010 - Hand Flaps

7/31/2019 010 - Hand Flaps

1/20

LOCAL HAND FLAPS

BY JEROME D. CHAO, MD, JOSEPHINE M. HUANG, MD, AND THOMAS A. WIEDRICH, MD

Wounds of the hand continue to be a challenge for the hand surgeon. The repairof hand wounds has evolved from the simple, such as allowing primary closure,to the complex, such as free tissue transfer. This evolution has occurred because ofbetter understanding of the vascular supply to the skin of the hand along with the

development of improved, more sophisticated surgical technique. Our review of theliterature has shown numerous local hand flaps that have stood the test of time.Though lower on the reconstructive ladder, these flaps continue to aid the hand

surgeon in dealing with soft tissue losses of the hand. It would be impossible tocatalogue all local hand flaps in this article. Thus, we present many of the mostuseful and historic flaps, which we feel should be a part of every hand surgeons

armamentarium.Copyright 2001 by the American Society for Surgery of the Hand

T

he practitioner of hand surgery usually has an

algorithm for the closure of hand wounds that

involve soft tissue losses. That algorithm in-cludes the use of a combination of primary wound

healing, grafts, local flaps, distant flaps, and free tissue

transfers. Many hand wounds can be closed by simple

measures. When more complex wounds present them-

selves, hand surgeons generally rely on a few favorite

local tissue coverage options. The advent of free tissue

transfer has made this means an attractive way to close

the most complicated wounds. A review of the liter-

ature has shown a great number of local hand flaps

that have stood the test of time and can be called on

as effective tools to aid the hand surgeon in dealingwith soft tissue losses of the hand. These flaps can

generally be divided into flaps for the fingertips, dig-

its, thumb, palmar hand, and dorsal hand.

RANDOM FLAPS

The principles that govern the use of random flaps

can be used throughout the hand and fingers.

Generally these flaps are of greater use over the dorsal

surfaces, but in the correct circumstances they can be

applied to the palmar aspect of the hand as well. A

form of transposition flap with which the hand sur-

geon is familiar is the Z-Plasty (Fig 1). The Z-plasty

is of great value when dealing with skin contractures

over the volar aspects of the hand, especially contrac-tures that cross the normal volar skin creases. When

the Z-plasty technique is used, all the limbs of the

Z-plasty should be of equal length. The most common

angle Z-plasty is the 60 Z-plasty. Theoretically,

there will be a 75% increase in length of the long axis

of the Z-plasty. The greatest theoretical gain mathe-

matically comes from a 90 Z-plasty, but this is not

clinically feasible.

In the first web space, a 4-flap Z-plasty can be used.

Four 60 equilateral triangles are arranged as shown

From the Division of Hand Surgery, Northwestern University Med-ical School, Chicago, IL.Address reprint requests to Thomas A. Wiedrich, MD, 448 EastOntario Street, Suite 500, Chicago, IL 60611.

Copyright 2001 by the American Society for Surgery of the Hand1531-0914/01/0101-0003$35.00/0doi:10.1053/jssh.2001.21783

JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND VOL. 1, NO. 1, FEBRUARY 2001 25

7/31/2019 010 - Hand Flaps

2/20

(Fig 2) and are transposed as shown to increase length

theoretically one and a half times. Another series of

transposition flaps of use in the first web space is theso-called jumping-man flap. The flap receives its name

based on the pretransposition drawing. The flap is

transposed as shown (Fig 3). This flap does more to

deepen the web space than it does to increase length.

Another transposition flap often used is the Lim-

berg Flap.1 This flap is occasionally referred to as the

rhomboid flap. In this flap, the defect is turned into a

rhomboid. A line is extended that equals the height of

the rhomboid. This line is then extended parallel to

one of the sides as shown (Fig 4). The flap is elevated

and transposed into the defect. The wound can then be

primarily closed.Rotational flaps are used frequently over the dor-

sum of the hand and fingers (Fig 5). These flaps are

designed to allow a defect to be closed by dividing the

tension of closure over a much larger surface area. To

design this flap the surgeon outlines the defect, de-

cides which adjacent area provides the most tissue,

and designs a curved incision, which will allow rota-

tion into the defect when the flap is elevated. The use

of a small back cut or creation of a Burows triangle

can help gain some small extra rotation.

One technique that can help in certain instanceswhen extra tissue is needed and delay of the flap is

warranted is the use of tissue expansion. This can be

done safely over the dorsum of the hand and can allow

the surgeon to gain extra tissue, which has excellent

vascularity because of the delay phenomenon.

LOCAL FLAPS FOR FINGERTIP WOUNDS

The decision on which method of wound closure

should be used depends entirely on the geometry

of the wound and on local wound factors. The main

factors leading to the use of flaps are (1) exposed vitalstructures such as bone, tendon, and nerve; (2) a

wound not suitable for healing by secondary intention

or grafting; or (3) a need for soft tissue padding. The

following are many of the options for closure of fin-

gertip wounds.

V-Y Advancement Flap (Atasoy Flap)

The V-Y advancement flap was first described by

Tranquilli-Laeli2 in 1935 and was reported first in the

FIGURE 1. Z-plasty. A standard Z-plasty with 60angles. Thetheoretical gain in length is 75%. (Reprinted with permis-sion.28)

FIGURE 2. Four-flap Z-plasty. A 4-flap X-plasty in which allmeasurements are equal. The theoretical gain in length is150%. (Reprinted with permission.29)

FIGURE 3. Jumping-man flap. The 5-flap Z-plasty. (Reprintedwith permission.30)

FIGURE 4. Limberg flap. The rhomboid flap of Limberg isshown. (Reprinted with permission.30)

26 LOCAL HAND FLAPS CHAO ET AL

7/31/2019 010 - Hand Flaps

3/20

United States by Atasoy and colleagues in 1970.3 The

indications for this flap are transverse or dorsal oblique

amputations with exposed bone and sufficient nail bed

support and length. This flap is contraindicated in

volar oblique tip amputations.

