Soft Tissue Defects Of Fingers Research Articles

Direct and reversed dorsal digital island flaps: A review of 65 cases

BackgroundReconstruction of soft tissue defects in fingers continues to be a challenging problem. The purpose of this study is to report the reconstruction of small-to-moderate defects of fingers with dorsal digital island flap (DDIF) and to evaluate the efficacy of use of the flap. MethodsOver last six years, a retrospective study was conducted with 65 patients who had soft tissue defects of fingers treated with the DDIF. Sixty-nine soft-tissue defects were found in 69 fingers in 65 patients. Based on the flow direction of blood supply, the patients were divided into two groups: the direct (n=35) and reversed (n=30) DDIF groups. In addition, based on the different donor sites, the direct DDIF group was divided into two subgroups: the proximal phalangeal direct DDIF subgroup (n=16) and the extended pedicle direct DDIF subgroup (n=19). The main outcomes were static 2-point discrimination and Semmes–Weinstein monofilament scores of flap and joint motion. ResultsAt the final follow-up, the mean static two-point discrimination of the flaps was 9.7mm (range, 8 to 12mm) in the proximal phalangeal direct DDIF subgroup and 8.3mm (range, 7 to 11mm) in the extended pedicle direct DDIF subgroup, with a significant difference (p=0.005). In the direct DDIF group, there was no significant difference in total active motion between the donor fingers and the opposite sides. In the reversed DDIF group, the mean total active motion of the donor fingers was 170° and the data of the opposite sides was 181°, with a significant difference (p=0.024). Maximum amplitude losses of 15° were seen in 12% of patients in the distal interphalangeal joint. ConclusionsThe DDIF is reliable and technically easy for reconstructing small-to-moderate defects of fingers. The extended pedicle direct DDIF may be an optional solution when sensory reconstruction is needed.

Clinical applications of free arterialized venous flaps

Venous flaps are flaps by which tissue perfusion is accessed through the venous network. Despite originally being questioned due to potential perfusion problems, as the dynamics of tissue perfusion have been more fully comprehended, venous flaps appear to have a far wider range of application than first thought. In our study, we analyzed the clinical results of the applications of free arterialized venous flaps along with the factors that can affect flap survival. Forty-one flaps were assessed retrospectively. Type of the trauma, traumatized area, the time duration between trauma and application of the flap, donor area, type and count of the anastomosis, encountered complications, and flap survival rates were analyzed. Regression and classification trees were used to study the relationship between flap surface area, anastomosis count, and flap survival. Circulatory abnormalities such as early congestion and edema were seen in 53.6% of the applied flaps. A total of four flaps (9.7%) developed necrosis which presented as full thickness in three flaps and partial thickness in one flap. It can be said that there was a weak but positive correlation between the size of the flap area and the number of anastomosis. Although the results of arterialized venous flaps are inconsistent in the literature, those flaps can be preferred as an alternative treatment option in single finger defects where tissue compatibility and cosmetic results are quite impressive. In the meantime, syndactylized venous flaps are the preferred method regarding multiple finger soft-tissue defects.

Repair of Middle and Distal Finger Skin and Soft Tissue Defect with Dorsal Metacarpal Artery Reversed Island Flap

Repair of Middle and Distal Finger Skin and Soft Tissue Defect with Dorsal Metacarpal Artery Reversed Island Flap

Heterodigital Free Flap of Index Finger Amputee for Coverage of the Long Finger Soft Tissue Defect

Heterodigital Free Flap of Index Finger Amputee for Coverage of the Long Finger Soft Tissue Defect

Reconstruction of lateral finger soft tissue defects using tibial side free flap from the second toe with digital artery and nerve anastomosis

Objective To investigate the surgical procedure and treatment outcomes of repairing soft tissue defects of the finger accompanied by proper digital artery and nerve defects.Methods Eight patients with soft tissue defects on the hteral side of the proximal and middle phalanx of the fingers accompanied by proper digital artery and nerve defects were treated by the second toe tibial side skin flap.The defects of the proper digital artery and nerve were bridged at the same time.The sizes of the soft tissue defects varied from 4.0 cm×1.5 cm to 2.0 cm × 1.0 cm.The sizes of skin flaps harvested varied from 4.2 cm × 1.8 cm to 2.5 cm ×1.5 cm.The average length of the proper digital artery and nerve defects was 2.4 cm,ranging from 1.0 to 4.0 cm.Results All flaps survived.Postoperatively the patients were follow-up for 6 to 36 months with an average ef 15 months.The contour of the repaired fingers was good.The fingertips were warm,without cold intolerance.The Allen test was negative for all the fingers.2-PD of the repaired side of the fingertip averaged 8mm,ranging from 6 to 15 mm.The donor sites healed well.Conclusion It is an ideal method to repair lateral soft tissue defects of the fingers using tibial flap from the second toe with the defects of the proper digital artery and nerve bridged.This method can restore the appearance,blood supply and sensation of the injured finger. Key words: Finger injuries; Surgical flaps; Transplantation; Toes

