Dorsal Metacarpal Artery Flap Research Articles

Osteoplastic Reconstruction of the Thumb: a case report

Background & Objectives: Thumb accounts for 50% of the hand function. Amputation of the thumb severely jeopardises the hand function. Thumb replantation, toe transfer are the ideal methods for restoring the hand function, but is not always possible owing to type of injury, time to presentation, surgical skill and set up. Osteoplastic thumb reconstruction for amputation around the metacarpophalangeal joint is a good treatment option to restore the hand in a developing setup. Presentation of Case: A 25 yrs male with amputation of thumb around metacarpophalangeal joint with delayed presentation and crushing component of distal part underwent multiple staged osteoplastic reconstruction of the thumb. The procedures consisted of bony structure fixation with bone graft followed by coverage with a thinned tubed groin flap which was divided at 2 weeks interval. The thumb was made sensate with sensate flap (first dorsal metacarpal artery flap). Discussion: Thumb replantation is ideal in acute setup in a clean traumatic amputation, while toe transfer is ideal in a delayed setup with healed wound. This requires a good operating room set up with microsurgical set up and skilled manpower, which is difficult in a developing country. Osteoplastic reconstruction requires multiple staged procedures that can be done at a primary level setup. Conclusion: Osteoplastic thumb recontruction is a good option for amputation around the metacarpophalangeal joint to restore hand function in a resource limited set up.

Anatomy, evolution, and clinical aspects of the superextended-intercompartmental-supraretinacular artery perforator flap (SISAP-flap): A proof of concept

BackgroundExtended soft tissue defects of the fingers—irrespective of their origin—are challenging to treat. In cases of missing amputates or crush injuries, the options are often limited to further amputation, ray resection, or free tissue transplantation. The SISAP-flap was developed to add an extra option to treat finger avulsion injuries or otherwise extended soft tissue finger defects. MethodsCadaveric SISAP-flaps were individually dissected, tested for arterial perfusion using red ink and radiopaque dye, and transposed into artificially created same-size defects. After introducing this flap in the clinic, which was partially successful in the first patient, we modified the flap to its definite design. ResultsAverage cadaver flap size ranges between 11 cm and 22 cm in length, allowing dorsal wrapping of the flap over the fingertip and way back to the palmar metacarpophalangeal-joint. The flap is based on the distal web space perforator, which is commonly used by a dorsal metacarpal artery flap and supercharged using an intercompartmental, supraretinacular artery. Donor sites were closed primarily with little tension. Application of the flap in the clinic resulted in satisfactory functional and esthetic outcomes. ConclusionThe SISAP-flap is a new option for the reconstruction of extended finger defects and should be added to the reconstructive surgeon’s armamentarium of pedicled flaps, providing relatively short operating times and promising clinical outcomes.

Neurotized first dorsal metacarpal artery flap for reconstruction of thumb defects: does it helps to improve sensory outcomes?

Restoration of tactile sensation after reconstruction of a thumb pulp defect is important for hand function. We have evaluated the functional, sensory and aesthetic outcomes of neurotized first dorsal metacarpal artery (FDMA) flap in reconstruction of various soft tissue defects of the thumb. For a period of 18 months (January 2021 to June 2022), a total of 20 patients were considered for the study and divided into two groups that is neurotized (group A) and conventional (group B) FDMA flaps. One flap in each group underwent complete necrosis. Results were compared with patients treated by the conventional Foucher’s FDMA flap without nerve repair. At the final follow-up, flap sensation was assessed using static two-point discrimination and Semmes–Weinstein monofilament (SWM) testing. The mean values for active range of motion, total time for procedure, average time to return to routine work and time period of cortical reorientation were statistically significantly different from the values in the control group (p value <0.05). 2-PD, SWM and cold severity score were found to be statistically non-significant. Neurotized FDMA island flap provides a stable, sensate and reliable option for sensory reconstruction of thumb pulp defects with earlier cortical reorientation that allows easier physical rehabilitation and earlier ability to return to previous work to the patients.

The first dorsal metacarpal artery flaps versus reverse homodigital dorsal flaps for thumb reconstruction: a systematic review and meta-analysis.

