SOFT TISSUE RECONSTRUCTION WITH OMENTAL FREE FLAP IN COMPLEX UPPER EXTREMITY INJURIES: REPORT OF 13 CASES M.D., DANIELA ALEJANDRA LEON-L MARTIN IGLESIAS, M.D.,* PATRICIA BUTRON, OPEZ, M.D., SOFIA GARCIA-MANCILLA, M.D., ISRAEL ESPINO-GAUCIN, M.D., and ALETHIA RUBIO, M.D.
Although there is a wide list of free flaps options for soft tissue reconstruction of complex upper extremity injuries, the omental flap has some useful anatomical and biochemical advantages. We report 13 patients who underwent hand or upper extremity reconstruction with omental free flaps. Nine patients had extensive tissue damage, resulting with digital cyanosis and hypothermia, and some of them with areas of cutaneous necrosis, or avulsed tissues with tendons and bones exposed or infected. The remaining four patients had minor extensive tissue damage without circulatory problems. Patient’s average age was 34.6 years. Twelve flaps were harvested through laparotomy and one laparoscopically. All flaps were covered with a skin graft. None of the flaps were lost. The average follow-up time was 20 months. There was one major and two minor donor site complications. One patient had minor loss of the skin graft in the recipient site, and two required minor additional surgeries to improve the appearance or function of the hand or upper extremity. There were no late abdominal complications in any patient. The morphological appearance and functional results were favorable in 11 of them, and permitted their reincorporation into society without the need for additional complex surgeries. Only two patients had a poor outcome. Our experience C 2014 Wiley confirms that the omental flap may be a good option for reconstruction of some complex hand and upper extremity injuries. V Periodicals, Inc. Microsurgery 34:425–433, 2014.
Complex
upper extremity injuries cause destruction of tissues and can compromise the circulation in remaining tissues.1 The resulting inflammation and fibrosis diminish the function of the entire upper extremity. To regain maximum function, these patients occasionally require secondary surgeries to release adhesions or to reconstruct tissues. For this reason, the period of rehabilitation and recovery can be lengthy and functional outcome is uncertain. Therefore, the reconstruction of these complex injuries is still a great challenge for plastic surgeons.2 There is a wide range of free flaps that can be used for reconstruction of cutaneous cover and soft tissue in complex hand or upper extremity injuries, but none of them has the many biochemical and anatomical advantages of the omental flap.3–8 Its biochemical advantages include: (1) secretion of growth factors such as vascular endothelial growth factor,7,8 basic fibroblast growth factor,9 epidermal growth factor, platelet-derived growth factor, and tumor necrosis factor alpha; (2) production of neurochemical substances including beta-endorphins, serotonin, and norepinephrine; and (3) the presence of interleukins (IL-1, IL-6, and IL-8) and interferon gamma.5,7–10 These biochemical characteristics offer the advantage of great immunological protection and bactericidal action in the presence of acute and chronic infections; a greater capacity for revascularization of ischemic dicas y Nutricio n Plastic Surgery Service, Instituto Nacional de Ciencias Me n, Mexico City, Mexico Salvador Zubira *Correspondence to: Martin Iglesias, M.D.; Monte de Antisana 47, Colonia ~a, C.P. 14210, Me xico D.F., Me xico. Jardines en la Montan E-mail: [email protected] Received 22 May 2013; Revision accepted 16 January 2014; Accepted 24 January 2014 Published online 12 February 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22236 Ó 2014 Wiley Periodicals, Inc.
tissue; and more fluid production and absorption.3,5,6,11–15 The surgical advantages conferred by the omental flap include a large area of up to 500 cm2, large and consistent blood vessels that facilitate the microsurgical repair, great plasticity that allows for better modeling of the flap at the reconstructed site, persistent pliability that prevents scarring and contraction, and low metabolic demand that permits a long ischemia time.4,6 Although the omental flap has been used in hand reconstruction since 1964,16 published reports are still rare.1,3,17,18 Its main indications are complex hand injuries that not only require soft-tissue reconstruction but also have ischemic tissues. Some authors have considered it only when other surgical procedures have failed.6–8,19,20 The objective of this article was to present our experience with 13 soft tissue reconstructions in hand and upper extremity injuries. PATIENTS AND METHODS
From 2002 to 2012, eight female and five male patients with complex hand and limb injuries underwent reconstruction with transfer of an omental free flap. A retrospective analysis was completed of their clinical files of patients. The average age was 34.6 years old (range, 8–68 years). The injury etiology was trauma in six patients, infection in two, chemotherapy extravasation in two, tumor resection in two, and burn in one. The skin and subcutaneous tissue was injured in all patients, and muscles, tendons, nerves, arteries, and bones were also injured in some patients. The first nine patients had extensive tissue damage, resulting with digital cyanosis and hypothermia, and
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some of them with areas of cutaneous necrosis, or avulsed tissues with tendons and bones exposed or infected. The amputation or stump remodeling was the initial proposed treatment for almost all of them. This extensive tissue damage resulted in scarring and poor circulation. The remaining four patients had minor tissue damage and no circulatory problems. Demographic factors, diagnoses, comorbidities, and affected tissues, are described in the Table 1. SURGICAL TECHNIQUE
Two surgical teams performed the surgery. One team harvested the omental flap while the other team worked on the upper extremity. The omental flaps were obtained by plastic and general surgeons according to reported open techniques.3,5,6,21 Laparoscopic technique was modified from the one described by Saltz22 and Crabtree.23 Two 5-mm trocars were placed lateral to the abdominal rectus muscle (left and right) and one 10-mm umbilical trocar was placed. Pneumoperitoneum was induced with CO2 at 15 mmHg, followed by endoscopic dissection of the omentum in a similar manner as described in the open technique. The umbilical port incision was extended to allow flap removal. Fixation of the greater curvature of the stomach was not needed in any of the cases. Before surgery, a wide resection of scar and injured tissue was executed. Then the tendons, nerves, and bony structures were evaluated. Lysis of adhesions and reconstruction of all affected tissues occurred in a one-stage procedure, simultaneous with the microsurgical transfer of the omental flap. When appropriate, the omentum was interposed between the anatomic structures to isolate and/or to revascularize them. Microsurgical end-to-end or end-to-side anastomoses were used in artery and vein repair. As a final step in most of the cases, a skin graft was placed. Full-thickness skin grafts were obtained from the abdomen or inguinal region, and partial-thickness skin grafts were obtained from the thigh. EVALUATION