LOCAL FLAPS AND SPLIT;

Background: Two point discrimination (TPD).is the minimum distance between two stimulus points on the skin, which areperceived as distinct points, Among the two types of TPD i.e., static and dynamic, static two-point discrimination (STPD) is commonly used todetermine digital nerve integrity. Local flaps usually do well in maintaining sensibility of the covered area in terms of two point discrimination incontrast to s-plit thickness skin grafts (STSG). Objective: The objective of this study was to determine the frequency of sensory deficit in termsof TPD in STSG and local flaps for soft tissue defects of fingers after three months. Study design: It was a Quasi experimental study. Settings:Patients admitted in the indoor of Plastic surgery department, Services Hospital Lahore. Period: February 2009 to January 2010. Material andMethods: Thirty five patients underwent local flap coverage and other thirty five underwent split thickness skin grafting for soft tissue defects offingers depending upon nature of defect. Patients were followed up at 2, 4, 8 and 12 weeks. Results: The sensory deficit observed at the end of12th week post operatively was in 8.6% of the patients with local flap coverage (3 patients) and 45.7% of those with STSG (16 patients).Patients with no sensory deficit were 91.4% (32 patients) in the local flap coverage and 54.3% (19 patients) in the STSG at 12th week of followup. The relative ratio of sensory deficit in local flaps and STSG was 5 (>2). Conclusions: The results of this study show that Local flaps arebetter options in terms of TPD preservation as opposed to STSG for soft tissue defects of fingers.

Dorsal Metacarpal Artery Flaps with Extensor Indices Tendons for Reconstruction of Digital Defects

ABSTRACTIntroduction: Distally based dorsal metacarpal artery (DMCA) flaps are an established technique for the reconstruction of extensive finger defects. In many cases, such defects also include an injury of the extension tendon over the proximal and distal finger joint, which can lead to a reduced range of motion or finger deformation such as boutonniére deformity. To prevent this, operative techniques are necessary that allow complete defect coverage while simultaneously stabilizing the extension apparatus.Methods: In two cases, DMCA flaps were combined with vascularized extensor indices tendons for the reconstruction of extensive dorsal finger skin and soft tissue defects, particularly when tendon and bone are exposed.Results: After three weeks of postoperative immobilization, physiotherapy could be intensified. In a six months’ follow-up, the results obtained from the standpoint of both function and appearance were excellent, the flaps remained viable at all times and full-finger length and sensory function were maintained. Regarding operation time, pain and finger appearance, both patients stated satisfaction.Conclusion: The vascularized tendon incorporated in DMCA flaps provides a sufficient method to restore a satisfactory finger function and prevent finger deformity, arthrodesis, or amputation, especially in cases with severe injuries of the extension apparatus.

Repair of finger soft tissue defect with retrograde island flap of dorsal branch of the proper digital artery

Objective To investigate the clinical outcomes of repairing finger soft tissue defects with retrograde island flap of dorsal branch of the proper digital artery.Methods From December 2008 to December 2010,25 cases of finger soft tissue defects were treated with retrograde island flap of dorsal branch of the proper digital artery.The axis blood vessel of the flap was the dorsal branch of the proper digital artery.The flap was designed on the dorsum of the proximal or middle phalanx.The flap was reversed to repair the distal finger soft tissue defect.The dorsal branch of the proper digital nerve was included in the flap and sutured with the nerve stump in the wound to restore sensation of the injured finger.Results All 25 flaps survived.The patients were follow-up for 6 to 18 months.The appearance,color,texture and sensation of the flaps were satisfactory.Two-point discrimination was 4 to 11 mm.Condusion Retrograde island flap pedicled on dorsal branch of the proper digital artery has a long vessel pedicle and large rotating arc.The surgical operation is simple and also restores sensation of the finger without sacrificing the proper digital artery and nerve.It is an ideal method for repairing finger soft tissue defects with a high success rate. Key words: Surgical flaps; Fingers; Proper digital artery; Soft tissue defect

