Reverse flow first dorsal metacarpal artery flap for covering the defect of distal thumb

Reconstruction of distal thumb injuries still remains a challenge for hand surgeons. Surgical treatment includes the use of local, regional, and free flaps. The purpose of this report is to present the results of the use of a sensitive reverse flow first dorsal metacarpal artery (FDMA) flap. The skin flap was designed on the radial side of the proximal phalanx of the index finger based on the ulnar and radial branch of the FDMA and a sensory branch of the superficial radial nerve. This neurovascular flap was used in five patients to cover distal soft‐tissue thumb defects. All flaps achieved primary healing except for one patient in whom superficial partial necrosis of the flap occurred, and the defect healed by second intention. All patients maintained the thumb original length and were able to return to their previous daily activities. The reverse flow FDMA flap is a reliable option to cover immediate and delayed defects of distal thumb, offering acceptable functional and cosmetic outcomes in respect to sensibility, durability, and skin‐match. © 2013 Wiley Periodicals, Inc. Microsurgery 34:283–286, 2014.     

拇指皮肤缺损的早期显微外科修复

目的 报道应用不同类型的皮瓣修复拇指皮肤软组织缺损的临床疗效。方法 对43例拇指皮肤缺损患者，急诊应用7种方法治疗。其中拇指掌侧推进皮瓣8例，示指近节背侧岛状皮瓣15例，第一掌背逆行筋膜皮瓣4例，中、环指邻侧双岛状皮瓣3例，桡动脉鼻烟窝皮支逆行岛状皮瓣5例，带骨间后动脉的前臂逆行岛状皮瓣4例，mu趾甲皮瓣游离移植4例。结果 本组43例中，坏死1例，改用其它皮瓣修复；部分坏死2例，经换药痊愈。其余40例拇指外形较好，指腹感觉存在，活动正常或稍差于健侧，拇指能与2～5指对指。结论 不同程度的拇指皮肤缺损选用合适的方法修复，疗效可靠。     

桡动脉腕背分支为蒂的手背逆行岛状筋膜皮瓣的临床应用

目的探讨手背部桡动脉腕背分支为蒂的三种逆行岛状筋膜皮瓣的手术方法及临床应用。方法桡动脉在腕背鼻烟窝穿出,与尺动脉掌深弓吻合之前,发出腕背皮支、第1掌背动脉、拇指背侧支以三支动脉为蒂,形成逆行鼻烟窝皮瓣、第1掌背动脉皮瓣、拇指背侧动脉皮瓣,修复虎口挛缩和指、示指、腕掌、腕背侧皮肤缺损。结果切取桡动脉腕背皮支逆行岛状皮瓣13例,修复拇指、虎口、指、腕掌、腕背组织损伤及缺损。术后随访皮瓣外形及手功能恢复效果满意。结论桡动脉腕背分支行岛状筋膜皮瓣血运好,质地柔软,切取方便,不牺牲主要动脉,是修复手部皮肤缺损的一种简单安全、损伤小的方法。     

Sensate first dorsal metacarpal artery flap for resurfacing extensive pulp defects of the thumb

Finding an appropriate soft-tissue grafting material to close a wound located over the distal phalanx of the thumb, especially the pulp region, can be a difficult task. A sensate first dorsal metacarpal artery flap, mobilized from the dorsum of the adjacent index finger and used as an island pedicle skin flap, can be useful for this purpose. The pedicle includes the ulnar branch of the first dorsal metacarpal artery, the dorsal veins, and the cutaneous branch of the radial nerve. Although this tiny artery is anatomically variable, safe dissection can be achieved by including the radial shaft periosteum of the secondary metacarpal bone and the ulnar head fascia of the first interosseous muscle.This approach has been used for 8 individuals with extensive pulp defects of the thumb over the past 3 years. Skin defects in all patients were combined with bone, joint, or tendon exposure. All flaps survived completely. This 1-stage procedure is reliable and technically simple. It provides sensate coverage to the pulp of the thumb but also avoids nerve repair or more complicated microsurgery.     