This flap is generally described as having the base of

the volar triangle as the distal edge of the amputationand the apex occurring at the distal interphalangeal

(DIP) crease (Fig 6). It has also been described to

extend proximal to the DIP crease without sequelae.

Many drawings show the base of the flap to be narrow,

but it is helpful and in fact desirable to make the base

extend from radial midaxial line to ulnar midaxial

line. This will increase the number of vessels flowing

into the flap. The flap is mobilized by gently dividing

the fibrous septa, which attach the skin to the deeper

structures. The deep margin of the flap is cut directly

off the periosteum and the flexor sheath. The neuro-

vascular structures should be preserved. With careful

and complete mobilization, approximately 1 cm of

advancement can be obtained. After advancement the

wound is closed as a Y; hence the name V-Y advance-

ment. This flap provides excellent sensation as well as

soft tissue coverage.

Bilateral Triangular Advancement Flap

(Kutler Flap)

Kutler4 described a double lateral advancement flap

in 1947. Shepard5 has modified this original tech-

nique. This flap has been included in most treatises

describing fingertip coverage. Although it is probably

described far more than it is actually used, there is the

occasional patient in whom this flap is useful. The

Kutler flap has been condemned primarily because

generally the flap does not allow for advancement of

more than 3 to 4 mm, and there is a sagittal scarplaced on the tip of the finger. Classically, this flap is

indicated in patients with transverse or volar oblique

amputations. In actuality, the patient in whom this

flap is useful generally will have an amputation where

there is more tissue on the radial and ulnar margins of

an amputation and exposed distal phalanx.

As in the V-Y advancement flap, the bases of the

triangles are the cut edges of the wound, this time the

radial and ulnar aspects of the wound (Fig 7). The

dorsal edges of the 2 flaps begin 1 to 2 mm volar to

the edge of the fingernail and extend volarly 7 to 8

mm. The apex of the flap sits just distal to the DIP

crease. Soft tissues are mobilized as with the V-Y

advancement flap. It is not necessary to close the skin

centrally over the fingertip as long as there is good soft

tissue closure over the exposed distal phalanx. The

wound is then closed as a Y, again as in the V-Y

advancement flap.

Oblique Triangular Flap

With the description of the volar V-Y advancement

flap and the lateral V-Y advancement flap, Ven-

FIGURE 5. (A) Rotational flap and outline of planned skin incisions. (B) Rotational flap. Excision of Burrows triangle facilitatessliding of the flap toward the defect. (Reprinted with permission.28)

LOCAL HAND FLAPS CHAO ET AL 27

7/31/2019 010 - Hand Flaps

4/20

kataswami and Subramanian described the obliquetriangular flap (Fig 8) in 1980.6 As suggested in its

name, establishing an oblique triangle in essence cre-

ates this flap. This flap has the advantage in that it can

be used for palmar/oblique amputations and it can be

converted to a neurovascular island pedicle flap if

more advancement is required than can be obtained

with a standard elevation of the flap.

The flap is outlined beginning at the midlateral

line and is extended proximally 2.5 times the diam-

eter of the wound. The opposite midlateral line is

identified, and an oblique incision is made from thedistal midlateral wound edge to the proximal mar-

gin of the midlateral incision. Care is taken to

preserve the neurovascular bundle near the straight

midlateral incision. With elevation, the flap is ad-

vanced, inset, and then closed in a V-Y fashion. If

additional mobilization is necessary, the flap is then

converted to a neurovascular island flap (described

below) and advanced further into the defect. Clo-

sure of the donor site with a full-thickness skin

graft may be necessary.

FIGURE 6. V-Y advancement flap. (A) Skin incision andmobilization of triangular flap. (B) Advancement of flap. (C)Closure of defect with V-Y technique. (D) V-Y advancementflap. Advancement of triangular flap. (Parts A, B, and Creprinted with permission.31)


7/31/2019 010 - Hand Flaps

5/20

Cross-Finger Flap (Transdigital Flap)

When there is a loss of greater that one third of thevolar tissue of the fingertipespecially with exposed

flexor tendon, joint, or bonemore tissue is required

than with advancement-type flaps. The cross-finger

flap is a popular option under these circumstances (Fig

9). This technique was first described by Cronin7 in

1951 and is still widely used. Multiple fingertips can

be covered simultaneously. Diseases that limit joint

motion (such as arthritis and Dupuytrens disease) are

contraindications. Patients with impaired digital cir-

culation are also considered contraindications.

There are multiple donor choices for this flap. The

middle finger can be used to cover the thumb, index,or ring fingers. The ring finger can be used to cover

the long or small fingers. Once the donor digit has

been selected, the recipient finger is debrided. The

flap from the donor digit should be designed slightly

larger than the recipient defect. The flap is rectangular

and is based on the midlateral line closest to the

recipient digit. The plane of dissection is just dorsal to

the paratenon. Care must be taken not to injure the

paratenon during elevation. The donor site is covered

with a full-thickness skin graft, and the flap is sutured

to the recipient site. The digit is held together either

with a splint or with Kirschner wires. At 10 days to

3 weeks, the flap is separated from the donor site and

the remainder of the flap is inset.

