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Free Muscle Flap Coverage of Hand and Upper Extremity Wounds
Erik Marques, MD; Jonathan Swope, MD, DMD; Minsue Chen, MD
University of Texas Health Science Center- Houston / McGovern Medical School, Houston, TX
Introduction: Free flaps are sometimes the best available option for coverage of extensive hand and upper extremity soft tissue defects. Although traditionally considered to be too bulky for coverage in this region, free muscle flaps can provide a substantial quantity of well-vascularized soft tissue. The purpose of this study was to review our experience with use of free muscle flaps for coverage of hand and upper extremity soft tissue defects.
Methods: We conducted a retrospective chart review over an 11 year period of all free muscle flaps performed by a single surgeon (EM) to address extensive soft tissue defects of the hand and upper extremity.
Results: 15 patients with complex wounds of the hand and upper extremity underwent free muscle flap coverage. Soft tissue defects resulted from trauma in 87 % (13/15) of the patients and included: gunshot wounds (2 cases), motor vehicle collisions (6 cases), industrial machinery (4 cases), and a circular saw injury (1 case). 13 % of patients had wounds following debridement for advanced infections. Wounds involved the hand in 47 % (7/15) of patients, the wrist in 60 % (9/15), and the forearm in 60 % (9/15).
Free flaps utilized included the latissimus dorsi muscle in 10 patients (67 %) and the rectus abdominis muscle in 5 patients (33 %). All of the free muscle flaps were covered with split thickness skin grafts. Flaps provided coverage of the following critical structures: bone 80 % (12/15), tendon 80 % (12/15), and nerve 27 % (4/15). There were no microvascular complications, and all flaps survived.
Follow-up ranged from 0-11 years (median= 1.25 years). All of the muscle flaps atrophied to conform to the surrounding tissue such that future debulking procedures were not required in any patients. During the follow-up period, 7 flaps required elevation for various reasons: nonunion (1 case), symptomatic or infected hardware (3 cases), wrist fusion with bone grafting (1 case), extensor tendon reconstruction (1 case), and flap advancement for a wound (1 case).
Conclusion: Free muscle flaps can reliably cover extensive soft tissue defects of the hand and upper extremity. These flaps can be readily elevated and re-inset for any future procedures required. We have not found the initial bulkiness of free muscle flaps to be problematic, as they predictably atrophy. Free muscle flaps have an important role in hand and upper extremity soft tissue reconstruction.
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