FLAPS FOREARM AND HAND

Christian Dumontier, MD, PhD

Centre de la Main, Guadeloupe, FWI
To be downloaded at www.diuchirurgiemain.org

FLAPS FOREARM AND HAND ?

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Carina Nebula, 7500 light-years away

 THIS IS A FLAP

• Axia

• Revers

• Fascio-cutaneou

• Island

5 years
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 THIS ARE ALSO FLAPS

• Random vs axia

• Innervated ap vs non-
innervate

• Fascial vs Cutaneous
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 FLAP: DEFINITION
• A ap is a unit of tissue that
maintains its own blood
supply while being
transferred from a donor
site to a recipient site.

• Classi ed according to their

vascularity, tissue
composition, method of
movement,…
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 VASCULARITY
• Random aps based off the subdermal
plexus

• Axial pattern aps (single direct

cutaneous artery within the longitudinal axis
of the ap).

• Reverse- ow axial pattern aps are

axial aps in which the source vessel is divided
proximally, and blood ows in a retrograde
fashion through the distal vessel. This is made
possible by venae comitantes, bypass vessels,
and valvular incompetence.
A: direct cutaneous branch of a muscular vesse
B Septocutaneous perforato
• Island aps are axial pattern aps raised on C: direct cutaneou
a pedicle devoid of skin to facilitate distant D: Myocutaneous perforato
E: direct septocutaneou
transfer F: perforating cutaneous of a muscular vessel

McGregor I A, Morgan G. Axial and random pattern aps. Br J Plast Surg 1973;26:202
Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classi cation of skin aps according to their vascularization.
Ann Plast Surg 16:1, 1986.

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 TISSUE COMPOSITION
• Fascial and fasciocutaneous
ap

• Muscle and myocutaneous

ap

• Vascularized bone ap

• Visceral ap

• Compound and composite

aps
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 METHOD OF MOVEMENT

• Local aps (Advancement,

rotation, transposition

• Interpolation ap

• Distant aps (direct, reverse,

microsurgical)

Lucas JB. The Physiology and Biomechanics of Skin Flaps. Facial Plast Surg Clin N Am 25 (2017) 303–311
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 FLAPS ARE MOSTLY MADE

FOR SKIN COVERAGE
• There are many techniques
to obtain skin healin

• Flaps are only one of those

technique

• So why choose a ap ?
[Poor recipient bed; large
area, exposed structures,…]

Lucas JB. The Physiology and Biomechanics of Skin Flaps. Facial Plast Surg Clin N Am 25 (2017) 303–311
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FOR FINGER PULP: FLAP VERSUS ?

• Replantations

• Secondary healing

• Skin grafts

• Arti cial dermis

• Biological regeneration is not available in

the clinical setting
A frequent question: 4,8 millions of pulp injuries seen in the ER in USA every year
(Sorock, 2002)
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 IMMEDIATE BENEFITS

• Produce primary healing

• Prevent infection,

• Preserve the viability of exposed underlying

structures.

 LONG-TERM
BENEFITS

• Provide a durable skin cover to withstand everyday use

• Provide sensation at key points in the hand;

• Permit mobility of underlying structures, especially tendons;

• Permit later reconstruction procedures to repair the deep

structures;

• Prevent the development of contractures.

 FLAPS MAY BE DIFFICULT TO PERFORM

inadequate debridement, too small
ap = Surgeon’s mistake !

• They are associated with a high number

of complication

• 118 pedicled aps: 79 antegrades, 10

retrogrades, 6 intermetacarpal, 5 kite
ap, 6 dorso-ulnar ...

• 42 complications dans 42 cas (39%

smokers +++) with 10 partial
necroses, 13 epidermolysis, 4 venous
congestion, 4 super cial infection, 3
deep infection, 8 secondary healing
of ap edges,….mostly in antegrade
aps

Henry M. Speci c complications associated with different types of intrinsic pedicle aps of the hand. J Reconstr Microsurg.
2008;24(3):221-5.
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SURGERY ALWAYS STARTS WITH A LARGE
DEBRIDEMENT AND A LAVAGE

Savoir réparer ce que l’on pare - Raymond Vilain

 OTHER BASIC PRINCIPLES
• One stage surgery with early
rehabilitatio

• Which sensibility

• Which sequelae on the donor sit

• Which cosmetic sequelae ? Beware of

cutaneous units
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 HOW CAN WE AVOID TO BE IN

DIFFICULT SITUATIONS ?

• You may know all the described

ap

• But it is impossible…s

• You must at least know:

Anatomy of the hand, and particularly vascular

anatomy (see www.diuchirurgiemain.org)
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 THE MOST IMPORTANT

• Some aps which experience has

shown that were reliable, reliable,
useful and widely used and so
reproducible

• Do the simplest ap, the one you

are familiar with (if indicated) and
that you know how to perform ! The reverse Atasoy’s ap
A not yet described
totally useless ap
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Tang JB et al. Repair and Reconstruction of Thumb and Finger Tip Injuries. A Global View. Clin Plastic Surg 41 (2014) 325–359
 PULP RECONSTRUCTION
• Homodigital aps (Gatewood 1929- Thenar
ap, Tranquili-Leali 1936, Geissend rfer 1943;
Kutler 1947, Venkataswami 1980, Seegmuller
1976, Lai 1989

• Heterodigital (Cross- nger aps -Cronin

1945; Gudin et Pangman 1950; with an axial
pedicle -Hingerfeldt 1950 ; Moberg & Littler To be avoided
1959-1960)

