Impact of Timing of Admission and Microvascular Reconstruction on Free Flap Success Rates in Traumatic Upper Extremity Defects.

BACKGROUND: Despite a growing body of knowledge, the timing of microsurgical reconstruction for the upper extremity remains a controversial topic. Most of the available literature deals with lower extremity reconstruction and the few reports on microsurgical reconstruction of the upper extremity are mostly concerned with infection rates and rarely consider thrombosis and changes in coagulation parameters. METHODS: We performed a retrospective review of all free flaps performed for upper extremity reconstruction at our institution from 2000 to 2010. Only acute, isolated traumatic defects of the upper extremity requiring a free flap for reconstruction were included in this study. A review of medical records was performed to assess, among others, comorbidities, timing of reconstruction, and platelet levels. RESULTS: A total of 41 patients were included in this study, 70% of whom were male. Mean age at the time of surgery was 40.8 ± 15.4 years. Patients who were directly referred to our hospital underwent reconstruction significantly faster than those who were transferred secondarily (p = 0.0001). The number of surgical revisions as well as the flap loss rate was higher in patients undergoing reconstruction more than 1 week after trauma (p = 0.09 and 0.033, respectively). A significantly higher platelet count was seen in the patients undergoing delayed reconstruction (p = 0.002). CONCLUSION: In our study, early microsurgical reconstruction of the upper extremity yielded better results in terms of lower rates of surgical revisions and flap loss. This might be partly because of a trauma-induced thrombocythemia, with a maximum level of platelets in the 2nd week post trauma. We, therefore, advocate a timely coverage of these defects along with an anticoagulatory regimen including some form of platelet inhibition.

Comparison of donor-site morbidity and satisfaction between anterolateral thigh and parascapular free flaps in the same patient.

The purpose of this study was to compare donor-site morbidity after anterolateral thigh (ALT) and parascapular (PS) free flap harvest in the same patient. A total of 13 patients were included in this study. Because of initial flap loss, each patient received ALT as well as PS free flap transplantation. A total of 10 patients were available for follow-up. The average follow-up time was 44.5 months. Besides physical examination, range of motion and scar dimensions were assessed to objectify donor-site deficiencies. The subjective donor-site morbidity was assessed by the patients using a self-report questionnaire. In addition, patients were requested to state their donor-site preference. ALT donor site revealed more sensitivity deficiencies compared with the PS harvest site (8 vs. 4). The latter provoked less functional impairments (1 vs. 2). Scar dimensions were larger at PS harvest site (25.8 × 4.3 cm vs. 23.3 × 3.6 cm). Patients' satisfaction was in favor of the PS donor site (1.9 vs. 2.7). Among the 10 patients, 7 patients preferred the PS and 3 patients preferred the ALT donor site. Comparison of donor-site morbidities in the same patient reveals a valuable tool to diminish individual bias. Despite the low number of cases, we were able to demonstrate the superiority of PS compared with ALT donor sites.The Level of Evidence of the study is III.

Comparison of anterolateral thigh, lateral arm, and parascapular free flaps with regard to donor-site morbidity and aesthetic and functional outcomes.

BACKGROUND: The purpose of this study was to compare the morbidity and the aesthetic and functional outcomes of primarily closed donor sites of three commonly used free flaps. METHODS: Sixty patients who had undergone free flap reconstruction (20 anterolateral thigh, 20 parascapular, and 20 lateral arm flaps) were included in this study. The average follow-up time was 50 months (range, 6 to 135 months). Patients assessed subjective donor-site morbidity and satisfaction with the aesthetic and overall functional result using a self-report questionnaire. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire; the Lower Extremity Functional Scale; and the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire. RESULTS: No significant differences in range of motion or in questionnaire, scale, or survey scores were detected. Sensory disorders were present in 100 percent (lateral arm), 90 percent (anterolateral thigh), and 45 percent (parascapular). No correlation to flap size was detected (187 cm for parascapular and anterolateral thigh, and 70 cm for lateral arm flaps). Postoperative complications were seromas (parascapular, n = 2), hematomas (parascapular, n = 1; lateral arm, n = 2), and dehiscence (n = 4 for each flap). Patient satisfaction with the donor site was rated 2.9 for lateral arm and anterolateral thigh flaps and 2.5 for parascapular flaps (1 = excellent, 6 = poor). Seventy percent of anterolateral thigh, 85 percent of lateral arm, and 100 percent of parascapular flap patients would choose their flap again. CONCLUSION: In terms of reducing donor-site morbidity, the parascapular flap represents a valuable alternative to the anterolateral thigh and lateral arm flaps, but side positioning and increased seroma are drawbacks.