Reconstruction of volar skin and soft tissue defects of the digits including the pulp: Experience with the free SUPBRA flap

Abstract

The ideal flap for volar defects on the digits should provide glabrous skin, maintain length, be sensate and supple enough to allow unimpeded motion of the joints. When local flap options are either inadequate or unavailable, this constitutes a challenge that usually requires free tissue transfer. We describe our experience of the use of the free transfer of glabrous skin based on the superficial palmar branch of the radial artery (SUPBRA) for digital (volar) reconstruction. Between May 2005 and June 2011, we used this flap to reconstruct digital defects in 13 patients with mean age of 40.1 years (range 18-68 years) and a follow up range from 0.7 to 3.5 years (mean 1.5 years). The dimension of the flaps ranged from 2×5cm to 2×10cm. The indications for surgery included traumatic loss of tissue/amputation, severe pulp space infection, dog bite injury, crush injury/ischaemic loss and salvage of failed local flap. The donor site was closed directly in all cases. There were no flap failures. All wounds healed with good functional outcomes with ideal tissue match, minimal donor site morbidity and return of protective sensation despite no neurorrhaphy performed except in one patient. The free SUPBRA flap has many advantages, approaching ideal replacement for the volar tissues of the fingers, excellent tissue match, minimal donor site morbidity with an excellent camouflaged scar in the mid palmar crease, one operation field, non sacrifice of a major vessel, can be made 'sensory', neurotises well and offers a single site for rehabilitation. We believe that the free SUPBRA flap is a very reliable and useful option in the armoury of the reconstructive hand surgeon.