A reverse ulnar hypothenar flap for finger reconstruction

Cutaneous Perforators and Their Clinical Implications on Intrinsic Hand Flaps: A Systematic Review

Background:

Most hand flaps are local intrinsic flaps because hand perforators are small and fragile. The purpose of this review was to gather anatomical data on cutaneous perforators of the hand and their implications on intrinsic hand flaps.

Methods:

An electronic search was performed through PubMed, Scopus, ScienceDirect, ProQuest, and CINAHL in April 2021. The search terms included “hand,” “palm,” “manus,” “cutaneous artery,” “angiosome,” and “perforasome.” Studies were filtered according to the PRISMA flow chart, and critically appraised using the Quality Appraisal for Cadaveric Studies (QUAC) and Appraisal Tool for Cross-sectional Studies (AXIS).

Results:

A total of 33 studies were included, of which 20 were pure anatomical studies, 10 combined anatomical and clinical studies, and three imaging-based clinical studies. A total of 643 hands and 406 fingers were included. The dorsal aspect of the hand, the dorsal digits, hypothenar, midpalm, thenar, and dorsal wrist consistently have adequate, closely distributed perforators of small diameters and short pedicle lengths. A series of clinical studies proved the success of elevating local perforator flaps on each of these areas.

Conclusions:

The hand contained densely interlinked cutaneous perforators of varying sizes and pedicle lengths. Although some areas of the hand are still unexplored, knowledge on cutaneous perforators of the hand allows the creation of a variety of possibilities for intrinsic hand flap designs.

Propeller Flaps for Hand and Digit Reconstruction

The reconstruction of soft tissue defects of the hand, as seen often after trauma or tumor excision, is a challenge due to the great differentiation of tissues depending on the hand area involved. The classical intrinsic "workhorse flaps" of the hand are associated with a significant donor-site morbidity. Capturing perforator vessels in discrete donor areas can reduce the amount of soft tissue that has to be dissected and included in what now would be a perforator flap, while also insuring robust vascularization of those transferred tissues. Moreover, the presence of perforator vessels both on the dorsal and volar sides of the hand allows harvest of perforator flaps that will respect the like-with-like principle by maintaining the main characteristics of volar and dorsal skin as desired. However, the dissection of these flaps, especially those based on volar palmar and digital perforators, still requires microsurgical skills to preserve the fine vascularization of these flaps. These small flaps are also amenable for application of the propeller flap concept. This is an especially valuable means for preserving the length of an amputated finger where bone is exposed by using more proximal uninjured tissues. Although in general only a short dissection is required to raise a propeller flap in this region, most often the donor site will have to be closed by a skin graft.

Palmar Ulnar Artery Perforator Free Flap for Fingertip Reconstruction: Anatomical and Clinical Study

Background

Fingertips are a common site for hand injuries. The ideal substitute for fingertip pulp is tissue that matches texturally with minimal donor site morbidity. We described anatomical findings from cadaveric studies and the reliability of the palmar ulnar artery perforator (PUAP) free flap techniques for the reconstruction of fingertips injuries.

Methods

The cadaveric study involving 8 hands was conducted to illuminate the anatomy of the hypothenar region. We investigated the emerging point of perforators, diameter of the artery at the origin, and the length of the pedicle. Forty-four patients with fingertip injuries underwent fingertip reconstruction using PUAP free flaps. Data on the baseline patient demographics, hospital courses, and flap sizes were obtained retrospectively. The 6-month postoperative sensory capacity was determined using a 2-point discrimination test.

Results

The cadaveric study found that the PUAP pedicles arose from the superficial palmar arch, the mean length of pedicles, and the diameter and location of perforators were also analyzed. The PUAP flap sizes varied from 2.0 × 2.3 cm to 2.5 × 3.5 cm, and the mean operative time was 124 min. In all cases, we performed neurorrhaphy for fingertip sensory restoration. All donor sites were closed primarily, and the 2-point discrimination test result was 5.7 ± 0.87 mm 6 months after surgery.

Conclusions

We confirmed the anatomical consistency of the PUAP. Among the numerous reconstruction options available for fingertip injuries, the PUAP free flap is a useful fingertip reconstruction option.

Hypothenar island flap: A safe and excellent choice for little finger defects

Soft-tissue defects of the little finger are challenging especially when bone, tendon or vascular pedicle is exposed because of trauma. The hypothenar island flap is easy to harvest and has a good colour and texture match to the little finger pulp. We present nine clinical cases of soft tissue defects of the little finger covered using the reversed hypothenar fasciocutaneous island flap. This article intends to highlight the ease of elevation and good clinical results of the hypothenar flap which is rarely used.

An evolutionary perspective on the history of flap reconstruction in the upper extremity

Examining the evolution of flap reconstruction of the upper extremity is similar to studying the evolution of biological species. This analogy provides a perspective to appreciate the contributing factors that led to the development of the current arsenal of techniques. It shows the trajectory for the future and provides a glimpse of the factors that that will be influential in the future.

