Advertisement

Thin and superthin free flaps: An innovative approach to pediatric extremity reconstruction

  • Graeme E. Glass
    Correspondence
    Corresponding author. C1, 120, 1st Floor, OPC, Sidra Medical & Research Center, Al-Gharrafa St., Ar-Rayyan, Doha, State of Qatar.
    Affiliations
    Attending Plastic & Craniofacial Surgeon, Department of Surgery, Sidra Medicine, Doha, Qatar

    Associate Professor of Clinical Surgery, Weill Cornell Medical College, New York, Qatar
    Search for articles by this author
  • Robert MT Staruch
    Affiliations
    Trainee in Burns, Plastic & Reconstructive Surgery & DPhil Student, University of Oxford, Oxford, United Kingdom
    Search for articles by this author
  • Branavan Sivakumar
    Affiliations
    Attending Plastic, Reconstructive and Hand Surgeon, Department of Surgery, Sidra Medicine

    Consultant Plastic Surgeon, Great Ormond Street Hospital for Children, London, UK
    Search for articles by this author
  • Mitchell A. Stotland
    Affiliations
    Associate Professor of Clinical Surgery, Weill Cornell Medical College, New York, Qatar

    Division chief, Plastic, Craniofacial and Hand surgery, Department of Surgery, Sidra Medicine
    Search for articles by this author

      Abstract

      Introduction

      Published standards for the management of open extremity fractures have improved limb salvage, fracture union, and deep infection rates, but the aesthetic and functional importance of our flap choices has been overlooked. Thin and superthin free flaps exhibit advantages over traditional free flaps in some situations but have seldom been reported in children. The aim of this paper is to present our experience of thin and superthin free flaps in pediatric extremity reconstruction.

      Methods

      Children (≤13 years) who underwent soft tissue reconstruction using a thin and superthin free flap following major extremity trauma are presented.

      Results

      Five patients (5 flaps) met the inclusion criteria. The median age was 9 (range 6–13). There were 3 Gustilo IIIB open fractures and 2 multiplanar degloving injuries. The median mangled extremity severity score (MESS) was 4 (range 2–6). The median time from injury to definitive soft tissue closure was 72 h (range 28–120 h). Four anterolateral thigh (ALT) flaps were raised as thin flaps, and 1 superficial circumflex iliac artery perforator (SCIP) was raised as a superthin flap. There was one re-exploration owing to venous congestion, and a second venous anastomosis was performed to enhance flap drainage. The same ALT flap exhibited necrosis at one margin, which was debrided and grafted before discharge. There were no other flap complications. No flap-related secondary surgeries were required.

      Conclusion

      Thin and superthin free flaps are viable options in pediatric extremity reconstruction. They exhibit excellent aesthetic and functional contouring when a slender fasciocutaneous flap is needed, especially when body habitus renders traditional options unfavorable.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Eccles S
        • Handley B
        • Khan U
        • McFadyen I
        • Nanchahal J
        • Nayagam S.
        Standards for the management of open fractures.
        Oxford University Press, 2020
      1. Eccles S, Handley B, Khan U, McFadyen I, Nanchahal J, Nayagam S. Standards for the management of open fractures. In 2020. p. Chapter 7.

      2. Eccles S, Handley B, Khan U, McFadyen I, Nanchahal J, Nayagam S. Standards for the management of open fractures. 2020. Chapter 8.

      3. National Institute of Health and Care Excellence. Fractures (complex): assessment and management. 2016.

      4. Eccles S, Handley B, Khan U, McFadyen I, Nanchahal J, Nayagam S. Standards for the management of open fractures. 2020. Chapter 14.

        • Khadim MF
        • Emam A
        • Wright TC
        • Chapman TWL
        • Khan U.
        A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly.
        Injury. 2019; 50: 1376-1381
        • Abo Elhassan W
        • Abulezz T
        • Ali A
        • GY E
        Comparison between Free Anterolateral Thigh Flap and Free Medial Sural Artery Perforator Flap in Reconstruction of Post Traumatic Soft Tissue Defects of Dorsum of the Foot.
        Autin J Surg. 2021; 8: 1276
        • Kim TG
        • Choi MK.
        Secondary contouring of flaps.
        Arch Plast Surg. 2018; 45: 319-324
        • Serra JM
        • Samayoa V
        • Valiente E
        • Kloehn G.
        Neurotization of the remaining latissimus dorsi muscle following muscle flap transplant.
        J Reconstr Microsurg. 1988; 4: 415-420
        • Cherubino M
        • Berli J
        • Turri-zanoni M
        • Battaglia P
        • Maggiulli F
        • Corno M
        • et al.
        Sandwich Fascial Anterolateral Thigh Flap in Head and Neck Reconstruction: Evolution or Revolution?.
        Plast Reconstr Surg - Glob Open. 2017; 5https://doi.org/10.1097/GOX.0000000000001197
        • Cherubino M
        • Di Summa P
        • Stocco C
        • Valdatta L
        • Ronga M
        • Tamborini F
        • et al.
        Comparisons of fascio-cutaneous anterolateral thigh and sandwich fascial ALT free flap in the distal extremity reconstruction.
        Microsurgery. 2020; 40: 452-459
        • Hong JP
        • Choi DH
        • Suh H.
        A New Plane of Elevation : The Superficial Fascial Plane for Perforator Flap Elevation. 2014; 30: 491-495
        • Hyakusoku H
        • Ogawa R.
        The subdermal vascular network flap: the concept of the ‘“super-thin flap,”’ ‘“perforator flaps.”’.
        in: Blondeel P.N. Morris SF Hallock GG Perforator flaps anatomy, technique, & clinical applications. Quality Medical Publishing, St Louis, Missouri2006
        • Narushima M
        • Yamasoba T
        • Iida T
        • Yamamoto T
        • Yoshimatsu H
        • Hara H
        • et al.
        Pure skin perforator flap for microtia and congenital aural atresia using supermicrosurgical techniques *.
        J Plast Reconstr Aesthetic Surg. 2011; 64: 1580-1584
        • Narushima M
        • Yamasoba T
        • Iida T
        • Matsumoto Y
        • Yamamoto T
        • Yoshimatsu H
        • et al.
        Pure Skin Perforator Flaps : The Anatomical vascularity of the superthin flap.
        Plast Reconstr Surg. 2018; 142: 351-360
      5. British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons Audit Standards for Trauma: Open fractures. 2017; https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92.

