CME

Upper Extremity Microsurgery

William C. Pederson, M.D.
San Antonio, Texas

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the indications for free
flap coverage of the upper extremity. 2. Know the advantages and disadvantages of the flaps discussed. 3. Have a basic
understanding of the anatomy of the flaps discussed. 4. Have a variety of options for free tissue transfer.

The application of microsurgical tissue transfer to re-
construction of the upper extremity allows repair of sig-
nificant bone and soft-tissue defects. Through the years
the approach has changed from one of simply getting the
wound covered to primary reconstruction to preserve or
regain function. A wide variety of free flaps offers the
potential to reconstruct nearly any defect of the arm and
hand. Vascularized bone transfer can be utilized to repair
large bony defects, while innervated free muscle transfer
can replace missing muscle function. The total array of
flaps and their indications is beyond the scope of a single
discussion, but this article focuses on a few flaps that have
found application for coverage and functional restoration
in the hand and upper extremity. (Plast. Reconstr. Surg.
107: 1524, 2001.)
Since its inception, microsurgery has found
wide application in reconstructing the upper
extremity. Digital replantation, which was first
performed in 1968,1 probably represents the
pinnacle of reconstruction in the hand, be-
cause it allows exact replacement of the miss-
ing part. The replacement of missing parts in
kind was extrapolated in 1969, when Cobbett2
reported the first great toe transfer to replace a
missing thumb. Although the first successful
free flap reported in 19733 was to the lower
limb, the technique of free tissue transfer rap-
idly became incorporated into reconstructive
surgery of the hand and arm. Through the
study of vascular anatomy of potential donor
sites, the plastic surgical community has given
itself a wide variety of available tissues for re-
constructive purposes.4 Almost any composite
defect of the upper limb can now be recon-
structed with a free tissue transfer. This article
will discuss options for the reconstruction of
the upper extremity with free tissue transfers.5,6
APPROACH
The topic of upper extremity microsurgery is
a wide one, and for the purposes of this discus-
sion, it will be divided into two areas: coverage
and functional reconstruction. Although many
situations will be encountered in which soft-
tissue coverage is the only requirement, it
should not be forgotten that coverage and
functional reconstruction can be accomplished
in one step with the appropriate application of
microsurgical tissue transfer. In assessing a
wound of the upper extremity, the surgeon
should first decide on the ultimate goal of the
reconstruction. This will be predicated on
many factors, not the least being the patient’s
age, occupation, other injuries, and future
plans. The surgeon should have in mind a plan
in terms of how the initial procedure fits with
what else may be necessary in the future. Al-
though soft-tissue coverage may be the first
priority in a patient with an avulsion injury to
the hand, the type of flap chosen not only
should allow later surgery but should be per-
formed in a way that will maximize later efforts.
When a patient initially presents with a
wound of the upper extremity, the surgeon
must carefully assess the wound and make a
number of important decisions. The assess-
ment of the injury should take into account the
status of the wound (clean or dirty), the pres-
ence or absence of fractures (and/or bony de-
fects), and the status of neurovascular struc-

