Microsurgical Flaps in Repair and Reconstruction of the Hand

Flexibility of the Superficial Circumflex Iliac Artery Perforator Free Flap for Hand Reconstruction

Background

The superficial circumflex iliac artery perforator (SCIP) flap has several advantages in hand reconstruction. It is thin and pliable, the extensive branching of the arterial system allows for multiple components, and the donor site can be closed inconspicuously. This article reports our experience using the SCIP flap for hand reconstruction, and we highlight the flexibility of the SCIP for extended and chimeric flaps.

Methods

We conducted a retrospective cohort study from November 2022 to January 2024 of patients with complex hand defects (exposure and/or defect of the bone or tendon) who underwent reconstruction with an SCIP flap. The plane of dissection was above the layer of superficial fascia. In overweight patients, the superficial fat lobules were removed under the microscope to thin the flap. Tailoring, chimeric, and supercharged flaps were constructed as needed for complicated hand defects. Data collected included defect characteristics, flap design, and outcomes.

Results

A total of 44 flaps were performed on 43 patients. The average flap length was 17.8 cm (range 10-42 cm), the average flap width was 7.6 cm (range 2-11 cm), and the average flap thickness was 2.5 mm (range 2-4 mm). Hand defects were reconstructed with 9 chimeric flaps, 8 tailored flaps, 3 chimeric and tailored flaps, and 2 supercharged flaps. Overall, 42 flaps (95.5%) survived and 2 flaps (4.5%) experienced necrosis.

Conclusions

The SCIP flap is a reliable option for complex hand defect reconstruction. This technique can provide a large, thin, pliable skin paddle incorporating components from the external oblique fascia and iliac bone. We did not encounter any recurrent issues when using it as a supercharged flap, tailored flap, or chimeric flap. Reconstructive surgeons should develop comfort with the SCIP flap in hand reconstruction given its versatility.

Multidetector-row Computed Tomography Analysis of the Radial Midpalmar Flap: A Retrospective Anatomical Study

Background

Soft tissue defects on the palm side of the thumb can be effectively covered by using the radial midpalmar (RMP) flap, which is usually harvested as a pedicled flap. However, previous anatomical studies on this flap are limited. We analyzed multidetector-row computed tomography angiograms of the radial midpalm of hands to more precisely characterize the 3-dimensional anatomical structure of the perforators in living patients.

Methods

This retrospective cross-sectional study included all eligible patients from 2014 to 2019. All Digital Imaging and Communications in Medicine (DICOM) data were analyzed by the DICOM viewer. RMP area vascularization pattern and cutaneous perforator number, location, origin, internal diameters, and bifurcation-to-dermis lengths were recorded.

Results

In total, 41 perforators were found in 30 patients: 21 patients had 1 perforator, 7 had 2, and 2 had 3 perforators. All were located inside a 23.2-mm diameter circle with an origin on the second metacarpal bone axis approximately 10 mm distally from the Kaplan cardinal line. Their origins were the superficial palmar arch system (61%), palmar arteries of the thumb (24%), and radialis indicis artery (15%). The mean perforator diameter and length were 0.61 and 8.48 mm, respectively.

Conclusions

All patients had at least 1 reliable perforator in the radial midpalm. Our results suggest that plastic surgeons can easily and safely plan the RMP flap design, potentially without preoperative perforator mapping. Guidelines for this flap are proposed.

Anatomical basis and clinical application of the dorsal metacarpal cutaneous branch flap of radial digital artery of index finger

OBJECTIVE

This study explored the surgical technique and clinical application of the dorsal metacarpal cutaneous branch flap of the radial digital artery of the index finger.

METHODS

Through the anatomical dissection of 10 hand specimens, we examined the origin and characteristics of the artery and its branches towards the hand dorsum. Furthermore, the soft tissue defects of the index finger in 12 patients admitted to our hospital between 2017 and 2021 were surgically repaired using the dorsal metacarpal cutaneous branch flap of the radial digital artery of the index finger.

