V-Y Dorsal Metacarpal Flap: A New Technique for the Correction of Syndactyly without Skin Graft M. Magdi Sherif, M.D. air, Ey Anew technique for web reconstruction in conge syndactyly is described. Twenty-one web spaces in 12 pa- tients were treated using this method. The dorsal meta- carpal flap was used as an island V-Y advancement to cover the newly created web space, thus avoiding skin graft in this space. A follow-up of 6 months to 2 years showed neither recurrence of the deformity nor web creep of any degree, The operation is rapid, easy, and reproducible. It is suggested that this technique can be used in all types of syndactyly. (Plast. Reconstr. Surg. 101: 1861, 1998.) Syndactyly is one of the most common con- genital hand deformities."® The objectives of treatment are both functional and cosmetic. ‘This is accomplished (1) by covering the newly separated digits by supple skin that does not limit their motion and (2) by adjusting the position, size, and shape of the web to match other interdigital webs.* Current techniques for syndactyly correction utilize a zigzag inci- jon along the full length of the syndactyly to avoid the contracture that might follow a straight line closure."® The web itself is recon- structed by a local skin flap. Alternative tech- niques for web space reconstruction may uti lize a dorsal triangular flap," a dorsally based rectangular flap,'""" or a combination of inter~ digitating dorsal and volar triangular flaps.41-!° As the separated fingers have a greater su face area than the syndactylized digits, addi tional skin coverage is always necessary.® This is usually provided in the form of a skin graft applied to the base of the fingers. Some sur- geons advocate the use of split-thickness skin graft." which seems to have a high incidence of secondary graft contracture that may compro- mise the functional and aesthetic result of the release." Currently, most authors prefer the use of full-thickness skin grafts?" that should result in less contracture, However, full- thickness skin graft is a time-consuming op. ation, and it is often difficult to get a perfect take on a small area. Although minor skin defects heal rapidly in young patients, this may result in the formation of hypertrophic scar ring and unpredictable finger contractures." Web creep and contracture are common fol- lowing correction of syndactyly, leading to re- cu nce of the deformity and re-operation in 5 to 59 percent of the cases.!™!7 The main reason seems to be related to the type and take of the skin graft used.2"""517 However, it may also result from bad postoperative dre or inadequate splinting." Besides contractures, skin grafts can have many additional problems s pig- mentation, hair growth, exc ring at the edges of the graft, or donor site scarring. To reduce the size of skin graft, Colville advocated an advancement kite flap to cover one side of the released fingers. Tissue expand- ers were also used"; however, tissue expan- on is a two-stage operation with repeated in- jection over a long period. It also carries a high percentage of complication, especially in the upper limb, and seems to be inadequate in the correction of complete syndactyly.”? Re- cently, the use of skin grafts was completely avoided by extending the dorsal flap on the proximal phalanx of the syndactylized fin- From the Department of Plastic Surgery at Ain Shams Universiy- Received for publication April 90, 1907; revised August 6, 1997, Presented atthe 2 h Annual Meeting ofthe Egyptian Society of Pastc andl Reconstructive Surgeons in Cairo, Egypt, February 260 1861 1097,1862 gers. However, Ekerot spaces had one case (6 percent) still requiring skin grafting and 3 (17.6 percent) needing secondary Corrections for insufficient web space or later web creep. To avoid the use of skin graft in the correc- tion of syndactyly, a new operation has been developed. A dorsal metacarpal island flap is advanced distally to completely cover the web space. This procedure was used in the recon- struction of 21 web spaces in 12 patients with varying degree’s of congenital syndactyly MATERIALS AND METHODS. Twelve patients with 21 syndactylous webs were operated on using a dorsal metacarpal artery flap. There were six males and six fe- males. The age of the patients at the time of the operation varied from 6 months to 17 years. Syndactyly was unilateral