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Jayachandiran AP, Rajendran S, Mahipathy SRRV, Durairaj AR, Sundaramurthy N, Ananthappan M. Revisiting Elliot's Modification of Moberg's Flap and Our Improvisation. Indian J Plast Surg 2024; 57:116-122. [PMID: 38774733 PMCID: PMC11105812 DOI: 10.1055/s-0044-1779658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024] Open
Abstract
Thumb tip injuries constitute one of the most common hand injuries. There are various reconstructive options for thumb tip injuries. We present our series of thumb tip injuries reconstructed using Elliot's modification of the Moberg flap, which provides like-for-like tissue. We also present our flap improvisation, which can be useful in the armamentarium of plastic surgeons. Background Moberg described the advancement flap for thumb defects in 1964, which was modified by O'Brien in which the proximal part of the flap is incised and advanced. Although it is a popular flap, it has the disadvantage of interphalangeal (IP) joint flexion deformity. Among the various modifications of the Moberg flap, Elliot's flap provided more tissue with minimal donor site morbidity and no usage of skin grafts or first web skin. Methods We retrospectively analyzed the patients who underwent reconstruction of thumb defects by Elliot's modified Moberg's flap. The size of the defect, etiology, and IP joint movement were analyzed. Two patients underwent our improvised flap where a daughter flap was elevated within Elliot's flap. Results Between January 2021 and September 2023, 12 patients underwent reconstruction by Elliot's flap. All flaps settled well. There was no IP joint deformity. Two patients had scar hypertrophy that was managed conservatively. Conclusion Elliot's modification of the Moberg flap is a very useful but underutilized flap for thumb tip injuries that provides like tissue with sensation and with little donor site morbidity. It can be used for thumb tip defects of up to 3 cm . It is possible to incorporate a second V-Y flap in patients for whom additional movement is required for tension-free closure.
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Affiliation(s)
- Anand Prasath Jayachandiran
- Department of Plastic & Reconstructive Surgery, Saveetha Medical College & Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Thandalam, Kanchipuram, Tamil Nadu, India
| | - Suresh Rajendran
- Department of Plastic & Reconstructive Surgery, Saveetha Medical College & Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Thandalam, Kanchipuram, Tamil Nadu, India
| | - Surya Rao Rao Venkata Mahipathy
- Department of Plastic & Reconstructive Surgery, Saveetha Medical College & Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Thandalam, Kanchipuram, Tamil Nadu, India
| | - Alagar Raja Durairaj
- Department of Plastic & Reconstructive Surgery, Saveetha Medical College & Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Thandalam, Kanchipuram, Tamil Nadu, India
| | - Narayanamurthy Sundaramurthy
- Department of Plastic & Reconstructive Surgery, Saveetha Medical College & Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Thandalam, Kanchipuram, Tamil Nadu, India
| | - Manoj Ananthappan
- Department of Plastic & Reconstructive Surgery, Saveetha Medical College & Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Thandalam, Kanchipuram, Tamil Nadu, India
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Goh E, Kulkarni S, Moura F, Norton S. Reconstruction of Soft-Tissue Defects of the Thumb Using Reverse-Flow Homodigital Flaps: A Systematic Review. J Hand Microsurg 2024; 16:100013. [PMID: 38854372 PMCID: PMC11127543 DOI: 10.1055/s-0042-1758671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction Soft-tissue thumb defects are common reconstructive challenges, the main goals being restoration of tactile sensibility, range of movement, pulp padding, length, and cosmesis. The reverse-flow dorsoulnar and dorsoradial collateral artery flaps are homodigital flaps used to cover both distal dorsal and volar thumb defects. These flaps can be used as compound flaps including skin, fat, and/or nerves. As there is no critical analysis of these studies, this study aims to create a synthesized comprehensive systematic review. Methods Systematic review was performed using the databases PubMed, Embase, and Medline. Eligible studies followed the inclusion criteria: English language and all studies published to date. The primary outcome was flap survival. Other data collected included anatomical area of the defect, flap constituents and dimensions, donor-site closure and complications, transfer method, reoperation, revision, and functional outcomes. Results A total of 19 articles incorporating 189 flaps met the inclusion criteria. These flaps were categorized and analyzed as dorsoradial (50%), dorsoulnar (39%), and turnover flaps (11%). Dorsoradial flaps were used in fasciocutaneous fashion alone. Partial flap failures occurred in five cases. Dorsoulnar flaps were used as fasciocutaneous or as osteocutaneous flaps. Complete flap failure was reported in one patient alone, whereas partial necrosis was reported in four patients. Adipofascial turnover flaps had two partial flap failures reported but no complete failures. The overall complete and partial flap failure rates were 0.5 and 6.5%, respectively. Conclusion Reverse-flow homodigital random or axial-based flaps provide a reliable means of reconstruction for soft-tissue defects with reasonable success rate and good functional outcomes. They have a consistent anatomy with a good potential for personalization and therefore increased versatility.