This review was performed to systematically compare the effectiveness and safety of the first dorsal metacarpal artery flaps (FDMAF) and reverse homodigital dorsal flaps (RHDF) for thumb reconstruction. All literatures, which compared FDMAF versus RHDF for thumb reconstruction, were acquired through a comprehensive search in multiple databases from inception until 31st August 2022. A meta-analysis was performed using the Cochrane Collaboration's RevMan 5.4 software. A total of 19 articles were retrieved, comprising 396 patients in the FDMAF group and 423 patients in the RHDF group. The pooled estimates suggested that there were no significant differences in venous congestion, complications about flap necrosis and reduced range of motion (ROM) of thumb, static 2-point discrimination (S-2PD) between the two groups. On the other hand, patients in the RHDF group had less vascular crisis (odds ratio [OR] = 3.15, 95%CI, 1.31-7.56), complications about poor cortical reorientation (OR = 440.02, 95%CI, 91.97-2105.27) and higher satisfaction rate (OR = 0.56, 95% CI, 0.33-0.96) than those in the FDMAF group. The two surgical procedures were both safe and reliable since no significant differences were found in flap necrosis between the two groups. However, the patients in the RHDF group had less complications about vascular crisis, poor cortical reorientation and higher satisfaction rate. Accordingly, we thought RHDF may be more superior for thumb reconstruction than FDMAF.

Efficacy of Bi-lobed Second Dorsal Metacarpal Artery Flap in Pediatric Electric Hand Burns

Background: Bi-lobed second dorsal metacarpal artery (SDMA) flap is a viable option for the reconstruction over electrical burns of hand in the pediatric patients. The purpose of this study is to evaluate of the success rate and donor site range of motion after SDMA flap. Methods: A prospective observational cohort study was undertaken in all patients who underwent reconstruction with SDMA flap at institution from March 2016 to March 2018. Data was collected regarding flap success rate and active motion arcs of metacarpophalangeal joint (MCPJ) and proximal interphalangeal joints (PIPJ) of donor area. Results: Among 32 patients, survival rate of flap is 96.87 percent (n=31) with only partial loss of 3.12 percent (n=1). At mean follow up of 12 months, donor finger movements at MCPJ and PIPJ were almost similar to that on opposite side. Conclusion: Second dorsal metacarpal artery flap is useful and reliable flap in complex reconstruction of burn hands in pediatric group in terms of survival and range of motion. Key words: Second dorsal metacarpal artery flap, Metacarpophalangeal joint, Hand burn, Pediatric

Outcome and Utility of First Dorsal Metacarpal Artery Flap for Finger Defects

Outcome and Utility of First Dorsal Metacarpal Artery Flap for Finger Defects

Reverse homodigital dorsoradial flap for thumb soft tissue reconstruction

Primary and secondary reconstruction of the thumb is a common reconstructive challenge for the hand and plastic surgeons. Currently, The kite flap or the First dorsal metacarpal artery flap remains the regular choice and is believed to be the best for distal thumb defects, but it’s the first time we have utilized a reverse homodigital dorsal radial flap for the thumb with an expected outcome. A 37 - year - old male patient suffered partially, obliquely, and radially necrotic thumb tip in the second week following conservation stitching of the wound due to a motorcycle accident. The necrotic tissues were desbrided and the residual defect was covered simultaneously by reverse homodigital dorsoradial flap. The Interphalange (IP) and Metacarpalphange (MCP) joints were flexible, and the active rang of motion (ROM) of the affected thumb was not limited at 3 months post - op. The reverse homodigital dorsoradial flap has become a useful and valuable material for thumb reconstruction. The flap provides acceptable aesthetic results with primary closure of the donor site and returns the essential functionality to the affected thumb.

