SRPS PS - Plastic Surgery Internal

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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. 27
SRPS Volume 10, Issue 25, 2009 The free groin flap constitutes an unsurpassed donor site and allows the transfer of a large quantity of hairless skin. Like the pedicled groin flap, it is too bulky for resurfacing the hand and requires revision defatting and/or liposuction. Recent interest in perforator flaps has led to the growing popularity of the anterolateral thigh flap 544,545 and the tensor fasciae latae perforator flap 546,547 in dorsal hand reconstruction. Large flaps of very thin skin can be raised with minimal donor site morbidity. Because the flaps are based on perforating vessels, the motor function of the underlying tensor fascia latae is preserved. The anatomy of the temporal region has been elucidated by several authors. 548–550 Upton et al. 551 discussed the various applications of free temporoparietal fascial flaps in dorsal hand resurfacing. Temporoparietal fascia most commonly is used in the upper extremity to wrap exposed or contracted tendons. 551–556 The deep areolar surface of the flap is turned toward the tendons to provide a smooth gliding surface. The overlying fascia is thin and pliable for metacarpal contouring. A skin graft completes the reconstruction. This fascial flap is also excellent for filling the three-dimensional defect resulting from the extensive release of complex first web space REFERENCES 1. Brucker MJ, Edstrom L. The use of grafts in acute and chronic fingernail deformities. J Am Soc Surg Hand 2002;2:14–20. 2. Zook EG. Anatomy and physiology of the perionychium. Hand Clin 1990;6:1–7. 3. Verdan CE, Egloff DV. Fingertip injuries. Surg Clin North Am 1981;61:237–266. 4. Guy RJ. The etiologies and mechanisms of nail bed injuries. Hand Clin 1990;6:9–19. 5. Ashbell TS, Kleinert HE, Putcha SM, Kutz JE. The deformed finger nail, a frequent result of failure to repair nail bed injuries. J Trauma 1967;7:177–190. 6. Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin 1990;6:23–35. 7. Stevenson TR. Fingertip and nailbed injuries. 28 contractures. The donor defect on the scalp is insignificant. Potential complications of flap transfer include palsy of the frontal branch of the facial nerve and permanent alopecia. Another extremely thin fascial flap is the serratus anterior fascial flap. 557–560 The serratus anterior fascial flap consists of the loose areolar tissue between the latissimus dorsi and serratus anterior muscles and is supplied by the thoracodorsal vessels. It has a long constant vascular pedicle, very thin well-vascularized tissue, and low donor site morbidity, and it allows simultaneous donor and recipient site dissection. It can also be combined with other flaps of the subscapular system. Free muscle flaps can provide only crude protective sensibility through pressure receptors, but their malleability makes them well suited to difficult contour problems in the hand, especially the palm. For small defects, the serratus anterior 561,562 seems most useful, and for moderate-sized wounds, the rectus abdominis 563,564 flap has been suggested. For very large wounds of the upper extremity, the latissimus dorsi is the muscle of choice. These three flaps have largediameter pedicles of very adequate length with minimal donor site morbidity. Functional free muscle transfers are discussed in the “Microsurgery” issue of Selected Readings in Plastic Surgery. Orthop Clin North Am 1992;23:149–159. 8. Bindra RR. Management of nail–bed fracturelacerations using a tension-band suture. J Hand Surg [Am] 1996;21:1111–1113. 9. Inglefield CJ, D’Arcangelo M, Kolhe PS. Injuries to the nail bed in childhood. J Hand Surg [Br] 1995;20:258–261. 10. McCash CR. Free nail grafting. Br J Plast Surg 1955;8:19–33. 11. Shepard GH. Nail grafts for reconstruction. Hand Clin 1990;6:79–102. 12. Zook EG, Russell RC. Reconstruction of a functional and esthetic nail. Hand Clin 1990;6:59–68. 13. Pessa JE, Tsai TM, Li Y, Kleinert HE. The repair of nail deformities with the nonvascularized nail bed graft: Indications and results. J Hand Surg [Am] 1990;15:466–470.
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