Reconstruction of a fingertip with a thenar perforator island flap

Abstract

We raised thenar island flaps that were supplied by perforators that originated in the superficial palmar arch or the superficial palmar branch of the radial artery for the reconstruction of fingertip defects in eight patients. The flap was so well-vascularised that a large flap with increased mobility could be raised. The donor site was covered with well-vascularised thick tissue, and skin grafting of the donor site was avoided in all cases. No patient developed a complication, and all flaps survived. Functional and cosmetic results of both fingertips and donor sites were excellent. A perforator island flap from the thenar eminence can be raised easily without injuring any digital and palmar arteries. They have a good colour and texture that matches the fingertips and donor site defects on the palm.     

Reverse-flow island flap from the thenar area of the hand

A reverse-flow island flap from the thenar eminence of the hand was applied in six patients to treat palmar skin defects, and amputation injuries of the thumb. There was one female and five males, and the patients' ages at the time of surgery averaged 48 years. A 3 x 2 to 5 x 3.5-cm fasciocutaneous flap from the radial aspect of the thenar eminence, located over the abductor pollicis brevis muscle, was designed and transferred in a retrograde fashion, to cover skin and soft-tissue defects of the thumb. The flap was based on the superficial palmar branch of the radial artery and, in three patients, was made sensate by the palmar branch of the superficial radial nerve. Follow-up periods averaged 61 months. The postoperative course was uneventful, and all the flaps survived without significant complications. The donor site was primarily closed in five patients, and one patient required flap coverage. A reverse island flap from the thenar area is easily elevated, contains durable fasciocutaneous structures, and has good color and texture, matching to the finger pulp. This flap offers a good alternative for reconstruction of palmar skin and soft-tissue defects of the thumb in selected patients.     

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.     

六种皮瓣修复拇指腹缺损的远期疗效观察

目的评价6种皮瓣修复拇指腹缺损的远期疗效.方法对2001年12月前,在我科接受6种皮瓣修复拇指腹缺损（锁骨下带蒂皮瓣、手指掌侧推进皮瓣、示指背侧皮瓣、带血管神经蒂的大鱼际近端皮瓣及趾腹游离皮瓣）共142例患者,进行了远期随访.随访内容有术后拇指腹色泽、外形、质地、出汗情况、拇指的痛觉、触觉、两点分辨觉、综合质地感觉及运动功能等.结果142例均获得了完整资料.6种皮瓣中,其中锁骨下带蒂皮瓣与示指背侧皮瓣修复的拇指腹,从皮肤色泽、外形、质地、出汗情况等均比其它4种皮瓣差,综合质地感觉优良率也明显低于其它4种皮瓣.结论手指掌侧推进皮瓣、指侧方血管蒂岛状皮瓣、带血管神经蒂的大鱼际近端皮瓣及趾腹游离皮瓣修复拇指腹缺损远期临床效果良好,但指侧方血管蒂岛状皮瓣对手部创伤较大,影响患手美观及供区手指的感觉.     

Histological investigation of common insensate flaps obtained from the hand and forearm regions for use in fingertip reconstruction

Objective: Many skin flaps have been described for fingertip reconstruction; however, they have not been compared histologically. The aim of this study is to compare the histological features of common insensate flaps that are used for fingertip reconstruction.

Method: Skin from fingertips and common flap donor sites on the hand and forearm of cadavers were harvested. This study investigated four histological characteristics, namely thickness of the epidermis and dermis; the ratio of collagen to elastic fibres (C/E ratio) in subdermal tissues, and distribution densities of Merkel cells and Meissner’s corpuscles. It then compared the values obtained to determine which flap donor site best matched the fingertip.

Results: Epidermal thickness of the reverse digital artery island flap, thenar flap, and hypothenar flap was similar to that of fingertip tissue; dermal thickness of the hypothenar flap was similar to that of fingertip tissue. The C/E ratio of the reverse digital artery island flap was similar to that of fingertip tissue. Merkel cells were abundant in the reverse digital artery island flap, but Meissner’s corpuscles were few in each of the flaps compared with fingertip tissue.

