Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 33:
Secondary Reconstruction After Replantation
  One must assess the need for soft tissue cover and functional muscle restoration after successful replantation as one would view any complex injury. Unstable cover, contractures limiting function, and missing tissues and muscle groups must be replaced with like tissue. This can be accomplished occasionally with local tissue transfers and skin grafts, but the circumferential segmental nature of the replantation wound usually precludes this approach. Tissue carrying its own blood supply is needed to bridge the defect or replace missing parts. The advent of microsurgical transplantation has revolutionized the solution to these problems. Transplantation of reinnervated muscle to restore functional flexion or extension may allow a previously assisting hand to return to useful function.63 Soft tissue reconstruction can be considered at the same time as any or all of the procedures mentioned earlier. Simultaneous transplantation of multiple tissues 37 makes possible the global solution of complex problems allowing restoration of functional digits, bony skeleton and soft tissue coverage in one operative setting. The principles of multiple transplants are defined in the chapter on this subject. Tissue expansion is a new technique that has limited use in amputated parts, but a wider application in the proximal tissues. 63,64 For example, a replanted scalp may be secondarily expanded to allow excision of adjacent hairless, scarred areas. Skin-grafted compartment release wounds can be secondarily removed by expanding the adjacent tissues in preparation for functional muscle transplants to these deficient compartments. Though rewarding in the upper extremities, secondary wound complications following tissue expansion are frequent when these techniques are used in the lower extremities. 65

  The replacement of specialized tissues of the fingertips, palms, and soles can be a particularly rewarding microsurgical procedure. The tactile pulp of the thumb and or opposable digits can be restored with a microsurgical transplant of an island of similar tissue from the large toe as outlined in the section on neurovascular island transplants. The glabrous tissue of the palms and soles can be replaced with sensory neuritized muscle transplants that do not slip and slide like unstable skin flaps with subcutaneous fat creating shearing planes.

Little has been written about the secondary reconstruction of lower extremity replants, probably because of the lower incidence of replantable injury and the more stringent criteria used in selecting cases for replantation.66 Leg length, once thought to be a critical factor even in young individuals, may be less important now that the Ilizarov limb-lengthening technique is gaining recognition.67 The acceptance of a lower limb amputation is more common since prostheses are functional, particularly at the BK level. Pliable, minimally sensate tissue must, however, be present on the amputation stump and secondary revisions may require the transplantation of durable cover in the form of a microvascular skin flap or muscle transplant. 68

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