Treatment of thumb soft-tissue defects using a bipedicle island flap of the index finger: anatomical basis and clinical application

Purpose

Reconstruction of the thumb with exposure of bone and tendon is challenging. We designed a bipedicle island flap from the dorsum of the index finger to repair thumb defects. One pedicle includes the radial proper palmar digital artery (PDA) of the index finger, another pedicle includes the first dorsal metacarpal artery (FDMA). The aim of the study was to investigate the anatomical basis and clinical application of this flap.

Methods

Eleven fresh cadaver hands were dissected, the FDMA and the radial proper PDA were exposed. Their origin, distribution and diameter in different locations, especially in the dorsum of the proximal phalanx of the index finger, were examined. Ten patients (11 hands) underwent thumb reconstruction using this flap. During follow-up, the flap survival and hand function were evaluated.

Results

The origin of the FDMA in three cadaver hands was abnormal. The FDMA was mainly distributed in the proximal area of the dorsum of the proximal phalanx. The radial proper PDA of the index finger formed one constant dorsal branch, mainly distributing in the middle and distal area of the dorsum of the proximal phalanx. All flaps survived. At follow-up, the span of the first web and the range of motion of the thumbs and index fingers reached more than 94 % of the contralateral finger. All patients were satisfied with the hand function according to the Michigan Hand Outcomes Questionnaire (MHQ).

Conclusions

The bipedicle island flap has two arterial systems to provide sufficient blood supply. This technique provides another option for thumb reconstruction when a large supercharged FDMA island flap needs to be designed, or when there is an additional injury to the radial side of the dorsum of the hand or if there are anatomical variations of the FDMA, or if damage to the FDMA occurs during surgery.     

指背血管蒂岛状皮瓣修复拇指组织缺损

目的 探讨拇指组织缺损的修复方法。方法 利用8具尸体16只手进行解剖学研究，观察了拇指背动脉、第1掌背动脉及食指桡侧指背动脉。临床上分别以拇指背动脉、示指桡侧指背动脉为蒂于手背侧设计岛状皮瓣进行应用。结果 拇指背动脉外径0．24～0．46mm，平均0．37mm，示指桡侧指背动脉0．26～0．56mm，平均0．44mm，血管恒定。临床应用拇指背血管蒂逆行皮瓣、示指桡侧指背血管蒂皮瓣修复拇指组织缺损12例；皮瓣带人桡神经指背支形成有感觉皮瓣，效果更满意。结论 以指背血管为蒂的手背侧皮瓣是修复拇指组织缺损的较为理想方法。     

拇指指腹缺损的显微外科修复

目的 探讨含感觉神经的微型皮瓣修复拇指指腹缺损的临床疗效.方法 2000年2月-2010年3月,采用食指背岛状皮瓣、中指侧方岛状皮瓣、以桡侧指动脉为蒂逆行岛状皮瓣、桡动脉掌浅支为蒂的逆行皮瓣、拇指尺背侧动脉逆行皮瓣、拇指背皮神经营养血管皮瓣、第2趾趾腹皮瓣、？？趾甲皮瓣、大鱼际部浅静脉动脉化逆行皮瓣共9种皮瓣修复重建拇指指腹缺损134例.结果 3例皮瓣坏死,131例成活,6个月～1.5年随访108例,皮瓣外形血供充分,质地柔软,感觉测定S2～S4＋,两点辫别觉6～11mm.结论 采用含感觉神经的微型皮瓣修复拇指指腹缺损,对供区影响小、效果佳、为理想的术式选择.     

急诊修复拇指指腹缺损三种方法的研究

目的 报道采用不同方法急诊修复拇指指腹缺损的疗效。方法 采用示指背侧岛状皮瓣，拇指桡侧指动脉逆行岛状皮瓣转位有趾腹皮瓣游离移植三种方法，为21例线指指腹缺损进行急诊修复。结果 20例以瓣成活，1例失败。术后随访半年－2年，平均10个月。所有皮瓣血运，弹性，质地均良好。指腹二点分辨觉：示指背侧岛状皮瓣平均为92.mm，拇指桡侧动脉逆行岛状皮瓣平均为8mm，趾腹皮瓣平均为5.6mm。结论 急诊修复拇指指腹缺损首选趾腹皮瓣，其次为拇指桡侧指动脉逆行岛状皮瓣或示指背侧岛状皮瓣。     

