Share this article on:

Hand Allograft Saved by an Ultrathin Groin Flap

Château, Joseph MD; Gazarian, Aram MD; Boucher, Fabien MD; Badet, Lionel MD, PhD; Braye, Fabienne MD, PhD; Saint-Cyr, Michel MD; Mojallal, Ali MD, PhD

Plastic and Reconstructive Surgery – Global Open: September 2016 - Volume 4 - Issue 9 - p e869
doi: 10.1097/GOX.0000000000000806
Case Report
France
Watch Video
Face The Case

Summary: We report a case of a young double-hand allotransplant patient who presented with a full-thickness skin necrosis of the dorsum of the left hand after vascular compromise of the allotransplantation. Considering the lack of viable dorsal tissue overlying the extensor tendons and the need for early hand rehabilitation, an ultrathin pedicled groin flap was used for the coverage. This procedure resulted in salvaging the allotransplantation, and the patient was able to successfully return to work after his surgery. To our knowledge, this is the only case of an upper extremity allotransplant salvaged by a pedicled flap.

Supplemental Digital Content is available in the text.

From the *Plastic, Reconstructive and Aesthetic Department, Croix-Rousse Hospital, Hospices Civils de Lyon, France; Hand Surgery Department, Clinique du Parc, Lyon, France; Transplantation Surgery Department, Edouard Herriot Hospital, Lyon, France; and the §Plastic Surgery Department, Mayo Clinic, Rochester, Minn.

Received for publication February 8, 2015; accepted May 4, 2016.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by for by the authors.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Ali Mojallal, MD, PhD, Plastic, Reconstructive and Aesthetic Department, University of Lyon Claude Bernard 1, Croix-Rousse Hospital, Hospices Civils de Lyon, 103, Grande rue de la Croix-Rousse, 69004, Lyon, France

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

For the past 20 years, composite allotransplantation has become increasingly popular due to the experience and success gained from multiple worldwide hand and face allotranplantations.

The Lyon team has gained significant experience; despite this, some surgical setbacks after allotransplantation can be difficult to avoid. We present a case of hand allotransplantation salvaged by an ultrathin pedicled groin flap.

Back to Top | Article Outline

CASE

This case report describes a right-handed 27-year-old patient who suffered a bilateral upper limb amputation at the distal quarter of both forearms after an explosion from an artisanal bomb at 16 years of age.

After his injury, the patient was declared unable to work, and his Disabilities of Arm Shoulder and Hand score was 44 of 100 for both upper limbs. He requested a bilateral hand transplantation to restore and reach the highest level of social integration.

A multidisciplinary evaluation conducted by the allotransplantation team from the University of Lyon failed to show any medical and psychological contraindication for surgery.

A bilateral forearm/hand allotransplantation was performed on July 11, 2009 (Fig. 1). Unfortunately, on postoperative day 11, the patient developed grade 1 bilateral allotransplantation acute rejection.

Fig. 1

Fig. 1

A Doppler ultrasonography showed a right radial artery thrombosis at the elbow and a left proximal ulnar artery thrombosis. Despite this, both allotransplants remained vascularized.

Five days later, acute ischemia of the left allotransplantation developed after the loss of blood flow in both ulnar and radial arteries.

A humeroradial venous bypass was performed urgently. Postoperatively, a compressive hematoma occurred that caused a second ischemic event in the left allotransplantation. Surgery was urgently performed to evacuate the hematoma and restore proper blood flow to the upper extremity.

A third-degree burn developed over the dorsum of the left hand after the urgent bypass surgery. Eight days later, excision of the burn eschar led to exposure of the extensor tendons with the loss of the peritendon (Fig. 2).

Fig. 2

Fig. 2

The initial attempt at covering the exposed extensor tendons with artificial dermis failed; finally, a decision was made to perform a left pedicled groin flap.

An ultrathin flap was dissected under the operative microscope to preserve the maximal amount of perforator arteries from the superficial circumflex iliac artery and enhance vascularity.

Three weeks later, the section of the pedicle was performed after a positive pedicle clamp test. No postoperative complications occurred. Stable and thin coverage over the left hand dorsum was obtained, and aggressive postoperative rehabilitation was instituted right after the flap procedure. To further improve function and appearance, a debulking procedure was performed 2 years later (Fig. 3).