Variations of the cross-finger flap have been de-

scribed in which dorsal nerves have been included and

anastomosed to the digital nerve stump with reported

improvement in sensation. A reverse cross-finger flap

has also been described by Atasoy8 in which the

epidermis and papillary dermis are divided and the

reticular dermis and subcutaneous tissue have been

used to cover the dorsum of an adjacent digit (Fig 10).

The skin flap is laid back into place over the donor

site. A full-thickness graft is then placed on the

reverse flap.

Hueston Flap

Hueston9 described a lateral palmar advancement

flap to cover the tip of the amputated finger (Fig 11).

Souquet10 described a similar flap (Fig 12). The dif-

ference between the 2 flaps is that the Hueston flap

includes only the neurovascular bundle at the base of

the flap, whereas Souquets flap includes both neuro-

vascular bundles. Both flaps are technically rotation

advancement flaps. In the Hueston flap the longitu-

FIGURE 7. Bilateral triangular advancement flap (Kutler). (A)Designing and developing 2 triangular flaps on the midlateralaspect of the distal phalanx. (B) Incisions are deepened intothe subcutaneous tissue. (C) Flaps are advanced and su-tured by converting V to Y. (Redrawn from Germann.32)

FIGURE 8. Oblique triangular flap. (A, B) Designing the flapon the side of the finger and incision. (C) Raising the flapbased on a digital neurovascular bundle. (D, E) Advancingthe flap and closing the defect with the V to Y technique.(Redrawn from Germann.32)


7/31/2019 010 - Hand Flaps

6/20

dinal incision is made volar to the neurovascular bun-

dle, and in the Souquet flap the incision is made dorsal

to the bundle. The incision is generally 2 to 3 cm

long. A transverse back cut is made across the volar

aspect of the finger, and the flap is elevated off the

flexor tendon sheath. Next, the flap is elevated and

rotated into the defect. There will generally be a

triangular defect proximally, and this must be closed

with a skin graft.

Thenar Flap (Thenar H-Flap)

The thenar flap is used to cover defects and preserve

length in tip injuries to the index and long fingers

(Fig 13). This flap is not used to cover defects in the

ring and small fingers. Contraindications to this flap

are similar to that for the cross-finger flaps.

The donor site is found by taking the tip of the

injured index or ring finger and placing it against the

thenar eminence. It is helpful to draw a circle around

FIGURE 9. Standard cross-finger flap. (A) The donor site is grafted. (B) Flaps raised on hinges. (C) Flaps inset and donor

defects covered with full-thickness skin graft. (D) Divided and healed result. (Part A reprinted with permission.32

)


7/31/2019 010 - Hand Flaps

7/20

the area of contact. An H is drawn that is slightly

larger than the outlined circle. The transverse portion

of the H is made at the distal-most portion of the

circle. The H is incised, and flaps in the subcutaneous

plane are elevated. The ends of the flaps are sutured to

the respective dorsal and volar fingertips and to each

other along the lateral margins. This method effec-

tively advances the edges of the donor defects to one

another. The digit is left attached to the donor site for

approximately 2 weeks, and the flap is then divided by

using the proximal flap to cover the fingertip and the

distal flap to fill in the donor site.

Dorsal Middle Phalangeal Finger Flap

Hirase and colleagues11 described a potentially sen-

sate flap to cover the fingertip from the dorsum of the

long finger (Fig 14). The dorsal middle phalangealfinger flap has been described to be used for the tips of

any finger except the thumb. This flap requires that

digital Allens test be normal in the donor digit.

The flap is outlined exactly as would be a cross-

finger flap. However, the flap is incised as an island,

and the base is taken volar enough to include a

vascular bundle. The dorsal sensory branch of the long

finger is taken with enough length proximally to

perform an anastomosis with the recipient digital

nerve. The vascular pedicle is dissected proximally

either to the level of the common digital artery oreven to the superficial arch if needed. Once the dis-

section is complete, the island flap is transferred to the

recipient site by means of an incision from the origin

of the pedicle to the recipient defect. The wound is

closed after the neural anastomosis is carried out.

Finally, a full-thickness skin graft is used to close the

donor defect. Joshi12 describes a similar flap but uses

it exclusively on the donor digit.

Homodigital Bipedicle Island Advancement Flap

The homodigital bipedicle island advancement flap

is useful for defects over the volar aspect of the fingerin the area of the middle phalanx. OBrien13 and

Snow14 originally described an advancement flap for

injuries to the tip of the thumb. This flap was also

applied to the other digits. After a wave of initial

enthusiasm, the use of the flap decreased because of

problems with flexion contractures of the digits and

the risk of dorsal skin loss. Whereas the thumb has

relatively independent volar and dorsal circulation,

the dorsum of the fingers have circulation more de-

pendent on the volar blood supply. That said, there is

FIGURE 10. Reverse cross-finger flap. (A) Design of the flap.(B) Raising a full-thickness skin flap. (C) Raising a full-thick-ness subcutaneous flap in the opposite direction. (D) Suturingthe reversed flap along the defect. (Redrawn from Ger-mann.32)

FIGURE 11. Hueston flap. (A) Outline on the radial border ofthe thumb. (B) Dissection anterior to pedicle. (C) Flap inplace. (Reprinted with permission.34)

FIGURE 12. Souquet flap. (A) Outline. (B) Dissection. (C)Flap in place. (Reprinted with permission.34)


7/31/2019 010 - Hand Flaps

8/20

still some value for the neurovascular island flap in the

digits. Although the flap is generally described to

cover fingertip injuries, it can also be used to cover

defects of the volar middle phalanx. Damage to the

digital arteries is a contraindication to the use of this

flap. Advancement of 10 to 15 mm can usually be

achieved.

