas a compromised bed leads to edemaand induration of the flap.

Plan the Flap in Reverse

Comfort after inset of the flap is the main criteriafor a successful outcome. The blood supply ofthe lower abdominal wall is good enough to allowone to plan the flap to cover any raw areas of thelimb in a position of comfort. The hand or thepart needing soft tissue cover is placed in a posi-tion of comfort and an appropriate flap of suitabledimensions is planned by making a pattern of thedefect with a cloth piece or any pliable material.The flap can either be planned with the pediclebased superiorly or inferiorly as needed. Forexample, dorsal hand and forearm defects areeasily covered by inferiorly based flaps based on

the superficial circumflex and SIEAs. Volar forearmdefects are better managed by superiorly basedflaps raised on the paraumbilical perforators. Thetechnique of planning in reverse refers to markingthe flap by following the steps in a reverse order(Fig. 3). “Measure twice, or thrice but cut once”is the key.

Keep the Base Narrow and Raise CustomDesigned Flaps

The vessels on which these flaps are based arefairly constant in origin and course, so it is possibleto keep the base narrow to include the vessels inthe pedicle. By keeping the base narrow, the insetis increased and a flap to match the defect can beraised. If the base is broad, the flap does notmatch the defect and it results in bunching or un-evenness of the flap at the time of suturing withcosmetically unacceptable results. Even largeflaps can be raised by incorporating the SCIA,SIEA, and SEPA and the base could be as narrowas 8 cm (Fig. 4).

Keep Appropriate Length of the Pedicle

Adequate mobility depends on the length of thepedicle and is essential for comfort. Along with asmall base, an adequate length of the pedicle al-lows movement of the flap-covered part duringthe postoperative period. It also facilitates therapy.Most of the time this idea is taken too far and avery long tubed pedicle is created. Too long apedicle also results in the waste of well-vascularized tissue in the bridge segment andcompromised blood supply in the distal end beingattached to the defect. Most of the time we do nottube the pedicle; we just plan the pedicle length toallow supination and pronation of the forearmwhen the hand is being covered. There is a smallraw area at the base of the pedicle that is dressedregularly. During division, the pedicle part of theflap is returned to cover the raw area and thusno valuable tissue is lost. Tubing the pedicle tightlycan also cause edema of the flap.

Thin the Business End of the Flap

The SCIA, SIEA, and SEPA vessels course at adeep plane for a very short distance and theybecome progressively superficial and branch outinto tissues that are raised as the flap. The distalpart of the flap basically acts as a random patternflap and survives exclusively on the subdermalplexus of vessels. Hence, this part of the flap couldbe radically thinned. This is the area that is insetinto the defect and used for reconstruction andexcellent aesthetic outcomes could be obtainedby “relatively ruthless but careful” thinning of the

Fig. 3. (A) Crush avulsion injury to the left arm in a road traffic accident resulting in loss of skin and muscles onthe lateral side with an open elbow joint and extensive contamination. (B) Postdebridement picture. (C) Planningin reverse: the arm is placed on the side of the body with the patient on the lateral side and a cloth piece marksthe final flap required. (D) The arm removed and the pattern placed on the trunk and the flap marked. (E) Theflap raised as per the mark and (F) inseted into the defect. The critical area is covered by the flap and the rest skingrafted. (G, H) Postoperative result. Patient had tendon transfers for the radial nerve loss and is back to all hisactivities.

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Fig. 4. (A, B) Major crush injury to the forearm and hand with circumferential skin and soft tissue loss with flaprequirement along the whole length up to the metacarpal head. (C) Flap marked on the lower abdomen incor-porating the groin flap, SIEA, and SEPA and opposite SEPA territory. (D) The flap raised keeping the SCIA, SIEA,and ipsilateral SEPA in the base. The small base helps to achieve good inset into the defect and the noncriticalareas skin grafted. (E, F) Postoperative result with the thumb and the index finger fully functional.

Pedicled Flap for Upper Limb Reconstruction 189

flap.14 This fact was emphasized very early on inthe French literature by Colson and colleagues,15

who raised skin flaps at the level of the subdermalplexus with virtually very little subcutaneous fatand found surprisingly large flaps can surviveapparently entirely on this plexus. Even in obeseindividuals, the groin area is much thinner thanthe territories of the commonly used free flaps,such as the anterolateral thigh flap or the lateralarm flap. This fact combined with the techniquesof primary thinning of the flap could result in athin flap even in an obese individual.