The final functional-morphological outcome was evaluated with the concepts of the Hand Transplantation Score System at the end of the follow-up period for each of the patients.24 Fifty variables that fit into six general categories were evaluated: (1) morphologic appearance, (2) sensitivity, (3) movement, (4) social and psychological acceptance, (5) work and daily activities, (6) patient satisfaction and well being. The value of each concept was modified to maximum score of 50 points. The outcomes were classified favorable from 50 to 21, and poor from 20 to 0 points. Microsurgery DOI 10.1002/micr
Our institution does not require Institutional Review Board approval for retrospective studies. RESULTS
Twelve omental flaps were harvested through laparotomy and one was harvested laparoscopically. The size of the omental flap was usually larger than the defect size, and sometimes up to two times the defect size. The reasons were, because the flap was sometimes wrap around the anatomical structures or because it was sometimes folded on itself with the purpose to add volume. The time for harvesting the omental flap ranged from 45 to 180 minutes. A full-thickness skin graft obtained from the abdomen and/or groin was used in eight patients, and a partial-thickness skin graft obtained from the thigh was used in five patients. Only one patient required one pack of red blood cells because of anemia secondary to autoimmune hepatitis and concomitant coagulation abnormalities. All of the flaps survived. The average follow-up time was 23 months (range, 1–60 months). The morphological appearance and functional outcomes were favorable in 11 of them, and permitted their reincorporation into society without the need for additional complex surgeries. Only two patients had a poor outcome (Table 1). One major donor site complication occurred. One patient suffered devascularization of the transverse colon, requiring a colectomy, and colostomy with a subsequent colostomy takedown. This patient had two failed free flaps previous to the omental free flap transfer. There were two minor donor site complications. One patient had a small abdominal wall hematoma requiring evacuation as an outpatient, and other patient developed third spacing of fluid and abdominal pain, but did not require surgery. There was one recipient site minor complication; this patient developed a minor loss of the skin graft. Two patients required additional minor surgeries. One was to decrease the volume of the flap and to achieve a better aesthetic appearance because the patient gained weight. This was performed 24 months after the initial surgery. Another patient required surgery to correct flexor tenolysis at the wrist. There were no late abdominal complications in any patient. CASE REPORTS Case 1
A 35 year old male suffered a car accident that caused amputation of the right first metacarpal and thumb, fracture of the fourth metacarpal and avulsion of soft tissues from the hand, wrist, and forearm, and exposure of extensor tendons and carpal bones. The patient had two failed reconstruction surgeries at another
35 (M)
25 (F)
45 (f)
35 (M)
31 (F)
8 (M)
23 (M)
12 (F)
17 (F)
42 (F)
Age (Y/O) and gender
3rd degree burn of the total right palm and fingers. Thenar and hypothenar muscles, flexor tendons and nerves were exposed, with 4th and 5th fingertip necrosis Mucormycosis of the dorsum of the left hand. The 2nd, 3rd, and 4th extensor tendons were injured with granulation tissue. 3rd and 4th metacarpal bones were exposed. Fourth left finger avulsion-amputation with flexors and extensors tendons, digital nerves, arteries, and veins avulsed. Proximal phalanx was exposed. Severe right hand crush injury. Flexors and extensors tendons, arteries, and nerve were crushed and exposed with 3rd finger necrosis from proximal phalanx, and 3rd and 4th metacarpal fractures. Left hand and forearm crush injury. Flexor and extensor tendons were crushed and exposed at the distal forearm third, exposed radial fracture, loss of the 1st metacarpus, and median nerve. Severe left hand crush injury with extensor tendons crushed and exposed, 3rd and 4th metacarpal fracture, 3rd finger amputation Total degloving of the cutaneous cover of the right distal third of forearm, hand’s dorsum and partial of the palm with avulsion of the first ray, 4th metacarpal fracture. Initially the defect was cover with skin grafts. Left hand crush injury complicated with infection and Compartmental syndrome. Extensor tendons, metacarpophalangeal joints, and metacarpal bones were exposed. Mucormycosis of the right forearm. Losses of flexor and extensor muscles; median, ulnar and radial nerves; radial and ulnar arteries, and extensive and diffuse fibrous tissue, covered initially by skin grafts. Cavernous hemangioma of the 3rd finger of the left hand The radial digital artery, radial collateral digital nerve, flexor and extensor tendons, and proximal phalanx were exposed.
Injurya
Diabetes mellitus
Obesity and heavy smoking
Two failed free flaps previously
Autoimmune hepatitis
Convulsive syndrome
Co-morbidities
534
28 3 20
11 3 13
18 3 15
14 3 10
15 3 10
636
735
838
10 3 20
Defect size (cm)
CDA of the 3rd space and DV
BA and CV at proximal third of the arm
RA and CV
RA and CeV at middle third of the forearm.
RA and CV
RA and CeV at middle third of forearm.
RA and CV
CDA of the 3rd space and DV
RA and CV
RA and CV
Recipient vessels
Table 1. Patient Characteristics
No
No
Small abdominal wall hem atoma (mi)
Transverse colon devacularization (Ma)
No
No
No
No
No
No
Third space losses (mi)
No
No
No
No
Minor loss of the skin graft (mi)
Recipient site complications
No
No
No
No
Donor site complications
60
24
36
12
4
24
29
1
7
36
Follow-up time (months)
Favorable
Favorable
Favorable
Favorable
Favorable
Favorable
Favorable
Poor
Favorable
Favorable
Outcomes
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Microsurgery DOI 10.1002/micr
Favorable Chemotherapy extravasation of the hand’s dorsum. Extensor tendons and metacarpal bones were exposed. 64 (F)
68 (F)
Microsurgery DOI 10.1002/micr
a All patients lose the skin and subcutaneous tissue. F, female; M, male; mi, minor; Ma, major; BA, brachial artery; RA, radial artery; CV, comitant vein; CDA, common digital artery; DV, dorsal vein; CeV, cephalic vein.
9 No RA and CV 939
No
Favorable 8 No RA and CV 838
Non-Hodgkin’s lymphoma, diabetes mellitus and glaucoma Renal cancer
No
12 No No RA and CV 533 Reflex sympathetic dystrophy
Chondromatosis of the right wrist and recidivate carpal tunnel syndrome with extensive fibrous tissue Chemotherapy extravasation of the hand’s dorsum. Extensor tendons and metacarpal bones were exposed.