A rectangular incision is made from midlateral line

to midlateral line (Fig 15). The flap is elevated, and

the radial and ulnar neurovascular bundles in the flap

are preserved. The flap is elevated off the flexor sheath

with care not to expose the flexor tendons. By using

gentle traction, the neurovascular bundles are pre-

served, and the flap is advanced with the aid of gentle

FIGURE 13. Thenar flaps can be based (A) proximally, (B) distally, or (C) both. The donor site is closed primarily. (D) A Thenarflap. (Parts A, B, and C reprinted with permission. 32)

FIGURE 14. Dorsal middle phalangeal finger flap. Illustration of the steps for elevation. (Reprinted with permission.35)


7/31/2019 010 - Hand Flaps

9/20

dissection of the neurovascular bundles. The flap is

then inset, and the donor defect is covered with a

full-thickness skin graft.

Turkisk Flap (C-Ring Cross-Finger Flap)

The Turkisk flap can be used to cover relatively

large defects of the volar and dorsal skin of the fingers

(Fig 16). It is sometimes used to cover degloved finger

stumps. An abnormal digital Allens test is a contra-

indication for the use of this flap.

The flap is based on one of the digital vascular

bundles and can be based distally or proximally. The

digital nerve is not included in the flap. Although the

flap is based on the dorsum of the finger, it can include

volar skin of the area of the middle phalanx. As with

many of these flaps, the plane of dissection is just

superficial to the paratenon, with care taken to leave

the paratenon intact. Although a small skin bridge is

left intact to protect the digital artery, the flap can be

made into an island flap to allow for more flap mo-

FIGURE 15. Homodigital bipedicle island advancement flap (OBrien flap). (A) Outline. (B) Elevation of flap and proximaldissection of the pedicle. (C) Flap in place. (D) Outline of flap drawn adjacent to defect. (E) Flap sutured in place distally withfull-thickness skin graft covering secondary defect. (Parts A, B, and C reprinted with permission. 34)


7/31/2019 010 - Hand Flaps

10/20

bility. The flap is then inset into the recipient defect.

For a degloving injury the flap can be sewn to itself to

create a cap over the degloved segment defect. A

full-thickness skin graft is used to cover the donor

site. Flap division is carried out at 10 to 14 days.

Reverse Vascular Pedicle Digital Island Flap

The reverse vascular pedicle digital island flap was

described in 1989 by Lai et al15 and then in 1990 by

Kojima et al.16 Although most local coverage of the

finger relies on antegrade arterial flow, this flap func-

tions on the digit much as the reverse radial forearm

flap does on the hand and arm. A positive digital

Allens test is a contraindication to the use of this flap.

An island of skin is outlined at the base of the

affected finger (Fig 17). The flap is centered on one ofthe digital arteries. The flap is elevated from a prox-

imal to distal direction and the digital vessel is ligated

proximally. Elevation of the flap continues in a distal

direction. Digital vessels are kept in the soft tissues of

the flap. Once the island has been elevated, the digital

vessel along with a cuff of perivascular fat is taken to

include the venae commitantes. The vessels are dis-

sected distally to the level of the midmiddle phalanx.

The flap is then rotated into the recipient site and

sutured in place. The donor site is skin grafted.

FLAPS FOR COVERAGE OF THE VOLAR THUMB

Many of the flaps that have been described for use

in covering the thumb were originally described

to aid in thumb reconstruction. With the advent of

microvascular toe-to-thumb transfer, some of these

flaps are used with less frequency. There still are

specific indications, however, for which knowledge of

these flaps is of value.

Moberg Volar Advancement Flap

Moberg17 first described the thumb advancementflap in 1964 as a means to preserve length in the

distally amputated thumb. There are certain reasons

why this flap is an attractive option for the closure of

wounds for the tip of the thumb. First, the flap

vascular supply is easily identified at the end of the

wound. Second, the blood supply to the dorsal aspect

of the thumb is quite independent of the volar blood

supply. Third, as opposed to the fingers, a resultant

flexion contracture of the thumb generally leaves the

thumb in a functional position.FIGURE 16. Steps for elevation and inset of C-ring cross-finger

flap (Turkisk flap.) (Reprinted with permission from the ChristineM. Kleinert Institute for Hand and Microsurgery, Inc.32)

7/31/2019 010 - Hand Flaps

11/20

Mobergs thumb advancement flap is used when

there are amputations through the distal phalanx. The

neurovascular bundles are identified and incisions are

made on either side of the thumb, dorsal to the

bundles (Fig 18). Dissection is carried down to the

flexor sheath, and the flap is elevated off the flexor

sheath. Usually the proximal metacarpal phalangeal

crease of the thumb is the proximal margin of the

dissection. The flap is then advanced to cover the

defect. If necessary, the interphalangeal joint of the

thumb can be flexed. This flap can be converted into

a bipedicle island flap to gain greater length if neces-sary. The resulting defect can be skin grafted with a

full-thickness skin graft.

Neurovascular Island Pedicle Flap

Before free tissue transfer for thumb reconstruction,

the neurovascular island pedicle flap was used to at-

tempt to provide sensation to an insensate thumb

reconstruction. There were those surgeons who were

very enthusiastic about the flap, but there was diffi-

culty in that the brain would still interpret sensory

information as coming from the donor digit. A po-

tential solution was to suture the digital nerve from

the proximal thumb to the divided distal nerve in the

flap. The problems with this, however, are incomplete

sensory recovery and possible damage to the vascular

structures in the pedicle. Currently, the only indica-

tion for the use of this flap is the scarred and sensitive

thumb with ischemic pain.