A new approach for reconstruction of the gunshot defect of the flexor surface of the ungual (distal) phalanx by the proper transverse branch of the digital artery: a case report of combat patient injured in the Russo-Ukrainian war

BackgroundGunshot injury to the hand is severe trauma, requiring complicated reconstruction surgery for the damaged anatomic site to restore all the hand functions. The aim of this study was to show the example of the distal phalanx reconstruction by using a flap with distal transverse digital artery (DTDA) blood supply as well as to demonstrate the utility of the audio Doppler application at the reconstruction stage in the combat patient injured in the Russo-Ukrainian war.Case presentationIn this report, we present a case of a 26-year-old service member of the Ukrainian Armed Forces delivered to the Military Medical Clinical Centre on the fourth day after the gunshot gutter shrapnel wound of the distal flexor of the 2nd digit with a gunshot fracture of the ungula (distal) and middle phalanges of the 2nd digit of the right hand along with a bone deficiency of the osseous structure of the distal and middle phalanges, volar soft tissues. The dorsal metacarpal artery (DMCA) flap is a universal variant among the tools of the reconstructive plastic surgeon engaged in reconstructing defects of the digital dorsum and flexors with a limited range of flaps. We consider this to be a key that conforms with the majority of the reconstructive principles, such as ‘analog replacement’, and which is simple, adequate, and easy for operating with a minimal sequela of the donor site.ConclusionsThe distal transverse digital artery (DTDA) could be considered for hand reconstructive surgery for repairing defects of the flexor surface of the digit injury and hands after severe gunshot injury.

Reconstruction of soft tissue defects of hand: A systematic approach.

A thorough insight into the management of hand injuries can shape the approach of a surgeon in order to achieve optimal outcomes for the patients. The aim of this study was to share our experience in reconstruction of the hand and establishing an algorithm for classification and treatment of hand injuries. This is a descriptive cross sectional study and was conducted from January 2020 to August 2022 at Burns and Plastic Surgery center, Peshawar. Data was collected from medical records about the patient demographics, mechanism of injury and type of procedures done. Defect size was classified into small (<5cm), medium (5cm to 10 cm) and large (>10cm). The defect site and size was cross tabulated against the method of soft tissue reconstruction in order to make the algorithm for reconstruction of hand injuries. Data was analyzed using SPSS. The study population included 41 (75.9%) male and 13 (24.1%) female patients, mean age 31.56±14.1. Machine injuries (33.3%) and electric burns (24.1%) were the most common cause of hand soft tissue defects. The most commonly performed flap was Posterior introsseous artery (PIA) flap, followed by First dorsal metacarpal artery (FDMA) flap. Flap necrosis was observed in three cases (5.6%). This treatment algorithm for coverage of soft tissue defects in hand injuries will help with the decision making process of hand reconstruction and has didactic value for novice surgeons. It will also form the foundation for further work on this aspect of hand injuries.

Repair of Fingertip Degloving Injuries Using the Extended Reverse Second Dorsal Metacarpal Artery Flap.

This study aimed to introduce modified reverse second dorsal metacarpal artery flap (MRSDMAF) transfer for the treatment of fingertip degloving injuries. From January of 2004 to March of 2020, 31 patients with fingertip degloving injuries underwent MRSDMAF transfer. The mean defect and flap size were 4.5 × 1.6 cm and 4.7 × 1.7 cm, respectively. Nerve repair was performed in 18 fingers. Flap sensation, function restoration of the reconstructed fingers, and donor-site morbidity were assessed. For comparison, we reviewed a cohort of 45 patients undergoing modified cross-finger flap (MCFF) transfer. Complete flap survival was achieved in 28 fingers, and partial distal flap necrosis was noted in 3 fingers. After a mean of 24 months, the static 2-point discrimination was 8.6 ± 1.0 mm and 7.2 ± 0.8 mm in the MRSDMAF and MCFF groups, with a significant difference ( P < 0.0001). Sensory restoration of the MRSDMAF group was inferior to that of the MCFF group. In addition, the MRSDMAF group presented a higher incidence of fingertip pain ( P = 0.019) and suboptimal appearance of the reconstructed finger ( P = 0.036). On the donor site, the MRSDMAF group presented a lower incidence of scar pain ( P = 0.030) and better appearance ( P = 0.025). MRSDMAF transfer is an alternative treatment for fingertip degloving injuries, especially when MCFF transfer is not feasible. Therapeutic, III.

