Various Free Flap Reconstruction Techniques after Hand and Foot Melanonychia Ablation: A Case Series

(1) Purpose: The management of melanonychia is highly controversial. With growing melanonychia, in case of doubt, the entire lesion should be examined. It may appear similar to nail melanoma or may turn into melanoma. Here, we present surgical cases of nail bed total removal and free flap reconstruction. (2) Methods: Between 1 January 2020 and 31 December 2022, eleven patients were operated on for growing melanonychia, involving the hand and foot. After complete resection of the nail root and plate, immediate reconstruction was performed using a fasciocutaneous free flap. The authors describe the procedures in detail with a few illustrations and clinical photographs depicting the techniques. (3) Results: All patients underwent complete nail unit removal around the anatomic boundaries of the nail. Histology showed a nevus and no malignancy in all cases. We used three onychocutaneous flaps, three hypothenar flaps and five venous flaps. All flaps survived, with one case of partial necrosis which spontaneously healed with secondary intention. In the follow-up periods, there was no recurrence or nail regrowth. (4) Conclusions: These free flap techniques are very useful for total nail bed defect reconstruction after melanonychia lesion total ablation.

Multiple digit resurfacing with a lateral thoracic free flap: Two-stage mitten hand and division procedures

PURPOSE

The conventional abdominal and groin flaps for resurfacing the defect have several disadvantages, including the risk of flap failure due to accidental traction or detachment, immobilization of the arm before division, and aesthetic dissatisfaction because of the flap bulkiness. The aim of this study was to share our experiences with the free lateral thoracic flap and elucidate the optimal timing of division in complex hand reconstruction, which yielded favorable outcomes in terms of both functionality and aesthetics.

METHODS

This article is a retrospective review of multiple digit resurfacing using free tissue transfer from 2012 to 2022. Patients who underwent two-stage operation including mitten hand creation using superthin thoracodorsal artery perforator (TDAp) free flap and secondary division were included. A flap was elevated over the superficial fascia layer the midportion between the anterior border of the latissimus dorsi and pectoralis major muscles and once the pedicle was found, an outline that matched the defect was created. A process named "pushing with pressure and cutting" was carried out before pedicle ligation until all the superficial fat tissue had been removed except for around the perforator. Two cases (18%) involved defects of the entire fingers reconstructed by TDAp flap with anterolateral thigh flap. Six cases (55%) had a super-thin TDAp flap only. In two cases (18%), non-vascularized iliac bone grafting was required for finger lengthening. One case (9%) was resurfaced with a TDAp chimeric flap including a skin paddle with the serratus anterior muscle. The primary outcome was defined as the survival or failure of the flap, while the secondary outcomes associated complications such as infection and partial flap necrosis. A statistical analysis was not performed due to the size of the case series.

RESULTS

All 13 flaps survived completely without any complications. Flap dimension ranged from 12 cm × 7 cm to 30 cm × 15 cm. Mitten hand duration prior to division was 41.9 days on average which was essential for the optimal result. During the division procedures, there were nine cases of debulking (82%), six cases of split-thickness skin graft (STSG) (55%), and three cases of Z-plasty performed on the first web space (27%). The mean follow-up period was 20.2 months. Mean Disability of the Arm, Shoulder, and Hand (DASH) Questionnaire score was 10.76.

CONCLUSIONS

We resurfaced severe soft tissue defects of multiple fingers with thin to super-thin free flaps, mainly TDAp flaps. Surgeons can restore original hand shape using a two-stage reconstructive strategy of mitten hand creation and proper division timing to create a 3-dimensional hand structure, even in severely injured hands with multiple soft tissue defects of the digits.

Reconstruction of Digit Soft Tissue Defects With the Fourth Common Digital Artery Perforator Flap

PURPOSE

The hand has unique skin characteristics. Intrinsic flap donors are limited due to functional specificity and compactly connected structures. The hypothenar area is a reliable option for the reconstruction of finger defects. We performed anatomic studies elucidating the blood supply of this area and hypothesized that the fourth common palmar digital artery perforator free flap can be used to reconstruct soft tissue defects in fingers with minimal donor site morbidity.