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Affiliation(s)
- Esther Goh
- Department of Plastic Surgery, Norfolk and Norwich University Hospitals, Norwich, United Kingdom
| | - Shreya Kulkarni
- Department of Plastic Surgery, Norfolk and Norwich University Hospitals, Norwich, United Kingdom
| | - Francisco Moura
- Department of Plastic Surgery, Norfolk and Norwich University Hospitals, Norwich, United Kingdom
| | - Samuel Norton
- Department of Plastic Surgery, Norfolk and Norwich University Hospitals, Norwich, United Kingdom
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Shi H, Huang Y, Shen Y, Wu K, Zhang Z, Li Q. The first dorsal metacarpal artery flaps versus reverse homodigital dorsal flaps for thumb reconstruction: a systematic review and meta-analysis. J Plast Surg Hand Surg 2024; 59:24-31. [PMID: 38407389 DOI: 10.2340/jphs.v59.12435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 01/21/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE This review was performed to systematically compare the effectiveness and safety of the first dorsal metacarpal artery flaps (FDMAF) and reverse homodigital dorsal flaps (RHDF) for thumb reconstruction. METHODS All literatures, which compared FDMAF versus RHDF for thumb reconstruction, were acquired through a comprehensive search in multiple databases from inception until 31st August 2022. A meta-analysis was performed using the Cochrane Collaboration's RevMan 5.4 software. RESULTS A total of 19 articles were retrieved, comprising 396 patients in the FDMAF group and 423 patients in the RHDF group. The pooled estimates suggested that there were no significant differences in venous congestion, complications about flap necrosis and reduced range of motion (ROM) of thumb, static 2-point discrimination (S-2PD) between the two groups. On the other hand, patients in the RHDF group had less vascular crisis (odds ratio [OR] = 3.15, 95%CI, 1.31-7.56), complications about poor cortical reorientation (OR = 440.02, 95%CI, 91.97-2105.27) and higher satisfaction rate (OR = 0.56, 95% CI, 0.33-0.96) than those in the FDMAF group. CONCLUSIONS The two surgical procedures were both safe and reliable since no significant differences were found in flap necrosis between the two groups. However, the patients in the RHDF group had less complications about vascular crisis, poor cortical reorientation and higher satisfaction rate. Accordingly, we thought RHDF may be more superior for thumb reconstruction than FDMAF.
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Affiliation(s)
- Haifeng Shi
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China.
| | - Yongjing Huang
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Yong Shen
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Ke Wu
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China.
| | - Zhihai Zhang
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Qian Li
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, China
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Zheng Y, Hallock GG, Levin LS, Zhang Y, Min P. Mini-Shaped Kiss Flap Design for Palmar and Digital Soft-Tissue Resurfacing. Plast Reconstr Surg 2024; 153:411-421. [PMID: 37036310 DOI: 10.1097/prs.0000000000010518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
BACKGROUND Although palmar and digital soft-tissue resurfacing with intrinsic flaps may provide functional and aesthetic reconstruction, the donor site may result in a tight closure or need for a skin graft once the flap is raised. In this series, the "mini-shaped kiss flap" was used to increase the resurfacing efficiency and preserve hand function. METHODS The mini-shaped kiss flaps, based on common palmar digital arteries (eg, princeps pollicis artery and ulnar palmar digital artery), were developed for the resurfacing of distal or proximal finger areas. The tiny skin paddles were "kissed" together and transferred as pedicled in proposed dimensions and shape. The flap size, donor/recipient site, perforator source, whether free or pedicled, surgical outcome, and donor-site morbidity were evaluated. RESULTS Twenty mini-shaped kiss flaps were harvested for the purpose of palmar and digital resurfacing. The flap sizes varied from 3 × 1.2 cm to 5 × 2 cm. All 19 patients, aged 6 to 52 years (mean, 35 years), achieved successful reconstruction without major complications after 6- to 12-month follow-up. CONCLUSIONS The mini-shaped kiss flap technique exhibited favorable surgical outcomes with excellent color and texture match to the recipient sites. The reverse midpalm, thenar, and hypothenar island flap can be raised at the cost of an unnoticeable linear scar with minimized functional compromise in the donor area. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Youmao Zheng
- From the Department of Hand and Foot Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University
| | | | - L Scott Levin
- Department of Orthopedic Surgery, University of Pennsylvania
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University College of Medicine
| | - Peiru Min
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University College of Medicine
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Wang H, Yang X, Huo Y, Hao R, Wang B, Wang W. Reverse homodigital dorsal wraparound flap for reconstruction of distal thumb. J Plast Surg Hand Surg 2023; 57:336-342. [PMID: 35724236 DOI: 10.1080/2000656x.2022.2088542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Reconstruction of degloving injury or amputation of distal thumb with no indication of replantation has always been a challenging problem for hand surgeons. In this study, a reverse homodigital dorsal wraparound flap innervated by the dorsal digital nerve was devised to repair degloving injury or amputation of distal thumb in 20 consecutive cases. In nine cases of thumb amputation, we skeletonized the phalanxes of the amputated part as a free cortical bone with Kirschner wires. All flaps survived uneventfully. The radiographs showed bone healing in all the patients of thumb amputation within 6 weeks postoperatively. At final follow-up, the appearance of the reconstructed thumb was acceptable and flap sensation and range of joint motion were satisfactory. This flap is a simple and reliable alternative method for degloving injury or amputation of distal thumb when replantation is impossible and patients refuse to donate tissues from toes. Type of study/level of evidence Therapeutic IV.
