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Local and Regional Flaps for Hand Coverage Debdut Biswas, MD, Robert W. Wysocki, MD, John J. Fernandez, MD, Mark S. Cohen, MD
Hand surgeons are frequently challenged by the unique requirements of soft tissue coverage of the hand. Whereas many smaller soft tissue defects without involvement of deep structures are amenable to healing by secondary intention or skin grafting, larger lesions and those with exposed tendon, bone, or joint often require vascularized coverage that allows rapid healing without wound contraction. The purpose of this review was to present an overview of local and regional flaps commonly used for soft tissue reconstruction within the hand. (J Hand Surg Am. 2014;39(5):992e1004. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Coverage, finger, flap, hand, soft tissue.
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can result from a variety of mechanisms including trauma, infection, and malignant disorders. Reconstructive surgeons who encounter these conditions must account for the unique requirements and challenges of soft tissue coverage specific to the hand. The optimal soft tissue reconstruction protects against the development of contractures and facilitates tendon and joint mobility, while maintaining durability and sensibility of the hand. This is particularly true in situations where palmar soft tissue coverage is required. The “reconstructive ladder,” originally described by Mathes and Nahai,1 is based on the principle of using the simplest approach of coverage that adequately restores form and optimizes function. The simplest technique includes direct primary closure, followed by skin grafting, local and regional flaps, and ultimately, free vascularized tissue transfer. The purpose of this review was to describe the clinical indications and outcomes of local and regional flap reconstructions commonly performed for soft tissue defects in the hand. Traditional techniques as OFT TISSUE DEFECTS IN THE HAND
Current Concepts
From the Section of Hand and Elbow Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL. Received for publication January 4, 2013; accepted in revised form September 16, 2013. R.W.W. is a consultant for Acumed, Hillsboro, OR. Corresponding author: Mark S. Cohen, MD, Section of Hand and Elbow Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison Street, Chicago, IL 60612; e-mail: [email protected]. 0363-5023/14/3905-0031$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.09.027
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well as recent innovations in soft tissue coverage will be presented with a particular focus on a systematic approach to treating these challenging conditions. CLINICAL EVALUATION AND WOUND PREPARATION Sharp lacerations in the hand without substantial contamination or active infection are typically amenable to debridement and primary repair. For wounds not amenable to primary closure, the decision must be made as to what type of coverage to provide and the timing in doing so. Although skin grafts will survive on a vascular tissue bed, the exposure of “white structures” (nerve, tendon, and bone) typically requires vascularized soft tissue reconstruction. If local or regional flap coverage is being considered, healthy tissues in proximity to the defect should be evaluated as potential donor sites; additional studies may be necessary to determine the suitability of these tissues (ie, Doppler ultrasonography or angiography). A systematic approach to soft tissue defects in the setting of complex hand trauma is mandatory. Although soft tissue coverage should be performed as expeditiously as possible, the need for radical and serial debridements of contaminated wounds is necessary before any soft tissue reconstruction. Quantitative tissue culture may be advisable before proceeding with skin grafting or flap coverage, particularly in chronically infected wounds or those with considerable contamination. In such cases, multiple debridements can decrease bacterial load
LOCAL AND REGIONAL FLAPS FOR HAND COVERAGE
and optimize the condition of the wound bed to accommodate a skin graft or flap. Skeletal stabilization of fractures is mandatory to provide a foundation for soft tissue coverage, and repair or reconstruction of nerve, arterial, or tendon injuries is typically performed before proceeding with flap reconstruction. In certain situations, definitive tendon reconstruction is delayed and silicone spacers are placed if a scar-free bed for tendon gliding cannot be ensured. Ideally, soft tissue coverage using skin grafts and flaps should be achieved within 48 hours to avoid the development of granulation tissue and no later than 10 days of injury to minimize infection risk. Although the development of granulation tissue can help achieve relatively noninvasive biologic coverage of soft tissue defects in the lower extremities and trunk, granulation tissue development within the hand frequently matures into scar tissue, which fosters contracture and inhibits motion. Stable flap coverage is necessary to limit the development of granulation tissue and help best restore motion after soft tissue trauma to the hand. Recent technical innovations in vacuum-assisted closure (VAC) therapy deserve special mention. These devices have improved the management of wounds before soft tissue closure by removing exudate, decreasing edema, and decreasing the dead space and overall dimensions of soft tissue defects. Although the application of such devices should be performed judiciously and temporarily when tendon or neurovascular structures are exposed, the use of VAC therapy may decrease requirements for flap coverage and safely delay definitive soft tissue reconstruction in select situations. Nonetheless, prolonged use of VAC therapy should be avoided because of concerns regarding the development of granulation tissue and its propensity for scar formation and resultant contracture. For the hand specifically, a VAC should be used only for short-term periods, typically less than 48 hours, to avoid excessive granulation tissue and scar development before definitive flap closure. Areas such as the midarm and midforearm are more tolerant of scarring and skin contracture and a VAC can be applied more liberally in those locations.
can also be covered with skin grafts if the paratenon is intact. Split-thickness skin grafts are often performed for defects involving the dorsum of the hand, which require pliable, low-profile soft tissue coverage. Full-thickness grafts are almost always required for defects on the palmar side, to minimize contracture and restore optimal durability and sensibility. Efforts continue to be devoted toward the development of synthetic skin substitutes, including several commercially available dermal regeneration templates that can achieve coverage even when deep structures are exposed. These products facilitate the formation of a neodermis and optimize conditions for staged split-thickness skin grafting once a fully vascularized bed is present.2 Favorable cosmetic and functional outcomes have been reported with the use of dermal regeneration templates for deep hand defects after burns,3 tumor excision,4 and digital soft tissue injuries not amenable to local flap coverage.5 Although these series involved limited numbers of patients, favorable outcomes reported with the application of these synthetic products clearly highlight their use for hand coverage.
Local flaps Local flaps (ie, V-Y advancement, z-plasty) originate from tissues directly adjacent to a defect and are typically completed in a single stage. Many of these flaps are random-pattern flaps that have no specifically recognized perfusing vasculature. They are typically transferred to the recipient site by a combination of rotation, transposition, or advancement. The Burow triangle rotation flap (Fig. 1) is a frequently performed rotation flap that distributes the tension of closure over a defect to a larger surface area. This is accomplished by designing a curved incision incorporating a large adjacent region of soft tissue to be rotated into the defect; a back-cut helps achieve greater mobility and less tension on the repair. Rhomboid flaps are common transposition flaps performed by converting an existing defect into a rhomboid configuration and then pivoting adjacent donor tissue into the defect, such as defects involving the dorsum of the hand, r
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LOCAL AND REGIONAL FLAPS: PRINCIPLES AND DEFINITIONS Although skin grafts may be appropriately applied to cover an adequately vascularized tissue bed, the hand surgeon frequently encounters other hand defects with exposed bone or tendon that require more advanced flap coverage. A myriad of local and regional flaps have been described for treatment of these defects, and are the focus of this review.
SKIN GRAFTING The use of skin grafting deserves brief mention, because it remains a common technique within the armamentarium of hand surgeons for treatment of defects of the hand, particularly in cases in which only subcutaneous tissue or muscle are exposed. Tendons J Hand Surg Am.
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FIGURE 2: Classification of fingertip injuries. Zone II and IV injuries are frequently amenable to local or regional flap coverage.6 FIGURE 1: Schematic diagram of a Burow rotation flap; a back cut (blue) is created to facilitate the transposition of a wider area of skin into a primary defect (red).
Free vascularized tissue transfer represents the most advanced form of soft tissue reconstruction of the upper extremity. A variety of fasciocutaneous (lateral arm and anterolateral thigh) and muscular (latissimus dorsi and gracilis) free vascularized flaps have been extensively described in the literature and should be considered when soft tissue defects are not amenable to local, regional, or multistage pedicled distant flap reconstruction.
where the elasticity of the tissues permits rotation of skin flaps. The V-Y advancement flap is a local flap frequently used for distal fingertip defects by mobilizing a V-shaped flap distally and primarily closing the skin at the apex of the defect or allowing it to heal by secondary intention.
LOCAL AND REGIONAL FLAPS: TREATMENT BY LOCATION Fingertip defects Fingertip injuries are the most common open defects encountered by hand surgeons, and the primary objective of treatment is a painless fingertip with durable and sensate skin. The principal determinants of treatment are the exposure of bone and the quantity of soft tissue involved in the defect; these injuries have been classified into 4 main patterns6 (Fig. 2). Transverse tip amputations without exposed bone, including most type 1 injuries, may be treated with healing by secondary intention; more proximal injuries near the distal interphalangeal (DIP) joint (type 3) may be considered for replantation when appropriate, or revision amputation with favorable results. Although injuries that feature more extensive softtissue loss with exposed bone (type 2) may be treated with skeletal shortening and primary closure, these techniques are associated with nail plate abnormalities, particularly when over 50% of the nail plate is involved.6,7 Soft tissue reconstruction is frequently performed for type 2 injuries as well as type 4 injuries in which the injury is limited to the volar soft tissues.
