Free Flap From the Superficial Palmar Branch of the Radial Artery (SPBRA Flap) for Finger Reconstruction

Superficial palmar branch of radial artery flap for digital skin reconstruction: anatomical study and clinical applications

BACKGROUND

This study investigates the anatomy of the superficial palmar branch of the radial artery (SUPBRA) for palmar skin reconstruction. It aims to detail SUPBRA's anatomical features for hand/finger reconstruction and pinpoint reference points for efficient harvesting.

MATERIALS AND METHODS

Nineteen male hand specimens (aged 18-70 years), fixed in 10% formalin, were dissected to study the anatomy of SUPBRA island flap. All measurements such as the external diameter of the SUPBRA, its bifurcation point from the radial artery, length of the SUPBRA pedicle, accompanied by venae comitantes, the number and location of perforators were used analyzed. Two flap techniques based on SUPBRA, the mid-palmar axis and wrist line axis, were studied. SUPBRA flap designs were used in three hand injury cases.

RESULTS

The distance from SUPBRA's origin to the styloid process averaged 9.4 ± 1.1 mm, and its mean diameter was 2.4 ± 1.5 mm. It has not been encountered a pattern with a narrow diameter of 1.1 mm or less, which is considered hypoplastic and unsuitable for a flap due to inadequate nourishment, in SUPBRA. Mean length of the SUPBRA pedicle was 31.0 ± 6.3 mm. The SUPBRA was typically accompanied by two vena comitantes. The location of the musculocutaneous perforators, approximately 10 mm distal to the scaphoid tubercle, suggests that when the SUPBRA flap is designed transversely along the distal wrist crease, the direct cutaneous perforators will play a crucial role in providing adequate blood supply to the flap as a pedicle. Flap sizes ranged from 1.5 × 3.0 mm to 2.5 × 6.5 mm. To obtain a longer pedicle, the flap was designed with a long-skin pattern along the long-axis direction, and the accompanying veins were dissected proximally to the radial artery. All cases confirmed the SUPBRA flap's viability for microvascular anastomosis in the thenar regions.

CONCLUSION

SUPBRA flap isa valuable option for hand and finger reconstruction,. providing detailed anatomical insights, including its external diameter, bifurcation point from the radial artery, flap length, presence of venae comitantes, and the number and locations of perforators. This flap is particularly suitable for reconstructing palmar defects of the radial digits, palm, and first webspace, and its arterial dimensions and lengths make it well-suited for microvascular anastomosis.

The free Thenar flap for thumb pulp reconstruction: A case report

The thumb is acknowledged to contribute significantly to hand function, accounting for up to 40% of its overall capability. Consequently, injuries affecting the thumb can have a profound impact on the quality of life experienced by patients. When it comes to the surgical reconstruction of thumb injuries, the primary objective is to promptly provide coverage of the affected area with glabrous skin, thus preserving both the length and functionality of the thumb. Managing injuries specifically involving the thumb pulp can be particularly challenging due to the digit's size and vital role. Acquiring an adequate amount of glabrous soft tissue poses a difficulty in such cases. Various reconstructive approaches, encompassing a range of options on the reconstructive ladder, have been documented for thumb pulp injuries. The most popular options include pedicled flaps and free flaps obtained from both the hands and feet. However, a consensus regarding the optimal method for reconstructing the thumb pulp has yet to be reached. We present a case of total thumb pulp reconstruction for a 40 × 30 mm defect using the free thenar flap in a 65-year-old carpenter who sustained a work-related injury. This flap was designed and raised on the superficial branch of the radial artery with a single subcutaneous vein and a branch of the palmar cutaneous nerve, the flap measured 43 × 32 mm. It was inset transversely with an end-to-end arterial anastomosis to the ulnar digital artery, venous anastomosis to the dorsal digital vein and nerve coaptation to the ulnar digital nerve. The postoperative course was uneventful, and the patient was discharged the following day without any complications. Eight months after surgery, the patient was extremely satisfied with the results of the procedure in terms of both function and appearance. The patient had experienced an improvement in function, sensation, and aesthetics. The patient had a QuickDASH disability/symptom score of 15.91 and a QuickDASH work module score of 18.75; the range of motion in the treated thumb was almost the same as the opposite thumb. The patient successfully resumed work three weeks following the procedure, initially with modified duties, and fully regained their work capacity within six weeks. As the patient's primary concern was their ability to return to work, the utilization of a free thenar flap offered several distinct advantages. These included minimal post-operative complications, facilitated by a single operative site, allowing for reconstruction under regional anesthesia. Moreover, the procedure was conducted in a single stage, enabling the patient to be discharged on the same day without the need for further procedures. Furthermore, similar to several other reconstructive options for the thumb, the utilization of a free thenar flap offered the advantage of providing high-quality, like-for-like glabrous tissue.