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Affiliation(s)
- Hui Wang
- Hand Surgery Department, The Second Hospital of Tangshan, Tangshan, P.R. China
| | - Xiaoxi Yang
- The College of traditional Chinese Medicine, North China University of Science and Technology, Tangshan, P.R. China
| | - Yongxin Huo
- Hand Surgery Department, The Second Hospital of Tangshan, Tangshan, P.R. China
| | - Ruizheng Hao
- Hand Surgery Department, The Second Hospital of Tangshan, Tangshan, P.R. China
| | - Bin Wang
- Hand Surgery Department, The Second Hospital of Tangshan, Tangshan, P.R. China
| | - Wei Wang
- Hand Surgery Department, The Second Hospital of Tangshan, Tangshan, P.R. China
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Zhang Q, Li W, Chen Q. Reverse homodigital dorsoradial flaps for thumb coverage obtained good sensory recovery after a long time follow up. J Plast Surg Hand Surg 2023; 57:172-177. [PMID: 35034565 DOI: 10.1080/2000656x.2021.2024558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Reverse homodigital dorsoradial flap (RHDF) of the thumb has become a qualified option for the reconstruction of thumb tissue defects. However, the sensory recovery of the flap in long term is still unknown. Therefore, this study focused on the sensory recovery of RHDFs for the coverage of thumb in hand after a long-term follow-up. From January 2010 to March 2011, 18 patients (14 men and four women) were treated consecutively with an RHDF. All the patients were followed up two times. The pain and cold intolerance of the flap were self-reported by the patients. The sensory recovery of the flap was evaluated using Semmes-Weinstein (SW) monofilament, moving two-point discrimination (M-2PD) and static two-point discrimination (S-2PD) tests. The average times of the first and second follow-up were 39 ± 4 and 88 ± 6 months, respectively. The mean value of SW monofilament sensitivity score and M-2PD at first follow-up was significantly higher than that of the second follow-up and contralateral thumb. The mean value of S-2PD at the second follow-up was significantly lower than that of the first follow-up and higher than that of the contralateral thumb. The cold intolerance severity score (CISS) at the first follow-up was higher than that at the second follow-up. No significant difference was found in terms of the pain between the two follow-ups. RHDFs without nerve coaptation for thumb coverage could obtain good sensory recovery after a long-term follow-up. Abbreviations: RHDF: reverse homodigital dorsoradial flap; CISS: cold intolerance severity score; SW: Semmes-Weinstein monofilament sensitivity score; M-2PD: moving two-point discrimination; S-2PD: static two-point discrimination; VAS: visual analog scale.
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Affiliation(s)
- Qiaoyun Zhang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, PR China
| | - Wenyi Li
- School of Medical Imaging, Xuzhou Medical University, Xuzhou, PR China
| | - Qingzhong Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, PR China
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Abstract
This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.
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Affiliation(s)
- Roberto Adani
- Department of Hand Surgery and Microsurgery, University Hospital of Modena, Modena, Italy
| | - Jin Bo Tang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - David Elliot
- St Andrew's Centre for Plastic Surgery, Broomfield Hospital, Chelmsford, UK
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[Reconstruction of defects on the hand]. Unfallchirurg 2021; 124:789-796. [PMID: 34533596 DOI: 10.1007/s00113-021-01077-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
From a reconstructive viewpoint, injuries of the hand are particularly challenging. They are often associated with exposed tendons, bones, nerves and vessels, whereas little skin and soft tissue reserves are available for coverage. Functional and esthetic requirements necessitate a differentiated approach, depending on the location and extent of the defect. This article gives an overview of reconstruction techniques and flap surgery on the hand for various defect sizes and locations.
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The Sensory Collateral Nerve-Pull Technique: A Viable Maneuver to Aid Harvesting the Pedicle of the Moschella Flap. Plast Reconstr Surg 2021; 147:571e-572e. [PMID: 33395005 DOI: 10.1097/prs.0000000000007663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Berthier C, Arthozoul M, Taizou M, Grolleau JL, de Bonnecaze G, Chaput B. Is the dorsal vascular system sufficient to vascularize the entire teguments of the thumb? Surg Radiol Anat 2021; 43:397-403. [PMID: 33392700 DOI: 10.1007/s00276-020-02627-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Simultaneous lesions of both proper digital arteries of the thumb are common in hand trauma surgery. The purpose of this anatomical study was to determine if the dorsal arterial network could be sufficient to ensure the vascularization of the thumb skin sheath. METHODS We carried out a cadaveric study on 22 hands. The ulnar and radial proper digital arteries of the thumb were ligated at the base of the first phalanx. Red dye was injected into the radial artery and blue dye into the ulnar artery at the wrist level. Visual evaluation of skin staining and systematic photographs was done at 1, 3 and 10 min after injection of dyes. RESULTS Staining of the thumb sheath was obtained in 100% of the dissections and complete in 91.91% of cases. Staining originated from mixed radial and ulnar artery origins in 81.82% of cases. It was incomplete in 9.09% of cases with a missing on the dorsoradial edge of the proximal phalanx. In one dissection, the whole hand skin was only stained red, and in another dissection only stained blue. CONCLUSION The dorsal vascular network ensures the substitution of the skin vascularization in more than 90% of cases when ligating the proper digital arteries of the thumb. A clinical impression of good skin vascularization after injury of both proper digital arteries might lead the surgeon not to perform systematic revascularization, but the risk of variable damages of adjacent tissues due to an interruption of one major arterial system requires a palmar arterial anastomosis whenever possible.
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Affiliation(s)
- Charline Berthier
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France.
| | - Marion Arthozoul
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
| | - Mohcine Taizou
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
| | - Jean-Louis Grolleau
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
| | - Guillaume de Bonnecaze
- Department of Otorhinolaryngology Head and Neck Surgery, CHU Rangueil-Larrey, University of Toulouse, Toulouse, France.,Department of Anatomy, CHU Rangueil-Larrey, University of Toulouse, Toulouse, France
| | - Benoit Chaput
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
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Homann HH, Gojowy D, Sacher M, Schreier D. [Moschella island flap for coverage of thumb defects]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2020; 32:494-500. [PMID: 33201291 DOI: 10.1007/s00064-020-00682-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/19/2020] [Accepted: 04/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The homodigital island flap according to Moschella is used to cover palmar and radiodorsal soft tissue defects of the thumb. INDICATIONS Soft tissue reconstruction of the thumb with exposed bone and/or tendon if reconstruction of the soft tissue is required. CONTRAINDICATIONS Extensive scars in the harvesting area of the flap; vascular occlusions of the radial artery. SURGICAL TECHNIQUE After Doppler sonographic imaging of the origin of the vessel radially at the thumb, the pivot point is determined. The flap is then cut from ulnar to radial, including the dorsoradial artery of the thumb. Removal of the origin of the vessel from the radial artery in the tabatiére and preparation from proximal to distal to the pivot point of the flap at the junction of the artery with the palmar vessels. If necessary, a part of the skin can remain palmar to the pivot point to improve venous drainage. The donor site of the flap can primarily close defect sizes up to 5 × 4 cm. POSTOPERATIVE MANAGEMENT Until wound healing, soft cotton dressing should protect the vascular pedicle from pressure; immobilisation on a palmar splint may be helpful. RESULTS In 9 men, sufficient soft tissue reconstruction of thumb defects could be achieved with the described Moschella flap. Eight patients had additional injuries to the fingers and hand.