Proximally the flap could be of full thickness inthe pedicle part and the flap used to cover thedefect can be thinned well. The flap is raised su-perficial to the external oblique aponeurosisinitially and then thinned. This is because if thedonor area needs to be covered with skin graft,the graft takes better on the fascia over theexternal oblique than on fat.

Bevel the Fat at the Skin Edge Before Inset

For ease of inset and better aesthetic appearanceat the line of attachment, the fat at the skin edge is

beveled (Fig. 5). A thick flap edge causesincreased tension while suturing. Tight suturescause unsightly suture marks and sometimeseven necrosis of the edge of the flap.

Need for Delay Before Division of the Flap

During inset, if the flap is sutured to more than80% of the perimeter of the defect, then the flapcan be divided without a prior delay procedurebefore division. These flaps are well vascularizedtissues and hence the flaps could be designed tofit the defect to increase vascular ingrowth. Anaesthetically good outcome is thus obtained(Fig. 6). Often pedicled flaps get a bad reputationbecause of improper planning of the flap. It seemsthat the pedicle flap picks up more blood supplyfrom the edges than from the base. This is prob-ably because the fat on the underside of the flapis not a great interface to pick up blood supplyfrom the bed. If the inset has less peripheral con-tact or the bed is infected then a prior delay isadvised.

However, all tubed pedicled flaps must be de-layed before division. Tubed flaps for osteoplastic

Fig. 6. (A, B) Major crush injury to the hand in a motor vehicular accident, heavily contaminated with compositeloss of skin, extensors, and the radiograph showing the bony loss. (C) The picture after debridement with thethumb positioned in an abducted and opposed position and the metacarpophalangeal joints in flexed position.(D) A custom designed flap marked incorporating both the groin and hypogastric flap vessels. (E) The flap raised.Note the small base of only 5 cm, which allows the flap to be rotated into the defect. (F–J) The final result withsecondary iliac crest bone grafting and one round of thinning of the flap.

Fig. 5. (A) The edge of the flap withthe line showing the level of excisionof the fat at the edge. (B) The slopingedge when sutured to the bed pro-vides good aesthesis.

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Pedicled Flap for Upper Limb Reconstruction 191

reconstruction of the thumb or to cover a circum-ferentially degloved finger must be delayed beforedivision. The flap is divided 7 to 10 days after thedelay procedure. Delay involves making an inci-sion in the base of the flap and ligating or coagu-lating the main feeding vessels to the flap.Familiarity with the anatomy is helpful to identifythe main vessel or Doppler can be used to findthe location of the vessel.

Complex Primary Reconstruction withPedicled Flaps for Cover

Emergency free flaps ushered in the era of com-plex primary reconstructions including primarybone and tendon grafting. There is always a lurkingfear in the mind of the surgeon whether primarybone and tendon grafting is possible with pedicledflaps as cover. Early literature even recommendeddelayed cover of acute crushed hand injuries todecrease complications, such as infection, localtissue necrosis, and subsequent loss of flap.16

With pedicled flaps, the pedicle proximal side isopen and there is concern whether this couldresult in infection and failure. In our experience,this fear is unfounded (Fig. 7). We have treated20 digits in 15 patients with dorsal combinedtissue loss with radical debridement, primary non-vascularized iliac crest bone graft, and immed-iate abdominal flap cover. Eighteen of 20 digitsachieved primary bone union and infectionoccurred in only one digit. Infection after bonegrafting is related to the quality of debridementand stabilization of the fractures and early soft tis-sue cover.17 It does not matter if the wound iscovered by a free flap or a pedicled flap.

Anesthesia

We prefer the combination of brachial block and asubarachnoid block for the preparation of thehand and for the flap surgery. If the flap to beraised involves supraumbilical region the brachialblock is combined with general anesthesia.Brachial block also helps in immediate postopera-tive pain relief.

