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Pomares G, Ledoux A, Duysens C, Jager T, Fouasson-Chailloux A. Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers. HAND SURGERY & REHABILITATION 2024; 43:101673. [PMID: 38432517 DOI: 10.1016/j.hansur.2024.101673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/05/2024]
Abstract
Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.
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Affiliation(s)
- Germain Pomares
- Institut Européen de la Main, Luxembourg, L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg
| | - Amandine Ledoux
- Institut Européen de la Main, Luxembourg, L-2540, Luxembourg
| | | | - Thomas Jager
- Institut Européen de la Main, Luxembourg, L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg
| | - Alban Fouasson-Chailloux
- Institut Européen de la Main, Luxembourg, L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg; Service de MPR Locomotrice et Respiratoire, Nantes Université, CHU Nantes, 44093 Nantes, France; Institut Régional de Médecine du Sport (IRMS), Hôpital St Jacques, 44093 Nantes, France.
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Shah A, Taupin P. Strategies for extremity reconstruction with exposed bones and tendons using acellular dermal matrices: concept of sequential vascularization. Case Reports Plast Surg Hand Surg 2022; 9:7-14. [PMID: 34993271 PMCID: PMC8725911 DOI: 10.1080/23320885.2021.2011289] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We report 3 cases of patients treated with Bilayer Wound Matrix over exposed structures. In all patients, dermal matrices revascularization occurred sequentially over the course of 6–12 weeks, leading to successful wound closure. Acellular dermal matrices allow more difficult areas with poor vascularity to be covered from the ‘inside-out’.
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Affiliation(s)
- Ajul Shah
- The Plastic Surgery Center, Institute for Advanced Reconstruction, Shrewsbury, NJ, USA
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Lee M, Lee YK, Kim DH. The clinical result of arterialized venous free flaps for the treatment of soft tissue defect of the fingers. Medicine (Baltimore) 2019; 98:e16017. [PMID: 31169744 PMCID: PMC6571264 DOI: 10.1097/md.0000000000016017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The purpose of this study is to report the clinical results of the arterialized venous free flaps in reconstructing soft tissue defects of the finger and to extend the indications for the use of the flaps based on clinical experiences of the authors.We retrospectively reviewed the records of 35 patients who underwent an arterialized venous free flaps for a finger reconstruction, between May 2007 and August 2015. The mean size of flap was 4.8 ± 1.23 × 3.1 ± 0.84 cm. The donor site was the ipsilateral volar aspect of the distal forearm in all cases. There were 17 (48.6%) cases of venous skin flaps, 9 (25.7%) cases of innervated venous flaps, 7 (20%) cases of tendocu taneous flaps, and 2 (5.7%) case of innervated tendocutaneous flap. The vascularity of recipient beds was good except 8 (22.9%) cases (partial devascularity in 3, more than 50% avascularity [bone cement] in 3, and chronic infected bed in 2).Of the 35 cases, 29 (82.9%) cases (including 3 cases who had more than 50% avascularity recipient bed) showed complete survival. 3 (8.6%) cases, which had partially devascularity of distal phalanx in recipient bed, showed partial necrosis (P = .015). The mean number of included veins was 2.4 ± 0.5 for a flap.A forearm arterialized venous free flap is a useful procedure for single-stage reconstructing of a soft tissue or combined defect of a finger, we consider that this technique could be applied to fingers despite an avascular or insufficient vascular recipient bed if the periphery of recipient bed vascularity was good and if the recipient beds were free from infection.