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Affiliation(s)
- Heinz-Herbert Homann
- Klinik für Handchirurgie, Plastische Chirurgie, Zentrum für Brandverletzte, BG-Klinikum Duisburg, Grossenbaumer Allee 250, 47249, Duisburg, Deutschland.
| | - David Gojowy
- Klinik für Handchirurgie, Plastische Chirurgie, Zentrum für Brandverletzte, BG-Klinikum Duisburg, Grossenbaumer Allee 250, 47249, Duisburg, Deutschland
| | - Maxi Sacher
- Klinik für Plastische Chirurgie, Handchirurgie, Brandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Detlef Schreier
- Klinik für Handchirurgie, Plastische Chirurgie, Zentrum für Brandverletzte, BG-Klinikum Duisburg, Grossenbaumer Allee 250, 47249, Duisburg, Deutschland
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Qin H, Ma T, Xia J, Zhang W. Comparison of reverse dorsoradial flap for thumb reconstruction: narrow pedicle versus wide pedicle. Arch Orthop Trauma Surg 2020; 140:987-992. [PMID: 32367376 DOI: 10.1007/s00402-020-03467-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The reverse homodigital dorsoradial flap remains a useful alternative for covering thumb defects. However, the description of pedicle width of dorsoradial flap is not clear. The aim of this study was to compare the results of narrow pedicle with wide pedicle in dorsoradial flaps and describe our experience with the thumb reconstruction. MATERIALS AND METHODS From July 2014 to February 2019, 42 patients were treated with the reverse dorsoradial flap for thumb reconstruction. The patients were divided as Group A (pedicle width ≤ 0.8 cm) and Group B (pedicle width > 0.8 cm). Flap survival, time to return to work, flap sensibility, the range of motion (ROM) of the joints, and final aesthetic outcomes were evaluated. RESULTS Respectively in the Group A (17 cases) and Group B (25 cases), 14-19 flaps survived uneventfully, whereas 3-6 flaps experienced venous congestion with no or partial flap loss. No significant difference was identified between the two groups for the incidence of venous congestion, static 2-point discrimination and ROM of the injured thumbs. Time to return to work was significantly shorter in Group A. The aesthetic satisfaction of the patients in Group A was significantly better comparing with that in Group B. CONCLUSIONS The reverse homodigital dorsoradial flap with narrow pedicle width is associated with more favorable outcomes in terms of time lost from work and aesthetic satisfaction of the patients.
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Affiliation(s)
- Hongjiu Qin
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Tao Ma
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Jiang Xia
- Department of Orthopedics, Tongji Hospital of Tongji University, Shanghai, China
| | - Wenxian Zhang
- Department of Orthopedics, Gansu Provincial Hospital of TCM, Lanzhou, 730000, Gansu, China.
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Neustein TM, Payne SH, Seiler JG. Treatment of Fingertip Injuries. JBJS Rev 2020; 8:e0182. [PMID: 32539263 DOI: 10.2106/jbjs.rvw.19.00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The goal of care when treating fingertip injuries is to minimize the risk of infection while maximizing function, tactile sensation, digit length, pulp padding, and appearance. This outcome can be achieved with careful soft-tissue coverage and, if possible, nail-bed preservation. When replantation for a fingertip amputation is not possible for anatomic or logistical reasons, local or regional flap reconstruction can be a useful alternative to gain early soft-tissue coverage and allow more functional rehabilitation. Reviewing current fingertip soft-tissue coverage procedures and demonstrating key anatomic and technical points with cadaveric dissections provides a foundation for the incorporation of these techniques into practice.
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Affiliation(s)
- Thomas M Neustein
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Mao T, Xie R, Wang G, Xing S. Application of a modified dorsoulnar artery pedicle flap in the repair of thumb tip defects: A case report. Exp Ther Med 2020; 19:3300-3304. [PMID: 32266026 PMCID: PMC7132239 DOI: 10.3892/etm.2020.8583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 01/06/2020] [Indexed: 11/06/2022] Open
Abstract
Between February 2012 and March 2014 10 patients were admitted to the Affiliated Hospital of Nantong University for surgery due to a thumb tip defect. Nine of these patients were male and one was female and there were 7 cases of left thumb defects and 3 cases of right thumb defects. The surgical procedures followed were first, modification of the flap tail to an equilateral triangle, which facilitated pedicle suturing of soft tissue defects, caused mild tension and effectively reduced venous disorders, and second complete opening of the flap pedicle to the soft tissue defects at the tunnel. All patients were followed up at 6 and 12 months after surgery. Grip and pinch strength were measured 6 and 12 months after surgery. Static two-point discrimination testing of the modified flap showed minor differences from the uninjured hand. Post-surgery grip and pinch strength were restored to approximately 85% of the level of that in the uninjured hand. The modified dorsoulnar artery pedicle flap provided excellent thumb tip defect coverage and is an effective and safe technique for the restoration of grip and pinch strength to the hand after the repair of a thumb tip defect.