Fig. 3

Fig. 3

At present, the left allotransplant mobility is not limited by the flap, and the cosmetic result is good (See video, Supplemental Digital Content 1, which displays a preoperative aspect on the left and at 2 years post operation on the right, http://links.lww.com/PRSGO/A229). The donor-site morbidity is very low.

Video

Video

Back to Top | Article Outline

DISCUSSION

The important experience of the Lyon surgical team for hand allotransplantation1 combined with strict patient selection criteria has contributed to the absence of surgical failures.

However, viewing the complexity of such a procedure, the absence of complication is almost impossible. This case report illustrates this with 2 episodes of ischemia, leading to the development of a full-thickness skin necrosis of the allotranplant.

The burn injury of the left hand dorsum was probably related to prolonged contact with the ice during transportation. The microvascular lesions created during the first procedure were probably revealed by the ischemia secondary to a radial and ulnar thrombosis.

The depth of the burn injury did not allow us to cover the soft tissue loss by a skin graft. The use of artificial dermis for the initial dorsal hand coverage failed and led us to consider using a flap.

A homolateral locoregional flap was not possible, and given the vascular status of the allotransplantation, a free flap was deemed too high risk.

For all these reasons, a viable reconstruction with a pedicled groin flap was selected.

Described for the first time by McGregor2 in 1972, one of the major shortcomings of the groin flap is the thickness. In order not to impede the range of motion and therapy postoperatively, flap thickness has to remain limited.

For these reasons, flap elevation was performed under microscope magnification as described by Kimura and Saitoh3 in 2006 referring to the work by Acland4 in 1979 and Murakami et al5 in 1996.

The objective was to optimize the subdermal vascularization of the groin flap by conserving as many perforating vessels from the circumflex iliac artery as possible. Because of the operative microscope, the dissection was more precise and allowed the surgeon to keep the maximum of perforating vessels intact by the “worm-eating defatting” technique described by Kimura and Saitoh3 and Kimura et al.6

The thickness of the ultrathin groin flap was well comparable with the thin skin of the hand dorsum, particularly in the metacarpophalangeal region.7–10 There were no postoperative healing problems of the flap because of the reliability of the subdermal vascularization.

We have not found any reports of flap reconstruction for composite allotransplant in the literature. This case report is a meeting of 2 microsurgical evolutions: on one hand, composite allotransplantation and on the other, microsurgical debulking during flap elevation.

Back to Top | Article Outline

CONCLUSIONS

This case report has described the salvage of a composite hand allotransplant with a traditional flap. Technical refinements in microsurgery and knowledge of vascular anatomy have allowed optimization of the groin flap reliability and applications.

To our knowledge, this is the first case report describing the salvage of composite allotransplant using a pedicled groin flap.

Back to Top | Article Outline

PATIENT CONSENT

The patient provided written consent for the use of his image.

Back to Top | Article Outline

REFERENCES

1. Gazarian A, Abrahamyan DO, Petruzzo P, et al. [Hand allografts: experience from Lyon team]. Ann Chir Plast Esthet. 2007;52:424–435.
2. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25:3–16.
3. Kimura N, Saitoh M. Free microdissected thin groin flap design with an extended vascular pedicle. Plast Reconstr Surg. 2006;117:986–992.
4. Acland RD. The free iliac flap: a lateral modification of the free groin flap. Plast Reconstr Surg. 1979;64:30–36.
5. Murakami R, Fujii T, Itoh T, et al. Versatility of the thin groin flap. Microsurgery 1996;17:41–47.
6. Kimura N, Saitoh M, Hasumi T, et al. Clinical application and refinement of the microdissected thin groin flap transfer operation. J Plast Reconstr Aesthet Surg. 2009;62:1510–1516.
7. Taglialatela Scafati S, Lalinde Carrasco E. Microsurgically thinned groin flap for partial scrotal reconstruction. Brit J Plast Rec Surg. 2011;65:690–691.
8. Saint-Cyr M, Wong C. The split pedicle groin flap: new refinement in groin flap application and technique for combined thumb and dorsal hand defects. Plast Reconstr Surg. 2012;129:396e–397e.
9. Hsu WM, Chao WN, Yang C, et al. Evolution of the free groin flap: the superficial circumflex iliac artery perforator flap. Plast Reconstr Surg. 2007;119:1491–1498.
10. Koshima I, Nanba Y, Tsutsui T, et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg. 2004;113:233–240.

Supplemental Digital Content

Back to Top | Article Outline
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.