The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger

Fingertip injuries and their reconstruction, focusing on nails

The fingertip is a complex anatomical structure that is frequently injured, especially in manual workers. Different classifications have been reported, considering injury orientation, level and geometry. To optimize treatment planning, the area of soft-tissue defect should be considered. Treatment aims to conserve as long a finger as possible, restore sensation (S3 + or more) and ensure a pleasant esthetic appearance. When amputation occurs, the best treatment is replantation when conditions allow. When this is not possible, the fingertip should be used as a composite graft or the nail complex can be grafted and soft tissue reconstructed, according to the preferred method. In defect without amputation or if the distal part of the finger is not present or not useful, many reconstructive techniques have been described. Depending on the injury, patient characteristics and requirements and the surgeon's skills and experience, the treatments vary from secondary healing to free flaps. In this paper, the various treatment options are described and discussed. Nowadays, considering most variables, the best treatment in fingertip injury is secondary healing with occlusive or non-occlusive dressing, even in case of bone exposure. This simple solution is able to restore a nearly normal fingertip with good sensation without further injuring the hand.

Reconstruction of Soft-Tissue Defects of the Thumb Using Reverse-Flow Homodigital Flaps: A Systematic Review

Introduction

Soft-tissue thumb defects are common reconstructive challenges, the main goals being restoration of tactile sensibility, range of movement, pulp padding, length, and cosmesis. The reverse-flow dorsoulnar and dorsoradial collateral artery flaps are homodigital flaps used to cover both distal dorsal and volar thumb defects. These flaps can be used as compound flaps including skin, fat, and/or nerves. As there is no critical analysis of these studies, this study aims to create a synthesized comprehensive systematic review.

Methods

Systematic review was performed using the databases PubMed, Embase, and Medline. Eligible studies followed the inclusion criteria: English language and all studies published to date. The primary outcome was flap survival. Other data collected included anatomical area of the defect, flap constituents and dimensions, donor-site closure and complications, transfer method, reoperation, revision, and functional outcomes.

Results

A total of 19 articles incorporating 189 flaps met the inclusion criteria. These flaps were categorized and analyzed as dorsoradial (50%), dorsoulnar (39%), and turnover flaps (11%). Dorsoradial flaps were used in fasciocutaneous fashion alone. Partial flap failures occurred in five cases. Dorsoulnar flaps were used as fasciocutaneous or as osteocutaneous flaps. Complete flap failure was reported in one patient alone, whereas partial necrosis was reported in four patients. Adipofascial turnover flaps had two partial flap failures reported but no complete failures. The overall complete and partial flap failure rates were 0.5 and 6.5%, respectively.

Conclusion

Reverse-flow homodigital random or axial-based flaps provide a reliable means of reconstruction for soft-tissue defects with reasonable success rate and good functional outcomes. They have a consistent anatomy with a good potential for personalization and therefore increased versatility.

Reversed distal laterodigital adipofascial flap for nail-bed reconstruction

BACKGROUND

Lesions of the distal phalanges of the fingers frequently involve the nail bed. There are few therapeutic options for nail-bed reconstruction and they often lead to painful scars and onychodystrophy. We present our experience with the distal adipofascial laterodigital reverse flap.

METHODS

Fifteen patients (average age 46.33 years, range 28-73) with tumors or traumatic injuries (crush injuries, nail avulsion, and partial fingertip amputations) of the nail bed, underwent digital reconstruction through the distal adipofascial laterodigital reverse flap from June 2018 to August 2019. The size of the fingertip defect covered with the flap was ranged between 1.1 × 1.1 and 1.6 × 1.2 cm (average size 1.4 × 1.2 cm). The flap was harvested enrolling subcutaneous tissue from the lateral aspect of the middle and distal phalanx from the less damaged side.

RESULTS

The average size of the harvested flaps was 1.3 × 1.2 cm (range 1.1 × 1.0 to 1.4 × 1.1 cm). All adipofascial flaps survived entirely and the nail bed healed in all patients, with an average healing time of 21 days and a subsequent regrowth of the nail. The follow up ranged from 6 to 12 months, with a mean of 7 months.

CONCLUSIONS

The distal reverse adipofascial flap provides a very versatile and reliable coverage of the distal finger and its nail bed. It is a rapid and reproducible surgical procedure with poor morbidity for the donor site.

LEVEL OF EVIDENCE

IV.

Concepts in soft-tissue reconstruction of the contracted hand and upper extremity after burn injury

Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints.

The Bridged Digital Artery Perforator Flap as an Alternative Reconstructive Option for Dorsal Digital or Toe Soft Tissue Defects

BACKGROUND

Dorsal digital soft tissue defects are considered among the most challenging to reconstruct. Numerous treatment options are proposed, including advancement flaps, antegrade, retrograde flow flaps, adipofascial flaps, and digital artery perforator flaps. However, the optimal treatment remains controversial. The concept of the "bridge principle," consisting of the indirect transfer of the flap to the defect area through a muscular bridge, has recently introduced by authors for medial canthal reconstruction. The aim of the study was to examine the feasibility of its application in digital reconstruction for dorsal defects and the development of a new flap. The utilization of the dorsal subcutaneous adipofascial digital or toe tissue as a "bridge" led to description and development of bridged digital artery perforator flaps as an alternative treatment of such defects.

METHODS

From November 2017 to September 2019, a series of 14 patients (mean age of 57.1 years) suffered from dorsal digital or toe soft tissue defects of different dimensions and sustained reconstruction with this new technique.