The donor site is usually the ulnar aspect of the

long or ring finger. Most surgeons prefer the long

finger, because the pedicle is longer. It is essential to

perform a digital Allens test to the donor finger aswell as to the adjacent finger before considering this

flap. Attention is first turned to the recipient site. The

scarred and sensitive area of the thumb tip is excised,

and the defect is created and measured. The ulnar

digital nerve is found and is prepared for anastomosis.

The flap is then outlined on the donor digit and is

incised, preserving the neurovascular bundle (Fig 19).

The bundle is traced proximally as far as the superficial

arch. As much perivascular fat as possible is kept with

the bundle. The common digital vessel with the adjacent

FIGURE 17. Steps for elevation and inset of reverse vas-cular pedicle digital island flap. (Reprinted with permis-sion.36)


7/31/2019 010 - Hand Flaps

12/20

finger is divided, and the vessel is taken back to the

superficial arch. A subcutaneous tunnel is created to the

recipient site, and the island flap is passed into therecipient site. The flap should not be twisted or be tight

in any way. The nerve transposition is then performed. A

full-thickness graft is used to cover the donor site.

Holevich Racquet Flap

Holevich18 described the racquet flap in 1963 as a

means of restoring sensibility to the thumb by using

tissue from the dorsum of the hand, especially for

chronic median nerve lesions. His flap used portions of

the superficial branch of the radial nerve to substitute

for the lost sensation over the volar thumb. This flap

can be used to add soft pliable tissue to contractures or

defects of the first web space.A proximally based flap is created over the base of

the second metacarpal (Fig 20). The flap includes 2 to

3 branches of the dorsal sensory branch of the radial

nerve. The flap is extended distally to the level of the

metacarpal head. Because the second dorsal intermeta-

carpal artery is included in the flap, the flap can be

made quite narrow (2 to 3 cm) relative to its length.

The flap can be easily elevated from the extensor

tendons. An incision is made from the donor site to

the defect on the thumb. The flap is then inset into

FIGURE 18. Moberg flap. (A) A Z-plasty at the base of the flap facilitates mobilization. (B) Volar flap advanced distally to coverdefect. (C) Advancement of flap. (D) Clinical appearance after graft has healed. (Part A reprinted with permission.28)


7/31/2019 010 - Hand Flaps

13/20

the recipient site. The donor defect can sometimes be

closed primarily, but if tension of the closure is too

great, a full-thickness graft can be used to close the

donor site.

Foucher Kite Flap

As a logical extension of the previous flap, Foucher

and Braun19 in 1979 improved on the Holevich flap

by undertaking a detailed description of the anatomy

of the first dorsal metacarpal artery. By defining theanatomy so precisely, they were able to devise an

island flap from the dorsum of the index finger to the

thumb. This flap is an excellent choice when there is

a need for soft tissue coverage on the thumb. The flap

has also been used when there is trophic scarring of

the thumb or a sensory deficit of the thumb that

cannot be managed in other ways. The flap is contra-

indicated when the soft tissue tunnel is so scarred that

the resulting tight tunnel would jeopardize circula-

tion of the flap.

The flap is outlined over the dorsum of the proxi-

mal phalanx of the index finger (Fig 21). The flap can

include the skin overlying the metacarpophalangeal

joint if necessary. An incision is then made in the

dorsal first web space, and dissection is carried down

to the first dorsal metacarpal artery, which arises from

the radial artery. With a very complete dissection, a

pedicle of 7 to 8 cm can be created. The flap is thenincised and elevated at the level of the paratenon from

a distal to proximal direction. Fascia adjacent to the

second metacarpal along with adjacent fat are kept

intact along the course of the vessels. A subcutaneous

tunnel is created from the donor site to the recipient

site, and the flap is brought through, with care taken

not to kink or twist the pedicle. The dorsal proximal

phalanx is covered with a full-thickness skin graft.

Annular Flap

Goumain et al20 described the tetrapedicled ho-

modigital island flap in 1972 (Fig 22). This flap isused especially when sensory tissue is required to

cover defects of the thumb, particularly at the level of

the proximal phalanx, but occasionally it has been

used also for the ring finger. The flap is contraindi-

cated when there has been disruption of one or both

neurovascular bundles.

A circular area is outlined approximately 2 cm

proximal to the edge of the soft tissue defect. Only the

skin and subcutaneous tissue are dissected. The neu-

rovascular bundles are freed proximally to allow the

FIGURE 19. Neurovascular island pedicle flap. The island isoutlined to include the blood supply and nerve. (Reprinted

with permission.37

)

FIGURE 20. Holevich flap. (A) Skin defect on thumb. (B)Elevation of flap. (C) Flap in place with donor defect skingrafted. (Reprinted with permission.34)

FIGURE 21. Foucher kite flap. (A) Skin defect on thumb. (B)Elevation of flap. (C) Placement of flap throught subcutane-ous tunnel. (Reprinted with permission.34)


7/31/2019 010 - Hand Flaps

14/20

annular flap to advance distally 10 to 12 mm. The

distal wound can thus be closed, and the proximal

wound is either grafted or allowed to heal by second-

ary intention.

COVERAGE OF DEFECTS OF THE HAND AND

PROXIMAL FINGERS

With defects of the hand, often the tissues im-

mediately adjacent to the wound are of insuf-

ficient quantity to close the wound. In some instancesrecruitment of the local tissues of the forearm are

necessary to gain adequate coverage of the wound. The

skin and subcutaneous tissues of the forearm are an

excellent match in quality and depth to cover wounds

of the hand.

Dorsal Island Digital Flap (Axial Flap)

Lister21 has advocated and described a flap from the

dorsal proximal phalanx of a digit that can be used to

cover adjacent defects of the finger and hand. This flap

usually covers defects of the ipsilateral or adjacent

digit to the level of the proximal interphalangealjoint. This flap is based on the dorsal digital artery of

the adjacent finger.

