An Updated Surgical Approach of Using Flap and Cutaneous Nerve in the Lateral Arm to Reconstruct Complex Injuries of the Forearm and Hand

Abstract

Background Complex injuries involving the nerves and other soft tissues in the forearm and hand lead to functional and aesthetic defects. In such situations, multiple types of nerve autografts and flap donor sites are available. However, multiple donor sites cause donor morbidity in different locations and may lead to awkward operational positions. Therefore, based on the anatomical characterization, we aimed to modify the utilization of the lateral arm donor site for reconstruction, which restricts donor morbidity in the affected upper extremity. Methods We report a case series (N = 6) using a lateral arm flap (LAF) to reconstruct complex soft tissue defects in the forearm, palm, and finger. The posterior antebrachial cutaneous nerve (PACN) is the primary option for nerve bridging, whereas the LAF can carry the lower lateral brachial cutaneous nerve (LBCN) as a sensory flap. Once the PACN was insufficient, the LBCN was harvested simultaneously. All the cases included in this study were performed between January 2012 and August 2021. Demographic information, flap and nerve characteristics, complications, and hand function were analyzed. Results The LAF plus PACN or plus LBCN as nerve autograft, both successfully repaired 6 complex injuries: 2 cases in the forearm side, 1 in the hand palm, and 3 in the finger defects. Posterior antebrachial cutaneous nerve was the most used (8–15 cm), and LBCN plus PACN was used to bridge nerve defects when necessary (in total, 20 and 21 cm). The average follow-up time was 19.7 months. The disabilities of the arm, shoulder and hand score ranged between 6 and 12, and the mean 2-point discrimination values ranged between 6 and 12. The Semmes-Weinstein monofilament test result was under 5.46. In addition, 2 patients underwent a secondary debulking surgery. The average length of hospital stay was 10.4 days. Hematoma occurred in 2 cases, and all patients reported numbness in the donor nerve innervated areas. Conclusions This surgical refinement can reconstruct complex injuries in the forearm and hand. In addition, this approach restricts donor morbidity in the affected limb, comforts the operational position, and is achieved under brachial plexus anesthesia.