Clinical experience using the dorsal reverse metacarpal flap for the treatment of congenital syndactyly: report of four cases

Skin grafts and local flaps are conventional methods of repair for simple complete syndactyly, but the results obtained are not always as functional and aesthetic as desired and frequently leave postoperative scars and residual syndactyly. In this article, we describe a new surgical technique for the correction of syndactyly that utilizes a metacarpal dorsal reverse flap to provide skin coverage to the interdigital space and also to 1 side of the finger, therefore avoiding the use of skin grafts and resulting postoperative scar contracture. We report 4 cases using this procedure, with a 12-month follow up. The technique is safe, easily performed, and reproducible and requires a single surgical procedure. It uses donor tissue identical in color, texture, and thickness, which renders acceptable cosmesis and good hand function.     

Distally based venous flap: a new technique for the correction of syndactyly without skin graft in adult patients

Skin grafts and local flaps are conventional methods for repairing simple syndactyly. Skin grafts usually leave unsightly appearance and contracture formation. In this study, unipedicled distally based venous flap were raised from third or fourth metacarpal area of the hand for syndactyly treatment. The distally based venous flap was to provide skin coverage to one side of the finger, in order to avoid complications arising from using skin graft. Nine patients’ syndactylies (5 simple incomplete and 4 simple complete syndactyly) were treated using this method. The mean follow-up period of the flaps was 14 months, ranging from 12 to 16 months. Mild edema and venous congestion occurred in all flaps. Superficial necrosis involving two flaps did not affect flap survival. All flaps survived completely. In this article, we have described a new surgical technique for the correction of syndactyly in a single surgical procedure that utilizes a distally based venous flap to provide skin coverage without skin graft.     

Island flap reconstruction of the web space in congenital incomplete syndactyly

A number of techniques have been described for the correction of incomplete syndactyly, some of which may produce obvious dorsal scarring of the fingers or hand while others rely on the use of skin grafts. Many of the methods require complex planning. We present our experience of a new technique which simplifies the operative planning, allows a natural looking web space to be reconstructed with minimal dorsal scarring and should minimize the need for skin grafts. Seven patients (nine webs) who underwent correction of incomplete syndactyly were reviewed (follow-up range, 6-32 months). Only one patient early on in the series required a small skin graft to cover a residual defect, following which modifications to the flap design were made. All the web spaces healed without complication and at review there were good functional and aesthetic results.     

Dorsal metacarpal island flap in syndactyly treatment

Web space reconstruction is an important component of syndactyly treatment. There are several methods for a skin graft-free reconstruction. Previously, the dorsal metacarpal island flap based on a direct cutaneous branch of the dorsal metacarpal artery has been used as an island V-Y advancement for web defects in syndactyly. In this study, dorsal metacarpal artery flap was raised similarly as an island but was used instead as a transposition flap in a series of 19 web defects. Early results of a median (range) follow-up of 3 (1-5) years reveal neither recurrence of the deformity nor web creeping. Such utilization of the flap enables a better use of the skin territory proximal to the pedicle and a more comfortable reconstruction of the web space.     

指背五边形皮瓣重建先天性并指指蹼

目的 介绍一种并指分指后不需植皮指蹼一期重建的方法.方法 10例先天性并指患儿,在相邻两个并指的近节指背侧设计五边形皮瓣,皮瓣顶角在两指间正常指蹼掌侧缘平面,两个侧角在两指侧背缘正常指蹼背侧缘平面,两个底角在掌指关节背侧中心.并指分指后,用形成的五边形皮瓣一期重建指蹼,共重建17个指蹼.结果 所有指蹼一期获得重建,指蹼区不需植皮,指背创面直接缝合.术后所有皮瓣均存活.随访4～25个月,平均15个月,指蹼外观和功能良好.结论 采用指背五边形皮瓣能够达到一期重建指蹼不需植皮的目的 ,且损伤小,手术简单.对于多指并指患者,可同时重建两个指蹼.     