Co-morbidities Injurya Age (Y/O) and gender
45 (M)
Follow-up time (months) Recipient site complications Donor site complications Recipient vessels Defect size (cm)
TABLE 1. Continued
Poor
Iglesias et al. Outcomes
428
hospital. At admission to our service, the patient presented with edema, digital paresthesias, and unstable cutaneous cover. The metacarpophalangeal (MCP) and interphalangeal joints were ankylosed (Fig. 1). A late reconstruction was performed with a 18 3 15 cm omental free flap. All scarred tissue was resected from the hand and the extensor tendons were released. An arthroplasty of the MCP joints was performed along with release of intrinsic muscles. Veins at the dorsal aspects of the second and fourth interdigital spaces were identified. The recipient vessels, the radial artery, and the cephalic vein were dissected at the middle third of the forearm. A portion of the omental flap was placed between the metacarpal and the extensor tendons, and the remaining flap over the tendons (Fig. 2). An end-toend anastomosis was performed to revascularize the omental vein to the cephalic vein, and an end-to-side anastomosis from the omental artery to the radial artery. In addition, two veins from the omentum were anastomosed end-to-end with the second and fourth interdigital space veins. On the third day after surgery, the patient had abdominal pain and serous secretion through the abdominal wound. He underwent another surgery where a colon resection and colostomy were performed with a subsequent colostomy take-down. There were no further complications at the recipient site (Fig. 3). The active movement of the phalanges was normal at 60 months of follow-up. The patient does not desire to continue with thumb reconstruction (Fig. 4). Case 2
A 25 year old male had mucormycosis on the right forearm secondary to traumatic injury. He was managed with multiple surgical debridements until cultures were negative for Rhizopus spp. The cutaneous cover of the forearm and distal third of the arm was lost. Almost all muscles and tendons of the wrist and fingers were lost, except the flexor pollicis longus and extensor carpi radialis brevis. Furthermore, the radial and ulnar arteries and median, ulnar and radial nerves were partially resected. There was poor circulation through the interosseous artery. Initially, the residual tissue was covered with split-thickness skin grafts (Fig. 5). The patient then received mucormycosis treatment for three months, after which a reconstruction was performed. The skin grafts were removed. An omental free flap of 30 3 35 cm was harvested by open technique. The right gastroepiploic artery was anastomosed end-to-side to the brachial artery at the distal third of the arm. The omental vein was anastomosed end-to-end to a deep vein at the distal third of the arm. The left gastroepiploic artery was anastomosed end-to-end to the ulnar artery at the level of the wrist. The median and ulnar nerves were reconstructed with 15- and 20-cm long sural nerve grafts (Fig. 6). A gracilis
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Figure 1. Patient with loss of cutaneous cover and subcutaneous tissues of the hand and forearm, thumb avulsion and fracture of the 3rd and 4th metacarpal bones. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 2. Late reconstruction. Resection of scarred tissue and tenolysis of extensor tendons. Extensor tendons were wrapped with omental flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
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Figure 3. Morphological appearance of the reconstruction at 5 months postoperative. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 4. Functional result at 60 months after the reconstruction. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
Figure 5. Clinical appearance at 4 months post-trauma and infection. The hand had slow capillary filling, hypothermia, edema, and total anesthesia of the hand. The cutaneous cover was unstable. There wasn’t wrist and finger active movement. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Figure 6. The hand and omental revascularization through omental flap as by pass flap. The arrows show the proximal end of the median and ulnar nerves. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 8. Nine months after surgery, with active flexion of the fingers. The tinel sign was positive at wrist level. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]
extension of the wrist secondary to the flexion and extension of the fingers (Fig. 8).
DISCUSSION
Figure 7. The nerves were reconstructed. The free gracilis muscle flap was transferred and connected to the distal tendon flexor profundus of 2nd, 3rd, and 4th fingers. The flexor pollicis longus tendon was repaired. The star shows the gracilis muscle flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
muscle free flap was transferred to reconstruct the flexor digitorum profundus. Its artery was anastomosed end-toside to the right gastroepiploic artery, and its vein was anastomosed end-to-side to a epiploic vein. The gracilis muscle was inserted to the medial condyle of the humerus and its tendon was sutured to all flexor profundus tendons at the wrist. The extensor carpi radialis brevis was transferred to the extensor digitorum communis. The flexor pollicis longus was repaired (Fig. 7). In addition, two omental veins were anastomosed end-to-end to two dorsal hand veins at wrist level. Finally, the omental flap was wrapped around the forearm and a medium split skin graft was applied. The patient’s postoperative clinical progress was without complications. Nine months after surgery, the patient had protective sensibility and total active flexion and extension of the distal and proximal interphalangeal joints. There was flexion and
The objective of hand or upper extremity reconstruction after a severe injury is to obtain maximal functional capacity and the best morphological appearance possible. To achieve this objective, an aggressive resection of damaged tissue must be performed. Several anatomical structures are lost this way and others may be ischemic or exposed. Therefore, the reconstruction should be as complete as possible, and preferably in one surgical stage, to avoid fibrosis and secondary surgeries. The upper extremity is poorly tolerant of prolonged immobilization, which predictably results in joint stiffness and tendon adhesions. Consequently, the reconstruction should be as early as possible, factoring in local wound conditions, and the health of the patient. With current success rates of over 95%, and the availability of multiple donor sites, free flaps offer virtually unlimited freedom in soft tissue reconstruction of hand or upper extremity injuries. The ideal free flap in these cases is one that has enough volume to cover the defect but not excessive volume, and a long pedicle of large caliber. This enables anastomosis out of the field of inflammation or fibrosis, thus reducing the risk of vessel spasm and thrombosis at the anastomosis site, without the necessity of vein grafts.25 Muscle flaps are indicated for the reconstruction of complex defects where the filling of dead space is required. Microsurgery DOI 10.1002/micr