RESULTS

The radial digital artery of the index finger had two types of origins: 70% (14 sides) were derived from the main artery of the thumb, and 30% (6 sides) were derived from the superficial palmar arch. The artery emitted 2 to 4 cutaneous branches from between the origin point and the head of the second metacarpal bone to the skin at the first dorsal interosseous muscle, with a cutaneous branch outer diameter of approximately (0.55 ± 0.01) mm, supplying the skin on the dorsum of the radial side of the hand. Clinical outcomes showed successful flap survival, without any arterial or venous vascular crises. Follow-up examinations at 1 to 3 years postoperatively showed that the skin flap had good blood supply, texture, elasticity, a natural and aesthetic appearance, and no swelling. The protective sensation was recovered and there was no need for secondary repair surgery.

CONCLUSION

The dorsal metacarpal cutaneous branch flap of the radial digital artery is a safe, reliable option for index finger tissue repair, maintaining palm skin integrity and demonstrating positive clinical efficacy.

Microsurgical Reconstruction with and without Microvascular Anastomosis of Oncological Defects of the Upper Limb

INTRODUCTION

The choice of the most adequate surgical technique for upper limb defects remains challenging. The aim of this article is to discuss the main microsurgical (pedicled or free) reconstructive options for the post-oncological reconstruction of different anatomical areas of the upper extremity.

MATERIALS AND METHODS

We reviewed different reconstructive methods reported in the literature needing microsurgical expertise and compared them to our clinical experience, in order to provide further guidance in the choice of different flaps for upper limb soft tissue reconstruction. Six clinical cases, one for each anatomical district, are presented as examples of possible solutions.

RESULTS

We report the options available in the literature for post-oncologic upper limb reconstruction, dividing them by anatomical area and type of flap: local flaps, regional flaps, free flaps, and distant pedicled flaps. Our examples of the reconstruction of each anatomical area of the upper limb include one reverse ulnar pedicled perforator flap, one free Antero-Lateral Thigh (ALT) flow-through flap, one perforator-based lateral arm flap, two myocutaneous latissimus dorsi pedicled flaps, and one parascapular perforator-plus flap.

CONCLUSIONS

In oncological cases, it is important to consider reconstructive options that provide stable tissue and allow for the early healing of the donor and recipient site if the patient needs to undergo adjuvant radiotherapy or chemotherapy. A wider range of flap options is essential when choosing the proper technique according to the patient's needs, surgeon's preference, and logistical possibilities. Perforator flaps combine the advantages of other flaps, but they require microsurgical expertise. Free flap reconstruction remains the gold standard to obtain a better overall and cosmetic outcome in complex and wide defects, where no suitable local pedicled flap option exists. The pedicled latissimus dorsi flap should still be included among the reconstructive options for its strong vascularization, size, and arc of transposition.

The Mangled Upper Extremity-Algorithm for Salvage: My Workhorse Flaps

Mangling injuries of the upper extremity are severe, high-energy traumas that damage multiple functional systems including skin, nerves, vascular, tendon, and bone. Management requires familiarity with various techniques in orthopedic, vascular, and plastic surgery. A specific technique cannot be described due to the various combinations of injuries that can occur with mangled upper extremities, but we present principles and recommendations for treatment and judgment.

Propeller Perforator Flaps Used for Hand and Digit Reconstruction: A Systematic Review

Background

Propeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction.

Methods

A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected.

Results

Out of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm2. Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%.

Conclusion

PPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival.

The Foot as a Donor Site for Reconstruction in the Hand

The foot contains a unique collection of tissue types that can be used in the reconstruction of the hand. Numerous reconstructive options have been presented, some of which have been adopted, such as modifications to procedures that have been described in the past or even newly developed options for hand reconstruction. It is possible to reconstruct missing fingers and other hand structures using tissues taken from the foot rather than removing healthy tissue from a hand that has already been injured. This makes it possible to avoid having healthy tissue removed from an injured hand.

Mid-term Clinical Outcome of Microvascular Gracilis Muscle Flaps for Defects of the Hand

PURPOSE

Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand.

AIM

To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity.

METHODS

16 patients aged 44.3 (range 20-70) years were re-examined after a mean follow-up of 23.6 (range 2-77) months. Mean defect size was 124 (range 52-300) cm2 located palmar (n = 9), dorsal (n = 6), or radial (n = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft.

