Jurnalul de Chirurgie
 Jurnalul de chirurgie
Aparitie trimestriala in a doua luna a trimestrului
Published quarterly in the second month of the quarter
ISSN: 1584 - 9341 Vol.10 Nr.3 - Iulie-Septembrie 2014 | sâmbătă, 15 august 2020
ISSN: 1584 - 9341 Vol.10 No.3 - July-September 2014
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D. Pieptu, N. Ghetu, Oana Grosu, Sidonia Susanu
Department of Plastic and Reconstructive Surgery,
“Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
Jurnalul de chirurgie 2010; 6 (4): 562-566
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Hand and upper limb traumatic injuries are common presenting pathology in the emergency department. Extensive trauma patients approach is standardized and internationally accepted guidelines are followed. The care for the traumatic injury is secondary to the patient’s general status stabilization. After debridement, lesions inventory is made and priority is established according to their gravity. Flap surgery is a ubiquitous strategy in soft tissue reconstruction. Extensive soft tissue defects, especially over exposed bones, joints, vessels and nerves, need immediate coverage with well-vascularized tissues. Besides the obvious reason for saving critical anatomical structure, is the only way to maximize the chances for functional recovery. One-stage reconstruction, even for complex defects, is possible due to flaps versatility. Composite tissue transfer, including two three or more types of tissues, can successfully address combined bone, muscle, vessels, nerves or skin loss. The best example is the subscapular system, which offers no less than 5 different tissues and wide combinations of flaps. Even if the procedure per se involves large human, technical and financial resources, on a long term it was proved to be cost-effective, in reducing number of operations, hospital stay and rehabilitation time. Muscle flaps share first place in soft tissue reconstruction with the fasciocutaneous flaps. Yet, in functional reconstruction or in combined defects in need for composite flaps, nothing can beat the muscle flaps. In our hands, muscles flaps and the omentum are the workhorse for soft tissue and/or combined defects reconstruction. Pedicled latissimus dorsi can cover tissue defects from shoulder down to the elbow, but also reconstruct the function of shoulder muscles or totally or partially biceps or triceps loss, with minimal or no donor-site functional deficit. Whenever defects are more distal, free flap transfers are needed for optimal reconstruction provided adequate vessels are present or previously reconstructed. Microsurgery is more than a technique for vessels anastomosis. Is a strategy, a choice from many decision-making algorithms available, with different success rate, taking into account all factors, the patient, the problem, expected result, back-up solutions, surgeon, etc. Distant soft tissues as rectus abdominis muscle or the omentum are ideal for complex or deep defects, due to their plasticity. The well-vascularized tissues, filling the dead spaces, provide effective anti-microbial resistance and improve surrounding tissue viability. Omentum wrapped around the tendons can provide the gliding surface, promoting forearm muscles function.
Microsurgical reconstruction is a challenge due to technical constraint and amount of resources involved. Difficult enough, flap surgery is not only the best treatment for complex upper limb defects; it is also the last line treatment. When it fails, the life boat is another flap surgery. There is no down staging after flap surgery, if maximal functional reconstruction is the goal. Flap surgery is rewarding whenever the patient is restored to optimal life quality. Patients’ satisfaction is the best evaluation tool for surgeons work. The other side of the coin shows the tradeoffs. The donor-site morbidity is rightfully an important part in the overall results. Endoscopic-assisted flap harvesting improves the donor-site outcome, but also reflects in patients postoperative increased comfort, and shorter hospitalization. Flap surgery and endoscopic techniques have similar outcome regarding patients’ functional outcome, rehabilitation, comfort and hospitalization. When combined, the positive effects will add-up, to patients benefit.


Correspondence to: Associate Professor Dragos Pieptu, MD, PhD, Department of Plastic and Reconstructive Surgery, “St John”, Emergency Hospital, e-mail:

: Creative Commons License
Jurnalul de chirurgie [Journal of Surgery] by Editorial Board, Department of Surgery University of Medicine and Pharmacy Iasi, E. Tarcoveanu, R. Moldovanu is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
Based on a work at www.jurnaluldechirurgie.ro.