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Affiliation(s)
- Tian Mao
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Renguo Xie
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Guheng Wang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Shuguo Xing
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
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Karjalainen T, Jokihaara J. A Review and Meta-analysis of Adverse Events Related to Local Flap Reconstruction for Digital Soft Tissue Defects. Hand Clin 2020; 36:107-121. [PMID: 31757343 DOI: 10.1016/j.hcl.2019.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We reviewed the current literature to estimate incidence rates for adverse events with pedicled flaps in the hand. We identified 241 different studies reporting adverse events for 6693 flaps. The average incidence rate was 5.4% and total or partial loss of flap constituted 65% of all reported complications. Flaps with reverse or perforator-based flow may be more prone to vascular complications compared with flaps with antegrade flow or skin pedicle. The incidence rates were acceptable in all flaps (1%-10%) and thus the flap can be chosen primarily based on considerations other than risk of adverse events.
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Affiliation(s)
- Teemu Karjalainen
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash Department of Clinical Epidemiology, Cabrini Hospital, Monash University, Malvern, Australia; Department of Surgery, Central Finland Central Hospital, Keskussairaalantie 16, Jyväskylä 40620, Finland.
| | - Jarkko Jokihaara
- Department of Hand Surgery, Tampere University Hospital, TAYS/TUL2, Teiskontie 35, Tampere 33521, Finland; Faculty of Medicine and Health Technology, Tampere University, TAYS/TUL2, Teiskontie 35, Tampere 33521, Finland
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The width of pedicle included in reverse dorsoradial flap of the thumb: As wide as possible? J Plast Reconstr Aesthet Surg 2019; 72:2064-2094. [DOI: 10.1016/j.bjps.2019.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/20/2019] [Accepted: 10/05/2019] [Indexed: 11/19/2022]
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Tu Q, Liu S, Chen T, Li S, Yan H, Li Z. A Comparative Study of Finger Pulp Reconstruction Using Free Distal Ulnar Artery Perforator Flaps and Reverse Dorsal Homodigital Island Flaps. Ann Plast Surg 2019; 83:650-654. [PMID: 31714294 DOI: 10.1097/sap.0000000000002106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Qiming Tu
- From the Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Adani R, Mugnai R, Petrella G. Reconstruction of Traumatic Dorsal Loss of the Thumb: Four Different Surgical Approaches. Hand (N Y) 2019; 14:223-229. [PMID: 29039226 PMCID: PMC6436130 DOI: 10.1177/1558944717736396] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This article outlines our methods for thumb reconstruction following dorsal skin loss injury located between the metacarpophalangeal joint (MPj) and the entire nail affecting skin, nail, tendon, and bone in different combinations but with intact sensate palmar skin. METHODS Between 1990 and 2015, 24 patients were treated for dorsal thumb defects using 4 different surgical techniques. Five cases of dorsal compound traumatic loss were reconstructed by custom-made dorsal great toe transfer. Four patients with dorsal skin and nail loss located at the distal phalanx level were covered with the homodigital flap with reverse flow vascularization. In 9 patients presenting skin defects between the MPj and the nail, reconstruction was achieved by means of the kite flap. Six cases suffered extensive dorsal skin loss, and reconstruction was performed using different types of radial forearm flaps (cutaneous, tendineocutaneous, osteocutaneous, and fascial). RESULTS Flap survival was obtained in all cases. No vascular complications occurred with free vascularized compound toe transfer. CONCLUSIONS Reconstruction of dorsal thumb defects is imperative and its approach is strictly correlated to type of defect, patient's requests, and flap alternatives. For defects with nail involvement, the free osteo-onychocutaneous flap harvested from the great toe provides the best aesthetic result in selected young and well-motivated patients. An alternative is represented by the dorsoulnar flap, when the defect is located distally, or the fascial pedicle radial forearm flap, for major dorsal thumb defects, in patients refusing microsurgical reconstruction. The kite flap still represents a feasible solution for medium-size defects with an intact nail.
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Affiliation(s)
- Roberto Adani
- University Hospital of Modena, Italy,Roberto Adani, Department of Hand Surgery and Microsurgery, University Hospital of Modena, Policlinico, Largo del Pozzo 71, Modena 41124, Italy.
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Unglaub F, Langer MF, Unglaub JM, Müller LP, Hahn P, Spies CK, Löw S. Defektdeckung an den Fingern und am Daumen. Unfallchirurg 2018; 121:321-334. [DOI: 10.1007/s00113-018-0469-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shubinets V, Elliott RM. Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap. J Hand Surg Am 2018; 43:89.e1-89.e7. [PMID: 29132790 DOI: 10.1016/j.jhsa.2017.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/14/2017] [Indexed: 02/02/2023]
Abstract
The thumb ulnar pulp is a critical component of key pinch and precision manipulation. Injuries to this area should be reconstructed with robust, sensate tissue that restores bulk and contour. The existing reconstructive options, however, have substantial risks and drawbacks. We describe an anterograde homodigital neurovascular island flap that provides both sensate and durable coverage of the ulnar thumb pulp. The flap uses innervated glabrous tissue, limits donor site morbidity to the thumb and first web space, and does not require microvascular anastomoses or nerve coaptation. The flap has been previously described for nonthumb fingertip injuries, but it has not been applied to the thumb. We discuss several important technical modifications that are essential to raising and insetting this flap in the thumb, review potential pitfalls, and highlight key steps to ensuring judicious intraoperative decision making and success.