in seven p tients (58.3 percent) and bilateral in five (41.7 percent). The middle-ring web was the most commonly affected (12/21 or about 57 per cent) followed by the index-middle web (7/21 or 33 percent) and then the ring.ittle web (2/21 or 9.5 percent). The first web space was not included in this series. Eighteen (85.7 per- cent) of the syndactylous webs were simple, with 12 incomplete (57.1 percent) and 6 com- plete (28.6 percent). The remaining three webs (14.3 percent) were complex complete syndactyly Two of the patients with bilateral syndactyly released at two different stages, whereas in the other four patients, both hands were operated th e time. Light dressing was ap- plied, covering only the newly separated finger and allowing the remaining fingers to move freely. In two patients, two alternative webs in the same hand were released during one oper- ative intervention. The follow-up period ranged from 6 months to 2 years, Surgical Technique The fingers are separated by the standard zigzag incision described by Skoog.” A flap is designed over the dorsum of the hand at the intermetacarpal space centered 0.5 to 1 cm proximal to the metacarpophalangeal joint, with a distal concave edge and a proximal tri- angular tip (Fig. 1). The length of the flap varies from 1 to 3 cm and its width from 1 to 2 cm, according to the age of the patient. The flap was narrowed at its middle so that it would lie easily in the released web, At the palmar PLASTIC AND RECONSTRUCTIVE SURC Oe) ny, Junne 1998 | i Fic. 1. Desigh used for con ) LS Z > y y ction of syndactyly and webs space reconstruction using an island dorsal metacarpal artery flap. A standard zigaag incision is drawn along the digits to be separated. (Left) On the dorsal surface, the proximal patt of this incision is concave and is situated along the line of the proposed web space (dotted lin). It forms the distal edge of the dorsal flap. This flap is centered (x) 0.5 10 | em proximal to the metacarpophalangeal joints. The proximal edge of the flap is V shaped to allow for closure of the donor area, and the flap is constricted laterally to fit in the released web space (Right) On the palmar surface, the most proximal ine of the Zigzag incision isconvex to receive the prox of the flap, surface, a transverse slightly convex line w: designed at the level of the new web to accept the distal concave edge of the flap. All dissec- tion was done under tourniquet; complete ex- sanguination is avoided to help in the visual- ation of the neurovascular bundles of the fingers and pedicle of the flap. Excess fat around the neurovascular bundles along the fingers and at the web space was excised to help in closure of the finger defect without tension. The younger the patients, the more fat is present around the neurovascular bundle. With increasing age, the amount of fat de- creases, and the closure is usually done under slight tension. In the first three cases, the dor- sal metacarpal artery flap was undermined carefully from the sides until the perforator vessel supplying the flap was seen. This vessel is usually present just distal to the intertendinous connection of corresponding intermetacarpal space. In the remaining cases, the pedicle was not dissected, and the skin was advanced with- out undermining of the flap. Some of the su- perficial veins draining the flap can usually be preserved (Fig. 2). However, ligating all the superficial veins can be safely done as the ar- tery supplying the flap is accompanied by mul- tiple small veins. The flap is then advanced distally, and the defect is closed directly. AVol. 101, No. 7 / VY DORSAL METACARPAL FLAP Fic, 2 Intraoperative photograph showing the blood sup- ply and venous drainage of the flap. A small perforator can be seen entering the deep surface of the flap at its center (asterisk). Thisisaccompanied by some veins. Additional veins are preserved at the proximal part of the flap (ara) usual hand dressing is done with petrolatum gauze on the suture line and flufly gauze in between the fingers and a light pressure ban- dage. The patient is usually discharged on the s . The first dressing is done after | ResuLtS Inall the operated hands, the appearance of the reconstructed web was similar to that of the adjacent webs regarding the skin quality and color as well as the dimension of the web and its dorso-palmar inclination. After