The Journal of Foot & Ankle Surgery xxx (2015) 1–5
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Technique of Dorsal Transversely Oriented Transposition Flap for Web Reconstruction in Toe Syndactyly Surgery Susumu Saito, MD, PhD 1, Yoshihisa Suzuki, MD, PhD 2, Shigehiko Suzuki, MD, PhD 3 1 2 3
Assistant Professor, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan Chief, Department of Plastic and Reconstructive Surgery, Tazukekofukai Medical Research Institute, Institute Kitano Hospital, Osaka, Japan Professor, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
a r t i c l e i n f o
a b s t r a c t
Keywords: flap polysyndactyly surgery syndactyly toe
In toe desyndactyly, a dorsal or plantar commissural flap, combined with skin grafts, will ensure an acceptable result. However, the parallel unsightly scars in the longitudinal direction on the dorsum of the toes will sometimes fail to satisfy the patient’s and/or the parents’ aesthetic expectations. To address this issue, we developed a technique using a transversely oriented transposition flap for web reconstruction, which can spare the dorsal interdigital skin maximally to shift the dorsal scars plantarly such that they become inconspicuous. The design of the flap is simple and uncomplicated surgically. Moreover, the donor site morbidity is minimal, owing to the good healing potential of the transverse scars. This technique could be an alternative in web reconstruction of toe desyndactyly, especially in cases with high cosmetic priority. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
The aim of desyndactyly surgery is to reconstruct, not only functionally independent, but also cosmetically pleasing digits. In syndactyly of the toes, surgery is occasionally indicated to meet the patient’s and/or the parents’ cosmetic and functional requests. Just as for repair of hand syndactyly, reconstructive procedures with a dorsal or plantar commissural flap, combined with skin grafts, have been used. However, the unsightly longitudinal scars on the dorsum of the toes sometimes fail to satisfy the patients’ or the patients’ parents’ expectations. Also, the symmetric appearance of the dorsal scars remains a reminder that the toes were surgically separated. In an attempt to address these issues, we have used a dorsal transversally oriented transposition flap for web reconstruction. Surgical Technique The technique is used for web creation in cases of syndactyly and polysyndactyly of the toes. The surgery is performed with the patient Financial Disclosure: None reported. Conflict of Interest: None reported. The present study was presented at the 12th Quadrennial European Meeting of A European Voice For Plastic Surgery 2014 (ESPRAS 2014), July 6 to 11, 2014, Edinburgh, Scotland, as an oral presentation. Address correspondence to: Susumu Saito, MD, PhD, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, 54, Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail address: [email protected] (S. Saito).
under general anesthesia, with tourniquet control, although intravenous sedation and local anesthesia could also be used. A transversely oriented flap is designed dorsally on the base of one of the involved toes (Fig. 1). Its pedicle, measuring approximately 5 mm in width (the width of the flap can be adjusted according to the size of the toes and the amount of skin tension), is placed at the proximal one third to one quarter of the interdigital space of the proximal phalanx. Two parallel incisions, constituting both edges of the flap, are made to run transversely and slightly curve distally to join at the opposite aspect of the toe (Figs. 2B and 3B). The skin is raised, along with the underlying subcutaneous fat and superficial fascia, preserving the random dermal, subdermal vascular plexus that supplies the skin in the flap. A dorsal zigzag incision is then made distally to create multiple triangular interdigitating flaps. On the plantar side, a small triangular flap is designed at the base, and a zigzag incision is extended distally in the same manner as on the dorsal side. With care to not injure the underlying adipose layer, the transversely oriented flap is raised (Fig. 2C) and redirected 90 to be inset into the commissure (Figs. 2D and 3C). The V-shaped distal tip is trimmed into a rectangular configuration (Fig. 3D). After tight closure of the donor site using absorbable dermal sutures, the lateral aspects of the toes are resurfaced with the interdigitating flaps. If skin defects remain, they are covered with fullthickness skin grafts harvested from the submalleolar region or sinus tarsi. A bulky dressing is applied, and the extremity is held in cast immobilization until the sutures are removed at approximately
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.03.003
2
S. Saito et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
Fig. 1. Illustrations showing the surgical design of the transversely oriented dorsal transposition flap. Pairs of dots indicate the dorsal peak of the webs.