虎口挛缩的皮瓣修复

目的 介绍虎口挛缩的皮瓣修复体会.方法 回顾1985年以来诊治的112例116个虎口挛缩病例,就其皮瓣修复的手术适应证及预后进行总结分析.结果 术后116个皮瓣完全成活112个,有4例前臂骨间后动脉逆行岛状皮瓣尖端有3.0 cm×1.5 cm表皮坏死,经换药后愈合.有16例皮瓣在术后3～6个月再次行皮瓣整形术.术后随访1～24个月,平均4.5个月.虎口饱满,外形满意,皮色正常,无继发挛缩;拇指对掌、内收、外展功能均近于正常.移位皮瓣在术后3个月开始恢复感觉功能.结论 恰当的皮瓣移植修复可以保证虎口的外形及功能的恢复.     

虎口挛缩的皮瓣修复

目的 介绍虎口挛缩的皮瓣修复体会.方法 回顾1985年以来诊治的112例116个虎口挛缩病例,就其皮瓣修复的手术适应证及预后进行总结分析.结果 术后116个皮瓣完全成活112个,有4例前臂骨间后动脉逆行岛状皮瓣尖端有3.0 cm×1.5 cm表皮坏死,经换药后愈合.有16例皮瓣在术后3～6个月再次行皮瓣整形术.术后随访1～24个月,平均4.5个月.虎口饱满,外形满意,皮色正常,无继发挛缩;拇指对掌、内收、外展功能均近于正常.移位皮瓣在术后3个月开始恢复感觉功能.结论 恰当的皮瓣移植修复可以保证虎口的外形及功能的恢复.     

虎口挛缩的皮瓣修复

目的 介绍虎口挛缩的皮瓣修复体会.方法 回顾1985年以来诊治的112例116个虎口挛缩病例,就其皮瓣修复的手术适应证及预后进行总结分析.结果 术后116个皮瓣完全成活112个,有4例前臂骨间后动脉逆行岛状皮瓣尖端有3.0 cm×1.5 cm表皮坏死,经换药后愈合.有16例皮瓣在术后3～6个月再次行皮瓣整形术.术后随访1～24个月,平均4.5个月.虎口饱满,外形满意,皮色正常,无继发挛缩;拇指对掌、内收、外展功能均近于正常.移位皮瓣在术后3个月开始恢复感觉功能.结论 恰当的皮瓣移植修复可以保证虎口的外形及功能的恢复.     

应用改良的示指近节背侧皮瓣修复轻中度虎口挛缩

目的 介绍改良的示指近节背侧皮瓣在轻中度虎口挛缩治疗中的应用体会.方法 将原来的示指背侧岛状瓣或舌状瓣改成连同虎口一起的示指背侧局部转移皮瓣重建虎口,使皮瓣游离和虎口开大整体进行,简化了手术方法.结果 临床应用111例皮瓣全部成活,术后经3～18个月(平均8.5个月)的随访,局部外形美观,拇指功能恢复良好.虎口开大的优良率为94.6%.结论 改良的示指近节背侧皮瓣转位重建虎口是修复虎口挛缩的有效方法.     

应用改良的示指近节背侧皮瓣修复轻中度虎口挛缩

目的 介绍改良的示指近节背侧皮瓣在轻中度虎口挛缩治疗中的应用体会.方法 将原来的示指背侧岛状瓣或舌状瓣改成连同虎口一起的示指背侧局部转移皮瓣重建虎口,使皮瓣游离和虎口开大整体进行,简化了手术方法.结果 临床应用111例皮瓣全部成活,术后经3～18个月(平均8.5个月)的随访,局部外形美观,拇指功能恢复良好.虎口开大的优良率为94.6%.结论 改良的示指近节背侧皮瓣转位重建虎口是修复虎口挛缩的有效方法.     

