1. Summer Anatomy Lab July 25, 2013 Jennifer Klok
Local Hand Flaps
Summer Anatomy Lab
July 25, 2013
Jennifer Klok

2. Reconstructive Ladder
Healing by secondary intention
Primary closure
Skin graft
Local flap
Regional flap
Free flap

3. Cross-Finger Flap Design: Vascular supply: Skin and subcutanous tissue
Designed over dorsal aspect middle phalynx
Vascular supply:
Dorsal digital artery
Digital perforators

4. Cross-Finger Flap Clinical Applications
Coverage of volar aspect of adjacent digits’ middle phalangeal area
Distal digital tip coverage
Volar oblique fingertip amputations with exposed bone or tendon

5. Anatomy Dorsal Digital Artery (1mm)
Dorsal skin distal to the distal proximal phalynx depends on perforating branches from digital arteries
Course through Cleland’s ligament
Supplies the flap
Digital Perforators passing dorsally around finger ( mm)
The vascular supply of the dorsal skin distal to the distal portion of the proximal phalynx depends on perforating vessels from the digital arteries. These dorsal branches supply the flap. The perforating vessels course through Cleland’s ligament and anterior dorsal network, where they support a rich dermal and subdermal plexus. This supplies a laterally based cross-finger flap. There are two to four perforators over the proximal phalynx, midportion of the middle phalynx and distal third of the middle phalynx

6. Design and Markings Designed with base adjacent to injured finger
Proximal and distal flap marked transversely
Connect these with a longitudinal line just dorsal to mid-axis of dorsum of finger
3-sided rectangle
Incisions made to encompass whole surface of middle phalynx

7. Volar finger defects

8. Dissection
Incise skin based on markings down to SC fat until loose areolar plane
Elevate flap in this plane, taking care to leave the paratenon behind
Dissect to Cleland’s ligament; may need to divide ligament to increase pedicle length
Cover donor site with skin graft
Inset flap
Divide flap 2-3 weeks later

9. Fingertip Defects

10. Reverse Cross-Finger Flap
For adjacent dorsal digital wound coverage
Elevate flap in subdermal plane
Adipofascial flap to cover dorsal defect

11. Thenar Flap To cover defects on the index and long fingers Green’s:
“Use where preservation of length is considered important and other techniques that have less potential for complications are not applicable”

12. Thenar Flap

13. Thenar Flap
Donor site found by taking tip of index or ring finger and placing it against thenar eminance
Draw circle around area of contact
Draw H or curved incision at this point
Elevate flaps in subcutaneous plane
Inset flap
Divide in days
For the H flap, the proximal flap covers the finger defect and distal flap advanced to cover donor

15. Points about the Thenar Flap
To avoid potential for joint stiffness or unsightly scar in donor area:
Design flap near the MP crease of the thumb; avoid the midpalmar area
Fully flex the MP joint with whatever amount of flexion is required in the IP joints of the recipient finger
Detach pedicle days post-op and start immediate AROM
To avoid the potential for joint stiffness with a permanent flexion contracture or unsightly scar in the donor area, one must keep in mind the three cardinal technical principles outlined by Melone and colleagues[70]: (1) design the flap near the metacarpophalangeal (MP) crease of the thumb and avoid the midpalmar area; (2) fully flex the MP joint with whatever amount of flexion is required in the IP joints of the recipient finger; and (3) detach the pedicle 10 to 14 days postoperatively and begin immediate active range of motion.
Contraindications to either the cross-finger flap or the thenar flap would be any general condition that might lead to finger stiffness, such as rheumatoid arthritis, Dupuytren's contracture, any connective tissue disease involving the hand, and advanced age with its concomitant degenerative changes. Complications seem to be more prevalent in those patients older than 30 years of age with a greater tendency for the development of joint stiffness. We believe that the risk of this complication is a relative contraindication to the use of the thenar flap in patients older than age 30.

16. First Dorsal Metacarpal Artery Flap
Classification:
Type A fasciocutaneous flap
From dorsal skin over proximal phalynx (FDMA)
Clinical Applications:
For defects in the thumb

17. FDMA Dominant Pedicle: Minor Pedicle: Nerve Supply:
First dorsal metacarpal artery (FDMA)
Minor Pedicle:
Cutaneous perforators of the FDMA
Nerve Supply:
Dorsal sensory branches of the radial and ulnar nerves

18. Anatomy Dorsal metacarpal arteries
From dorsal carpal arch formed from dorsal carpal arteries
Gives rise to 4 dorsal metacarpal arteries
These course over dorsal interosseous muscles
Communicates with deep palmar arch
Proximal to web space divides into 2 dorsal digital branches
Then divide into terminal branches midway along proximal phalynx
The dorsal carpal arch is formed from dorsal carpal arteries arising from the ulnar and radial arteries. The vessels anastamose across the dorsum of the distal carpal row to form a vascular arcade that gives rise to four dorsal metacarpal arteries. Each metacarpal vessel courses distally over the dorsal interosseous muscle bellies to supply the skin and subcutaneous tissues covering the dorsum of each finger and its adjacent dorsal web space. The first dorsal metacarpal artery (FDMA) tends to be a discrete terminal branch of the radial artery rather than arising directly from that dorsal carpal arch. The fifth dorsal metacarpal artery may also arise as a terminal branch of the ulnar artery.
From its origin, each vessel courses distally toward the web space and communicates through the interosseous space with the deep palmar arch. Proximal to the web space, each of the second, third and fourth dorsal metacarpal arteries divide into two dorsal digital branches, on to each adjacent side of the index, middle, ring and little fingers. The FDMA supplies the dorsum of the thumb and radial side of the index finger, and the fifth dorsal metacarpal artery supplies the ulnar side of the little finger. Traveling distally along each side of the finger, the vessels divide into terminal branches midway along the proximal phalynx. The vessels supply the dorsal skin of the finger as far as the proximal interphalangeal (PIP) joint. Distally, the dorsal skin is supplies by branches of the palmar digital arteries.

19. Anatomy
The first dorsal metacarpal artery (FDMA) tends to be a discrete terminal branch of the radial artery rather than arising directly from that dorsal carpal arch
Found in the first intermetacarpal space, just distal to the extensor pollicis longus tendon
Supplies the dorsum of the thumb and radial side of the index finger

21. Flap Markings From MCP joint to the PIP joint of index
Radial & ulnar borders 1st the midlateral lines on either side of digit

22. Flap Dissection Incision in 1st dorsal web space, down to FDMA
Elevate flap distal to proximal, just above paratenon
Fascia and fat adjacent to 2nd metacarpal kept intact to protect vessels
Transfer and inset flap
Cover donor with skin graft
An incision is then made in the
dorsal first web space, and dissection is carried down
to the first dorsal metacarpal artery, which arises from
the radial artery. With a very complete dissection, a
pedicle of 7 to 8 cm can be created. The flap is then
incised and elevated at the level of the paratenon from
a distal to proximal direction. Fascia adjacent to the
second metacarpal along with adjacent fat are kept
intact along the course of the vessels. A subcutaneous
tunnel is created from the donor site to the recipient
site, and the flap is brought through, with care taken
not to kink or twist the pedicle. The dorsal proximal
phalanx is covered with a full-thickness skin graft