The "Heart"-Shaped Flap for Soft-Tissue Reconstruction in Complex Avulsion Injury of the Hand.

Abstract

Sir: We have read the article by Goh et al. with interest.1 The authors pointed out the benefits of the superficial circumflex iliac artery perforator flap as a thin skin flap, very useful for single-stage reconstruction of cutaneous defects. Their modifications to the original technique2 extended the possibilities for its application. In our experience, there are situations where a larger flap is needed that requires bulk in the central part, whereas a thinner flap is preferred at the periphery. We recently treated a case with both of these needs, using a free bilobed “heart”-shaped superficial circumflex iliac artery flap allowing fish-mouth closure3 for the coverage of a multidigit defect. A 26-year-old abattoir worker caught his nondominant left hand in a meat-processing machine, sustaining an avulsion of the index, middle, and ring fingers, with a bony level at the proximal interphalangeal joints and a soft-tissue level below the metacarpophalangeal joints. The long flexors were avulsed from the muscular insertions, but extensor mechanisms and intrinsic function were preserved. The amputate was not salvageable, having subsequently dropped into a vat of hot water as part of the machine’s process. A bilobed free groin flap was used to provide adequate volar and dorsal padding while being thin enough to retain function, particularly where inset into the webspaces (Fig. 1).Fig. 1: Flap raised in “heart” shape as a bilobed groin flap. Black arrow indicates main pedicle (superficial circumflex iliac artery and vein). White arrow indicates superficial inferior epigastric vein.We used the supra-Scarpa plane dissection laterally while harvesting the flap on the main superficial circumflex iliac artery vessel without isolating the perforator4 for several reasons. First, we wanted to increase the reliability of the flap. The complex nature of our defect required a tailored, large skin paddle, so the decision was made to add a venous supercharge by including the superficial inferior epigastric vein. Second, by raising the flap in a deeper plane centrally, the bulk of the flap provides padding on the radial aspect of the first metacarpal and the volar surface. The authors outlined disadvantages of their technique in terms of vessel caliber and flap size. We feel that if there is a need for a larger flap, it is safer to raise it on the main vessel, but peripheral supra-Scarpa dissection, as they described, can still provide a flap with a thin component.5 This approach is particularly useful for defects that are deeper centrally than in the periphery, and also when there is the need to have bulk in part for padding, whereas the remainder needs thin, pliable tissue. Third, the bilobed heart-shaped tailoring allowed us to perform a fish-mouth closure and contour the flap to the defect (Fig. 2). Fourth, it also allowed a T-shaped donor-site closure, avoiding a longer longitudinal scar to correct possible dog-ears. We have found this flap suitable for large, three-dimensional defects requiring different thicknesses in the same flap.Fig. 2: Volar view of the flap inset.DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Sergio Razzano, M.D. Nicholas Sheppard, F.R.C.S.(Plast.) Richard Haywood, F.R.C.S.(Plast.) Samuel Norton, F.R.C.S.(Plast.)