SITE-SPECIFIC TECHNICAL CONSIDERATIONSFlaps for the Fingers

There are few local flap options for cover forextensive raw areas in multiple adjacent fingersor circumferential raw area in a single finger.When it involves adjacent fingers, the fingers aretemporarily syndactylized by covering with apedicle flap. We usually prefer the hypogastricflap (based on SIEA) or the groin flap. The flaphas to be custom designed and inset well into

the proximal and distal ends of the raw areas.The pedicle has to be kept narrow to facilitategood inset. When the pedicle is well inset, flap di-vision can be done at 3 weeks without delay and atthe same time, syndactyl separation can also bedone. Because of the fat content of the flap, theflap appears bulky on the dorsum of the fingers.The fat in the flap could be radically thinned atthe time of syndactyly separation. Although itmight look alarming, the flap usually surviveswith the distal and proximal skin attachmentalone. Thus, it is important to obtain good approx-imation of the skin edges during the primary insetto make it possible. Thinning of the flap providesmore skin to drape around the fingers. In case ofresidual raw areas in the margins, split skin graftis applied at the same sitting or a few days laterwhen the thinned flap gets adherent to the bed(Fig. 8).

Sometimes a single finger may need a distantpedicle flap. This usually happens when there iscomposite tissue loss that requires primary recon-struction or would need secondary reconstruction.When a single finger is covered, the part is kept inthe most comfortable position and flap raised. Ifwe are including the named arteries in the base,then the base could be made narrow and the insetincreased.

Tubed flaps are provided for cover of deglovedfingers or as the first step for osteoplastic thumbreconstruction. The inset has to be adjusted insuch a way that the flap points in the right direc-tion. The flap draped around the finger must bethinned to make it aesthetically acceptable. Alltubed flaps to a single finger must be delayedbefore division, because the skin attachment isproportionately less compared with the extent ofthe flap. Without delay there is unacceptable inci-dence of tip necrosis of the flap.

Flaps to the Hand

Both groin (SCIA based) and hypogastric (SIEAbased) flaps could be used for the purpose. Ourfirst preference is for the hypogastric flap becauseit is easy to raise and the base could be reliablymade narrow. For dorsal defects it insets better.If the lower abdomen is fat, we prefer the groinflap. The same flap could be used to cover eitherthe dorsum or the volar side by the way the donorarea is narrowed or closed.18 We use a key stitchin the base to turn the direction of the flap (Fig. 9).The donor area could be primarily closed if thewidth of the flap is less than 6 to 9 cm dependingon the profile of the patient.

It is essential to plan and thin the flap so thatappropriate contour is obtained. The inset canalmost reach 90% for these flaps. If secondary

Fig. 7. (A) Radiograph of a textile machinery injury showing extensive loss of middle and distal phalanges. (B) Theinjury also resulted in loss of volar skin, flexors with viable dorsal skin up to the tip of the fingers. Fingers recon-structed with primary bone graft from the iliac crest and the fingers syndactalyzed before flap cover. (C) Flap de-signed to match the defect raised based on the SIEA and the donor area primarily closed. (D) Dorsal view. (E–G)Long-term pictures showing good outcome with good incorporation of the bone graft.

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Fig. 8. (A) Dorsal composite loss in the distal segment of adjacent fingers. (B, C) Covered by hypogastric flap aftersyndactylization of the fingers with primary closure of the donor area. (D) The flap divided at 3 weeks withoutdelay and immediate separation of syndactyly along the marked lines. (E) The flap thinned to the layer of thedermis with attachments only on the proximal and distal sides. (F) Long-term result.

Pedicled Flap for Upper Limb Reconstruction 193

tendon reconstruction is needed the flap is kept alittle bulky for the passage of the tendon graftsthrough the fat. However, the flaps to the palmmust be made as thin as possible so that grip ispossible. A bulky flap in the palm is aestheticallyunacceptable and functionally disabling. It actsas if the patient has already something in thehand.