RESULTS

Twelve digits and 2 toes have been concerned. The mean size of the defects was 1.3 × 1.1 cm. All flaps survived without a sign of venous congestion. No functional digital or toe problems were observed during the follow-up period (mean of 11.6 months). Minor wound dehiscence presented in 2 cases (2 of 14 [14.3%]) and a transient skin swelling around the flap in 1.

CONCLUSIONS

A new concept was introduced to resolve a challenging problem. Initial outcomes are very encouraging. These flaps could be a valuable and reliable reconstructive option.

Multi-dorsal metacarpal artery perforator adipofascial turnover flap for index to little finger reconstruction: Anatomical study and clinical application

Reconstruction of the dorsum of the hand and fingers is one of the main challenges in hand surgery. Regional flaps from the forearm, free flaps, or pocket procedures are options when multiple digits are injured with tendon damage and bone exposure. These procedures can be technically demanding and are often plagued by a texture mismatch. We conducted an anatomical study of 20 fresh frozen hands. The second, third and fourth intermetacarpal spaces were analyzed with the aim of defining the vascular foundation of dorsal hand adipofascial-turnover flaps based on dorsal metacarpal artery (DMA) perforators, analyzing their potential for reconstruction procedures on the dorsum of the hand. In three cases, the 4th intermetacarpal space lacked the DMA. A mean of 3.5 arterial communications were found between the DMA and palmar arterial system. Each hand had 11 ± 2 dorsal skin perforators, which were equally distributed among different intermetacarpal spaces. At least one perforator was present in each one-third of the space. The most distal perforators were the largest in all spaces but missing in two hands. A clinical case of multiple index finger to little finger reconstruction with this new multi-dorsal metacarpal artery perforator (mDMAP) adipofascial turnover flap is presented. Our anatomical study confirmed previous descriptions of the anatomy of the dorsum of the hand. It supports the safety of the mDMAP adipofascial turnover flap based on all distal arterial perforator for the simultaneous reconstruction of index to little finger injuries. Similarly, adipofascial turnover flaps can be raised from more proximal perforators arising from DMAs if more than one intermetacarpal space is included.

Evolution and refinements of a dorsal adipofascial digital artery perforator flap

BACKGROUND

Soft tissue defects to the dorsum of fingers are quite demanding for the reconstructive surgeon especially in the cases that bone and extensor tendons are exposed. The purpose of our study was to describe a new adipofascial island flap by a single dorsal digital perforator (dorsal adipofascial digital artery perforator, DADAP).

MATERIALS

Methods: In 8 patients (7 male, 1 female), 12 soft tissue defects to the dorsum of the fingers (3 index, 6 middle, 2 ring, 1 little finger), ranging from 1 × 2 cm to 2 × 4 cm, were reconstructed using the DADAP flap.

RESULTS

The flaps sizes ranged from 2.5 × 1.5 cm to 8 × 3 cm. The defects were covered in 9 cases by a propeller-rotation type flap and in 3 by a turn-over flap. In 4 cases a tendon graft was used to cover the tendon defect and in 3 cases an open joint was reconstructed. In all cases a splint thickness skin graft (SSG) covered the flaps. Mean follow-up was 18 months. One patient developed distal tip flap necrosis and was treated conservatively. Delayed wound healing with partial SSG failure due to haematoma was observed in 3 fingers, but the underlying flap was viable and complete healing was achieved by secondary intention.

CONCLUSIONS

The use of DADAP flap is a fast, safe and reliable solution to cover the defects of the dorsum of fingers and can be performed under local anaesthesia as a day surgery.

Adipofascial, Transposition, and Rotation Flaps

Soft tissue loss over the dorsum of the finger could potentially expose critical structures like extensor tendon, bone, and joint. These exposed structures often require flap coverage. Local flap is one of the available options to cover most small-sized defects on the dorsum of fingers. One of the primary requisites for any flap used on the dorsum of the finger, especially over a joint, is to enable the full range of motion of the finger. Even though skin over the dorsum of the fingers can be pinched easily in extension, with full flexion such suppleness is not demonstrated.

A Review and Meta-analysis of Adverse Events Related to Local Flap Reconstruction for Digital Soft Tissue Defects

We reviewed the current literature to estimate incidence rates for adverse events with pedicled flaps in the hand. We identified 241 different studies reporting adverse events for 6693 flaps. The average incidence rate was 5.4% and total or partial loss of flap constituted 65% of all reported complications. Flaps with reverse or perforator-based flow may be more prone to vascular complications compared with flaps with antegrade flow or skin pedicle. The incidence rates were acceptable in all flaps (1%-10%) and thus the flap can be chosen primarily based on considerations other than risk of adverse events.

A New Technique in Tamai Zone 1 Reconstruction: Reverse Dorsal Terminal Vein Flap (Hat Flap)

Introduction The aim of this study was to determine usability of the reverse dorsal terminal vein flap (hat flap) in the reconstruction of Tamai zone 1 defects. Materials and Methods A total of 31 patients with fingertip amputation in Tamai zone 1 defect in the finger operated upon between 2014 and 2016 were included in this study. Flaps were designed from the proximal end of the nail bed to the middle phalanx according to the defect size. After passing through the skin, the proximal parts of the dorsal vein and branches were knotted. The flap was harvested by preserving the paratenon and dorsal digital terminal vein. Then, the flap was rotated and the defect was closed. Results A total of 32 patients were included in this study. The average size of the defects was 2 × 2.2 cm. Loss of epidermis in five patients and partial flap loss in two patients were observed (7/32, 21.8%), but total flap loss was not observed in any patient. Conclusion The reverse flow terminal dorsal vein-based pedicle flaps can be used as a viable surgical technique in the reconstruction of Tamai zone 1 amputations. Level of Evidence This is a Level IV study.