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Affiliation(s)
- Valeriy Shubinets
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
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Qin H, Xia J, Hu B, Wang H, Xu L, Wang Y. [Repair of thumb defects with modified radial dorsal fasciocutaneous flap of thumb]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:841-844. [PMID: 29798530 DOI: 10.7507/1002-1892.201703053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the operative method of repairing soft tissue defect of the thumb with modified radial dorsal fasciocutaneous flap and its effectiveness. Methods Between June 2015 and December 2016, 15 patients with volar or dorsal defects of the thumb were treated with modified radial dorsal fasciocutaneous flaps which distal pedicles were cut off. Of 15 cases, 11 were male and 4 were female, aged 35-70 years (mean, 46 years). The causes of injury included crush injury in 12 cases and avulsion injury in 3 cases. Because all patients had volar or dorsal defects of the thumb which were accompanied by tendon or bone exposure, they had no condition or desire to replant. There were 12 cases of volar defect of thumb and 3 cases of dorsal defect. The area of defects ranged from 2.0 cm×1.2 cm to 3.0 cm×2.5 cm. The time between injury and operation was 16 hours to 2 days (mean, 30.4 hours). The radial dorsal fascio-cutaneous flaps of 2.3 cm×1.5 cm to 3.3 cm×2.8 cm in size were adopted to repair defects. The donor sites were directly sutured. Results All flaps survived, and no severe swelling or tension blister occurred. The donor sites and wounds healed by first intention. All patients were followed up 3-12 months (mean, 6 months). The color and texture of the grafted flaps were similar to those of normal skin, with no bloated appearance. According to total active motion standard at last follow-up, the finger function was excellent in 8 cases and good in 7 cases. Conclusion Modified radial dorsal fasciocutaneous flap of the thumb is a reliable flap with easy dissection and less trauma in repair of soft tissue defects of the thumbs, and satisfactory clinical outcome can be obtained.
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Affiliation(s)
- Hongjiu Qin
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
| | - Jiang Xia
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001,
| | - Bin Hu
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
| | - Haisheng Wang
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
| | - Lei Xu
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
| | - Yinze Wang
- Department of Hand and Foot Surgery, Yijishan Hospital of Wannan Medical Collage, Wuhu Anhui, 241001, P.R.China
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Germann G, Rudolf KD, Levin SL, Hrabowski M. Fingertip and Thumb Tip Wounds: Changing Algorithms for Sensation, Aesthetics, and Function. J Hand Surg Am 2017; 42:274-284. [PMID: 28372640 DOI: 10.1016/j.jhsa.2017.01.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 02/02/2023]
Abstract
Management of fingertip and thumb tip injuries has recently undergone substantial changes. The time-proven traditional armamentarium of local flaps has been expanded and replaced by a wide variety of flaps. Simultaneous with the development of new flaps, the conservative treatment of fingertip and thumb tip injuries with semiocclusive dressings has also become a more acceptable treatment for these injuries. The excellent results with respect to restoring contour, sensibility of the pulp, and aesthetics of the finger justify this more tedious and time-consuming treatment of fingertip and thumb tip injuries. This article gives an update of the most commonly used flaps and the semiocclusive dressing treatments of fingertip and thumb tip injuries.
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Affiliation(s)
- Günter Germann
- Ethianum for Clinic Plastic, Hand and Reconstructive Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Klaus D Rudolf
- Ethianum for Clinic Plastic, Hand and Reconstructive Surgery, University of Heidelberg, Heidelberg, Germany
| | - Scott L Levin
- Ethianum for Clinic Plastic, Hand and Reconstructive Surgery, University of Heidelberg, Heidelberg, Germany
| | - Manuel Hrabowski
- Ethianum for Clinic Plastic, Hand and Reconstructive Surgery, University of Heidelberg, Heidelberg, Germany
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Sun YC, Gong YP, Chen QZ. A reverse dorsoradial pedicled flap from the thumb for a soft tissue defect in the finger. J Hand Surg Eur Vol 2015; 40:1000-1. [PMID: 26160854 DOI: 10.1177/1753193415595192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Y C Sun
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Y P Gong
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Q Z Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
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Abstract
Hand aesthetics in general and aesthetic refinements of soft-tissue coverage of the hand in particular have been increasingly considered over the past few years. Advancements of microsurgery together with the traditional methods of tissue transfer have expanded the number of techniques available to the reconstructive surgeon, thus shifting the reconstructive paradigm from simply "filling the defect" to reconstructive refinement to provide the best functional and aesthetic results. However, drawing the boundary between what does and what does not constitute "aesthetic" reconstruction of the hand is not straightforward. The selection among the vast amount of currently available reconstructive methods and the difficulties in objectively measuring or quantifying aesthetics have made this task complex and rather arbitrary. In this article, the authors divide the hand into several units and subunits to simplify the understanding of the basic functional and aesthetic requirements of these regions that may ultimately bring order to complexity.
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Management of thumb tip injuries. J Hand Surg Am 2015; 40:614-22; quiz 623. [PMID: 25708438 DOI: 10.1016/j.jhsa.2014.09.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 09/24/2014] [Accepted: 09/28/2014] [Indexed: 02/02/2023]
Abstract
The management of thumb tip injuries has undergone great changes in recent years. The traditional armamentarium of flaps has been expanded and replaced by a wide variety of flaps with more versatility and less donor side morbidity. Parallel to the development of new flaps, the conservative treatment of thumb tip injuries with semi-occlusive dressing has gained ground in the treatment of these injuries. Although tedious and time-consuming, and requiring intensive communication with the patient to explain the look and occasionally fetid smell of the wound, this technique yields excellent results with respect to restoring contour and sensibility in pulp injuries. The article gives an update on the current options for treating thumb tip injuries including the most commonly applied flaps.