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They provide well-vascularized tissue that has the advantage of indirect revascularization and controlling bacterial inoculation. However they may be initially too bulky, and cannot be wrapped around repaired structures independently, as omental flaps can. Perforator muscle flaps allow for better tailoring to fit the recipient defect, but their vascular pedicle length is short, which is a disadvantage.25 Fasciocutaneous flaps are indicated for the coverage of shallow wounds. They can restore contour and provide an excellent gliding surface for tendons and joints at the extremities. Some fasciocutaneous flaps have as main advantage the possibility to be used as neurovascular flap. The lateral arm flap, free or pedicled radial forearm flap, free dorsal pedis artery flap, and the anterolateral thigh flap26 are most common. This is important for the reconstruction of protective sensation of the palm. The free medial plantar artery flap is useful, however its utility is limited to reconstruction of small defects of the palm.27 Their disadvantages are that they do not fill dead space, do not provide great circulatory contributions, and some of them have short vascular pedicles.25 The fascial flaps as the free temporoparietal fascial flap or local pedicled radial forearm flap with instep skin graft are a good surgical treatment only when there is no severe trauma.27 The omental flap has anatomical advantages: a large area of up to 500 cm2, large and consistent blood vessels that facilitate microsurgical repair and great plasticity that allows for better modeling of the flap at the reconstruction site.4–6 In addition, the omentum flap has biochemical characteristics that offer immunological protection, bactericidal action, a persistent pliability that prevents scarring and contractions and a greater capacity for revascularization of ischemic tissue.3,5,6,11–13,19 Given these properties, free or pedicled omental flaps have been used for the reconstruction and/or revascularization of large and complex lesions in all body segments without regard to the etiology (traumatic, oncological, ischemic, radiotherapy, etc.).20,23,28–32 We considered it a good flap for reconstruction of the soft tissues in complex hand or upper extremity injuries, and the one that allows the maximum functionality and best morphological appearance. However, with donor site morbidity reported up to 18.5%, and the severity thereof, it has limited surgical application.3 For this reason, the utility of this flap is limited to the reconstruction of complex bodily defects involving chronic ischemia or chronic infections, and where other methods of reconstruction have failed. Therefore most authors consider it as a rescue flap.1,6– 8,19,20,23,28–30,33 Under these conditions, it has been used for the reconstruction of complex lesions of the hand since 1964.16,18,34,35 However published reports for hand or upper extremity reconstruction are rare.1,3,17,18 Only small case series have been reported.1,3–5,33 The biggest case series reported is with a maximum of 12 patients.36 Microsurgery DOI 10.1002/micr
In Seitz’s series of seven cases,4 there was only one wound infection of the abdominal donor site, and two patients required secondary surgeries at the recipient site. The outcomes from Seitz’s series are impressive. In Prowan’s study of 13 cases,36 of which 12 had upper extremity reconstructions, one patient developed a ventral hernia and five developed significant abdominal pain. In this series, eight used free flaps and five used pedicled flaps. Two flaps were lost, one free and one pedicled. The rate of complication in the Prowan’s report was lower than the 18.5% reported previously. There were no major complications that endangered the lives of patients.36 Under these principles, we treated nine patients with complex and large lesions with fibrosis and/or poor circulation of the remaining tissues. Only one patient had a major complication. The remaining donor site complications were minor and considered similar to donor site morbidity with other flaps (hematoma and pain). Our approach to reduce donor site morbidity is to perform all reconstructions with a free flap and to have an experienced general surgeon harvest the flap with the help of a plastic surgeon. With this strategy, we have not had any major complications at the donor site. The only minor complication at the donor site was the loss of a small portion of skin graft, which healed secondarily. Two minor secondary surgeries were performed; one for improving function and the other for improving appearance. Given the functional and morphological outcomes obtained in the first nine cases, we decided to use this flap in patients with minor extension of tissue damage and no circulatory problems, even when other free flaps could be used. The results were favorable, as the omental flap plasticity allowed us to cover the required volume of the defect without additional surgeries to remodel the flap. There were no complications at the donor or recipient sites, and the functionality and appearance of the hand or upper extremity were favorable. Although the final functional-morphological outcomes could be evaluated with many scales as Disability Arm Shoulder and Hand, Michigan Hand Outcomes Questionnaires or Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) we decided to use some of the principles of Hand Transplantation Score System. The reason is because this test takes into consideration the hand and the body as a total unit to evaluate the final function of the hand, and no evaluate finger-by-finger, nerve-by-nerve, or joint-by-joint. This could be questionable, and could require further study. Patients with a body mass index (BMI) of 30 must be carefully evaluated. Previous surgeries and abdominal infections could produce adherence or scarring of the omentum. In these cases, endoscopic revision can help to determine whether harvesting of an omental flap
Omental Flap in Upper Extremity Injuries
should be performed. Some contraindications include ascites, acute peritonitis, and suspicion of absence of an omentum. Although this series reports one case of laparoscopic harvesting of an omental flap, we agree with other authors that this harvesting method may have advantages for the patient.37 The omental flap meets the criteria of an ideal free flap. For this reasons, it was chosen to reconstruct the cutaneous cover and soft tissues, to avoid fibrosis and development of adhesions of the repaired tissues, to reconstruct all damaged tissues and to be able to mold the flap in the shape and volume required by the limb. According to our outcomes, it may represent a good option for reconstruction of some complex hand or upper extremity injuries.
REFERENCES 1. Maloney CT Jr., Wages D, Upton J, Andrew Lee WP. Free omental tissue transfer for extremity coverage and revascularization. Plast Reconstr Surg 2003;111:1899–1904. 2. Herter F, Ninkovic M, Ninkovic M. Rational flap selection and timing for coverage of complex upper extremity trauma. J Plast Reconstr Aesthet Surg 2007;60:760–768. 3. Hultman CS, Carlson GW, Losken A, Jones G, Culbertson J, Mackay G, Botswick J III, Jurkiewicz J. Utility of the omentum in the reconstruction of complex extraperitoneal wounds and defect. Ann Surg 2002;235:782–795. 4. Seitz IA, Williams CS, Wiedrich TA, Henry G, Seiler JG, Schetchter LS. Omental free-tissue transfer for coverage of complex upper extremity and hand defects-The forgotten flap. Hand (NY) 2009;4:397–405. 5. Williams R, White H. The greater omentum: Its applicability to cancer surgery and cancer therapy. In: Ravitch MM, editor. Current Problems in Surgery. Chicago, IL: Year Book Medical Publisher; 1986. pp 793–865. 6. Liebermann-Meffert D. The greater omentum: Anatomy, embryology, and surgical applications. Surg Clin North Am 2000;80:275– 293. 7. Zhang QX, Magovern CJ, Mack CA, Budenbender KT, Ko W, Rosengart TK. Vascular endothelial growth factor is the major angiogenic factor in the omentum: Mechanism of the omentummediated angiogenesis. J Surg Res 1997;647:147–154. 8. Goldsmith H, Griffith A, Catsimpoolas N. Increased vascular perfusion after administration of an omental lipid fraction. Surg Gyn Obst 1986;162:579–584. 9. Bikfalvi A, Alterio J, Inyang AL, Dupuy E, Laurent M, Hartmann MP, Vigny L, Raulais D, Courtois Y, Tobelem G. Basic fibroblast growth factor expression in human omental microvascular endothelial cells and the effect of phorbol ester. J Cell Physiol 1990;144: 151–158. 10. Hishida M, Toriyama K, Yamashita Y, Akatsuka S, Hayakawa A, Torii S, Kamei Y. Omental flap closure of refractory wounds: Rat model. Nagoya J Med Sci 2010;72:91–99. 11. Cartier R, Brunette I, Hashimoto K, Bourne WM, Schaff HV. Angiogenic factor: A possible mechanism for neovascularization produced by omental pedicles. J Thorac Cardiovasc Surg 1990;99: 264–268. 12. Adams W, Ctercteko G, Bilous M. Effect of an omental wrap on the healing and vascularity of compromised intestinal anastomoses. Dis Colon Rectum 1992;35:731–738. 13. Shilov BL, Milanov NO, Liebermann-Meffert D. Biological acivity of tissue flaps in the treatment of complicated irradiated rounds. Eur J Plast Surg 1995;18:46–49.