Contrary intermittent skin release of complete syndactyly without skin graft in adults

INTRODUCTION: There are many different surgical treatment techniques of complete syndactyly. Most of them are techniques involving using skin grafts. We developed a surgical technique that does not require skin grafts, which cause problems in the distal nail border pulp and interdigital web space. MATERIALS AND METHODS: Syndactyly release was performed in 12 web spaces of 11 adult male patients. The average age was 21. In addition to a zig-zag incision, contrary intermittent skin release was performed. Primary coverage of the interdigital web space and nail border pulp was achieved without skin graft. RESULTS: We obtained good results by the contrary intermittent skin release method that we developed, in adult complete syndactyly patients who had no chance for the surgical treatment due to several reasons, previously. CONCLUSION: With such a surgical technique, in our cases we obtained successful results, both cosmetic and functional. The presented technique is an alternative method for syndactyly release without using skin graft in adult patients.     

Long-term results of primary syndactyly correction by the trilobed flap technique.

This paper describes the long term results of a surgical technique used for correction of syndactyly. This technique has been practised by the senior author since 1987 and was published in 1990. The technique involves the use of a dorsal trilobed flap for the reconstruction of the commissure and zig-zag incisions for the fingers. This technique does not require the use of skin grafts. This technique has been used in 62 webs in 44 patients. In this total group, there were 30 patients of primary hand syndactyly with 40 webs. Seventeen patients of primary syndactyly with 25 webs were followed up. The follow-up of these patients ranged from 2 years to 12 years. The long term results reveal a simple, effective technique which does not require the use of skin grafts, and is associated with good functional and far superior cosmetic results.     

Results of surgical treatment in simple syndactily using a commissural dorsal flap. About 54 procedures

OBJECTIVE: The authors evaluate their results of congenital syndactyly correction using a classic commisural dorsal flap technique and full thickness skin grafts to cover the lateral and medial aspect of the fingers. MATERIAL AND METHOD: It is a retrospective study on a homogeneous series of 38 children (54 simple syndactylies) operated over a 10-year period. Twenty-two children were included with a mean follow-up of five years and 10 months. RESULTS: This technique is reliable, reproducible, with a low rate of complications (only four complications requiring reoperation). Long-term outcomes are satisfactory in 92% of cases. CONCLUSION: This is an effective technique, restoring the natural shape of the web space. Procedures without skin-graft are less time-consuming in terms of operational time and cosmetically acceptable, but still need to prove their worth.     

Web space reconstruction with a M-V flap

An operative technique for the construction of a supple and broad commissure in syndactyly and web contracture release is introduced. The technique is based on a M-V flap framework. Sixty-three flaps were done in 33 patients who were followed-up for an average of 19 months. Excellent results were obtained in 90% of the cases. There were no neurologic or vascular complications in any of these cases. The versatility of this method has allowed its use in the majority of our cases that necessitated web release or web space reconstruction.     

Hourglass dorsal metacarpal island flap: a new design for syndactylized web reconstruction

Web space reconstruction is the key point and an important component of syndactyly treatment. A design of the dorsal metacarpal artery flap was used as an island flap based on the direct cutaneous branch arising from the dorsal metacarpal artery at the distal end of the flap to reconstruct congenital web syndactyly. The flap rotated from 0 degrees to 180 degrees and passed under a skin bridge at the distal end of the flap to reach the web defect. Such design enables a better use of the skin territory from the intermetacarpal space proximal to the pedicle, with a short donor site scar and a more supple reconstruction of the web space.     

Dorsal pentagonal island flap: a technique of web reconstruction for syndactyly that facilitates direct closure.

Though many techniques have been described for the correction of syndactyly, current methods result in skin deficiency that requires skin grafting, especially at the finger bases. We discuss the technical aspects and document our experience with the dorsal pentagonal metacarpal island flap for reconstruction of the web commissure in a series of 12 patients (22 webs) with syndactyly of varying complexity. In appropriately selected cases, this technique can improve reconstruction of the web commissure, facilitating direct closure, minimising the need for skin grafts and offers the potential for continued growth. This reduces operative time significantly and simplifies post-operative wound care. In this series, all our cases healed primarily in two to three weeks with minimal donor site morbidity. There were no post-operative complications, although the prominent dorsal scar remains a concern. At an average follow-up of 33.7 months, no cases of contracture or web creep after correction were noted.     

