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Local Hand Flaps

Local Hand Flaps. Summer Anatomy Lab July 25, 2013 Jennifer Klok. Reconstructive Ladder. Healing by secondary intention Primary closure Skin graft Local flap Regional flap Free flap. Cross-Finger Flap. Design: Skin and subcutanous tissue

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Local Hand Flaps

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  1. 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: • 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 (0.2-0.3mm)

  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 thenareminance • Draw circle around area of contact • Draw H or curved incision at this point • Elevate flaps in subcutaneous plane • Inset flap • Divide in 10-14 days • For the H flap, the proximal flap covers the finger defect and distal flap advanced to cover donor

  14. 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 10-14 days post-op and start immediate AROM

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

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

  17. 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

  18. 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 pollicislongus tendon • Supplies the dorsum of the thumb and radial side of the index finger

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

  20. 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

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