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14. Goldsmith HS, editor. The Omentum: Research and Clinical Applications. New York: Springer; 1990. 15. Beelen RHJ. The greater omentum: Physiology and immunological concepts. Neth J Surg 1991;43:145–151. 16. Shilov B. Greater omental autotransplantation in plastic surgery. Plast Reconstr Surg 2004;114:1342–1343. 17. Kiricuta I. Plastic surgery using part of the epiploon. Prior vascularization of the transplant on the dorsal surface of the hand (author’s transl). Nouv Presse Med 1978;7:4295–4297. 18. Martin FF, Le Quang C, Texier M, Bonnet F, Dufourmentel C. Treatment of radionecrosis of the wrist using a great omentum flap and skin graft. Ann Chir Plast 1974;19:247–249. 19. Erol OO, Spira M. Development and utilization of a composite island flap employing omentum: Experimental investigation. Plast Reconstr Surg 1980;65:405–418. 20. Shilov B, Milanov N. Free transfer of the great omentum. Ann Plast Surg 1993;31:546–549. 21. Serafin D. The great omentum flap. In: Serafin D, editor. Atlas of Microsurgical Composite Tissue Transplantation. Philadelphia: Saunders; 1996. pp 705–716. 22. Saltz R, Stowers R, Smith M, Gadacz TR. Laparoscopically harvested omental free flap to cover a large soft tissue defect. Ann Surg 1993;217:542–547. 23. Crabtree JH, Fishman A. Laparoscopic omentectomy for peritoneal dialysis catheter flow obstruction. A case report and review of the literature. Surg Laparos Endosc 1999;9:228–233. 24. Petruzzo P, Lanzetta M. A comprehensive functional score system in hand transplantation. In: Lanzetta M, Dubernard JM, editors. Hand Transplantation. Milano, Italy: Springer-Verlag; 2007. pp 355– 362. 25. Saint-Cyr M, Wong C, Buchel EW, Colohan S, Pederson W. Free tissue transfer and replantation. Plast Reconstr Surg 2012;130:858e– 878e. 26. Peng F, Chen L, Han D, Xiao C, Bao Q, Wang T. Reconstruction of two separate defects in the upper extremity using anterolateral thigh chimeric flap. Microsurgery 2013; doi: 10.1002/micr.22170. 27. Engelhardt TO, Rieger UM, Schwabegger AH, Pierer G. Functional resurfacing of the palm: Flap selection based on defect analysis. Microsurgery 2012;32:158–166. 28. Domene CE, Volpe P, Onari P, Szachnowics S, Birbojm I, Barreira LF, Reiff AM, Pinotti HW. Omental flap obtained by laparoscopic surgery for reconstruction of the chest wall. Surg Laparos Endosc 1998;8:215–218. 29. Jurkiewicsz MJ, Nahai F. The omentum. Its use as a free vascularized graft for reconstruction of the head and neck. Ann Surg 1982; 195:756–765. 30. Cothier-Savey I, Tamtawi B, Dohnt F, Raulo Y, JBaruch J. Immediate breast reconstruction using a laparoscopically harvested omental flap. Plast Reconstr Surg 2001;107:1156–1163. 31. Weinzweig N, Schuler J, Vitello J. Simultaneous reconstruction of extensive soft-tissue defects of both lower limbs with free hemiflaps harvested from the omentum. Plast Recontr Surg 1997;99:757–762. 32. Herrera F, Buntic R, Brooks D, Buncke G, Antony AK. Microvascular approach to scalp replantation and reconstruction: A thirty-six year experience. Microsurgery 2012;32:591–597. 33. Ala-Kulju K, Virkkula L. Use of the omental pedicle for treatment of Buerger’s disease affecting the upper extremity: A modified technique. Vasa 1990;19:330–333. 34. Chiricuta I. Plastic surgery of the thumb, using the epiplon: The problem of integrating mechanical hand prostheses into the body. Rev Chir Oncol Radiol ORL Oftalmol Stomatol Chir 1978;27:187– 197. 35. Dijkstra R, Smith WG. Treatment of X-ray ulcers by omental transposition. Arch Chir Neer 1975;27:35–39. 36. Prowans P. An attempt to restore protective sensation after a greater omentum flap coverage due to circular soft tissue defect in the hand. Chirurgia Narzadow Ruchu I Ortopedia Polska 1999;64:453–456. 37. Zaha H, Inamine S, Naito T, Nomura H. Laparoscopically harvested omental flap for immediate breast reconstruction. Am J Surg 2006; 192:556–558.
Microsurgery DOI 10.1002/micr
Although there is a wide list of free flaps options for soft tissue reconstruction of complex upper extremity injuries, the omental flap has some useful anatomical and biochemical advantages. We report 13 patients who underwent hand or upper extremity reconstruction with omental free flaps. Nine patients had extensive tissue damage, resulting with digital cyanosis and hypothermia, and some of them with areas of cutaneous necrosis, or avulsed tissues with tendons and bones exposed or infected. The remaining four patients had minor extensive tissue damage without circulatory problems. Patient’s average age was 34.6 years. Twelve flaps were harvested through laparotomy and one laparoscopically. All flaps were covered with a skin graft. None of the flaps were lost. The average follow-up time was 20 months. There was one major and two minor donor site complications. One patient had minor loss of the skin graft in the recipient site, and two required minor additional surgeries to improve the appearance or function of the hand or upper extremity. There were no late abdominal complications in any patient. The morphological appearance and functional results were favorable in 11 of them, and permitted their reincorporation into society without the need for additional complex surgeries. Only two patients had a poor outcome. Our experience C 2014 Wiley confirms that the omental flap may be a good option for reconstruction of some complex hand and upper extremity injuries. V Periodicals, Inc. Microsurgery 34:425–433, 2014.
Complex
upper extremity injuries cause destruction of tissues and can compromise the circulation in remaining tissues.1 The resulting inflammation and fibrosis diminish the function of the entire upper extremity. To regain maximum function, these patients occasionally require secondary surgeries to release adhesions or to reconstruct tissues. For this reason, the period of rehabilitation and recovery can be lengthy and functional outcome is uncertain. Therefore, the reconstruction of these complex injuries is still a great challenge for plastic surgeons.2 There is a wide range of free flaps that can be used for reconstruction of cutaneous cover and soft tissue in complex hand or upper extremity injuries, but none of them has the many biochemical and anatomical advantages of the omental flap.3–8 Its biochemical advantages include: (1) secretion of growth factors such as vascular endothelial growth factor,7,8 basic fibroblast growth factor,9 epidermal growth factor, platelet-derived growth factor, and tumor necrosis factor alpha; (2) production of neurochemical substances including beta-endorphins, serotonin, and norepinephrine; and (3) the presence of interleukins (IL-1, IL-6, and IL-8) and interferon gamma.5,7–10 These biochemical characteristics offer the advantage of great immunological protection and bactericidal action in the presence of acute and chronic infections; a greater capacity for revascularization of ischemic dicas y Nutricio n Plastic Surgery Service, Instituto Nacional de Ciencias Me n, Mexico City, Mexico Salvador Zubira *Correspondence to: Martin Iglesias, M.D.; Monte de Antisana 47, Colonia ~a, C.P. 14210, Me xico D.F., Me xico. Jardines en la Montan E-mail: [email protected] Received 22 May 2013; Revision accepted 16 January 2014; Accepted 24 January 2014 Published online 12 February 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22236 Ó 2014 Wiley Periodicals, Inc.