Giesen T, Adani R, Carmes S, Dumontier C, Elliot D, Calcagni M. IFSSH scienti c committee on skin coverage: 2015 report. Hand Surg Rehabil.
2016 Oct;35(5):307-319.
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 SOME USEFUL FLAPS
• Atasoy ☞ Prefer Elliot’s Tranquili-Leali neurovascula

• Thenar ap ☞ index and middle nger only, limited

los

• Axial ap ☞ « Venkataswami, Seegmuller, Gilbert 

• Reverse axial ap ☞ Lai and Brunelli

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LIMITED INDICATIONS FOR ATASOY’S FLAP

• Limited advancement (5
mm

• Limited sensibilit

• Not always perfect esthetic

appearance

If I need an
Atasoy’s ap,
then a Mennen
occlusive
dressing is
probably enough Atasoy E. JBJS 1970;52A:921-926
)

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 TRANQUILLI-LEALI NEUROVASCULAR (ELLIOTT)’S FLAP

• A variation of a bi-pedicled
ap at the nge

• Incisions should stay distal

to the PIP creas

• Advancement up to 14 m
Elliot D, Moiemen NS, Jigjinni VS. The neurovascular Tranquilli-Leali ap. Journal of Hand Surgery, 1995;20B: 815–823
Lorea et al. JHS 2006:31B:280-284 - 22 cases, 18% of complications
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 THENAR FLAP
• Easy to us

• Index and middle nger onl

• Good published result

• 150 cases, no necrosis, satisfaction

98%, Weber 7 mm, PIP stiffness 4

• 20 cases; no necrosis, satisfaction

100%, Weber 6,5 mm (3-10 mm), no
stiffness

Melone, JHS 1982;7:291-29

Barbato et al, Ann Plast Surg 1996; 37: 135-139
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 AXIAL ISLAND FLAP

• Described in 1980 for the

thumb (Venkataswami PRS
1980;66:296-300

• Drawing variations between

an extended Kutler
ap(Seegmüller 1976) and a
direct island ap (Gilbert
1980)
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 AXIAL FLAP

• May cover 10-15 mm - 7%

necrosi

• Sensibility is limite

• PIP Stiffness (Average 20°

of PIP extension lag

• Up to 20% exclusion of the

index
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 REVERSE AXIAL FLAP

• 1st publication 1985 (Lai. Ann.
Plast. Surg 1989; 22: 495-500)

• « Chinese » nger ap based on

retro-tendinous anastomose

• Need to sacri ce one the nger

arter

• May cover 1-2 cm (an entire

pulp

• No need for nger immobilisation

)

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 THUMB RECONSTRUCTION
• The thumb has two phalange

• Vessels are shorter than at the

ngers - cannot be dissected
proximal to the MP creas

• Volar radial artery has many

variation

• Dorsal vascularisation is
independent from the volar on

• Pulp reconstruction is the major

issue
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THUMB PULP RECONSTRUCTION

• Hueston’s advancement aps ☞ limited
advancemen

• Venkataswami’s ap ☞ more logical on the radial

side with > 20% variations of the radial arter

• Gaul’s cross- nger ap ☞ 2 stages, dorsal ski

• Dorso-ulnar Brunelli’s ap ☞ dorsal ski

• Kite- ap ☞ dorsal ski

• Bi-pedicles aps are preferred (Moberg;

O’Brien)
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 BI-PEDICLED FLAPS
• Advancement up to 15 m

• Cannot extend dissection

proximal to MP creas

• Snow ☞ prefer Elliot’s variation

• Moberg-O’Brien ☞ prefer
dissection to the MP crease
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 DORSO-ULNAR FLAP

• Based on the dorsal

anastomose

• Can cover a pul

• Easy, reliabl

• Dorsal skin (too thin)

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 KITE FLAP
• Large surfac

• Reliabl

• Donor site sequela

• Dorsal skin
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 DO NOT FORGET THAT THE RESULTS ALSO

DEPEND OF THE PATIENT

• 82 pulp injurie

• DASH post-op 35 (normal 10 in the USA

• DASH at one month 1

• Over half of the variations in the clinical results were

related to a depression or the mechanism of injury.
Depression was related to pain intensity, DASH score and
the length out of work
Bot AGJ, Bossen JKJ, Mudgal CS, Jupiter JB, Ring D. Determinants of Disability After Fingertip Injuries. Psychosomatics
2014:55:372–380
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 HAND & WRIST

• Pseudo-island ap

• Radial

• Dorso-ulnar (Becker

• Island ap

• Radial (chinese

• Ulna

• Posterior interosseou

• Anterior interosseou

• Distant ap

• Pedicled (groin ap

• Free aps (LD, ALT, scapular,…)

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DORSO-ULNAR (BECKER) FLAP

• On the dorsal branch of the
ulnar arter

• 2-4 cm above the ulnar styloi

• Coverage: Anterior and

posterior wrist; ulnar side of
the hand; median nerve
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RADIAL ARTERY FLAP (CHINESE)

• Based on the radial arter

• Can be very larg

• Can reach the nger

• Can include bone,

tendons, .

• w/wo the skin

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 POSTERIOR INTEROSSEOUS FLAP

• Not easy to dissec

• May cover the wrist and

dorsal han

• Can be extended up to
nger

• Do not sacri ce a major

arterial axis

Brunelli F., Valenti P., Dumontier C., Panciera P., Gilbert A. The posterior interosseous reverse ap: Experience with 131 aps. Ann.
Plast. Surgery. 2001;47:25–30
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 CONCLUSION
• Many aps are available at the han

• Discuss their indicatio

• Most of surgical wound can be covered by well-

described and known aps that you should be able
to us

• Almost all aps can be done within a few days

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