When both the volar and dorsal defects have tobe covered, a bilobed flap is planned. The groinand the hypogastric flap are raised in a bilobedmanner on a single pedicle and each turned overto cover the hand, which is sandwiched betweenthe two flaps. In such situations the groin flapcovers the dorsum, whereas the hypogastric flapcovers the volar defect (Fig. 10). This design canbe combined with forearm flaps to primarily covertotal degloving injuries of the hand.19

Flaps to the Forearm and for CombinedDefects

When the soft tissue defect of the hand extends tothe fingers or proximally into the forearm, largeflaps can be raised by incorporating adjacent ter-ritories of the vessels. When all four vessels areincluded in the base, a large flap of 30 by 15 cmcan be raised reliably without delay and it isenough to cover a defect extending from theelbow to the metacarpophalangeal joint of the fin-gers. The lateral margin goes up to the posterioraxillary line and medially it can cross the midlineup to the lateral margin of the rectus sheath ofthe opposite side. These flaps could be raised pri-marily without delay, but it is safer to delay suchlarge flaps before division. Delay is done bydividing one-third of the flap on either side andthe whole flap is divided and inset a week later.

Fig. 9. (A) Defect on the dorsum of the hand. (B) Groin flap raised. (C) The closure technique resulting in the flappointing to cover the defect. (D) The flap inset into position.

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Flaps to the volar side of the forearm requiremeticulous planning. The flap is based on theparaumbilical perforators (Fig. 11).20

Flaps to the Elbow

This is a challenge for a reconstructive surgeon,particularly when it happens as part of a majorhigh-velocity trauma, such as sideswipe injurieswith associated comminuted fractures. Skeletalstability is of paramount importance beforeproviding pedicled flap cover. The fixation qualityhas to be of a higher order than a free flap forcover. Loose skeletal fixation causes severe painin the postoperative period. Internal fixation isour choice for all upper limb skeletal injuries andin the region of the elbow if there is some instabilitybecause of the comminution of the fractures orbone loss, an auxiliary external fixator is appliedon the lateral side.Flap planning is made easier by putting the pa-

tient on the lateral side. The arm and elbow arekept on the body in a comfortable position andthe flap planned. For defects on the anterior sidethe flap is based anteriorly (Fig. 12) and for poste-rior defects a posteriorly based flap is designed.The perforators from the intercostal arteries andlumbar arteries are present along the midaxillaryline and that is kept as the base of the flap. Donorarea is skin grafted. When done in that position, wehave found that the patient is very comfortablewhile walking and being in bed. On rare occasions

when the elbow needs circumferential cover, and iffree flaps cannot be done, pedicle flaps can beplanned. We have devised a technique for such in-stances whereby an anteriorly based trunk flap isused to cover the anterior defect. The donor areaexposes the latissimus dorsi muscle and an inferi-orly based latissimus dorsi muscle flap is raised tocover the posterior aspect of the elbow. The elbowis sandwiched between the skin flap anteriorly andmuscle flap posteriorly. Trunk flaps are an easyand reliable technique for defects of the elbowextending from the distal third of the arm to theproximal third of the forearm. Yunchuan andcolleagues21 used lateral intercostal perforator-based pedicled abdominal flap for upper limbwounds from severe electrical injuries.Defects proximal to the distal third of the arm are

easily and better covered with pedicled latissimusdorsi or pectoralis muscle flaps.

Flaps in Children

Contrary to popular thinking, children do very wellwith pedicled flaps.22 We have done pedicledabdominal flaps in children as young 4 monthswithout any problem. One needs to restrain themwhen they come out of anesthesia, but onceawake, they do exceptionally well. Children donot pull away the flaps because it causes pain.Nevertheless, the hand is restrained by elastoc-repe bandage or tapes until the flap is divided. Inour experience the children are discharged from

Fig. 10. (A, B) A 10-day-old hand injury requiring flap cover on the dorsum and the palmar aspect of the hand. (C)A bilobed flap marked, one a groin flap and the other the hypogastric flap on a common pedicle. (D, E) The raisedflap, the donor area skin grafted, and the hand in preparation of inset. (F) The hypogastric flap used to cover thepalm. (G) The groin flap covers the dorsum of the hand.

Pedicled Flap for Upper Limb Reconstruction 195

the hospital in 4 to 5 days and do very well at home(Fig. 13).