Cutaneous branches of second and third dorsal metacarpal artery fasciocutaneous flaps for repair of distal- and middle-segment finger soft tissue defects

Objective To evaluate the clinical efficacy of cutaneous branches of reverse second and third dorsal metacarpal artery fasciocutaneous flaps for repair of distal- and middle-segment finger soft tissue defects. Methods A total of 14 patients with distal- and middle-segment finger soft tissue defects complicated by exposure of the phalanx or tendon were repaired by using cutaneous branches of second and third dorsal metacarpal artery fasciocutaneous flaps ranging between 2.0 cm × 4.5 cm and 3.0 cm × 7.0 cm.Resuits All of the skin flaps survived after surgery.Follow-up data during a 6-40 month period showed that the flaps exhibited a satisfactory appearance.They were not fat or clumsy,with a 2-point discrimination of 59 mm,and there was good recovery of finger function.The donor site was able to be directly sutured without dermoplasty.Pigmented linear surgical streaks appeared in the donor site. Conclusion The cutaneous branches of Second and third dorsal metacarpal artery fasciocutaneous flaps provide a good approach for the repair of distal- and middle-segment finger soft tissue defects and functional reconstruction because of convenient dissection,little trauma,sufficient use of the dorsal metacarpal artery. Key words: Finger; Dorsal metacarpal artery; Fasciocutaueous flap; Microsurgical operation

Application of the Dorsal Metacarpal Artery Perforator Flap for Resurfacing Soft-Tissue Defects Proximal to the Fingertip

The dorsal metacarpal artery perforator flap is a versatile solution for resurfacing soft-tissue defects of fingers. The authors present their experience in applying this flap for a variety of finger wounds for which conventional means may not be amenable. Fifty-eight dorsal metacarpal artery perforator flaps were used to resurface 60 finger soft-tissue defects in 56 patients over a 5-year period. Fifty-two patients were men and their average age was 37 years. This flap was used to reconstruct soft-tissue defects after débridement of infected wounds in 28 patients, traumatic wounds in 26 patients, and electrical burns in two patients. The average flap size was 4.6 × 2.3 cm; 34 flaps were based on the second dorsal metacarpal artery perforator, 14 were based on the third dorsal metacarpal artery perforator, and 10 were based on the fourth dorsal metacarpal artery perforator. Twenty-one flaps were used to resurface defects distal to the proximal interphalangeal joint, and 37 flaps were used to resurface defects over the proximal interphalangeal joint and proximal to it. Skin grafting was needed to close the donor defect in seven patients. Complications included venous congestion in six flaps and arterial insufficiency in three flaps, with total loss of two flaps and infection in one case. The dorsal metacarpal artery perforator flap is a thin, pliable flap that is simple to raise, has minimal donor-site morbidity, and can reliably cover soft-tissue defects up to the proximal half of the middle phalanx. Therapeutic, IV.

Reverse Second and Third Dorsal Metacarpal Artery Fasciocutaneous Flaps for Repair of Distal- and Middle-Segment Finger Soft Tissue Defects

The present study evaluated the clinical efficacy of reverse second and third dorsal metacarpal artery fasciocutaneous flaps for repair of distal- and middle-segment finger soft tissue defects. A total of 14 patients with distal- and middle-segment finger soft tissue defects complicated by exposure of the phalanx or tendon were repaired using second and third dorsal metacarpal artery fasciocutaneous flaps ranging between 2.0 cm × 4.5 cm and 3.0 cm × 7.0 cm. All of the skin flaps survived after surgery. Follow-up data during a 6- to 40-month period showed that the flaps exhibited a satisfactory appearance. They were not fat or clumsy, with a 2-point discrimination of 5 to 9 mm, and there was good recovery of finger function. The donor site was able to be directly sutured without dermoplasty. Pigmented linear surgical streaks appeared in the donor site. The second and third dorsal metacarpal artery fasciocutaneous flaps provide a good approach for the repair of distal- and middle-segment finger soft tissue defects and functional reconstruction because of convenient dissection, little trauma, sufficient use of the dorsal metacarpal artery, large harvested area of the flap, and a good dissection range.