RESULTS

Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss (n = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap (n = 1) with renewed split thickness skin cover. A surplus of the flap (n = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3-96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1-3) (1 = excellent; 4 = poor).

CONCLUSIONS

Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure.

LEVEL OF EVIDENCE

IV observational.

Chicken Feet: A Model for Practising Locoregional Flaps of the Hand

Background: The aim of this study was to determine the feasibility of the chicken foot model for surgical trainees interested in practising the designing, harvesting and inset of locoregional flaps of the hand. Methods: A descriptive study was performed to demonstrate the technical aspects of harvesting four locoregional flaps in a chicken foot model: fingertip volar V-Y advancement flap, four-flap and five-flap Z-plasty, cross-finger flap and first dorsal metacarpal artery (FDMA) flap. The study was performed in a surgical training laboratory on non-live chicken feet. No participants were involved in this study, apart from authors performing the descriptive techniques. Results: All flaps were successfully performed. Anatomical landmarks, soft tissue texture and flap harvest, as well as inset closely resembled clinical experience with patients. Maximal flap sizes were 12 × 9 mm for volar V-Y advancement, 5 mm limbs for Z-plasties, 22 × 15 mm for cross-finger flaps and 22 × 12 mm for FDMA flaps. The maximal webspace deepening with four-flap/five-flap Z-plasty was 20 mm and the FDMA pedicle length and diameter was 25 and 1 mm, respectively. Conclusions: Chicken feet can be effectively used as simulation models for hand surgical training with respect to gaining familiarity with the use of locoregional flaps of the hand. Further research requires testing for reliability and validity of the model on junior trainees.

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.

[Repairing large skin defect of hand with modified dorsal metacarpal artery reverse island flap]

OBJECTIVE

To investigate the effectiveness of modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries in repairing large skin defect of the hand.

METHODS

Between September 2017 and March 2021, 15 cases of large skin defect of the hand were treated. There were 11 males and 4 females with an average age of 42 years (range, 24-66 years). The injury causes included machine twist injury in 6 cases, pound injury in 5 cases, and crush injury in 4 cases. The injured parts included 6 cases of finger skin defect and 9 cases of distal skin defect of palm and dorsum of hand, all of which had tendon, joint, and bone exposure. The interval from injury to operation ranged from 2 to 6 hours (mean, 4 hours). The defect sizes after thorough debridement ranged from 3.5 cm×3.0 cm to 8.0 cm×4.5 cm. The modified dorsal metacarpal artery reverse island flap with a range of 3.8 cm×3.3 cm to 9.0 cm×5.0 cm was used to repair the defect, and the flap donor site was repaired with full-thickness skin graft.

RESULTS

All the flaps survived successfully after operation, and the wounds in the recipient site and the skin grafts in the donor site healed by first intention. All patients were followed up 9-24 months, with an average of 14 months. The appearance of the flap was good, and its texture and color were similar to those of the surrounding normal tissue. There was no obvious scar contracture, depression, and pigmentation in the donor site. At last follow-up, the static two-point discrimination of the flap was 8-20 mm, with an average of 13.6 mm. According to the Michigan Hand Outcome Questionnaire, 5 patients were very satisfied with the appearance of the flap, and 10 patients were satisfied.

CONCLUSION

The modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries has reliable blood supply, larger harvested area, simple procedure, and minimal donor site damage, which is suitable for emergency repair of large skin defect of the hand.

The profunda artery perforator flap for upper limb reconstruction: A case report and literature review on the flap applications in reconstruction

