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Procurement of Extended Vascularized Skin Flaps from the Donor Enables Hand Transplantation in Severe Upper Extremity Burns: An Anatomical Study

Dalla Pozza, Edoardo, M.D.; Bassiri Gharb, Bahar, M.D., Ph.D.; Papay, Francis A., M.D.; Drake, Richard L., Ph.D.; Steckler, Andrew, M.S.; Rampazzo, Antonio, M.D., Ph.D.

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 425–437
doi: 10.1097/PRS.0000000000004575
Hand/Peripheral Nerve: Original Articles
Cover Article

Background: Hand transplantation in patients with severe upper extremity burns can be associated with an increased risk of exposure of vessels, tendons, and nerves because of extensive skin and soft-tissue deficit. This study evaluated how to reliably transfer additional extended skin flaps with a standard hand allograft.

Methods: Twenty-five upper extremities were used. Sixteen were injected with latex to map the perforating branches of the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries. Nine hand allografts were procured, injected with blue ink through the brachial artery to assess the perfusion of the skin flaps, and then mock transplanted.

Results: Sizable perforators from the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries were used to augment the vascularization of the skin flaps. The average stained area of the medial arm flap was between 85.7 and 93.9 percent. The stained area of the volar forearm flap was the smallest when based on perforators within 6 cm from the wrist crease (51.22 percent). The dorsal forearm flap showed the least amount of staining (34.7 to 46.1 percent). The average time to repair tendons, nerves, and vessels was longer when a single volar forearm-arm flap was harvested (171.6 minutes). Harvest of the allograft associated with a distally based forearm flap and islanded arm flap was the fastest (181.6 ± 17.55 minutes).

Conclusion: Extended skin flaps, based on perforators of the main axial vessels, can be reliably transplanted with a standard hand allograft based on the brachial or axillary vascular pedicle.

Cleveland, Ohio

From the Plastic Surgery Department and the Orthopedic Surgery Skills Laboratory, Cleveland Clinic Foundation; and the Department of Anatomic Studies, Cleveland Clinic Lerner College of Medicine.

Received for publication August 6, 2017; accepted February 2, 2018.

Presented at 28th Annual Meeting of the European Association of Plastic Surgeons, in Pisa, Italy, May 24 through 27, 2017; and at Plastic Surgery The Meeting 2017, Annual Meeting of the American Society of Plastic Surgeons, in Orlando, Florida, October 6 through 10, 2017.

Disclosure: The authors have no conflict of interest to disclose.

Antonio Rampazzo, M.D., Ph.D., Plastic Surgery Department, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A60-522, Cleveland, Ohio 44195,

©2018American Society of Plastic Surgeons