Modified homodigital dorsolateral proximal phalangeal island flap for the reconstruction of finger-pulp defects

BACKGROUND

Reconstruction of finger-pulp defects remains a challenge, although the treatment varies widely. The homodigital island flap based on dorsal branches of the proper digital artery (PDA) is one of the most popular methods for repair of finger-pulp defects. The aim of this study was to introduce our experiences of using modified dorsolateral proximal phalangeal island flaps for reconstruction of finger-pulp defects.

METHODS

From July 2016 to November 2018, 16 modified dorsolateral proximal phalangeal (MDPP) island flaps were performed for finger-pulp reconstruction. The comparison group included 11 patients treated with homodigital dorsal perforator (HDP) flaps. Flap survivals were assessed and active range of motion (ROM) of the joints, time to return to work, static 2-point discrimination and hand performance were analysed at final follow-up.

RESULTS

Both the Group MDPP and the Group HDP had similar satisfactory flap survival. There were no differences in static 2-point discrimination, time to return to work and the ROM of the injured fingers. However, the Michigan Hand Outcomes Questionnaire (MHQ) summary scores of the satisfaction and aesthetics were much better in Group MDPP.

CONCLUSIONS

The modified homodigital dorsolateral proximal phalangeal island flap is a reliable alternative for finger-pulp reconstruction with good functional and cosmetic outcome.

A Comparative Study of Finger Pulp Reconstruction Using Free Distal Ulnar Artery Perforator Flaps and Reverse Dorsal Homodigital Island Flaps

PURPOSE

This study aimed to compare and analyze the outcomes of finger reconstruction using free distal ulnar artery perforator (FDUAP) and reverse dorsal homodigital island (RDHI) flaps.

METHODS

The study included 27 patients with finger pulp defects that were reconstructed using FDUAP or RDHI flaps. Standardized assessment of outcomes included objective sensory recovery, duration of operation, range of motion in the repaired fingers, pain at the reconstructed finger pulps and donor sites, and recovery time before returning to work. Subjective assessment of outcomes included the cold intolerance, aesthetic appearance, and functional recovery.

RESULTS

All flaps in the series showed complete survival. The average surgical time for the RDHI flaps was significantly smaller than that for the FDUAP flaps. Sensory recovery was significantly better with FDUAP flaps than with RAHI flaps. No significant differences were detected between the 2 procedures regarding range of motion, cold intolerance, or pain of the injured finger pulps and donor sites. The outcomes of aesthetic result and functional recovery satisfied all patients. Optimal cosmetic satisfaction was obtained in the FDUAP flap group.

CONCLUSIONS

Although both types of flaps offer a satisfactory approach for finger reconstruction with small-to-medium defects, FDUAP flaps are more suitable for such operations because of the better sensory reconstruction and aesthetic results.

The experience of the free superficial palmar branch of the radial artery perforator flap application

PURPOSE

The purpose of this study is to retrospect and summarize clinical efficacy and experience of the free perforator flap base on the superficial palmar branch of the radial artery for tissue defect reconstruction in hand.

METHOD

17 patients who underwent tissue defect in hands reconstruction by the free superficial palmar branch of the radial artery (SPBRA) perforator flaps in our department from July 2014 to October 2018 were reviewed.

RESULTS

All the flaps in our series application were survival uneventful except one, which was necrosis because of venous thrombosis postoperative 5 days, and then the abdominal pedicle flap was executed to recover the defect in second stage. The first dorsal metacarpal artery flap and the arterial venous flap were utilized to cover the defect in one right index finger and one right ring finger due to the absence variation of the SPBRA. 2 cases presented tension vesicle of superficial skin and 1 case occurred venous congestion. All donor sites were closed primarily. The follow-up period means 13.5 months (range, 4-50 months). The static 2 point discrimination test mean 7.53 mm (range, 4-11 mm). All flaps acquire protective feeling at the latest follow-up. The self-assessment of patients: 13 cases in good, 4 cases in fair.

CONCLUSION

The goal of physiological reconstruction and esthetic effect can be achieved for hand tissue defect by the free SPBRA perforator flap, multiple tissues of the flap can be contained according to the defect. Even though the SPBRA is variation, arterial venous flap could be applied thanks to abundant superficial cutaneous veins.