METHODS

From November 2017 to February 2020, 30 procedures of fourth common digital artery perforator free flaps were performed to cover digital skin defects. A retrospective chart review was performed, and the cases were analyzed.

RESULTS

The mean patient age was 42.4 years (range, 1-75 years; median age, 40 years). Defects were located at the fingertip (n = 12), the dorsum (n = 3), the palmar (n = 9) aspect of the finger, and both the dorsal and palmar aspects of the finger (n = 6). Indications included emergent coverage (n = 13), coverage after necrosis (n = 11), oncological resection (n = 1), and contracture release (n = 5). The defect size ranged from 1.5 × 0.8 cm (1.2 cm²) to 6 × 2.5 cm (15 cm²). The perforator was located approximately 1 cm proximal to the distal palmar crease as it arose from the fourth common digital artery at a right angle. It continued to the ulnar border of the hand through the superficial fascia of the hypothenar muscles before running in a proximoulnar direction toward the dorsum of the hand. The diameter of the perforator was between 0.5 and 0.7 mm. All flaps survived. One case required a split-thickness skin graft for donor site closure, and all others could be closed primarily.

CONCLUSIONS

The fourth common digital artery perforator is a versatile flap and can be used for both palmar and dorsal defects, including for the fingertip. The location of the perforator used differs from previous descriptions but is routinely and reliably located.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[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.

Treatment of cold intolerance following finger pulp amputations: a case comparison between immediate finger replantation and delayed pulp and digital arterial arch reconstruction with flow-through free hypothenar flap

We report a unique case of cold intolerance following identical fingertip amputations of two fingers on the same hand. The index finger was replanted and the middle finger was reconstructed with a free flow-through hypothenar perforator flap to anatomically restore the digital arterial arch circulation and successfully treat cold intolerance.

Expanding indication of free hypothenar flap transfer: Sequential pedicled ulnar palm flap transfer to a relatively large hypothenar flap donor site

BACKGROUND

Free hypothenar flap (HTF) transfer allows sensible soft tissue reconstruction of the fingertip. However, HTF is basically indicated for a relatively small soft tissue defect, as width of an HTF is limited up to approximately 20 mm to allow primary donor site closure. Combined with sequential local flap to an HTF donor site, a larger HTF can be used without the contracture risk. The aim of this study was to evaluate feasibility of free HTF transfer and sequential ulnar palm flap (UPF) transfer (HTF-UPF) for relatively large fingertip reconstructions.

METHODS

Medical charts of patients who underwent HTF-UPF for fingertip reconstruction were reviewed. An HTF was designed transversely proximal to the proximal palmar crease, and a slightly smaller hemi-spindle-shaped UPF was designed longitudinally on the mid-lateral aspect of the ulnar palm; the UPF was used to close the HTF donor site. Patient and flap characteristics, intra-operative findings, and postoperative results were evaluated.

RESULTS

Twelve patients with average age of 42.7 years were included. HTF-UPF procedure was performed on 12 fingers. HTF's length/width ranged from 45/20 to 70/40 mm (average, 52.5/32.1 mm). UPF's length/width ranged from 40/20 to 55/30 mm (average, 46.7/24.2 mm). Time for sequential UPF transfer ranged from 3 to 9 min (average, 5.1 min). All HTFs and UPFs survived without flap necrosis or scar contracture. Postoperative sensation was comparable with the contralateral fingertip.

CONCLUSIONS

HTF-UPF procedure allows relatively large fingertip reconstruction with a minimum risk of HTF donor site contracture.

[Repair of digital volar complex soft tissue defect with heterodigital antegrade digital artery island flap innervated by digital nerve]

OBJECTIVE

To investigate the effectiveness of heterodigital antegrade digital artery island flap innervated by proper digital nerve and the dorsal branch of proper digital nerve for repairing digital volar complex soft tissue defects.

