Flaps in the hand

Aims
The treatment objectives
in hand reconstruction
are to:
• close the wound
• maximize sensory
return
• preserve length
• maintain joint
function
• obtain a satisfactory
cosmetic appearance

Anatomy
 The volar pulp is also
stabilized by the Grayson and
Cleland ligaments, extending
from the flexor sheath and
distal phalanx volar and
dorsal to the neurovascular
bundles, respectively.

Arterial supply of the fingertip
 The digital arteries
and nerve
trifurcate near the
distal
interphalangeal
joint.
 The proper digital
artery crosses the
distal
interphalangeal
joint, sending a
branch to the nail
fold, nail bed, and
finger pad

Venous drainage of the fingertip

Innervation of the
fingertip
 Each digital nerve trifurcates
near the distal interphalangeal
joint, sending branches to the
perionychium, fingertip, and
volar pad.
 The digital nerves lie volar to
the digital arteries near the
fingertip.
 The fingertip is the organ of
touch and feel and is
abundantly supplied with
sensory receptors, including
Pacinian and Meissner
corpuscles and Merkel cell
neurite complexes.

Nail Physiology and anatomy
 The dorsal surface of the
fingertip comprises the nail
fold, nail bed, and nail plate (=
perionychium).
 The perionychium includes the
entire nail bed and
paronychium complex.
 The paronychium is the skin
surrounding the nail plate
radially and ulnarly.
 The eponychium is the
epidermal shelf at the base of
the nail.
 The lunula is the white
semicircle at the base of the
nail bed. The fingernail is a
specialized epidermal structure,
like hair.

Nailbed production
 The proximal one third of the
nailbed, from the nail fold to the
edge of the lunula, is the germinal
matrix. It has two components, the
dorsal and intermediate nail. The
two thirds of the nailbed distal to
the lunula is the sterile matrix or
ventral nail.
 Fingernail production occurs in 3
areas of the nailbed, the dorsal nail
and intermediate nail of the
germinal matrix and the ventral nail
of the sterile matrix. Of these areas
the intermediate germinal matrix
produces 90% of nail volume. The
remainder of the nail substance is
produced by dorsal nail of the
germinal matrix and ventral nail of
the sterile matrix.

Nail growth rates
 The dorsal roof of the germinal matrix deposits
cells on the nail surface.
 The two thirds of the nail bed distal to the
lunula, the ventral nail or sterile matrix, acts as
a conveyor belt for the advancing nail and
adds squamous cells to the nail, making it
thicker and stronger (Zook, 1994).
 The nail is not merely attached to the bed but
rather is a continuum of a single structure
from basilar cells in the nail bed.
 Nail growth occurs at a rate of 3-4 mm a
month. It takes 3-4 months for growth to full
nail length and 1 year for the nail to achieve
maximal pre-injury smoothness.

Local Flaps
 Flap tissue is attached temporarily or permanently to
its donor site by a pedicle through which
vascularisation is maintained
 Beasley cites 3 indications of flap coverage
Unsuitable for revascularisation with a skin graft
Subcutaneous as well as skin replacement
Protection is required of an exposed vital structure eg
nerve,joint
 Flaps can be local, regional and distant

Fingertip injury
assessment
 Level of injury
 Mechanism
 Depth of loss
 Exposed bone/tendon
 Nailbed support
 Contamination
 Patient factors

Local flap options for
fingertips
 When bone or tendon is exposed at the base of a fingertip
wound, a local flap is required.
 The various local flaps used to reconstruct fingertips include
volar V-Y, bilateral V-Y flaps, cross-finger flap, thenar flap, and
island flaps.
 Flap choice depends on orientation and configuration of the
wound, injured finger, and sex of the patient.
 Surgeons can optimize the reliability of these local flaps by
avoiding tension on the suture line and preserving the
traversing sub-dermal blood vessels into the flap

Volar V-Y flap
 Though frequently termed the
Atasoy flap, Tranquilli-Leali first
described the volar V-Y flap in
1935 (Atasoy 1970).
 The volar V-Y flap is a triangular-
shaped volar advancement flap
outlined with its tip at the distal
interphalangeal crease.
 The local flap is most applicable
for transverse and dorsal
avulsions when a relative
abundance of pulp skin is present
 Then the V is scored through the
dermis only to avoid injuring the
traversing vessels into the
triangular-shaped flap

Bilateral V-Y flaps
 In 1947 Kutler described the
bilateral V-Y flaps for fingertip
injuries.
 Best applied for volar and
transverse avulsions with
exposed bone when excess
lateral skin is present.
 These flaps are designed
along the midlateral line and
should not extend proximal to
the distal interphalangeal
joint.
 In raising these flaps the
incisions are performed
through the dermis only to
preserve vessels.
 The flaps are mobilized for
•The disadvantages of Kutler flaps
distal advancement by include partial or complete flap
dissecting fibrous septae from

The Cross Finger Flap
 Originally termed the
transdigital flap by Gurdin
and Pangman in 1950, the
cross-finger flap is
commonly used for volar-
directed tip injuries with
exposed bone or tendon
when insufficient pulp for
the volar V-Y flap is
present.
 Requires two operations
and a skin graft.
 Moreover, the fingers
become stiff during the
delay between these two
stages.

