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Three Part Question

Patient characteristics:
[Patient with hand defect from injury or other pathology needed reconstruction with flap] there is [an ideal flap for resurfacing of hand wound] to [show the best functional and cosmetic outcome with minimal donor morbidity.]

Clinical Scenario

A 21 year-old man who has admitted with left dorsal hand injury with full thickness skin loss and exposed extensor tendons. It extended about half of the dorsum with dorsum of the whole index finger. 1-2.5 cm defect has noticed to the EDCs index and Middle finger. After through debridement one stage reconstruction has done using free ALT flap with fascia lata. Radial vessels were used as recipient vessels and dorsal hand cutaneous nerve was connected with lateral femoral nerve to neurotise the flap area at anatomical snuff box. Fascia lata has used to bridge the gap in extensor tendons. After two months of initial surgery a second operation was performed to debulk the flap as well as release of reconstructed extensor tendons. Post operative mobilization has started from the next day. After six month good extension of MCPJ and PIPJ noted to the reconstructed fingers with reduced sensation on flap territory compared to normal dorsal skin. (1)

Search Strategy

Medline search from November 2009 to November 2019 using the PubMed interface

((((('lateral thoracic flap') OR 'groin flap') OR ' ALT flap') OR 'thigh flap') AND 'hand reconstruction') OR 'hand resurfacing’