Utility of the "seagull" flap for unoperated simple complete syndactyly in adults

The versatility of the seagull flap for creating a new web in adults' unoperated simple congenital syndactyly is described. The technique can produce a realistic web that does not subsequently advance distally and is wide enough to allow adequate digital separation when fingers are abducted.     

Three-square-flip-flap reconstruction for post burn syndactyly.

INTRODUCTION: Burns of the hands may result in the formation of web space contractures-post burn syndactyly. We present our experience using the three-square technique originally described by Bandoh for minor syndactyly. METHOD: Tissues of the contracted web are regard as forming three facets of a cube. If elevated and transposed 90 degrees on their base the facets will fall into place and line the interior of the cube creating a deepened web-space. The first flap is based on the web itself either dorsally or volarly. The second flap is based distally on one of the fingers. The third flap is based laterally on the other finger. Surgery is followed by a splinting regimen. RESULTS: The design of the flaps is simple and the operation is easy to perform. This technique has achieved good functional and cosmetic results; there have been no flap losses or significant complications. CONCLUSION: The three-square-flip-flap is a simple reliable and safe method for the treatment of post burn syndactyly.     

Dancing girl flap: a new flap suitable for web release

To create a deep web, a flap must be designed to have a high elongation effect in one direction along the mid-lateral line of the finger and also to have a shortening effect in the other direction, crossing at a right angle to the mid-lateral line. The dancing girl flap is a modification of a four-flap Z-plasty with two additional Z-plasties. It has a high elongation effect in one direction (>550%) and a shortening effect in the other direction at a right angle (<33%), creating a deep, U-shaped surface. This new flap can be used to release severe scar contracture with a web, and is most suitable for incomplete syndactyly with webs as high as the proximal interphalangeal joint.     

掌背侧菱形推进皮瓣在先天性并指治疗中的应用

目的 报告应用掌背侧菱形推进皮瓣重建指蹼治疗先天性并指畸形的疗效.方法 对5例先天性并指畸形患儿,分指后在患指掌背侧掌骨头间设计并切取掌背侧菱形推进皮瓣以重建指蹼.术后评价指标包括:手指功能情况,指蹼形态学观察和患儿家长的满意度.结果 皮瓣切取面积最大为2.0cm×0.9cm,最小1.5cm×0.6cm.术后所有皮瓣愈合良好,未出现淤血、边缘坏死等现象.术后随访时间为6～12个月,平均8.5个月,患指屈伸功能良好,重建指蹼深度、宽度合适,并形成较好的指蹼坡度,患儿家长对指蹼形态及术后手指功能均感满意.结论 在治疗先天性皮肤性并指分指术中,应用背侧菱形推进皮瓣重建指蹼,术式简单,外形美观,是一种理想的方法.     

手先天性并指畸形的治疗

目的 介绍手先天性并指畸形的治疗。方法 42例先天性并指畸形患者中，2指并指36例，多指并指6例；软组织并指30例，远节指骨骨性并指12例。均采用并指间背侧矩形皮瓣形成指蹼，指间掌背侧锯齿状皮瓣进行分指。皮瓣移位后指部外露创面用游离植皮覆盖，指端骨外露者用局部皮瓣覆盖。结果 3例的游离植皮部分坏死，创面经换药后愈合；39例的创面均I期愈合。术后1年12例失访，30例的指蹼坡度良好，指尖部软组织饱满，手术指的外展良好。12例术毕因指间关节侧弯，术后用支架纠正畸形，效果满意。结论 并指畸形的治疗关键是指蹼的形成，指间关节侧弯术后使用支架纠正为一良好的方法。     

V-Y and rectangular flap combination for syndactyly repair

Objective: For syndactyly repair, several delicate, well-planned flap combination techniques have been reported. This study presents technique details with functional and aesthetic results of a dorsal rectangular and volar V-Y advancement flap combination for web reconstruction and S incisions for finger separation in patients with syndactyly.

