The authors, based in Latvia, present two case reports illustrating the principles and utility of distally-based soft tissue composite flaps for complex hand reconstruction with combined coverage and revascularization. Both patients were treated for occupational saw injuries to the hand. One patient was treated 21 days post-injury after initial stabilization with continued vascular compromise to the hand. The second patient was treated emergently for segmental bone, tendon, vascular and soft-tissue injuries. Both radial and ulnar artery based retrograde flaps were used, with skin paddles of 10x10 cm and 8x5 cm, respectively. The donor sites were closed with split-thickness skin grafts. In both cases the transfer of soft tissues to provide coverage was combined with anastomosis of the proximal flap artery (with retrograde flow from the wrist) to the injured distal vessels. The radial artery was used to revascularize a pollicized index finger with an injured common digital artery; the ulnar artery was used to revascularize the fourth web space common digital artery and the ring/small fingers. Both flaps were successful and the patients returned to physical labor. Average hospitalization was 9 days.
This paper illustrates the aggressive use of distally-based retrograde flow-through flaps from the radial and ulnar arteries in the forearm to reconstruct complex composite tissue losses in the hand with arterial compromise. The authors should be commended for their creative and courageous use of available tissues to salvage function in these severely injured hands. The successful revascularization of distal parts with retrograde arterial flow-through flaps is a unique concept, and one that takes the principle of distally-based flap coverage to its most radical conclusion. The authors review the evolution of the flow-through concept and outline the pro’s and con’s of distally-based tissue flaps. They discuss the alternatives of distant pedicled and free microvascular tissue transfers and cite their reasons for selecting local retrograde flaps for coverage. Indeed, in the emergent setting, and in centers where skilled microsurgical personnel and/or facilities are not available, this technique offers the opportunity to successfully salvage the severely injured distal extremity with composite tissues and vascular reconstruction with a limited surgical team and with some versatility. One must use caution, however, in applying this technique, given the significant donor site morbidity, potential for compromise of the distal circulation from loss of the radial or ulnar artery, and limitations of size and position of the flaps that these techniques present.
Journal of Reconstructive Microsurgery