This is a retrospective review of all free flaps performed for dorsal hand coverage at a high volume microsurgical unit between 2002-2008. Flaps were divided into muscle flaps with skin grafts, fascial flaps with skin grafts, fasciocutaneous flaps, and venous skin flaps. A total of 125 free flaps were performed and aesthetic scoring was performed by blinded plastic surgeons and aestheticians. No functional analysis was performed. Average rates for wound debridement were 1.6 per wound. Average time to coverage was 5.6 days post-injury. There were no cases of flap loss. Partial flap loss was 2% and infection rate was 5%. There were no differences in these rates between flap types.
The most aesthetic flap reconstruction was deemed to be venous flap reconstruction where forearm skin is taken suprafascially and only venous anastamoses are performed to perfuse the flap. Fascia flaps with skin grafts were followed closely by muscle flaps with skin grafts for the next best scorers, with the least aesthetic reconstructions being fasciocutaneous flaps. The authors subdivided skin grafted flaps into split thickness grafts that were unmeshed (sheet grafts) and meshed skin grafts and found the unmeshed grafts to be aesthetically superior.
The authors discuss their choice of flaps with venous flaps being used for smaller defects due to limitations in the size of flap possible to harvest with this technique. They prefer to use partial muscle free flaps as they cause less donor site morbidity by selecting the superior portion of the latissimus or a partial medial rectus flap with the added benefit of less flap bulkiness. Fascial flaps used included the lateral arm flap, dorsal thoracic fascial flap and anterolateral thigh (ALT) fascial flap with skin grafts applied. These had the lowest donor site morbidity and are used preferentially by the authors for medium to large sized defects unless hardware exposure requires a thicker flap.
Fasciocutaneous flaps using the lateral arm and ALT donor sites were found to provide the least cosmetically appealing reconstruction and the most donor site wound healing problems. They are reserved for large wounds or wounds with significant hardware exposure that weren’t covered by muscle flaps. They required more post-reconstructive debulking. The donor sites more frequently required skin grafting but flap elevation for future stages in hand reconstruction was easier than with muscle flaps.
The authors conclude that due to the highly successful nature of microsurgery today, simply covering a defect with a flap that survives is no longer the only measure of a successful outcome. Minimizing donor site morbidity and maximizing functional and aesthetic results are now also primary concerns. While this article did not address function, the aesthetic review demonstrated results from their single institution study that now guide their reconstructive algorithms to further improve their results.