The flap is outlined over the dorsum of the proxi-

mal phalanx of the donor digits (Fig 23). Flaps up to

3 3 cm can easily be raised. The dorsal digital artery

is identified. It generally arises as a branch of the

proper digital artery but may also arise from the dorsal

metacarpal artery. When the vessel is identified, it is

preserved with the dorsal regional venous drainage.

The flap is then elevated as an island from distal to

proximal, preserving the extensor paratenon. With

full elevation of the flap, the flap is rotated into

position, with care taken to avoid kinking of the

pedicle. The donor defect is closed with a full-thick-

ness skin graft.

Fillet Flap

The fillet flap should always be considered when

one is dealing with injuries requiring amputation of a

digit. The soft tissues of a digit can sometimes be

salvaged by fillet of the bony structures from the soft

tissue and skin. The flap is useful for covering palmar

or dorsal hand wounds. In designing the fillet flap, the

pulp tissue is usually discarded (Fig 24). A longitu-

dinal incision is made according to the location of the

defect to be closed. An incision is made approximately0.5 cm proximal to the nail fold. The phalanges and

tendons are excised. The flap is placed into the defect

with the base of the flap as a hinge point.

Radial Forearm Flap/Radial Forearm Fascial

Flap

Chang and Wang22 published their results with a

retrograde flap based on the radial artery in 1980. This

flap has proven to have wide use in the hand and even

fingers to cover relatively large defects. The flap has also

been popular as a free tissue transfer. Occasionally, the

flap can be used as a fascial flap as well if skin and

subcutaneous tissue are not needed at the recipient site.

The flap is contraindicated in instances where, either

congenitally or because of trauma, the palmar arch is

incomplete. There is discussion as to whether or not to

reconstruct the radial artery after flap transfer, but this

does not appear to be necessary most of the time.

The flap is designed along the longitudinal axis of

the radial artery (Fig 25). There is some variation in

designing the flap to allow for varying lengths of the

FIGURE 22. Annular flap. (A) Amputation with protrudingbone. (B) Dissection and advancement. (C) Distal closure.(Reprinted with permission.34)

FIGURE 23. Dorsal island digital flap (axial). The dorsaldigital artery may arise either from the proximal digital arteryor from the dorsal interosseous metacarpal artery. (Reprintedwith permission.38)


7/31/2019 010 - Hand Flaps

15/20

pedicle. Thus, the flap can be designed to cover either

proximal or distal hand wounds. More distal defects

will require more proximal skin paddles. Dissection is

first carried out through the distal forearm to expose

the radial artery and the venae comitantes. When the

distal border of the flap is encountered, the flap is

dissected first from its ulnar border. The dissection

continues to the pedicle. The plane of dissection is

superficial to the palmaris longus and flexor carpi

radialis. Just radial to the flexor carpi radialis, the

pedicle will be found lying within a septum. The

pedicle and the perforators, which supply the flap, are

FIGURE 24. Fillet flap. (A) Third metacarpal and digit with extensive injury. (B, C) Dissection of soft tissue from skin. (D, E) Useof skin for coverage of defect on hand dorsum. (Reprinted with permission.39)


7/31/2019 010 - Hand Flaps

16/20

kept contiguous with the flap. Dissection is then

begun over the radial aspect of the flap, and the

dissection continues radially until the septum isreached. The dissection then proceeds under the radial

vascular bundle, and muscular branches are ligated

and divided. The radial artery is divided at the level of

the proximal margin of the flap, and the dissection

continues distally. When the flap and pedicle are

adequately dissected distally, the flap is rotated, with

care taken not to kink the radial artery. The flap and

pedicle can be brought into a defect either by gener-

ous tunneling or by using an incision to connect the

distal pedicle incision to the recipient site. A tunnel is

generally preferred over the radial wrist because of the

superficial radial nerve. Care should be taken over the

ulnar wrist in the area of the dorsal sensory branch ofthe ulnar nerve. The donor site is then covered with a

split-thickness skin graft.

When a radial forearm fascial flap is to be used, a

longitudinal or zigzag incision is used throughout the

forearm. The skin and subcutaneous tissue are ele-

vated, leaving the antebrachial fascia intact. The flap

is designed on the fascia, and the dissection proceeds

as with the standard reverse radial forearm flap. The

donor site is closed primarily, and the fascia is covered

with a split-thickness skin graft at the recipient site.

FIGURE 25. Radial forearm flap. (A) Flap outlined. (B) Dissection. (C) Inset. (D) Flap covering traumatic amputations with lossof soft tissue, syndactylizing the long and ring fingers. (E) After maturation of graft and division of long and ring fingers. (F) Thekey point in raising a radial forearm flap is recognizing the level of the septum containing the radial artery and its septocutaneousperforators. BR, brachioradialis; FCR, flexor carpi radialis; FDS, flexor digitorum superficialis; PL, palmaris longus; R, radius;RA, radial artery; U, ulna. (Reprinted with permission.40)


7/31/2019 010 - Hand Flaps

17/20

Posterior Interosseous Forearm FlapThe posterior interosseous forearm flap was de-

scribed by Penteado, Masquelet and Chevrel23 as well

as by Zancolli and Angrigiani.24 This flap is another

retrograde flap that is based on the posterior interosse-

ous artery (PIA). Defects of the first web space,

thumb, dorsal hand to the level of the proximal in-

terphalangeal joints, palm, and anterior wrist are po-

tentially covered by this flap. Significant injuries to

the wrist are contraindications to this flap as is any

other condition that may cause PIA thrombosis.