Regional flaps Flaps that originate from other sites not directly adjacent to the primary defect but are derived from the ipsilateral limb are termed regional flaps; these flaps may have either a random pattern or an axial pattern of blood supply with the presence of a specific longitudinal blood supply along the length of the flap. Random-pattern regional flaps, such as the crossfinger and thenar flaps, almost always require 2 stages: the first is for flap harvest and application to the defect, and the second is for dividing and insetting the flap from the donor site once the flap is vascularized by the recipient bed. Axial pattern regional flaps, including the radial forearm and dorsal metacarpal arterial flap, may be completed in a single procedure because the flap is merely rotated on its pedicle and the blood supply is transferred in conjunction with the soft tissue flap. Current Concepts
Distant flaps Flaps originating from outside the ipsilateral limb of the defect are commonly referred to as distant flaps. Aside from free tissue transfer, these flaps almost always require at least 2 stages for harvest and application, followed by insetting and division of the flap. The pedicled groin flap is an example of a less commonly used distant axial pattern flap used for the reconstruction of soft tissue defects of the upper extremity. J Hand Surg Am.
Homodigital flaps (V-Y advancement) The V-Y flap is a local advancement flap that can be applied to transversely oriented soft tissue defects and r
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those with predominantly dorsal rather than palmar soft tissue loss in all fingertips, including the thumb. Two main variants are frequently performed, depending on the availability of proximal volar versus radially or ulnarly based pulp tissue. The Atasoy V-Y advancement is performed with a proximally based V incision with its apex immediately distal to the distal interphalangeal flexion crease. A full-thickness flap is elevated to the level of the neurovascular structures and flexor tendon sheath and fibrous septae are divided; the flap is then advanced into the defect while the donor site is J Hand Surg Am.
primarily repaired or allowed to granulate in (Fig. 3). Patients should be counseled regarding the possibility of nail plate deformities, specifically the long-term development of a hook nail. When the availability of a palmar donor site is limited, the Kutler V-Y advancement (lateral V-Y) may be used instead by raising radially or ulnar based flaps. The flaps are raised in a fashion similar to that of the palmar technique and advanced distally into the recipient defect. Variable outcomes have been reported with these flaps, including issues related to scar hypersensitivity,6 although other r
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FIGURE 3: Patient presenting with a transverse fingertip injury. A, B Over 50% of the nail bed remains. CeE A V-Y advancement flap was used to treat this defect. F, G The patient demonstrated a fully sensate, pain-free digit at final follow-up.
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FIGURE 4: A, B A patient sustained a soft tissue injury with extensive palmar tissue loss over the middle and distal phalanx of the little finger. C, D A cross-finger flap was harvested from the dorsal middle phalanx of the ring finger and E was inset into the defect; F the donor site was covered with a skin graft. The flap was divided at 2 weeks; the patient reported a fully sensate digit with no appreciable flexion contractures of the PIP or DIP G, with excellent cosmesis.
authors have reported favorable results after use of the Kutler flap.8
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crease of the thumb; care is taken to avoid injury to the radial digital nerve of the thumb, which crosses the thumb axis at this level. The flap is then primarily sutured to the recipient defect site, with the MCP and DIP joints flexed as much as possible to minimize flexion required at the PIP joint; the flap is typically divided and formally inset after a period of 2 to 3 weeks. Although the fear of developing or exacerbating PIP contractures led many authors to recommend this technique only for children and adults under the age of 30 years, Melone et al9 reported favorable outcomes in older patients; only 4% of patients in that series of 150 flaps developed a PIP contracture.
Heterodigital flaps Thenar flap: Despite favorable results after the performance of the V-Y advancement flaps, certain injuries may limit the availability of proximally based donor tissue for use in an Atasoy or Kutler flap, especially defects with more palmar soft tissue loss. The thenar flap is frequently used for larger volar defects, particularly for the index and long fingers. Although the technique is an excellent method of restoring the soft tissue of more extensive defects of the fingertips, the procedure requires the digit to be immobilized in flexion and risks the development of proximal interphalangeal (PIP) flexion contractures. The flap is typically constructed by elevating a proximally based flap of skin and subcutaneous tissue near the metacarpophalangeal (MCP) flexion J Hand Surg Am.
Cross-finger flap: The cross-finger flap (Fig. 4) is favored for larger palmar defects of the middle and distal phalanx that are not amenable to homodigital flap reconstruction. Although some authors favor the cross-finger flap as an alternative to the thenar flap to r
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prevent PIP contracture, the amount of flexion of the PIP necessary to graft the defect site for fingertip injuries, especially for the long finger, has been noted to be similar between both techniques. The donor site is typically designed on the dorsal aspect of the middle phalanx of an adjacent digit as a 3-sided rectangular flap (Fig. 4C); the base of the flap is at the mid-axial line closest to the injured digit; a full-thickness flap is then elevated typically from the PIP distal extension to the DIP proximal extension crease (Fig. 4D), taking care not to violate the paratenon of the extensor tendon. After suturing the flap into the defect (Fig. 4E), a full-thickness skin graft is applied to the donor site (Fig. 4F), usually from the ipsilateral medial arm or hypothenar eminence. The recipient digit is splinted in as minimal flexion as possible while maintaining minimal tension on the flap; the flap is typically divided and formally inset after a period of 2 to 3 weeks. Regardless of wound size, fingertip injuries without exposed deep structures that heal by secondary intention will often provide acceptable cosmesis with the greatest return of sensibility and without the donor morbidity of the flaps described earlier. In cases where more than 50% of the nail plate is absent, skeletal shortening and revision amputation are commonly recommended.
Dorsal metacarpal arterialebased regional flaps Axial regional flaps based off the dorsal metacarpal arterial system (DMCA) have been extensively refined and modified since their original description by Muryama10 over 2 decades ago. Anatomically, the second through fourth dorsal metacarpal arteries arise from the dorsal carpal rete, a continuation of the dorsal branch of the radial artery, and provide cutaneous perforators to the dorsal soft tissues and skin. At the level of the web space, the metacarpal arteries are reliably present, particularly the first and second dorsal metacarpal arteries. In conjunction with the palmardorsal anastomosis at the level of the metacarpal neck, this vascular network serves as the basis for several axial flaps, including the flag flap and first dorsal metacarpal (FDMA) and second dorsal metacarpal axial flaps. From the dorsum of the middle finger, for example, the flag flap is typically elevated as a fullthickness subcutaneous flap from the dorsum of the proximal phalanx from mid-axial line to mid-axial line and from the extension crease of the PIP to the web space proximally; it can then be rotated to provide coverage to the dorsum of either the proximal phalanx of the adjacent digits or the MCP joint of either the index or the middle finger. The flag flap can also be passed through the web space to provide coverage palmarly at the level of the proximal phalanx.11 The reverse DMCA flap (Fig. 6) relies on retrograde perfusion from the anastomosis mentioned earlier, particularly the second metacarpal artery between the index and long finger, which is reliably present in most patients. The flap is designed typically as an ellipse on the dorsum of the hand over the given dorsal metacarpal artery, and the dissection is carried down to include the fascia over the interosseous musculature (Fig. 6B). The entry point of the dorsal metacarpal artery is ligated proximally and the flap is rotated from proximal to distal to cover dorsal or palmar digital defects as far distal as the PIP joint. The donor site can usually be repaired primarily for smaller flaps or covered with a skin graft, and there is the option to transfer this as a fascial flap only without skin, to ensure closure of the donor site. Further anatomic evaluations revealed the presence of palmar to dorsal anastomoses in the distal aspect of the web space at the proximal phalanx, leading to the development of extended DMCA flaps, which could provide coverage as far as the distal phalanx.12 The use of the DMCA flap is rapidly rising as the understanding the vascular anatomy of this reconstruction evolves. This flap has been successfully used to enhance or salvage
DIGITAL DEFECTS PROXIMAL TO FINGERTIPS Reverse cross-finger flap The reverse cross-finger flap is commonly used to treat dorsal defects of the digits that are unable to support a skin graft, most commonly over the middle and proximal phalanges. This technique transfers the dorsal fat and subcutaneous tissue of a donor digit to a dorsal defect of an adjacent finger so that it may support the application of a skin graft. The donor site is typically designed dorsally as a 3-sided rectangular flap similar to a cross-finger flap; the distinction is that the base of the flap is at the mid-axial line opposite the injured digit in the reverse cross-finger flap. The skin is elevated only to the level of the dermis, leaving the underlying fat and subcutaneous tissue, which is then elevated in the opposite direction so that the hinge of this subcutaneous flap is adjacent to the finger defect. This flap of subcutaneous tissue is sutured into the defect and a fullthickness skin graft is then applied over the flap (Fig. 5). The hinged full-thickness skin originally elevated from the donor digit is then primarily sutured back down over donor digit extensor paratenon. J Hand Surg Am.
