Ziegler Benjamin, Hundeshagen Gabriel, Will Patrick A, Bickert Berthold, Kneser Ulrich, Hirche Christoph
From the Department of Hand, Plastic and Reconstructive Surgery, Microsurgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwigshafen, Germany.
Ann Plast Surg. 2020 Aug;85(2):115-121. doi: 10.1097/SAP.0000000000002412.
Severe thermal trauma to the hand can result in major impairment and reduced function due to defective healing or even extremity loss. Full-thickness injuries frequently incur exposure of tendons or bone and require an early and stable coverage with soft tissue transplants to allow for rapid induction of exercise and to preserve structures and hand function. Free tissue transfer to the hand after thermal trauma is a rare indication, and safety, management, and outcome of free flap surgery for severe acute burn injuries to the hand remains underreported.
Patients with primary reconstructions of full-thickness burn injuries to the hand undergoing microsurgical free tissue transfer surgery were retrospectively assessed in a period from 2013 to 2016. Salvage strategy of the extremity, postoperative complications, length of hospital stay, and primary reconstructive result were quantified and analyzed. Functional outcome measures (range of motion and grip strength) were assessed during clinical follow-up examinations.
During the investigated period, 13 patients were identified undergoing reconstruction of 14 hands via free flap transplantation after severe burn injury in the acute phase. Nine anteriolateral thigh flaps (64%), 3 latissimus dorsi flaps (18%), 1 serratus anterior flap, and 1 tensor fasciae lata flap (7%) were performed. In all cases, salvage of the affected extremity was achieved, although 1 flap (7%) was lost during the early postoperative period requiring secondary reconstruction via pedicled groin flap. Further complications were venous thrombosis (n = 2; 14%) and hematoma (n = 2; 14%). Mean length of hospital stay was 51 days. Functional outcome during follow-up examination after an average of 9.3 months was inhomogeneous depending on the pattern of injury and ranged from complete recovery to nearly entire loss of hand function.
Free flap transfer can be a mandatory and valuable tool to cover full-thickness burn injuries of the hand early in the clinical course of thermal trauma and may provide extremity salvage by favorable means of reconstruction to achieve acceptable functional outcomes, in the most severe cases. Although microsurgical failure rates in burn patients are slightly higher than in free flap transfer to the upper extremity in general, it can be performed with reasonable risk-to-benefit ratio.
手部严重热烧伤可因愈合不良甚至肢体缺失导致严重功能障碍和功能减退。全层损伤常导致肌腱或骨骼外露，需要早期用软组织移植进行稳定覆盖，以便迅速开始锻炼并保留组织结构和手部功能。热烧伤后对手部进行游离组织移植是一种罕见的治疗方法，对于手部严重急性烧伤的游离皮瓣手术的安全性、治疗方法及结果仍鲜有报道。
回顾性评估2013年至2016年期间因手部全层烧伤接受显微外科游离组织移植手术进行一期重建的患者。对肢体的挽救策略、术后并发症、住院时间和一期重建结果进行量化和分析。在临床随访检查中评估功能结局指标（活动范围和握力）。
在研究期间，确定有13例患者在急性期严重烧伤后通过游离皮瓣移植对14只手进行了重建。共进行了9例股前外侧皮瓣（64%）、3例背阔肌皮瓣（18%）、1例前锯肌皮瓣和1例阔筋膜张肌皮瓣（7%）移植。尽管术后早期有1例皮瓣（7%）坏死，需要通过带蒂腹股沟皮瓣进行二期重建，但所有病例的患侧肢体均得以挽救。其他并发症包括静脉血栓形成（2例，14%）和血肿（2例，14%）。平均住院时间为51天。平均9.3个月的随访检查显示，功能结局因损伤类型而异，从完全恢复到几乎完全丧失手部功能不等。
游离皮瓣移植可作为一种必要且有价值的手段，在热烧伤临床过程早期覆盖手部全层烧伤，在最严重的病例中，通过良好的重建方式挽救肢体，以获得可接受的功能结局。尽管烧伤患者的显微外科手术失败率略高于一般上肢游离皮瓣移植，但手术的风险效益比合理。