From the Hand Center of San Antonio and the Departments of Surgery and Orthopaedic Surgery, the University of Texas Health Science
Center at San Antonio. Received for publication April 20, 2000; revised August 25, 2000.
1524
Vol. 107, No. 6 / UPPER EXTREMITY MICROSURGERY
tures (distal vascular supply and nerve
function). All of these considerations are im-
portant in choosing the proper approach to
reconstruction. Clean wounds with defects in
structures other than soft-tissue coverage
should be considered for primary reconstruc-
tion. Untidy wounds will usually require de-
bridement and, although they may require free
flap soft-tissue reconstruction, repair of other
structures may best be left until a closed wound
is obtained.
PLANNING
Regardless of the type of flap chosen, preop-
erative planning is essential for success. The
primary issue in microvascular tissue transfer is
vascular access for vessel anastomosis. Al-
though the upper extremity has a rich vascular
supply, trauma or tumor extirpation may limit
the available choices for anastomosis. In most
patients, the hand will maintain adequate per-
fusion if only one of the major arteries (radial
or ulnar) is open. If the hand is viable and
either one of these pulses is strong, I think that
arteriography is unnecessary. If there is any
question regarding the status of hand perfu-
sion, an arteriogram should be performed, es-
pecially if free flap transfer is contemplated. In
choosing where to perform vascular anastomo-
ses, a site out of the zone of injury should be
chosen. If one is not sure, the vessels should be
explored and followed proximally until there is
no blood staining in the vascular sheath. For
coverage of the hand, anastomosis is usually
performed to either the radial or ulnar arter-
ies. For the radial side of the hand and dorsum,
the radial artery in the snuffbox may be used
for end-to-end or end-to-side anastomosis. If
both the radial and ulnar arteries are patent,
an end-to-end anastomosis at this level should
not compromise circulation to the hand. In
most instances, however, it is probably safer to
perform an end-to-side anastomosis. For cover-
age of the forearm, anastomosis can be per-
formed to either of these vessels or to the
brachial artery in the antecubital fossa. If there
is significant trauma to the forearm, a proximal
end-to-side anastomosis to the brachial artery is
preferable. In the upper arm, most anastomo-
ses will be to the brachial system. Venous anas-
tomosis is usually best done to one of the su-
perficial veins of the forearm, because the
deep venous system is small and anastomosis
may be difficult. The surgeon must be sure that
1525
there is no proximal injury to the chosen vein
to avoid outflow obstruction and thrombosis.
For most free flaps, a two-team approach is
the most expeditious. The recipient site can be
debrided and vessels made ready for anastomo-
sis while the flap is dissected. This may not be
feasible in some settings, especially if the cho-
sen flap is to come from the injured arm (i.e.,
the lateral arm flap). If there is inadequate
surgical help for this approach, the wound is
debrided and measured, and then an appro-
priate flap is harvested. Once the flap has been
harvested, it is left attached by its pedicle for
perfusion while the vessels are dissected on the
recipient limb. When the recipient vessels are
ready, the pedicle is divided and the flap is
transferred.
COVERAGE
The approach to wounds of the upper ex-
tremity should follow the usual parameters of
soft-tissue reconstruction. Many wounds can be
covered with a split-thickness skin graft or with
regional flaps, particularly in the hand. The
ultimate morbidity of any local or regional flap
must be considered, however, especially in re-
lation to later hand function. Because the hand
is highly visible, the cosmetic aspect of certain
local and regional flaps must be considered as
well. Although certain wounds may be ade-
quately covered with a flap from the same ex-
tremity, one should consider what offers the
best coverage in terms of the overall recon-
struction.7 This will often lead to the use of a
free flap for many hand wounds. The following
discussion will cover the considerations regard-
ing which flaps may be used for soft-tissue re-
construction in the hand and arm.
The wound must be considered both in
terms of its tidiness and size. The first step
before flap coverage is always conversion of a
grossly untidy wound to a clean one. Debride-
ment should not be compromised to avoid
making the wound larger, because almost any
wound in the upper extremity can be covered
with free tissue transfer. This concept was pro-
moted by Godina, who coined the term
“necrectomy”8 to describe the removal of all
nonviable and contaminated tissue. In this ap-
proach, intact neurovascular structures are left
in place and large bony fragments may be
cleaned and replaced in their anatomic posi-
tion if adequate coverage can be obtained.
Once the wound has been debrided, flap selec-
tion should be considered. Dirty wounds are
1526
usually best covered with muscle, because mus-
cle manages infection better than skin only.8,9
Vascularized fascia also has advantages in terms
of potential contamination,10 and it may be
considered in some untidy wounds. The selec-
tion of flap coverage for a clean wound allows
the use of composite tissue in many cases. Par-
ticularly in the case of tumor extirpation, the
reconstructive surgeon may have the option of
reconstructing a complex defect with a single
flap. Although many smaller wounds in the
upper extremity are amenable to local or re-
gional flaps (i.e., the pedicled groin flap), this
discussion will center on the use of free flaps
for wound management.
Muscle Flaps for Coverage
The selection of which muscle to transfer is
based largely on the experience of the sur-
geon, but the “workhorses” in large wounds of
the upper extremity are the latissimus dorsi
and rectus abdominis muscles. Smaller defects
can be covered with either a portion of one of
these muscles or a smaller muscle flap, such as
the serratus anterior or gracilis muscle.
Latissimus dorsi. The latissimus dorsi muscle is
a large muscle of the back and shoulder, and its
vascular supply for free transfer is based on the
subscapular-thoracodorsal system.11,12 The pedi-
cle is lengthy (8 to 11 cm) and has a relatively large
diameter proximally (up to 6 mm). This is the
largest single muscle available for transfer, and its
area of coverage can be expanded by including a
portion of the serratus anterior muscle through
its branch off the thoracodorsal artery.13 It can be
used as an innervated muscle because of the sin-
gle thoracodorsal nerve,14 but the latissimus is
generally used to cover large, degloving-type
wounds. Its advantages are that it has a totally
reliable vascular supply and is very large. Its pri-
mary disadvantage is that the patient must be
turned in the lateral decubitus position for muscle
harvest. If the contralateral muscle is taken, the
patient can be turned on the side, and the injured
arm can be prepared simultaneously with muscle
harvest (assuming that appropriate surgical assis-
tance is available). It can be taken as a myocuta-
neous flap, but for most indications in the upper
extremity, only the muscle is taken; it is then cov-
ered with a split-thickness skin graft. The donor
site is easily closed, but seroma formation is a
common sequelae of this donor site. The func-
tional morbidity from the loss of muscle is mini-
mal in most patients, but its use should be avoided
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
in patients who must adduct the arm strongly
(crutch-walkers and paraplegics).
Rectus abdominis. The rectus abdominis is a
muscle widely used in microsurgery, primarily
as part of the TRAM (transverse rectus abdo-
minis musculocutaneous) flap for breast recon-
struction. This muscle is on the anterior ab-
dominal wall and runs from the medial lower
ribs to the pubis. It lies in a sheath composed
anteriorly of continuations of the external and
internal oblique muscle layers. The posterior
sheath is a continuation of the transversus ab-
dominis, but in the lower abdomen, it is quite
thin (below the linea semicircularis). This is a
fairly large muscle, and it has a reliable vascular
pedicle based on the deep inferior epigastric
system. The pedicle is fairly long (5 to 7 cm),
and its diameter is fairly large (2.5 to 3 mm).
The rectus abdominis muscle will cover most
defects of the hand and forearm,15,16 and it will
cover large defects of the forearm if most of the
muscle is harvested and it is placed “barber
pole” fashion around the arm.17 The advantages
of this muscle are that it has a reliable vascular
pedicle and may be taken with the patient su-
pine. The disadvantage of this muscle is that a
hernia can result from its harvest if fascia is
taken (for a myocutaneous flap) or if the an-
terior sheath is weak. For coverage of the upper
extremity, this muscle is usually harvested with-
out a skin paddle and covered with a split-thick-
ness skin graft.
Serratus anterior. This muscle is very useful
for covering smaller hand defects.13,18 It consists
of nine slips of muscle that connect from the
ribs at the anterior axillary line to the tip of the
scapula. The lower slips are vascularized by a
branch coming off the thoracodorsal artery,
and the upper slips are vascularized by a branch
of the lateral thoracic artery. The lower three
slips may be taken individually or together as a
free muscle flap based on the thoracodorsal
pedicle. This dissection is tedious because
branches of the long thoracic nerve may be
intertwined with the vessels, and damage to the
nerve supplying the remaining slips of muscle
can lead to winging the scapula.19 The branch
to the serratus is usually taken with the proximal
thoracodorsal vessels, both to lengthen the
pedicle and because of the larger diameter of
the proximal vessel. This can give a very lengthy
pedicle (15 to 17 cm) with a large diameter (3
to 6 mm). The primary advantage of this muscle
is its small size and lengthy vascular pedicle. The
disadvantages of this muscle are the potential
Vol. 107, No. 6 / UPPER EXTREMITY MICROSURGERY
for long thoracic nerve injury and the decubitus
