Digital Reconstruction Using Free Fascial Flaps for Major Trauma

The digit is a challenging level at which to achieve good flap coverage when the wound is large and extends the length of the digit. Smaller wounds can often be well-managed by homodigital, heterodigital, or reverse flow metacarpal artery flaps. If a transposition or pedicle flap is unable to accomplish the wound reconstruction, a free flap is required. Free skin flaps can be directly innervated but are thicker than fascial flaps. Free fascial flaps can contour much better around the convex surface of the cylindrical digit. When placed on a flexor surface, a fascial flap can also fold to accommodate digital flexion better than a bulkier skin flap.

A series was presented of free fascial flaps used to cover digits subjected to major open combined trauma. The wounds were all judged too large or incorrectly located for coverage by simpler techniques but did not include the volar pulp where an innervated skin flap is preferred for discriminative sensibility. Ten male patients with a mean age of 38.2 years (range: 9 to 60 years) underwent 9 lateral arm (posterior radial collateral artery) and one serratus anterior (branch of thoracodorsal artery) free fascial flaps with immediate split-thickness skin grafts, non-meshed. The mean defect size was 4.4 cm × 7.6 cm (smallest, 4 × 4 cm and largest 7 × 15 cm). Eight cases were individual digits and two cases were multiple digits. Four cases reconstructed the volar surface of the digit, and 6 cases the dorsal surface (including the two multidigit cases). The posterior radial collateral artery was used as a flow-through reconstruction for digital salvage in two of the volar reconstruction cases. Reconstruction was of one thumb, 5 index fingers, 5 long fingers, and one ring finger. The flaps covered tendon repair sites in all cases, nerve grafts in the four volar reconstructions, and skeletal fixation sites with hardware in 6 cases. The mechanism of injury was 5 roll-over motor vehicle accidents, 3 table saw injuries, and 2 industrial machine crush injuries.

Table 1 Center Cases Showed Consistent Profits Over Two Years (M = $1,000,000):

Year	Cases	Income	Profit
I	206	$1.5M	$.49M
II	182	$2.2M	$.46M

Table 2 Routine Cases Showed Marginal Profits or Losses:

Year	Cases	Income	Profit
I	124	$0.3M	$0.005M
II	221	$0.4M	($0.2M)

Table 3 Inpatient Consults had Decreasing Losses:

Year	Cases	Income	Profit
I	48	$1.1M	($0.6M)
II	32	$1.3M	($0.1M)

There were no complications in terms of non-union of the underlying osteosysnthesis site, rupture of the underlying tendon repair site, or infection. All flaps were judged at 100% survival, as were all of the immediately applied non-meshed skin grafts. Patients entered hand rehabilitation within 72 hr of leaving the hospital, and none have required additional surgical procedures.