Method: Ten patients with 16 syndactyly webs were treated. Patients were examined in terms of function and aesthetic. Evaluation criteria included the Vancouver Scar Scale, range of motion, degree of web creeping, parent’s satisfaction rates, and finger abduction. During the initial period, vascular compromise of fingers, haematoma, infection, seroma, flap necrosis, or graft failures were not noted in any patients. No patients required revision surgery. During the later period, parent satisfaction scores were excellent or good, finger function was complete, and the Vancouver Scar Scale showed that two webs had hyperpigmented areas and two had supple pliability.

Conclusion: This simple syndactyly release technique can provide a low rate of web creep, good scar quality, and optimal functional results.     

Reconstruction of Syndactyly and Polysyndactyly of the Toes With a Dorsal Pentagonal Island Flap: A Technique That Allows Primary Skin Closure Without the Use of Skin Grafting

Syndactyly and polysyndactyly are common congenital conditions involving the foot, and surgery to reconstruct the toes may be indicated for cosmetic, psychological, and practical reasons. A dorsal flap is traditionally used for web space reconstruction, with skin grafts for the bases of the toes. Skin grafting has associated morbidity and can result in pigmentation mismatch. Single-stage direct closure with a specially designed flap has advantages including a reduction of morbidity from avoidance of skin grafting and shorter surgery. Four patients (6 feet) were included in the study. There were 2 cases of syndactyly and 2 cases of polysyndactyly. Bilateral involvement occurred in 2 patients. The average age was 18 months at time of first surgery. Direct closure was achieved with a dorsal pentagonal island flap with dorsal and plantar triangular flaps. The average duration of follow-up was 19.8 months. At final follow-up, all patients had acceptable web depth and pulp contour. The distance between the proximal interphalangeal joints of adjacent toes and the web slope of the reconstructed web space were acceptable. Complications included partial synechiae, cellulitis, and keloid formation. The dorsal pentagonal island flap is an acceptable technique in providing another means for single-stage reconstruction of the web space in syndactyly and polysyndactyly. Good functional and cosmetic outcomes can be expected. However, the potential complication of keloid formation can affect cosmesis and overall outcome, and must be understood by patients and parents.     

Open treatment of syndactyly of the foot.

The aim of reconstruction of the webs for syndactyly of the foot is cosmetic improvement, so skin grafting should be avoided. We present our long-term results of 19 feet with simple cutaneous syndactyly in 15 patients who were treated by an open technique. The bottom of the web was covered with a dorsal rectangular flap and the remaining skin defect was left open to epithelialise spontaneously. This took about 4 weeks. After a mean follow-up of 5.7 years (range 3-9), no hypertrophic scar or pigmentation of the skin had developed. Creeping of the web was seen only during the first postoperative year. The final depth of the web satisfied the families of all patients. As the aim of web reconstruction for syndactyly of the foot is purely cosmetic, we conclude that this simple method is reasonable treatment.     

OPEN TREATMENT OF SYNDACTYLY OF THE FOOT

The aim of reconstruction of the webs for syndactyly of the foot is cosmetic improvement, so skin grafting should be avoided. We present our long-term results of 19 feet with simple cutaneous syndactyly in 15 patients who were treated by an open technique. The bottom of the web was covered with a dorsal rectangular flap and the remaining skin defect was left open to epithelialise spontaneously. This took about 4 weeks. After a mean follow-up of 5.7 years (range 3-9), no hypertrophic scar or pigmentation of the skin had developed. Creeping of the web was seen only during the first postoperative year. The final depth of the web satisfied the families of all patients. As the aim of web reconstruction for syndactyly of the foot is purely cosmetic, we conclude that this simple method is reasonable treatment.