The profunda femoris artery perforator (PAP) flap has been recently popularized as an alternative option for microsurgical reconstruction. The use of PAP flap has never been reported and described for reconstruction of the upper extremities, in particular the forearm. The purpose of this case report is to describe a case suggesting the PAP flap as a further reconstructive option in the upper limb. A 16-year-old girl who sustained a traumatic injury to her right dominant forearm resulting in subtotal circumferential tissue loss following a road traffic accident was referred to the authors' department 2 years post-trauma. The disabling fibrotic sequelae on her volar forearm (15 × 10 cm) resulted in a nonfunctional hand. She was unable to perform any active movement of her wrist or digits. Passive movements in the finger joints were preserved. Following debridement and reconstruction of nerves and tendons, soft tissues were resurfaced with a PAP flap. The transverse skin paddle, 12 × 7 cm, was placed distally with the adipofascial portion positioned proximally above the muscle bellies and anastomoses site. A small raw area (4 × 3 cm) was covered with an acellular dermal matrix (ADM). The postoperative course was uneventful. At 9 months postoperatively, the patient demonstrated active flexion and extension of the fingers with independent function. The patient reported satisfaction with the flap donor site and forearm resurfacing. The PAP flap can be a further option for areas requiring soft tissue coverage in patients refusing visible scars. This flap had both the advantage of reducing the morbidity and visibility of the donor site, as well as the ability to resurface a large recipient site with soft and pliable tissue, covering exposed nerves and tendons.

The First Dorsal Metacarpal Artery Perforator Free Flap: The Comet Flap

BACKGROUND

Distal extremity defects pose a particular challenge to the reconstructive surgeon, however, advances in perforator flaps have expanded the armamentarium of potential reconstructive options. Herein, we present our experience in reconstructing distal extremity defects using a thin, cutaneous free flap based on the perforator of the first dorsal metacarpal artery - "the Comet flap."

METHODS

A retrospective review was performed on all patients who presented with a distal extremity defect and underwent reconstruction using a Comet flap between 2015 and 2019. Patient demographics, flap anatomy and harvest, and postoperative course were reviewed and analyzed.

RESULTS

A total of sixteen patients were included. The mean patient age was 36.5 years old. Trauma was the most common etiology. The average defect size was 5.4x3.2cm. The average pedicle length of the Comet flap ranged from 3.5 to 30cm, depending on involvement of the radial vessels. All donor sites underwent uncomplicated closure with local rhomboid flaps. One flap was complicated by an acute venous thrombosis that was successfully treated operatively. Flap survival rate was 95%. All patients were able to maintain their preoperative range of motion and were satisfied with their final outcome. Follow-up time ranged from 6 to 50 months.

CONCLUSION

Local flaps remain an important reconstructive approach for distal extremity defects; however, in complex soft tissue injuries, free tissue transfers become necessary. The Comet flap is a safe, versatile, and reliable flap for reconstructing upper and lower extremity defects that can be performed in a single procedure under regional anesthesia.

Soft and tissue repair of the hand and digital reconstruction

This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.

Eccentric free muscular perforator flaps in the proximal lateral leg for hand and foot reconstruction

BACKGROUND

We aimed to introduce our modifications by using eccentrically located muscular perforators to shorten the distance between the recipient vessels and the flap pedicle for overcoming the "short pedicle" drawback of the proximal lateral leg perforator (PLLP) flap.

PATIENTS AND METHODS

A retrospective review of 12 cases undergoing free PLLP flap for hand and foot regions reconstruction during 2010 and 2019. The mean age was 43.3 years. Most defects resulted from burn and trauma injuries. The dimensions of defects ranged from 8 × 1.5 cm² to 12 × 6.5 cm² . Muscular perforators were designed eccentrically 1-3 cm away from the central point of the flap to shorten the distance between the recipient vessels and the pedicle. The flap was designed to be 0.5-1 cm larger than the defect.

RESULTS

The flap size ranged from 9 × 2 cm² to 15 × 6 cm² . All pedicles were long enough to ensure an appropriate anastomosis without tension. The post-operative course in all cases was uneventful. All flaps survived without complications. Primary repair of the donor sites was performed in all patients. Donor leg function was not hampered by flap harvesting. All patients were satisfied with the scar after at least 1 year of follow-up.

CONCLUSION

Based on our experience, selection of the eccentric locations of the musculo-cutaneous perforators were effective methods to overcome the short pedicle length of this flap type. Using our modifications, thin PLLP flaps can be used in foot and hand reconstruction with minimal donor site morbidity and a high success rate.

Upper limb traumatic injuries: A concise overview of reconstructive options

Different options for upper limb reconstruction are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common. Local and regional flaps can represent the reconstructive options for small defects while large wounds require the use of free flaps or distant pedicled flaps. In case of large wound, the use of free flaps rather than distant pedicle flaps is usually preferred. To choose the best reconstructive option, it is essential for the surgeon to have a general overview about the different methods.

