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.     

Reverse-flow first dorsal metacarpal artery flap for index fingertip reconstruction

Dorsum of the hand is an ideal skin-flap donor site for coverage of hand or finger defects. We elevated 8 reverse-flow first dorsal metacarpal artery flap in 9 patients for soft-tissue cover of index fingertip injuries distal to distal interphalangeal joint with exposed bone. In 3 patients, the digital branch of the superficial radial nerve was coapted to the digital nerve. All flaps healed uneventfully, except for 1 patient in which partial necrosis of the flap occurred. Postoperative follow-up was 4-12 months (mean, 8 months). Reverse-flow first dorsal metacarpal artery flap is a good alternative for reconstruction of index fingertip injuries.     

The first dorsal metacarpal artery neurovascular island flap

A first dorsal metacarpal artery island flap from the index finger was used in 20 cases for reconstruction of defects in the hand. In six cases it was used as a neurovascular flap for sensory resurfacing of the thumb and in five cases for release of a contracted first web. One flap underwent necrosis and there was a complication in one donor site.     

The second dorsal metacarpal artery neurovascular island flap

Eleven patients have had second dorsal metacarpal sensate island flaps used to cover local skin defects in the hand. The arterial supply is reliable but if the flap is extended beyond the proximal interphalangeal joint, distal flap necrosis or donor site difficulties may occur. Possible applications for this flap are demonstrated and some untried variations to increase its range are suggested. Its main use appears to be in the release of first web contractures and for resurfacing radio-palmar and thumb defects.     

Stepladder dorsal metacarpal flaps for dorsal finger and hand reconstruction.

The authors demonstrate successful cases of stepladder dorsal metacarpal V-Y advancement and rotation-advancement flaps for reconstructing defects on the dorsum of the finger and hand. One side of the flap is designed in a multilobed shape, and each lobed flap is designed on the dorsum of adjacent fingers. These flaps are supplied by dorsal metacarpal vessels. Consequently, this method has the elements of the stepped incision technique, in combination with the V-Y and rotation-advancement principle. All flaps survived completely. This technique may be a useful option for reconstruction of defects of the dorsum of the finger and hand.     

Combined first dorsal metacarpal artery flap and dorsal transposition flap for correction of extensive first web space contracture: a case report and literature review

First web space contracture is a common sequela after hand trauma and exerts tremendously negative effects on hand function. To restore hand function, it is mandatory to release contracted first web structures, which usually results in a large skin defect. Dorsal transposition flaps sometimes are not sufficient to cover the whole defect. Microvascular flaps provide abundant soft tissue, but they are lengthy procedures and exhibit risks of complete flap failure. In this study, we present an alternative approach to address this difficult clinical problem. A 25-year-old man developed extensive contracture over the first web space after trauma. After release of the contracted structures, the extensive skin defect was covered by a dorsal transposition flap with an extension to the territory of the first dorsal metacarpal artery flap. The functional and cosmetic results were excellent, without recurrence of contracture postoperatively. The combined first dorsal metacarpal artery flap and dorsal transposition flap appeared to be an effective and relatively simple method for the reconstruction of severe first web space contracture.     

拇指桡侧血管筋膜蒂第Ⅰ掌骨侧皮瓣的临床应用

目的 探讨以拇指桡侧血管筋膜为蒂的第１掌骨背侧皮瓣修复手指软组织缺损的临床效果。方法 设计以线指桡掌侧动脉掌指关节周围分支为主要血供来源,经拇指背静脉通过头静脉及拇指深静脉为主要回流途径的血管筋膜常皮瓣,逆行移位或带蒂移位修复拇、示、中、环指软组织抽损创面１４例。结果 １例皮瓣部分远端坏死,２例早期皮瓣呈红紫色并水泡,其余成活良好。术后随访３个月至１年,皮瓣质地良好,不臃肿,有感觉。结论 该皮瓣血     