Repair of digital soft tissue defects with a modified reversed island flap pedicled on a perforating branch of the dorsal metacarpal artery

Objective To report operative procedures and clinical results of repairing finger soft tissue defects with a modified reversed island flap pedicled on a perforating branch of the dorsal metacarpal artery. Methods From January 2005 to March 2008,we repaired 38 finger soft tissue defects in 31 patients (26 men and 5 women) with a modified reversed island flap pedicled on a distal perforating branch of the dorsal metacarpal artery and anastomosis of the cutaneous nerve.Their ages ranged from 14 to 66 years,with a mean of 29.6 years.Altogether 11 index,18 middle,6 ring and 3 little fingers were injured.Nine patients were complicated with rupture of tendons,3 with extenso-tendon defects and 5 with middle phalanx fractures.The defect areas ranged from 1.0 cm × 0.8 cm to 3.2 cm× 2.5 cm.The flap areas ranged from 1.2 cm× 1.0 cm to 3.5 cm× 2.8 cm.The flap did not carry a full length of the dorsal metacarpal artery but only the distal perforating branch of the artery.The rotating point of the flap pedicle was altered from the dorsal to the palmar side to extend the vessel pedicle.The donor sites were closed by suture or skin graft. Results Twenty-eight patients (35 fingers) were followed up for 3 to 25 months (mean,15.3 months) .All flaps survived with satisfactory appearance,sensation and function.All flaps and donor sites obtained primary healing.The two-point discrimination was 6 to 9 mm (mean,7.7 mm).According to Total Active Movement (TAM) evaluation system,the results were excellent in 20,good in 13 and fair in 2 fingers,with a good to excellent rate of 94.3％. Conclusion The modified reversed island flap pedicled on a distal perforating branch of the dorsal metacarpal artery and anastomosis of the cutaneous nerve is an easy,safe and effective treatment for finger soft tissue defects. Key words: Fingers; Soft tissue injuries; Dorsal metacarpal artery flaps; Repair

Clinical application of reverse radial hypothenar flap for finger soft tissue defect

To investigate the therapeutic effect of reverse radial hypothenar flap for finger soft tissue defect. From Mar. 2006 to Mar. 2010, 13 cases (14 fingers) with finger soft tissue defects were treated with reverse radial hypothenar flaps pedicled with ulnar palmar digital artery of little finger. The defects were 1.9 cm x 1.5 cm -4.0 cm x 2.0 cm in size. The flap size ranged from 1.5 cm x 2.0 cm to 4.0 cm x 2.0 cm. All the flaps survived completely with primary healing both in donor and recipient area. 12 cases (13 fingers) were followed up for 1-3 years. The flaps color was similar to the unaffected fingers. Cicatricial contracture happened in one case due to contracture of palmar fascia. The two-point discrimination distance on flap was 3.2-5.3mm. The active and passive movement of finger joints was evaluated as excellent in 12 fingers, good in one finger. There was no complaint about the feeling at the donor site. Two months after operation, all patients could go back to work. The reverse radial hypothenar flap is very suitable for finger soft tissue defect with less morbidity to donor site.

The Free Dorsoradial Forearm Perforator Flap

The perforator flaps are characterized by their thinness and the adjustable length of their vascular pedicle. The purpose of this investigation is to refine the anatomy of the perforators in the middorsoradial forearm and present our clinical experience using this free perforator flap in the reconstruction of finger defects. Anatomic study was conducted on 46 cadaver forearms. It was noted that a perforator was consistently observed in the midforearm exhibiting 4 patterns, in which a dorsoradial perforator was present with 37 cases (80.4%) originating from the interosseous artery system (patterns 1-3) and 9 cases (19.6%) from the descending branch of the radial recurrent artery (pattern 4). This perforator consistently emerged in the intermuscular septum between the extensor carpi radialis longus and extensor digitorum communis. Twenty free flaps based on this middorsoradial cutaneous perforator were elevated for the coverage of soft tissue defects of fingers (range: 3 cm × 2.0 cm to 5 cm × 2.5 cm) in 17 patients. All the flaps survived with satisfactory outcomes. Clinical findings on this perforator in terms of its origins and courses coincided with the anatomic results (χ2 = 0.287, P = 0.962). The free flap based on this perforator is a reliable perforator flap in spite of varied origins.

