SRPS PS - Plastic Surgery Internal

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Figure 15. Design of reverse dorsal metacarpal flap and cross-section at distal flap (Reprinted with permission from Maruyama. 432 ) interconnections between terminal branches of the dorsal metacarpal arteries and the deep digital and palmar arterial systems. 434–436 Maruyama raised flaps on all five dorsal metacarpal arteries and reported a largely successful experience in eight cases. Figure 16. Arterial basis of distally based dorsal hand flap is direct branch from dorsal metacarpal artery that enters skin 0.5 to 1 cm proximal to adjacent metacarpophalangeal joint. (Reprinted with permission from Quaba and Davison. 433 ) SRPS Volume 10, Issue 25, 2009 In contrast, several authors 433,437 reported that the flaps are nourished by a direct cutaneous branch of the dorsal metacarpal artery that enters the skin 0.5 to 1 cm proximal to the adjacent metacarpophalangeal joint (Fig. 16). The authors raised reverse dorsal metacarpal artery flaps on the second, third, and fourth intermetacarpal spaces in 21 patients and reported one partial loss and one failure. 433 Donor sites up to 2 cm wide can be closed primarily. Large Defects of the Hands or Digits Regional Flaps The regional flaps applicable for resurfacing the hand are based on the three major arteries of the forearm: the radial, ulnar, and posterior interosseous arteries. 438 Yang et al. 439 described the territory of the radial forearm flap in 1981. The skin on the flexor surface of the forearm is relatively hairless, thin, and pliable, which makes it ideal for resurfacing the dorsum of the hand. The radial forearm unit can be raised as a composite of fascia-skin, 440–442 fascia, 443,444 bone-musclefascia-skin, 445–447 or fascia-tendon-skin. 448–450 In 1984, Lin et al. 451 noted ample retrograde flow into the radial artery from the ulnar artery via the deep palmar arch and proposed a “reverse” forearm flap. The flap is nourished by this retrograde circulation and can be elevated on its long pedicle for reconstruction anywhere in the hand. The authors described a crossover pattern of communicating branches between the paired venae comitantes and identified small superficial collateral branches of each vein, which effectively bypass the valves. This system enables the flap to be drained despite competent valves. Even in cases of significant hand trauma in which the palmar arches are in question, the flap has been successfully raised, based on communications proximal to the wrist. 452,453 The radial forearm flap has two main disadvantages. Foremost is that a major vessel to the hand is sacrificed, but Kleinman and O’Connell 454 found the only significant objective difference between patients who had undergone flap transfer and controls to be an 18% delay in reconstitution of normothermia after cold stress testing. Reconstruction of the vessel rarely is necessary. 455,456 Weinzweig et al. 457 described a technique for elevating a distally based fasciocutaneous flap with preservation of the radial 25
SRPS Volume 10, Issue 25, 2009 artery, and Braun et al. 458 similarly elevated a retrograde radial fascial turn-down flap based on distal perforators of the radial artery, leaving the main radial artery intact. The unesthetic and potentially unstable grafted donor site of the radial forearm flap remains the major detractor of this otherwise excellent flap. 459 Skin graft take usually is not a problem with flaps used for hand reconstruction, because the flap is based proximally over the muscle bellies. If the flap needs to be raised in the distal forearm over the flexor tendons, graft take can be improved by a suprafascial dissection of the flap. 460 Many methods have been proposed to improve the donor site, including direct closure, full-thickness skin grafts, local flaps, and tissue expansion. 461–466 Split thickness skin grafting remains the standard at most centers. In 1984, Lovie et al. 467 described the ulnar artery island flap and 4 years later reported their experience with this method for hand and forearm reconstruction. 468 The skin territory of the flap overlies the proximal ulnar aspect of the forearm, which is almost always hairless and less visible than the radial border. The authors and others 469–472 found the ulnar flap to be superior in terms of esthetics, easier harvesting of bone and muscle (flexor carpi ulnaris), direct closure of donor site, and lower morbidity. The posterior interosseous artery flap is based on the communication between the anterior and posterior interosseous arteries. 473–478 The posterior interosseous artery runs in a fascial septum between the extensor carpi ulnaris and extensor digiti minimi muscles (Fig. 17). 479 A segment of ulna can be taken as a composite flap. 480 The advantages of this flap are good pedicle length and primary closure of the donor site. Its disadvantages are a relatively hairy donor site, an obvious scar on the visible dorsum of the forearm, limited size of the flap, and unreliability of the vascular communication. 481–484 Distant Flaps Large flaps of skin can be transferred to the hand from distant sites by means of traditional pedicled techniques or microvascular free tissue transfer. Pedicled flaps—Flaps of skin from remote sites over the chest and abdomen traditionally were used 26 Figure 17. Cross-section of distally based posterior interosseous island flap taken at middle one-third of forearm. Posterior interosseous artery reaches overlying skin in space between extensor carpi ulnaris and extensor digiti minimi proprius. (Reprinted with permission from Landi et al. 479 ) for resurfacing large wounds of the upper extremity. The most commonly used pedicled flap is the groin flap based on the superficial circumflex iliac artery 485–488 or the superficial inferior epigastric artery. 489 Groin flaps are axial-pattern flaps with reliable vascularity. However, they necessitate two surgical stages and the hand remains dependent during the initial period of flap attachment, encouraging edema and stiffness. In addition, groin flaps are too bulky for dorsal hand resurfacing and require subsequent revision surgery. Chow et al. 490 presented their experience with 36 groin flaps used in delayed primary or elective secondary hand resurfacing. Arner and Möller 491 highlighted potential complications. Microvascular Free Tissue Transfer—Microvascular free tissue transfer allows a single-stage composite reconstruction of complex hand defects, 492–500 obviating the need for cumbersome, two-stage pedicled procedures and their inherent shortcomings. Free flaps can also be used to provide vascular conduits and soft tissue coverage. 501,502 Free flaps are the definitive form of soft-tissue cover in emergency situations. 503–508 Successful reconstruction of soft tissue of the upper extremity with free flaps must be approached with the goals of providing stable coverage and, more importantly, restoring function. The hand does not tolerate prolonged immobilization. Radical débridement and restoration of all tissue components at the time of coverage encourages early mobilization. 509
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