Gliding Tissue Reconstruction Using a Dorsal Digital Adipofascial Flap in Complex Extensor Injury

BACKGROUND

Postoperative scar adhesions between tendons and phalanx bones cause persistent disability in complex injuries involving tendons and bones of the hand. Although gliding tissue reconstruction is effective in preventing peritendinous adhesion formation and a dorsal digital adipofascial flap is a reliable method to prevent scar adhesion between tendon and bone after extensor tendon repair, no comparative clinical reports exist. This study aimed to determine the usefulness of a gliding tissue reconstruction method by comparing postoperative range of motion between patients who underwent gliding tissue reconstruction and those who did not.

METHODS

Medical records of patients with complex extensor tendon injury who underwent extensor repair between April 2005 and March 2018 were retrospectively analyzed. Ten patients underwent extensor repair with gliding tissue reconstruction using a dorsal digital adipofascial flap and 13 underwent only extensor repair. A triangular flap was separated after zig-zag incision to expose the injured extensor tendon into dermal and adipofascial flaps. The adipofascial flap, based on a dorsal branch of the digital artery, was placed on the injured bone as the tendon gliding surface. The same extensor tendon suture method and rehabilitation protocol were used in both groups. All patients were followed up for 6 to 12 months.

RESULTS

The mean ± SD % total active movements were 84.1% ± 12.4% and 57.6% ± 13.0% in the groups with and without gliding tissue reconstruction, respectively. Significant differences were found between the 2 groups (P < 0.05).

CONCLUSIONS

Patients with gliding tissue reconstruction had better functional recovery. This reconstruction is recommended to restore the extensor function in cases of complex extensor injury involving finger tendons and bones.

Modified single pedicle reverse adipofascial flap for fingertip reconstruction

BACKGROUND

Homodigital adipofascial flap is a well-established method for treating a distal fingertip defect; nonetheless, its use has some limitations. Reconstruction of fingertip injuries, with radial or ulnar tissue loss, may lead to some difficulties in providing an adequate bone coverage. The standard bipedicled technique did not allow the flap to cover the bone exposure without excessive tension. In our series, the reverse adipofascial flap had a single pedicle. The modified technique, because of its improved degree of rotation, granted the flap to reach either radial or ulnar tissue losses.

PATIENTS AND METHODS

We treated 15 fingertip amputations distal to the lunula (9 Allen's type II and 6 type III), the mean size of defects was 2.7 cm² (range, 1.8-3.2 cm² ), the mean age of patients was 44 years (range, 22-63 years). Quick Disabilities of the Arm, Shoulder, and Hand score and Visual Analogue Scale were evaluated along with a 2-point discrimination test; the aesthetic satisfaction of the patients was estimated subjectively using a 5-point Likert scale.

RESULTS

Mean flap size was 3.6 cm² (range, 2.5-4.2 cm² ), primary flap survival was observed in 14 out of 15 cases, partial flap necrosis was observed in 1 case, the nail grew in all fingers in about 6 months. Mean proximal and distal interphalangeal joint motion was 89° (range, 80°-100°) and 71° (range, 65°-80°), respectively. No complications were observed at the donor site. The median static 2-point discrimination was 4.5 mm (range, 3-8 mm), the mean quick DASH score was 2.6 (range, 0-9.1). All patients returned to work within a mean of 4.4 weeks (range, 4-5 weeks). The follow-up was 12 months.

CONCLUSIONS

Single pedicle reverse adipofascial flap is an effective technique. This modified procedure allows a wider degree of flap rotation; it represents the ultimate arrow in our bow to address some particular defect geometry.

Is the adipofascial flap the key to regenerative surgery?

Objectives

"Form and function restoration" is the ultimate goal of reconstructive surgery, which is oriented toward regeneration rather than reparation. Recently, research in reconstructive surgery has focused on the regenerative potential of the adipose tissue. The aim of the study is to illustrate the surgical methods and show the functional and aesthetic results achieved by the reconstruction of finger soft-tissue defects using homodigital dorsal adipofascial reverse flap (HDARF).

Materials and methods

A total of 63 cases (45 acute and 18 elective) were included between September 2010 and August 2016. In each case, we preliminarily performed surgical debridement and then harvested an adipofascial flap from the back of the finger. Nine injured thumbs that were repaired with the flap as emergency cases were also included. The average age of the patients was 46 (range: 4-69) years.

Results

All flaps survived without any complications during the 24-month follow-up. Good nail regrowth through the flap and full regeneration were observed in approximately all cases. Sensitivity tests and histological analysis of biopsy samples of the regenerated fingers confirmed full regeneration of the epidermis, dermis, cutaneous adnexa, and nerves. All the patients were satisfied with the hand functionality and aesthetic appearance.

Conclusion

The HDARF represents a very useful alternative for the reconstruction of nailbed crushes, achieving regeneration of injured segments in deformities caused by trauma or infection.