3 weeks postoperatively. Thereafter, a sponge-pad (RestonÔ, 3M Health Care Ltd, Tokyo, Japan) compression on the commissure is maintained for 3, and preferably 6, months postoperatively (Fig. 4). Discussion During a 6-year period, we operated on 11 webs in 8 children, 5 male (62.5%) and 3 female (37.5%) patients, with congenital syndactylous webs of the foot, using the present technique. Of the 11 web desyndactylizations, 9 (81.8%) were corrections of simple syndactyly of the toes and 2 (18.2%) of postaxial polysyndactyly of the toes. Except for the case of a 13-year-old female, all the patients were 1 to 2 years old when surgery was performed. In the cases with
residual proximal separation defects after desyndactyly, the total surface area that required skin graft coverage was
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Technique of Dorsal Transversely Oriented Transposition Flap for Web Reconstruction in Toe Syndactyly Surgery Susumu Saito, MD, PhD 1, Yoshihisa Suzuki, MD, PhD 2, Shigehiko Suzuki, MD, PhD 3 1 2 3
Assistant Professor, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan Chief, Department of Plastic and Reconstructive Surgery, Tazukekofukai Medical Research Institute, Institute Kitano Hospital, Osaka, Japan Professor, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
a r t i c l e i n f o
a b s t r a c t
Keywords: flap polysyndactyly surgery syndactyly toe
In toe desyndactyly, a dorsal or plantar commissural flap, combined with skin grafts, will ensure an acceptable result. However, the parallel unsightly scars in the longitudinal direction on the dorsum of the toes will sometimes fail to satisfy the patient’s and/or the parents’ aesthetic expectations. To address this issue, we developed a technique using a transversely oriented transposition flap for web reconstruction, which can spare the dorsal interdigital skin maximally to shift the dorsal scars plantarly such that they become inconspicuous. The design of the flap is simple and uncomplicated surgically. Moreover, the donor site morbidity is minimal, owing to the good healing potential of the transverse scars. This technique could be an alternative in web reconstruction of toe desyndactyly, especially in cases with high cosmetic priority. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
The aim of desyndactyly surgery is to reconstruct, not only functionally independent, but also cosmetically pleasing digits. In syndactyly of the toes, surgery is occasionally indicated to meet the patient’s and/or the parents’ cosmetic and functional requests. Just as for repair of hand syndactyly, reconstructive procedures with a dorsal or plantar commissural flap, combined with skin grafts, have been used. However, the unsightly longitudinal scars on the dorsum of the toes sometimes fail to satisfy the patients’ or the patients’ parents’ expectations. Also, the symmetric appearance of the dorsal scars remains a reminder that the toes were surgically separated. In an attempt to address these issues, we have used a dorsal transversally oriented transposition flap for web reconstruction. Surgical Technique The technique is used for web creation in cases of syndactyly and polysyndactyly of the toes. The surgery is performed with the patient Financial Disclosure: None reported. Conflict of Interest: None reported. The present study was presented at the 12th Quadrennial European Meeting of A European Voice For Plastic Surgery 2014 (ESPRAS 2014), July 6 to 11, 2014, Edinburgh, Scotland, as an oral presentation. Address correspondence to: Susumu Saito, MD, PhD, Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, 54, Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail address: [email protected] (S. Saito).
under general anesthesia, with tourniquet control, although intravenous sedation and local anesthesia could also be used. A transversely oriented flap is designed dorsally on the base of one of the involved toes (Fig. 1). Its pedicle, measuring approximately 5 mm in width (the width of the flap can be adjusted according to the size of the toes and the amount of skin tension), is placed at the proximal one third to one quarter of the interdigital space of the proximal phalanx. Two parallel incisions, constituting both edges of the flap, are made to run transversely and slightly curve distally to join at the opposite aspect of the toe (Figs. 2B and 3B). The skin is raised, along with the underlying subcutaneous fat and superficial fascia, preserving the random dermal, subdermal vascular plexus that supplies the skin in the flap. A dorsal zigzag incision is then made distally to create multiple triangular interdigitating flaps. On the plantar side, a small triangular flap is designed at the base, and a zigzag incision is extended distally in the same manner as on the dorsal side. With care to not injure the underlying adipose layer, the transversely oriented flap is raised (Fig. 2C) and redirected 90 to be inset into the commissure (Figs. 2D and 3C). The V-shaped distal tip is trimmed into a rectangular configuration (Fig. 3D). After tight closure of the donor site using absorbable dermal sutures, the lateral aspects of the toes are resurfaced with the interdigitating flaps. If skin defects remain, they are covered with fullthickness skin grafts harvested from the submalleolar region or sinus tarsi. A bulky dressing is applied, and the extremity is held in cast immobilization until the sutures are removed at approximately
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.03.003
2
S. Saito et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
Fig. 1. Illustrations showing the surgical design of the transversely oriented dorsal transposition flap. Pairs of dots indicate the dorsal peak of the webs.
3 weeks postoperatively. Thereafter, a sponge-pad (RestonÔ, 3M Health Care Ltd, Tokyo, Japan) compression on the commissure is maintained for 3, and preferably 6, months postoperatively (Fig. 4). Discussion During a 6-year period, we operated on 11 webs in 8 children, 5 male (62.5%) and 3 female (37.5%) patients, with congenital syndactylous webs of the foot, using the present technique. Of the 11 web desyndactylizations, 9 (81.8%) were corrections of simple syndactyly of the toes and 2 (18.2%) of postaxial polysyndactyly of the toes. Except for the case of a 13-year-old female, all the patients were 1 to 2 years old when surgery was performed. In the cases with
residual proximal separation defects after desyndactyly, the total surface area that required skin graft coverage was