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FIGURE 5: A A patient presented with a fingertip defect with volar soft tissue loss of the middle finger. B A reverse-cross finger flap was performed to provide coverage by using donor tissue overlying the dorsum of the ring finger, first by elevating a 3-sided, full-thickness skin flap only to the level of the dermis, with the hinge on the ulnar aspect of the flap. The paratenon was preserved overlying the extensor mechanism overlying the middle phalanx of the ring finger. C A 3-sided flap consisting of fat and subcutaneous tissue was then elevated in the opposite direction, with its hinge on the radial side of the donor site, and rotated to cover the volar defect of the middle finger. D The original skin flap was then sutured to cover the donor site and a full-thickness skin graft was applied to cover the rotated subcutaneous flap at the recipient site E.
Current Concepts
replants13,14 as well as provide coverage for several soft tissue defects after trauma or infection.15
tissue injuries distal to the interphalangeal (IP) joint through zone I are frequently amenable to local or regional reconstructive techniques.
THUMB DEFECTS Several classifications have been described regarding injuries to the thumb; proximal injuries not amenable to replantation through zone II (proximal phalanx) are typically treated with pollicization or distraction lengthening, whereas zone III (MCP joint) injuries typically require microvascular toe transfer. Soft
V-Y advancement (Tranquilli-Leali technique) Similar to other fingertip defects, the V-Y advancement techniques (Atasoy and Kutler) take advantage of available palmar tissue proximal to a distal defect of the thumb. Originally described by Atasoy and Tranquilli-Leali,16 recent modification of the flap incorporates more proximal elevation of the flap with
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Moberg advancement flap The Moberg advancement flap (Fig. 7) is useful for coverage of thumb amputations distal to the IP joint. The presence of the dorsal arterial supply to the thumb allows the palmar tissue to be advanced with the volar neurovascular pedicles without jeopardizing perfusion of the dorsal tissue.
the radial and ulnar neurovascular bundles, allowing for more distal advancement than traditional V-Y flaps, which relied solely on perforator vessels within the subcutaneous tissue of the pulp. Elliot et al17 described favorable results in their series of 55 flaps and broadened the indications to include distal tip amputations of the thumb. J Hand Surg Am.
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FIGURE 6: A A patient presented with a full-thickness burn over the dorsum of the proximal and middle phalanges of the middle finger that required debridement and soft tissue coverage. B A reverse fasciocutaneous DMCA flap was raised from the interosseous muscle fascia and rotated into the defect. C The donor site underwent primary repair.
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FIGURE 7: A A patient presented with a chronic soft tissue defect of the volar tip of the thumb and B, C underwent a Moberg advancement. D Postoperatively, the patient experienced excellent cosmesis with full extension of the IP joint.
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The flap is raised from distal to proximal at the level of the flexor tendon sheath, incorporating both neurovascular bundles to the radial and ulnar side and typically terminating proximally at the MCP flexion crease. It can be extended proximally into the thenar eminence to obtain additional mobility of the flap. The major concern with the Moberg flap is the potential introduction of a thumb IP flexion contracture to reduce tension at the closure site. Although this typically does not occur in the absence of trauma or arthritis in the joint, other options to maximize length without excessive IP flexion include a transverse cross-cut across the base of the flap with pedicle preservation and skin graft application at the base of J Hand Surg Am.
the donor site (or incorporating Burow triangles at the base of the flap18). First dorsal metacarpal artery flap (kite flap) Based off the first dorsal metacarpal artery ulnar branch to the index finger, the kite flap is an axial flap harvested from the dorsoradial aspect of the hand at the level of the index finger metacarpal head or the MCP joint for treatment of dorsal defects of the thumb as far distal as the IP joint.19 A full-thickness flap is harvested, including the underlying fascia of the first dorsal interosseous on top of which the vessel runs. One should mobilize a wide swath of tissue proximal to the flap without direct dissection of the r
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pedicle until sufficient mobility is achieved to transfer the flap to the defect; a sensory branch of the radial nerve may be incorporated with the flap if sensibility is desired. The donor site may be repaired primarily or covered with a skin graft. Cortical reorientation refers to the process of the brain interpreting sensation from a transferred flap as originating from the defect site instead of the donor site. Although certain authors have suggested that division of the donor digital nerve and cooptation to the recipient proper digital nerve may improve cortical reorientation, diminished 2-point discrimination may result. Trankle et al20 reported favorable results after innervated FDMA reconstruction of thumb defects with minimal donor site morbidity at the index finger; those authors did not divide the digital nerve at the donor site and coapt it to the proper digital nerve of the recipient site. Although cortical reorientation occurred in only half of this cohort, the authors reported no functional consequence of this deficit and did not recommend routine microsurgical coaptation of the digital nerves.
Reversed radial forearm flap Frequently referred to as a “reconstructive chameleon,” the radial forearm flap is a preferred, versatile regional flap for reconstruction of large soft tissue defects of the hand. It may be harvested as a fasciocutaneous, fascia-only, osteoseptocutaneous, or perforator flap and can provide coverage for nearly all wounds of the hand owing to its distant pedicle. Principal disadvantages of the flap included the harvest of the radial artery, which is contraindicated in patients without adequate flow to the entire hand through the ulnar artery based on the Allen test, and poor cosmesis of the donor site when fasciocutaneous flaps are harvested and a skin graft is applied directly to the donor forearm musculature. The traditional fasciocutaneous radial forearm flap (Fig. 8) is designed along the axis of the radial artery in the forearm at a level such that a point of rotation at the wrist crease will allow the flap to be transferred to the desired portion of the hand without kinking of the vessel. The radial artery and venae comitantes are clearly identified proximally and distally (Fig. 8A). The flap is then elevated in an ulnar to radial direction, superficial to the palmaris longus and flexor carpi radialis, and the vascular pedicle to the flap is carefully dissected with its associated perforators and carefully separated from muscular perforators, which are ligated. After elevation of the flap, the radial artery is divided and ligated at the proximal margin of the flap. The flap is then rotated and transferred to the recipient site through either a subcutaneous tunnel or an incision connecting the pedicle and recipient sites, and a split-thickness skin graft is applied to the donor site (Figs. 8C, 8D). Efforts have been developed toward improving the cosmesis of the donor site, which frequently assumes an unsightly appearance; this includes the development of fascia-only radial forearm flaps that permit primary closure of the donor site with application of split-thickness skin graft to the recipient site.24 In an effort to address risks of hand ischemia or cold intolerance from harvest of the radial artery,
DEFECTS PROXIMAL TO THE MCP JOINT The dorsal soft tissues of the hand are thin and are intimately associated with the underlying extensor tendons and metacarpals. Although skin grafting may r
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be performed with a viable recipient wound bed, the hand surgeon frequently encounters large defects with exposure of bone or tendon without periosteum or paratenon that require more advanced techniques within the reconstructive ladder. Regional axial rotational flaps, distant pedicled flaps, and free tissue transfer are frequently required for defects involving the dorsal hand.
Neurovascular island flaps Neurovascular island flaps are a reconstructive option for palmar and tip defects when donor tissue availability is limited for the V-Y or Moberg techniques. Although the flap may be harvested from any digit, the most common donor sites include the distal ulnar aspect of the middle finger or the distal ulnar aspect of the ring finger (Littler flap). The flap is elevated from the ulnar aspect of the distal and middle phalanx of the donor digit (typically the middle or ring finger), and dissection of the neurovascular bundle is carried toward the superficial palmar arch. The proper digital artery to the neighboring digit is ligated to maximize mobility of the flap for transfer to the thumb; perfusion of the neighboring digit should be confirmed preoperatively before the flap transfer. The major historical disadvantage of neurovascular island flap coverage for thumb defect included sensory dysfunction at the recipient site, including loss of 2-point discrimination and poor cortical reorientation.21,22 However, several authors have reported improved sensory function and cortical reorientation with division of the donor digital nerve and cooptation to the recipient site nerve.23
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FIGURE 8: A The reverse radial forearm flap is typically raised along the axis of the radial artery; the radial artery of the flap is exposed both distally and proximally where it is ligated. B A patient was treated with a radial forearm flap after sustaining a traumatic defect involving the volar aspect of the thenar compartment and thumb; the template of the proposed flap was marked. Postoperative photographs after reconstruction of the forearm C and recipient site D; note the use of a split-thickness skin graft for coverage of the donor site.
perforator fascial flaps based off perforating vessels of the radial artery were developed to spare the principal radial artery. Hansen and colleagues25 described favorable outcomes with a distally based radial forearm fascial flap based on radial artery perforators for treatment of a variety of hand defects; the vascular pedicle of these grafts was typically located near the radial styloid. Current Concepts
particularly for flaps extending beyond the MCP joints. Absent or limited communication between the anterior and posterior interosseous arterial systems has been reported, and its presence should be confirmed either angiographically or intraoperatively before elevating the flap.26 The axis of the flap is typically along a line connecting the lateral epicondyle and distal radioulnar joint, with a pivot point based approximately 2 cm proximal to the distal radioulnar joint. The proposed flap is elevated in a subfascial fashion along the extensor digiti minimi and extensor carpi ulnaris toward the pedicle. After adequate dissection of the pedicle and flap, the proximal aspect of the posterior interosseous artery should be clamped, and retrograde perfusion to the flap should be confirmed before transferring the flap into the recipient site. The donor site may be closed primarily or skin grafted if it exceeds 3 to 4 cm in width.