position necessary for harvest. This flap can be
used to cover the dorsal or palmar hand and
first webspace. It has the potential for innerva-
tion with a branch of the long thoracic nerve,
but this application would be limited in the
upper extremity.
Although there are certainly other muscles
available for use in the upper extremity, these
three will afford coverage for almost any wound.
The gracilis muscle will be discussed below in the
section on functional reconstruction.
Fascia and Fasciocutaneous Flaps
In the case of clean traumatic wounds or tu-
mor excision, a cutaneous free flap may offer the
best option for reconstruction. These flaps usu-
ally offer a better cosmetic result than a muscle
covered with a skin graft, and they are probably
better in terms of performing later surgery
through or under the flap. This is particularly
true in the case of later tendon surgery, where
the fascia contained in these flaps may offer a
better gliding surface for tendons. In a hand with
multiple digital amputations, a cutaneous flap is
better in terms of providing coverage for later toe
transfer as well. There are any number of fascial/
fasciocutaneous flaps available, but the primary
flaps are the radial forearm, lateral arm, scapular,
and temporoparietal fascial free flaps. Although
the groin flap is used in some centers as a free
flap and has some definite advantages (primarily
donor-site cosmetics), the variability and limited
length/size of its vascular pedicle make it a sec-
ond level choice for free transfer in most centers.
Radial forearm free flap. This flap offers al-
most ideal characteristics for hand reconstruc-
tion.20 Its primary application is as a pedicled
flap based on reversed flow through the distal
radial artery and venae comitantes.21 Nonethe-
less, it may be used as a free flap in certain
instances, and it affords excellent hand cover-
age. This flap can be raised anywhere along the
course of the radial artery, and a skin island
from very small to quite large may be taken. The
radial artery provides a large caliber vessel for
anastomosis, and it may be used for revascular-
ization of the distal limb if necessary as a “flow-
through” free flap. The venous drainage is
through the dual concomitant veins of the ra-
dial artery, but larger flaps can be drained using
cutaneous veins. There has been some contro-
versy regarding the primary venous drainage of
these flaps, but the venae comitantes offer re-
liable drainage, even in the absence of super-
1527
ficial veins. This flap may be innervated by anas-
tomosis of the lateral antebrachial cutaneous
nerve, part of which is invariably in the flap. The
quality of sensation in such reinnervated flaps is
not great, but it may be useful. If the patient has
a palmaris longus tendon, it may be taken in the
flap as well, and this provides an excellent op-
tion for tendon reconstruction, especially on
the dorsal hand. Because the tendon is taken
with its surrounding tissue, it has excellent glid-
ing when transferred as part of the flap. A por-
tion of the volar radius may be harvested with
the flap as well, and this is particularly useful in
the reconstruction of missing segments of meta-
carpal.22,23 The radial artery can be taken with
the fascia only; this provides a thin flap that is
particularly useful in reconstructing the palm.
The advantages of using this flap as a free flap
are its thinness, its reliability (based on the radial
artery), and the multitude of other tissues that
may be harvested with it. The main disadvantage
of this flap is the resulting donor site, which must
usually be covered with a skin graft. The donor
site is usually aesthetically unpleasant, but it
causes few functional problems. Another relative
contraindication to this flap is the loss of the
radial artery, but studies have shown that signifi-
cant problems are unusual. Cold sensitivity is
seen, but this may be related to other factors.
Although the radial forearm flap is an excellent
free flap, it can usually be used as a distally pedi-
cled island flap for hand reconstruction. If this
flap is not available for some reason as a pedicled
flap, I usually select a skin flap from another area
and do not take a radial forearm flap from the
contralateral uninjured arm.
Lateral arm free flap. This cutaneous flap
from the lateral distal upper arm is based on the
radial collateral artery, a branch of the profun-
dus brachii.24 This vessel runs with the radial
nerve in the spiral groove and comes to lie in
the intermuscular septum between the brachia-
lis and lateral head of the triceps. It gives arterial
supply to the skin overlying the septum and to
the underlying humerus. Distal to the intermus-
cular septum, the posterior radial collateral ar-
tery has a rich system of anastomoses with ves-
sels in the proximal lateral forearm, which will
allow extension of the flap onto the proximal
forearm. The pedicle for this flap is relatively
short (5 to 7 cm), and the proximal artery has
a small diameter (1.5 to 2 mm) when compared
with the flaps previously discussed. The length
of the pedicle is limited by the fact that it exits
the spiral groove with the radial nerve, and dam-
1528
age to this nerve must be avoided in dissection.
The skin paddle can be based directly over the
intermuscular septum for a smaller flap or ex-
tended distally for a larger one. Donor sites up
to 7 cm in width can be closed primarily, but
larger ones will require a skin graft.25 When
closed primarily, the donor site can be very
cosmetic, but in some patients, the scar will
widen significantly. The lateral cutaneous nerve
of the arm is in the flap, and thus the skin can
be innervated if necessary.26 A portion of the
lateral humerus can be taken with the flap for
bony reconstruction, based on its vascular sup-
ply from the overlying pedicle.27
The lateral arm flap is purported to be a
“thin” flap, but because of the tissue in the
intermuscular septum, it is a bit bulky when
placed on a flat recipient site (i.e., the back of
the hand). This problem can be avoided by
using the fascia only, which also decreases do-
nor-site problems.25,28 The primary advantages
of this flap are that it can be taken from the
ipsilateral arm (of injury),29 it avoids the sacri-
fice of a major vessel, and the donor site can
often be closed primarily. The primary disad-
vantages of the lateral arm flap are its some-
what limited size and the short and small-
diameter pedicle. It is very useful in covering
small defects of the hand and works very well in
the first webspace. In thin patients, it can be
used to cover a degloving injury of the thumb,
with the added benefit of reinnervation by the
cutaneous nerve (Fig. 1).
Scapular flap. The scapular and parascapu-
lar flaps offer a versatile large skin flap to
cover defects in the upper extremity (Fig.
2).30 The vascular supply is based on the
circumflex scapular vessels, which branch
from the subscapular system.31 The pedicle
for this flap is long (4 to 6 cm) because the
subscapular vessels can be taken if necessary,
and this provides vessels of large diameter at
the takeoff from the axillary artery. The ves-
sels lie in the fascia with branches to the
overlying skin. There are two primary
branches, thus giving rise to the “transverse”
scapular flap, which is sited transversely
across the back, and the “parascapular” flap,
which is sited obliquely down the back. Based
on this vascular supply, a very large skin flap
can be designed that will cover most defects
of the forearm and/or arm.32 Although a
number of cutaneous nerves enter the skin,
there is not a dominant nerve to this area,
and thus this flap has poor potential for in-
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
nervation. Branches from the primary pedi-
cle feed the lateral surface of the scapula,
and a portion of this bone can be taken to
repair bony defects. This bone is quite flat,
however, and its primary indication is in the
reconstruction of smaller defects in the
hand. Donor sites in the 8-cm range can
usually be closed primarily, but this is usually
limited to the parascapular design of the
flap.
The primary advantages of this flap are the
length and diameter of its pedicle, along with its
potential large size. The primary disadvantage of
this flap is the need for turning the patient to
harvest it. The scapular flap is an excellent choice
to cover large wounds of the forearm, and it can
be used in place of a pedicled groin flap for hand
coverage. It can be combined with the latissimus
dorsi and serratus anterior muscle flaps on a
single pedicle to provide a huge amount of tissue
and to cover different surfaces of the hand and
arm (Fig. 3).33,34
Temporoparietal fascia flap. The temporopa-
rietal fascia offers a flap of specialized tissue that
has great utility in hand reconstruction.35 This
flap is supplied by the superficial temporal ar-
tery and vein, and it has a pedicle in the 2- to
3-cm range that is about 1.5 to 2.5 mm in di-
ameter.36 The temporal fascia lies on the tem-
poral region of the skull, beginning on the zy-
goma and running superiorly. There is a
superficial and deep layer, and both may be
taken with this flap. The use of both layers of
fascia has been promoted for use in wrapping
adherent tendons on the dorsum of the hand
after tenolysis in a scarred bed. The deep fascia
can also provide tissue for reconstructing small
tendons on the dorsal hand as well. A flap of
moderate dimensions may be taken (in the
range of 8 to 10 cm). The potential for harvest-
ing vascularized bone with this flap exists, but
the thin, outer table bone available has few (or
no) indications in the hand. Although the do-
nor scar is one of the best in terms of cosmesis,
the problem of alopecia exists because the su-
perficial fascia must be dissected from just be-
neath the hair follicles of the scalp.
The primary advantages of this flap are its
potential to provide a gliding surface and its
good donor site (one of the best in terms of
cosmesis). The primary disadvantage of this
flap is that it is very thin and must be covered
with a skin graft. Temporoparietal fascia offers
very nice coverage for defects of the fingers
and hand, but the size of the flap is limited.37
Vol. 107, No. 6 / UPPER EXTREMITY MICROSURGERY 1529