a minimum follow-up of 6 months, the reconstructed webs remained satisfactory in both appearance and function. Figures 3 to 8 show some of the re- sults of this technique. There was no reported case of web creep during this period and none of the patients required a secondary operation. The scar over the dorsum of the hand usu- ally fades within 6 months (Fig. 8) and was barely noticeable by the parents. There was only one case of hypertrophic scarring in a 2year-old patient, and it has settled down 8 months after the operation. There was no flap loss due to cither arterial or venous insuffi- ciency. Discussion Despite the various types of skin incisions, web flaps, and skin grafting, there is still a significant incidence of secondary surgical cor- rection after syndactyly repair. Even with a technically well executed reconstruction, distal web creep and contractures are common.??- 1018 This seems to be related to the use of skit graft applied at the base of the fingers,” 1863, Fic, 3. The web space reconstructed by the island dorsal metacarpal lap. The flap is advanced distally, and the donor area is closed in a VY manner. No skin graft is used, where skin is usually deficient in the standard technique of syndactyly release. To avoid the use of skin graft at the time of syndactyly correction, an island dorsal metacar- pal artery flap has been used to reconstruct 21 web spaces in 12 patients. The skin of the syndactylized fingers is thus completely used to cover the newly separated fingers while addi- tional skin is brought to the web space from the dorsum of the hand to cover the web area. As the size of the advanced flap is large enough to cover the whole web space with no suture lines in the web area, web contracture did not occur in this series and is not expected in the subsequent cases. Furthermore, the presence of a skin flap in the web area did not require a special dressing to avoid skin contracture. The dressing is simple and consists of the usual fluffs in the web area. Tight hand bandage is avoided to prevent pressure on the flap. The dressing is kept for only 7 days, and a lighter1864 PLASTIC AND RECONSTRUCTIVE SURGERY, June 1998 Pr Fic, 4. An 18:month-old boy with simple incomplete syndactyly involving the third bilaterally. The second web space is minimally involved on the left hand. A constriction ri the left thumb was operated on at the same stage. Preoperative dorsal (lf) and palmar ( views of the left hand. "3 5. Early postoperative result, Some sutures are still present, and the scar is still active Fic. 6. Preoperative view of a 4-yearold git! with simple incomplete syndactyly involving the second web space. Notice the mild degree of syndactyly of the third space and the hypoplastic index finger dressing is applied until removal of the sutures, used. In adults, dressing can be applied to allowing the patient to resume normal activity. the newly separated fingers only, allowing the his is in contrast to the 2- to 4week period of patients to use the nonoperated fingers, thus dressing when full-thickness skin graft is being permitting a simultaneous bilateral releaseVol. 101, No, 7 / V-¥ DORSAL METACARPAL FLAP Fic, 7, One month postoperatively, showing a normal locking web lined with dorsal skin and some scarring over the dorsum of the hand. Fic, 8. Photograph of the same patient after I year show= ing fading of the dorsal scar; no web creep or contracture of the web § structed § be released. ace can be seen on the palmar view, The recon- ace is deeper th n the third web, which needs to The flap is designed so that its concave distal nargin rests in the defect created by the re- lease incision on the palmar aspect of the base of the fingers. This concave edge gives an extra length to the web and avoids secondary con- tracture. The suture line is palmar to the mid- 1865 lateral line of the web floor with two small triangular flaps in the base of the digits. This breaks the linear scar at the volar side of the web and prevents its contracture to the small flaps used by Moss and Foucher to prevent contracture at its most likely point The narrowed part at the middle of the flap allows it to lie easily in the space and prevent the redundancy of dorsal skin at either side of the flap that is frequently seen in the dorsal rectangular technique.” The proximal triangu- lar tip facilitates the