[Clinical observation of superficial branch of radial artery wrist crease flap for repairing ring tissue defect of fingers]

Objective

To explore the effectiveness and operation method of the superficial branch of radial artery wrist crease flap for repair of ring tissue defect of the fingers.

Methods

Between June 2013 and March 2016, the superficial branch of radial artery wrist crease flap was used to repair ring finger tissue defect in 20 cases (21 fingers). There were 14 males and 6 females with an average age of 39.3 years (range, 12-61 years). The causes included machine injury in 9 cases, traffic accident injury in 6 cases, heat inury in 2 cases, and avulsed injury in 3 cases. The index finger was involved in 6 cases, middle finger in 6 cases, ring finger in 3 cases, and little finger in 6 cases. Combined injuries included exposure of bone, tendon, vessel, and nerve. The mean time of injury to operation was 3 hours (range, 0.5-5.5 hours) in 17 patients undergoing emergency operation, and was 8.5 days (range, 7-10 days) in 3 patients undergoing selective operation. The superficial palmar branch of the radial artery from the flap was used for bridging proper digital artery. The donor site was directly sutured in 19 cases and was repaired by skin grafting in 1 case.

Results

One case had blood blister at distal flap, which was cured after dressing change; the other flaps survived, and primary healing was obtained. Healing of incision at the donor site healed by first intention. The patients were followed up 6-24 months (mean, 12 months). The appearance, texture, and color of the flaps were satisfactory. The two-point discrimination ranged from 6 to 13 mm (mean, 9 mm) at 6 months after operation. According to the Chinese Medical Association Society of hand surgery of thumb and finger reconstruction function evaluation standard, the results were excellent in 13 cases, good in 4 cases, and fair in 3 cases; the excellent and good rate was 85%.

Conclusion

The superficial branch of radial artery wrist crease flap is an ideal choice for the repair of ring tissue defect of the fingers.

Thumb Replantation Using the Superficial Palmar Branch of the Radial Artery

The thumb is the most important part of the hand. If thumb is amputated, all efforts should be made to replant it to preserve hand functions. Good functional outcome can be obtained with successful thumb replantation than with other reconstructive surgery. We present a case of thumb amputation of a 44 -year-old male with severe damage to the soft tissues and bony structures of the radial part of the hand. We performed the replantation anastomosing the superficial palmar branch of the radial artery as donor artery as the proximal part of thumb digital arteries were severely damaged due to crush injury and got favorable result.

Thumb reconstruction via a pedicled flap based on the superficial palmar branch of the radial artery from the wrist crease area

BACKGROUND

The free flap based on the superficial palmar branch of the radial artery (SPBRA) has been extensively reported. A reversed pedicled flap based on the SPBRA, harvested from the wrist crease area, can be a potential candidate for the reconstruction of the soft-tissue and artery defects in the thumb.

METHOD

Between January 2012 and October 2013, this flap was used in seven patients to reconstruct soft-tissue defects in the thumb. In three patients, blood circulation of the thumb was reestablished using flow-through flaps. The Michigan Hand Outcomes Questionnaire was used for patient self-evaluation.

RESULTS

In one patient, the surgery was abandoned due to blood vessel variation. All the flaps and thumbs survived in the other six patients. The wounds healed primarily. All patients were followed up for a mean of 16.5 months (range, 12-26 months). At the last follow-up, the mean static two-point discrimination was 7.3 ± 0.9 mm on the affected side and 4.6 ± 0.7 on the contralateral side. The range of motion of the metacarpophalangeal joint and the interphalangeal joint were 66.8 ± 8.4° (contralateral, 85.2 ± 3.8°) and 67.0 ± 6.9° (contralateral, 80.5 ± 5.0°), respectively. Patient self-evaluations were good in five cases and fair in one case.

CONCLUSION

The reverse island flap based on the SPBRA is feasible for soft-tissue defects and establishing blood circulation in the thumb. The donor site can be closed primarily, and the scar is inconspicuous in the wrist crease.

Dermatofibrosarcoma protuberans, a rare but locally aggressive tumor on finger: clinical and aeromedical considerations

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow growing, locally infiltrative tumor of intermediate malignancy. It is mostly found on the trunk and head, rarely on hands. The course of evaluation and treatment of a young pilot with DFSP on left middle finger is reported. The clinical issues and aeromedical considerations of this rare tumor is discussed.

