Non microsurgical coverage of hand
- 1. Non microsurgical coverage of hand B.Punithavasanthan Hand and microsurgery fellow SKIMS-SOURA.
- 2. Aims The treatment objectives in Non microsurgical coverage of hand are to: • close the wound • maximize sensory return • preserve length • maintain joint function • obtain a satisfactory cosmetic appearance
- 3. Options available. • Healing by secondary intention. • Vaccum assisted coverage. • Skin grafting(stsg,ftg). • Local flaps, • Regional flaps. • Distant flaps. • Skin substitutes.
- 4. Healing by secondary intention • If the skin loss is no larger than about 1.5 cm wound may be allowed to granulate and heal spontaneously. • This type of treatment is especially well suited to children and the elderly.
- 5. Elliot et al .Homodigital reconstruction of the digits: The perspective of one unit . Indian J Plastic Surg July- December 2003 Vol 36 Issue 2 re- epithelialisatio n under moist antiseptic dressings for 4 weeks Healing by re- epithelialisation under moist antiseptic dressings was achieved in 6 weeks while mobilisation was continued
- 6. • If skin can replace itself under moist antiseptic dressings, then operating to achieve skin cover, per se, is a dubious indication for surgery A crush avulsion injury of the left thumb of a 53 year old man (a), The same thumb tip after debridement showing irregular but viable flaps of tissue at the digital tip which were used to achieve bone cover (b), Healing of the thumb under moist antiseptic dressings at three weeks (c), Complete reepithelialisation of the thumb
- 7. Pre-operative views of a palmar-facing amputation at nail fold level showing the marking of the neurovascular Tranquilli-Leali flap (a and b), Flap advanced, with the corners of the leading edge marked prior to excision of the corners and suturing (c), Fingertip af ter completion of epithelialisation
- 8. Pre-operative views of the thumb of a 47 year old man with a typical crush avulsion of the distal pulp (a), Markings of a V-Y modification of the Moberg flap shown pre-operatively (b), Intra-operative view of the fully mobilised flap (c), Immediate post- operative view with the flap advanced to provide pulp cover of the distal bone Final result after epithelialisation of the tip under moist antiseptic Dressings
- 9. • Vaccum assisted coverage Seyhan H, Kopp J, Polykandriotis E, Horch RE. Vacuum-assisted closure as temporary coverage in the "problem zone hand". Zentralbl Chir. 2006;131(Suppl 1):S33–S35. doi: 10.1055/s-2006- 921436. Vacuum therapy represents a usefull procedure for temporary wound coverage. Especially at hand defects, when nerves, tendons or bones following trauma or staged procedures are exposed, vacuum therapy can be successfully applied utilizing the special surgical "hand glove" technique.
- 10. • Matsui et al,Nonmicrosurgical options for soft tissue reconstruction of the hand Curr Rev Musculoskelet Med. 2014 Mar; 7(1): 68–75.Published online 2013 Nov 30. doi: 10.1007/s12178-013-9193-8 In our practice, we use negative pressure wound therapy primarily when staged debridement of a large wound is required. It is used as a dressing in between débridements until a stable, healthy wound bed is established, after which formal soft tissue coverage is performed.
- 11. ANTHONYFOO ET AL, THE ‘HAND-IN-GLOVES’ TECHNIQUE: VACUUM- ASSISTED CLOSURE DRESSING FOR MULTIPLE FINGER WOUNDS Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e129ee130 . During hand mobilisation, the seams of the pressur- ised gloves are under greater stretch and the loose outer glove serves as an insurance to ensure the maintenance of vacuum.
- 12. The longitudinal palmar veins do not travel with the arteries. They are situated more superficially and have a more random pattern, traveling in and out of Cleland and Grayson ligaments
- 13. dorsal metacarpal arteries progressively decrease in caliber and constancy from the radial to the ulnar side of the hand
- 14. The middle transverse and distal arches are 1.5 times larger than the proximal. Their location is constant(c3,fdp), basis for distally based vascular island flaps
- 15. The thumb has two arterial systems, the palmar and the dorsal systems, either of which is sufficient to support the vascularity of the distal thumb independent of the other. The robust dorsal vasculature of the thumb allows for mobilization of the entire volar skin on the palmar vasculature as in the Moberg flap without compromising the vascularity of the dorsal skin
- 16. local flap • A local flap consists of skin and subcutaneous tissue that is harvested from a site nearby a given defect while maintaining its intrinsic blood supply • With these flaps the majority of small-to- medium sized defects of the fingers, thumb and dorsum of the hand can be reconstructed with minimal donor site morbidity and excellent functional and aesthetic results because a tissue defect is replaced with similar tissue type from the immediate anatomic vicinity of the defect.