POSTOPERATIVE CARE

At the end of the procedure, the limb is immobi-lized by broad plaster tapes that restrain the

patient from pulling the flap away from the body.It should also prevent kinking of the flap. Thisneeds to be done irrespective of whether the pro-cedure has been done under regional anesthesiaor general anesthesia. Postoperative monitoringand adjustment are made easy by a techniquethat we follow.23 After the correct position of

Fig. 12. (A) A patient with electrical burns with skin-grafted area in the anterior aspect of the elbow with loss ofelbow flexors. (B) The skin graft excised. (C) An anteriorly based trunk flap has been given with the patient in thelateral position. (D) The long-term outcome. The patient subsequently had pectoralis major transfer.

Fig. 11. (A) A patient with electrical burns sequelae with skin-grafted lower forearm needing flap cover forfuture reconstruction. (B) Skin graft excised and the nerve ends marked. (C, D) A superiorly based flap basedon the paraumbilical perforators raised and inset into the defect. (E) Long-term result. (F) The donor area.

196

Fig. 13. (A, B) Severe postburn contracture of the hand in an infant. (C) The baby comfortable with the flap. Thepicture shows the type of restraint applied to the child in the immediate postoperative period. (D) The resultshowing the thumb functioning again.

Fig. 14. Technique of immobilization after an abdom-inal flap. Note the three lines that run along the fore-arm and then on the abdomen of the patient to guidethe patient and the family as to the hand position.

Pedicled Flap for Upper Limb Reconstruction 197

immobilization is safeguarded by plaster re-straints, three lines are drawn on the forearm andcontinued on to the abdomen. The patient andthe relatives are instructed to keep the lines in con-tinuity and that makes the whole process easier(Fig. 14). We remove the restraints after about5 days, and we have not had any complications.In addition, the physiotherapist massages andmobilizes the shoulder and elbow and the wristas much as possible. It is also possible to mobilizethe fingers with the flap in situ in the immediatepostoperative period. Patients usually are mobi-lized from the bed in 24 to 48 hours and are dis-charged when they are comfortable.

SECONDARY PROCEDURESThinning of the Flap

Pedicled flaps have the advantage over free flapsin that during secondary thinning, the entire flap

can be thinned almost to the subdermal level.This is achieved by making small access incisionson the border of the flap at intervals and using theaccess to excise all the fat that is accessible to the

Fig. 15. (A, B) Technique of thinning of the flap. Small access incisions made to gain access and the whole flap canbe thinned to subdermal level in a single sitting.

Sabapathy & Bajantri198

incision. By strategically placing the incisions theentire flap can be thinned in one sitting (Fig. 15).It is our estimate that up to one-third of the perim-eter could be incised for access incisions and wehave not had any problem.

Secondary Reconstructions Under the Flap

Edema in the flap and induration at the suture linesettle in about 6 to 8 weeks after the flap inset.When the flap becomes supple and the indurationat the suture line is reduced, the patient is readyfor the secondary procedure. This is a betteryardstick than to have a rigid time frame for sec-ondary reconstruction. The flap is opened on oneside for bone grafting. If tendon grafts are done itis better to tunnel them through the flap. The flapmargins are the sites of maximum resistance forthe passage of tendon grafts and also the sitewhere tendon adhesions often occur. If we areaware of the need for secondary tendon recon-struction, great effort is taken to massage thescar line from the very beginning. We also providecustom-made compression garments to reducethe edema.

COMPLICATIONS

Necrosis of the flap is the worst complication onecan have, but fortunately loss of the whole pedicleflap is very rare. Marginal necrosis can occur. Thepatient is conservatively treated if excision of thecompromised flap would not expose a vital struc-ture or another flap is considered.Physiotherapy instituted immediately after the

patient comes out of anesthesia helps to preventstiffness of the joints. A good amount of patientcounseling before the operation and spendingsome time with the patient in the immediate post-operative period encourages the patient to followthe therapy instructions. We divide the flap underbrachial block and after division the shoulder isput through the whole range of movement. This

mobilization under anesthesia is helpful to getthem moving quickly.

SUMMARY

Pedicled flaps remain a valuable technique of softtissue cover in upper limb reconstructive surgery.They are versatile, have less demand on infra-structure, and if technical refinements are prac-ticed they also prove to be cost effective.Demands on the period of training, attention todetail, and skill in execution are no less thanwhat a free microsurgical flap would need for suc-cess. Proficiency in pedicled flaps provides thehand surgeon a higher level of confidence whenfaced with a complex defect or when a free flapseems difficult or risky to execute.

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