Free Dorsoulnar Perforator Flap Transfers for the Reconstruction of Severely Injured Digits

Observation of the Absence of Ulnar Artery in a Patient Planned to Free Dorsoulnar Artery Perforator Flap for Finger Defect: Is Preoperative Doppler evaluation of Perforator Alone Sufficient?

Background Volar finger defects where critical structures exposed are always challenging for plastic surgeons. In these types of defects, local flaps, cross finger flaps, abdominal flaps, and free flaps are used. Free dorsoulnar artery perforator (DUAP) flaps and superficial palmar branch of radial artery (SPBRA) flaps are also used. In this case, we present a patient who was scheduled to receive a DUAP flap to address defect on the second finger of right hand; however, we repaired the defect with a SPBRA flap because intraoperative absence of the ulnar artery was observed.

Materials and Methods A 34-year-old male patient was admitted with a wound that exposed the tendon and neurovascular bundle on the volar side of the second finger of the right hand. A free DUAP flap was planned for the patient. A perforator was detected during the preoperative Doppler ultrasound examination. While dissecting the perforator, we noted the absence of an ulnar artery proximal to the perforator vessel. The elevated SPBRA flap from same extremity and the defect were closed.

Results Postoperative computer tomography showed an absence of the ulnar artery distal to the right antecubital region. No complications were seen in the donor and recipient areas. Long-term motor movements were natural, and the patient's quality of life was good.

Conclusion Determining the perforator site using Doppler alone may not be sufficient in preoperative evaluation of patients scheduled to receive DUAP flaps. Performing an Allen test and using advanced imaging methods can prevent surgeons from encountering a bad surprise.

Reconstruction of thumb defects with medial sural artery perforator flap: case series

Background

Digital defect is one of the most common types of emergency hand injuries. Plastic surgeons continue to search for a better method to repair digital defects, especially those of the thumb. The medial sural artery perforator (MSAP) flap has been widely used as a popular method for limb and head reconstruction. Our findings have led us to advocate the use of free medial sural artery perforator flap to repair large thumb defects.

Methods

From July 2010 to July 2013, we used free MSAP flaps to resurface large defects of 9 thumbs in 9 clinical cases. There were 6 men and 3 women among the participants, aged 21–49 years (average age: 37.6 years). Flap sizes varied from 2 cm × 3 cm to 3 cm × 6 cm. Perforators of all flaps were accurately located by color Doppler detection.

Results

According to color Doppler detection, the distance from the popliteal crease to the points where first/second perforator pierced the deep fascia was 10.1±1.1/15.2±0.8 cm. The distance from the midline to the first/second perforator was 2.8±0.8/3.5±0.5 cm. A total of nine flaps fully survived. All defects of the nine thumbs were adequately resurfaced. Postoperative follow-up conducted at 12–24 months revealed satisfaction in both cosmetic and function results.

Conclusions

The MSAP flap, which can be easily harvested and well thinned, is an ideal choice to repair thumb defects. Accurate location of the perforator by Doppler detection ensures the surgical success, and minimizes injury to the donor site.

Microsurgical Free Tissue Options for Fingertip Reconstruction

Fingertip injuries occur commonly owing to trauma in everyday life. Performing amputation or stump revision for a fingertip injury can make it possible to quickly return to daily life, but causes functional and cosmetic problems. We believe that free flaps are the ideal way to minimize donor site morbidity and provide satisfactory reconstruction. Fingertips have different anatomic characteristics on the dorsum, volar aspect, and pulp, so it is necessary to select the appropriate free flap. Sometimes for larger defects, composite tissue transfer can be considered for reconstruction. This article discusses various free flap options for different fingertip defects.

Free medialis pedis venous flap transfer for reconstruction of volar finger defects: Clinical application and esthetic evaluation

BACKGROUND

There have been many reports about venous flaps, which are often used for the reconstruction of soft tissue defects after finger injury because such flaps are simple to elevate. Recently, high viability rates and nearly normal histological findings were reported for venous flaps, although the mechanism of flap survival remains unclear. This study investigated the esthetic outcomes after the reconstruction of volar finger defects with free medialis pedis venous flaps, which are venous flaps that elevated between the submalleolar and medial plantar regions.

MATERIALS AND METHODS

Reconstruction of volar finger defects was performed in 6 patients. All flaps were arterialized flow-through flaps with the venous anastomosis as the outflow. All 6 patients were men, with a mean age of 32.0 years. The defect involved the finger shaft in 4 patients and the finger pulp in 2 patients, and the mean size of the venous flap was 16.7 mm (width) × 34.2 mm (length). Five plastic surgeons specializing in maxillofacial surgery evaluated the color match of the flaps at 6 months postoperatively by assigning a score (maximum: 5 points).

