Indications, selection, and use of distant pedicled flap for upper limb reconstruction.

Despite the inherent advantages of free flaps for soft tissue cover in upper limb reconstruction, pedicled flaps remain the workhorse in many centers worldwide. Presumed disadvantages of pedicled flaps are that it requires multiple stages, longer hospital stay, are bulky, and primary reconstruction of composite defects cannot be done. Refinements in technique during planning can offset many of the disadvantages. Pedicled flaps are quick and easy to raise and do not need any special microsurgical expertise. Where free flaps are not possible or they fail, pedicled flaps are the lifeboat. An upper limb reconstructive surgeon must be adept at performing these flaps in challenging situations.

Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects.

OBJECTIVE: Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle. PATIENTS AND METHODS: A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles. RESULTS: Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients. CONCLUSION: This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.

Tips to orient pedicled groin flap for hand defects.

A groin flap is an axial-patterned cutaneous flap based on the superficial circumflex iliac arteriovenous system, which can provide soft-tissue coverage to defects on any aspect of the hand and the distal two thirds of the forearm. One of the presumed disadvantages of the pedicled groin flap is the discomfort experienced by the patient during the time required before flap division. These disadvantages can be greatly reduced by proper planning to orient the flap toward the defect, avoid any kinking at the base, and increasing the inset. We present our technique of orienting the flap to fit to the defect to be covered with ease. This technique avoids a lengthy flap and tubing, increases the patients comfort, and also makes the division and inset of the flap easier. As described, we have found this method simple and easy to duplicate.

Wound coverage considerations for defects of the lower third of the leg.

Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles, vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Free flaps continue to be the gold standard for the coverage of lower third leg wounds because of their ability to cover large defects with high success rates and feasibility of using it in acute situations by choosing distant recipient vessels. Reverse flow flaps are more useful for the coverage of the ankle and foot defects than lower third leg defects. The perforators in the lower third leg on which these flaps are based are often damaged during the injury. In medium-sized defects of less than 50 cm(2) size, local transposition flaps, perforator flaps, or propeller flaps can be used. Preoperative identification by the Doppler is essential before embarking on these flaps. Of the muscle flaps, the peroneus brevis flap can be used in selected cases with small defects. In spite of all recent developments, cross-leg flaps continue to remain as a useful technique. In rare occasions when other flaps are not possible or when other options fail it can be a life boat. In the author's practice free flaps continue to be the first choice for coverage of wounds in the lower third leg with gracilis muscle flap for small and medium defects, latissimus dorsi muscle flap for large defects and anterolateral thigh flap when a skin flap is preferred.

Nail bed injuries and deformities of nail.

Nail bed injuries are common and management of these requires good knowledge of the nail bed anatomy. Proper management of these injuries will ensure good healing and prevent late deformities. When loss occurs it is challenging to reconstruct which can be done by grafts or microsurgical reconstruction to restore aesthetic appearance of fingers.

Management of post burn hand deformities.

The hand is ranked among the three most frequent sites of burns scar contracture deformity. One of the major determinants of the quality of life in burns survivors is the functionality of the hands. Burns deformities, although largely preventable, nevertheless do occur when appropriate treatment is not provided in the acute situation or when they are part of a major burns. Reconstructive procedures can greatly improve the function of the hands. Appropriate choice of procedures and timing of surgery followed by supervised physiotherapy can be a boon for a burns survivor.