        • Broer PN
        • Moellhoff ÃN
        • Mayer ÃJM
        • Heidekrueger PI
        • Ninkovic M
        • Ehrl D.
        Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions.
        J Reconstr Microsurg. 2020; 36: 432-437
        • Nanchahal J
        • Nayagam S
        • Khan U
        • Moran C
        • Barrett S
        • Sanderson F
        • et al.
        Standards for the management of opern fractures of the lower limb.
        Royal Society of Medicine Press Ltd, London2009
        • Rinker B
        • Valerio IL
        • Stewart DH
        • Pu LLQ
        • Vasconez HC.
        Microvascular Free Flap Reconstruction in Pediatric Lower Extremity Trauma: A 10-Year Review.
        Plast Reconstr Surg. 2005; 115: 1618-1624
        • Upton J
        • Guo L.
        Pediatric free tissue transfer: A 29-year experience with 433 transfers.
        Plast Reconstr Surg. 2008; 121: 1725-1737
        • Kim JH
        • Kim KN
        • Yoon CS.
        Reconstruction of Moderate-Sized Distal Limb Defects using a Superthin Super fi cial Circum fl ex Iliac Artery Perforator Flap.
        J Reconstr Microsurg. 2015; : 631-635
        • Gabriel MG
        • Wakefield CE
        • Vetsch J
        • Karpelowsky JS
        • Darlington AE
        • Grant DM
        • et al.
        The Psychosocial Experiences and Needs of Children Undergoing Surgery and Their Parents : A Systematic Review.
        J Pediatr Heal Care. 2018; 32: 133-149
        • Ilda T
        • Yamamoto T
        • Yoshimatsu H
        • Abe N
        • Tsuchiya M
        • Nemoto N
        • et al.
        Supermicrosurgical free sensate superficial circumflex iliac artery perforator flap for reconstruction of a soft tissue defect of the ankle in a 1-year old child.
        Microsurgery. 2016; 36: 254-258
        • Tawa P
        • Levy J
        • Brault N
        • Madar Y
        • Qassemyar Q.
        Superficial circumflex iliac artery perforator free flap in pediatric reconstruction: A case report.
        Ann Chir Plast Esthet. 2020; 65: 338-342
        • Hong JP.
        The Use of Supermicrosurgery in Lower Extremity Reconstruction: The next step in evolution.
        Plast Reconstr Surg. 2009; 123: 230-235
        • Cao Z
        • Du W
        • Qing L
        • Zhou Z
        • Wu P
        • Yu F.
        Reconstructive surgery for foot and ankle defects in pediatric patients : Comparison between anterolateral thigh perforator fl aps and deep inferior epigastric perforator flaps.
        Injury. 2019; 50: 1489-1494
        • Jabir S
        • Sheikh F
        • Connor EFO
        • Griffiths M
        • Niranjan N
        • Jabir S
        • et al.
        A systematic review of the applications of free tissue transfer for paediatric lower limb salvage following trauma.
        J Plast Surg Hand Surg. 2015; 49: 251-259
        • Thakkar M
        • Bednarz B.
        Systematic Review of Free Tissue Transfer Used in Pediatric Lower Extremity Injuries.
        Eplasty. 2021; 21: 9-16
        • Khouri RK
        • Shaw WW.
        Reconstruction of the lower extremity with microvascular free flaps: A 10-year experience with 304 consecutive casses.
        J Trauma Acute Care Surg. 1989; 29: 1086-1095
        • Srivastava G
        • Fox CK
        • Kelly AS
        • Jastreboff AM
        • Browne A
        • Browne N
        • et al.
        Clinical Considerations Regarding the Use of Obesity Pharmacotherapy in Adolescents with Obesity.
        Obesity. 2019; 27: 190-204
        • Busaidi N Al
        • Shanmugam P
        • Manoharan D
        Diabetes in the Middle East : Government Health Care Policies and Strategies that Address the Growing Diabetes Prevalence in the Middle East.
        Curr Diab Rep. 2019; 19 (doi.org/)https://doi.org/10.1007/s11892-019-1125-6
      6. National Health Strategy 2018-2022: Our health, our future. Available from: https://www.moph.gov.qa/StyleLibrary/MOPH/Files/strategies/NationalHealthStrategy2018-2022/NHSEN.pdf.

        • Anderson PM
        • Butcher KF
        • Whitmore D.
        Understanding recent trends in childhood obesity in the United States.
        Econ Hum Biol. 2019; 34: 16-25
        • Visconti G
        • Bianchi A
        • Hayashi A
        • Cina A
        • Maccauro G
        • Almadori G
        • et al.
        Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound.
        Arch Plast Surg. 2020; 47: 365-370
        • Venkatramani H
        • Rodrigues J
        • Sabapathy S.
        Revisiting the reconstructive surgery framework : The reconstruction.
        J Plast Reconstr Aesthetic Surg. 2019; 72: 529-531