Free Skin Anterolateral Thigh Flap and Vacuum-Assisted Closure Therapy for Reconstruction of Snakebite-Induced Complex Hand Defects.

Introduction: Cobra (Naja species) envenomation in tropical regions like Vietnam frequently leads to severe hand tissue necrosis, creating complex defects that challenge conventional reconstruction. This study evaluates a staged approach combining vacuum-assisted closure (VAC) therapy with free anterolateral thigh (ALT) flap for these challenging injuries. Methods: Eleven patients with extensive hand defects involving skin and/or tendon due to cobra envenomation were included. Following surgical debridement, VAC therapy was applied to prepare the wound bed. Subsequently, definitive reconstruction was performed using tailored ALT flaps, which included fasciocutaneous or thinned configurations depending on defect complexity. Postoperative evaluation included flap viability, range of motion (ROM), and complication assessment. Results: The mean duration of VAC therapy was 11.5 ± 4.2 days. Eleven ALT flaps with an average dimension of 14.5×7.0 cm were harvested. Flap thinning was performed in eight cases (72.7%), achieving a mean final thickness of 4.6 ± 1.3 mm. Eight flaps (72.7%) were used to cover defects spanning both digital and dorsal or palmar subunits. Over a mean follow-up of 15.3 months, patients with digital reconstruction achieved a functional ROM at the metacarpophalangeal joint, with 0° of extension and up to 60° of flexion. The main issue was flap bulkiness; no donor-site morbidity was observed. Conclusion: A staged approach combining VAC therapy for wound bed preparation and subsequent reconstruction with a free ALT flap is a safe and effective strategy for managing complex hand defects resulting from cobra bites. This method facilitates optimal wound conditions and provides versatile, well-vascularized tissue coverage, thereby promoting functional hand recovery.