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Abstract
BACKGROUND The volar aspect of the thumb often requires local flaps for reconstruction. This study characterizes perforators of the princeps pollicis artery (PPA) and evaluates the potential of a local propeller-type flap raised using these perforators for reconstruction of these defects. METHODS Cadavers underwent whole-body lead-oxide injection and were then imaged using a 64-slice spiral computed tomographic scanner. The DICOM images were imported into Materialise's Interactive Medical Imaging Control System (Materialise, Belgium) for 3-dimensional reconstruction of the microvasculature. The number, length, caliber, and location of perforators arising from the PPA were determined and a plot was generated illustrating the relative distribution of perforators. RESULTS A total of 16 PPA perforators were identified in the 8 specimen hands. Perforators had a mean (SD) diameter of 1.2 (0.4) mm and mean (SD) length of 8.9 (4.8) mm. The PPA perforators were consistently identified along the radial aspect of the thenar region. Seventy percent of all PPA perforators can be found over the distal 50% of the MC [20%-54%; mean (1SD)]. CONCLUSIONS Perforators of the PPA were found in all hands and the average caliber and length of the perforators identified is sufficient for the creation of a local perforator flap. This, coupled with the mean location of these perforators, arising near the base of the thumb, confirms that a cutaneous flap from the thenar region can be raised based on this perforator as a propeller flap to obtain coverage of distal cutaneous defects of the thumb.
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Liu Y, Jiao H, Ji X, Liu C, Zhong X, Zhang H, Ding X, Cao X. A comparative study of four types of free flaps from the ipsilateral extremity for finger reconstruction. PLoS One 2014; 9:e104014. [PMID: 25098605 PMCID: PMC4123926 DOI: 10.1371/journal.pone.0104014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 07/07/2014] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Yujie Liu
- Department of Orthopedic and Traumatic Surgery, General Hospital of Jinan Military Command, Jinan, P. R. China
- The Hand Surgery Center of Chinese People’s Liberation Army, The 401 Hospital of CPLA, Qingdao, P. R. China
| | - Hongsheng Jiao
- The Hand Surgery Center of Chinese People’s Liberation Army, The 401 Hospital of CPLA, Qingdao, P. R. China
| | - Xiang Ji
- The Hand Surgery Center of Chinese People’s Liberation Army, The 401 Hospital of CPLA, Qingdao, P. R. China
| | - Chunlei Liu
- The Hand Surgery Center of Chinese People’s Liberation Army, The 401 Hospital of CPLA, Qingdao, P. R. China
| | - Xiaopen Zhong
- The Hand Surgery Center of Chinese People’s Liberation Army, The 401 Hospital of CPLA, Qingdao, P. R. China
| | - Hongxun Zhang
- The Hand Surgery Center of Chinese People’s Liberation Army, The 401 Hospital of CPLA, Qingdao, P. R. China
| | - Xiaohen Ding
- The Hand Surgery Center of Chinese People’s Liberation Army, The 401 Hospital of CPLA, Qingdao, P. R. China
| | - Xuecheng Cao
- Department of Orthopedic and Traumatic Surgery, General Hospital of Jinan Military Command, Jinan, P. R. China
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Abstract
A local flap consists of skin and subcutaneous tissue that is harvested from a site near a given defect while maintaining its intrinsic blood supply. Local skin flaps can be a used as a reliable source of soft tissue replacement that replaces like with like. Flaps are categorized based on composition, method of transfer, flap design, and blood supply, but flap circulation is considered the most critical factor for the flap survival. This article reviews the classification of local skin flaps of the hand and offers a practical reconstructive approach for several soft tissue defects of the hand and digits.
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Coverage of the neurovascular unit of the fingertip using a reverse homodigital dorsal flap. Case Rep Surg 2014; 2014:315081. [PMID: 24523980 PMCID: PMC3912637 DOI: 10.1155/2014/315081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 12/17/2013] [Indexed: 11/24/2022] Open
Abstract
The exposure of bone, tendons, vessels, and nerves in a digital defect is one of the most frequent and severe problems to solve in hand surgery and current approaches are still disappointing. We show the use of an homodigital adipofascial flap taken from the same finger for covering the pulpar defect in a one-step surgical technique able to preserve the digital artery.
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Demiri EC, Dionyssiou DD, Pavlidis LC, Papas AV, Kostogloudis NH, Lykoudis EG. Soft tissue reconstruction of the thumb with the dorsoradial forearm flap. J Hand Surg Eur Vol 2013; 38:412-7. [PMID: 23345542 DOI: 10.1177/1753193413475749] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The dorsoradial flap is a recently described cutaneous flap, which is harvested from the distal forearm and indicated for covering dorsal soft tissue defects of the hand and thumb. Vascularization of the flap is assured by a cutaneous branch of the radial artery, which arises at the level of the first intermetacarpal space and supplies the skin of the distal quarter of the forearm dorsum. This area corresponds to the skin island of the dorsoradial flap. We report our clinical experience on seven patients where this flap was used for covering post-traumatic defects of the thumb. Dimensions of the defect varied from 18 to 28 cm(2). The donor site was skin grafted. All flaps survived and provided satisfactory coverage of the defect. Based on a secondary vascular axis, the flap has a large skin paddle and a wide rotation arc that allows soft tissue reconstruction of the dorsal and radiopalmar areas of the thumb.
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Affiliation(s)
- E C Demiri
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Greece.