第1掌背动脉皮瓣一期修复儿童拇指软组织缺损

目的探讨第1掌背动脉皮瓣一期顺行修复儿童拇指软组织缺损的临床效果。方法选取自2009-06—2012—06收治的拇指皮肤组织缺损息儿11例,行急诊清创、残端修整及伴肌腱断裂的修补,骨折患者给予克氏针内固定,11例均予一期第1掌背动脉皮瓣修复拇指组织缺损。结果术后组织瓣全部成活,供区、受区伤口均一期愈合,质地与色泽较好。随访时间为3。24个月,平均10个月,无继发性感染发生,感觉恢复S3一S4,肢体外形与功能满意。结论儿童拇指软组织缺损应用第1掌背动脉皮瓣移植修复、重建软组织,可以避免儿童患拇指功能障碍。采用该皮瓣技术血供可靠、操作简单,是一期修复儿童拇指皮肤缺损理想的治疗方法。     

第1掌骨背桡侧动脉蒂岛状皮瓣的临床应用

目的探讨第1掌骨背桡侧动脉岛状皮瓣在拇指远端软组织缺损修复中的临床应用。方法应用第1掌骨背桡侧动脉岛状皮瓣修复拇指远端软组织缺损20例。结果本组20例皮瓣全部成活．术后随访3-12个月,拇指外形满意,质地柔软,皮神经修复者两点辨别觉8～12mm。结论第1掌骨背桡侧动脉岛状皮瓣具有操作简便、质地良好、血供可靠、损伤小等优点,是修复拇指远端软组织缺损的较好方法。     

The reverse dorsal metacarpal flap

The dorsal metacarpal vessels contribute to the fascial plexus which supplies the skin of the dorsum of the hand. We have successfully used eight reverse dorsal metacarpal flaps based on the dorsal metacarpal arteries. The design and use of the reverse dorsal metacarpal flap is described; it appears to have a reliable vascular basis and its usefulness in covering small soft tissue defects in the hand is illustrated.     

An alternative approach in the treatment of Dupuytren's contracture skin defects: first dorsal metacarpal artery island flap

Skin defects are often present following surgery for Dupuytren's contracture. The first dorsal metacarpal artery island flap (FDMA) has been used by others for soft tissue reconstruction about the radial and dorsal aspect of the hand, thumb and fingers. We have used it successfully to fill the skin defects often seen following palmar fasciectomy for Dupuytren's contracture. The thin nature of the flap makes it suitable for this application. The FDMA arises from the radial artery just before the radial artery enters the first dorsal interosseous muscle and divides into three branches: 1 to the thumb, 1 to the index finger (radiodorsal branch) and a muscular branch. It is the radiodorsal branch that supplies the skin over the index finger. The island flap based on this artery includes the dorsal terminal branches of the radial nerve and venae comitantes. The flap is formed to include the fascia of the first dorsal interosseous muscle to avoid injury to a possible deep artery and to yield sufficient fat to promote venous drainage. The flap is passed subcutaneously through the first web space and sutured in place to cover the skin defect in the palm. A full thickness skin graft is used to cover the defect over the proximal phalanx of the index finger.     

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.     

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.     

The reverse dorsal metacarpal flap from the first web

Summary Experience with the distally pedicled first dorsal metacarpal flap is presented. The anatomical basis of the flap is discussed, and four examples are presented from a group of ten cases. In this series, all flaps were successful. The possibility of using a second web reverse dorsal metacarpal flap and venous reverse flap of the dorsal part of the hand is also discussed.     

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。     

The compound dorsal metacarpal artery tendofasciocutaneous flap: an attractive reconstructive tool for complex digital defects

Different modifications of flaps based on the dorsal metacarpal arterial system have been reported as reliable tools for reconstruction of dorsal and palmar phalangeal soft tissue defects. For simultaneous reconstruction of the extensor aponeurosis and joint in complex injuries of the dorsal index, we used a distally based pedicled fasciotendocutaneus second dorsal metacarpal flap, including the complete vascularized extensor indicis tendon in 2 cases. Clinical results of this procedure have not been reported so far.     

