Local Hand FlapsSummer Anatomy LabJuly 25, 2013Jennifer 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▫Designed over dorsal aspect middle

phalynx

•Vascular supply:▫Dorsal digital artery▫Digital perforators

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

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)

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

Volar finger defects

Dissection

1. Incise skin based on markings down to SC fat until loose areolar plane

2. Elevate flap in this plane, taking care to leave the paratenon behind

3. Dissect to Cleland’s ligament; may need to divide ligament to increase pedicle length

4. Cover donor site with skin graft5. Inset flap6. Divide flap 2-3 weeks later

Fingertip Defects

Reverse Cross-Finger Flap•For adjacent dorsal digital wound coverage

▫Elevate flap in subdermal plane▫Adipofascial flap to cover dorsal defect

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”

Thenar Flap

Thenar Flap

1. Donor site found by taking tip of index or ring finger and placing it against thenar eminance

2. Draw circle around area of contact3. Draw H or curved incision at this point4. Elevate flaps in subcutaneous plane5. Inset flap6. Divide in 10-14 days

For the H flap, the proximal flap covers the finger defect and distal flap advanced to cover donor

Points about the Thenar Flap

•To avoid potential for joint stiffness or unsightly scar in donor area:

1. Design flap near the MP crease of the thumb; avoid the midpalmar area

2. Fully flex the MP joint with whatever amount of flexion is required in the IP joints of the recipient finger

3. Detach pedicle 10-14 days post-op and start immediate AROM

First Dorsal Metacarpal Artery Flap•Classification:

▫Type A fasciocutaneous flap▫From dorsal skin over

proximal phalynx (FDMA)

•Clinical Applications:▫For defects in the thumb

•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

FDMA

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

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 pollicis longus tendon

•Supplies the dorsum of the thumb and radial side of the index finger

Flap Markings

•From MCP joint to the PIP joint of index

•Radial & ulnar borders 1st the midlateral lines on either side of digit

Flap Dissection1. Incision in 1st dorsal web

space, down to FDMA2. Elevate flap distal to

proximal, just above paratenon

3. Fascia and fat adjacent to 2nd metacarpal kept intact to protect vessels

4. Transfer and inset flap5. Cover donor with skin graft