Flap design is carried out by drawing a line from

the lateral epicondyle to the ulnar styloid with theelbow held at 90 of flexion (Fig 26). This line ap-

proximates the septocutaneous axis of the flap. The

PIA arises at the junction of the proximal to middle

thirds of this line. Along the course of the PIA there

are 7 to 14 cutaneous perforators, which supply the

skin and fascia. The most proximal perforator arises

close to the proximal/middle third junction. The cen-

ter of the flap should be located distal to this perfo-

rator. The PIA anastomoses with the dorsal wrist

arcade 2 cm proximal to the end of the drawn axis

line. Dissection is begun at this point to ascertainintegrity of the PIA. Technically, a flap 6 to 7 cm

wide can be raised, but defects greater than 4 cm in

width are difficult to close primarily.

The radial incision is created first, and a subfascial

dissection is carried ulnarly. By retracting the extensor

digiti quinti proprius, extensor indicis proprius, and

extensor digitorum communis radially, as well as the

extensor carpi ulnaris ulnarly, the septum containing

the PIA and venae comitantes can be identified. Mus-

cular branches of the PIA are ligated and divided. Care

must be taken to avoid injury to the posterior in-

terosseous nerve, which lies radial to the vessels. Dis-section continues proximally to the main septal per-

forator (most proximal perforator). The artery is

separated from the posterior interosseous nerve. The

vessels are ligated proximal to the main perforator to

the flap. Next, the ulnar border of the flap is elevated,

and the pedicle including the septum is released from

the ulnar shaft. The flap and pedicle are dissected

proximally until enough length of the pedicle is ob-

tained to rotate into the defect. The vessels cannot be

kinked at the rotation point, and the most distal

FIGURE 26. (A) Posterior interosseous forearm flap. Land-marks: the epicondyle, the distal radioulnar articulation, andthe straight line that joins them. The origin of the posteriorinterosseous artery is located at the junction of the proximaland middle third of this line. The center of the flap should bebased distal to this point. (B) Loss of small finger and ulnarside of hand because of injury. (C) Flap inset into defect.(Part A reprinted with permission.34)


7/31/2019 010 - Hand Flaps

18/20

vessels can be rotated 2 cm proximal to the distal end

of the initial axis line.

Dorsal Ulnar Artery FlapBecker and Gilbert25 described a flap based on the

dorsal ulnar artery in 1992 (Fig 27). This flap can be

used to cover defects of the dorsal or palmar hand.

To construct this flap, an incision is made 2 cm

proximal to the pisiform. The flexor carpi ulnaris is

retracted to reveal the origin of the dorsal branch of

the ulnar artery, which arises 2 to 5 cm proximal to

the pisiform. The flap is then centered along the axis

of the ulna with the palmaris longus as the volar limit

and the extensor digitorum communis to the ring

finger as the dorsal limit of the dissection. The length

of the flap is variable and designed to fit the defect.

The rotation point of the flap is 2 to 4 cm from the

pisiform, depending on the origin of the dorsal branch

of the ulnar artery. The flap is elevated from proximal

to distal. When the dorsal branch of the ulnar artery

is reached, the flap can be rotated and inset. The donor

site is covered with a split-thickness skin graft.

Retrograde Radial Forearm Fascial Flap

Weinzweig et al26 described the retrograde radial

forearm fascial flap in 1994 (Fig 28). Some additional

clinical applications were discussed by Braun et al27 in

1995. This flap is unlike the other radial forearm flap

in that the radial artery is left in situ. Essentially, this

flap is a distally based turnover flap of the volarforearm fascia. Vascularity of the flap comes from

distal perforating vessels of the radial artery. This flap

can be used to cover defects of the volar and dorsal

hand.

The design of the flap is such that the flap should

minimally be 2 to 3 cm wide. The pivot point is

generally 5 to 8 cm proximal to the radial styloid. In

addition, the flap needs to be designed to be larger

than the defect it is to fill. A gentle S-shaped incision

is made over the volar forearm. Skin flaps are elevated

just deep to the hair follicles. Branches of the radialand lateral antebrachial cutaneous nerve are identified

and freed from the subcutaneous tissue. Once the skin

flaps are elevated to expose the area of flap desired, the

subcutaneous tissue and fascia are incised and elevated

in a proximal to distal direction. Dissection ends at

the pivot point, and the flap is turned over or rotated

into position. Care needs to be taken to avoid undue

tension on the flap.

There are many different problems in wound

coverage because of the many different wounds that

FIGURE 27. Dorsal ulnar artery flap. (A) Anatomy of the dorsal ulnar artery: 1, muscular branch; 2, osseous branch to thepisiform; 3, cutaneous branches (ascending and descending). (B) Elevation of the flap. (Reprinted with permission. 34)


7/31/2019 010 - Hand Flaps

19/20

the hand surgeon will encounter. Working know-

ledge of a number of local coverage options will aid the

hand surgeon in dealing with these sometimes vexing

wounds.

REFERENCES

1. Limberg A. Mathematical principles of local plastic proce-dures on the surface of the human body. Leningrad: Medgis,1946.

2. Tranquilli-Leali L. Ricostruzione dellapice delle falangi un-gueali medianti autoplastica volare peduncolata per scorri-mento. Infort Traum Lavoro 1935;1:186-193.

3. Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction ofthe amputated finger tip with a triangular volar flap. A newsurgical procedure. J Bone Joint Surg Am 1970;52A:921-926.