Treatment of Hand Allodynia Resulting from Wrist Cutting with Radial and Ulnar Artery Perforator Adipofascial Flaps

In this article, we report two cases in which recurrent adhesive hand neuropathy with allodynia were successfully treated with radial and ulnar artery adipofascial perforator flap coverage. Treatment of recurrent neuropathy, such as recurrent carpal tunnel syndrome and re-adhesion after neurolysis using free and pedicle flaps to cover the nerves, has been reported to show good results. However, for severe painful nerve disorders, such as complex regional pain syndrome, the efficacy of this treatment was unclear. We present two cases diagnosed with recurrent adhesive hand neuropathy with allodynia, resulting from wrist cutting; these cases were treated with neurolysis and flap coverage with good results and no recurrence. This suggests that neurolysis and flap coverage are effective methods for treating complex regional pain syndrome.

Fenestrated Adipofascial Reverse Flap: A Modified Technique for the Reconstruction of Fingertip Amputations

AIMS OF THE STUDY

Fingertip injuries can be treated in different ways, including shortening with primary closure, skin graft, and local or distant flaps. Several local flaps for the reconstruction of the amputated fingertip were described. We present our experience with a new concept of homodigital adipofascial reverse flap that avoids the second surgical stage and allows a complete and anatomically perfect reconstruction of nail bed, with preservation of the nail lamina.

MATERIALS AND METHODS

Between March 2014 and February 2015, five patients with digital amputations (distally to the nail matrix) were treated using the Fenestrated Adipofascial Reverse (F.A.R.) flap. The patients were evaluated measuring 2-point discrimination (2PD) value and range of motion of the distal interphalangeal joint (DIP). Scar evaluation was performed using the Vancouver Scar Scale (VSS).

RESULTS

All the flaps completely survived. A normal nail grow has been observed in first two-three months of post operatory follow-up. Length of the digits was preserved and good aesthetic as functional outcome were archive. The F.A.R. flap provided excellent coverage of fingertip defects and preserved finger length. After 1 year of follow, the mean static 2PD value at the reconstructed finger was 4.2 mm (range 3-5 mm), reconstructed fingers' mean range of motion for the DIP joint was 78 degrees and the VSS score ranged from 0 to 2 (mean score: 0.6). No complications were reported.

CONCLUSIONS

F.A.R. flap is one of the most useful techniques in order to achieve all the goals in fingertip reconstruction.

A Systematic Review of Outcomes and Complications of Primary Fingertip Reconstruction Using Reverse-Flow Homodigital Island Flaps

BACKGROUND

Fingertip reconstruction using reverse-flow homodigital island flaps has been very popular over the years. However, the outcomes of reconstruction have not been clearly understood. In these circumstances, a systematic review of available literature is warranted.

OBJECTIVE

To assess the outcomes and complications of fingertip reconstruction using reverse-flow homodigital island flaps. To justify the usage of reverse-flow homodigital island flaps for fingertip reconstruction.

SEARCH METHODS

A PubMed [MEDLINE] electronic database was searched (1985 to 15 April 2015).

SELECTION/ELIGIBILITY CRITERIA

Retrospective case series that met the following criteria were included: (1) Study reported primary data; (2) Study included at least five cases of fingertip defects treated using reverse-flow homodigital island flaps; (3) Study reported outcomes and complications of fingertip reconstruction, either primary or delayed, using reverse-flow homodigital island flaps; (4) The study presented at least one of the following functional outcomes: Static two-point discrimination, return-to-work time, range of motion of distal interphalangeal joints; (5) The study presented at least one complication.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed search results, and two other review authors analyzed the data and resolved disagreements. The following endpoints were analyzed: survival rate of the flap, sensibility, and functional outcomes and complications.

MAIN RESULT

Eight studies were included in this review. The included studies were published between 1995 and 2014, and a total of 207 patients with 230 fingertip defects were reported. The overall survival rate of the flap was 98 % (including partial survival). The mean static two-point discrimination (2PD) was 7.2 mm. The average range of motion of the DIP joint was 63°. The average return-to-work time was 7 weeks after injury. On average, 2 % of the patient had complete flap necrosis, 5 % had partial flap necrosis, 4 % developed venous congestion, 4 % developed flexion contracture, and 12 % experienced mild-to-moderate cold intolerance.

AUTHORS' CONCLUSIONS

Survival of reconstructed fingertips (98 %) is better with reverse-flow homodigital island flaps than fingertip replantation (86 %). The sensibility outcome using sensate flaps (mean s2PD = 7.2 mm) is similar to the sensibility outcome following replantation (mean s2PD = 7 mm). The common complications include cold intolerance, venous congestion, and flexion contracture. Therefore, reverse-flow homodigital island flaps may not be the ideal choice but are a very reliable alternative for fingertip reconstruction.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Flap or graft: The best of both in nasal ala reconstruction

The area of the nose immediately medial to the nasofacial groove is a common site for relatively small but penetrating basal cell carcinomas (BCCs). Although larger lesions may necessitate formal subunit reconstruction, smaller lesions pose a considerable dilemma. Full-thickness skin grafts (FTSGs) often result in an unsightly contour defect. Local flap options exist, but they frequently violate subunit boundaries or anatomical landmarks. In particular, the single-stage nasolabial transposition flap is particularly prone to blunting of the nasofacial angle and fullness or pin-cushioning of the flap with concomitant loss of facial symmetry.

METHOD

We present a consecutive case series of 21 patients with lesions at this site who underwent reconstruction with a combination of a subcutaneous flap from the adjacent cheek fat, which is then resurfaced with an overlying FTSG.