Soft-Tissue Coverage of Complex Dorsal Hand and Finger Defects Using the Turnover Adipofascial Flap

Complex hand wounds with exposed tendon or bone often require free tissue transfer. We report results in 13 patients with complex dorsal hand or digital wounds who underwent soft-tissue reconstruction using a turnover adipofascial flap and skin grafting over a 35-month period. The mean patient age was 44 years. Mechanism of injury included the following: three gunshot, four degloving, one table saw, three chain saw, one thumb avulsion, and one crush. Flap sizes varied from 2 × 4 to 10 × 18 cm, involving the dorsum of the hand in four patients, thumb in two patients, index finger in one patient, long finger in three patients, long and ring fingers in one patient, and web space in two patients. Skin graft survival was 100% in 12 patients. One patient died of sepsis from unrelated medical conditions. All fractures were healed at follow-up, and there were no donor site complications. The adipofascial flap is a good alternative to free tissue transfer for the coverage of complex dorsal hand and finger soft-tissue defects and is associated with technical ease, good cosmetic results, and minimal donor site morbidity.

Application of perforator flap for repair of finger soft tissue defect

Objective To explore the surgical design and surgical techniques of perforator flap transfer for repairing soft tissue defects of the fingers. Methods Perforator flaps from anterolateral, inferomedial and lateral side of the lower leg and distal dorsal interosseous perforator mini flap were used to repair soft tissue defect of the fingers in 13 cases. Results All 13 flaps survived. The function and appearance of both the donor and recipient sites were good. Condusion Designing and harvesting a flap pedieled on a perforator or an axial vessel in the extremity for free transfer to cover soft tissue defects of the fingers offers a new surgical option for treating hand trauma, since it causes less pain and leas damage while providing satisfactory wound coverage. Meanwhile, however, it is technically more challenging to the surgeon. Key words: Surgical flaps; Finger injuries; Perforator flaw

Arterial anatomical basis of the dorsal digito-metacarpal flap for long fingers

Several flaps have been described to treat severe soft tissue defects of the finger dorsal side. Many authors studied vascular organization of the hand on its dorsal side; most of them insisted on deep vascularization into the intermetacarpal spaces, which is formed by the dorsal metacarpal arteries. Those dorsal metacarpal arteries are the anatomical support of many flaps, which do not preserve the dorsal interosseous muscles fascias. Only few authors described dorsal vascular organization at the level of the proximal phalanx; however, using a rotation point of a flap distally to the metacarpal head with a donor site on the dorsal aspect of the hand could cover all distal soft tissue defect of long finger. In order to determine the technical limitations of dorsal digito-metacarpal flap procedures, we studied number and location of arterial anastomoses between the reticular subcutaneous dorsal network and the rest of the vascularization at this level, which was formed by the deeper dorsal metacarpal arteries, common palmar digital arteries and proper palmar digital arteries, and between the dorsal digital arteries. Twenty-four long fingers from embalmed cadavers were studied after a reverse flow injection of colored latex and dissected layer-by-layer preserving the digital-metacarpal arterial network. At the level of the hand, the dorsal metacarpal arteries of the third and fourth intermetacarpal spaces were inconstant. When present, two or three arteries anastomosed in star shape with the reticular network. No such arterial anastomosis was observed proximally to the level of the intertendinous connections (junctura tendinorum) that bridge the extensor digitorum communis tendons. When no dorsal metacarpal artery was present, some communicant arteries arose from the common palmar digital arteries. Moreover, all the nutrient branches were more numerous distally to the intertendinous connections (junctura tendinorum). At the level of the metacarpophalangeal joints, the hand cutaneous network was always anastomosed with the dorsal cutaneous network. At the level of fingers, the dorsal cutaneous network was always supplied by four branches arising from the proper digital artery. Our study supported the reliability of dorsal digitometacarpal flaps, supplied by numerous palmodorsal digital anastomoses and by a rich plexiforme network joining the hand skin supply and that of the dorsal finger skin. During the procedure, we recommend limiting the surgical dissection of the flap at the level of the middle phalanx.

The Boomerang Flap in Digital Reconstruction

The anatomic and clinical bases for the reliable and versatile boomerang flap in reconstruction of complex distal finger injuries are presented. This one-step procedure, utilizing the dorsolateral skin of the proximal phalanx of an adjacent digit as a reverse island flap, has proved valuable in the salvage of severely injured digits. The boomerang flap was applied in ten cases with distal phalanx injuries. Soft tissue defects in all patients were combined with bone, joint, or tendon exposure. The flaps were transferred as a neurovascular flap for sensory resurfacing of the major pulp loss. This flap preserves the proper palmar digital artery to the fingertip and provides an extended and innervated skin paddle to cover finger soft tissue defect as well as to improve flap sensibility in the distal pulp.