FIG. 1. (Above, left) Degloving injury to the thumb in a 23-year-old man. (Above, right) A piece of cloth is used for a template
for a lateral arm flap. (Center, left) The flap is marked on the lateral upper arm. (Center, right) The flap is placed. Note that the
“seam” was placed dorsally, with anastomosis of the lateral cutaneous nerve of the arm to the ulnar digital nerve of the thumb.
(Below, left) Results at 8 months. Protective sensation had returned. (Below, right) Flexion at 8 months.

This tissue does seem to improve the gliding FUNCTIONAL RECONSTRUCTION

ability of tendons, particularly on the dorsum.
When covered with a split-thickness skin graft,
the temporoparietal fascia flap offers the thin-
nest coverage available (excluding other fascial
flaps). It is probably not the best choice when
later surgery through the flap is contemplated,
however.
Composite tissue transfer offers the ability to
reconstruct functional deficits with flaps con-
taining skin, bone, joint, and reinnervated
muscle. Detailed discussion of each of these
areas is beyond the scope of this article, but a
brief outline of procedures to deal with signif-
1530
FIG. 2. (Above) The hand of a baby with dorsal wrist con-
tracture after a burn. (Below) The hand after scar excision,
wrist release, and scapular flap.
FIG. 3. Multiple flaps are available on single pedicle. Here
a portion of serratus anterior, latissimus dorsi, and a scapular
cutaneous flap have been harvested on a single subscapular
pedicle.
icant bone loss, muscle necrosis, and digital
loss will be covered.
Free Fibula
Most bony defects in the upper extremity
can be managed with standard bone grafts;
however, long defects (⬎ 6 cm) and those
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
associated with recurrent failure to heal may be
candidates for microvascular bone transfer.38
Although there are several flaps available that
can include a portion of vascularized bone (il-
iac crest, lateral arm, radial forearm, dorsalis
pedis), the fibula osseocutaneous flap offers
the best piece of bone for reconstructing sig-
nificant defects of the long bones of the upper
extremity.39,40 Smaller defects, such as those in
the hand, can be managed by one of the pre-
viously discussed flaps, with inclusion of a seg-
ment of bone. Larger defects of the radius,
ulna, or humerus will usually require a piece of
bone such as the fibula.41 The vascular supply
of the free fibula is based on the peroneal
vessels of the leg. These vessels run along the
deep surface of the fibula from just below the
tibioperoneal trunk to the level of the ankle.
Although the peroneal vessels provide a nutri-
ent artery to the medullary canal of the fibula,
they also provide a rich periosteal blood supply
to the cortical surface. The proximal portion of
the fibula can be taken to reconstruct the ra-
diocarpal joint, but this segment of bone gets
its primary blood supply from a branch of the
anterior tibial artery,42 which must be taken to
assure viability of this segment.
A portion of the skin overlying the fibula can
be taken with the bone, and thus compound
defects can be managed with this flap (Figs. 4
and 5). The perforators to the skin run around
the posterior aspect of the bone, and thus it is
best to include a cuff of muscle along the
posterior surface of the bone if a skin paddle is
to be included. If a skin paddle is taken, most
donor sites will require a skin graft on the
overlying muscles. The primary advantage of
this donor site is the large amount of bone that
can be taken. In adults, a total of up to 24 to 26
cm of bone may be harvested. The fibular head
should be left in place at the knee level, and 6
cm of the distal fibula should remain to avoid
problems with the ankle. In children, a screw
should be placed across the fibular-tibial joint
to avoid proximal migration of the fibula. The
disadvantages of this donor site are few: the
pedicle is relatively short (2 to 4 cm) and there
is some morbidity from harvesting, but these
do not usually present functional problems.
Innervated Gracilis Transfer
In some instances, there is a need to replace
damaged or excised muscle in the forearm or
upper arm. Although many losses can be ade-
quately reconstructed with standard tendon
Vol. 107, No. 6 / UPPER EXTREMITY MICROSURGERY 1531