RESULTS

A range of defects of dimensions up to 17 mm diameter were included in the series. There were no instances of haematoma, post-operative infection or graft failure. A single patient, who smoked 30 cigarettes daily, underwent a complex reconstruction combining a cartilage graft with a fat flap and a skin graft. He experienced some epidermal loss that healed without intervention, with a remarkable outcome. The results show this to be a reliable and reproducible method that delivers excellent restoration of the contour without disrupting the symmetry of the nasofacial sulcus.

CONCLUSION

Augmenting a skin graft with a subcutaneous fat transposition flap is a simple technique that is quick to learn and straightforward to execute. Excellent outcomes were consistently obtained without the asymmetry and pin-cushioning often associated with local flaps at this site.

Full-thickness skin grafting with de-epithelization of the wound margin for finger defects with bone or tendon exposure

Background

Full-thickness skin grafts (FTSGs) are generally considered unreliable for coverage of full-thickness finger defects with bone or tendon exposure, and there are few clinical reports of its use in this context. However, animal studies have shown that an FTSG can survive over an avascular area ranging up to 12 mm in diameter. In our experience, the width of the exposed bones or tendons in full-thickness finger defects is <7 mm. Therefore, we covered the bone- or tendon-exposed defects of 16 fingers of 10 patients with FTSGs.

Methods

The surgical objectives were healthy granulation tissue formation in the wound bed, marginal de-epithelization of the normal skin surrounding the defect, preservation of the subdermal plexus of the central graft, and partial excision of the dermis along the graft margin. The donor site was the mastoid for small defects and the groin for large defects.

Results

Most of the grafts (15 of 16 fingers) survived without significant surgical complications and achieved satisfactory functional and aesthetic results. Minor complications included partial graft loss in one patient, a minimal extension deformity in two patients, a depression deformity in one patient, and mild hyperpigmentation in four patients.

Conclusions

We observed excellent graft survival with this method with no additional surgical injury of the normal finger, satisfactory functional and aesthetic outcomes, and no need for secondary debulking procedures. Potential disadvantages include an insufficient volume of soft tissue and graft hyperpigmentation. Therefore, FTSGs may be an option for treatment of full-thickness finger defects with bone or tendon exposure.

Can an adipofascial flap be used to prevent adhesions after plating of the proximal phalanx? A case report

Tendon adhesions in zone IV after proximal phalangeal fractures are common and may lead to loss of range of motion at the proximal interphalangeal joint. The type of fracture, surgical technique and rehabilitation strategy also influence the final functional outcome. Plate fixation is a reliable solution in cases of comminuted phalangeal fracture. This article describes how adhesions between the plate and extensor apparatus in cases of comminuted fractures of the proximal phalanx can be reduced by using an adipofascial flap.

Reverse adipofascial flap after resection of a malignant perineurioma of the forearm

The authors describe a patient with recurrent perineurioma arising in the subcutaneous tissue of the dorsal forearm and extending along the forearm fascia. Soft tissue perineurioma is a rare, originally benign peripheral nerve sheath neoplasm arising from the perineurium, a protective cell barrier surrounding the individual fascicles in peripheral nerves. Perineurioma has only recently been recognized as an entity distinct from other nerve sheath tumors, such as schwannoma and neurofibroma, with unique morphologic, ultrastructural, and immunoreactive features. The recurrent tumor had converted into malignant perineurioma, defined as increased nuclear pleomorphism and cellularity. The ill-marginate feature extending along the fascia required wide resection, leaving a substantial defect on the distal forearm. Surgical repair of large forearm skin defects is challenging because of limited skin extensibility for flap creation, the prominence of the site in terms of aesthetic outcome, and the risk of damage to extrinsic muscles that control delicate hand movements. The reverse forearm adipofascial flap, which was based on distal perforators of the radial artery, was suitable for the current case to cover the exposed myotendinous junctions of the forearm extensor muscles. This flap did not sacrifice skin, a major vessel, or skeletal muscles, and preserved function at both the donor and the recipient sites. The texture of the graft was similar to that of the surrounding skin. The clinical and histopathologic features of this rare tumor are also described to aid in the differential diagnosis and as a reference for surgeons who treat soft tissue neoplasms and may encounter this type of soft tumor.

The free fillet flap after traumatic amputation: a review of literature and case report

Severe, mutilating hand injuries present difficult reconstructive scenarios. Often in these cases, portions of the amputated tissue may be used for reconstruction of the remaining digits and hand using the spare parts principle. The free fillet flap follows the spare parts concept. A literature review of free fillet flaps for hand and forearm coverage is provided. We also present a case report of a multi-digit and dorsal hand free fillet flap for coverage of a traumatic metacarpal hand. This flap demonstrates the value of ingenuity in planning during emergent trauma reconstruction.

Open fractures of the hand with soft tissue loss

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

Bilateral V-Y rotation advancement flap for fingertip amputations

BACKGROUND

Fingertip amputation is the most common type of injury in the upper limb. Goals in fingertip amputation reconstruction are covering the defect, establishing maximum tactile gnosis, keeping the length of the finger, protecting the joint function, acquiring a well-padded pulp tissue, providing a bed for growing nail, obtaining a satisfactory cosmetic appearance and allowing the patient to return to work as soon as possible. Adjacent skin and soft tissue are the best covers for fingertip injuries. However, local homodigital flaps lack enough tissue to cover the defect. To solve this problem, we used V-Y rotation advancement flap bilaterally in fingertip amputations which meets all the reconstruction goals. Rotation besides advancement makes this flap more mobile and easier to cover larger defects in all amputation planes.