- 18. The Rotation Flap • refers to the vector of movement of the flap • the arc of flap rotation should be designed at least 3-4 times larger the diameter of the defect to allow sufficient rotation of the flap and closure without excessive tension. • design the flap relatively large from the outset to avoid this situation. A common mistake is to design a flap that is too small and cannot be sufficiently rotated into the defect.
- 19. This technique has proved useful in reconstruction of defects up to 3 cm in diameter on the dorsum of the hand overlying the distal half of the metacarpals
- 20. Rotation flap to cover a large defect on the dorsum of the hand Ahmed M. Al Maksoud J Surg Case Rep. 2015 Nov; 2015(11): rjv139. Published online 2015 Nov 1. doi: 10.1093/jscr/rjv13 9 . The flap offers repair with local skin of similar colour, texture and thickness. The end results were excellent both functionally and cosmetically.
- 21. Transposition flap (Random) Rhomboid Flap: It relies on the looseness of adjacent skin to transfer a rhomboid shape flap into a defect that has been converted into similar rhomboid shape. the rhomboid flap consists of an equilateral parallelogram with two angles of 120° and two of 60°. To execute this flap, first the defect is converted into a rhomboid. A line is extended that equals the height of the rhomboid. This line is then extended parallel to one side of the rhomboid
- 23. • Z Plasty Indication. volar scar contracture and web space contracture. Technical points. Central tight scar should be excised. Tip of small flap should not be hold with forceps. Base should be thicker. Avoid suture in midpart of flap. Limbs should be 60 degree to central limb…watchout for 45 degree limb. Length achieved is 70 -75 % of the original central limb
- 25. Transposition flap (Axial) Flag flap. • The flag flap is a pedicled dorsal digital flap, combining a skin paddle (the “flag”) and a vascular pedicle (the flag “pole”). Its vascularisation depends on the dorsal metacarpal arteries • indications:small and medium Soft-tissue defects on the dorsal aspect of fingers between the metacarpophalangeal and the distal interphalangeal joint as well as on the tip of the thumb.
- 27. Kite Flaps (1st Dorsal MCA) • 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
- 28. • The DMCA flap is used for coverage of dorsal finger up to the level of the PIP joint.and thumb defects. One must not attempt to isolate the perforator as this may lead to its damage and affect flap viability.
- 31. Quaba flap In 1990, Quaba and Davison introduced another subset of flaps called the distally based dorsal metacarpal artery (DMCA) flap that is not based on the dorsal metacarpal arteries, but rather on a constant palmar-dorsal perforator present in the digital web-space
- 32. • The flap is harvested from proximal to distal, raising the skin flap above the paratenon of the underlying extensor tendon. • The pedicle is traced along the course of the perforator usually arises immediately distal to the juncturae tendinum at the interdigital space. The flap is usually centered on location of the palmar-dorsal perforator of deep palmar arch. The boundaries of the flap extends between the distal edge of the extensor retinaculum proximally and the MCP joint distally and the outer borders of the adjoining metacarpals on either side.
- 37. DMAP flap is a reliable alternative for treating small to moderate sized defects on the dorsum of the hand, soft-tissue defects of the fingers (proximal to the finger tip), web space, and distal palm defects. The flap offers the surgeon a simple and fast procedure to cover defects with minimal donor site morbidity and with preservation of the functional and esthetic outcomes of the hand.
- 38. The Homodigital Island flap • homodigital island flap that is based on the volar blood supply of the fingers, either the radial or ulnar digital artery . • it is a distally based flap used for fingertip cover mostly in middle and ring finger.
- 39. The reverse flow Dorsoulnar and Dorsoradial Collateral Artery Flap supplied by the ulnar dorsocollateral and radial dorsocollateral arteries that arise from the radial artery at the level of the head of the first metacarpal bone and run on their respective sides to supply the skin over the dorsum of the thumb. Dissect upto the level at middle of the proximal phalanx to preserve the anastomosis between palmar and dorsal vessels
- 41. Advancement flap. Atasoy flap. 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 oblique amputation 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 triangularshaped flap
- 42. - the flap is only advanced a maximum of 1 cm, -If the closure is tight instead of closing the V-shaped donor site defect in a Y pattern, the defect is left open and allowed to heal by secondary intention. -The advantages to the modification such as potential reduction in the risk of hook nail deformities. This is explained by the fact that there is less tension at the tip of the finger because a counteractive proximal closure is not present at the apex on the V.
- 45. • 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 DIP joint. • In raising these flaps the incisions are performed through the dermis only to preserve arborizing vessels. • The flaps are mobilized for distal advancement by dissecting fibrous septae from the distal phalanx.