The little finger ulnar palmar digital artery perforator flap: anatomical basis

PURPOSE

The aim of this study was to explore the cutaneous vascularization of the hypothenar region and investigate the anatomical basis for perforator propeller flaps for coverage of the flexor aspect of the little finger.

METHODS

The area between the pisiform and the base of the little finger was studied in 14 hands of fresh cadavers injected with red latex. An oval flap 1.5 cm large was raised along the axis between these two points. Perforators going into the flap were dissected up to their origin from the ulnar palmar digital artery of the little finger, and their distance from the proximal edge of the A1 pulley was recorded.

RESULTS

The mean number of perforator arteries entering the flap was 5.8 (range 4-8). A constant sizeable perforator was identified within 0.7 cm from the proximal margin of the A1 pulley in all 14 specimens. In the majority of cases (64 %), the most distal perforator was located at this level. Dissection of the flap was carried out suprafascially on the most distal perforator and 180° rotation allowed the flap to reach the flexor surface of the fifth finger. The donor site was closed primarily.

CONCLUSION

Distal perforators of the ulnar palmar digital artery of the little finger are constantly found. Our anatomical findings support the possibility of raising a propeller perforator flap from the hypothenar region for coverage of the flexor aspect of the little finger. Its clinical application could provide a quick and straightforward single-stage option with a negligible donor-site morbidity for reconstruction of such defects.

The ulnar digital artery perforator flap: A new flap for little finger reconstruction - A preliminary report

An ulnar digital artery perforator flap was used for little finger reconstruction. The flap has a reliable blood supply, being perfused by a constant sizeable perforator. This paper describes a study of a cadaveric dissection with methylene blue dye that was conducted to prove the rationality and reliability of the blood supply. The position of the perforator is confirmed intraoperatively by an exploratory incision before committing to the distal incision. The flap used to cover the flexor aspect of the little finger in three cases yielded positive results. To our knowledge, a digital artery perforator flap of this nature is unprecedented. We propose to call this flap the B.J. Flap after our institute.

The vascular anatomy of the abductor digiti minimi and the flexor digiti minimi brevis muscles

PURPOSE

The abductor digiti minimi (ADM) and the flexor digiti minimi (FDM) brevis muscles could be used as flaps with their low functional morbidity, especially in severe crushed injuries of the hand. The vascular anatomy of both of the muscles were investigated to classify the muscles according to the Mathes-Nahai classification.

METHODS

Nine cadavers embalmed with formaline were dissected under loupe magnification (x4) from the wrist proximally to the proximal phalanx of the small finger distally, delineating the branches of the ulnar artery along the ADM and FDM muscles.

RESULTS

The dissections and the microangiography of the muscles revealed 1 major and 2 minor pedicles. Both of the muscles could be classified as type II muscles according to the Mathes-Nahai classification.

CONCLUSIONS

The vascular pattern of the ADM muscle has been described previously, this study explored the vascular anatomy of the FDM muscle. The information regarding the vascular supplies of these muscles could be of help to the clinician when manipulating the muscles. The FDM muscle could be a suitable alternative for the ADM muscle in opponensplasty. When the pedicles are preserved the muscles could be used--based proximally or distally.

Reconstruction of fingertip and stump using a composite graft from the hypothenar region

Finger amputation with bone exposure when replantation is not feasible requires a procedure for closure and padding of the stump. To preserve the length and provide adequate coverage, various flaps are used. A situation may occur in which local flaps are not sufficient and distant flaps are preferred. However, distant flaps often require a two-stage procedure, prolonged immobilization, and skin grafts. Thus, a simpler approach for fingertip or stump reconstruction while maintaining the padding effect of a flap was designed. The composite of glabrous skin and subcutaneous fat provided such padding, was performed in a single stage, and the donor site morbidity was negligible. During a 5-year period from 1996 to September 2002, 15 cases of finger stumps were reconstructed using the hypothenar composite graft. The age of the patients ranged from 1 to 63 years (average, 30 years). The average follow-up was 35 months. The donor sites were closed primarily and there were no marked complications related to this site. The graft showed relatively good contour and color match to the adjacent field, with an average two-point discrimination of 5.7 mm, indicating satisfactory reinnervation. The hypothenar composite graft for reconstruction of finger stumps can provide protective padding, maximal stump length, and minimal donor site morbidity, leading to satisfactory aesthetic and functional recovery.

[The fasciocutaneous hypothenar flap: preliminary anatomical and clinical study]

The authors have studied the vasculatization of the hypothenar area on 11 fresh hands. X ray done after injection and dissection under magnification confirm the possibility to take a fascio cutaneous flap vascularised by the ulnar digital artery of the fifth finger. Three patients who presented a loss of substance of the palmar site of the fifth finger received a fascio cutaneous hypothenar flap. The donor site was directly closed. This flap was proposed for the loss of substance of the palmar site of the fifth finger in competition with the others flaps.