METHODS

Between 2007 and 2009, we performed bilateral V-Y rotation advancement flap on seven male patients' pulpa (average age, 37.6 years) whose fingertips were not replantable.

RESULTS

Fourteen flaps were made on 7 fingers. There was neither total nor partial flap loss. Patients had neither cold intolerance nor scar hypersensitivity. Stiffness of the PIP joint did not occur. No obvious hooked nail occurred in patients who have remaining nail matrix. Because flaps contain neurovascular bundle, there was no difference in sensation and perfusion between the finger's pre-operative and post-operative status. The result was satisfactory with painless pinching.

CONCLUSION

In addition to the various and versatile fingertip reconstruction methods, we want to present V-Y rotation advancement flap as a quick, reliable and aesthetic method.

[The reversed homodigital island flap: 28 cases]

AIMS

The purpose of the study is to evaluate the coverage of the distal tissue defect of long fingers using reversed homodigital island flap and comparison with other flaps.

PATIENTS AND METHOD

It was a retrospective study of 28 cases of reversed homodigital island flap practiced in 28 patients to cover skin finger distal loss. The mean age was 29 years, the sex ratio was 0.17. The variety of à pédicule exclusivement vasculaire was the most used (89%). Partial necrosis of the flap was noticed only in two cases (7%). Six criteria were used to evaluate this coverage: the quality of the flap, the donor site, the neuroma formation, the cold intolerance, the mobility of the finger, and the satisfaction of the patient. A final score for every case was attributed.

RESULTS

At the middle last follow-up, the results were good in 89% and average in 11%.

CONCLUSION

The reversed homodigital island flap is a safe method offering multiple advantages and constitutes an interesting alternative in front of the distal tissue defect of the long finger.

Bilateral temporoparietal fascial free flaps for reconstruction of bilateral hand defects: a report of two cases

Bilateral temporoparietal fascial free flaps were used for reconstruction of bilateral hand defects in two male patients. A 42-year-old man sustained crushed injury to both hands with avulsion defects and exposed bones and tendons. The two separate procedures were performed under general anesthesia. The temporoparietal fascial free flap was skin grafted on the ward on the following day after the operation. The other patient was a 61-year-old leprosy patient who had bilateral high ulnar nerve palsy for 28 years. One simultaneous procedure was performed under local anesthesia for harvesting the temporoparietal fascial free flaps and under brachial block for preparation of the recipient sites. The free flaps were used for augmentation of the atrophic first web spaces. The postoperative results of the two cases were satisfactory. The functions of both hands were restored with normal gliding mechanism of the tendons in the first case, and permanent correction of the atrophic web spaces was demonstrated in the second case. The temporoparietal fascial free flap is an ideal flap for coverage of hand defects as well as augmentation of first web space atrophy.

Treatment of ischial pressure sores with double adipofascial turnover flaps

Despite a variety of flap reconstruction options, the ischium remains the most difficult pressure sore site to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using double adipofascial turnover flaps.After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the 2 flaps. The skin is then closed with sutures in 2 layers. A total of 15 patients with ischial sores were treated using this surgical procedure.The follow-up period ranged from 11 to 159 months, with a mean of 93.6 months. Overall, 86.7% of the flaps (13 of 15) healed primarily. One patient had a recurrent grade II ischial pressure sore again 11 months after the operation. The other 14 patients did not have a recurrence.Treatment of ischial pressure sores with adipofascial turnover flaps provides an easy, minimally invasive procedure, with preservation of future flap options, and a soft-tissue supply sufficient for covering the bony prominence and filling dead space. This technique is a reliable and safe reconstructive modality for the management of minor ischial pressure sores.

The "open book" flap: a heterodigital cross-finger skin flap and adipofascial flap for coverage of a circumferential soft tissue defect of a digit

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.

The cross-digital dorsal adipofascial flap

The "homodigital distally based" dorsal adipofascial flap has been used by various authors to cover small, complex, dorsal, digital defects. In 2004, Al-Qattan reported on 3 cases in which a "distally based" dorsal adipofascial flap was used in a "cross-digital" fashion. In the current report, we expand on the concept of cross-digital adipofascial flaps in which the flaps are based not only distally but also proximally or laterally located. A total of 14 patients with complex dorsal digital defects were reconstructed with cross-digital adipofascial flaps. The main indication for using the cross-digital technique was a concurrent dorsal skin shear injury adjacent to the complex defect, which precluded the use of the homodigital technique. There were 11 males and 3 females, with a mean age of 27 years. All defects were located on the distal 2 phalanges of the digits. The adipofascial flap was based distally in 2 patients, laterally in 2 patients, and proximally in the remaining 10 patients. Six patients had associated extensor tendon injury. The cross-digital flap was covered with a split skin graft at the time of transfer, and its pedicle was divided 3 weeks later under local anesthesia. The mean follow-up time was 6 months. All flap survived, with no dehiscence or infection. One flap required regrafting at the time of flap division. The mean total range of motion of the involved distal joint of the digit varied according to associated extensor tendon injury from 60 degrees in patients with no concurrent tendon injury to 20 degrees in patients with segmental tendon loss requiring tendon grafts. Patients who had concurrent nailbed injury developed nail plate deformities such as thinning and ridging. One patient had nonadherence of the nail plate. All other patients were happy with the esthetic appearance of the hand following reconstruction.

