The free instep flap for palmar and digital resurfacing

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.

Medial plantar artery perforator (MPAP) flap is an ideal option for reconstruction of complex soft tissue defect in the finger: Clinical experience from 11 cases

Introduction

Soft tissue defects of fingers are common in reconstructive plastic surgery, and reconstruction of the defects remains challenging for plastic surgeons. In our study, we reported our experience in finger reconstruction with a medial plantar artery perforator (MPAP) flap, especially using a lobulated MPAP flap for the complex multifinger soft defect.

Patients and methods

From the period April 2012 to October 2018, 11 patients (9 males and 2 females) with an average age of 44 years old (ranging from 11 to 58) received finger reconstruction with a free MPAP flap. In total, 11 flaps (8 single-lobulated flaps and 3 two-lobulated flaps) were raised from the ipsilateral or contralateral instep area. Trauma and scar contracture caused hand soft tissue loss in all cases.

Results

The sizes of the flaps ranged from 2×3 to 5×7.5 cm2. All flaps survived intact with no complications. One donor site was closed primarily, and other donor sites were covered with a full-thickness skin graft. The mean follow-up time was 6 months (ranging from 3 to 8 months). During the follow-up period, the patients were satisfied with their appearance without any traces of flap plastic surgery.

Conclusion

The MPAP flap is a reliable and acceptable option for the reconstruction of complex soft tissue defects in the finger. Depending on the two branches of the medial plantar artery, the use of the lobulated MPAP flap holds promise in the treatment of multifinger soft tissue defects.

Treatment of volar defects of the finger using dorsal digital-metacarpal flap versus free medial plantar artery flap: a comparative study

Background

The treatment of defects on the volar surface of the finger has been scarcely reported, and its utility for digital resurfacing remains unclear. This study compared the outcomes of free medial plantar artery flap (MPAF) and dorsal digital–metacarpal flap (DDMF) in finger reconstruction.

Methods

This retrospective cohort study included 24 patients with soft-tissue defects on the volar surface of the finger from March 2014 to March 2017. The patients were divided into two groups: the MPAF group and the DDMF group. The operation time, complications, such as flap necrosis, graft loss, infection, paresthesia, and donor-site morbidity, as well as two-point discrimination (2-PD) were carefully recorded. The Michigan Hand Outcomes Questionnaire was used for conduct follow-up assessment.

Results

After more than 12 months of follow-up, the MPAF group had a longer operative time compared with DDMF group, but there was no significant difference between postoperative complications and 2-PD test result in patients without nerve injury. And in terms of overall function, Modified VSS score and 2-PD test (the patients with nerve injury), There were relatively obvious statistical differences, MPAF was superior to DDMF (p < 0.005).

Conclusion

MPAF and DDMF are reliable for reconstruction of the volar surface of the finger; however, MPAF offers better functional outcomes and is associated with a lower incidence of postoperative complications.

Reconstruction of Severe Palm Injury with Sensate Medial Plantar Artery Flap and Nerve Grafting

A 28-year-old, healthy man presented with an abrasion injury of the left palm, including a full-thickness glabrous skin defect, an open injury of the carpal tunnel with 50% transection of the median nerve, and a multilevel traction/avulsion injury of the thenar motor branch. He underwent repair with a free medial plantar artery flap, nerve transfer of the palmar cutaneous nerve to the medial plantar cutaneous nerve, grafting of the median nerve, and direct neurotization of the thenar muscles via an end-to-side nerve graft from the median nerve. At 8 months postoperative, both donor and recipient areas had healed completely, and the patient had regained meaningful 2-point discrimination of the palm and fingers, achieved innervation of the thenar muscles, and returned to work as a cook.