Conclusion: The flap donor site with histological properties most similar to fingertip tissue was the palmar lateral aspect at the finger base, representative of the reverse digital artery island flap with respect to epidermal thickness, C/E ratio, and presence of Merkel cells. The thenar and hypothenar flaps also showed similar properties.     

Fingertip reconstruction with flaps and nail bed grafts

We retrospectively reviewed the cases of 14 fingertips reconstructed with a combination of local or regional flaps and nail bed grafts, some of which were placed wholly or partially over a de-epithelialized flap. Most of the fingertips sustained a crushing injury and were reconstructed at the time of the injury. Soft tissue coverage was provided by palmar V-Y flaps in 6 cases, thenar flaps in 4, lateral V-Y flaps in 2, a Moberg flap in 1, and a cross-finger flap in 1. Split toenail bed grafts were used in 6 cases, full-thickness nail bed grafts from the amputated part in 6, and split nail bed grafts from the injured digit in 2. There was 1 partial graft loss and 1 partial flap loss. The remaining cases had completely successful grafts and good soft tissue healing. Subsequent nail growth and adherence were good in all but the 1 digit requiring secondary composite grafting.     

Propeller flaps for leg reconstruction.

Leg soft tissue defects with bone or tendon exposure need to be covered with a flap. Various local and free flaps with more or less consistent donor site defects have been described in the past. After the introduction of the perforator-based flap concept, new flaps have also been described for the leg. An evolution and simplification of the perforator flap concept, together with the 'free style' flap harvesting method, are the propeller flaps, i.e. local flaps, based on a perforator vessel, which becomes the pivot point for the skin island that can, therefore, be rotated up to 180 degrees . In this prospective study, six consecutive patients, having post-traumatic soft tissue defects of the leg or knee prosthesis infection, with bone or tendon exposure, were treated with propeller flaps. Complete and stable coverage of the soft tissue losses was obtained in all cases with an inconspicuous, only cosmetic, donor site defect. No flap necrosis was observed, with the exception of a small superficial necrosis of the tip of one flap, due to the inclusion in the design of scarred tissue. In two cases, transient venous congestion was observed and resolved spontaneously. Mean operative time was 2 h (ranging from 60 min to 6 h when an orthopaedic procedure was also needed) and mean hospital stay after surgery was 10 days. Propeller flaps allow the coverage of wide defects, can be raised with a relatively simple surgical technique, have a high success rate and good cosmetic results without functional impairment. In the light of this they can be considered among the first surgical choices to resurface complex soft tissue defects of the leg.     

跖内侧皮瓣联合肋骨移植修复多手指末节骨与软组织缺损

目的 总结跖内侧皮瓣联合肋骨移植修复多手指末节掌侧骨与软组织缺损的临床应用结果. 方法 2004年2月至2006年7月,应用吻合血管的跖内侧皮瓣联合肋骨移植修复5例(男4例,女1例)手指末节掌侧骨与软组织缺损,年龄19～43岁(平均31岁).其中,双指损伤3例,3指损伤2例.皮瓣血管蒂与受区的血管行端端吻合,供区创面行中厚网状游离植皮修复. 结果 1例术后供区发生表浅感染,经更换敷料逐渐自行愈合.皮瓣全部成活,随访10～28个月(平均19个月),供区与受区外形较好,手指感觉恢复.两点分辨觉5～14 mm(平均8 mm).结论 跖内侧皮瓣以跖内侧动脉为血供,血运丰富、血管解剖恒定、血管蒂长以及切取容易,联合肋骨移植很适宜修复多手指末节掌侧骨与软组织缺损.     

The ad hoc perforator flap for contracture release.