METHODS

Between May 2014 and January 2018, 27 patients with digital volar complex soft tissue defects were treated. There were 17 males and 10 females with an average age of 37 years (range, 18-60 years). The causes included electric saw injury in 8 cases, twisted injury in 12 cases, and heavy pound injury in 7 case. There were 9 thumbs, 5 index fingers, 6 middle fingers, 3 ring fingers, and 4 little fingers. The interval between injury and admission ranged from 1 to 4 hours (mean, 2.5 hours). The defect size ranged from 2.2 cm×1.4 cm to 3.8 cm×2.3 cm. The mean length of unilateral proper digital nerve defect was 2.9 cm (range, 2-4 cm). All defects were repaired with heterodigital antegrade digital artery island flap innervated by the proper digital nerve and the dorsal branch of the proper digital nerve. The proper digital nerve and the dorsal branch of the proper digital nerve in the flap were anastomosed with the proper digital nerve stumps in the wound. The flap size ranged from 2.4 cm×1.6 cm to 4.1 cm×2.6 cm. A segment of dorsal branch of the proper digital nerve was intercalated into the defect of the proper digital nerve in donor site. And the defect of donor site was repaired with the full-thickness skin graft.

RESULTS

All flaps and skin grafts survived, and the wounds healed by first intention. All patients were followed up 12-24 months (mean, 17 months). The appearance, color, and texture of the flaps were similar to the surrounding tissue. There was no pain and double sensibility in any flap. At last follow-up, the static two-point discrimination of the flaps ranged from 4 to 8 mm (mean, 5.3 mm). And the two-point discrimination of digital pulps of recipient and donor fingers ranged from 4 to 10 mm with the average of 6.2 mm and 6.0 mm, respectively. According to the functional assessment criteria of the upper limb formulated by the Hand Surgery Society of the Chinese Medical Association, the results were excellent in 18 cases and good in 9 cases. No scar contracture was observed in donor site.

CONCLUSION

The heterodigital antegrade digital artery island flap innervated by the proper digital nerve and the dorsal branch of the proper digital nerve provides a safe and simple technique with minimal donor site cost and satisfactory effectiveness, which could be an ideal option for repairing digital volar defect, especially for the defect complicated with digital nerve defect.

Evaluation of Neurotized Hypothenar Free Perforator Flaps Used for Fingertip Reconstruction

INTRODUCTION

In reconstruction of digital amputations of the upper extremity, composite tissue alternatives with similar features are limited for finger tip reconstruction. Among these alternatives, free perforator flaps elevated from the hypothenar region (HFPFs) are defined, but reluctancy goes on for utilization of these flaps.In this study, we aimed to highlight the sensory results of HFPFs when a neural repair is incorporated to the flap and also to justify their usage by presenting functional and aesthetic outcomes of the reconstructions performed with HFPFs.

METHODS

This clinical study was conducted from June 2015 to June 2017. Twelve patients with acute finger tip amputations were examined. Distal amputation levels were subgrouped according to Ishikawa classification. Patient demographics and amputation etiology were listed. All fingertip defects were reconstructed with a neurotized HFPF. All perforator anastomoses were performed in an end-to-end fashion. During follow-up, 2-point discrimination and dynamometric test were conducted. In addition, the Michigan Hand Outcomes Questionnaire was carried out. Evaluation of the results from a cosmetic standpoint was also conducted, with 4 blinded, independent surgeons using the visual analog scale.

RESULTS

Of 12 digital amputations reconstructed with neurotized HFPFs, 10 were totally viable during follow-up, whereas partial loss was observed in 2 flaps. The mean age was 38.8 ± 11.8 years. Most of the amputations were classified as Ishikawa subgroup 2 (50%). The mean dynamic 2-point discrimination was 3.2 ± 0.11 mm and slightly greater compared with contralateral digit (P = 0.003). Also minor decreases were measured in forced grip and pulp-to-pulp grip strengths (P = 0.003). Overall satisfaction was 92.7% in Michigan Hand Outcomes Questionnaire. Average visual analog scale score was 7.25 out of 10.

CONCLUSIONS

Hypothenar free perforator flaps, with incorporation of neural repair, give promising results for reconstruction of the fingertip. In addition to superior sensorial outcomes, HFPFs yield satisfying results from aesthetic and functional perspectives.