Reconstruction of volar skin and soft tissue defects of the digits including the pulp: experience with the free SUPBRA flap

BACKGROUND

The ideal flap for volar defects on the digits should provide glabrous skin, maintain length, be sensate and supple enough to allow unimpeded motion of the joints. When local flap options are either inadequate or unavailable, this constitutes a challenge that usually requires free tissue transfer. We describe our experience of the use of the free transfer of glabrous skin based on the superficial palmar branch of the radial artery (SUPBRA) for digital (volar) reconstruction.

METHODS

Between May 2005 and June 2011, we used this flap to reconstruct digital defects in 13 patients with mean age of 40.1 years (range 18-68 years) and a follow up range from 0.7 to 3.5 years (mean 1.5 years). The dimension of the flaps ranged from 2 × 5cm to 2 × 10 cm. The indications for surgery included traumatic loss of tissue/amputation, severe pulp space infection, dog bite injury, crush injury/ischaemic loss and salvage of failed local flap. The donor site was closed directly in all cases.

RESULTS

There were no flap failures. All wounds healed with good functional outcomes with ideal tissue match, minimal donor site morbidity and return of protective sensation despite no neurorrhaphy performed except in one patient.

CONCLUSION

The free SUPBRA flap has many advantages, approaching ideal replacement for the volar tissues of the fingers, excellent tissue match, minimal donor site morbidity with an excellent camouflaged scar in the mid palmar crease, one operation field, non sacrifice of a major vessel, can be made 'sensory', neurotises well and offers a single site for rehabilitation. We believe that the free SUPBRA flap is a very reliable and useful option in the armoury of the reconstructive hand surgeon.

Pedicled (antegrade) SUPBRA flap - for wound cover on volar aspect of thumb

A dictum of reconstruction is to replace like with like. Therefore, glabrous skin is best replaced with like tissue from the palm or the soles of the feet. We have previously presented our experience with free tissue from the palm based on the superficial palmer branch of the radial artery to reconstruct defects on the volar aspect of the digits following the original description of this flap by Kamei et al. There are situations where an antegrade pedicled flap from this area lends well as a choice for reconstruction. We describe the use of a pedicled flap from this axis for a defect on the radial aspect of the thumb and we believe it is the first report of its kind.

False aneurysm of the common digital artery. Is reconstruction with an arterial graft worth the efforts? A case report

False aneurysms in the hand are rare. A false aneurysm of the common digital artery in the palm for the second and third finger is reported, illustrating our experience with arterial graft reconstruction after excision as a valid alternative surgical therapy to a vein graft, when ligation or end-to-end anastomosis are not indicated or feasible. The superficial palmar branch of the radial artery was chosen as donor vessel based on the similarity in vessel diameter and wall thickness to the common digital arteries. Ease of harvesting and performing the microvascular anastomosis using an arterial graft allows for a viable reconstruction after false aneurysm excision in the palm.

Reconstruction of finger-pulp defect with a homodigital laterodorsal fasciocutaneous flap distally based on the dorsal branches of the proper palmar digital artery

OBJECTIVE

The purpose of our study was to introduce the surgical procedure and long-term follow-up of finger-pulp defect treated with the homodigital laterodorsal fasciocutaneous flap, which is based on the dorsal branches of the proper palmar digital artery.

METHODS

Seven cases with finger-pulp defect, which were treated by the homodigital laterodorsal fasciocutaneous flap based on the dorsal branches of the proper palmar digital artery, were involved in this study. The defect size ranged from 14.5 mm x 14.5 mm to 24.5 mm x 16.5 mm. Average duration of follow-up was 12 months (range, 10-36 months). Standardised assessment of outcome in terms of the defect size of finger-pulp, survival size of the flap, the static and moving two-point discrimination, time of returning to work and subjective assessment (satisfactory, good and very good) was completed.

RESULTS

All flaps in this series survived uneventfully. No loss of the flap in this series was noted. The average size of the flaps was 18.43 mm x 15.28 mm. The flaps had a good appearance, texture and blood circulation. The average static two-point discrimination and moving two-point discrimination of the flaps were 4.5mm (range, 4-6 mm) and 4.3 mm (range, 3-6 mm). All patients were content with the aesthetic and functional outcome of the surgery, and returned to their original job after an average of 4 weeks (range, 3-8 weeks) postoperatively.

CONCLUSION

The homodigital laterodorsal fasciocutaneous flap based on the dorsal branch of the proper palmar digital artery is an ideal alternative to reconstruct the finger-pulp for single-stage reconstruction without sacrificing the proper palmar digital artery and nerve.