Release and autografting remains a mainstay of treatment of cutaneous and joint-associated contractures. However, owing to secondary contraction of grafts and the increase of children undergoing burn reconstructive surgery, recurrence of contractures is not uncommon. Locally available, well-vascularised tissue that will contract minimally and grow with the patient is the ideal for contracture release. Many 'predesigned' cutaneous flaps have been described, but use of these may involve tailoring a defect to fit a known flap. We introduce the concept of the 'ad hoc' perforator flap, an improvised island flap based on a perforator, innominate or otherwise, that happens to be adjacent to a particular soft-tissue defect and can be reliably raised on scarred skin. We carried out a retrospective analysis of all patients undergoing contracture release within our unit. Twenty-three ad-hoc perforator flaps in 20 patients were carried out between 2000 and 2005. Eleven of the 20 patients were children, and all but one case was subsequent to a burn injury. Fifteen of the 23 flaps were upper limb. In one case, a significant complication involving total flap loss occurred. Only one patient required a skin graft to close the flap donor site, and no patients required revisional surgery for contracture recurrence. The ad hoc perforator flap is a safe and simple technique for the management of contractures, and fulfils the ideal of well-vascularised tissue that can grow with the patient. The flap can be designed as required and, with experience, the concept is applicable not only to contracture release, but many other reconstructive scenarios.     

带指掌侧静脉的指动脉逆行岛状皮瓣的临床应用

介绍一种新的指动脉逆行岛状皮瓣。１９９３年１０月～１９９６年１２月，采用指动脉逆行岛状皮瓣修复１３例１７指皮肤缺损，并对皮瓣带或不带指掌侧静脉进行了对比性研究。结果表明，本组１７块皮瓣均成活。在术后早期并发症中，不带指掌侧静脉皮瓣的静脉危象发生率为８７．５％（７／８），带指掌侧静脉的皮瓣仅为１１．１％（１／９）。认为，带指掌侧静脉的指动脉逆行岛状皮瓣，可明显减少该皮瓣静脉危象的发生，提高皮瓣成活率     

微型外固定架联合吻合神经的交指皮瓣在修复手指末节掌侧软组织缺损的应用

目的评价微型外固定架联合吻合神经的交指皮瓣修复手指末节掌侧软组织缺损的方法和疗效。方法采用吻合指固有神经背侧支的交指皮瓣修复手指末节掌侧软组织缺损，同时应用微型外固定架（HoffmannlI型）固定伤指及供指，共计15例。供区行患肢上臂内侧的全厚皮片游离植皮覆盖。术后次日进行伤指、供指主动及被动功能锻炼。术后3～4周断蒂。断蒂后第14天记录伤指及供指主动关节活动度（totalactivemotion，TAM法）。结果术后所有皮瓣及供皮区植皮均存活，创面I期愈合。断蒂后第14天，记录伤指及供指主动关节活动度，并用TAM法评价，优21指，良9指，优良率100％。所有患者获得随访6—24个月，平均13个月。伤指皮瓣区指腹饱满，色泽正常，质地柔韧，外观满意，无疼痛。供指植皮区有6例发生色素沉着。两点辨别觉为5．2～9．8mm，平均为6．4mm。结论带神经的交指皮瓣修复手指末节指腹软组织缺损不仅能修复缺损的外形，而且有利于皮肤感觉的恢复；运用微型外固定架固定交指皮瓣有利于术后的护理及手部关节功能的早期恢复。     

反流轴型耳后岛状皮瓣修复鼻尖缺损

目的:探讨应用颞浅动脉供血的反流轴型耳后岛状皮瓣转移修复鼻尖缺损的手术方法,以提高鼻缺损畸形的美学修复效果。方法:自1997年3月以来,设计以颞浅动脉供血的耳后岛状皮瓣,经鼻面部皮下隧道转移至鼻尖,对11例鼻尖缺损畸形行鼻尖再造。结果:10例皮瓣色泽、质地和形态良好。1例皮瓣远端坏死,经局部皮瓣转移修复。结论:反流轴型耳后岛状皮瓣修复鼻尖缺损,色泽形态良好,供区皮瓣组织量充足且隐蔽,是修复鼻尖缺损的好方法。     

