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American Association for Hand Surgery
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Theme: Inclusion and Collaboration Theme: Inclusion and Collaboration

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Upper Extremity Reconstruction Using Large Pedicled Flaps in Military, Academic and Community Hospitals
1Joseph Meyerson, MD; 2Anthony L Logli, BA; 2Brian J Bear, MD; 1Ian L. Valerio, MD, MS, MBA
1The Ohio State University, Columbus, OH; 2University of Illinois College of Medicine at Rockford, Rockford, IL

Introduction
Extensive soft tissue loss of the upper extremities poses a formidable challenge to the reconstructive surgeon. These defects may not be amendable to skin grafting or local and regional flaps. Large surface area coverage demand either free tissue transfer or large distant pedicled flaps.  Patients that are non-microsurgical candidates, a lack of microsurgical capabilities, or a bailout option for failed free flap reconstruction demand large pedicled flaps as an essential reconstructive option. Because of their reliable pedicles and low technical requirement, these flaps can be performed in military, academic and community practices. We describe a series of large pedicled flaps in various practices including military, academic and community and describe a novel technique using intraoperative angiography (IOA) to evaluate retrograde inflow to large pedicled flaps that may optimize the timing for flap division and improve patient outcomes.

Methods
A multi-institution, retrospective, consecutive case series review was performed for all cases in which large pedicled flaps (thoracoepigastric and groin flaps) were used for upper extremity reconstruction. Institutions included military, academic and community based practices. The preliminary focus of the study looked at outcomes from each institution of large pedicle flaps for upper extremity coverage. Outcomes focused on patient demographics, flap type, flap necrosis, flap loss and need for additional reconstruction. Additionally, the study focused on the novel use of intraoperative angiography for timing of flap division as a technique for flap division.

Results
From 2003-2016, thirty-seven large pedicled flaps for extremity coverage were reviewed from three different institutions. Multivariate analysis was performed. No significant differences were found in patient demographics or outcomes by flap type or by type of institution. There were 17 throacoepigastric and 20 groin flaps. Two complete flap losses occurred, both in the military setting and without the use of IOA (5.4%, p<0.05). Partial flap necrosis occurred in 7 patients (18.9%), 6 in the non-IOA group, equally split between military and academic practices (p<0.05).

Conclusion
Large pedicled flaps are a useful technique in upper extremity reconstruction that is not amenable to free flap procedures. We have demonstrated that this procedure is an effective and reliable in all practice types from military to academic to community. Critical to their success is timing of flap division. This is the first series describing large pedicled flaps using the technique of flap division utilizing intraoperative angiography potentially decreasing complications and reducing additional surgeries for patients with large surface upper extremity defects.


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