Dr. HARSH AMIN

LOCO-REGIONAL FLAPS FOR HAND DEFECTS

INTRODUCTION

Hand is an organ where skin envelope covers multiple tendons, nerves, vessels, bones and joints

For proper function this envelope has to be elastic and non adherent and large enough to allow freedom of motion

Relevant anatomy

Problem

GOALS OF RECONSTRUCTION

Restoration of functional, sensate and aesthetically acceptable hand

Coverage always follows proper debridement & skeletal

stabilization

Achieve Primary wound healing (To minimize contracture and joint stiffness)

Palmar skin - Palmar defects require thick, sensate glabrous skin for resurfacing, to withstand pressure and friction while grasp and pinch

Dorsal skin - Thinner , more elastic and loose enough to allow flexion at joints

PRINCIPLES

Palmar Defect

Multiple septal fibers and Grayson and Cleland’s ligaments compartmentalize the fat pads and neurovascular bundles and mobilization of volar flaps require division of these

Patients with thick palmar skin are not ideal candidates for extensive volar dissection

Large pulp defects in the thumb and radial side of index may warrant heterodigital island flap for sensate reconstruction despite the donor morbidity.

Dorsal Defect

Skin grafting over the dorsum often results in adherence and limited finger flexion.

Dorsal transposition flaps are ideal for resurfacing.

Aesthetic considerations of color matching and contour can be important to the patient as this is the exposed surface of the hand.

Factors affecting planning

DefectDonor site

PatientDoctor

Site of the defect Size of defect Mechanism of injury Cleanliness of wound

Defect

Handedness occupation Age Sex Overall health Preference

Patient

Donor site

Availability

Doctor

Experience Set up/ team

RECONSTRUCTIVE OPTIONS

Options for coverage of Hand Defects

Amputation

Primary Closure

Secondary intension

Skin graft

STG

FTG

flap

Free

Pedicled

Local

Regional

Distant

Local flaps

Transposition

Random

Type 1

Type 2

Axial

Flag

FDMA (Kite/Foucher)

SDMA

Digital artery island flap

Rotation

Advancement

Moberg

V-Y

Atasoy

kutler

Regional flaps

Random

Cross Finger

Classic

Reversed

Innervated

Thenar

Axial

Neurovascular island flap

Fillet flap

Forearm flaps

Reverse radial forearm

Reverse ulnar forearm

Post. Interrosseous

Dorsal Ulnar

When flaps?

LOCAL FLAPS

Flaps that come from adjacent area to defect

Identical in quality

Requires only one procedure for completion

Transposition Flaps

(Random)

Type 1Requires STG for Donor

Type 2Donor is closed Primarily

Transposition Flaps

(Axial)

FDMA flap

Flag Flap

Digital Artery Island Flap

Dorsal metacarpal artery flap

Rotation Flap

Advancement Flap

REGIONAL FLAPS

Flap that is raised from area of the limb that is not adjacent to defect

May require 2 stages if not axial pattern

SELECTION OF FLAP

Fingertip reconstruction <0.5cm2 no bone exposed healing by epithelialization 0.5-1cm2 no bone exposed FTSG bone exposed VY plasty 1-2cm2 Homodigital island flap

Moberg flap for thumb 2-5cm2 Cross finger flap or reverse flow

digital island flap Heterodigital island flap for thumb

Dorsal finger resurfacing defect <2 cm2 Dorsal transposition flap distal defect 2-5cm2 Reverse dermis cross

finger flap proximal defect 2-5cm2 Dorsal metacarpal

artery perforator flap

Volar finger Resurfacing Defect <2 cm2 Intrinsic perforator based local

flaps Defect 2-5cm2 Cross finger flaps, dorsal metacarpal artery perforator flaps, heterodigital

island flaps Defect > 5cm Extrinsic pedicled flap (radial

forearm, posterior interosseous artery) or free flaps

POST OPERATIVE CARE

COMPLICATIONS

CONCLUSION

THANK YOU