Successful Balanced Gait after Reconstruction of the Weight-bearing Mid Plantar Region Using a Free Contralateral Medial Plantar Flap

Although soft tissue sarcoma, especially in the sole of the foot, is a rare disease, weight-bearing region reconstruction considering postoperative gait is needed. For functionally satisfactory sole reconstruction, it is important to cover the weight-bearing region with a nonbulky but durable skin paddle that can withstand a significant amount of shear pressure. We herein present a case in which a free contralateral medial plantar flap was used for reconstruction of the weight-bearing mid plantar region for a 41-year-old man who suffered from mid-foot sarcoma. Gait analysis was performed 6 months after the operation with the lower limb loading gauge sheet, and the result indicated that postoperative balanced gait was obtained. The free medial plantar flap transfer after sole sarcoma resection has several advantages. First, the characteristic of this flap with solid anchoring to deep tissue to resist shearing makes it possible to lower the chances of postoperative ulceration. Second, the medial plantar flap has optimal thickness and good color and texture match for sole reconstruction. Third, a sensate flap can be achieved if the medial plantar nerve is included. Although further clinical investigations such as long-term follow-up will be required to confirm its efficacy, this method would be one option for treating sole sarcoma.

Innervated dorsoradial perforator free flap: A reliable supermicrosurgery fingertip reconstruction technique

INTRODUCTION

This study demonstrates the use of a modified free innervated DRAP flap utilizing the supermicrosurgery technique for fingertip reconstruction.

MATERIALS AND METHODS

From January 2010 to February 2014, 20 cases of fingertip reconstruction were performed using a short pedicle mini innervated transverse DRAP flap. The patients demographics, the mechanism of injury, the defect size and anatomical location, the source of pedicle vessels, the recipient vessels, the nerve branch used for innervation, the follow-up and sensation outcomes are reported. Three cases are presented demonstrating different anatomical fingertip injury reconstructions.

RESULTS

20 consecutive traumatic fingertip injuries (M:F-14:6) were reconstructed with a free DRAP flap from the same hand. 6 index, 6 middle, 5 ring and 3 little finger defects were included in this study. All procedures were performed under regional anaesthesia and sedation. There were no intra- or post-operative complications. The average operative time was 105 (85-120) minutes. Each flap size was matching the size of the defects. All donor sites achieved primary closure and good cosmesis. The average follow-up was 12.8 (6-28) months. Follow-up demonstrated a static two-point discrimination of the flaps with an average distance of 5.5 (4-7) mm.

CONCLUSION

The innervated DRAP flap has proven to be an easy, reliable and effective sensate fingertip reconstruction option, utilizing the supermicrosurgery technique.

LEVEL OF EVIDENCE

Level IV, retrospective series.

Free Medial Plantar Flap Connection with a Posterior Tibial Artery Flap in Reconstruction of Fore-Mid Foot Skin Defect

BACKGROUND

Although there are many surgical treatments for covering the skin defect of the fore-mid foot, how to reconstruct the weight-bearing region remains a challenge. The weight-bearing region of the sole needs to withstand the pressure and shearing stresses of walking, so the plantar skin is anatomically different from other skins in the areas of texture, thickness, subcutaneous tissue, etc. Medial plantar flaps that are harvested from the instep region are regarded as the first choice for weight-bearing region reconstruction because of their excellent functional and aesthetic long-term result. However, when facing an extensive skin defect on a weight-bearing area such as a fore-mid foot avulsion, the application of this flap is limited because if we put the flap in a weight-bearing area of the forefoot, the set of vessels will be exposed to outside.

METHODS

We suggest 2 connected free flaps (posterior tibial artery flap and medial plantar flap) pedicled with 1 set of vessels. The medial plantar flap was used to cover the skin defect of the weight-bearing area in the forefoot. The dorsal skin defect of the injured foot was covered with a posterior tibial artery flap and supplied the medial plantar flap with the posterior tibial vessel. The midfoot skin defect was repaired by a full-skin grafting.

RESULTS

Long-term follow-up results showed that the shape and function of the injured limbs recovered almost entirely.

CONCLUSION

This method of connected flaps is suitable for repairing large skin defects of the fore-mid foot.

Skin Coverage Considerations in a Mutilating Hand Injury

The foremost goal of managing a mutilated hand is provision of adequate skin coverage. The most suitable method is free tissue transfer. The specific role of volar surface requires replacement tissue to have similar texture for aesthetically satisfactory and functionally acceptable outcomes. Hand surgeons must approach mutilating hand injuries with the recognition that no 2 injuries are ever the same. The injured hand must be evaluated on the individual demand and characteristics of hand use. Optimal function and aesthetic outcomes require appropriate selection of skin coverage. Lost tissues must be replaced like with like tissue.