A New Flap for Reconstruction of Pilonidal Sinus

BACKGROUND

"Adipofascial turnover flap" is a well-known procedure, but it is generally not used for the surgical treatment of pilonidal sinus disease. The "lumbar adipofascial turnover flap" has been used in this study for the reconstruction of uncomplicated pilonidal sinus disease.

METHODS

Ten cases (8 male and 2 female patients) were operated on by this technique. The reconstruction was performed with the lumbar adipofascial turnover flap. The flap sizes ranged from 4 x 7 cm to 5 x 9 cm (mean, 4.5 x 8 cm), and they were elevated with length-to-base ratio below 2:1. The follow-up period was 14 to 26 months.

RESULTS

Postoperative magnetic resonance imaging, computed tomography scan, and power Doppler ultrasound examinations revealed viability of the flaps in all patients. There was no distortion of anatomic landmarks in any of the cases. The esthetic results were satisfying for all patients as well. There was no recurrence in any cases.

CONCLUSIONS

The hospital stay and mean time off work were shorter compared with other methods of reconstruction and there was no recurrence. We advocate that the lumbar adipofascial turnover flap is an excellent choice for reconstruction of cases with uncomplicated pilonidal sinus disease.

Dorsal Metacarpal Adipofascial Flaps for Palmar Finger and Hand Reconstruction

Palmar finger and hand soft tissue reconstruction using a dorsal metacarpal adipofascial flap as well as using a split-thickness skin graft obtained from a nonweight-bearing area of the sole is reported. Two cases of posttraumatic palmar hand scar contracture, 1 case of postburn palmar hand scar contracture, and 1 case of excisional palmar finger defect were repaired using this operation. Excellent results were obtained in all cases without any complications. This procedure is thought to be an effective method having many advantages and bringing about satisfactory results esthetically as well.

Transpositional adipofascial flaps for complicated acute finger injries

Seven patients who presented with complicated acute finger injuries were treated successfully with local transpositional adipofascial flaps. This is a one-stage procedure with advantages of simplicity and rapidity. This flap is thin with good pliability and provides a very versatile and reliable covering for soft-tissue defects of the fingers. Full-thickness skin grafts were applied to the raw surface of the adipofascial flaps in all patients. All cases had excellent wound healing and restored full range of motion. This procedure facilitates early wound healing and early range of motion for finger joints; it also reduces wound pain, minimizes scar formation, and eliminates the need for second-stage surgery.

Reverse Homodigital Artery Flap Coverage for Bone and Nailbed Grafts in Fingertip Amputations

The main aim of the treatment of fingertip amputations with no indication of replantation was to establish the functional and esthetic construction. The critical point in the utilization of the bone and nail tissue as a graft for reconstruction was to choose a flap that is sufficiently vascular to nourish these grafts. We have performed homodigital artery flaps to cover the bone and nailbed grafts taken from the amputation to restore fingertip function with an acceptable result. The venous insufficiency with the increased probability in flap failure should be taken into consideration. We proposed the preservation of some amount of soft tissue around the vascular pedicle to overcome the venous insufficiency and in our point of view, digital artery sacrifice was worth it to preserve the length of the finger and the esthetic nail appearance.

Anatomic basis of dorsal finger skin cover

This study describes the anatomy of the dorsal cutaneous vascular system of 180 digits (36 thumbs, index, middle, ring, and little fingers) from 18 pairs of fresh human cadaver hands. The aim of this paper is to incorporate the anatomic data into the current way of designing the homodigital adipofascial turnover flap for cutaneous coverage of the dorsum of the finger. We have carried out an anatomic study in preserved cadaver hands to define the distance between the joint and the origin of the dorsal cutaneous branches of the proper palmar digital artery in the proximal and middle phalanx of the long fingers and for the thumb to metacarpal and interphalangeal joint. All branches of the proper digital artery that ran to the dorsal skin were then identified, and their diameters and the distances of their origins from the proximal interphalangeal joint were measured. We showed that 2 constant branches in the proximal and middle phalanx from each proper digital artery have consistent sites of origin at predictable distances from the proximal interphalangeal joint for the long fingers and the metacarpal and interphalangeal joint for the thumb. The flap survival was excellent, and no donor site complications were observed. We showed that these branches have consistent sites of origin at predictable distances from the proximal interphalangeal joint. The adipofascial turnover arterial flap has appeared as an excellent alternative to achieve early coverage of cutaneous wounds at the dorsal aspect of the fingers.

The use of adipofascial turnover flaps for coverage of complex dorsal ring finger defects caused by electric burns

This paper describes a unique occupational electrical injury that results in a complex defect on the dorsal aspect of the ring finger. The injury was seen in seven electricians working while wearing a ring on the ring finger. All patients were treated successfully using random adipofascial turnover flaps. The electric current was found to cause a zone of subcutaneous necrosis adjacent to the skin burn. This zone of subcutaneous necrosis varied in size but never exceeded 5mm and it was easy to recognize the extent of this zone intraoperatively because of the presence of the thrombosed dorsal subcutaneous veins within the necrotic subcutaneous tissue. These observations suggested that adequate debridement and then location of the base of the adipofascial flap proximal to the edge of the debrided area was an appropriate procedure. Other technical considerations were described to ensure a successful outcome. It was concluded that adipofascial turnover flaps were not only reliable in these electrical injuries, but also had several advantages when compared with other flaps commonly used to reconstruct dorsal digital defects.