In this review the Authors will refer to the most commonly used methods to cover soft tissues injuries affecting the dorsum and the palm of the hand and the forearm (excluding fingers). The aim is to show all flap reconstructive options so as to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

•

Reconstruction of traumatic injuries of the upper limbs can be challenging.

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Small defects can be covered by local and regional flaps while large wounds need the use of free or distant pedicled flaps.

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The literature shows different opinions whether to use pedicled flaps (regional or distant) or free flaps.

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Dermal substitutes can be considered in patients who are not suitable for flaps reconstruction.

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Patient related factors and surgical background can significantly interfere with the surgical reconstructive solution.

A Retrospective Comparative Functional and Aesthetic Outcome Study of Muscle versus Cutaneous Free Flaps for Distal Upper Extremity Reconstruction

BACKGROUND

 Function and cosmesis are crucial in upper extremity reconstruction. Yet, there persists a lack of outcome evaluations, particularly regarding differences between free flap types.

METHODS

 In a single-center retrospective analysis, outcomes were compared between patients with cutaneous or muscle free flaps for distal upper extremity reconstruction between 2008 and 2018. The Disabilities of Arm, Shoulder and Hand -Score, Michigan-Hand (MHQ), and Short Form 36 Health Survey (SF-36) Questionnaires were assessed, motor function was quantified, and self-reported measures of cosmesis were compared, including the Vancouver Scar-Scale (VSS), MHQ aesthetics-subscale (MAS), and Moscona's cosmetic validation-score (CVS).

RESULTS

 One-hundred forty-one cases were identified, with a shift toward cutaneous flaps over the study period. Muscle flaps were used for larger defects (251 vs. 142 cm², p = 0.008). Losses, thromboses, and donor-site complications were equally distributed. Partial necroses were more frequent in muscle flaps (11 vs. 1%, p = 0.015). Seventy patients with 53 cutaneous versus 17 muscle flaps were reexamined. There was no difference in the timing of flap coverage (after 16 vs. 15 days, p = 0.79), number of preceding (2 vs. 1.7, p = 0.95), or subsequent operations (19/53 vs. 5/17, p = 0.77). Patients with cutaneous flaps showed higher grip strength (25 vs. 17 kg, p = 0.046) and reported better hand function (MHQ: 58 vs. 47, p = 0.044) and general health (SF-36: 70 vs. 61, p = 0.040), as well as more favorable appearance (MAS: 71 vs. 57, p = 0.044, CVS: 77 vs. 72, p = 0.048), and scar burden (VSS: 0 vs. 3, p < 0.001).

CONCLUSION

 Cutaneous flaps yielded better motor function, self-perceived cosmesis, patient satisfaction, and quality of life in our cohort of distal upper extremity reconstructions.

Soft tissue coverage of the upper limb: A flap reconstruction overview

Different opinions about the reconstructive choice for upper limb are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common reconstructive options. Local and regional flaps can be used to cover small defects while large wounds require the use of free flaps or distant pedicled flaps. The coverage of large wounds opens a discussion about when to use free flaps and when distant pedicled flaps. This review will describe the different methods used for the coverage of soft tissues injuries affecting hand and/or forearm (excluding fingers). The aim is to show all flap reconstructive options in order to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

Microsurgical Tissue Transfer in Complex Upper Extremity Trauma

Microsurgical tissue transfer may provide reconstructive option for extensive loss of tissues due to upper extremity trauma or tumor resection. This article reviews the authors' experience in using microsurgical tissue transfers for reconstruction of upper extremity trauma.