RESULTS

The flap showed complete viability with little postoperative atrophy in all 6 patients. The mean color match score for the flaps was 3.7, and it decreased as the flaps were raised further from the medial plantar region.

CONCLUSION

Free medialis pedis venous flaps can be used for the reconstruction of volar soft tissue defects of the finger. Acceptable esthetic results can be obtained if flaps are harvested from an appropriate location in the medialis pedis region by a suitable method.

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.

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.

Thumb Reconstruction With Thin Proximal Ulnar Perforator Free Flap

Soft tissue defects of the thumb with exposure of tendons, periosteum, or neurovascular bundles require a complex reconstruction aimed at restoring both skin coverage and the essential function of pinching and manipulation. When large defects are involved, a free tissue transfer is indicated. The proximal ulnar perforator flap represents an interesting solution without the drawbacks of other more widespread free flaps. This report describes the case of a patient with a squamous cell carcinoma of the thumb that required circumferential resection of the soft tissue of the distal phalanx and the interphalangeal joint. The exposed structures were covered with pliable and texture-matching skin harvested from the proximal volar forearm and based on the proximal ulnar perforator. After 12-month follow-up, the patient was satisfied with the aesthetic outcome. Donor-site morbidity was minimal and no functional impairment in daily-life activities was reported. Even though a skilled microsurgical technique is required for the dissection of the perforator, its constant vascular anatomy and the low risk of damage to the main neurovascular bundle should make this flap reliable for the majority of hand surgeons.

A comparative study of four types of free flaps from the ipsilateral extremity for finger reconstruction

AIM

To compare the outcomes of finger reconstruction using arterialized venous flap (AVF), superficial palmar branch of the radial artery (SPBRA) flap, posterior interosseous perforator flap (PIPF), and ulnar artery perforator free (UAPF) flap harvested from the ipsilateral extremity.

METHODS

We retrospectively reviewed the outcomes for 41 free flaps from the ipsilateral extremity in the reconstruction of finger defects in 41 patients with small/moderate skin defects, including 11 AVFs, 10 SPBRA flaps, 10 PIPFs, and 10 UAPF flaps. Standardized assessment of outcomes was performed, including duration of operation, objective sensory recovery, cold intolerance, time of returning to work, active total range of motion (ROM) of the injured fingers, and the cosmetic appearance of the donor/recipient sites.

RESULTS

All flaps survived completely, and the follow-up duration was 13.5 months. The mean duration of the complete surgical procedure for AVFs was distinctly shorter than that of the other flaps (p<0.05). AVFs were employed to reconstruct skin defects and extensor tendon defects using a vascularized palmaris longus graft in 4 fingers. Digital blood supply was reestablished in 4 fingers by flow-through technique when using AVFs. Optimal sensory recovery was better with AVFs and SPBRA flaps as compared with UAPF flaps and PIPFs (p<0.05). No significant differences were noted in ROM or cold intolerance between the 4 groups. Optimal cosmetic satisfaction was noted for the recipient sites of AVFs and the donor sites of SPBRA flaps. The number of second-stage defatting operations required for AVFs was considerably lesser than that for the other flaps.

CONCLUSION

All 4 types of free flaps from the ipsilateral extremity are a practical choice in finger reconstruction for small/moderate-sized skin defects. AVFs play an important role in such operations due to the wider indications, and better sensory recovery and cosmetic appearance associated with this method.

Versatility of the reverse dorsoulnar fasciocutaneous flap in coverage of hand defects: clinical experience with 36 cases

PURPOSE

Local flap reconstruction is often required for soft tissue defects of the hand. The optimal reconstruction method should provide thin, supple, well-vascularized tissue with minimal donor-site morbidity. Short operating time and a sizable pedicle for microsurgical anastomosis are helpful. In this study, outcomes of hand defects after reconstruction with a reverse dorsoulnar flap were retrospectively analyzed.

METHODS

Between 2001 and 2008, 36 patients were evaluated (28 men, 8 women). Twenty-seven pedicle flaps and 9 free flaps were used. Nineteen patients had flexion contractures in their palms and fingers after burn injuries, 14 patients had traumatic soft tissue loss, and 3 patients had defects after tumor exicision. In 26 cases the defects were on the palm site, and in 10 cases the defects were on the dorsum of the hand. Mean follow-up was 12 months.

RESULTS

The success rate was 100%, with satisfactory cosmetic results. Functional recovery of the hands showed good results as well as acceptable donor healing without complication.