De-epithelialized cross-finger flaps versus adipofascial turnover flaps for the reconstruction of small complex dorsal digital defects: a comparative analysis

PURPOSE

To compare the results of 2 reconstructive options (the de-epithelialized cross-finger flap vs the adipofascial turnover flap) for coverage of small complex dorsal digital defects.

METHODS

A total of 73 patients with small complex dorsal digital defects were included in the study and were classified into 2 groups: group 1 (n = 31) had reconstruction using the de-epithelialized cross-finger flap and group 2 (n = 42) had reconstruction using the adipofascial turnover flap. The type of complication and patient dissatisfaction with the appearance of the donor site were documented in each study group.

RESULTS

All flaps in both groups survived with no infection or hematoma. Specific complications were found in group 1 patients and included flap dehiscence (1 patient), considerable skin graft loss (2 patients), stiffness of the donor finger (5 patients), and inclusion cyst (1 patient). The only specific complication for group 2 patients was the occasional epidermolysis of the skin of the donor site, which was observed in 6 patients. Patient dissatisfaction with the appearance of the donor site was documented in 10 patients in group 1 and none in group 2. The elective flap division in the cross-finger-flap group was considered a disadvantage in children because it required general anesthesia.

CONCLUSIONS

The versatility of both flap techniques in digital reconstruction is confirmed; however, considering the type of complication and the need for general anesthesia in children for cross-finger-flap division, the adipofascial flap was determined to be superior in the following specific groups: children, older patients, and patients with osteoarthritis and multiple defects of adjacent border digits.

Anatomical study of subcutaneous adipofascial tissue: a concept of the protective adipofascial system (PAFS) and lubricant adipofascial system (LAFS)

The subcutaneous adipofascial tissue over the entire body was radiographically and macroscopically investigated in 20 fresh and embalmed cadavers. The subcutaneous adipofascial tissue was made up of two adipofascial layers. Because the superficial layer forms a solid structure and is thought to protect against external forces, the adipofascial system formed by the solid structure was named the "protective adipofascial system (PAFS)". Because the deep layer forms a mobile layer and is thought to lubricate musculoskeletal movement, the adipofascial system formed by the mobile structure was named "lubricant adipofascial system (LAFS)". By classifying subcutaneous adipofascial tissue by its functional characteristics, we found we could understand the subcutaneous adipofascial structure over the entire body well.

Reconstruction of the great toe ski-slope, sunken-nail deformity with a buried adipofascial flap

Development of a ski-slope deformity following loss of the great toe nail plate is a problematic condition with few conservative or surgical options available. The condition becomes more difficult to treat when the distal, medial, and lateral labial nail folds are hypertrophied, creating the appearance of a sunken nail. We present a case of ski-slope, sunken-nail deformity following multiple attempts at chemical nail matrixectomy. The patient's persistent pain and deformity were managed through 1) nail plate avulsion and complete surgical excision of the germinal nail matrix, 2) remodeling of the distal phalanx, and 3) elevation of an adipofascial flap from the plantar tuft of the great toe, which was brought from plantar to dorsal and interposed between the dorsal aspect of the distal phalanx and the overlying nail bed in buried fashion. The combination of these procedures elevated the nail bed, which restored normal architecture to the great toe and relieved the pain associated with the chronic deformity. This case demonstrates a potential complication of a commonly performed procedure and a salvage technique useful for dealing with the resultant ski-slope, sunken-nail deformity.

The adipofascial turn-over flap for coverage of the dorsum of the finger: a modified surgical technique

PURPOSE

The exact distances from the cutaneous dorsal branches of the digital artery to the proximal interphalangeal joint have been established in a previous anatomic study. The aim of this report is to incorporate these anatomic data into the current way of designing the homodigital adipofascial turn-over flap for cutaneous coverage of the dorsum of the finger. Our clinical experience with this modified surgical technique to this flap is reported.

METHODS

The clinical series presented here consists of 40 patients with loss of cutaneous coverage at the dorsal aspect of the middle and distal phalanges. Based on our anatomic findings the flap was designed to include at least 1 dorsal branch in its pedicle.

RESULTS

The flap survival was excellent and no donor site complications were observed.

CONCLUSIONS

The adipofascial turn-over arterial flap has appeared as an excellent alternative for achieving early coverage of cutaneous wounds at the dorsal aspect of middle and distal phalanges of the long fingers. This flap can be designed as an arterial flap in a predictable and reliable way based on new anatomic data on the vascularization of the dorsum of the finger.

Triple Coverage of Ischial Ulcers with Adipofascial Turnover and Fasciocutaneous Flaps

Despite a wide variety of flap options, ischial ulcers remain the most difficult pressure ulcers to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using adipofascial turnover flaps combined with a local fasciocutaneous flap. After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the two flaps. A local fasciocutaneous flap (Limberg flap) is applied to the raw surface of the turnover flaps. Twenty-two patients with ischial ulcers were treated using this surgical procedure. Overall, 86.4 percent of the flaps (19 of 22) healed primarily. Triple coverage with the combination of double adipofascial turnover flaps and a local fasciocutaneous flap allows for an easily performed and minimally invasive procedure, preservation of future flap options, and a soft-tissue supply sufficient for covering the prominence and bony prominence and filling dead space. This technique provides successful soft-tissue reconstruction for minor to moderate-size ischial pressure ulcers.