Hypothenar Skin Research Articles

Donor-Site Morbidity Analysis of Thenar and Hypothenar Flap.

Background For the small glabrous skin defect, Thenar and Hypothenar skin are useful donors and they have been used as a free flap. Because of similar skin characteristics, both flaps have same indications. We will conduct comparative study for the donor morbidity of the Free thenar flap and Hypothenar free flap. Methods From January 2011 to December 2021, demographic data, characteristics of each flap, and complications using retrospective chart review were obtained. Donor outcomes of the patient, who had been followed up for more than 6 months, were measured using photographic analysis and physical examination. General pain was assessed by Numeric Rating Scale (NRS) score, neuropathic pain was assessed by Douleur Neuropathique 4 Questions (DN4) score, scar appearance was assessed by modified Vancouver Scar Scale (mVSS), and patient satisfaction was assessed on a 3-point scale. Statistical analysis was performed on the outcomes. Results Out of the 39 survey respondents, 17 patients received Free thenar flaps, and 22 patients received Hypothenar free flaps. Thenar group had higher NRS, DN4, and mVSS ( p < 0.05). The average scores for the Thenar and Hypothenar groups were 1.35 and 0.27 for NRS, 2.41 and 0.55 for DN4, and 3.12 and 1.59 for mVSS, respectively. Despite the Hypothenar group showing greater satisfaction on the 3-point scale (1.82) compared with the Thenar group (1.47), the difference was not significant ( p = 0.085). Linear regression analysis indicated that flap width did not have a notable impact on the outcome measures, and multiple linear regression analysis revealed no significant interaction between flap width and each of the outcome measures. Conclusion Despite the limited number of participants, higher donor morbidity in general pain, neuropathic pain, and scar formation was noted in the Thenar free flap compared with the Hypothenar free flap. However, no difference in overall patient satisfaction was found between the two groups.

The Cutaneous Branch of the Deep Palmar Artery and Blood Supply to the Proximal Hypothenar Skin: An Anatomic Research Oriented to Flap Design.

Background: The distal half of the hypothenar eminence (HE) skin vascularization has been extensively investigated. Different flaps have been described based on these arteries. Similarly, the vascularization of the proximal half of HE has also been investigated, although to a lesser extent. The aim of this paper is to determine, in a cadaver sample, the anatomy of the hypothenar cutaneous branches in their proximal half. Methods: In all, 20 adult, red-colored-latex-injected hands were studied. Dissections were performed with a 4X to 10X magnification. Cutaneous branches in the proximal half of the HE were found. Their variants were studied, and they were classified into different types according to their relationships. Results: A cutaneous branch of the deep palmar artery (CBDPA) was identified. It was located in the subcutaneous cellular tissue thickness in the proximal half of the HE. Moreover, it presented 3 anatomical variants, classified according to its relationships with the superficial ulnar nerve branch (SUN). Type 1 variant: the CBDPA and the PDA ran in front of the SUN (60% of cases). Type 2: the CBDPA and the DPA ran behind the SUN (30% of cases). Type 3: the CBDPA ran in front of the SUN while the DPA ran behind it (10% of cases). Conclusion: There is a CBDPA which is the HE proximal half main cutaneous branch. Although it presented several variants, its existence is constant, making it possible to use it as pedicle for proximal hypothenar flaps.

P58-T Electrophysiological assessment of small fibres in carpal tunnel syndrome

Background Conventional nerve conduction techniques have limitations on carpal tunnel syndrome (CTS) diagnosing, because dysfunction of small fibres is beyond the resolution of these studies. The lack of the gold standard of CTS evaluation and common misdiagnosis underlie the treatment failure. Evaluation of small fibres susceptibility to damage and the sequence of decline of different types of fibres in CTS were analyzed. Materials and methods 75 hands, in 43 patients, 35 females, 8 males, with elecrophysiologically confirmed CTS were studied. The control group consisted of 35 volunteers (63 hands), sex and age-matched. Standard motor and antidromic sensory nerve conduction velocity studies in the median and ulnar nerves, with distal onset latency, conduction velocity, and amplitude assessment were done. Conduction velocity distribution test (CVD) was performed in the same nerves with estimation of conduction velocities in 10, 50, 90 decyl, and the conduction spread between 90 and 10 decyl. Quantitative sensory testing (QST) for detection temperature, pain and vibratory theresholds were done from thenar and hypothenar skin. Results CVD values of the median nerve in all decyls differed significantly between the carpal tunnel syndrome group and the control group, without any significant differences in the spread of conduction values. The thresholds of temperature and pain were similar, but the vibratory thresholds were significantly higher in the CTS group. Conclusions Mainly large fibers of the median nerve are damaged in the initial stage of CTS. Evaluation of small fibers is not useful in the early diagnosis of CTS.