FIG. 4. (Above, left) Humeral nonunion in a patient who had undergone seven prior proce-
dures to attempt union. (Above, right) Intraoperative x-ray. Note that the fibula is held in place
with only two screws, while the plate spans the defect at the site of resection of nonunion. (Below)
Arm after vascularized fibular transfer to nonunion. Hemostat points to plate over fibula.

transfers, patients with significant loss of mus-
cle substance (such as those with Volkmann’s
ischemic contracture) may benefit from recon-
struction of function with a microvascular mus-
cle transfer (Fig. 6).43 The muscles available for
this include the gracilis, latissimus dorsi, and
rectus femoris. This latissimus dorsi can be
used in the forearm as a free functional trans-
fer,44 but it is not ideal. The rectus femoris has
been used for this in the past, but again it is not
the optimal muscle. The gracilis muscle, how-
ever, is nearly ideal for reconstruction of the
muscles of the forearm. It has adequate excur-
sion to provide finger flexion or extension, it is
of the appropriate size (both length and
width), and it has an excellent neurovascular
pedicle. The gracilis is a muscle in the medial
thigh that runs from the pubis to the medial
tibia. It has a primary vascular pedicle (a
branch of the profundus femoris) and enters
the muscle at its undersurface about 6 to 12 cm
below its origin. The pedicle is rather short (5
to 6 cm) and of relatively small diameter (1 to
2 mm). There are usually two or three second-
ary pedicles that enter the muscle distally, but
the muscle is well-perfused by its primary pedi-
cle alone after microvascular transfer. The gra-
cilis is powered by a single nerve, the anterior
1532
FIG. 5. Results from the patient shown in Figure 4 at 2
years postoperatively. Note incorporation and hypertrophy of
the fibula.
branch of the obturator nerve, which enters
the muscle at the level of the vascular pedicle
proximally. The distal third of the muscle is
tendinous, and this tendon is ideal for attach-
ment to the distal flexors or extensors of the
digits. The primary advantage of this muscle as
an innervated free transfer is that its size and
excursion closely match those of the muscles of
the forearm. The primary disadvantage of this
muscle for free transfers is its relatively short
and small pedicle.
The primary indication for innervated mus-
cle transfer to the forearm is loss of muscle
mass, as in Volkmann’s ischemic contracture
or traumatic avulsion of the muscles. The pre-
requisites for successful innervated muscle
transfer include adequate passive excursion of
the distal joints, intact sensation in the hand,
available neurovascular structures for anasto-
mosis, adequate distal soft-tissue for coverage
of the tendon repairs, and lack of a simpler
solution for the problem.43 In certain in-
stances, some of these requirements can be
modified if the others are present. In general,
however, this procedure should be reserved for
those patients with a severe problem that is not
amenable to more standard solutions.
Toe Transfer
Microvascular toe transfer represents one of
the pinnacles of reconstructive surgery. The
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
ability to replace in kind a missing digit with a
mobile, sensate toe offers the best type of re-
construction available. Although this is a com-
plex microsurgical procedure that should not
be undertaken without experience,45 it remains
the benchmark for thumb and most digital
reconstructions. There are a number of varia-
tions of toe transfer, and almost any tissue
needed for digital reconstruction can be trans-
ferred. These range from pulp-only transfers to
double second and third toe transfers to recon-
struct the metacarpal hand. Because this is an
overview, the discussion here will be limited to
anatomy and a few technical points.
All great and second toe transfers ideally
have their vascular basis on the dorsalis pedis–
first dorsal metatarsal system. This anatomy is
highly variable, however, and a thorough
knowledge of it is the basis for safe harvesting
of these flaps. The venous drainage is based on
the dorsal superficial veins of the foot, because
the deep system that accompanies the arterial
supply is usually very small. The flaps can be
innervated by the proper plantar digital nerves
to the toe(s) and by the deep peroneal nerve,
which accompanies the dorsalis pedis/dorsal
metatarsal vessels.
Joint reconstruction. Destruction of the prox-
imal interphalangeal or metacarpophalangeal
joint in a finger remains a formidable recon-
structive problem. Although arthroplasty with
artificial joints continues to be an option in
these patients, results are poor in young, active
patients. The possibility of reconstructing a
missing finger joint with a joint from a toe
would seemingly obviate the problems associ-
ated with artificial joint replacement.
There have been a number of reports of
joint replacement in the hand with toe
joints.46 –50 The metatarsophalangeal joint and
proximal interphalangeal joints of the second
toe are used most often to reconstruct the
analogous joints in the hand. Despite early
enthusiasm for this procedure, it remains prob-
lematic. Extensor lag at the transferred joint is
common,49 –52 and complication rates are fairly
high and include vascular failure, infection,
and late joint destruction.50,52 Active range of
motion for transferred metatarsophalangeal
joints is in the 30-degree range, with less in
transferred interphalangeal joints.50 –52 In chil-
dren, transferred toe joints provide some po-
tential for growth, but reports vary on the
amount of growth obtained from the trans-
ferred epiphyses.52–54 Although this procedure
Vol. 107, No. 6 / UPPER EXTREMITY MICROSURGERY 1533

FIG. 6. (Above, left) Intraoperative view of the forearm of a 12-year-old boy after a propeller injury. Note the disrupted median
nerve (over background). (Above, right) Intraoperative view after innervated gracilis transfer. The skin paddle for monitoring
is over the proximal muscle. (Below) Extension (left) and flexion (right) at 8 months postoperatively.