Reversed posterior interosseous artery flap Based off an anastomosis between the anterior and posterior interosseous arteries at the level of the distal radioulnar joint, the posterior interosseous flap is a retrograde, fasciocutaneous flap that may be performed predominantly for dorsal hand defects. The major advantage of this flap is that it spares major perfusing vessels (ie, radial artery). Although the flap may provide coverage as far distal as the PIP joint, distal necrosis has been reported in multiple series, J Hand Surg Am.
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DISTANT FLAPS AND FREE TISSUE TRANSFER Although not the focus of this review, the role of distant flaps and free vascularized tissue transfer deserves brief mention, because these more advanced techniques along the reconstructive ladder have evolved with expanded applications for upper extremity coverage using modern microvascular surgical procedures. They may be considered when local or regional flaps may not be reasonably performed, commonly when local donor tissue is inadequate for coverage requirements or if harvest of local tissue may further compromise the function of a traumatized limb. A variety of free vascularized fasciocutaneous (lateral arm,27 anterolateral thigh,28 and scapular29) and muscular (latissimus dorsi30,31 and gracilis32) flaps have been described for treatment of a variety of soft tissue defects of the upper extremities, with favorable results. Distant pedicled flaps, including the groin and intercostal flaps, remain a useful soft tissue coverage modality for defects not amenable to local flap coverage or for defects for which free tissue transfer is not possible or not likely to succeed. Although less J Hand Surg Am.
commonly used today, the groin flap remains a versatile soft tissue coverage option for a variety of hand defects owing to its abundance of donor skin and subcutaneous tissue, and it has historically been a reliable reconstructive procedure since its original description in 1972.33 However, disadvantages include the need for 2 procedures and the bulk of the flap with subsequent debridement procedures often necessary to optimize hand function.34 Despite these drawbacks, the groin flap has continued to be proven effective for a variety of applications in hand and forearm reconstruction over the past 5 decades.35 In addition, other pedicled flaps based off the lateral intercostal arterial system have been described, with favorable outcomes for soft tissue coverage of the elbow and proximal forearm.36,37 The decision between a distant pedicle flap and a free flap is complex, because distant flaps require additional procedures for delayed sectioning and often debulking. This is frequently encountered following application of the the groin flap. Several advantages are offered by distant flaps, however, including the ability to perform the procedure without
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FIGURE 9: Schematic of soft tissue reconstructive procedures based on location of the primary defect.
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microvascular techniques, as well as reduced operative time and less intense postoperative monitoring than that required after free tissue transfer. Certain surgeons may prefer the use of a distal flap for these reasons instead of free tissue transfer, especially in patients with major comorbidities, who may be at risk of flap failure after free tissue techniques and microvascular anastamoses. In conclusion, innovations and refinements in local and regional flaps for the hand allow surgeons increasing flexibility for soft tissue coverage that optimizes cosmesis and function while minimizing donor site morbidity. Given the many options available, we favor an algorithmic approach based on the location of defect to best identify potential sources of flap coverage (Fig. 9). Thorough debridement followed by timely coverage in adherence to the reconstructive ladder of Mathes offers the best opportunity to restore form and optimize function. Small to medium defects without exposed deep structures are often best managed with healing by secondary intention or skin grafting, whereas larger lesions or those with exposed deep structures will benefit from flap coverage or the application of dermal regeneration templates.
13. Saalabian AA, Unglaub F, Horch RE, et al. Free vascularized metacarpal bone graft combined with extended dorsal metacarpal artery flap for phalangeal bone and soft tissue loss: case report. Arch Orthop Trauma Surg. 2012;132(1):137e140. 14. Saba SC, Lee J, Pathy VV, et al. Salvage of a thumb replant using a bilobed dorsal metacarpal artery island flap: case report and literature review. Hand (N Y). 2008;3(4):366e371. 15. Herold C, Vogt P, Strub D, Spies M. [Delayed DMCA-flap in a case of infection in the finger] [in German]. Handchir Mikrochir Plast Chir. 2008;40(2):138e142. 16. Gharb BB, Rampazzo A, Armijo BS, et al. Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study. J Plast Reconstr Aesthet Surg. 2010;63(4):681e685. 17. Elliot D, Moiemen NS, Jigjinni VS. The neurovascular TranquilliLeali flap. J Hand Surg Br. 1995;20(6):815e823. 18. Mutaf M, Temel M, Gunal E, et al. Island volar advancement flap for reconstruction of thumb defects. Ann Plast Surg. 2012;68(2):153e157. 19. Gebhard B, Meissl G. An extended first dorsal metacarpal artery neurovascular island flap. J Hand Surg Br. 1995;20(4):529e531. 20. Trankle M, Sauerbier M, Heitmann C, et al. Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap. J Hand Surg Am. 2003;28(5):758e766. 21. Krag C, Rasmussen KB. The neurovascular island flap for defective sensibility of the thumb. J Bone Joint Surg Br. 1975;57(4):495e499. 22. Murray JF, Ord JV, Gavelin GE. The neurovascular island pedicle flap: an assessment of late results in sixteen cases. J Bone Joint Surg Am. 1967;49(7):1285e1297. 23. Adani R, Squarzina PB, Castagnetti C, et al. A comparative study of the heterodigital neurovascular island flap in thumb reconstruction, with and without nerve reconnection. J Hand Surg Br. 1994;19(5):552e559. 24. Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg Am. 2006;31(5):847e856. 25. Hansen AJ, Duncan SF, Smith AA, et al. Reverse radial forearm fascial flap with radial artery preservation. Hand (N Y). 2007;2(3): 159e163. 26. Costa H, Pinto A, Zenha H. The posterior interosseous flap—a prime technique in hand reconstruction. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstr Aesthet Surg. 2007;60(7):740e747. 27. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg. 1984;12(6): 489e500. 28. Pribaz JJ, Orgill DP, Epstein MD, et al. Anterolateral thigh free flap. Ann Plast Surg. 1995;34(6):585e592. 29. Datiashvili RO, Yueh JH. Management of complicated wounds of the extremities with scapular fascial free flaps. J Reconstr Microsurg. 2012;28(8):521e528. 30. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg. 1981;67(5):637e641. 31. Tobin GR, Moberg AW, DuBou RH, et al. The split latissimus dorsi myocutaneous flap. Ann Plast Surg. 1981;7(4):272e280. 32. Macchi V, Vigato E, Porzionato A, et al. The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study. Clin Anat. 2008;21(7):696e704. 33. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25(1):3e16. 34. Chuang DC, Colony LH, Chen HC, et al. Groin flap design and versatility. Plast Reconstr Surg. 1989;84(1):100e107. 35. Chow JA, Bilos ZJ, Hui P, et al. The groin flap in reparative surgery of the hand. Plast Reconstr Surg. 1986;77(3):421e426. 36. Yunchuan P, Jiaqin X, Sihuan C, Zunhong L. Use of the lateral intercostal perforator-based pedicled abdominal flap for upper-limb wounds from severe electrical injury. Ann Plast Surg. 2006;56(2):116e121. 37. Acarturk TO. Lateral intercostal artery perforator-based reverse thoracic flap for antecubital reconstruction. J Plast Reconstr Aesthet Surg. 2008;61(11):e5ee8.
REFERENCES
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1. Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011;127(suppl 1):205Se212S. 2. Eo S, Cho S, Shin H, et al. The utility of Alloderm in hand resurfacing. J Plast Reconstr Aesthet Surg. 2010;63(1):e41ee43. 3. Dantzer E, Queruel P, Salinier L, et al. Dermal regeneration template for deep hand burns: clinical utility for both early grafting and reconstructive surgery. Br J Plast Surg. 2003;56(8):764e774. 4. Carothers JT, Brigman BE, Lawson RD, et al. Stacking of a dermal regeneration template for reconstruction of a soft-tissue defect after tumor excision from the palm of the hand: a case report. J Hand Surg Am. 2005;30(6):1322e1326. 5. Taras JS, Sapienza A, Roach JB, et al. Acellular dermal regeneration template for soft tissue reconstruction of the digits. J Hand Surg Am. 2010;35(3):415e421. 6. Ramirez MA, Means KR Jr. Digital soft tissue trauma: a concise primer of soft tissue reconstruction of traumatic hand injuries. Iowa Orthop J. 2011;31:110e120. 7. Fassler PR. Fingertip injuries: evaluation and treatment. J Am Acad Orthop Surg. 1996;4(1):84e92. 8. Bickel KD, Dosanjh A. Fingertip reconstruction. J Hand Surg Am. 2008;33(8):1417e1419. 9. Melone CP Jr, Beasley RW, Carstens JH Jr. The thenar flap—An analysis of its use in 150 cases. J Hand Surg Am. 1982;7(3):291e297. 10. Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg. 2007;60(7):731e739. 11. Yang D, Morris SF. Reversed dorsal digital and metacarpal island flaps supplied by the dorsal cutaneous branches of the palmar digital artery. Ann Plast Surg. 2001;46(4):444e449. 12. Pelissier P, Casoli V, Bakhach J, et al. Reverse dorsal digital and metacarpal flaps: a review of 27 cases. Plast Reconstr Surg. 1999;103(1):159e165.