- 46. •The disadvantages of Kutler flaps include partial or complete flap necrosis, risk for pincher nail deformity, and excess scar on fingertip risking hypersensitivity. These disadvantages are increased compared to other flaps
- 47. Segmüller & Venkataswami flaps unilateral V-Y flap is designed on the radial or ulnar aspect (depending on the injury configuration and tissue availability), with the apex at the DIP crease Each lateral flap is raised as an island on its own neurovascular bundle and has a much bigger volume and reconstructive potential than Kutler flaps.
- 52. Moberg flap This is a rectangular volar flap based on both neurovascular bundles. • The flap is raised in the distal to proximal direction to the MCP crease superficial to the flexor pollicis sheath . • This flap can usually be advanced 1.5 cm distally. • The Moberg flap is indicated for coverage of small-to-medium sized defects over the volar aspect of the distal phalanx of the thumb . • This flap provides excellent soft-tissue coverage with highly sensate, well-padded skin of similar color and texture
- 53. The main disadvantage of the Moberg flap is tendency for interphalangeal (IP) joint flexion deformity, if the flap is insufficiently mobilized to cover volar distal defect.
- 54. the proximal end of the flap can be modified to extend across the MCP flexural crease as a V- shaped incision converting the flap into an island flap to gain further length
- 55. Regional flaps. • Flaps that are raised from area of the limb that is not adjacent to the defect.
- 57. The cross finger flap. -A very robust and safe flap -Requires two operations and a skin graft -elevated from the adjacent finger dorsum in the plane above the peritenon to allow for grafting of the donor site. -avoid harvesting a flap from the index finger,
- 58. • Versatility and Modifications of the Cross- finger Flap in Hand Reconstruction G Karthikeyan, Gopi Renganathan, R Subashini International Journal of Scientific Study | September 2017 | Vol 5 | Issue 6 A total number of 153 patients had a cross- finger flap done. Of these, 94 patients underwent a classical cross-finger flap, and 59 were modifications of the classically done cross-finger flap.
- 60. Proximally based cross-finger flap The proximally based flap design was used for defects on the dorsal aspects of the fingers In total, 12 patients All the flaps survived fully, and the donor sites healed well with complete recovery of range of motion of the donor finger.
- 62. Indications -defect on the dorsal/dorsolateral aspects of the middle or ring fingers or the ulnar or radial aspects of the index and little fingers respectively. -The defect was classically at the level of the PIP joint or proximal to it, as the distal most edge of the proximal CFF was the DIP joint crease on the dorsal aspect Disadvantages -A longer flap will have to be raised to allow it to transpose comfortably to cover the defect. -The bridging segment is longer than in the classical cross-finger flap.
- 63. Distally based cross-finger flap This flap was ideal for patients who had distal soft-tissue defects mainly on the dorsolateral aspect of the finger, Four patients ,All the defects were on the middle fingers Disadvantages • Can be used only for dorsolateral aspect of the fingers. • Can be used only for distal defects, distal to the PIP joint level.
- 65. • Cross-finger adipofascial flap
- 66. • Cross-finger adipofascial flap
- 67. • Reverse dermis cross-finger flap Disadvantage • There is a possibility of developing inclusion cysts from the de-epithelialized area under the flap.
- 68. Folded cross-finger flap • 10 patients • The back cut can compromise the vascularity of • the flap and result in partial necrosis of the dorsal aspect of the flap.
- 70. Innervated cross-finger flap Innervated cross-finger flapInnervated cross-finger flap
- 71. • When the debridement of the wound was done, the cut digital nerve stump was identified and tagged. • While the flap was being raised, the sensory twigs on the dorsal aspect of the finger were identified and tagged
- 72. Multiple cross-finger flaps Indication • Multiple soft-tissue defects on 2 or threefingers involving only the pulp tissue distal phalanx. In individuals with long fingers with pliable joints Advantage • Multiple finger defects can be treated simultaneously with the safe and reliable cross-finger flap. Disadvantage • Involves more pliability of the finger joints, hence may not be advisable in short,stubby fingers.
- 74. Thenar flap Advantages. • better colour and texture match, highly functional, durable and glabrous shell, good sensitivity and aesthetic outcome, less scarring, minimal donor harm • Young women and children tend to have more supple joints and are therefore good candidates for the thenar flap. disadvantages: • limited flap extend, two stage procedure, need of intensive rehabilitation
- 77. • Littler heterodigital neurovascular island flap island flap raised from the ulnar aspect of the middle or ring finger based on the ulnar digital neurovascular bundle in order to reconstruct Advantages. Versatile area of coverage,Sensate Disadvantage. Lose sensation on donor site, Cortical reorientation Tunneling risk of kinking Technically demanding Cold intolerance
- 80. Complications for fingertip reconstructions • Major ones are hypersensitivity andcold intolerance,The rates of hypersensitivity and coldintolerance approximate 50%regardless of the treatment, includinghealing by secondary intention, skin grafting, and local flap reconstruction. • This hypersensitivity and cold intolerance is self-limited and almost always resolves after 1-2 years. Initial treatment includes scar massage, desensitization, and edema control.