Pedicled flap from the first dorsal branch of the proper palmar digital artery of the fingers: An anatomy study

The pedicled flap from the first dorsal branch of the proper palmar digital artery (FBPPDA) of the fingers is an option for reconstructing digital skin defects. It has the advantage of being innervated by the dorsal branch of the proper palmar digital nerve (DBPPDN) associated with the artery. However, no studies on the anatomical variations of the neurovascular pedicle have been performed yet. The objective of our study was to evaluate the anatomical variations in the neurovascular pedicle, determine its relationships with other anatomical structures, describe the dissection technique for the FBPPDA and explore potential indications. We conducted an anatomical study with eight upper limbs from fresh adult cadavers. Twenty-six fingers (6 index, 6 middle, 8 ring, 8 little) were dissected after intra-arterial silicone injection. We found a pedicle composed of the FBPPDA and the DBPPDN in all fingers. The artery arises an average 19mm from the bifurcation of the common palmar digital artery. The DBPPDN's configuration relative to the FBPPDA varied; in the main variant - found in 58% of cases - the nerve was superficial and proximal position to the artery. After its origin, the pedicle ran on the superficial aspect of the extensor hood along an oblique path from proximal to distal and from palmar to dorsal. Its path ended with its penetration into the skin paddle of the flap just upstream the proximal interphalangeal (PIP) joint. The skin paddle corresponded to the functional skin unit represented by the dorsal surface of the middle phalanx and that of the PIP joint. Its average length was 33mm (26-40) and its average width was 21mm (15-30). The arc of rotation was sufficient to reach homodigital and heterodigital cutaneous defects. Based on our findings, this flap is a reliable and reproducible option for finger skin defects. The size of its paddle and its innervation make it an interesting alternative to conventional flaps.

The V-Y advancement flap based on the dorsal carpal perforators for dorsal metacarpal reconstruction: Anatomical and clinical study

INTRODUCTION

Soft-tissue defects on the dorsal hand accompanied by exposed bone and tendon remain a challenge for plastic surgeons. The purpose of this study was to observe the morphological characteristics of the dorsal carpal perforators in the wrist and to design a V-Y advancement flap based on the dorsal carpal perforators.

MATERIALS AND METHODS

Thirty cadaveric hand specimens were dissected to observe the origin, course, branches, and anastomoses of the dorsal carpal perforators, and a V-Y advancement flap was designed based on these perforators. Clinically, nine cases of dorsal hand defects were reconstructed with this flap.

RESULTS

The dorsal carpal vascular network was formed by vascular anastomoses along the dorsal carpal branch of the radial artery, dorsal carpal branch of the anterior interosseous artery, ascending branch of the dorsal carpal perforator from the deep palmar arch, direct branch of the radial artery, dorsal carpal branch of the ulnar artery, posterior interosseous artery, and deep palmar branch of the ulnar artery; this network could be divided into a deep vascular network and superficial vascular network according to the anatomical plane. Among the perforators, the third and fourth perforators that pierce out bilaterally from the tendon of the extensor digitorium had a consistent occurrence rate (100%) with an outer diameter of 0.7 ± 0.3 mm and 0.6 ± 0.2 mm, respectively, and thus could be chosen as the vascular pedicle. In clinical applications, all flaps survived completely with excellent color and texture, a satisfactory appearance, and normal movement of the wrist joint.

CONCLUSIONS

A V-Y advancement flap based on the dorsal carpal perforators can become a useful choice for the repair of dorsal metacarpal defects caused by trauma or dorsal metacarpal arterial flaps.

Anatomical basis and clinical application of the dorsal perforator flap based on the palmar artery in the first web

PURPOSE

Soft-tissue defects of the thumb and index finger remain a challenge for plastic surgeons. Our purpose was to observe the morphological characteristics of the cutaneous vessels in the first web, to design a dorsal perforator flap based on the palmar artery in the first web and to propose its clinical application.

METHODS

Thirty preserved hand specimens were dissected to observe the origin, course, branch and anastomosis of the dorsal perforators in the first web, and the dorsal perforator flap based on the palmar artery in the first web was designed. Clinically, seven cases of hand defects were reconstructed using this flap.

RESULTS

The blood supply for the dorsum of the first web comprised the dorsal perforators from both the dorsal artery (the branch of the first dorsal metacarpal artery) and palmar artery (the radial palmar digital artery of the index finger and the ulnar palmar digital artery of the thumb). The first dorsal metacarpal artery constantly arose from the radial artery and was divided into the radial, ulnar and medial branches. The palmar artery sent out 1-2 perforators and formed a constant anastomosis with the medial branch of the first dorsal metacarpal artery to supply the dorsal skin of the first web. In clinical application, all the flaps survived completely without contracture of the first web or other complications and the donor regions all healed at the first stage.