CONCLUSIONS

The dorsoulnar flap as either pedicle or free flap provides good and reliable skin cover for substantial soft tissue defects on the palm, dorsum of the hand, and the fingers.

Posterior interosseous free flap for finger re-surfacing

BACKGROUND

The authors present their clinical experience and surgical methods of soft-tissue coverage for the finger using a posterior interosseous free flap.

METHODS

Twelve posterior interosseous free flaps, including two dual-paddle flaps, were performed in 12 patients. Indications included: 1) patients with soft-tissue coverage of the dorsum of the finger (n=4), pulp (n=1), fingertip and pulp (n=5), 2) patients subsequent to release of finger and palm contracture (n=1) and 3) patients subsequent to finger separation (n=1). The posterior interosseous vessels were ligated below the level at which the motor branch to the extensor carpi ulnaris crossed the vessel superficially. The recipient vessels were the proper digital artery and palmar subcutaneous vein (n=10), deep branch of the ulnar palm artery (n=1), superficial branch of the radial palm artery (n=1) and the vena comitante. The cosmetic appearance of the donor and recipient sites, static two-point discrimination and active total range of motion of the operated finger were evaluated in a follow-up visit.

RESULTS

All flaps survived completely and all donor sites were closed directly, leaving a linear scar. De-fatting of the flap was carried out in one case in the late postoperative period; all other patients achieved a cosmetically acceptable result. Static two-point discrimination scores averaged 11 mm (range: 8-15 mm). Postoperatively, seven patients maintained normal flexion and extension of the joint. Two patients who had experienced a fracture and flexor injury recovered near-normal flexion and extension after flexor release; the other patients only recovered partially due to severe preoperative joint stiffness. Preoperatively, the active total range of motion of the operated fingers averaged 187 (range: 20-260). The average active total range of motion of the operated fingers at the last follow-up was 210 (range: 60-260). There was a significant difference between the preoperative and follow-up values (p=0.042).

CONCLUSIONS

The posterior interosseous free flap may become one valuable option for finger re-surfacing. Avoiding the sacrifice of a main artery of the hand and shorter pedicle can reduce the morbidity and operative time associated with this procedure. In addition, separate regions can be reconstructed with a dual-paddle flap.

Wound therapy by marrow mesenchymal cell transplantation

BACKGROUND

Marrow mesenchymal cells are useful in regenerative medicine because they contain stem cells, but there have been few reports of clinical applications. The authors developed a new wound treatment technique by improving marrow mesenchymal cell culture methods and placing cultured cells in an artificial skin material. This new treatment was useful for tissue regeneration in 20 patients with skin wounds.

METHODS

Marrow mesenchymal cells from a 46-year-old man were cultured and placed in artificial dermis made of collagen sponge. This composite graft was implanted subcutaneously into the back of a nude mouse and removed 10 days later; immunohistological analysis confirmed regeneration of subcutaneous tissue using human marrow mesenchymal cells. Next, in 20 patients (nine men and 11 women; average age, 64.8 years; range, 22 to 91 years) with intractable dermatopathies, 10 to 20 ml of bone marrow fluid was aspirated from the ilium and cultured in medium containing either fetal calf or autologous serum. The resulting cultured cells were placed in artificial dermis made of collagen sponge, and this composite graft was used to treat skin wounds.

RESULTS

The wound mostly healed in 18 of the 20 patients; the remaining two patients died of causes unrelated to transplantation. In all patients, autologous marrow mesenchymal cell transplantation was shown to be therapeutically effective.

CONCLUSIONS

In skin regeneration therapy using a marrow mesenchymal cell/artificial dermis composite graft, skin regeneration is possible with bone marrow aspiration, a minimally invasive procedure. Compared with existing skin grafting techniques, the present technique is practical and much less invasive.

Extended reverse dorsal metacarpal artery flap: clinical experience and donor site morbidity

Extended reverse dorsal metacarpal artery (RDMA) flaps use the skin from the dorsum of the hand to cover defects of the long fingers up to the distal phalanx. The authors present a series of 12 patients who underwent closure of defects of the long fingers with these flaps. As relevant literature is scarce, special emphasis was put on donor site morbidity. Active and passive total range of motion (TRM) and pinch grip strength of the finger neighbouring the reconstructed one were evaluated and compared to the corresponding finger of the contralateral hand. The donor site was furthermore evaluated for cosmetic appearance and pain. There was no statistically significant difference for active and passive TRM. The difference for pinch grip reached statistical significance (p=0.04). Subjective evaluation of pain and cosmetic appearance by the patients revealed a mean pain value of 1.25 on a visual analogue scale (0=no pain, 10=maximal imaginable pain) and a mean estimation of cosmetic appearance of 8 (visual analogue scale, 0=worst cosmetic result, 10=best cosmetic result). In conclusion, compared to other flaps, the extended RDMA flap is a fast, secure and single-stage procedure for defect coverage on the long fingers with low donor site morbidity.