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Local and Regional Flaps for Hand Coverage Debdut Biswas, MD, Robert W. Wysocki, MD, John J. Fernandez, MD, Mark S. Cohen, MD
Hand surgeons are frequently challenged by the unique requirements of soft tissue coverage of the hand. Whereas many smaller soft tissue defects without involvement of deep structures are amenable to healing by secondary intention or skin grafting, larger lesions and those with exposed tendon, bone, or joint often require vascularized coverage that allows rapid healing without wound contraction. The purpose of this review was to present an overview of local and regional flaps commonly used for soft tissue reconstruction within the hand. (J Hand Surg Am. 2014;39(5):992e1004. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Coverage, finger, flap, hand, soft tissue.
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can result from a variety of mechanisms including trauma, infection, and malignant disorders. Reconstructive surgeons who encounter these conditions must account for the unique requirements and challenges of soft tissue coverage specific to the hand. The optimal soft tissue reconstruction protects against the development of contractures and facilitates tendon and joint mobility, while maintaining durability and sensibility of the hand. This is particularly true in situations where palmar soft tissue coverage is required. The “reconstructive ladder,” originally described by Mathes and Nahai,1 is based on the principle of using the simplest approach of coverage that adequately restores form and optimizes function. The simplest technique includes direct primary closure, followed by skin grafting, local and regional flaps, and ultimately, free vascularized tissue transfer. The purpose of this review was to describe the clinical indications and outcomes of local and regional flap reconstructions commonly performed for soft tissue defects in the hand. Traditional techniques as OFT TISSUE DEFECTS IN THE HAND
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From the Section of Hand and Elbow Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL. Received for publication January 4, 2013; accepted in revised form September 16, 2013. R.W.W. is a consultant for Acumed, Hillsboro, OR. Corresponding author: Mark S. Cohen, MD, Section of Hand and Elbow Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison Street, Chicago, IL 60612; e-mail: [email protected]. 0363-5023/14/3905-0031$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.09.027
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well as recent innovations in soft tissue coverage will be presented with a particular focus on a systematic approach to treating these challenging conditions. CLINICAL EVALUATION AND WOUND PREPARATION Sharp lacerations in the hand without substantial contamination or active infection are typically amenable to debridement and primary repair. For wounds not amenable to primary closure, the decision must be made as to what type of coverage to provide and the timing in doing so. Although skin grafts will survive on a vascular tissue bed, the exposure of “white structures” (nerve, tendon, and bone) typically requires vascularized soft tissue reconstruction. If local or regional flap coverage is being considered, healthy tissues in proximity to the defect should be evaluated as potential donor sites; additional studies may be necessary to determine the suitability of these tissues (ie, Doppler ultrasonography or angiography). A systematic approach to soft tissue defects in the setting of complex hand trauma is mandatory. Although soft tissue coverage should be performed as expeditiously as possible, the need for radical and serial debridements of contaminated wounds is necessary before any soft tissue reconstruction. Quantitative tissue culture may be advisable before proceeding with skin grafting or flap coverage, particularly in chronically infected wounds or those with considerable contamination. In such cases, multiple debridements can decrease bacterial load
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and optimize the condition of the wound bed to accommodate a skin graft or flap. Skeletal stabilization of fractures is mandatory to provide a foundation for soft tissue coverage, and repair or reconstruction of nerve, arterial, or tendon injuries is typically performed before proceeding with flap reconstruction. In certain situations, definitive tendon reconstruction is delayed and silicone spacers are placed if a scar-free bed for tendon gliding cannot be ensured. Ideally, soft tissue coverage using skin grafts and flaps should be achieved within 48 hours to avoid the development of granulation tissue and no later than 10 days of injury to minimize infection risk. Although the development of granulation tissue can help achieve relatively noninvasive biologic coverage of soft tissue defects in the lower extremities and trunk, granulation tissue development within the hand frequently matures into scar tissue, which fosters contracture and inhibits motion. Stable flap coverage is necessary to limit the development of granulation tissue and help best restore motion after soft tissue trauma to the hand. Recent technical innovations in vacuum-assisted closure (VAC) therapy deserve special mention. These devices have improved the management of wounds before soft tissue closure by removing exudate, decreasing edema, and decreasing the dead space and overall dimensions of soft tissue defects. Although the application of such devices should be performed judiciously and temporarily when tendon or neurovascular structures are exposed, the use of VAC therapy may decrease requirements for flap coverage and safely delay definitive soft tissue reconstruction in select situations. Nonetheless, prolonged use of VAC therapy should be avoided because of concerns regarding the development of granulation tissue and its propensity for scar formation and resultant contracture. For the hand specifically, a VAC should be used only for short-term periods, typically less than 48 hours, to avoid excessive granulation tissue and scar development before definitive flap closure. Areas such as the midarm and midforearm are more tolerant of scarring and skin contracture and a VAC can be applied more liberally in those locations.
can also be covered with skin grafts if the paratenon is intact. Split-thickness skin grafts are often performed for defects involving the dorsum of the hand, which require pliable, low-profile soft tissue coverage. Full-thickness grafts are almost always required for defects on the palmar side, to minimize contracture and restore optimal durability and sensibility. Efforts continue to be devoted toward the development of synthetic skin substitutes, including several commercially available dermal regeneration templates that can achieve coverage even when deep structures are exposed. These products facilitate the formation of a neodermis and optimize conditions for staged split-thickness skin grafting once a fully vascularized bed is present.2 Favorable cosmetic and functional outcomes have been reported with the use of dermal regeneration templates for deep hand defects after burns,3 tumor excision,4 and digital soft tissue injuries not amenable to local flap coverage.5 Although these series involved limited numbers of patients, favorable outcomes reported with the application of these synthetic products clearly highlight their use for hand coverage.
Local flaps Local flaps (ie, V-Y advancement, z-plasty) originate from tissues directly adjacent to a defect and are typically completed in a single stage. Many of these flaps are random-pattern flaps that have no specifically recognized perfusing vasculature. They are typically transferred to the recipient site by a combination of rotation, transposition, or advancement. The Burow triangle rotation flap (Fig. 1) is a frequently performed rotation flap that distributes the tension of closure over a defect to a larger surface area. This is accomplished by designing a curved incision incorporating a large adjacent region of soft tissue to be rotated into the defect; a back-cut helps achieve greater mobility and less tension on the repair. Rhomboid flaps are common transposition flaps performed by converting an existing defect into a rhomboid configuration and then pivoting adjacent donor tissue into the defect, such as defects involving the dorsum of the hand, r
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LOCAL AND REGIONAL FLAPS: PRINCIPLES AND DEFINITIONS Although skin grafts may be appropriately applied to cover an adequately vascularized tissue bed, the hand surgeon frequently encounters other hand defects with exposed bone or tendon that require more advanced flap coverage. A myriad of local and regional flaps have been described for treatment of these defects, and are the focus of this review.
SKIN GRAFTING The use of skin grafting deserves brief mention, because it remains a common technique within the armamentarium of hand surgeons for treatment of defects of the hand, particularly in cases in which only subcutaneous tissue or muscle are exposed. Tendons J Hand Surg Am.
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FIGURE 2: Classification of fingertip injuries. Zone II and IV injuries are frequently amenable to local or regional flap coverage.6 FIGURE 1: Schematic diagram of a Burow rotation flap; a back cut (blue) is created to facilitate the transposition of a wider area of skin into a primary defect (red).
Free vascularized tissue transfer represents the most advanced form of soft tissue reconstruction of the upper extremity. A variety of fasciocutaneous (lateral arm and anterolateral thigh) and muscular (latissimus dorsi and gracilis) free vascularized flaps have been extensively described in the literature and should be considered when soft tissue defects are not amenable to local, regional, or multistage pedicled distant flap reconstruction.
where the elasticity of the tissues permits rotation of skin flaps. The V-Y advancement flap is a local flap frequently used for distal fingertip defects by mobilizing a V-shaped flap distally and primarily closing the skin at the apex of the defect or allowing it to heal by secondary intention.
LOCAL AND REGIONAL FLAPS: TREATMENT BY LOCATION Fingertip defects Fingertip injuries are the most common open defects encountered by hand surgeons, and the primary objective of treatment is a painless fingertip with durable and sensate skin. The principal determinants of treatment are the exposure of bone and the quantity of soft tissue involved in the defect; these injuries have been classified into 4 main patterns6 (Fig. 2). Transverse tip amputations without exposed bone, including most type 1 injuries, may be treated with healing by secondary intention; more proximal injuries near the distal interphalangeal (DIP) joint (type 3) may be considered for replantation when appropriate, or revision amputation with favorable results. Although injuries that feature more extensive softtissue loss with exposed bone (type 2) may be treated with skeletal shortening and primary closure, these techniques are associated with nail plate abnormalities, particularly when over 50% of the nail plate is involved.6,7 Soft tissue reconstruction is frequently performed for type 2 injuries as well as type 4 injuries in which the injury is limited to the volar soft tissues.