tissue; and more fluid production and absorption.3,5,6,11–15 The surgical advantages conferred by the omental flap include a large area of up to 500 cm2, large and consistent blood vessels that facilitate the microsurgical repair, great plasticity that allows for better modeling of the flap at the reconstructed site, persistent pliability that prevents scarring and contraction, and low metabolic demand that permits a long ischemia time.4,6 Although the omental flap has been used in hand reconstruction since 1964,16 published reports are still rare.1,3,17,18 Its main indications are complex hand injuries that not only require soft-tissue reconstruction but also have ischemic tissues. Some authors have considered it only when other surgical procedures have failed.6–8,19,20 The objective of this article was to present our experience with 13 soft tissue reconstructions in hand and upper extremity injuries. PATIENTS AND METHODS
From 2002 to 2012, eight female and five male patients with complex hand and limb injuries underwent reconstruction with transfer of an omental free flap. A retrospective analysis was completed of their clinical files of patients. The average age was 34.6 years old (range, 8–68 years). The injury etiology was trauma in six patients, infection in two, chemotherapy extravasation in two, tumor resection in two, and burn in one. The skin and subcutaneous tissue was injured in all patients, and muscles, tendons, nerves, arteries, and bones were also injured in some patients. The first nine patients had extensive tissue damage, resulting with digital cyanosis and hypothermia, and
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some of them with areas of cutaneous necrosis, or avulsed tissues with tendons and bones exposed or infected. The amputation or stump remodeling was the initial proposed treatment for almost all of them. This extensive tissue damage resulted in scarring and poor circulation. The remaining four patients had minor tissue damage and no circulatory problems. Demographic factors, diagnoses, comorbidities, and affected tissues, are described in the Table 1. SURGICAL TECHNIQUE
Two surgical teams performed the surgery. One team harvested the omental flap while the other team worked on the upper extremity. The omental flaps were obtained by plastic and general surgeons according to reported open techniques.3,5,6,21 Laparoscopic technique was modified from the one described by Saltz22 and Crabtree.23 Two 5-mm trocars were placed lateral to the abdominal rectus muscle (left and right) and one 10-mm umbilical trocar was placed. Pneumoperitoneum was induced with CO2 at 15 mmHg, followed by endoscopic dissection of the omentum in a similar manner as described in the open technique. The umbilical port incision was extended to allow flap removal. Fixation of the greater curvature of the stomach was not needed in any of the cases. Before surgery, a wide resection of scar and injured tissue was executed. Then the tendons, nerves, and bony structures were evaluated. Lysis of adhesions and reconstruction of all affected tissues occurred in a one-stage procedure, simultaneous with the microsurgical transfer of the omental flap. When appropriate, the omentum was interposed between the anatomic structures to isolate and/or to revascularize them. Microsurgical end-to-end or end-to-side anastomoses were used in artery and vein repair. As a final step in most of the cases, a skin graft was placed. Full-thickness skin grafts were obtained from the abdomen or inguinal region, and partial-thickness skin grafts were obtained from the thigh. EVALUATION
The final functional-morphological outcome was evaluated with the concepts of the Hand Transplantation Score System at the end of the follow-up period for each of the patients.24 Fifty variables that fit into six general categories were evaluated: (1) morphologic appearance, (2) sensitivity, (3) movement, (4) social and psychological acceptance, (5) work and daily activities, (6) patient satisfaction and well being. The value of each concept was modified to maximum score of 50 points. The outcomes were classified favorable from 50 to 21, and poor from 20 to 0 points. Microsurgery DOI 10.1002/micr
Our institution does not require Institutional Review Board approval for retrospective studies. RESULTS
Twelve omental flaps were harvested through laparotomy and one was harvested laparoscopically. The size of the omental flap was usually larger than the defect size, and sometimes up to two times the defect size. The reasons were, because the flap was sometimes wrap around the anatomical structures or because it was sometimes folded on itself with the purpose to add volume. The time for harvesting the omental flap ranged from 45 to 180 minutes. A full-thickness skin graft obtained from the abdomen and/or groin was used in eight patients, and a partial-thickness skin graft obtained from the thigh was used in five patients. Only one patient required one pack of red blood cells because of anemia secondary to autoimmune hepatitis and concomitant coagulation abnormalities. All of the flaps survived. The average follow-up time was 23 months (range, 1–60 months). The morphological appearance and functional outcomes were favorable in 11 of them, and permitted their reincorporation into society without the need for additional complex surgeries. Only two patients had a poor outcome (Table 1). One major donor site complication occurred. One patient suffered devascularization of the transverse colon, requiring a colectomy, and colostomy with a subsequent colostomy takedown. This patient had two failed free flaps previous to the omental free flap transfer. There were two minor donor site complications. One patient had a small abdominal wall hematoma requiring evacuation as an outpatient, and other patient developed third spacing of fluid and abdominal pain, but did not require surgery. There was one recipient site minor complication; this patient developed a minor loss of the skin graft. Two patients required additional minor surgeries. One was to decrease the volume of the flap and to achieve a better aesthetic appearance because the patient gained weight. This was performed 24 months after the initial surgery. Another patient required surgery to correct flexor tenolysis at the wrist. There were no late abdominal complications in any patient. CASE REPORTS Case 1
A 35 year old male suffered a car accident that caused amputation of the right first metacarpal and thumb, fracture of the fourth metacarpal and avulsion of soft tissues from the hand, wrist, and forearm, and exposure of extensor tendons and carpal bones. The patient had two failed reconstruction surgeries at another
35 (M)
25 (F)
45 (f)
35 (M)
31 (F)
8 (M)
23 (M)
12 (F)
17 (F)
42 (F)
Age (Y/O) and gender
3rd degree burn of the total right palm and fingers. Thenar and hypothenar muscles, flexor tendons and nerves were exposed, with 4th and 5th fingertip necrosis Mucormycosis of the dorsum of the left hand. The 2nd, 3rd, and 4th extensor tendons were injured with granulation tissue. 3rd and 4th metacarpal bones were exposed. Fourth left finger avulsion-amputation with flexors and extensors tendons, digital nerves, arteries, and veins avulsed. Proximal phalanx was exposed. Severe right hand crush injury. Flexors and extensors tendons, arteries, and nerve were crushed and exposed with 3rd finger necrosis from proximal phalanx, and 3rd and 4th metacarpal fractures. Left hand and forearm crush injury. Flexor and extensor tendons were crushed and exposed at the distal forearm third, exposed radial fracture, loss of the 1st metacarpus, and median nerve. Severe left hand crush injury with extensor tendons crushed and exposed, 3rd and 4th metacarpal fracture, 3rd finger amputation Total degloving of the cutaneous cover of the right distal third of forearm, hand’s dorsum and partial of the palm with avulsion of the first ray, 4th metacarpal fracture. Initially the defect was cover with skin grafts. Left hand crush injury complicated with infection and Compartmental syndrome. Extensor tendons, metacarpophalangeal joints, and metacarpal bones were exposed. Mucormycosis of the right forearm. Losses of flexor and extensor muscles; median, ulnar and radial nerves; radial and ulnar arteries, and extensive and diffuse fibrous tissue, covered initially by skin grafts. Cavernous hemangioma of the 3rd finger of the left hand The radial digital artery, radial collateral digital nerve, flexor and extensor tendons, and proximal phalanx were exposed.