Excessive Peptidergic Sensory Innervation of Cutaneous Arteriole-Venule Shunts (AVS) in the Palmar Glabrous Skin of Fibromyalgia Patients: Implications for Widespread Deep Tissue Pain and Fatigue

To determine if peripheral neuropathology exists among the innervation of cutaneous arterioles and arteriole-venule shunts (AVS) in fibromyalgia (FM) patients. Cutaneous arterioles and AVS receive a convergence of vasoconstrictive sympathetic innervation, and vasodilatory small-fiber sensory innervation. Given our previous findings of peripheral pathologies in chronic pain conditions, we hypothesized that this vascular location may be a potential site of pathology and/or serotonergic and norepinephrine reuptake inhibitors (SNRI) drug action. Twenty-four female FM patients and nine female healthy control subjects were enrolled for study, with 14 additional female control subjects included from previous studies. AVS were identified in hypothenar skin biopsies from 18/24 FM patient and 14/23 control subjects. Multimolecular immunocytochemistry to assess different types of cutaneous innervation in 3 mm skin biopsies from glabrous hypothenar and trapezius regions. AVS had significantly increased innervation among FM patients. The excessive innervation consisted of a greater proportion of vasodilatory sensory fibers, compared with vasoconstrictive sympathetic fibers. In contrast, sensory and sympathetic innervation to arterioles remained normal. Importantly, the sensory fibers express α2C receptors, indicating that the sympathetic innervation exerts an inhibitory modulation of sensory activity. The excessive sensory innervation to the glabrous skin AVS is a likely source of severe pain and tenderness in the hands of FM patients. Importantly, glabrous AVS regulate blood flow to the skin in humans for thermoregulation and to other tissues such as skeletal muscle during periods of increased metabolic demand. Therefore, blood flow dysregulation as a result of excessive innervation to AVS would likely contribute to the widespread deep pain and fatigue of FM. SNRI compounds may provide partial therapeutic benefit by enhancing the impact of sympathetically mediated inhibitory modulation of the excess sensory innervation.

Abductor Digiti Minimi Myocutaneous Flap for Opponensplasty in Congenital Hypoplastic Thumbs

Although abductor digiti minimi transfer is a common form of opponensplasty for congenital hypoplastic thumbs, the inclusion of hypothenar skin with this flap--to create a myocutaneous flap--is not well-described. From a series of over 600 index pollicizations and hypoplastic thumb reconstructions performed from 1977 to 2007, 14 patients with congenital thumb hypoplasia are presented who had abductor digiti minimi myocutaneous flap transfer to improve thumb opposition. The primary indications for transfer were inadequate thumb opposition and aplastic palmar and thenar soft tissues. Follow-up ranged from 1 to 22 years. All 14 transfers survived and were successful in improving thumb opposition. Key pinch strengths averaged 40 percent of normal. The inclusion of the skin paddle eliminated routing the muscle through tight palmar soft tissues while improving thenar bulk and appearance. In select cases of congenital thumb hypoplasia, opponensplasty using the abductor digiti minimi myocutaneous flap is more advantageous than the traditional muscle transfer.