Regional flaps Flaps that originate from other sites not directly adjacent to the primary defect but are derived from the ipsilateral limb are termed regional flaps; these flaps may have either a random pattern or an axial pattern of blood supply with the presence of a specific longitudinal blood supply along the length of the flap. Random-pattern regional flaps, such as the crossfinger and thenar flaps, almost always require 2 stages: the first is for flap harvest and application to the defect, and the second is for dividing and insetting the flap from the donor site once the flap is vascularized by the recipient bed. Axial pattern regional flaps, including the radial forearm and dorsal metacarpal arterial flap, may be completed in a single procedure because the flap is merely rotated on its pedicle and the blood supply is transferred in conjunction with the soft tissue flap. Current Concepts
Distant flaps Flaps originating from outside the ipsilateral limb of the defect are commonly referred to as distant flaps. Aside from free tissue transfer, these flaps almost always require at least 2 stages for harvest and application, followed by insetting and division of the flap. The pedicled groin flap is an example of a less commonly used distant axial pattern flap used for the reconstruction of soft tissue defects of the upper extremity. J Hand Surg Am.
Homodigital flaps (V-Y advancement) The V-Y flap is a local advancement flap that can be applied to transversely oriented soft tissue defects and r
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those with predominantly dorsal rather than palmar soft tissue loss in all fingertips, including the thumb. Two main variants are frequently performed, depending on the availability of proximal volar versus radially or ulnarly based pulp tissue. The Atasoy V-Y advancement is performed with a proximally based V incision with its apex immediately distal to the distal interphalangeal flexion crease. A full-thickness flap is elevated to the level of the neurovascular structures and flexor tendon sheath and fibrous septae are divided; the flap is then advanced into the defect while the donor site is J Hand Surg Am.
primarily repaired or allowed to granulate in (Fig. 3). Patients should be counseled regarding the possibility of nail plate deformities, specifically the long-term development of a hook nail. When the availability of a palmar donor site is limited, the Kutler V-Y advancement (lateral V-Y) may be used instead by raising radially or ulnar based flaps. The flaps are raised in a fashion similar to that of the palmar technique and advanced distally into the recipient defect. Variable outcomes have been reported with these flaps, including issues related to scar hypersensitivity,6 although other r
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FIGURE 3: Patient presenting with a transverse fingertip injury. A, B Over 50% of the nail bed remains. CeE A V-Y advancement flap was used to treat this defect. F, G The patient demonstrated a fully sensate, pain-free digit at final follow-up.
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FIGURE 4: A, B A patient sustained a soft tissue injury with extensive palmar tissue loss over the middle and distal phalanx of the little finger. C, D A cross-finger flap was harvested from the dorsal middle phalanx of the ring finger and E was inset into the defect; F the donor site was covered with a skin graft. The flap was divided at 2 weeks; the patient reported a fully sensate digit with no appreciable flexion contractures of the PIP or DIP G, with excellent cosmesis.
authors have reported favorable results after use of the Kutler flap.8
Current Concepts
crease of the thumb; care is taken to avoid injury to the radial digital nerve of the thumb, which crosses the thumb axis at this level. The flap is then primarily sutured to the recipient defect site, with the MCP and DIP joints flexed as much as possible to minimize flexion required at the PIP joint; the flap is typically divided and formally inset after a period of 2 to 3 weeks. Although the fear of developing or exacerbating PIP contractures led many authors to recommend this technique only for children and adults under the age of 30 years, Melone et al9 reported favorable outcomes in older patients; only 4% of patients in that series of 150 flaps developed a PIP contracture.
Heterodigital flaps Thenar flap: Despite favorable results after the performance of the V-Y advancement flaps, certain injuries may limit the availability of proximally based donor tissue for use in an Atasoy or Kutler flap, especially defects with more palmar soft tissue loss. The thenar flap is frequently used for larger volar defects, particularly for the index and long fingers. Although the technique is an excellent method of restoring the soft tissue of more extensive defects of the fingertips, the procedure requires the digit to be immobilized in flexion and risks the development of proximal interphalangeal (PIP) flexion contractures. The flap is typically constructed by elevating a proximally based flap of skin and subcutaneous tissue near the metacarpophalangeal (MCP) flexion J Hand Surg Am.
Cross-finger flap: The cross-finger flap (Fig. 4) is favored for larger palmar defects of the middle and distal phalanx that are not amenable to homodigital flap reconstruction. Although some authors favor the cross-finger flap as an alternative to the thenar flap to r
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prevent PIP contracture, the amount of flexion of the PIP necessary to graft the defect site for fingertip injuries, especially for the long finger, has been noted to be similar between both techniques. The donor site is typically designed on the dorsal aspect of the middle phalanx of an adjacent digit as a 3-sided rectangular flap (Fig. 4C); the base of the flap is at the mid-axial line closest to the injured digit; a full-thickness flap is then elevated typically from the PIP distal extension to the DIP proximal extension crease (Fig. 4D), taking care not to violate the paratenon of the extensor tendon. After suturing the flap into the defect (Fig. 4E), a full-thickness skin graft is applied to the donor site (Fig. 4F), usually from the ipsilateral medial arm or hypothenar eminence. The recipient digit is splinted in as minimal flexion as possible while maintaining minimal tension on the flap; the flap is typically divided and formally inset after a period of 2 to 3 weeks. Regardless of wound size, fingertip injuries without exposed deep structures that heal by secondary intention will often provide acceptable cosmesis with the greatest return of sensibility and without the donor morbidity of the flaps described earlier. In cases where more than 50% of the nail plate is absent, skeletal shortening and revision amputation are commonly recommended.
Dorsal metacarpal arterialebased regional flaps Axial regional flaps based off the dorsal metacarpal arterial system (DMCA) have been extensively refined and modified since their original description by Muryama10 over 2 decades ago. Anatomically, the second through fourth dorsal metacarpal arteries arise from the dorsal carpal rete, a continuation of the dorsal branch of the radial artery, and provide cutaneous perforators to the dorsal soft tissues and skin. At the level of the web space, the metacarpal arteries are reliably present, particularly the first and second dorsal metacarpal arteries. In conjunction with the palmardorsal anastomosis at the level of the metacarpal neck, this vascular network serves as the basis for several axial flaps, including the flag flap and first dorsal metacarpal (FDMA) and second dorsal metacarpal axial flaps. From the dorsum of the middle finger, for example, the flag flap is typically elevated as a fullthickness subcutaneous flap from the dorsum of the proximal phalanx from mid-axial line to mid-axial line and from the extension crease of the PIP to the web space proximally; it can then be rotated to provide coverage to the dorsum of either the proximal phalanx of the adjacent digits or the MCP joint of either the index or the middle finger. The flag flap can also be passed through the web space to provide coverage palmarly at the level of the proximal phalanx.11 The reverse DMCA flap (Fig. 6) relies on retrograde perfusion from the anastomosis mentioned earlier, particularly the second metacarpal artery between the index and long finger, which is reliably present in most patients. The flap is designed typically as an ellipse on the dorsum of the hand over the given dorsal metacarpal artery, and the dissection is carried down to include the fascia over the interosseous musculature (Fig. 6B). The entry point of the dorsal metacarpal artery is ligated proximally and the flap is rotated from proximal to distal to cover dorsal or palmar digital defects as far distal as the PIP joint. The donor site can usually be repaired primarily for smaller flaps or covered with a skin graft, and there is the option to transfer this as a fascial flap only without skin, to ensure closure of the donor site. Further anatomic evaluations revealed the presence of palmar to dorsal anastomoses in the distal aspect of the web space at the proximal phalanx, leading to the development of extended DMCA flaps, which could provide coverage as far as the distal phalanx.12 The use of the DMCA flap is rapidly rising as the understanding the vascular anatomy of this reconstruction evolves. This flap has been successfully used to enhance or salvage
DIGITAL DEFECTS PROXIMAL TO FINGERTIPS Reverse cross-finger flap The reverse cross-finger flap is commonly used to treat dorsal defects of the digits that are unable to support a skin graft, most commonly over the middle and proximal phalanges. This technique transfers the dorsal fat and subcutaneous tissue of a donor digit to a dorsal defect of an adjacent finger so that it may support the application of a skin graft. The donor site is typically designed dorsally as a 3-sided rectangular flap similar to a cross-finger flap; the distinction is that the base of the flap is at the mid-axial line opposite the injured digit in the reverse cross-finger flap. The skin is elevated only to the level of the dermis, leaving the underlying fat and subcutaneous tissue, which is then elevated in the opposite direction so that the hinge of this subcutaneous flap is adjacent to the finger defect. This flap of subcutaneous tissue is sutured into the defect and a fullthickness skin graft is then applied over the flap (Fig. 5). The hinged full-thickness skin originally elevated from the donor digit is then primarily sutured back down over donor digit extensor paratenon. J Hand Surg Am.
