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Page 6 of 14 Bolletta et al. Plast Aesthet Res 2019;6:22 I http://dx.doi.org/10.20517/2347-9264.2019.22

A B

C D

Figure 1. A: The 45-year-old woman was affected by arteriovenous malformation of the left hand. The index finger had been previously
amputated due to recurrent and excessive bleeding. Before surgery, the residual lesion was marked according to angiography study; B: the
arteriovenous malformation was excised, after delicate dissection, under the aid of tourniquet; C: the defect was covered with a thin SCIP
flap. It provided good coverage of the tendons and nerves. Postoperatively, the range of movement was satisfactory. This picture shows
complete extension of fingers; D: good dexterity of fingers was achieved with thin flap coverage. As shown, the patient can completely
flex the fingers and good sensation of the finger tips was preserved

free flap [83-85] . It can be used as a sensate flap, offering ideal tissue for medium-sized defects with low donor
[86]
site morbidity, therefore an excellent option for coverage of the heel or the forefoot . In reconstruction
of larger weight bearing areas free flaps are needed and the choice between muscle or fasciocutanous flaps
can be difficult. Fasciocutaneous flaps have the advantage of providing supple tissue that allows aesthetical
and, if innervated, sensate reconstruction. On the other hand, they present high shear modulus in the
subcutaneous tissue, therefore determining instability [87,88] . The same problem affects muscle flaps, but it
seems to reduce with progressive muscle fibrosis due to atrophy. Over time, also the appearance of skin grafted
[89]
[90]
muscle flaps improves. They may still, though, incur in ulceration due to lack of sensation . Fox et al.
in 2015 performed a systematic review in order to evaluate the outcomes of heel reconstruction with
fasciocutaneous or muscle free flaps. They analyzed outcomes in terms of complication rate, revision
surgeries, time to mobilization and requirement for specialized footwear. Their work reported no
significant differences between the two groups, even though they admit that “the current evidence is
largely limited to small cohort studies (level IV evidence)” .
[90]

BONE RECONSTRUCTION
In the upper extremity, bone defects greater than 6 cm, both resulting from oncological resections or
traumatic injuries usually require a vascularized bone transfer, especially if there is risk of infection.
The free fibula flap is ideal for reconstruction of the long bones of the arm, due to its characteristics and
shape [91-93] . Its harvest presents low donor site morbidity, mostly represented by flexion contracture of the
great toe and ankle pain [94-96] . The medial femoral condyle is a valuable option in smaller upper extremity
bone defects, in particular in the carpal region. This vascularized cancellous bone can be used to treat non-
union and avascular necrosis of the scaphoid [97,98] . Donor site morbidity is represented by knee pain and
seroma formation .
[99]