Injurya
Diabetes mellitus
Obesity and heavy smoking
Two failed free flaps previously
Autoimmune hepatitis
Convulsive syndrome
Co-morbidities
534
28 3 20
11 3 13
18 3 15
14 3 10
15 3 10
636
735
838
10 3 20
Defect size (cm)
CDA of the 3rd space and DV
BA and CV at proximal third of the arm
RA and CV
RA and CeV at middle third of the forearm.
RA and CV
RA and CeV at middle third of forearm.
RA and CV
CDA of the 3rd space and DV
RA and CV
RA and CV
Recipient vessels
Table 1. Patient Characteristics
No
No
Small abdominal wall hem atoma (mi)
Transverse colon devacularization (Ma)
No
No
No
No
No
No
Third space losses (mi)
No
No
No
No
Minor loss of the skin graft (mi)
Recipient site complications
No
No
No
No
Donor site complications
60
24
36
12
4
24
29
1
7
36
Follow-up time (months)
Favorable
Favorable
Favorable
Favorable
Favorable
Favorable
Favorable
Poor
Favorable
Favorable
Outcomes
Omental Flap in Upper Extremity Injuries 427
Microsurgery DOI 10.1002/micr
Favorable Chemotherapy extravasation of the hand’s dorsum. Extensor tendons and metacarpal bones were exposed. 64 (F)
68 (F)
Microsurgery DOI 10.1002/micr
a All patients lose the skin and subcutaneous tissue. F, female; M, male; mi, minor; Ma, major; BA, brachial artery; RA, radial artery; CV, comitant vein; CDA, common digital artery; DV, dorsal vein; CeV, cephalic vein.
9 No RA and CV 939
No
Favorable 8 No RA and CV 838
Non-Hodgkin’s lymphoma, diabetes mellitus and glaucoma Renal cancer
No
12 No No RA and CV 533 Reflex sympathetic dystrophy
Chondromatosis of the right wrist and recidivate carpal tunnel syndrome with extensive fibrous tissue Chemotherapy extravasation of the hand’s dorsum. Extensor tendons and metacarpal bones were exposed.
Co-morbidities Injurya Age (Y/O) and gender
45 (M)
Follow-up time (months) Recipient site complications Donor site complications Recipient vessels Defect size (cm)
TABLE 1. Continued
Poor
Iglesias et al. Outcomes
428
hospital. At admission to our service, the patient presented with edema, digital paresthesias, and unstable cutaneous cover. The metacarpophalangeal (MCP) and interphalangeal joints were ankylosed (Fig. 1). A late reconstruction was performed with a 18 3 15 cm omental free flap. All scarred tissue was resected from the hand and the extensor tendons were released. An arthroplasty of the MCP joints was performed along with release of intrinsic muscles. Veins at the dorsal aspects of the second and fourth interdigital spaces were identified. The recipient vessels, the radial artery, and the cephalic vein were dissected at the middle third of the forearm. A portion of the omental flap was placed between the metacarpal and the extensor tendons, and the remaining flap over the tendons (Fig. 2). An end-toend anastomosis was performed to revascularize the omental vein to the cephalic vein, and an end-to-side anastomosis from the omental artery to the radial artery. In addition, two veins from the omentum were anastomosed end-to-end with the second and fourth interdigital space veins. On the third day after surgery, the patient had abdominal pain and serous secretion through the abdominal wound. He underwent another surgery where a colon resection and colostomy were performed with a subsequent colostomy take-down. There were no further complications at the recipient site (Fig. 3). The active movement of the phalanges was normal at 60 months of follow-up. The patient does not desire to continue with thumb reconstruction (Fig. 4). Case 2
A 25 year old male had mucormycosis on the right forearm secondary to traumatic injury. He was managed with multiple surgical debridements until cultures were negative for Rhizopus spp. The cutaneous cover of the forearm and distal third of the arm was lost. Almost all muscles and tendons of the wrist and fingers were lost, except the flexor pollicis longus and extensor carpi radialis brevis. Furthermore, the radial and ulnar arteries and median, ulnar and radial nerves were partially resected. There was poor circulation through the interosseous artery. Initially, the residual tissue was covered with split-thickness skin grafts (Fig. 5). The patient then received mucormycosis treatment for three months, after which a reconstruction was performed. The skin grafts were removed. An omental free flap of 30 3 35 cm was harvested by open technique. The right gastroepiploic artery was anastomosed end-to-side to the brachial artery at the distal third of the arm. The omental vein was anastomosed end-to-end to a deep vein at the distal third of the arm. The left gastroepiploic artery was anastomosed end-to-end to the ulnar artery at the level of the wrist. The median and ulnar nerves were reconstructed with 15- and 20-cm long sural nerve grafts (Fig. 6). A gracilis
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Figure 1. Patient with loss of cutaneous cover and subcutaneous tissues of the hand and forearm, thumb avulsion and fracture of the 3rd and 4th metacarpal bones. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 2. Late reconstruction. Resection of scarred tissue and tenolysis of extensor tendons. Extensor tendons were wrapped with omental flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
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Figure 3. Morphological appearance of the reconstruction at 5 months postoperative. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 4. Functional result at 60 months after the reconstruction. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
Figure 5. Clinical appearance at 4 months post-trauma and infection. The hand had slow capillary filling, hypothermia, edema, and total anesthesia of the hand. The cutaneous cover was unstable. There wasn’t wrist and finger active movement. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Figure 6. The hand and omental revascularization through omental flap as by pass flap. The arrows show the proximal end of the median and ulnar nerves. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 8. Nine months after surgery, with active flexion of the fingers. The tinel sign was positive at wrist level. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]
extension of the wrist secondary to the flexion and extension of the fingers (Fig. 8).