改良第四掌背动脉逆行岛状皮瓣的临床应用

目的：探讨用改良的第四掌背动脉逆行岛状皮瓣修复手指软组织缺损的临床效果。方法：对16例新鲜肢体作血管灌注造影,发现掌背动脉指背支与指动脉背侧支在近节指背中段相吻合。设计以指固有动脉背侧支为蒂的第四掌背动脉逆行岛状皮瓣修复环,小指软组织缺损13例。供区均直接缝合。结果：13例皮瓣全部成活。术后随访3个月至1年,皮瓣质地;厚度良好。结论：该皮瓣血供可靠,切取方便,旋转弧度较长,适用于修复环、小指末节软组织缺损。     

Free neurovascular flap from the first web of the foot in hand reconstruction.

To identify an anatomically reliable and functionally acceptable neurovascular free flap for use in hand reconstruction, 50 fresh cadaver feet were dissected under the operating microscope, with particular attention paid to the anatomy of the first web area. A distal communicating artery was seen in 100% of dissections, allowing either dorsal or plantar donor artery inflow to nourish the entire flap area. Because of the ease of dissection, the first dorsal metatarsal or dorsalis pedis is suggested as the donor artery, and a dorsal branch of the greater saphenous venous system is suggested as the donor vein. The deep peroneal nerve was seen to consistently innervate the first web and, along with the plantar digital nerves, is suggested as an anatomically identifiable donor nerve. Either part of the foot first web may be used alone or together as a free flap. When indicated further dorsal skin may be incorporated into the web flap to expand its application. Two-point discrimination studies of the lateral plantar surface of the great toe in 50 normal individuals showed an average of 11.2 mm. This was significantly better as a potential donor flap than the medial dorsum of the foot where the average was 32 mm. A single case demonstrating the application of this flap in hand reconstruction is presented.     

Clinical study of dorsal ulnar artery flap in hand reconstruction

Soft tissue defects of hand with exposed tendons, joints, nerves and bone represent a challenge to plastic surgeons. Such defects necessitate early flap coverage to protect underlying vital structures, preserve hand functions and to allow for early rehabilitation. Becker and Gilbert described flap based on the dorsal branch of the ulnar artery for defects around the wrist. We evaluated the use of a dorsal ulnar artery island flap in patients with soft tissue defects of hand. Twelve patients of soft tissue defects of hand underwent dorsal ulnar artery island flap between August 2006 and May 2008. In 10 male and 2 female patients this flap was used to reconstruct defects of the palm, dorsum of hand and first web space. Ten flaps survived completely. Marginal necrosis occurred in two flaps. In one patient suturing was required after debridement and in other patient wound healed by secondary intention. The final outcome was satisfactory. Donor areas which were skin grafted, healed with acceptable cosmetic results. The dorsal ulnar artery island flap is convenient, reliable, and easy to manage and is a single-stage technique for reconstructing soft tissue defects of the palm, dorsum of hand and first web space. Donor site morbidity is minimal, either closed primarily or covered with split thickness skin graft.     

Injuries of the first web. Surgical indications

Treatment of the first web injuries are based on the concept of one stage repair of the complex injuries of the hand with early motion. Radical debridement is specially important in case of muscular attrition. Fasciotomie of the first web is systematic in case of crush injuries for avoiding compartimental syndrome. For prevention of first web retraction, one or two Kirchner wires are placed in emergency between first and second metacarpal, and later a spilt in maximal anti-position of the first ray. In case of communited fractures, skeletal stabilisation use inlay internal devices, such the blocked intramedullary nail. First web reconstruction must take into consideration the cutaneous functionnal units of the hand, described by Michon. Thin and split-thickness grafts are rarely used for covering skin defects of the first web space, because their ability of retraction. Exposition of bone or tendons leads to the realisation of a flap. Soft tissue coverage must be achieved in emergency or after a second look within the first 48 hours. The kite flap is the most useful local flap for the first web space. The interosseous flap is the best choice among the regional pedicled flap. The use of the Chinese flap must be very careful, because the possibility of contusion of the radial pedicle in these types of injuries. It is only in case of contra-indication of the interosseous flap that free flaps can be realised, as the lateral arm flap or the parascapular flap. The groin flap keeps few indications for aesthetic reasons, or when regional flaps and microsurgery are contra-indicated.