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Tan HL, Tan DY, Zhao JK. Treatment of thumb soft-tissue defects using a bipedicle island flap of the index finger: anatomical basis and clinical application. Arch Orthop Trauma Surg 2013; 133:721-8. [PMID: 23443528 DOI: 10.1007/s00402-013-1704-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE Reconstruction of the thumb with exposure of bone and tendon is challenging. We designed a bipedicle island flap from the dorsum of the index finger to repair thumb defects. One pedicle includes the radial proper palmar digital artery (PDA) of the index finger, another pedicle includes the first dorsal metacarpal artery (FDMA). The aim of the study was to investigate the anatomical basis and clinical application of this flap. METHODS Eleven fresh cadaver hands were dissected, the FDMA and the radial proper PDA were exposed. Their origin, distribution and diameter in different locations, especially in the dorsum of the proximal phalanx of the index finger, were examined. Ten patients (11 hands) underwent thumb reconstruction using this flap. During follow-up, the flap survival and hand function were evaluated. RESULTS The origin of the FDMA in three cadaver hands was abnormal. The FDMA was mainly distributed in the proximal area of the dorsum of the proximal phalanx. The radial proper PDA of the index finger formed one constant dorsal branch, mainly distributing in the middle and distal area of the dorsum of the proximal phalanx. All flaps survived. At follow-up, the span of the first web and the range of motion of the thumbs and index fingers reached more than 94 % of the contralateral finger. All patients were satisfied with the hand function according to the Michigan Hand Outcomes Questionnaire (MHQ). CONCLUSIONS The bipedicle island flap has two arterial systems to provide sufficient blood supply. This technique provides another option for thumb reconstruction when a large supercharged FDMA island flap needs to be designed, or when there is an additional injury to the radial side of the dorsum of the hand or if there are anatomical variations of the FDMA, or if damage to the FDMA occurs during surgery.
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Affiliation(s)
- Hong-lue Tan
- Department of Orthopaedic Surgery, Wujin Hospital, Medical School of Jiangsu University, No. 2 Yongning Road, Changzhou, China.
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Silva JB, Faloppa F, Albertoni W, Gazzalle A, Cunha GLD. Adipofascial turnover flap for the coverage of the dorsum of the thumb: an anatomic study and clinical application. J Hand Surg Eur Vol 2013; 38:371-7. [PMID: 22357329 DOI: 10.1177/1753193412439168] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this report is to show how our anatomical findings have influenced the design of the dorsal homodigital adipofascial turnover arterial flap to the thumb. Thirty-six thumbs from 18 fresh cadavers were dissected at the Fèr à Moulin Laboratoire (Paris, France) between January 1998 and March 1999. All branches of the proper digital artery (PDA) were identified. During the clinical study, from 2002 to 2008, 12 patients with dorsal thumb skin defects were treated with adipofascial turnover flaps. The dorsal branches of the PDA typically emerge at the level of the metacarpophalangeal and interphalangeal joints, 10 mm apart from the joint line. Based on the anatomical study, the flap could be designed predictably and reliably. The main advantages of dorsal adipofascial turnover flaps include their simplicity; the possibility of a one stage procedure; avoiding the use of tissue from elsewhere on the limb/body; minimal donor-site deformity; and avoidance of damage to the volar digital arteries.
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Affiliation(s)
- J Braga Silva
- Service of Hand Surgery and Reconstructive Microsurgery, Hospital Sao Lucas, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil.
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Camporro D, Vidal D, Robla D. Extended applications of distally based axial adipofascial flaps for hand and digits defects. J Plast Reconstr Aesthet Surg 2010; 63:2117-22. [PMID: 20005789 DOI: 10.1016/j.bjps.2009.11.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Revised: 11/08/2009] [Accepted: 11/10/2009] [Indexed: 11/24/2022]
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Hrabowski M, Kloeters O, Germann G. Reverse homodigital dorsoradial flap for thumb soft tissue reconstruction: surgical technique. J Hand Surg Am 2010; 35:659-62. [PMID: 20353865 DOI: 10.1016/j.jhsa.2010.01.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 01/22/2010] [Indexed: 02/02/2023]
Abstract
A variety of local flaps are described for reconstruction of soft tissue defects of the thumb. Restored sensibility, low donor-site morbidity, full restoration of function and range of motion, and an acceptable aesthetic outcome are requirements in thumb reconstruction. Reverse homodigital dorsal radial flap of the thumb provides most of these requirements and allows for dependable coverage of radiopalmar or dorsal thumb defects without affecting other digits.
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Affiliation(s)
- Manuel Hrabowski
- BG-Trauma Center, Ludwigshafen, Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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Thumb Reconstruction Using the Radial Midpalmar (Perforator-Based) Island Flap (Distal Thenar Perforator-Based Island Flap). Plast Reconstr Surg 2010; 125:601-608. [DOI: 10.1097/prs.0b013e3181c82fd7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bakhach J, Guimberteau JC, Panconi B. The Gigogne flap: an original technique for an optimal pulp reconstruction. J Hand Surg Eur Vol 2009; 34:227-34. [PMID: 19282399 DOI: 10.1177/1753193408098904] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The reconstruction of digital pulp defects is still a challenge in hand surgery. Several reconstructive techniques are available, but in some cases, their advancement capacities are not sufficient for the flap to cover the whole defect. The Gigogne flap is a new, very simple and safe technique. It consists of harvesting two cutaneous flaps successively on the same neurovascular digital palmar bundle. The first plasty may be chosen among the well-known flaps usually applied in pulp reconstruction. The second plasty, the Gigogne flap, is an advancement VY plasty done on the main cutaneous paddle of the first proximal flap. We performed 15 Gigogne flaps in 13 patients, who suffered zone II and III digital pulp amputations. The Gigogne flap increased the advancement capacity of the proximal flap as well as restoring the physiological pulp fatty pad, thus reconstructing a functional and aesthetic fingertip.
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Affiliation(s)
- J Bakhach
- Institut Aquitain de Chirurgie Plastique, Microchirurgie et Chirurgie de la Main Pessac, Bordeaux, France.
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