Comparison of a simple method for quantitation of intraepidermal nerve fibres with a standard image analysis method using hypothenar skin

To compare a simpler method for counting intraepidermal nerve fibres with a standard computer based image analysis method in normal subjects with skin taken from the hypothenar region. In 40 healthy controls (mean age 41.1 years, range 21-71, 24 Chinese, 11 Indian, 5 Malay, 30 females) intraepidermal nerve fibres per length of epidermis were determined using immunoperoxidase staining with the panaxonal antibody PGP 9.5. Under brightfield microscopy, two methods of determining the length of the epidermis were compared. A simpler method employing a microscope intraocular lens ruler was compared with the more complex gold standard using image software analysis . Intraepidermal nerve fibres per length of epidermis using the intraocular ruler method were 3.07 nerve fibres/mm (2SD 1.56). The image software analysis obtained values of 3.05 nerve fibres/mm (2SD 1.54). Correlation between the two tests was excellent (r=0.999 p= or <0.00001). Epidermal nerve fibre counts from hypothenar skin are lower than in more proximal sites. A simple method for counting intraepidermal nerve fibres produces results similar to those using standard software image analysis. This should help the implementation of this technique for wider use.

Resurfacing of fingertip following deep burns: the hypothenar skin graft

In the reconstruction of the burned hand, each case must be carefully evaluated in the context of total patient care: only then can the proper procedure or management scheme be chosen. When the fundamental problem, is loss of surface coverage, it is usually necessary to add skin-by-skin grafts or flaps. Z-plastics and other local flaps, often do not provide enough tissue and present a higher complication rate when performed, in the context of scars contracture and increase tension, so that further stable tissue coverage is required [1‐5]. This paper suggests, the use of the hypothenar eminence as logical a donor site for pulp defects. The procedure is simple and produces an excellent end result. It works best where there is loss of fingertip skin but, when indicated, one can use this method to repair skin losses elsewhere in the hand.

Fingertip injury treated by hypothenar skin and fat graft

Fingertip injury treated by hypothenar skin and fat graft

Arterialized Venous Flaps from the Thenar and Hypothenar Regions for Repairing Finger Pulp Tissue Losses

Pulp tissue loss of the fingers was repaired with arterialized venous flaps from the thenar or hypothenar regions in 13 patients. Thirteen of the 15 flaps transferred survived completely. The thenar and hypothenar skin is durable and of appropriate texture for replacement of finger pulp defects. An average flap size of 2 x 3 cm was adequate for repairing the tissue loss of the fingers. These are not sensory flaps. However, they exhibited useful sensory recovery within 6 months of the operation. This method is simple and results in minimal donor-site morbidity. The arterialized venous flap is thus a useful alternative for the repair of finger pulp tissue losses.

SILICONE BREAST IMPLANTS AND DRUG-INDUCED ARTHRALGIA

Pulp tissue loss of the fingers was repaired with arterialized venous flaps from the thenar or hypothenar regions in 13 patients. Thirteen of the 15 flaps transferred survived completely. The thenar and hypothenar skin is durable and of appropriate texture for replacement of finger pulp defects. An average flap size of 2 x 3 cm was adequate for repairing the tissue loss of the fingers. These are not sensory flaps. However, they exhibited useful sensory recovery within 6 months of the operation. This method is simple and results in minimal donor-site morbidity. The arterialized venous flap is thus a useful alternative for the repair of finger pulp tissue losses.

The use of split-thickness hypothenar grafts for coverage of fingertips and other defects of the hand

Over a four year period, hypothenar split-thickness skin grafts were used to resurface a variety of fingertip and other hand defects in 27 patients. All patients achieved uncomplicated primary wound healing with minimal donor site morbidity. At one year follow-up, there was no evidence of late wound breakdown or fissuring of the wounds treated with hypothenar skin grafts.

The New Palmaris Brevis Musculocutaneous Flap

The palmaris brevis muscle is thin and subcutaneous on the ulnar side of the palm, attached to the medial border of the palmar aponeurosis. It ends in the dermis of the hand's ulnar border. A new musculocutaneous flap composed of the palmaris brevis muscle and its overlying hypothenar skin is presented. The free flap, from the vascular pedicle of the ulnar artery, was made. This flap sacrifices the ulnar artery. It was applied to 3 patients with palmar thumb defects, all of whom were successfully reconstructed.

Subcutaneous Pedicle Hypothenar Island Flap

The status of the blood supply to the hypothenar skin was investigated by anatomical and radiological studies. The investigation revealed that the hypothenar skin receives a rich blood supply from the arterial network by branches from the palmar ulnar artery of the little finger and the hypothenar branches. By making use of this abundance of vascular networking, a subcutaneous pedicle flap was obtained from this site. This method was clinically applied to 7 patients, and the procedures and advantages of the method are described.