closure of the donor area in a VY fashion. ‘The dorsal island flap used in this series is a safe and reliable flap. Skin graft was avoided in, all the patients operated on either by the au- thor or by plastic surgery residents in different stages of training. The use of this flap instead of skin graft has markedly shortened the oper- ative time of syndactyly No flap was lost either from arterial or venous complications. This is in contrast to the reversed flow dorsal metacarpal artery flaps where venous anasto- eas mosis is sometimes necessary to rel congestion." The present technique differs from those of Niranjan and De Carpentier and Ekerot, * in which a flap is raised from the dorsal surface of the fingers, and no tissue is added to correct the skin shortage invariably present in syndac- tyly. Ekerot, 2 in a series of 17 web spaces, had. one patient requiring the addition of skin graft and three cases (17.6 percent) needing sec ondary corrections for insufficiently corrected web space or for web creep. He also noted some minor skin defects that healed rapidly with “relatively marked scarring” without caus- ing any contractures in the follow-up period. With the V-Y advancement technique, the flap is large enough to fill the resulting defect in the web area so that no skin graft is needed in all the operated cases, and the resultant sears in the web space are usually inconspicuous. The dorsal hand skin can be closed primarily even with the reconstruction of two webs at the same time. This is especially true in younger patients, in whom defattening of dorsal skin allows for closure of the donor area without undue tension. The proximal metacarpal skin of the re- versed flow flap® and the dorsal skin of the proximal phalanges®®*” may be hair bearing and are not advisable in a child who has not yet developed hair in this area. This is contrary to jieve venous1866 the distal metacarpal skin used in this flap that is usually non-hair bearing. In contrast to the classical method of rectan- gular dorsal flap, this technique can be used in all degrees of syndactyly. It does not need a ufficient dorsal skin reaching as far as two thirds of the proximal phalanx. ‘The flap has also all the advantages of a local flap, namely color match, thickness, and tex- ture, which make it a perfect flap for covering the web defect. The only disadvantage for this, flap is the presence of scar on the dorsum of the hand. However, scars on the dorsum of the hand are known to settle down well and they were barely noticeable 6 months after the op- eration. Conciusions A new technique for the correction of syr dactyly is described, It is based on a well vascu- larized skin supplied by a known branch of the dorsal metacarpal arteries. This skin is ad- vanced in a V-Y fashion to reconstruct the web space. The operation is technically easy and is time saving. Neither flap necrosis nor web con- tracture was seen in this series. Dressing is sim- ple, and the operation is aesthetically appeal- ing. ‘M. Magdi Sherif, M.B. B.Ch., M.Sc., M.D. Assistant Professor of Plastic Surgery Ain Shams University Cairo, Egypt REFERENCES: 1. Flatt, ALE. Treatment of syndactylism, Plast. Reconstr Surg. 29: 336, 1962, 2 Toledo, L. C., and Ger, E, Evaluation of the operative treatment of syndactyly, J. Hand Surg. 4: 556, 1979, 3. Flau,A.E. Practical Factors in Treatment of Syndactyly In J. W. Lier, LH. Cramer, and J. H. Smith (Eds,) Symposium in Reconstructive Hand Surgery. St. Louis Mosby, 1974, 4. Cronin, T.D. Syndactytism: Results of zig-zag incision to prevent postoperative contracture. Plast. Reconstr Sug. 18: 460, 1956. 5, Skoog, T. Syndactyly: A clinical report on repair. Acta Chir. Scand. 130: 587, 1965. 6. Zeller, S. Abhandbung uber die ersten Exscheinung venerscher Lokat KrankheitsFormen, und deren Behandlung, samt einer dhuraen Anzeige 21 einer neven Operasions Methaden, nahin lick: Die angebornen verwachsenen Finger, und die Kastrazion betrefend. Vienna: Binz, 1810. Pp, 107-111 7. Bauer, T.B., Tondra, J. M., and Truster, HM. Tech- nical modification in repair of syndactylism, Plast. Re constr. Surg. 17: 985, 1956. 8. Dobyns,J-H. Syndaetyly. In D. P.Gi (EA), Operative PLASTIC AY ND RECONSTRUCTIVE SURGERY, June 1998 Hand Surgery, Vol. 1, 2nd Ed. New York: Churchill Livingstone, 1982, 9. Ketchum, LD. 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