CONCLUSION

The dorsal perforator flap based on the palmar artery in the first web is useful to repair soft-tissue defects of the thumb, the proximal phalanx of the index finger and thenar region, leading to a satisfactory appearance and good functional and sensory recovery.

Customized reconstruction of complex soft-tissue defect in the hand and forearm with individual design of chain-linked bilateral anterolateral thigh perforator flaps

BACKGROUND

Complex soft-tissue defects of upper extremities still have a high rate of amputation, as the reconstruction of complex soft-tissue defects is always difficult even with the largest conventional free flap. The anterolateral thigh perforator (ALTP) flap is one of the most popular procedures used for the coverage of complex soft-tissue defects of extremities. However, problems associated with donor-site morbidity and inability to repair complex soft-tissue defects in a one-stage procedure persist. The purpose of this study was to present a novel design of using chain-linked bilateral ALTP flap and its various designs for customized reconstruction of complex soft-tissue defects in the hands and forearms.

METHODS

From June 2009 to June 2017, we retrospectively analyzed 15 patients with complex soft-tissue defects in the hands and forearms. All patients in this series underwent extremity reconstruction using the chain-linked bilateral ALTP flaps. Three different types of chain-linked bilateral ALTP flaps were created in this study based on wound characteristics and the maximum available skin paddle size at all donor sites.

RESULTS

The chain-linked bilateral ALTP flaps were successfully harvested for the reconstruction of complex soft-tissue defects in the hands and forearms. Among them, ten cases were repaired with chain-linked bipaddle ALTP flaps, two cases were treated with chain-linked tripaddle ALTP flaps, and the remaining three cases were used with chain-linked multi-lobed ALTP chimeric flaps. The sizes of the skin paddles ranged from 11 cm × 7 cm to 42 cm × 8 cm. The areas of the total flaps ranged from 245 cm² to 650 cm² (mean 419.6 cm²). Only one case required re-exploration because of the venous congestion. The donor sites were closed directly. The mean follow-up time was 16.4 months. Most cases showed satisfactory contour.

CONCLUSION

The chain-linked bilateral ALTP flap is a reliable option for one-stage reconstruction of complex soft-tissue defects in the hands and forearms with limited donor-site morbidity. It also provides various flap designs, which allow for more individualized treatment approaches.

One-stage reconstruction of complex soft tissue defects in the hands using multidigit, chimeric, lateral arm, perforator flaps

PURPOSE

To describe our experience using microsurgically fabricated, multilobed, chimeric, lateral arm (LA) flaps to reconstruct hand injuries with complex, multidigit, soft tissue defects and to evaluate the morbidity and esthetic and functional outcomes of the donor sites.

METHODS

We performed a single center, retrospective analysis of 21 patients with hand wounds treated from October 2013 to February 2016. All patients underwent reconstruction using multilobed, chimeric, free, LA flaps. A self-reported questionnaire was used to assess donor site morbidity and satisfaction with the esthetic and overall functional result. Outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) score, static 2-point discrimination score, and visual analogue scale.

RESULTS

The study included 21 patients (20 males and 1 female), with an average age of 32.14 years (range 18-45 years), who sustained traumatic injuries in road traffic accidents (n = 2) or industrial devices (n = 19). The average DASH score was 28.25 ± 2.3, the average 2-PD score was 7.20 ± 1.30, and the average visual analogue scale (VAS) was 0.38 ± 0.40. All 21 patients had sensory disorders at the donor site. Postoperative donor site complications comprised wound dehiscence (n = 1) and hematoma (n = 3). The patient-rated satisfaction score for the donor site was 5.40 ± 0.90, and 70% of the patients would undergo the same surgery again.

CONCLUSION

Microsurgical fabrication of multilobed, chimeric, LA flaps can exhibit sensory recovery and minimal pain but may cause hematoma and sensory disorders at the donor site. The flaps are a viable alternative for the reconstruction of complex, multidigit, soft tissue defects of the hands.

Supermicrosurgery: History, Applications, Training and the Future

Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon's practice.