DISCUSSION
Figure 7. The nerves were reconstructed. The free gracilis muscle flap was transferred and connected to the distal tendon flexor profundus of 2nd, 3rd, and 4th fingers. The flexor pollicis longus tendon was repaired. The star shows the gracilis muscle flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
muscle free flap was transferred to reconstruct the flexor digitorum profundus. Its artery was anastomosed end-toside to the right gastroepiploic artery, and its vein was anastomosed end-to-side to a epiploic vein. The gracilis muscle was inserted to the medial condyle of the humerus and its tendon was sutured to all flexor profundus tendons at the wrist. The extensor carpi radialis brevis was transferred to the extensor digitorum communis. The flexor pollicis longus was repaired (Fig. 7). In addition, two omental veins were anastomosed end-to-end to two dorsal hand veins at wrist level. Finally, the omental flap was wrapped around the forearm and a medium split skin graft was applied. The patient’s postoperative clinical progress was without complications. Nine months after surgery, the patient had protective sensibility and total active flexion and extension of the distal and proximal interphalangeal joints. There was flexion and
The objective of hand or upper extremity reconstruction after a severe injury is to obtain maximal functional capacity and the best morphological appearance possible. To achieve this objective, an aggressive resection of damaged tissue must be performed. Several anatomical structures are lost this way and others may be ischemic or exposed. Therefore, the reconstruction should be as complete as possible, and preferably in one surgical stage, to avoid fibrosis and secondary surgeries. The upper extremity is poorly tolerant of prolonged immobilization, which predictably results in joint stiffness and tendon adhesions. Consequently, the reconstruction should be as early as possible, factoring in local wound conditions, and the health of the patient. With current success rates of over 95%, and the availability of multiple donor sites, free flaps offer virtually unlimited freedom in soft tissue reconstruction of hand or upper extremity injuries. The ideal free flap in these cases is one that has enough volume to cover the defect but not excessive volume, and a long pedicle of large caliber. This enables anastomosis out of the field of inflammation or fibrosis, thus reducing the risk of vessel spasm and thrombosis at the anastomosis site, without the necessity of vein grafts.25 Muscle flaps are indicated for the reconstruction of complex defects where the filling of dead space is required. Microsurgery DOI 10.1002/micr
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They provide well-vascularized tissue that has the advantage of indirect revascularization and controlling bacterial inoculation. However they may be initially too bulky, and cannot be wrapped around repaired structures independently, as omental flaps can. Perforator muscle flaps allow for better tailoring to fit the recipient defect, but their vascular pedicle length is short, which is a disadvantage.25 Fasciocutaneous flaps are indicated for the coverage of shallow wounds. They can restore contour and provide an excellent gliding surface for tendons and joints at the extremities. Some fasciocutaneous flaps have as main advantage the possibility to be used as neurovascular flap. The lateral arm flap, free or pedicled radial forearm flap, free dorsal pedis artery flap, and the anterolateral thigh flap26 are most common. This is important for the reconstruction of protective sensation of the palm. The free medial plantar artery flap is useful, however its utility is limited to reconstruction of small defects of the palm.27 Their disadvantages are that they do not fill dead space, do not provide great circulatory contributions, and some of them have short vascular pedicles.25 The fascial flaps as the free temporoparietal fascial flap or local pedicled radial forearm flap with instep skin graft are a good surgical treatment only when there is no severe trauma.27 The omental flap has anatomical advantages: a large area of up to 500 cm2, large and consistent blood vessels that facilitate microsurgical repair and great plasticity that allows for better modeling of the flap at the reconstruction site.4–6 In addition, the omentum flap has biochemical characteristics that offer immunological protection, bactericidal action, a persistent pliability that prevents scarring and contractions and a greater capacity for revascularization of ischemic tissue.3,5,6,11–13,19 Given these properties, free or pedicled omental flaps have been used for the reconstruction and/or revascularization of large and complex lesions in all body segments without regard to the etiology (traumatic, oncological, ischemic, radiotherapy, etc.).20,23,28–32 We considered it a good flap for reconstruction of the soft tissues in complex hand or upper extremity injuries, and the one that allows the maximum functionality and best morphological appearance. However, with donor site morbidity reported up to 18.5%, and the severity thereof, it has limited surgical application.3 For this reason, the utility of this flap is limited to the reconstruction of complex bodily defects involving chronic ischemia or chronic infections, and where other methods of reconstruction have failed. Therefore most authors consider it as a rescue flap.1,6– 8,19,20,23,28–30,33 Under these conditions, it has been used for the reconstruction of complex lesions of the hand since 1964.16,18,34,35 However published reports for hand or upper extremity reconstruction are rare.1,3,17,18 Only small case series have been reported.1,3–5,33 The biggest case series reported is with a maximum of 12 patients.36 Microsurgery DOI 10.1002/micr
In Seitz’s series of seven cases,4 there was only one wound infection of the abdominal donor site, and two patients required secondary surgeries at the recipient site. The outcomes from Seitz’s series are impressive. In Prowan’s study of 13 cases,36 of which 12 had upper extremity reconstructions, one patient developed a ventral hernia and five developed significant abdominal pain. In this series, eight used free flaps and five used pedicled flaps. Two flaps were lost, one free and one pedicled. The rate of complication in the Prowan’s report was lower than the 18.5% reported previously. There were no major complications that endangered the lives of patients.36 Under these principles, we treated nine patients with complex and large lesions with fibrosis and/or poor circulation of the remaining tissues. Only one patient had a major complication. The remaining donor site complications were minor and considered similar to donor site morbidity with other flaps (hematoma and pain). Our approach to reduce donor site morbidity is to perform all reconstructions with a free flap and to have an experienced general surgeon harvest the flap with the help of a plastic surgeon. With this strategy, we have not had any major complications at the donor site. The only minor complication at the donor site was the loss of a small portion of skin graft, which healed secondarily. Two minor secondary surgeries were performed; one for improving function and the other for improving appearance. Given the functional and morphological outcomes obtained in the first nine cases, we decided to use this flap in patients with minor extension of tissue damage and no circulatory problems, even when other free flaps could be used. The results were favorable, as the omental flap plasticity allowed us to cover the required volume of the defect without additional surgeries to remodel the flap. There were no complications at the donor or recipient sites, and the functionality and appearance of the hand or upper extremity were favorable. Although the final functional-morphological outcomes could be evaluated with many scales as Disability Arm Shoulder and Hand, Michigan Hand Outcomes Questionnaires or Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) we decided to use some of the principles of Hand Transplantation Score System. The reason is because this test takes into consideration the hand and the body as a total unit to evaluate the final function of the hand, and no evaluate finger-by-finger, nerve-by-nerve, or joint-by-joint. This could be questionable, and could require further study. Patients with a body mass index (BMI) of 30 must be carefully evaluated. Previous surgeries and abdominal infections could produce adherence or scarring of the omentum. In these cases, endoscopic revision can help to determine whether harvesting of an omental flap
Omental Flap in Upper Extremity Injuries
should be performed. Some contraindications include ascites, acute peritonitis, and suspicion of absence of an omentum. Although this series reports one case of laparoscopic harvesting of an omental flap, we agree with other authors that this harvesting method may have advantages for the patient.37 The omental flap meets the criteria of an ideal free flap. For this reasons, it was chosen to reconstruct the cutaneous cover and soft tissues, to avoid fibrosis and development of adhesions of the repaired tissues, to reconstruct all damaged tissues and to be able to mold the flap in the shape and volume required by the limb. According to our outcomes, it may represent a good option for reconstruction of some complex hand or upper extremity injuries.
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Microsurgery DOI 10.1002/micr