First dorsal metacarpal artery flap in soft tissue reconstruction of recurrent thumb squamous cell carcinoma

Background. Subungual squamous cell carcinoma (SCC) of thumb is a rare disease. However, it is the most common malignancy affecting the nail bed. Early recognition is crucial and important for prompt diagnosis and effective treatment. Often this tumour needs to be treated surgically with wide local resection, which results in a defect in the thumb. If not handled appropriately, such defects render restriction in functionality of the involved thumb as well as a poor aesthetic outcome. In the worst-case scenario, it may result in a poor function of involved hand. Thus, reconstruction of the involved thumb is necessary. The main aim of reconstruction is to regain the hands' function and preserved the thumbs' sensation. Secondarily, to have an aesthetically pleasing hand. Our hands carry out delegate job and important duty for daily function. Especially, the thumb working together with the other fingers to carry out the hand function as one unit. Loss of thumb function affects the whole performance of the hand. Case descriptions. We report a case of recurrent subungual squamous cell carcinoma of thumb, which had wide local resection and subsequently underwent soft tissue coverage with an islanded first dorsal metacarpal artery (FDMA) perforator flap. One month after surgery, the patient was able to regain a good functional outcome of the hand. In this report, we discussed the procedures that had been done. Conclusion. The patient regained full functional hand after reconstruction with preserved sensation over distal thumb. The aesthetic outcome is satisfactory. The FDMA perforator flap is a very pliable and robust flap for reconstruction of distal thumb defect.

Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects

Background: Thumb defects induced by trauma lead to significant functional disability. The goal of this study was to identify the safety, versatility, and limitations, benefits, and functional outcomes, range of motion and reestablish sensory experience. These characteristics, in addition to a secure soft tissue cover, are needed for thumb restructuring. Study design: This was a retrospective study carried out in the Plastic Surgery Department of Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi from November 2021 to December 2022. Methods: The total 17 participants with traumic thumb defects which insert and treated with island flaps. The participants included 5 females and 12 males, the age group was 20-50 years and the average age (36 years). All patients were evaluated for the occurrence of early post-operative complications in terms of flap necrosis. Results: The operative time was 1 hours. The 15 participants underwent island FDMA flap except 2 participants which show necrosis but without again treatment recover. To evaluate the esthetic and functional outcome by Kapandji score, 2-PD, SS score and esthetic outcome follow by one year. Regarding the functional recovery Kapandji, 2-PD, the esthetic and subjective satisfactory score outcome was evaluated and show significant changes p&lt;0.005. Conclusion: FDMA is one of the best choices for reconstituting distal thumb injuries, and it is a simple technique that has the potential to enhance the island's survival and lowering the rate of distal necrosis. The FDMA flap provides good functional results while causing little donor-site morbidity. Keywords: Cortical reorientation, Metacarpal artery, Island Flap, Two point discriminate.

Reconstruction of Thumb Defects Using the Second Dorsal Metacarpal Artery Flap with Two Pivot Points.

This study aimed to introduce reconstruction of thumb defects using the second dorsal metacarpal artery (DMA) flap with two pivot points. A retrospective study was conducted with 43 patients (group A) who underwent thumb reconstruction using the second DMA flap with two pivot points from July of 2012 to May of 2019. For comparison, the authors reviewed another cohort of 34 patients (group B) undergoing thumb reconstruction using the first DMA flap. Flap sensation and donor-site morbidity were assessed. In group A, the mean two-point discrimination was 8.7 mm (range, 6 to 12 mm) and 9.7 mm (range, 7 to 12 mm) on the innervated and noninnervated flaps at the final follow-up, with a significant difference ( P = 0.012). In group B, the mean two-point discrimination of the flaps was 7.4 mm (range, 6 to 10 mm). By comparison, group B presented better discriminatory sensation than innervated flaps with double pivot points ( P = 0.002). Based on the visual analogue scale score, the mean score of scar pain and appearance of the donor site were 0.1 (range, 0 to 3) and 0.4 (range, 0 to 2) in group A, and 0.5 (range, 0 to 3) and 1.0 (range, 0 to 4) in group B. By comparison, group A presented lower incidence of scar pain ( P = 0.020) and better appearance of the donor site ( P = 0.019). The second DMA flap with two pivot points has a long vascular pedicle, which allows the flap to repair thumb defects. It is associated with low donor-site morbidity but suboptimal sensory recovery. Therapeutic, III.

