Abstract
The concept of three dimensional reconstruction not only aims to replace missing tissues, also seeks to restore histological continuity and vascular integration. This text wants to illustrate this showing some cases of complex bone defects in the hand, which requires structural replacement of lost tissue with integration of living anatomical components and tissue interfaces. This article describes two clinical cases of vascularized bone free flaps incorporating both, osseous and soft tissues and its histological transitions as peritenon and periosteum, in order to restore the three-dimensional anatomical structure and functionality of the hand. The first case, a 38 year old man who had a giant cell tumor in the middle phalanx of the fifth finger with loss of pulleys A4 and A5. Reconstruction was performed using a vascularized medial femoral condyle block of bone with periosteal extensions to replace the missing pulley. The second case, a 23 year old woman who suffered a bicycle fall resulting in a transverse fracture of the middle phalanx of the third finger, treated with plate and screws, which later of plate broke developed defects on the skin and extensor tendon. A composite flap based on the first and second dorsal metacarpal arteries was harvested, including skin, the Extensor Indicis Propius tendon, and vascularized second metacarpal bone. Postoperative follow-up demonstrated smooth movement of the tendon and a solid bone union in the first patient, while in the second patient, complete restoration of tendon function and bone consolidation was achieved; the donor site morbidity was minimal in both cases. Both of these outcomes support that complex free flaps allow the reconstruction of various tissue types at the same time, while also providing durable function and low donor site morbidity.