Use of Skin Substitute to Facilitate Tension-Free Closure Over the Vascular Pedicle and Selective Periphery in Upper Extremity Microvascular Reconstruction

Advances in microsurgery enable surgeons to extend the boundaries of limb salvage and to provide functional restoration of extremities through free tissue transfers. However, complication rates remain relatively high. This senior author implemented a novel technique to mitigate the thrombogenic potential of tight primary closure by using a skin substitute (SS) as coverage over the vascular pedicle and noncritical areas at the periphery of the flap. A retrospective review was conducted of patients who underwent upper-limb microsurgical reconstruction with tension-free SS closure. Between June 2024 and March 2026, 13 patients (14 cases) were included. Patient demographics, comorbidities, flap characteristics, and surgical outcomes were analyzed. Patients were monitored for at least 30 days. The mean age at the time of index operation was 36.3 ± 16.4 years. Trauma was the most common etiology (69.2%). There were no intraoperative complications. Within the first 30 days, two patients (14.2%) returned to the operating room. One case returned secondary to pedicle kinking, requiring a saphenous vein graft. The second case involved total flap loss due to arterial insufficiency and was reconstructed with a pedicled groin flap. A case of partial flap necrosis was managed nonoperatively. Nine cases (64.3%) underwent secondary procedures with an average time to secondary procedures of 143.5 days (±105.4). This is a unique application of SS aimed at decreasing the rate of flap loss or take-back secondary to vascular insufficiency in microsurgical cases. Utilization of SS is demonstrated to facilitate a safe, tension-free closure in upper extremity reconstruction.