Comments on "Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects".

I reviewed the study “Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects,” by K. Aggarwal and K. Singh, published online in the Indian Journal of Plastic Surgery.[1] The study is well designed and the findings are presented in the discussion section accompanied by the literature.

Microsurgical Reconstruction of the Columella.

Traditionally, the columella can be difficult to reconstruct because of its unique contours, paucity of adjacent soft tissues, and tenuous vascularity. When local or regional tissues are unavailable, microsurgical transfer can provide a means for reconstruction. In this retrospective review, the authors report their experience with microsurgical reconstruction of the columella. Seventeen patients were enrolled in this study and divided into two groups: group 1, isolated columella defects; and group 2, defects of the columella and portions of adjacent soft tissues. There were 10 patients in group 1. Their average age was 41.2 years. Average follow-up was 10.1 years. Causes of the columellar defects included trauma, complication of nasal reconstruction, and complication of rhinoplasty. The first dorsal metacarpal artery flap was used in seven cases, and the radial forearm flap was used in five. Two flap losses were salvaged with a second free flap. The average number of surgical revisions was 1.5. In group 2, there were seven patients with an average follow-up of 10.1 years. Causes of the columella defects included cocaine injury, carcinoma, and complication of rhinoplasty. The average number of surgical revisions was 3.3. The radial forearm flap was used in all cases. There were no flap losses. All 17 cases in this series were brought to a successful conclusion. The authors' experience shows that microsurgical reconstruction of the columella provides a reliable and aesthetic means for reconstruction. This technique avoids the facial disfigurement and visible scarring that often accompany use of local flaps. In addition, microsurgical flaps can be preformed "off site," which may provide certain advantages in selected cases. Therapeutic, IV.

Chicken Feet: A Model for Practising Locoregional Flaps of the Hand.

Background: The aim of this study was to determine the feasibility of the chicken foot model for surgical trainees interested in practising the designing, harvesting and inset of locoregional flaps of the hand. Methods: A descriptive study was performed to demonstrate the technical aspects of harvesting four locoregional flaps in a chicken foot model: fingertip volar V-Y advancement flap, four-flap and five-flap Z-plasty, cross-finger flap and first dorsal metacarpal artery (FDMA) flap. The study was performed in a surgical training laboratory on non-live chicken feet. No participants were involved in this study, apart from authors performing the descriptive techniques. Results: All flaps were successfully performed. Anatomical landmarks, soft tissue texture and flap harvest, as well as inset closely resembled clinical experience with patients. Maximal flap sizes were 12 × 9 mm for volar V-Y advancement, 5 mm limbs for Z-plasties, 22 × 15 mm for cross-finger flaps and 22 × 12 mm for FDMA flaps. The maximal webspace deepening with four-flap/five-flap Z-plasty was 20 mm and the FDMA pedicle length and diameter was 25 and 1 mm, respectively. Conclusions: Chicken feet can be effectively used as simulation models for hand surgical training with respect to gaining familiarity with the use of locoregional flaps of the hand. Further research requires testing for reliability and validity of the model on junior trainees.

The second dorsal metacarpal artery flap relaying the dorsal island flap of the index finger for the repair of soft tissue defect of thumb