岛状皮瓣一期修复眼睑分裂痣的设计与技巧

目的 探讨应用邻位及远位岛状皮瓣一期修复眼睑分裂痣的设计与技巧.方法 切除眼睑分裂痣上、下睑病变后,根据缺损的部位、形态及面积,选择应用眼轮匝肌蒂岛状皮瓣、耳后SMAS蒂岛状皮瓣或逆行颞浅动脉岛状皮瓣一期修复上、下睑皮肤缺损,供区均直接缝合.结果 2003年以来,共收治患者16例,其中应用眼轮匝肌肌皮瓣10例,耳后SMAS筋膜蒂皮瓣3例及逆行颞浅动脉岛状皮瓣3例.切除痣体的最大面积上睑为2.5 cm ×2.0 cm,下睑为4.0 cm×3.0 cm.1例耳后SMAS筋膜蒂皮瓣及1例逆行颞浅动脉岛状皮瓣术后出现皮瓣远端静脉回流障碍、部分表皮坏死,经换药后自行愈合,其余14例皮瓣全部成活良好.结论 根据病变的部位、形态和面积等选择合适的邻位或远位岛状皮瓣修复眼睑分裂痣切除术后皮肤缺损,效果满意,且供区隐蔽、无继发畸形.     

顺行指动脉岛状皮瓣治疗掌筋膜挛缩

目的总结顺行指动脉岛状皮瓣治疗掌筋膜挛缩的临床应用结果。方法 2004年9月至2010年1月,应用顺行指动脉岛状皮瓣治疗掌筋膜挛缩8例。切除病变筋膜组织后,手掌软组织缺损用顺行指动脉岛状皮瓣修复,手指供区缺损由手掌的全厚皮片游离移植修复。结果本组皮瓣全部成活,1例皮瓣术后远端发生小面积表浅感染,经换药后愈合。随访1～5.6年(平均3.6年),本组患者中未发现明显的供区功能障碍,供区与受区外形和功能恢复较好。结论顺行指动脉岛状皮瓣成活率高、安全有效,是治疗掌筋膜挛缩的较好方法。     

Waveform-arranged multiple skin paddles: A novel design to reconstruct complex soft tissue defects of the extremities with a modified multi-lobed perforator flap

BackgroundMulti-lobed perforator flap was one of popular approaches for one-stage reconstruction of complex soft tissue defects because of its minimal donor-site morbidity. However, the area of skin island that can be harvested on the donor site is limited on the angiosome distribution, Moreover, large defects require more than the conventional skin island provided by a traditional multi-lobed perforator flap. For further extended skin paddles, this study presented a novel design of waveform-arranged skin paddles to elevated a modified multi-lobed perforator flap for the reconstruction of complex soft tissue defects in the extremities.MethodsFrom March of 2015 to March of 2020, fifteen patients underwent complex soft tissue defects reconstruction with waveform-arranged multi-lobed perforator flaps. According the size, shape and localization of the defects, two strategies were performed to design this modified multi-lobed flap.ResultsA total of fifteen waveform-arranged multi-lobed perforator flaps were successfully harvested to reconstruct complex soft tissue defects of the extremities. Among of them, Waveform–arranged dual skin paddles perforator flap were performed in eleven cases, and the waveform–arranged tripaddle perforator flaps were used in four cases. All the flaps survived and no flap related complication was observed postoperatively. The donor sites were closed directly in all cases. The mean follow-up time was 15.6 months. Most of the cases showed satisfactory contour.ConclusionThe waveform design of multi-lobed perforator flap was an alternative approach for reconstruction of complex soft tissue defects; it can maximize the harvested skin area of the donor site to provide extended skin island.     

Reliability of island flaps raised after superficial and deep burn injury

In select cases, to prevent any functional loss and to initiate early function during the early burn period, the reconstructive procedure of choice may be flap coverage. In these circumstances, when the ideal flap donor site is burned, the clinician may be hesitant to raise this flap because of questionable flap survival. The authors conducted this study to determine whether a superficially or deeply burned skin island flap would survive when elevated during the early postburn period. If these flaps are usable, they could expand the options available for burn wound coverage. They used a rat epigastric island flap model, and divided 50 study animals into two groups. In group 1 (N = 25), the right epigastric flap site was burned superficially and the left side was left uninjured. Island flaps were raised on both sides 4 days after the burn injury. The flaps were then sutured back into their original sites, and were evaluated 5 days after the surgery. In group 2 (N = 25), the right epigastric flap site was burned deeply and the left side was left uninjured. Island flaps were raised 4 days after the burn injury on both sides, as in group 1. The flaps were then sutured back into place and were evaluated 5 days after the surgery. All of the control flaps on the rats' left sides survived in both groups. In addition, all the superficially burned flaps survived in group 1 (100%), and 21 of the deeply burned flaps survived in group 2 (84%). There was no significant difference between superficially and deeply burned flaps with regard to survival, and the burned flaps were as successful as the unburned control flaps in both groups (p = 0.11). Skin island flaps elevated after superficial or deep burn injury are reliable in this animal model.     

