Case reports have provided multiple options for repair of complex upper extremity injuries. Despite the method of reconstruction chosen, we have universally noted that the authors address the importance of early repair as well as treatment in a center that specializes in microsurgical care. The use of the radial forearm free flow-through flap provides autologous soft tissue coverage as well as native vasculature to reestablish inflow to the involved extremity. To expand upon the review by Bullocks et al,1
we discuss the history of flow-through flaps and further discuss the evolution of artificial soft tissue substitutes.
In 1983, Soutar et al2
first described a radial artery flow-through flap to anastomose the external carotid artery to the facial artery for a head and neck reconstruction. Foucher et al,3
just 1 year later in 1984, performed the first radial forearm flow-through flap for an extremity reconstruction with a concomitant vascular defect. In 1991, Costa et al4
further addressed the importance of this type of flap with two cases of reconstruction involving the hand and foot. Since that time, flow-through flaps have become a valuable treatment modality for complex reconstructions.
In 1998, Yavuz et al5
described the case of a 13-year-old girl who sustained a gunshot to the cubital region that would have likely resulted in amputation. However, with the use of a radial forearm flow-through flap from the near amputated part, they were able to salvage the extremity. In 1999, Kasten et al6
described the case of a 28-year-old man who suffered an injury to the soft tissue, median nerve, and brachial artery in his dominant arm after punching a window. A radial forearm flow-through flap was used 1 week postoperatively after a failed saphenous vein reconstruction lead to an ischemic distal extremity. The authors cite the benefits of a single-stage reconstruction that avoids multiple donor sites and also provides an arterial conduit for vascular repair.
In 2007, Kesiktas et al7
described a series of 5 patients with wide tissue deficits and segmental defects in the brachial artery. The authors used a radial forearm flow-through flap for several purposes. They cite numerous advantages including working in a single surgical area, shorter dissection times, suitability of vessel caliber and length, as well as offering tissue from the distal aspect of the wound and avoiding additional areas of morbidity.
With regard to artificial dermal closure, in 1981, Burke et al8
described a physiologically acceptable artificial skin substitute for the treatment of extensive burn injuries. In 1990, Heimbach et al9
reported the first multicenter results demonstrating improved healing time and favorable aesthetic outcomes with the use of artificial dermal grafts. Application of the dermal template required a second operation for the placement of epidermal grafts at approximately 7 days postoperatively. The use of artificial dermis has since evolved to become a commonly used product for burn and reconstructive surgery, and a full background check of its use is beyond the scope of this review.
However, there have been reports in the literature of the application of negative pressure wound dressings placed over the dermal template to assist with wound closure. An article published in 2009 by Leffler et al10
reported the case of a 25-year-old man who required a dermal template (Integra) that was covered with a vacuum dressing that lead to complete graft take, avoided the need for dressing changes, and allowed the patient to be treated as an outpatient. Also, in 2009, Burd et al11
reported a series of 10 patients who underwent circular excisions for facial cancers that were successfully repaired using a single-stage Integra approach with subsequent successful closure of the epithelial defects with calcium alginate.
To our knowledge, this is the first case of a single-stage closure with placement of Integra and a thin piece of split-thickness skin graft at the original operation with successful closure beneath a NPWT device (EZ Care, Smith & Nephew). In 2007, Kim and Hong12
described a similar method by using a single-stage closure of a donor site with Alloderm (Lifecell Corp, Branchburg, NJ) and split-thickness skin graft under NPWT. They found a significantly improved rate of graft take as well as a decreased time to closure. From a technical perspective, it is important to note that both the Integra and the skin graft should be meshed 1.5 to 1 under a protective wound layer such as Acticoat (Smith & Nephew). This meshing allows for continued fluid removal beneath the grafts as well as improved imbibition of the grafts for improved graft take.