To investigate the effectiveness of the second dorsal metacarpal artery fascial vascular pedicle retrograde island flap relaying the dorsal island flap of the index finger in repairing skin and soft tissue defects of the thumb. The clinical data of 8 patients with skin and soft tissue defects of thumb between October 2019 and January 2021 were retrospectively analyzed. There were 3 males and 5 females with an average age of 35 years (range, 18-52 years). The causes of injury included machine injury in 2 cases, crush injury in 3 cases, and cutting injury in 3 cases. There were 2 cases of dorsal defect of the proximal part, 1 dorsal defect of the distal part, and 5 instances of the distal part defect. The skin and soft tissue defects ranged from 1.7 cm×1.4 cm to 3.0 cm×2.5 cm. The time from injury to flap repair was 7-21 days, with an average of 14 days. Firstly, the dorsal island flap of the index finger (dorsal side of the proximal part of the index finger) was used to repair the defect of the thumb. Then the second dorsal metacarpal artery fascia vascular pedicle retrograde island flap (near the radial side of the back of the hand) was used to repair the dorsal defect of the index finger; the donor site was sutured directly. Vascular crisis of the flap occurred in 1 case within 48 hours after operation, and the flap was bloated and bruised in 1 case due to excessive suture tension, and all the flaps survived after symptomatic treatment; partial skin margin of the flap was necrotic in 1 case after operation, and the incision healed after dressing change; the other 5 flaps survived, and all the wounds in the donor and recipient sites healed by first intention. All the 8 patients were followed up 3-10 months, with an average of 6 months. One patient had mild scar; the other patients had no significant difference in the color of the flap and the surrounding skin, no adhesion of tendons, and little interference of index finger function, and there was no obvious pain and dysfunction in the donor and recipient sites of the flap. At last follow-up, the extension-flexion range of motion of the metacarpophalangeal joint of the thumb was 0°-55°, and that of the interphalangeal joint was 0°-75°; the extension-flexion range of motion of the metacarpophalangeal joint of the index finger was 0°-82°, that of the proximal interphalangeal joints was 0°-90°, and that of the distal interphalangeral joints was 0°-65°. The application of the second dorsal metacarpal artery fascial vascular pedicle retrograde island flap relaying the dorsal island flap of the index finger to repair skin and soft tissue defect wounds of thumb is a feasible treatment with reliable blood supply, less postoperative complications, no need for skin grafting, less interference to the function of the index finger, and satisfactory wound repair effect.

Successful Use of WALANT in Local and Regional Soft Tissue Flaps: A Case Series.

A retrospective review was performed. Twenty-one patients who underwent a local or regional soft tissue flap surgery using the WALANT technique from February 2, 2018 to February 25, 2022 were included in our analysis. Overall, one Louvre flap, two posterior tibial artery perforator propeller flaps, two reverse radial forearm flaps, two Quaba flaps, six cross finger flaps, one reverse homodigital island flap, three first dorsal metacarpal artery flaps, two thenar flaps, and two Moberg flaps were performed. Patients were followed up for an average of 11.9 ± 8.1 weeks. During this time, no postoperative complications occurred. All patients demonstrated appropriate healing at donor and recipient sites. Full range of motion was regained for all patients. WALANT is safe and effective for use in local and regional soft tissue flap surgery. Surgeons should consider this technique for more involved procedures such as flap surgery, as preliminary results demonstrate positive outcomes and potentially superior recovery for patients.

Modified First Dorsal Metacarpal Artery Flap to Prevent Venosus Congestion: Retrospective Analysis of 37 Cases

Modified First Dorsal Metacarpal Artery Flap to Prevent Venosus Congestion: Retrospective Analysis of 37 Cases

First Dorsal Metacarpal Artery Flap : A Reliable Option for Reconstruction of Extensive Pulp Defects of the Thumb

Background: Thumb pulp defects are commonly due to avulsion injuries. The choice of reconstructive procedure for thumb depends on the amount and type of tissue lost. The First Dorsal Metacarpal Artery (FDMA) flap is a versatile method with minimum donor site morbidity which provides protective sensation, adequate length, stability and good mobility. Method: This study was done over a period of 2 years and involved 15 consecutive cases of thumb pulp defects treated at our institution. The patient included 13 men and 2 women ranging in age from 16 to 60 years. The defects were ranged from 2cm x 1.5cm to 5cm x 3cm. Results: All flaps survived completely except one had marginal flap necrosis healed without the need for a secondary procedure. Donor site was covered with full thickness skin graft that healed spontaneously. Conclusion: First dorsal metacarpal artery flap offers a sensate, pliable and versatile coverage for soft tissue defects of the thumb. It provides good functional Results with minimum donor site morbidity. J Bangladesh Coll Phys Surg 2023; 41: 53-57