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Affiliation(s)
- Malrey Lee
- The Research Center for Advanced Image and Information Technology, School of Electronics & Information Engineering, Chonbuk National University
| | - Young-Keun Lee
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University – Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Chonbuk, Republic of Korea
| | - Dong-Hee Kim
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University – Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Chonbuk, Republic of Korea
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Systematic Review and Meta-Analysis of Unconventional Perfusion Flaps in Clinical Practice. Plast Reconstr Surg 2017; 138:459-479. [PMID: 27465169 DOI: 10.1097/prs.0000000000002390] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although unconventional perfusion flaps have been in clinical use since 1975, many surgeons are still deterred from using them, because of some reports of high necrosis rates. METHODS The authors performed a systematic review and meta-analysis of all articles written in English, French, German, Spanish, and Portuguese on the clinical use of unconventional perfusion flaps and indexed to PubMed from 1975 until July 15, 2015. RESULTS A total of 134 studies and 1445 patients were analyzed. The estimated survival rate of unconventional perfusion flaps was 89.5 percent (95 percent CI, 87.3 to 91.3 percent; p < 0.001). Ninety-two percent of unconventional perfusion flaps (95 percent CI, 89.9 to 93.7 percent; p < 0.001) presented complete or nearly complete survival. Most defects mandating unconventional perfusion flap reconstruction were caused by trauma (63.6 percent), especially of the hand and fingers (75.1 percent). The main complication of all types of flaps was a variable degree of necrosis (7.5 percent of all unconventional perfusion flaps presented marginal necrosis; 9.2 percent and 5.5 percent had significant and complete necrosis, respectively). There was a positive correlation between the rate of postoperative infection and the need for a new flap (Pearson coefficient, 0.405; p = 0.001). Flaps used to reconstruct the upper limb showed better survival than those transferred to the head and neck or to the lower limb (p < 0.001). CONCLUSION Unconventional perfusion flaps show high survival rates and should probably be used more liberally, particularly in the realm of upper limb reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Shores JT, Hiersche M, Gabriel A, Gupta S. Tendon coverage using an artificial skin substitute. J Plast Reconstr Aesthet Surg 2012; 65:1544-50. [PMID: 22721977 DOI: 10.1016/j.bjps.2012.05.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 03/27/2012] [Accepted: 05/26/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Soft tissue deficits associated with exposed tendon and absent paratenon pose difficult reconstructive problems due to tendon adhesions, poor range of motion, poor cosmesis, and donor site morbidity. Integra Bilayer Matrix Wound Dressing (Integra Lifesciences Corp Plainsboro, NJ) is a skin substitute widely used in reconstructive surgery, including the incidental coverage of tendons. However, Integra's post-operative functionality of the tendons has not been well documented. We report the results of using Integra for soft tissue reconstruction overlying tendons with loss of paratenon in upper and lower extremity soft tissue defects. METHODS Forty-two patients (35 men and 7 women) with exposed tendons due to trauma (37), cancer excision (2) or chronic wounds (3) were reconstructed using Integra. Results were compiled in a prospective manner, including age, gender, wound location, wound size, time to final closure, operative time, follow-up length, split-thickness skin graft percentage take and active post-operative range of motion. Likewise using Medline, a literature search of current surgical techniques for the treatment of exposed tendons and the results from the literature were compared with these study results. RESULTS All patients healed with an average split-thickness skin graft take rate of 92.5% ± 6.1 (range, 80-100%). The thirty-two patients not lost to follow-up achieved an average range of motion of 91.2% ± 6.5 (range, 80-100%). CONCLUSION Integra offers a convenient, efficient operative procedure with minimal morbidity, demonstrating good cosmesis and tendon function. Thus, Integra may offer an alternative option for immediate tendon coverage in both the upper and lower extremities.
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Affiliation(s)
- Jaimie T Shores
- Johns Hopkins University School of Medicine, Department of Plastic and Reconstructive Surgery, Baltimore, MD, USA
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Yan H, Zhang F, Akdemir O, Songcharoen S, Jones NI, Angel M, Brook D. Clinical applications of venous flaps in the reconstruction of hands and fingers. Arch Orthop Trauma Surg 2011; 131:65-74. [PMID: 20461524 DOI: 10.1007/s00402-010-1107-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Indexed: 11/28/2022]
Abstract
In recent years, the venous flap has been highly regarded in microsurgical and reconstructive surgeries, especially in the reconstruction of hand and digit injuries. It is easily designed and harvested with good quality. It is thin and pliable, without the need of sacrificing a major artery at the donor site, and has no limitation on the donor site. It can be transferred not only as a pure skin flap, but also as a composite flap including tendons and nerves as well as vein grafts. All these advantages make it an optimal candidate for hand and digit reconstruction when conventional flaps are limited or unavailable. In this article, we review its classifications and the selection of donor sites, update its clinical applications, and summarize its indications for all types of venous flaps in hand and digit reconstruction.
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Affiliation(s)
- Hede Yan
- Division of Plastic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
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The Shunt-Restricted Arterialized Venous Flap for Hand/Digit Reconstruction: Enhanced Perfusion, Decreased Congestion, and Improved Reliability. ACTA ACUST UNITED AC 2010; 69:399-404. [DOI: 10.1097/ta.0b013e3181bee6ad] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Yan H, Brooks D, Ladner R, Jackson WD, Gao W, Angel MF. Arterialized venous flaps: A review of the literature. Microsurgery 2010; 30:472-8. [DOI: 10.1002/micr.20769] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tadiparthi S, Akali A, Felberg L. The "open book" flap: a heterodigital cross-finger skin flap and adipofascial flap for coverage of a circumferential soft tissue defect of a digit. J Hand Surg Eur Vol 2009; 34:128-30. [PMID: 19129359 DOI: 10.1177/1753193408094441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A case of circumferential digital skin loss with exposed tendons from the proximal phalanx to the distal interphalangeal joint is presented. This was treated with a two-layer heterodigital cross-finger ("open book") flap from the adjacent digit, utilising a skin-only cross-finger flap to cover the palmar defect and an adipofascial flap to cover the dorsal defect.