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FIGURE 5: A A patient presented with a fingertip defect with volar soft tissue loss of the middle finger. B A reverse-cross finger flap was performed to provide coverage by using donor tissue overlying the dorsum of the ring finger, first by elevating a 3-sided, full-thickness skin flap only to the level of the dermis, with the hinge on the ulnar aspect of the flap. The paratenon was preserved overlying the extensor mechanism overlying the middle phalanx of the ring finger. C A 3-sided flap consisting of fat and subcutaneous tissue was then elevated in the opposite direction, with its hinge on the radial side of the donor site, and rotated to cover the volar defect of the middle finger. D The original skin flap was then sutured to cover the donor site and a full-thickness skin graft was applied to cover the rotated subcutaneous flap at the recipient site E.
Current Concepts
replants13,14 as well as provide coverage for several soft tissue defects after trauma or infection.15
tissue injuries distal to the interphalangeal (IP) joint through zone I are frequently amenable to local or regional reconstructive techniques.
THUMB DEFECTS Several classifications have been described regarding injuries to the thumb; proximal injuries not amenable to replantation through zone II (proximal phalanx) are typically treated with pollicization or distraction lengthening, whereas zone III (MCP joint) injuries typically require microvascular toe transfer. Soft
V-Y advancement (Tranquilli-Leali technique) Similar to other fingertip defects, the V-Y advancement techniques (Atasoy and Kutler) take advantage of available palmar tissue proximal to a distal defect of the thumb. Originally described by Atasoy and Tranquilli-Leali,16 recent modification of the flap incorporates more proximal elevation of the flap with
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Moberg advancement flap The Moberg advancement flap (Fig. 7) is useful for coverage of thumb amputations distal to the IP joint. The presence of the dorsal arterial supply to the thumb allows the palmar tissue to be advanced with the volar neurovascular pedicles without jeopardizing perfusion of the dorsal tissue.
the radial and ulnar neurovascular bundles, allowing for more distal advancement than traditional V-Y flaps, which relied solely on perforator vessels within the subcutaneous tissue of the pulp. Elliot et al17 described favorable results in their series of 55 flaps and broadened the indications to include distal tip amputations of the thumb. J Hand Surg Am.
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FIGURE 6: A A patient presented with a full-thickness burn over the dorsum of the proximal and middle phalanges of the middle finger that required debridement and soft tissue coverage. B A reverse fasciocutaneous DMCA flap was raised from the interosseous muscle fascia and rotated into the defect. C The donor site underwent primary repair.
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FIGURE 7: A A patient presented with a chronic soft tissue defect of the volar tip of the thumb and B, C underwent a Moberg advancement. D Postoperatively, the patient experienced excellent cosmesis with full extension of the IP joint.
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The flap is raised from distal to proximal at the level of the flexor tendon sheath, incorporating both neurovascular bundles to the radial and ulnar side and typically terminating proximally at the MCP flexion crease. It can be extended proximally into the thenar eminence to obtain additional mobility of the flap. The major concern with the Moberg flap is the potential introduction of a thumb IP flexion contracture to reduce tension at the closure site. Although this typically does not occur in the absence of trauma or arthritis in the joint, other options to maximize length without excessive IP flexion include a transverse cross-cut across the base of the flap with pedicle preservation and skin graft application at the base of J Hand Surg Am.
the donor site (or incorporating Burow triangles at the base of the flap18). First dorsal metacarpal artery flap (kite flap) Based off the first dorsal metacarpal artery ulnar branch to the index finger, the kite flap is an axial flap harvested from the dorsoradial aspect of the hand at the level of the index finger metacarpal head or the MCP joint for treatment of dorsal defects of the thumb as far distal as the IP joint.19 A full-thickness flap is harvested, including the underlying fascia of the first dorsal interosseous on top of which the vessel runs. One should mobilize a wide swath of tissue proximal to the flap without direct dissection of the r
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pedicle until sufficient mobility is achieved to transfer the flap to the defect; a sensory branch of the radial nerve may be incorporated with the flap if sensibility is desired. The donor site may be repaired primarily or covered with a skin graft. Cortical reorientation refers to the process of the brain interpreting sensation from a transferred flap as originating from the defect site instead of the donor site. Although certain authors have suggested that division of the donor digital nerve and cooptation to the recipient proper digital nerve may improve cortical reorientation, diminished 2-point discrimination may result. Trankle et al20 reported favorable results after innervated FDMA reconstruction of thumb defects with minimal donor site morbidity at the index finger; those authors did not divide the digital nerve at the donor site and coapt it to the proper digital nerve of the recipient site. Although cortical reorientation occurred in only half of this cohort, the authors reported no functional consequence of this deficit and did not recommend routine microsurgical coaptation of the digital nerves.
Reversed radial forearm flap Frequently referred to as a “reconstructive chameleon,” the radial forearm flap is a preferred, versatile regional flap for reconstruction of large soft tissue defects of the hand. It may be harvested as a fasciocutaneous, fascia-only, osteoseptocutaneous, or perforator flap and can provide coverage for nearly all wounds of the hand owing to its distant pedicle. Principal disadvantages of the flap included the harvest of the radial artery, which is contraindicated in patients without adequate flow to the entire hand through the ulnar artery based on the Allen test, and poor cosmesis of the donor site when fasciocutaneous flaps are harvested and a skin graft is applied directly to the donor forearm musculature. The traditional fasciocutaneous radial forearm flap (Fig. 8) is designed along the axis of the radial artery in the forearm at a level such that a point of rotation at the wrist crease will allow the flap to be transferred to the desired portion of the hand without kinking of the vessel. The radial artery and venae comitantes are clearly identified proximally and distally (Fig. 8A). The flap is then elevated in an ulnar to radial direction, superficial to the palmaris longus and flexor carpi radialis, and the vascular pedicle to the flap is carefully dissected with its associated perforators and carefully separated from muscular perforators, which are ligated. After elevation of the flap, the radial artery is divided and ligated at the proximal margin of the flap. The flap is then rotated and transferred to the recipient site through either a subcutaneous tunnel or an incision connecting the pedicle and recipient sites, and a split-thickness skin graft is applied to the donor site (Figs. 8C, 8D). Efforts have been developed toward improving the cosmesis of the donor site, which frequently assumes an unsightly appearance; this includes the development of fascia-only radial forearm flaps that permit primary closure of the donor site with application of split-thickness skin graft to the recipient site.24 In an effort to address risks of hand ischemia or cold intolerance from harvest of the radial artery,
DEFECTS PROXIMAL TO THE MCP JOINT The dorsal soft tissues of the hand are thin and are intimately associated with the underlying extensor tendons and metacarpals. Although skin grafting may r
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be performed with a viable recipient wound bed, the hand surgeon frequently encounters large defects with exposure of bone or tendon without periosteum or paratenon that require more advanced techniques within the reconstructive ladder. Regional axial rotational flaps, distant pedicled flaps, and free tissue transfer are frequently required for defects involving the dorsal hand.
Neurovascular island flaps Neurovascular island flaps are a reconstructive option for palmar and tip defects when donor tissue availability is limited for the V-Y or Moberg techniques. Although the flap may be harvested from any digit, the most common donor sites include the distal ulnar aspect of the middle finger or the distal ulnar aspect of the ring finger (Littler flap). The flap is elevated from the ulnar aspect of the distal and middle phalanx of the donor digit (typically the middle or ring finger), and dissection of the neurovascular bundle is carried toward the superficial palmar arch. The proper digital artery to the neighboring digit is ligated to maximize mobility of the flap for transfer to the thumb; perfusion of the neighboring digit should be confirmed preoperatively before the flap transfer. The major historical disadvantage of neurovascular island flap coverage for thumb defect included sensory dysfunction at the recipient site, including loss of 2-point discrimination and poor cortical reorientation.21,22 However, several authors have reported improved sensory function and cortical reorientation with division of the donor digital nerve and cooptation to the recipient site nerve.23
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FIGURE 8: A The reverse radial forearm flap is typically raised along the axis of the radial artery; the radial artery of the flap is exposed both distally and proximally where it is ligated. B A patient was treated with a radial forearm flap after sustaining a traumatic defect involving the volar aspect of the thenar compartment and thumb; the template of the proposed flap was marked. Postoperative photographs after reconstruction of the forearm C and recipient site D; note the use of a split-thickness skin graft for coverage of the donor site.
perforator fascial flaps based off perforating vessels of the radial artery were developed to spare the principal radial artery. Hansen and colleagues25 described favorable outcomes with a distally based radial forearm fascial flap based on radial artery perforators for treatment of a variety of hand defects; the vascular pedicle of these grafts was typically located near the radial styloid. Current Concepts
particularly for flaps extending beyond the MCP joints. Absent or limited communication between the anterior and posterior interosseous arterial systems has been reported, and its presence should be confirmed either angiographically or intraoperatively before elevating the flap.26 The axis of the flap is typically along a line connecting the lateral epicondyle and distal radioulnar joint, with a pivot point based approximately 2 cm proximal to the distal radioulnar joint. The proposed flap is elevated in a subfascial fashion along the extensor digiti minimi and extensor carpi ulnaris toward the pedicle. After adequate dissection of the pedicle and flap, the proximal aspect of the posterior interosseous artery should be clamped, and retrograde perfusion to the flap should be confirmed before transferring the flap into the recipient site. The donor site may be closed primarily or skin grafted if it exceeds 3 to 4 cm in width.