Search Outcome

452 papers were found.
Of which 48 publications in the last 10 years were shortlisted
7 of these were excluded as they were not written in English.
Remaining 41 publications were included, 30 were less relevant to the specific topic.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lee, N. , Roh, S., Yang, K., and Kim, J. December’ 2009, uk	Total 6 patients ages ranged from 39 to 69 years, 2 with synovial sarcoma, 1 with fibrous sarcoma, 1 with MFH, and other 2 were leiomyosarcoma of upper extremity. Male :Female =2:1. After Wide excision defect size were 10x6cm-15x10cm. All defects reconstructed with Free ALT flaps.	Letter to editor	All flaps have survived, One of them had partial flap necrosis has managed by debridement and secondary healing.	ALT could be an ideal flap for reconstruction of sarcoma resection defect of upper limb.	It is only surgeons experience of only six cases and not an standard RCT/Research
Yokota, K., Sunagawa, T., Suzuki, O., Nakanishi, M., and Ochi, M. October’ 2010. Japan	8 patients ages ranged from 9 to 66 who have 8 reconstruction of upper extremity using free ALT flaps. Male :Female =3:1. 6 of the defects were from injury and 2 of them were from excision of malignant tumours. All cases radial artery used as recipient vessel with flow through techniques without sacrificed radial artery.	• Case series	All flaps have survived without major complication. One flap has partial necrosis which has debrided and re sutured. Post operative less congestion of flap noted. No marked donor site morbidity noted.	ALT flap also can used as flow through flap which reduced chance of flap congestion with no compromised hand vascularity. Damaged recipient vessel can reconstruct at the same time.	Small number of case series.
Zheng, X. Zheng, C., Wang, B., Qiu, Y., Zhang, Z., Li, H., and Wang, X. October 2016.  China	22 patients of aged 16-57 years who had free ALT chimeric (skin, fascia and muscle) flap reconstruction, 12 of them were used for upper extremity reconstruction. Only one patient was female rest of them were male. Data has taken from Jan 2010 to March 2012	Case series	All flaps were survived. One had venous thrombosis and needed re-repair vein using vein graft. 18-30 months follow up period patients were happy with outcome and donor site morbidity also minimal.	.Chimeric option given the versatility of ALT to reconstruct the hand defect.	Small number of case series. Combination of upper and lower limb reconstruction
Weichman, K., Allen, R., Thanik, V., Matros, E., and Mehrara, B. September’ 2015 USA	Total of 7 patients, who had reconstruction of their extremity defects with free aALT flaps. Age ranged from 7-51 years. Male: Female = 5:2. Among them only 3 of them had hand resurfacing at the period of 2005 to 2014.	Letter to editor	No flap failure with no donor site morbidity noted.	Pliable, less bulkiness, long reliable pedicle	Very small case series
Spindler N., Al-Benna S., Ring A., Homann H., Steinsträsser L., Steinau HU., and Langer S. February’ 2015 Germany	Total of 32 patients with mean age of 53 years had upper extremity reconstruction using free ALT flaps for the period of seven years from 2005 to 2012. Male : Female =3:1, Most of the defects were from post infection (44.6%) others were tumour (40%) and trauma (15.4%), Half of them were forearm reconstruction and a quarter of were hands. Rest of them were arms and elbows.	Retrospective study.	Total flap survival rate was 92.3%, 15.6% had partial flap necrosis. No donor site morbidity	ALT is a workhorse flap for upper extremity reconstruction. It is easy and rapid to harvest, has long large vascular pedicle, reliable skin paddle, adjustable volume. It is ideal flap for soft tissue reconstruction of hand and other part.	Retrospective study. Only quarter of cases were for hand resurfacing.
Torres-Ortíz Zermeño, C. A. and López Mendoza, J. November’ 2014, Mexico	Total 7 patients with 6 male and 1 female with age range 2-28 years. Male :Female = 6:1. All patient received Free ALT flap to reconstruct their upper extremity defects 3 of them were from burns and 4 were traumatic. Among them 5 of them were hands. All of those patients were operated during the one-year time from June 2010 to May 2011.	Retrospective study	Mean Follow up is 11.5 months. Aesthetic and functional outcome assessed with different scales. All of them were aesthetically good even one was very good. Functional outcome showed low disability rate.	Innervated and after thinning of ALT flap give good aesthetic outcome with minimal disability.	Only 7 cases
Sabapathy, S. R., Venkatramani, H., and Bhardwaj, P. March’ 2013. India	Total 8 patients had reconstruction of amputated thumb with groin flap and 2nd toe transfer from 2002 to 2011 Average follow up 4 years and 6 months	Retrospective	All flaps have survived. 6 out of 8 patients achieved basic function of hand.	Using 2nd toe transfer in conjunction with groin flap to reconstruct proximal thumb amputation could avoid pollicisation	Retrospective study with small case number, aesthetic outcome hasn’t mentioned.
Zhang, G., Su, H., Ju, J., Li, X., Fu, Y., and Hou, R. August 2019.  China	7 patients of 25-49 years old had reconstruction of both dorsal and palmar defect of same hand with free ALT flap from single donor site from January 2016 to May 2018. Male :Female = 4:3	Retrospective study	All flaps have survived. Mean Follow up 11.1 months 4 flaps needed 2ndary surgery. No donor site morbidity	ALT flaps from single donor site also applicable for large palmar and dorsal defect of hand	Only seven cases No comparison between other options
Amouzou KS., Berny N., El Harti A., Diouri M., Chlihi A., and Ezzoubi M. March 2017, Morocco	5 patients who had pedicle groin flap reconstruction for hand wounds from January 2013 to July 2015. Male : Female =3:2, Ages 18-55 years	Retrospective case study	All flaps have survived. 4 out 5 patients were happy with the flap and donor scars. One patient wasn’t satisfied with bulky flap needed further flap thinning.	Pedicle groin flap is safe reliable and acceptable option for hand resurfacing if free option is not available or microsurgical reconstructions are limited	Only 5 patients

Comment(s)

After evolution of reconstructive microsurgery, the free flap option has been taken over most of the pedicle option for resurfacing the hand defects. Further points come up with composite tissue loss which necessitates composite tissue transfer or multistage operations. Some of the modifications of free flap can be used as chimeric flap to reduce the number of operation. In our literature search we found, last ten years, free flaps were the mostly used option for hand resurfacing. Most of our literatures were came up with free Antero Lateral Thigh Flap (ALT-flap) for resurfacing of hand defect. It has the versatility of modification and can be used for composite tissue defects. It is not uncommon to need for reconstruction of the tendons as well as soft tissue at the same time. Some times, we may look for a sensate flap. All can be possible in one stage Antero Lateral Thigh Flap (ALT- flap). Now a day it is most common workhorse flap for reconstruction of hand defects. According to Zhang et al. (10) in recent years Antero Lateral Thigh Flap (ALT-Flap) is the most common free flap using for soft tissue resurfacing of hands which comprises 35% of all free flap reconstruction. The benefit of using ALT flap are, it has a reliable long pedicle, stable, can be used for multiple defect with single donor site, and its versatility. We can take fascia, muscle or nerve if needed. We can also raise it as fascial flap where bulkiness is an issue. It also showed minimal donor morbidity and less number of operations. Sometimes bulkiness of flap can be an issue, however it can be make thin perioperative or post operative period. We found very few pedicle groin flap reconstructions for hand resurfacing however most of them were not in English. Groin flap also can be modified and can be raise free or sensate. Very few literatures with small case numbers described about that. (12) Most of the cases it used as pedicle. Some time it has used in conjunction with thigh flap. (10) There is paucity of literature to show lateral thoracic flap for resurfacing of hand wound.