应用改良的示指近节背侧皮瓣修复轻中度虎口挛缩

目的 介绍改良的示指近节背侧皮瓣在轻中度虎口挛缩治疗中的应用体会.方法 将原来的示指背侧岛状瓣或舌状瓣改成连同虎口一起的示指背侧局部转移皮瓣重建虎口,使皮瓣游离和虎口开大整体进行,简化了手术方法.结果 临床应用111例皮瓣全部成活,术后经3～18个月(平均8.5个月)的随访,局部外形美观,拇指功能恢复良好.虎口开大的优良率为94.6%.结论 改良的示指近节背侧皮瓣转位重建虎口是修复虎口挛缩的有效方法.     

第一掌背动脉皮瓣修复拇、食指皮肤软组织缺损

目的报道第一掌背动脉皮瓣修复拇、食指皮肤软组织缺损的临床效果。方法2005年8月-2012年10月,采用第一掌背动脉皮瓣修复拇、食指皮肤软组织缺损35例,术后随访3-24个月。结果本组35例皮瓣成活良好,外观满意,两点辨别觉达6-10mm,无虎口挛缩,拇食指的对捏、对掌功能恢复良好。结论第一掌背动脉皮瓣修复拇、食指皮肤软组织缺损操作简单,供血血管变异率低,无需再次手术断蒂,也可制成带血运的掌骨、伸肌腱复合组织瓣,且能携带掌背皮神经重建感觉,值得临床推广。     

Reconstruction of radial half hand by using combined transplantation of pedicled phalanx,free toe,and island flap

Combined transplantation of (1) a residual proximal phalanx flap of the thumb with a fascial pedicle, (2) a reversed island flap based on the posterior interosseous artery, and (3) a free second toe was successfully used to reconstruct the radial half of the hand in a patient who had experienced loss of the second metacarpal bone and index finger, a defect to the shaft of the third metacarpal bone, and dry gangrene of the thumb, two-thirds of the radial dorsal skin and the first web space of the left hand. The reconstructive result was satisfactory and took advantage of each tissue flap. The operation was relatively simple and was completed in one stage. We believe the procedure provided good recovery of function and appearance at an appropriate cost. © 1994 Wiley-Liss, Inc.     

以骨间前动脉背侧支为蒂桡骨皮瓣的临床应用

目的为临床提供一种新的骨皮瓣移位术式。方法１０侧成人上肢标本经肱动脉灌注乳胶后，对其骨间前动脉背侧支的起始部位、口径、长度及其皮支、骨膜支的分布进行显微解剖观察。临床设计以骨间前动脉背侧支为蒂的桡骨皮瓣逆行移位，骨皮瓣中桡骨瓣支撑于第一、二掌骨间或修复掌骨缺损，皮瓣修复虎口、手背尺桡侧的皮肤缺损。结果临床应用６例，皮瓣全部成活。术后随访４～１２个月，受区移植骨已骨性愈合。结论骨间前动脉背侧支为蒂的逆行桡骨皮瓣，适用于修复掌部软组织合并掌骨缺损及重度虎口挛缩的病例。     

Correction of thumb deformities after burn: versatility of first dorsal metacarpal artery flap

In the management of a debilitated burned hand due to contractures, thumb reconstruction constitutes the most crucial part for a beneficial functional outcome. Among the limited local flap alternatives for the thumb, the first dorsal metacarpal artery flap, harvested from the dorsal aspect of the index finger can provide elastic, durable and sensate coverage for soft tissue defects after contracture release. In a 3-year period, neurovascular island first dorsal metacarpal artery flap was used in 14 patients suffering thumb deformities. The time elapsed after the underlying injury until reconstruction ranged from 5 months to 17 years. Follow-up revealed that all deformities were successfully treated with satisfactory functional recovery and cosmetic results. Donor site morbidity was minimal with an acceptable scar on the dorsum of the index finger and adequate tendon gliding without producing extension deficit. Our experience with management of deformities involving the thumb and/or adjacent thenar area revealed that the first dorsal metacarpal artery flap is a reliable local neurovascular island flap option, offering acceptable functional and cosmetic outcomes in respect to sensation, elasticity, durability and skin-match.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.