certainly has advantages over implant arthro-

plasty and fusion, it is a complex undertaking
and should be used selectively by surgeons with
experience.
Thumb reconstruction. Toe transfer in one of
its forms offers many of the best ways to recon-
struct defects of the thumb.55 For reconstruc-
tion of the pulp of the thumb alone, only the
lateral pulp of the great toe is taken; this may be
innervated by the lateral digital and deep per-
oneal nerves. This flap provides excellent re-
construction for the thumb and leaves little
morbidity at the foot. For partial thumb ampu-
tations (those from the mid-proximal phalanx FIG. 7. Patient 1 year after great toe wrap-around recon-
level), a great toe “wrap-around” flap may be struction of the left thumb.
used (Fig. 7). This modification takes only the
distal phalanx and surrounding soft tissue, struct missing joints. Because it leaves the prox-
which is trimmed to approximate the circum- imal phalanx intact, it has the potential to im-
ference of the missing thumb.56,57 This tech- part less morbidity at the foot than whole great
nique requires the use of an intercalated bone toe transfer. Wei et al58 advocate the “trimmed
graft segment between the proximal phalanx of toe” technique to circumvent the lack of motion
the thumb and distal phalanx of the toe. Al- of the wrap-around flap. In this technique, the
though this is arguably the most cosmetic type entire great toe is trimmed, including both the
of thumb reconstruction, it does not recon- soft-tissue and bony structures, to give a recon-
1534
structed thumb of appropriate circumference.
Their report showed a reasonable return of mo-
tion in the trimmed joints.
In cases of loss of the entire thumb, the
entire great toe may be transferred. It should
be noted that the metatarsophalangeal joints
act primarily in the extension arc. To avoid
hyperextension of this joint when transferred
to the hand, a dorsal oblique osteotomy is used
to place the toe in the proper position on the
hand. The flexor and extensor tendons are
taken with a total great toe transfer, and anas-
tomosis is ideally performed at the wrist level to
decrease the incidence of tendon adhesions.
The flexor tendon may be harvested through a
separate incision in the non–weight-bearing
surface of the arch of the foot and, if more
length is needed, another incision may be
made at the level of the tarsal tunnel. The
extensor tendon (extensor hallucis longus)
is usually taken through the dorsal incision
made for dissection of the neurovascular
structures.
Transfer of all parts of the great toe imparts
some morbidity to the foot, but the effect when
evaluated with gait studies is generally mini-
mal. Certainly, the tradeoff of a thumb for the
loss of the great toe is usually well-accepted by
the patient. The primary disadvantage of these
techniques is their inherent complexity and,
although they offer superb reconstructive op-
tions in patients with loss of all or part of the
thumb, their application should probably be
limited to those practitioners with experience.
Digital reconstruction. The second or second
and third toes may be transferred in a manner
similar to that used with the great toe to recon-
struct missing digits. A single toe transfer for a
single missing digit is generally not indicated,
and the application of this technique is gener-
ally reserved for those patients who have suf-
fered a transmetatarsal amputation (metacar-
pal hand).59 Smaller portions of the second toe
can be used for pulp and/or nail losses, but this
type of procedure is usually less necessary in the
digits than in the thumb. In the case of multiple
digital loss, two fingers may be reconstructed
with either a double toe (second and third com-
bined) from one foot60 or a second toe transfer
from each foot. The loss of the second toe only
imparts very minimal morbidity, but the loss of
two toes from one foot leaves a significant
deficit.61
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
CONCLUSIONS
This has been a brief overview of microsur-
gical reconstruction of the upper extremity.
The number of flaps available for hand and
arm reconstruction is large, and only a few
have been discussed here. There are a number
of flaps other than those discussed that have
application in the upper extremity, but I hope
this overview has given the reader a number of
options that offer a solution for most recon-
structive problems. For further reading, one
should seek out one of the many texts available
on the subject.12,62,63
William C. Pederson, M.D.
The Hand Center of San Antonio
9150 Huebner Road, Suite 290
San Antonio, Texas 78240
micro1@ix.netcom.com
REFERENCES
1. Komatsu, S., and Tamai, S. Successful replantation of a
completely cut-off thumb. Plast. Reconstr. Surg. 42: 374,
1968.
2. Cobbett, J. R. Free digital transfer: Report of a case of
transfer of a great toe to replace an amputated thumb.
J. Bone Joint Surg. (Br.) 51: 677, 1969.
3. Daniel, R. K., and Taylor, G. I. Distant transfer of an
island flap by microvascular anastomoses: A clinical
technique. Plast. Reconstr. Surg. 52: 111, 1973.
4. Cormack, G. C., and Lamberty, B. G. Fasciocutaneous
vessels in the upper arm: Application to the design of
new fasciocutaneous flaps. Plast. Reconstr. Surg. 74: 244,
1984.
5. Chen, H. C., Buchman, M. T., and Wei, F. C. Free flaps
for soft tissue coverage in the hand and fingers. Hand
Clin. 15: 541, 1999.
6. Brown, D. M., Upton, J., and Khouri, R. K. Free flap
coverage of the hand. Clin. Plast. Surg. 24: 57, 1997.
7. Upton, J., Havlik, R. J., and Khouri, R. K. Refinements
in hand coverage with microvascular free flaps. Clin.
Plast. Surg. 19: 841, 1992.
8. Godina, M. Wound care and timing of microvascular
flap transfer to the lower leg. In A Thesis on the Man-
agement of Injuries to the Lower Extremity. Ljubljana: Pre-
sernova Druzba, 1991. Pp. 77– 84.
9. Chang, N., and Mathes, S. J. Comparison of the effect
of bacterial inoculation in musculocutaneous and ran-
dom-pattern flaps. Plast. Reconstr. Surg. 70: 1, 1982.
10. Calderon, W., Chang, N., and Mathes, S. J. Comparison
of the effect of bacterial inoculation in musculocuta-
neous and fasciocutaneous flaps. Plast. Reconstr. Surg.
77: 785, 1986.
11. Bailey, B. N., and Godfrey, A. M. Latissimus dorsi mus-
cle free flaps. Br. J. Plast. Surg. 35: 47, 1982.
12. Jones, N. F., and Lister, G. D. Free skin and composite
flaps. In D. P. Green, R. N. Hotchkiss, and W. C.
Pederson (Eds.), Operative Hand Surgery, 4th Ed. Phil-
adelphia: Churchill Livingstone, 1999.
13. Whitney, T. M., Buncke, H. J., Alpert, B. S., Buncke,
G. M., and Lineaweaver, W. C. The serratus anterior
free-muscle flap: Experience with 100 consecutive
cases. Plast. Reconstr. Surg. 86: 481, 1990.
Vol. 107, No. 6 / UPPER EXTREMITY MICROSURGERY
14. Favero, K. J., Wood, M. B., and Meland, N. B. Transfer
of innervated latissimus dorsi free musculocutaneous
flap for the restoration of finger flexion. J. Hand Surg.
(Am.) 18: 535, 1993.
15. Horch, R. E., and Stark, G. B. The rectus abdominis free
flap as an emergency procedure in extensive upper
extremity soft-tissue defects. Plast. Reconstr. Surg. 103:
1421, 1999.
16. Rao, V. K., and Baertsch, A. Microvascular reconstruc-
tion of the upper extremity with the rectus abdominis
muscle. Microsurgery 15: 746, 1994.
17. Press, B. H., Chiu, D. T., and Cunningham, B. L. The
rectus abdominis muscle in difficult problems of hand
soft tissue reconstruction. Br. J. Plast. Surg. 43: 419,
1990.
18. Gordon, L., Levinsohn, D. G., Finkemeier, C., Angeles,
A., and Deutch, H. The serratus anterior free-muscle
transplant for reconstruction of the injured hand: An
analysis of the donor and recipient sites. Plast. Reconstr.