Clinical Bottom Line

Current evidence shows Free Antero-Lateral Thigh Flap (ALT-Flap) is the ideal workhorse flap for resurfacing of hand defect. (10) Second most common is Medial Sural Artery Perforator Flap (MSAP). (10) Neither of groin based or Lateral thoracic based flap has got popularity over Thigh based flap where microsurgical procedures are available or possible. Some of the units where microsurgery isn’t available pedicle groin flap still an option. (11) Further study with large series can be done in future.

References

1. Lee, N. , Roh, S., Yang, K., and Kim, J. Anterolateral thigh free flap for simultaneous reconstruction of digital extensor tendon and defect of the dorsal hand Chinese Journal of Traumatology 19(5), 309–310.doi:10.1016/j.cjtee.2015.11.019
2. Yokota, K., Sunagawa, T., Suzuki, O., Nakanishi, M., and Ochi, M. Short Interposed Pedicle of Flow-Through Anterolateral Thigh Flap for Reliable Reconstruction of Damaged Upper Extremity Journal of Reconstructive Microsurgery 27(02), 109–114.doi:10.1055/s-0030-1268209 
3. Zheng, X. Zheng, C., Wang, B., Qiu, Y., Zhang, Z., Li, H., and Wang, X. Reconstruction of complex soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap. International Journal of Surgery International Journal of Surgery 26, 25–31.doi:10.1016/j.ijsu.2015.12.035 
4. Weichman, K., Allen, R., Thanik, V., Matros, E., and Mehrara, B. Adipofascial Anterolateral Thigh Free Flaps for Oncologic Hand and Foot Reconstruction Journal of Reconstructive Microsurgery 31(09), 684–687. doi:10.1055/s-0035-1558431 
5. Spindler N., Al-Benna S., Ring A., Homann H., Steinsträsser L., Steinau HU., and Langer S. Free anterolateral thigh flaps for upper extremity soft tissue reconstruction GMS Interdiscip Plast Reconstr Surg DGPW 1. 2015 Feb 5;4:Doc05. doi: 10.3205/iprs000064. eCollection 2015.
6. Torres-Ortíz Zermeño, C. A. and López Mendoza, J. Aesthetic and Functional Outcomes of the Innervated and Thinned Anterolateral Thigh Flap in Reconstruction of Upper Limb Defects Plastic Surgery International 1. 2014, 1–7.doi:10.1155/2014/489012
7. Sabapathy, S. R., Venkatramani, H., & Bhardwaj, P Reconstruction of the thumb amputation at the carpometacarpal joint level by groin flap and second toe transfer. Injury j.injury 44(3), 370–375.doi:10.1016/j.injury.2013.01.012
8. Zhang, G., Su, H., Ju, J., Li, X., Fu, Y., and Hou, R. Reconstruction of Dorsal and Palmar Defects of Hand with Anterolateral Thigh Flaps from One Donor Site Journal of Plastic, Reconstructive & Aesthetic Surgery doi:10.1016/j.bjps.2019.08.002
9. Zhang Y, Gazyakan E, Bigdeli AK, Will-Marks P, Kneser U, Hirche C Soft tissue free flap for reconstruction of upper extremities: A meta-analysis on outcome and safety. Microsurgery 2019 Jul;39(5):463-475. doi: 10.1002/micr.30460. Epub 2019 Apr 19.
10. Amouzou KS., Berny N., El Harti A., Diouri M., Chlihi A., and Ezzoubi M. The pedicled groin flap in resurfacing hand burn scar release and other injuries: a five-case series report and review of the literature Ann Burns Fire Disasters 2017 Mar 31;30(1):57-61.