SRPS PS - Plastic Surgery Internal

Critical sensibility of the fingertip can be restored by
free neurosensory flaps 510–516 or microvascular toe-pulp
transfer. 517–519 Toe-to-hand transfers in cases of thumb
reconstruction are discussed in the “Microsurgery: Free
Tissue Transfer and Replantation” issue of Selected
Readings in Plastic Surgery. Protective sensibility of the
palm and dorsum of the hand usually is achieved by
thin muscle, fascial, or fasciocutaneous flaps. 520
The first web space flap of the foot is the “gold
standard” of neurosensory flaps. 513 It consists of the
lateral aspect of the great toe and the medial aspect of
the second toe. The flap is supplied by the first dorsal
metatarsal artery, a branch of the dorsalis pedis artery,
or the first plantar metatarsal artery. Its innervation is
through both the deep peroneal nerve and the medial
plantar nerve (Fig. 18). 511 Lee and May 516 found that the
first dorsal metatarsal artery arose from the dorsalis
pedis artery dorsal to the mid-metatarsal axis in 78%
of 50 cadaver dissections. The authors usually obtain
preoperative angiography to determine the vascular
anatomy. The main advantage of the first web space
flap for sensory reconstruction in the hand is
replacement with similar thin glabrous skin with
concentrated sensory receptors, allowing the best 2point
discrimination of any neurosensory flap.
The thin, malleable skin over the dorsum of the
foot can also be transferred as an innervated free
flap, 521–523 including the underlying extensor tendons 524–527
and second metatarsal for composite reconstruction, if
required. The dorsalis pedis flap is raised on the
dorsalis pedis artery, and venous drainage is via the
venae comitantes and saphenous vein. Its neural input
is from the superficial peroneal nerve. The donor site is
unforgiving, so meticulous attention must be paid to
flap dissection and wound care.
The free radial forearm flap and free ulnar forearm
flap can be used just as readily as the already
discussed pedicled flaps. They have neurosensory
potential via the lateral and medial cutaneous nerves
of the forearm, respectively.
The lateral arm flap is supplied by the posterior
radial collateral artery and innervated by the posterior
cutaneous nerve of the arm. 528–530 It can be raised as a
fasciocutaneous flap or as combinations of fascia, 531
muscle, tendon, 532,533 and bone. 534 Donor defects up to 6
cm wide usually can be closed primarily. Designs for
SRPS Volume 10, Issue 25, 2009
Figure 18. Innervation of the foot first web space and great
toe. (Reprinted with permission from May et al. 511 )
extending the flap have been described, 535,536 as have
techniques for extending the length of the vascular
pedicle. 537 The flap has the advantage of confining flap
harvest to the same extremity as the defect. However,
this popular flap comes with a price. Graham et al. 538
reviewed 123 lateral arm flaps and found that a
significant number of patients complained of
unsatisfactory appearance and hypersensitivity of the
donor site, elbow pain, numbness in the forearm, and
excessive flap bulk.
For large defects of the upper extremity, where
sensibility is not as important, the scapular and
parascapular flaps have found popularity. The
parascapular flap 539–541 allows a larger skin paddle to be
harvested with primary closure of the secondary
defect, and the resulting scar is less conspicuous than
that of the horizontal scapular flap defect. The scapular
flap can be raised as a fascial flap 542 or as an
osteofascial flap. 543 Both flaps have the disadvantage of
being bulky, even in thin individuals, and secondary
defatting or liposuction is necessary for an optimal
aesthetic contour.
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