Surg. 92: 97, 1993.
19. Derby, L. D., Bartlett, S. P., and Low, D. W. Serratus
anterior free-tissue transfer: Harvest-related morbidity
in 34 consecutive cases and a review of the literature.
J. Reconstr. Microsurg. 13: 397, 1997.
20. Braun, F. M., Hoang, P., Merle, M., Van Genechten, F.,
and Foucher, G. Technique and indications of the
forearm flap in hand surgery: A report of thirty-three
cases. Ann. Chir. Main 4: 85, 1985.
21. Soutar, D. S., and Tanner, N. S. B. The radial forearm
flap in the management of soft tissue injuries of the
hand. Br. J. Plast. Surg. 37: 18, 1984.
22. Yajima, H., Tamai, S., Yamauchi, T., and Mizumoto,
S. Osteocutaneous radial forearm flap for hand re-
construction. J. Hand Surg. (Am.) 24: 594, 1999.
23. Foucher, G., Van Genechten, F., Merle, M., and Michon,
J. A compound radial artery forearm flap in hand
surgery: An original modification of the Chinese fore-
arm flap. Br. J. Plast. Surg. 37: 139, 1984.
24. Katsaros, J., Schusterman, M., Beppu, M., Banis, J. C., Jr.,
and Acland, R. D. The lateral upper arm flap: Anat-
omy and clinical applications. Ann. Plast. Surg. 12: 489,
1984.
25. Chen, H. C., and el-Gammal, T. A. The lateral arm
fascial free flap for resurfacing of the hand and fin-
gers. Plast. Reconstr. Surg. 99: 454, 1997.
26. Harpf, C., Papp, C., Ninkovic, M., Anderl, H., and Hussl,
H. The lateral arm flap: Review of 72 cases and tech-
nical refinements. J. Reconstr. Microsurg. 14: 39, 1998.
27. Arnez, Z. M., Kersnic, M., Smith, R. W., and Godina,
M. Free lateral arm osteocutaneous neurosensory
flap for thumb reconstruction. J. Hand Surg. (Br.) 16:
395, 1991.
28. Yousif, N. J., Warren, R., Matloub, H. S., and Sanger,
J. R. The lateral arm fascial free flap: Its anatomy and
use in reconstruction. Plast. Reconstr. Surg. 86: 1138,
1990.
29. Scheker, L. R., Kleinert, H. E., and Hanel, D. P. Lateral
arm composite tissue transfer to ipsilateral hand de-
fects. J. Hand Surg. (Am.) 12: 665, 1987.
30. Burns, J. T., and Schlafly, B. Use of the parascapular
flap in hand reconstruction. J. Hand Surg. (Am.) 11:
872, 1986.
31. Barwick, W. J., Goodkind, D. J., and Serafin, D. The free
scapular flap. Plast. Reconstr. Surg. 69: 779, 1982.
32. Thoma, A., and Heddle, S. The extended free scapular
flap. Br. J. Plast. Surg. 43: 709, 1990.
1535
33. Germann, G., Bickert, B., Steinau, H. U., Wagner, H., and
Sauerbier, M. Versatility and reliability of combined
flaps of the subscapular system. Plast. Reconstr. Surg.
103: 1386, 1999.
34. Evans, G. R., and Luethke, R. W. A latissimus/scapula
combined myo-osseous free flap based on the sub-
scapular artery used for elbow reconstruction. Ann.
Plast. Surg. 30: 175, 1993.
35. Hing, D. N., Buncke, H. J., and Alpert, B. S. Use of the
temporoparietal free fascial flap. Plast. Reconstr. Surg.
81: 534, 1988.
36. Abul-Hassan, H. S., von Drasek Ascher, G., and Acland,
R. D. Surgical anatomy and blood supply of the fas-
cial layers of the temporal region. Plast. Reconstr. Surg.
77: 17, 1986.
37. Upton, J., Rogers, C., Durham-Smith, G., and Swartz,
W. M. Clinical applications of free temporoparietal
flaps in hand reconstruction. J. Hand Surg. (Am.) 11:
475, 1986.
38. Weiland, A. J., Kleinert, H. E., Kutz, J. E., and Daniel,
R. K. Free vascularized bone grafts in surgery of the
upper extremity. J. Hand Surg. (Am.) 4: 129, 1979.
39. Yajima, H., Tamai, S., Ono, H., Kizaki, K., and Yamauchi,
T. Free vascularized fibula grafts in surgery of the
upper limb. J. Reconstr. Microsurg. 15: 515, 1999.
40. Ihara, K., Doi, K., Yamamoto, M., and Kawai, S. Free
vascularized fibular grafts for large bone defects in the
extremities after tumor excision. J. Reconstr. Microsurg.
14: 371, 1998.
41. Gerwin, M., and Weiland, A. J. Vascularized bone grafts
to the upper extremity: Indications and technique.
Hand Clin. 8: 509, 1992.
42. Tang, C. H. Reconstruction of the bones and joints of
the upper extremity by vascularized free fibular graft:
Report of 46 cases. J. Reconstr. Microsurg. 8: 285, 1992.
43. Manktelow, R. T., and Anastakis, D. J. Functioning free
muscle transfers. In D. P. Green, R. N. Hotchkiss, and
W. C. Pederson (Eds.), Operative Hand Surgery, 4th Ed.
Philadelphia: Churchill Livingstone, 1999.
44. Park, C., and Shin, K. S. Functioning free latissimus
dorsi muscle transplantation: Anterogradely posi-
tioned usage in reconstruction of extensive forearm
defect. Ann. Plast Surg. 27: 87, 1991.
45. Lister, G. D., Kaisman, M., and Tsai, T. M. Reconstruc-
tion of the hand with free microneurovascular toe-to-
hand transfer: Experience with 54 toe transfers. Plast.
Reconstr. Surg. 71: 372, 1983.
46. O’Brien, B., Gould, J. S., Morrison, W. A., Russell, R. C.,
MacLeod, A. M., and Pribaz, J. J. Free vascularized
small joint transfer to the hand. J. Hand Surg. (Am.) 9:
634, 1984.
47. Foucher, G., Sammut, D., and Citron, N. Free vascu-
larized toe-joint transfer in hand reconstruction: A
series of 25 patients. J. Reconstr. Microsurg. 6: 201, 1990.
48. Tsai, T. M., and Lim, B. H. Free vascularized transfer of
the metatarsophalangeal and proximal interphalan-
geal joints of the second toe for reconstruction of the
metacarpophalangeal joints of the thumb and index
finger using a single vascular pedicle. Plast. Reconstr.
Surg. 98: 1080, 1996.
49. Chen, S. H., Wei, F. C., and Chen, H. C. Vascularized
toe joint transplantation. Hand Clin. 15: 613, 1999.
50. Imamura, K., Nagatani, Y., and Hirano, E. Vascularized
toe-to-finger joint transplantation: 11 patients fol-
lowed for 4 years. Acta Orthop. Scand. 63: 457, 1992.
51. Chen, S. H., Wei, F. C., Chen, H. C., Hentz, V. R., Chuang,
1536
D. C., and Yeh, M. C. Vascularized toe joint transfer
to the hand. Plast. Reconstr. Surg. 98: 1275, 1996.
52. Ellis, P. R., Hanna, D., and Tsai, T. M. Vascularized
single toe joint transfer to the hand. J. Hand Surg.
(Am.) 16: 160, 1991.
53. Ishida, O., and Tsai, T. M. Free vascularized whole joint
transfer in children. Microsurgery 12: 196, 1991.
54. Singer, D. I., O’Brien, B. M., McLeod, A. M., Morrison,
W. A., and Angel, M. F. Long-term follow-up of free
vascularized joint transfers to the hand in children.
J. Hand Surg. (Am.) 13: 776, 1988.
55. Lister, G. The choice of procedure following thumb
amputation. Clin. Orthop. 195: 45, 1985.
56. Morrison, W. A., O’Brien, B. M., and MacLeod,
A. M. Thumb reconstruction with a free neurovas-
cular wrap-around flap from the big toe. J. Hand Surg.
(Am.) 5: 575, 1980.
57. Doi, K. Microsurgical thumb reconstruction: Report of
six cases with a wrap-around free flap from the big toe
and an iliac bone graft. Ann. Acad. Med. Singap.11: 225,
1982.
PLASTIC AND RECONSTRUCTIVE SURGERY, May 2001
58. Wei, F. C., Chen, H. C., Chuang, C. C., and Chen,
S. H. Microsurgical thumb reconstruction with toe
transfer: Selection of various techniques. Plast. Recon-
str. Surg. 93: 345, 1994.
59. Wei, F. C., el-Gammal, T. A., Lin, C. H., Chuang, C. C.,
Chen, H. C., and Chen, S. H. Metacarpal hand: Clas-
sification and guidelines for microsurgical reconstruc-
tion with toe transfers. Plast. Reconstr. Surg. 99: 122,
1997.
60. Wei, F. C., Chen, H. C., Chuang, C. C., and Noordhoff,
M. S. Reconstruction of the hand, amputated at the
metacarpophalangeal level, by means of combined
second and third toes from each foot: A case report.
J. Hand Surg. (Am.) 11: 340, 1986.
61. Barca, F., Santi, A., Tartoni, P. L., and Landi, A. Gait
analysis of the donor foot in microsurgical reconstruc-
tion of the thumb. Foot Ankle Int. 16: 201, 1995.
62. Foucher, G. Reconstructive Surgery in Hand Mutilation. St.
Louis: Mosby, 1997.
63. Serafin, D. Atlas of Microsurgical Composite Tissue Trans-
plantation. Philadelphia: Saunders, 1996.
 Self-Assessment Examination

