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Outcome in Reconstruction of Upper Limb Defects After Free Flap Salvage
Christoph Hirche, MD; Amir Khosrow Bigdeli, MD; Emre Gazyakan, MD; Volker Jürgen Schmidt, MD; Frederick Jochen Hernekamp, MD; Thomas Kremer, MD; Ulrich Kneser, MD
BG-Trauma Center Ludwigshafen/University of Heidelberg, Ludwigshafen, Germany

Introduction: Microvascular free tissue transfer has become a reliable method for the reconstruction of complex upper limb defects. However, the reconstructive aim is not only soft tissue coverage, but also restoration of form, function, and sensation. Despite high success rates, microvascular complication after free tissue transfer is a major challenge and necessitates urgent reexploration. The aim of this study was to analyze functional and cosmetic long-term results after successful upper limb free flap salvage.

Materials & Methods: From 1999 to 2010, a total of 836 patients underwent free microvascular tissue transfer for reconstruction of differing defects at our center. The retrospective analysis identified 138 patients, who underwent free flap reexploration (17%). Free flap salvage was achieved in 81 patients (59%). Microvascular complications were arterial thrombosis (59%), venous thrombosis (36%), and combined arterial and venous thrombosis (5%), and led to urgent reexploration in 45 patients (33%). A subgroup analysis identified 10 patients with upper limb free flap salvage. Follow-up was obtained in 8 patients. The free tissue transferred included latissimus dorsi flap (n=2), osteocutaneous fibula flap (n=2), parascapular flap (n=1), combined osteocutaneous scapula/parascapular flap (n=1), lateral arm flap (n=1), and radial forearm flap (n=1). Active range of motion (AROM) was measured and force measurements were obtained with hand-held dynamometers. The subjective disability of the upper limb was evaluated by means of the disabilities of the arm, shoulder and hand (DASH) questionnaire. The Vancouver Scar Scale (VSS) was used to evaluate the scar appearance.

Results: Force measurements and AROM were higher than the requirements for coping with everyday tasks. The subjective outcome after upper limb free flap salvage reached an average DASH score of 30.7 points according to a moderate limitation in activities of daily living. According to the VSS, overall patient satisfaction with the scar appearance was good.

Conclusions: Microvascular free tissue transfer is a reliable method for the reconstruction of complex upper limb defects. Despite of upper limb free flap reexploaration due to microvascular complications, acceptable functional and cosmetic results were achieved. To be successful in face of economic pressure in hospitals, the recognition and reexploration of a compromised free flap must be immediate.

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