Thoracoumbilical Flap: Anatomy, Technique, and Clinical Applications in Upper Limb Reconstruction in the Era of Microvascular Surgery

Abstract

Purpose: Microvascular reconstruction is the standard of care for salvage of soft tissue defects in complex upper extremity due to their distinct advantages over the pedicled flaps. However, in the era of microsurgery, pedicled flaps have an acceptable significant role for reconstruction of complex soft tissue defects. The authors aim to demonstrate the versatility of pedicled thoracoumbilical flap (TUF) in selected clinical scenarios.

Patients and methods: Retrospective analysis of patients who underwent TUF for upper limb posttraumatic reconstruction was performed between January 2016 and October 2017. The demographic details, etiology, wound parameters, clinical circumstances, and complications were recorded.

Results: Ten patients were included in the retrospective case series. Out of them, nine of the patients had critical issues, which justified a pedicled TUF over free flap. The critical issues were severe comorbid illnesses ( n = 3), the paucity of recipient vessels ( n = 1), salvage of hand replant and revascularization ( n = 2), circumferential degloving injury to the multiple fingers and palm ( n = 1), coverage for metacarpal hand ( n = 1), and extensive scarring at the surgical site ( n = 1). Mean age was 34.4 years (range: 11-70 years), six of them were males, and four were females. Two patients had infections resulting in wound gaping. One of the patients had flap tip necrosis.

Conclusion: Pedicled flaps have a significant acceptable role in this era of microsurgery, and a pedicled TUF is a versatile option for coverage of complex soft tissue defects of the forearm, wrist, hand, and fingers.

Level of evidence: This is a level IV, therapeutic, and retrospective study.

Keywords: paraumbilical flap; pedicled flap; thoracoumbilical flap; upper limb.

Fig. 1

Image ( A ) showing marking and vascular anatomy of TUF. DIEA, deep inferior epigastric artery; PUP, paraumbilical perforator; SIEA, superficial inferior epigastric artery. ( B ) Right lateral image showing the extent of the flap (dotted lines indicate anterior and midaxillary lines).

Fig. 2

Image showing ( A ) extensive left upper limb wound following fasciotomy and debridement for high-voltage electrical injury. Serial debridement and skin grafting and TUF were done. ( B ) Well-settled TUF over mid and distal forearm. ( C ) Donor site hypertrophic scar.

Fig. 3

Image showing ( A ) nonhealing fasciotomy wound exposing radius in the left forearm. ( B ) Harvested ipsilateral TUF (dotted line indicates the axis of the flap). ( C ) Undersurface of the flap and closed donor site. ( D ) Inset of the flap (long bridge segment comfort in patient positioning).

Fig. 4

Image showing ( A ) extruded ulna in the middle one-third of right forearm with adjacent scarred and contracted wound following skin grafting. ( B ) X-ray showing both bone fracture with nonunion. ( C ) Wound dehiscence following TUF due to infection. ( D ) Well-settled flap following debridement and reinset.

Fig. 5

Image showing ( A ) total amputation of the right hand at the level of the wrist. ( B ) Dorsal skin necrosis following successful replantation. ( C ) In situ TUF for coverage of the wound following debridement. ( D ) Stable soft tissue cover.

Fig. 6

Image showing ( A ) soft tissue defect and exposed flexor tendons following unsuccessful revascularization of the ring finger. ( B ) TUF in situ. ( C ) Stable soft tissue cover in the follow-up period. ( D ) Acceptable donor site scar.

Fig. 7

Image showing ( A ) folded TUF for coverage of circumferential degloving injury of palm and all finger; gangrenous distal portion of the flap was debrided and covered with random abdominal flap. ( B ) Stable soft tissue cover over the dorsal surface. ( C ) Well-settled abdominal flap on the volar surface.