Internal mammary artery perforator flap for reconstruction of the chest wall

Abstract

We used internal mammary artery perforator (IMAP) flaps from the opposite side for reconstruction of small-to-medium-sized defects in the chest wall. The IMAP flaps were used in two patients who had unhealed, localised ulcers of the chest wall with exposure of the ribs after radical mastectomy. The lesion was excised widely, and the flap, based on a perforator vessel in the second or third intercostal space of the opposite chest wall, was raised. The flap was rotated from 90° to 180° along the vascular axis to the chest wall defect. The donor site was closed primarily. Both flaps showed stable postoperative circulation and survived completely. Defects of the chest wall could be covered with healthy, well-vascularised tissue on one perforator without deep infection. The IMAP flap is a reliable and less invasive option to be considered for medial, localised, reconstruction of the chest wall.     

大鱼际远近端逆行岛状皮瓣修复拇指软组织缺损的临床应用

目的总结大鱼际远、近端逆行岛状皮瓣在修复拇指软组织缺损中的临床应用。方法根据拇指掌、背侧软组织缺损的不同部位,采用大鱼际逆行远端岛状皮瓣修复17例,大鱼际逆行近端岛状皮瓣修复5例。结果术后22例皮瓣全部存活,供、受区伤口均Ⅰ期愈合。术后20例获得9～18个月的随访,2例失访。皮瓣弹性、色泽良好,两点分辨觉为7～10mm。拇指功能恢复优16例,良3例,中1例,优良率达95％。供区大鱼际处留有瘢痕,拇对掌功能无影响。结论大鱼际远、近端逆行岛状皮瓣可满足拇指大部分软组织缺损的修复需要。     

桡动脉浅支皮瓣修复手指皮肤缺损

目的：探讨应用桡动脉浅支皮瓣修复手指皮肤缺损的方法及临床疗效。方法2008年8月-2012年1月,采用游离桡动脉浅支皮瓣修复手部皮肤缺损伴骨或肌腱外露30例,以桡动脉浅支走行于腕掌侧设计皮瓣,其中20例于皮瓣近端切取正中神经掌皮支重建感觉。皮肤缺损范围为1.5 cm×2.5 cm～2.0 cm×3.5 cm。结果本组30例皮瓣全部成活,未发生血管危象。术后随访6～12个月,皮瓣质地血运良好,外形满意,两点辨别觉为5～7 mm,供区无并发症。结论游离桡动脉浅支皮瓣切取方便,供区损伤小,是修复手指皮肤缺损较为理想的方法。     

应用数字减影血管造影术指导皮瓣选择修复严重手外伤创面

目的本文探讨数字减影血管造影术(Digital subtraction angiography,DSA)在严重手外伤治疗中,对皮瓣选择的指导作用。方法回顾性分析我科治疗的6例手外伤患者,创面均有肌腱和(或)骨外露,所有患者均行DSA检查,明确前臂和手的血供情况,包括桡动脉、尺动脉的走行及其穿支动脉、掌深弓掌浅弓的存在与否等。根据造影结果,综合评价血管损伤情况和邻近的软组织条件,并据此选择逆行前臂岛状皮瓣或远位游离皮瓣修复创面。结果 4例患者前臂及手掌部主干血管无损伤,选择逆行前臂轴型皮瓣修复。2例患者因前臂桡动脉断裂、掌深弓掌浅弓完整性缺失而选择游离轴型皮瓣修复创面,术后皮瓣均存活。结论 DSA造影可以清晰显示患侧前臂和手的血管网,发现可能存在的血管损伤,能有效地指导皮瓣的选择,提高皮瓣选择的合理性和皮瓣移植的成功率。