A dynamic myocutaneous flap for hand reconstruction

Relocation of functional units by neurovascular pedicle transfer is firmly established in reconstructive hand surgery. Transfer of muscle and overlying skin, the myocutaneous flap, to provide skin cover is equally established. The dynamic myocutaneous flap is an extension of these concepts. Injection studies confirmed that the abductor digiti quinti muscle and its overlying hypothenar skin could be transferred on its neurovascular bundle. This dynamic myocutaneous flap was used to reconstruct both skin cover and functional opposition following resection of an arteriovenous malformation involving the thumb. Other clinical applications would include reconstruction of thenar skin and muscle lost secondary to electrical burns, avulsion, or tumor resection.

Palmar cutaneous branch of the ulnar nerve

With recent attention being placed on the median palmar cutaneous nerve, a surgical approach, ulnar to the axis of the ring finger ray, has been advocated for median nerve decompression at the wrist. Painful hypothenar neuromas have developed in two patients with this type of incision. After dissecting 21 cadaver forearms and hands, three classic and two variants of the ulnar palmar cutaneous nerve were identified and found to emerge in the subcutaneous tissue ulnar to the ring finger ray. The terminal branches supplied the hypothenar skin and extended radially to the ring finger ray axis. Because of these anatomic findings, we recommend an incision in line with the ring finger ray axis in an attempt to avoid injury to both ulnar and median palmar cutaneous nerves.

Incisions and technics in tendon grafting

W HEN STUDYmO the technics of different surgeons of great experience who perform tendon grafting, it is amazing to note the diversitv of technics they use. Many principles are not accepted unanimously. For instance, incisions are different; the amount of sheath removed is variable; usually the flexor profundus is reconstituted, but reconstitution of the superfieialis is sometimes advantageous; the sources of grafts are numerous. Some surgeons use long incisions to obtain grafts and insist on the value of the paratendon while others utilize a stripper or even intrasynovial tendons; junctures and sutures are various; as far as the suture material is concerned, every one admits that i thas to be thin, resistant, nonirritating, b u t some prefer silk, others wire or nylon. The duration of'immobilization after surgery has also been very controversial and Pulvertaft [2] has noticed, by comparison, that his results were not affected by either early mobilization or three weeks' immobilization. What principles are accepted by all the specialists in this surgery?They are not numerous but they are important [5]:(1) Only one graft of flexor tendon is placed in one finger. Because of fear of adhesion, noonehas, t o m y knowledge, a t tempted to reconstitute tt~e normal anatomy, namely, by two grafts. I t is sometimes possible in selected eases to substitute a graft for the profundus when thesuperfieialis is intact but intact superficialiS is never to be sacrificed. (2) The graft, taken fr0m the patient, is placed in the hand without delay. (3) The graft should be of Small ealiberand its extremities should be fixed Carefully, far from the fibrous sheath. (4 ) I t is preferable to spare at least one pulley to prevent bowstringing, (5) The tension of the graft must be calculated in each case. (6) There is one additional point common to all surgeons who perform this surgery with any success: patience and attention to minutiae. Atraumatic surgery, gentleness and careful suturing are essential for a good prognosis. The technic we use is not original. I t has been borrowed from the leading specialists of this surgery, mainly, Boyes [1 ], Pulvertaft [2] and Littler [3]. With experience wehave modified a few details. We will consider primarily the incisionsand the exposure of the lesions. Normally, the tissues of the fingers are rich in blood supply. This i vaseularization :depends mainly upon: thei: two proper: digital: arteries which are oftenwounded With the tendons: The skin o f t h ~ palm isSupplied: bysmal l vertical arteries whiehperforate the:fasciato nourish it. Conway and Stark i[4]~::: by vascular injection, have : ~lemonstrated: tlire~: i Well ~ V~cularized areas in:the palm:These are atlthelevel of the thenar and hypothenar skin and in the: palmar tissues distal: to:i the ~ transverse distal crease. They poorly mining sharp angles must be avoided. Sensation is imp¢ essential a t the level for ~exposure i Should digital nerves to the ineisein the usual zones of prehension or of pressure.