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Affiliation(s)
- S Tadiparthi
- Department of Plastic and Reconstructive Surgery, Whiston Hospital, Prescot, Liverpool, UK.
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Kong BS, Kim YJ, Suh YS, Jawa A, Nazzal A, Lee SG. Finger soft tissue reconstruction using arterialized venous free flaps having 2 parallel veins. J Hand Surg Am 2008; 33:1802-6. [PMID: 19084182 DOI: 10.1016/j.jhsa.2008.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Revised: 07/24/2008] [Accepted: 08/01/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE Arterialized venous free flaps with a single straight venous axis may require redirection of either the efferent or afferent vein for anastomosis to the digital vessels. To simplify these flaps, the authors propose use of an arterialized venous free flap having 2 parallel veins that does not require redirection of the veins. METHODS The authors performed 44 arterialized venous free flaps having 2 parallel veins for the reconstruction of digital soft tissue defects. The mean area of coverage was 6.5 cm(2). The donor sites included the volar aspect of the distal forearm in 35 cases, the thenar area in 8 cases, and the dorsal aspect of the foot in 1 case. RESULTS Thirty-nine of the 44 flaps survived. Complete flap necrosis occurred in 5 cases, and flap congestion was seen in 28 cases. CONCLUSIONS The authors had satisfactory results using arterialized venous free flaps having 2 parallel veins. By using these flaps, the authors were able to simplify the technique of arterialized venous flaps. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Byeong Seon Kong
- Hand and Microsurgery Center, Busan Centum Hospital, Busan, Republic of Korea.
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Atzei A, Pignatti M, Udali G, Cugola L, Maranzano M. The distal lateral arm flap for resurfacing of extensive defects of the digits. Microsurgery 2007; 27:8-16. [PMID: 17205572 DOI: 10.1002/micr.20308] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The distal lateral arm flap (DLAF) was used to reconstruct six extensive defects of the digits: 2 degloving injuries of the thumb and 4 major skin losses of the fingers. Two adjacent fingers were involved in 1 patient. Flap size ranged from 3 x 7 cm to 9 x 14 cm. Four flaps were reinnervated using the posterior cutaneous nerve of the forearm. All flaps survived, though 1 showed marginal necrosis. Average follow-up was 53.4 months. Thumb opposition scored 5 according to Kapandji; finger ROM averaged 50.75%; pinch strength 72.5%. Protective sensation with touch localization was restored. Patient satisfaction for resurfaced digits averaged 8.9 on a 10-points visual analogic scale. All donor sites resulted in a painless scar with good patient satisfaction. The DLAF offers a thin, pliable skin ideal for digit reconstruction, with low rate of donor site morbidity and can be considered when toe-to-hand flap transfer is not advisable or refused by the patient.
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Affiliation(s)
- Andrea Atzei
- Hand Surgery Unit, Policlinico G.B. Rossi, Azienda Ospedaliera-Universitaria, Piazzale L.A. Scuro 10, 37100 Verona, Italy.
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Koch H, Scharnagl E, Schwarzl FX, Haas FM, Hubmer M, Moshammer HET. Clinical application of the retrograde arterialized venous flap. Microsurgery 2004; 24:118-24. [PMID: 15038016 DOI: 10.1002/micr.20011] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Retrograde arterialized venous flaps were applied to skin and soft-tissue defects in 13 patients with an average age of 34.4 years. Ten defects were located on the hand, and three on the lower leg. All flaps were harvested from the flexor aspect of the forearm; they ranged in size from 2 x 1 to 11 x 7 cm. There was venous congestion with superficial epidermolysis in six flaps, but not in the other seven. Partial skin necrosis in two of the lower-extremity flaps necessitated secondary skin grafts. Our results suggest that retrograde perfusion enhances blood flow in the periphery of arterialized venous flaps and gives good results in terms of flap survival, especially on the upper extremity.
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Affiliation(s)
- Horst Koch
- Division of Plastic Surgery, Department of Surgery, Karl-Franzens University Hospital, Graz, Austria.
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