- 81. Regional flaps from forearm, • Reverse radial artery flap, • Reverse ulnar artery flap, • Posterior interosseous artery flap, • Dorsal ulnar forearm flap,
- 83. • thoraco-umbilical flap is supplied by paraumbilical perforators from the deep inferior epigastic vessels • The largest perforator is located at approximately 2 cm from the umbilicus, and directs toward the inferior angle of the scapula, anastomoses with the posterior intercostal artery and angulates 45° with the midline
- 84. Advantages. • The flap is technically easy to plan, almost effortless to drape around upper limb defects, with no significant donor site morbidity and also the post operative immobilization was fairly comfortable disadvantages. unsightly scar
- 86. • The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage Sharad Mishra and Ramesh Kumar Sharma Indian J Plast Surg. 2009 Jul-Dec; 42(2): 169– 175.doi: 10.4103/0970-0358.59274 -83 patient The thoraco-umbilical flap is a very useful flap for the coverage of upper-limb defects. A fairly large flap can be harvested and the donor site can be closed primarily in majority of the patients. . . Although the donor site scar is not concealed as in groin flap, majority of our patients accepted the donor scar because our traditional dresses conceal it anyway. This flap can become our workhorse for upper extremity defects, especially in an emergency setting, where defect size is large and/or emergency free flap is not feasible.
- 87. Thoracoumbilical Flap: Anatomy, Technique, and Clinical Applications in Upper Limb Reconstruction in the Era of Microvascular Surgery Ravikiran Naalla J Hand Microsurg. 2018 Apr; 10(1): 29–36. Published online 2018 Mar 20.doi: 10.1055/s- 0038-1630142 Pedicled flaps have a significant acceptable role in this era of microsurgery, and a pedicled TUF is a versatile option for coverage complex soft tissue defects of the forearm, wrist, hand, and fingers.
- 88. The groin flap • groin flap is a axial flap based on the superficial circumflex iliac artery arising from the femoral artery just below the inguinal ligament.
- 89. step ladder abdominal flap • If the defect is on the dorsum of the hand and extending on the dorsum of multiple fingers and extending beyond the interphalangeal joint • .
- 90. the defects extend whole of digit dorsumand more towards the ulnar side of the fingers: In such situations, the inferiorly based abdominal flaps are comfortable
- 91. • if the defects are more on the radial side, superiorly based abdominal flaps are more practical and useful.
- 92. • that one defect is on the radial side and one defect is on the ulnar side. radial side defect can have a superiorly based,and the finger with an ulnar side defect can have an inferiorly based abdominal flap. •
- 93. • the most cephalad flap is first raised, donor site closed primarily, the hand is placed again over the abdomen and the next finger defect is re planned tips
- 94. • flaps should follow the orientation of the fingers and not be planned in a straight line.
- 95. • stepladder flaps are random pattern flaps, 1:1 • a single layer of subcutaneous fat supports the dermal vascular network. This results in thin flaps that are pliable and cosmetically pleasing.
- 96. • Dermal substitutes • Modification of the reconstructive ladder incorporating dermal skin substitutes. (Adapted from Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011 Jan;127 Suppl 1:205S-212S
- 97. • Dermal substitutes are increasingly becoming an essential part of the burn care strategy. • Dermal substitutes are bio-matrices that fulfil the functions of the cutaneous dermal layer. • They act as matrices or scaffolds and promote new tissue growth and enhance wound healing , with enhanced pliability and a more favourable scar.
- 98. HUMAN-DERIVED NATURAL BIOLOGICAL MATERIALS 1) ALLODERM- human cadaver skin that has been chemically treated and freeze dried to remove all cellular material in the dermis. 2) GLYADERM- It is an acellular dermal collagen-elastin matrix obtained from human donorskin, preserved in 85% glycerol PORCINE-DERIVED NATURAL BIOLOGICAL MATERIALS Permacol,stratticeand Xenoderm. CONSTRUCTED OR ARTIFICIAL BIOLOGICAL MATERIALS 1)INTEGRA(GAG & cross-linked bovine tendon collagen-based dermal matrix ) outer layer of silicone which works as a temporary epidermis and serves to control moisture loss from the wound, The dermal layer contains many pores, and allow the optimal in-growth of patients’ own fibroblasts and endothelial cells,
- 99. • MATRIDERM • HYALOMATRIX SYNTHETIC MATERIALS • DERMAGRAFT( polyglactin (vicryl) mesh seeded with cryo-preserved neonatal allogeneic foreskin fibroblasts) • TRANSCYTE(semi-permeable silicone membrane and an extracellular matrix of newborn human dermal fibroblasts cultured on a porcine collagen-coated nylon mesh)