Cross finger flap technique
 The flap is elevated from the adjacent finger dorsum in the
plane above the peritenon to allow for grafting of the
donor site.
 A full-thickness graft can be taken to close the donor finger
dorsum.
 The flap is opened like a book cover, turned 180°, and
inset into the fingertip defect. The fingers may be sutured
together or even pinned to prevent flap dehiscence.
 During the delay, gentle active range-of-motion exercises
are critical to prevent joint stiffness of both fingers.
 At 2-3 weeks the flap is divided and inset and more
aggressive active and passive range-of-motion exercises
are begun.

Cross finger flap results
 Cohen and Cronin described innervated cross finger
with dorsal branch of digital nerve being divided
proximally and then rejoined to digital nerve of the
injured side
 Ie ulnar dorsal digital branch of MF to radial digital nerve of IF
 Attractive theoretically, seems as over kill when standard
cross-finger flaps have such good results
 Kleinert and colleagues
 70% have 2 point discrimination of less than 8mm
 Nicolai and Hentenaar
 53% had 2 point discrimination within 2mm of the same pulp in
the opposite hand

Cross finger flap results
 The disadvantage to the cross-finger flap is the need for
a second operation and the delay that results in stiffness.
 Accordingly, this flap is contraindicated for older
patients or those with Dupuytren syndrome or
rheumatoid arthritis.

Thenar flap
 The classic description of the
thenar flap by Gatewood in 1926
was proximally based
(Gatewood, 1926).
 Later, Smith and Albin (1976)
described the H-shaped
modification of the thenar flap.
 A 2 cm x 4 cm thenar flap can be
harvested from the MCP crease
and still allow primary closure of
the donor site with thumb
flexion.
 Care must be exercised in
harvesting this thenar flap at the
MCP crease to avoid injury to the
neurovascular bundles and flexor
pollicis longus tendon (Russell,
1981).

Laterally based pedicled flaps
 An alternative way to increase
the pulp advancement for more
oblique palmar sloping defects
is to use single pedicle lateral
flaps. The earliest of these
lateral flaps was described by
Geissendörfer in 1943. This flap
was subsequently popularised
by Kutler .
 It is vascularised by the small
vessels beyond the trifurcation
of the digital arteries.
 Do these flaps ever move as
much as in the drawings in
textbooks?

Segmüller &
Venkataswami flaps
 In 1976, Segmuller described a variant of the Kutler flap
that is elevated on the neurovascular bundle

 Each lateral flap is raised as an island on its own
neurovascular bundle and has a much bigger volume and
reconstructive potential than the Kutler flaps.
 Up to 20mm

 Originally, Segmüller raised the flaps only as far
proximally as the DIP joint crease. Lanzetta et al
described the use of a modification in which the flap is
extended back to the PIP joint.

Segmüller & Venkataswami
flaps
 The Segmüller flap can also be bilateral and carries its own
innervation while the advancing edge of the Venkataswami
flap furthest from the pedicle is denervated.

 Venkataswami then described an oblique triangular flap
based on the contralateral neurovascular bundle for oblique
dorsolateral tip amputations

Segmüller & Venkataswami
flaps


Moberg Flap
 Rectangular volar advancement flap
 Though often termed the Moberg
flap, the volar advancement flap was
first described by Littler in 1956
before being popularized by Moberg
in 1964.
 This is a rectangular volar flap based
on both neurovascular bundles.
 The flap is undermined in the distal
to proximal direction to the MCP
crease superficial to the flexor
pollicis sheath and advanced in the
distal direction. This flap can usually
be advanced 10-15 mm distally.

Moberg flaps
 Raised on both neurovascular pedicles, it has excellent
sensation and vascularity
 Midaxial incisions are made bilaterally, just dorsal to the
neurovascular bundles, both of which will be raised with the
flap
 However, this flap can be used reliably only in the thumb,
where an independent dorsal blood supply guards against
necrosis of the dorsal skin.

Axial Flag Flap
 Based on web space of
donor finger
 Dorsal MCA is reliably
present in the 2nd
interspace (less so in
others)
 Pedicle need only be as
wide as the vessel
therefore increased
mobility

An axial-based “flag flap” named for its configuration. The designed
narrow pedicle allows for great mobility of the flap

Kite Flaps
(1 Dorsal MCA)
st
 Island pedicle flap proximally based on the first
dorsal metacarpal artery and veins.
 Courses over 1st dorsal interosseous muscle from the
radial artery as it courses distal to snuffbox (doppler
pre-elevation)
Can be sensory with branches of superficial radial nerve
 Fascia carefully lifted off the DI muscle
 Can also be distally based on perforators near radial
base of 2nd metacaroal

Quaba Flap(1990)
 Distally based dorsal
hand flap
 Perforators consistently
present 0.5-1.0cm
proximal to MCPJ
through
intermetacarpal spaces
of 2-4 distal to
intertendinous
connecitons

Other Flaps
 Regional
Radial forearm
Ulnar forearm
PIN
 Distant
Groin
 Free flaps

Flaps in the hand

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