4. Kutler W. A new method for fingertip amputation. J AmMed Assoc 1947;133:29-30.

5. Shepard GH. The use of lateral V-Y advancement flaps forfingertip reconstruction. J Hand Surg [Am] 1983;8A:254-259.

6. Venkataswami R, Subramanian N. Oblique triangular flap: anew method of repair for oblique amputations of the fingertipand thumb. Plast Reconstr Surg 1980;66:296-300.

7. Cronin T. The cross finger flap: a new method of repair. AmSurg 1951;17:419-425.

8. Atasoy E. Reversed cross-finger subcutaneous flap. J HandSurg [Am] 1982;7A:481-483.

9. Hueston J. Local flap repair of fingertip injuries. Plast Re-constr Surg 1966;37:349-350.

10. Souquet R. The asymmetric arterial advancement flap indistal pulp loss (modified Huestons flap). Ann Chir Main1985;4:233-238.

11. Hirase Y, Kojima T, Matsuura S. A versatile one-stage neu-rovascular flap for fingertip reconstruction: the dorsal middle

phalangeal finger flap. Plast Reconstr Surg 1992;90:1009-1015.

12. Joshi BB. A local dorsolateral island flap for restoration ofsensation after avulsion injury of fingertip pulp. Plast Recon-str Surg 1974;54:175-182.

13. OBrien B. Neurovascular island pedicle flaps for terminalamputations and digital scars. Br J Plast Surg 1968;21:258-261.

14. Snow JW. The use of a volar flap for repair of fingertipamputations: a preliminary report. Plast Reconstr Surg 1967;40:163-168.

15. Lai CS, Lin SD, Yang CC. The reverse digital artery flap forfingertip reconstruction. Ann Plast Surg 1989;22:495-500.

16. Kojima T, Tsuchida Y, Hirase Y, et al. Reverse vascularpedicle digital island flap. Br J Plast Surg 1990;43:290-295.

17. Moberg E. Aspects of sensation in reconstructive surgery ofthe upper extremity. J Bone Joint Surg Am 1964;46A:817-825.

18. Holevich J. A new method of restoring sensibility to thethumb. J Bone Joint Surg Br 1963;45B:496-502.

19. Foucher G, Braun JB. A new island flap transfer from thedorsum of the index to the thumb. Plast Reconstr Surg1979;63:344-349.

20. Goumain AJ, Baudet J, Massard JF. Our experience withrecent thumb mutilations. Revue de Chirurgie Orthopediqueet Reparatrice de lAppareil Moteur 1972;58:563-574.

21. Lister G. The theory of the transposition flap and its practicalapplication in the hand. Clin Plast Surg 1981;8:115-127.

22. Chang TS, Wang W. Application of microsurgery in plastic

FIGURE 28. Radial forearm fascial flap. (A) Skin and tissueloss over dorsum of forearm and hand. (B) Identification offascial radial forearm flap on volar surface of forearm. (C)Fascial flap tunneled under skin, set into defect and coveredwith a split-thickness skin graft.


7/31/2019 010 - Hand Flaps

20/20

and reconstructive surgery. J Reconstr Microsurg 1984;1:55-63.

23. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basisof the fascio-cutaneous flap of the posterior interosseous ar-tery. Surg Radiol Anat 1986;8:209-215.

24. Zancolli EA, Angrigiani C. Posterior interosseous island fore-arm flap. J Hand Surg [Br] 1988;13B:130-135.

25. Becker C, Gilbert A. Lambeau antebrachial des branchesdistales de lartere cubital. Paris: Expansion Scientifique Fran-caise, 1990.

26. Weinzweig N, Chen L, Chen ZW. The distally based radialforearm fasciosubcutaneous flap with preservation of the ra-dial artery: an anatomic and clinical approach. Plast ReconstrSurg 1994;94:675-684.

27. Braun RM, Rechnic M, Neill-Cage DJ, et al. The retrograderadial fascial forearm flap: surgical rationale, technique, andclinical application. J Hand Surg [Am] 1995;20A:915-922.

28. Germann G. Principles of flap design for surgery of the hand.Atlas Hand Clin 1998;3(2):33.

29. Green DP, Hotchkiss R, Pederson WC. Greens operativehand surgery. Vol 2. London: Churchill-Livingstone, 1998.

30. Chase RA. Historical review of skin and soft tissue coverageof the upper extremity. Hand Clin 1985;1:599-608.

31. Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE.J Bone Joint Surg Am 1970;52:921-926.

32. Atasoy E, ONeill E. Local flap coverage about the hand. AtlasHand Clin 1998;3(2):179.

33. McCarthy JG, ed. Plastic Surgery. Vol 7. Philadelphia: Saun-ders, 1989.

34. Gilbert A. Pedicle flaps of the upper limb. Philadelphia:Lippincott, 1992.

35. Hirase Y, Kojima T, Matsuura S. A versatile one-stage neu-rovascular flap for fingertip reconstruction: the dorsal middlephalangeal finger flap. Plast Reconstr Surg 1992;20:1006-1015.

36. Kojima T. Reverse vascular pedicle digital island flap. Br JPlast Surg 1990;43:290-295.

37. Marks MW, Marks C. Fundamentals of plastic surgery. Phil-adelphia: Saunders, 1997.

38. Lister G. The theory of the transposition flap and its practicalapplication in the hand. Clin Plast Surg 1981;1:115-127.

39. Chase RA, ed. Atlas of Hand Surgery. Philadelphia: Saunders,1970.

40. Martin D, Bakhach J, Casoli V, Pellisier P, Ciria-Llorens G,Khouri RK, et al. Reconstruction of the hand with forearmisland flaps. Br J Plast Surg 1990;43:290-295.


010 - Hand Flaps

Documents

Transcript of 010 - Hand Flaps