Reversed posterior interosseous artery flap Based off an anastomosis between the anterior and posterior interosseous arteries at the level of the distal radioulnar joint, the posterior interosseous flap is a retrograde, fasciocutaneous flap that may be performed predominantly for dorsal hand defects. The major advantage of this flap is that it spares major perfusing vessels (ie, radial artery). Although the flap may provide coverage as far distal as the PIP joint, distal necrosis has been reported in multiple series, J Hand Surg Am.
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DISTANT FLAPS AND FREE TISSUE TRANSFER Although not the focus of this review, the role of distant flaps and free vascularized tissue transfer deserves brief mention, because these more advanced techniques along the reconstructive ladder have evolved with expanded applications for upper extremity coverage using modern microvascular surgical procedures. They may be considered when local or regional flaps may not be reasonably performed, commonly when local donor tissue is inadequate for coverage requirements or if harvest of local tissue may further compromise the function of a traumatized limb. A variety of free vascularized fasciocutaneous (lateral arm,27 anterolateral thigh,28 and scapular29) and muscular (latissimus dorsi30,31 and gracilis32) flaps have been described for treatment of a variety of soft tissue defects of the upper extremities, with favorable results. Distant pedicled flaps, including the groin and intercostal flaps, remain a useful soft tissue coverage modality for defects not amenable to local flap coverage or for defects for which free tissue transfer is not possible or not likely to succeed. Although less J Hand Surg Am.
commonly used today, the groin flap remains a versatile soft tissue coverage option for a variety of hand defects owing to its abundance of donor skin and subcutaneous tissue, and it has historically been a reliable reconstructive procedure since its original description in 1972.33 However, disadvantages include the need for 2 procedures and the bulk of the flap with subsequent debridement procedures often necessary to optimize hand function.34 Despite these drawbacks, the groin flap has continued to be proven effective for a variety of applications in hand and forearm reconstruction over the past 5 decades.35 In addition, other pedicled flaps based off the lateral intercostal arterial system have been described, with favorable outcomes for soft tissue coverage of the elbow and proximal forearm.36,37 The decision between a distant pedicle flap and a free flap is complex, because distant flaps require additional procedures for delayed sectioning and often debulking. This is frequently encountered following application of the the groin flap. Several advantages are offered by distant flaps, however, including the ability to perform the procedure without
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FIGURE 9: Schematic of soft tissue reconstructive procedures based on location of the primary defect.
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microvascular techniques, as well as reduced operative time and less intense postoperative monitoring than that required after free tissue transfer. Certain surgeons may prefer the use of a distal flap for these reasons instead of free tissue transfer, especially in patients with major comorbidities, who may be at risk of flap failure after free tissue techniques and microvascular anastamoses. In conclusion, innovations and refinements in local and regional flaps for the hand allow surgeons increasing flexibility for soft tissue coverage that optimizes cosmesis and function while minimizing donor site morbidity. Given the many options available, we favor an algorithmic approach based on the location of defect to best identify potential sources of flap coverage (Fig. 9). Thorough debridement followed by timely coverage in adherence to the reconstructive ladder of Mathes offers the best opportunity to restore form and optimize function. Small to medium defects without exposed deep structures are often best managed with healing by secondary intention or skin grafting, whereas larger lesions or those with exposed deep structures will benefit from flap coverage or the application of dermal regeneration templates.
13. Saalabian AA, Unglaub F, Horch RE, et al. Free vascularized metacarpal bone graft combined with extended dorsal metacarpal artery flap for phalangeal bone and soft tissue loss: case report. Arch Orthop Trauma Surg. 2012;132(1):137e140. 14. Saba SC, Lee J, Pathy VV, et al. Salvage of a thumb replant using a bilobed dorsal metacarpal artery island flap: case report and literature review. Hand (N Y). 2008;3(4):366e371. 15. Herold C, Vogt P, Strub D, Spies M. [Delayed DMCA-flap in a case of infection in the finger] [in German]. Handchir Mikrochir Plast Chir. 2008;40(2):138e142. 16. Gharb BB, Rampazzo A, Armijo BS, et al. Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study. J Plast Reconstr Aesthet Surg. 2010;63(4):681e685. 17. Elliot D, Moiemen NS, Jigjinni VS. The neurovascular TranquilliLeali flap. J Hand Surg Br. 1995;20(6):815e823. 18. Mutaf M, Temel M, Gunal E, et al. Island volar advancement flap for reconstruction of thumb defects. Ann Plast Surg. 2012;68(2):153e157. 19. Gebhard B, Meissl G. An extended first dorsal metacarpal artery neurovascular island flap. J Hand Surg Br. 1995;20(4):529e531. 20. Trankle M, Sauerbier M, Heitmann C, et al. Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap. J Hand Surg Am. 2003;28(5):758e766. 21. Krag C, Rasmussen KB. The neurovascular island flap for defective sensibility of the thumb. J Bone Joint Surg Br. 1975;57(4):495e499. 22. Murray JF, Ord JV, Gavelin GE. The neurovascular island pedicle flap: an assessment of late results in sixteen cases. J Bone Joint Surg Am. 1967;49(7):1285e1297. 23. Adani R, Squarzina PB, Castagnetti C, et al. A comparative study of the heterodigital neurovascular island flap in thumb reconstruction, with and without nerve reconnection. J Hand Surg Br. 1994;19(5):552e559. 24. Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg Am. 2006;31(5):847e856. 25. Hansen AJ, Duncan SF, Smith AA, et al. Reverse radial forearm fascial flap with radial artery preservation. Hand (N Y). 2007;2(3): 159e163. 26. Costa H, Pinto A, Zenha H. The posterior interosseous flap—a prime technique in hand reconstruction. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstr Aesthet Surg. 2007;60(7):740e747. 27. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg. 1984;12(6): 489e500. 28. Pribaz JJ, Orgill DP, Epstein MD, et al. Anterolateral thigh free flap. Ann Plast Surg. 1995;34(6):585e592. 29. Datiashvili RO, Yueh JH. Management of complicated wounds of the extremities with scapular fascial free flaps. J Reconstr Microsurg. 2012;28(8):521e528. 30. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg. 1981;67(5):637e641. 31. Tobin GR, Moberg AW, DuBou RH, et al. The split latissimus dorsi myocutaneous flap. Ann Plast Surg. 1981;7(4):272e280. 32. Macchi V, Vigato E, Porzionato A, et al. The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study. Clin Anat. 2008;21(7):696e704. 33. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25(1):3e16. 34. Chuang DC, Colony LH, Chen HC, et al. Groin flap design and versatility. Plast Reconstr Surg. 1989;84(1):100e107. 35. Chow JA, Bilos ZJ, Hui P, et al. The groin flap in reparative surgery of the hand. Plast Reconstr Surg. 1986;77(3):421e426. 36. Yunchuan P, Jiaqin X, Sihuan C, Zunhong L. Use of the lateral intercostal perforator-based pedicled abdominal flap for upper-limb wounds from severe electrical injury. Ann Plast Surg. 2006;56(2):116e121. 37. Acarturk TO. Lateral intercostal artery perforator-based reverse thoracic flap for antecubital reconstruction. J Plast Reconstr Aesthet Surg. 2008;61(11):e5ee8.
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1. Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011;127(suppl 1):205Se212S. 2. Eo S, Cho S, Shin H, et al. The utility of Alloderm in hand resurfacing. J Plast Reconstr Aesthet Surg. 2010;63(1):e41ee43. 3. Dantzer E, Queruel P, Salinier L, et al. Dermal regeneration template for deep hand burns: clinical utility for both early grafting and reconstructive surgery. Br J Plast Surg. 2003;56(8):764e774. 4. Carothers JT, Brigman BE, Lawson RD, et al. Stacking of a dermal regeneration template for reconstruction of a soft-tissue defect after tumor excision from the palm of the hand: a case report. J Hand Surg Am. 2005;30(6):1322e1326. 5. Taras JS, Sapienza A, Roach JB, et al. Acellular dermal regeneration template for soft tissue reconstruction of the digits. J Hand Surg Am. 2010;35(3):415e421. 6. Ramirez MA, Means KR Jr. Digital soft tissue trauma: a concise primer of soft tissue reconstruction of traumatic hand injuries. Iowa Orthop J. 2011;31:110e120. 7. Fassler PR. Fingertip injuries: evaluation and treatment. J Am Acad Orthop Surg. 1996;4(1):84e92. 8. Bickel KD, Dosanjh A. Fingertip reconstruction. J Hand Surg Am. 2008;33(8):1417e1419. 9. Melone CP Jr, Beasley RW, Carstens JH Jr. The thenar flap—An analysis of its use in 150 cases. J Hand Surg Am. 1982;7(3):291e297. 10. Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg. 2007;60(7):731e739. 11. Yang D, Morris SF. Reversed dorsal digital and metacarpal island flaps supplied by the dorsal cutaneous branches of the palmar digital artery. Ann Plast Surg. 2001;46(4):444e449. 12. Pelissier P, Casoli V, Bakhach J, et al. Reverse dorsal digital and metacarpal flaps: a review of 27 cases. Plast Reconstr Surg. 1999;103(1):159e165.
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