Use of free dorsoulnar perforator flap in the treatment of postburn contractures of the fingers

BACKGROUND

Burns of the hand cause not only the impairment of hand function but also cosmetic deformity. Cases with dysfunctional hands with severe contractures increase if rehabilitation of the acutely burned hand is not done properly.

PURPOSE

We present the use of free dorsoulnar perforator flap in the treatment of postburn contractures as an alternative when local flaps cannot be used.

METHODS

Free dorsoulnar perforator flap was used in the treatment of seven hands with postburn contracture. Five of them had multiple digital postburn flexion contractures. Combined use of cross-finger and side finger transposition flaps was preferred when the adjacent finger was suitable for being cross-finger flap donor. When the adjacent finger was not suitable for being cross-finger flap donor, the free dorsoulnar perforator flap was preferred. Two of the patients had postburn web contractures. Free dorsoulnar perforator flap was used to release the web and to form a new web commissure.

CONCLUSION

The free dorsoulnar perforator flap could be a good alternative to cover the defects created with the hand contracture release.

Reverse Homodigital Dorsal Radial Flap of the Thumb

BACKGROUND

Reconstruction of extensive distal defects of the thumb with exposure of bone, tendon, or joint can be a difficult problem because immediate closure is of paramount importance for preserving function and avoiding complications. Surgical treatment includes the use of local, reverse flow, and free flaps. The authors describe a new reverse homodigital flap to repair distal defects of the thumb. This flap is raised from the dorsal radial side of the first metacarpal area. It is pedicled on the dorsal radial collateral artery, which is constant for course, caliber, and communication with the palmar circuit.

METHODS

The flap is raised by means of distal to proximal dissection, the skin island is incised at the periphery, and the subcutaneous pedicle is separated from superficial and deep tissues, leaving a certain quantity of loose tissue to protect the vascular axis. The digital sensory radial nerve is enclosed in the pedicle. The dissection must stop near the middle point of the proximal phalanx, which constitutes the pivot point of the flap. The flap is distally transposed and sutured on the deficit site.

RESULTS

The homodigital dorsal radial flap was used on 16 patients to repair distal losses of substance of the thumb. The final results were good for reliability and coverage and from the aesthetic point of view for both the reconstructed area and the donor site. In pulp reconstruction, there was a good recovery of sensitivity, without a neural anastomosis being performed (the mean value of static two-point discrimination was 9 cm in this series).

CONCLUSION

Wider use of this flap has helped to improve knowledge of dorsal vascularization of the thumb and to give another option for the repair of distal losses of substance of the thumb.

Donor site morbidity in cross-finger flaps

As relevant literature is scarce, this study was undertaken to assess the donor site morbidity of cross-finger flaps. It included 23 patients who had undergone reconstruction of a finger defect with a cross-finger flap. Any additional trauma to the donor finger was an exclusion criterion. Split thickness skin grafts were employed for donor site closure in 13 cases, full thickness skin grafts were used in 10 cases. Follow-up time averaged 83 months. Active and passive total range of motion of the donor finger and maximal pinch grip strength in kilopascals were measured. Both parameters were compared to the corresponding finger of the other hand. The donor site scar was evaluated for instability and pain in the donor finger was determined subjectively with a visual analogue scale. Cold intolerance and the cosmetic appearance of the donor site were also assessed. Active total range of motion of the donor fingers averaged 156 degrees . Average active total range of motion of the contralateral control fingers was 173.6 degrees . There was a significant difference between the donor fingers and the control fingers (p = 0.03) but not between split thickness and full thickness grafted donor sites (p = 0.91). Grip strength was significantly impaired in the donor fingers (p = 0.03), but there was no significant difference between split thickness and full thickness grafted donor sites. Subjective cosmetic evaluation by the patients revealed significantly better results for full thickness grafted donor sites. Donor finger pain averaged 2.4 with a range of 0-8. Five of the 13 patients with split thickness grafted donor sites and two of the 10 patients with full thickness grafted donor sites mentioned cold intolerance. In conclusion, the cross-finger flap is a secure and valuable option. There is, however, significant donor site morbidity. Our results suggest that alternative solutions should also be considered and if a cross-finger flap is employed, donor sites should be closed with full thickness grafts.