Upper Extremity Microsurgery

by William C. Pederson, M.D.

1. THE LARGEST SINGLE MUSCLE AVAILABLE FOR MICROSURGICAL TRANSFER IS THE:

A) Rectus abdominis
B) Pectoralis major
C) Gluteus maximus
D) Latissimus dorsi
E) Trapezius

2. HARVEST OF THE SERRATUS ANTERIOR MUSCLE CARRIES THE RISK OF DAMAGE TO:
A) The thoracodorsal nerve
B) The pleura
C) The long thoracic nerve
D) The medial pectoral nerve
E) The axillary artery

3. THE MOST COMMON DONOR-SITE COMPLICATION OF TEMPOROPARIETAL FASCIA HARVEST IS:

A) Facial nerve injury
B) Temporal wasting
C) Temporomandibular joint malfunction
D) Alopecia
E) Necrosis of the scalp

4. A DEFINITE INDICATION FOR INNERVATED GRACILIS TRANSFER TO THE FOREARM WOULD BE:
A) Volkmann’s ischemic contracture
B) Electrical burn to the forearm
C) High median nerve injury
D) Degloving injury to the forearm
E) Radial nerve paralysis

5. THE TYPE OF GREAT TOE TRANSFER OFFERING THE BEST POTENTIAL FOR MOTION WOULD BE:
A) Great toe wrap-around
B) Whole great toe transfer
C) Trimmed great toe transfer
D) Great toe pulp transfer
E) Great toe interphalangeal joint transfer

6. THE TERM “NECRECTOMY” AS APPLIED TO WOUND DEBRIDEMENT IMPLIES THAT:

A) Only the margins of the wounds are excised
B) All tissues that may have been damaged, including nerves and vessels, are excised
C) All contaminated or nonviable tissue is excised with the exception of major neurovascular structures
D) All deep structures are left intact, regardless of contamination, because coverage with a free flap will take care of any residual
necrotic tissue or contamination
E) Only obviously necrotic tissue is excised

To complete the examination for CME credit, turn to page 1635 for instructions and the response form.