HAND/PERIPHERAL NERVE Free Vascularized Tissue Transfer to Preserve Upper Extremity Amputation Levels Alessio Baccarani, M.D. Keith E. Follmar, M.D. Giorgio De Santis, M.D. Roberto Adani, M.D. Massimo Pinelli, M.D. Marco Innocenti, M.D. Steffen Baumeister, M.D. Henning von Gregory, M.D. Gu ¨nter Germann, M.D., Ph.D. Detlev Erdmann, M.D., Ph.D., M.H.S. L. Scott Levin, M.D. Durham, N.C.; Modena and Florence, Italy; and Heidelberg, Germany Background: Free vascularized tissue transfer to preserve upper extremity am- putation level is an uncommon procedure. The authors investigate the role of free tissue transfer in preserving both morphology and function of the ampu- tated upper extremity, with the goal of facilitating prosthetic rehabilitation. Methods: Thirteen patients who underwent microsurgical free tissue transfer to preserve upper extremity amputation level were reviewed retrospectively. These cases were selected from four centers: Duke University Medical Center (Durham, N.C.) University Hospital of Modena (Modena, Italy), Careggi Uni- versity Hospital (Florence, Italy), and the University of Heidelberg (Heidelberg, Germany). Parameters that were evaluated included age, sex, cause of the defect, reconstructive procedure, structures to be salvaged, and functional outcome, among others. Results: The cause of amputation was trauma in 92 percent of patients. Mean age was 32 years. In 31 percent of the cases, an emergency free fillet flap was used, and in the remaining 69 percent, a traditional free flap was performed. Struc- tures/function to be preserved included pinch function to the hand, function of the elbow and shoulder joints, and skeletal length greater than 7 cm. Com- plications occurred in 38 percent of the cases, but the final goal of the procedure was achieved in all cases. A treatment algorithm for the management of the amputated upper extremity is presented. Conclusion: Use of free vascularized tissue transfer for preservation of upper extremity amputation level in well-selected cases facilitates prosthetic rehabilitation and improves residual limb function. (Plast. Reconstr. Surg. 120: 971, 2007.) U pper extremity defects resulting from trauma and oncologic resections often re- quire sophisticated reconstructive strate- gies. Total limb salvage is always the primary goal to be pursued. In those circumstances in which amputation is unavoidable, every effort should be made to provide the patient with the most functional residual limb, given the patient’s pre- reconstruction status. This usually means preser- vation of skeletal length and, when possible, sal- vage of a critical joint. The decision-making process can be challenging in these patients, especially in acute trauma situations. Decisions related to hemodynamic stability, indication for surgery, timing of surgery, and the operative plan must be made. If a traditional free flap is chosen to preserve part of the injured extremity, donor-site morbidity must be carefully weighed against the benefit the patient is to derive from preserving the amputation level. The “spare part” concept has become well- accepted for both the emergency and the elec- tive surgical treatment of oncologic resections 1 and of massive traumatic injuries to the limbs. 2–7 The rotation-transposition and the less frequent microsurgical transfer of tissue from a nonre- plantable amputated segment to cover an in- jured extremity (fillet flap) represent well- established technical resources. 8 Those so-called salvage replantations have been frequently reported in the lower extremity for knee preservation 9,10 but less frequently for the upper extremity. 11 The obvious benefit in From the Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Duke University Medical Center; Division of Plastic and Reconstructive Surgery, University of Modena and Reggio Emilia; Division of Reconstructive Microsurgery, Careggi University Hospital; and Department of Plastic, Reconstructive, and Hand Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg. Received for publication April 25, 2006; accepted July 7, 2006. Copyright ©2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000256479.54755.f6 www.PRSJournal.com 971