an atlas of flap in limb reconstruction

G
1
abductor hallucis
2 superficial branch I of medial plantar artery
3 cutaneous branch
4 medial plantar artery
5 lateral plantar artery
6 tibial nerve
7 posterior tibial artery
Blood supply to the lower limb
7
6
4
3
2
The plantar system is formed by
the division of the posterior tibial
artery
into
medial and lateral
plantar
arteries.
The
medial
plantar artery is the most interest-
ing. It is the basis of the medial
plantar flap (raised on the non-
weight-bearing area of the foot).
The medialis pedis skin flap is also
derived from the medial plantar
artery. Small muscles of the foot,
such as abductor hallucis brevis
and abductor ditigi quinti are
supplied by the plantar arteries,
and a dominant proximal pedicle
allows their mobilization as proxi-
mally based pedicled flaps for the
coverage of small areas of the
foot.

(Trang không có chữ)

3
Preoperative
planning

Preoperative planning
I ntroduction
When the patient is seen for the first time, it is very
important to spend enough time with him. Usually
the patient has had several procedures, some of
which have failed, and his attitude towards the
surgeon may show a hint of defiance.
Listening to the complete story is the first step. The
psychological state of the patient is critical. His co-
operation is needed, and he must have complete
confidence in the surgeon.
The defect is then assessed: its size, depth, infec-
tious status, duration, exposed bone and neighbour-
ing scars.
At that time several options are possible, and very
often the best choice is not possible right away. The
choice of local flap, microvascular flap or cross leg
flap is based on multiple factors. The joints of both
legs must be supple, as otherwise a cross leg flap is
not possible. Several deep scars or previous opera-
tions preclude the use of a local flap.
A microvascular flap needs a good recipient vascu-
lar pedicle. It may be necessary to perform an arteri-
ogram before the decision can be made.
Age, sex and occupation are assessed. Of great
importance is the existence of a smoking habit.
Complex lower leg reconstruction should not be
undertaken in a heavy smoker, especially if he needs
microvascular sutures. The patient should be made
aware of the higher rate of complications in smokers,
and should be ready to stop smoking at least 3 weeks
before the operation. We will not carry out microvas-
cular transfer in a patient who is not willing to stop
smoking.
Quite often the necessity for more investigations (X-
rays, arteriograms, blood tests) will not allow a defini-
tive choice at the first consultation and the patient
will have to be seen again.
when the decision is taken, it is very important to
inform the patient fully and in depth. He has to under-
stand:
• The technique used, with details of donor site, the
duration
of
operation,
and the postoperative
immobilization.
• The postoperative course: time in bed, when he
will be allowed to walk and the possibility of
complications.
The patient also has to know about the cosmetic
aspects of the operation: how long the flap will stay
bulky and the possibilities of secondary debulking.

The operation
The day before the operation, the operative plan is
reviewed with the patient. It is necessary to check
that he has stopped smoking.
The donor and recipient areas are prepared widely.
In case of doubt a second donor area will also be
prepared.
It is necessary to re-explain to the patient
whether he has to stay in bed for several days
postoperatively (free flap) or in a special uncom-
fortable position (cross leg flap). The rule is that the
average patient is always surprised by the post-
operative course.
The operation always starts with the recipient area.
It would be a serious mistake to start with the flap
dissection. During the preparation of the recipient
area a problem may arise, and there may be a change
in the site or the shape of the defect.
It is necessary to allow for two different possibili-
ties:
Replacing a scar. The scar is excised completely
before measuring the defect, as retraction may
make it larger. The borders must be excised until
the skin is supple and can be undermined, allow-
ing appropriate suture of the flap.
Covering a defect. The aims are different and the
most important is to cover the important struc-
tures such as bone, tendon and nerve; determin-
ing the size of the defect does not therefore
automatically give the size of the flap. In large
defects where large areas are covered by granu-
lating tissue, the flap does not need to cover the
whole defect. It is possible to simultaneously use
a flap to cover the important structures and skin
grafts on the granulating tissue, thus reducing the
size of the flap. This is a better solution than
putting a flap on granulating tissue, which can
lead to infection.
The main problem is, of course, the size of the
defect, but the depth may also present problems. In
some instances the defect is almost a deep hole, such
as in the treatment of osteomyelitis. The choice of the
flap will be critical.
Infection has to be minimized by a very thorough
excision. It can usually be done as one stage with the
flap, but, in some instances of severe infection, a two-
stage debridement is necessary.
Once the recipient area is prepared, it is carefully
measured, wet antiseptic gauze is applied and the
flap is raised with a new set of instruments. Rais-
ing the flap has peculiarities according to the
type of flap: island, fasciocutaneous, muscle or free
flap.
Raising an island flap
The operation
The raising of a fasciocutaneous island flap needs to
follow very strictly the principles of flap design,
pedicle dissection and length and rotation axis.
Design of the flap
This is based on the knowledge of the vascular terri-
tory of the arterial pedicle. The flap sometimes has to
be larger than the defect, depending on the retractil-
ity of the skin. Some flaps (supramalleolar flap)
contract more than others (medial plantar flap). In
general the flap should be slightly larger than the
recipient area, but not excessively, so that the place-
ment will be done with some tension.
Anatomy of the pedicle
Only the axial pattern flaps have a fixed pedicle
length, determined by the distance between the
origin of the artery and its penetration into the subcu-
taneous tissue. In contrast, a septal pattern flap may
be raised at different levels of the artery, according to
the number of cutaneous branches. A radial flap may
be raised at various levels of the forearm, but the
more extensive the flap, the shorter the pedicle.
We can say that:
• In axial flaps, the pedicle is a fixed factor but the
size of the flap may vary.
• In septalflaps, the vascular axis is constant but the
size of the flap and the length of the pedicle vary
in opposite directions.
The rotation axis
This is defined by the fixed origin of the pedicle, and
its range is determined by the length of the pedicle
and the length of the flap.
Raising a fasciocutaneous flap
The incision is made over a half-circumference of the
flap and over the pedicle. This type of incision has
the following advantages:

Preoperative planning
• The flap may be left in place if its vascularity or the
pedicle anatomy are not satisfactory.
• The vascular dissection is easier when the physio-
logical tension is maintained. In order to avoid
vascular injury to the pedicle, the deep fascia is
fixed to the dermis with resorbable sutures.
Dissection of the vascular pedicle
Each artery is accompanied by two venae comitantes
which are sufficient to ensure a satisfactory venous
outflow. Dissection must proceed away from the
vessels, keeping a perivascular protective sheath and
avoiding coagulation. The branches are ligated with
clips. If the dissection is too close, spasm may occur.
Haematoma should also be avoided by a careful
haemostasis.
Raising a muscle flap
The design and raising of a muscle flap must obey
several rules.
It is essential to understand the vascular anatomy of
the muscle, according to one of the five groups classi-
fied by Mathes and Nahai. Each muscle has specific
characteristics and its dissection will be determined
by the situation of the neurovascular hila, the number
and size of the muscular heads, and the individual
variations in length and thickness. The extent of
dissection
will
vary with these factors; in some
patients, gastrocnemius may have a muscle belly 30
per cent longer than in others.
Several techniques may be useful in the dissection
of a muscle flap:
• When using some small leg muscles such as flexor
hallucis longus or even tibialis anterior, the distal
part of the muscle belly may be detached from the
tendon and used as a rotation flap without inter-
rupting the continuity of the tendon.
• Some muscles (gastrocnemius) have a very thick
and extensive deep fascia. It is possible to lengthen
the flap by excising the fascia or even by incising
it at different levels.
This excision of the deep fascia also allows an
immediate skin grafting.
Mobilization of the flap may be done in several
ways - simple rotation, advancement, or turning
it upside down. It is possible in some cases to cut
both extremities of the muscles in order to move it
better.
When possible, the motor nerve of the muscle
should be cut in order to avoid contraction of the
muscle and sometimes pain in the long term.
Insetting the flap
Quite often the flap and its pedicle are distant from
the defect. They may be separated by a narrow skin
bridge or a larger one with poor-quality skin or several
scars. In both cases the skin bridge should be opened
and the pedicle left superficial, covered only by its
own skin or a skin graft.
If the skin bridge is large, there are two possibili-
ties:
Tunnelling the flap can be done either subcuta-
neously, which causes a risk to the skin vascular-
ization or subfascially, in which case there may be
a risk of compression. It is possible to split the
fascia subcutaneously, which allows a better space
for the pedicle.
If there is a risk of compression it is preferable to
split the skin band and let the pedicle he exposed.
The skin flaps may be closed partially over the
pedicle. A skin graft is usually necessary.
Donor site
Due to peripheral retraction, the donor area becomes
larger than the flap. This size can be reduced by
suture of the dermis to the deep tissues. If the depth
of the donor defect is not too great and if the area is
of good quality (muscle), a split skin graft can be
applied at the time of flap transfer. If not, it may be
necessary to wait a few days for good granulating
tissue before grafting. The cosmetic result may even
be better.

Postoperative care
This is essential and every little detail has an influence
on the result.
Dressing
The suture line is covered with antibiotic cream or
gauze. The dressing should be thick, with cotton, and
not tight. It will allow the nurse and doctor to monitor
the flap through an opening at the strategic area.
Elevation
The flap is kept slightly elevated, at the level of the
heart, but not too high since the blood pressure
decreases very quickly with elevation.
Postoperative period
This should be quiet and pain-free, since we know
that surgery and pain are responsible for spasm. Pulse
and blood pressure are monitored during the first 24
hours.
Fluid replacement must be adequate to ensure
maintenance of normal blood pressure. If there was
blood loss during the operation it is better not to
replace it completely, but to use other fluids instead.
In some instances we use vasodilating drugs and/or
aspirin. Antibiotics are routinely used_
Monitoring the flap
The immediate postoperative period and first 48
hours are critical, especially after a microsurgical
transfer.
The flap is observed, and its colour is noted; its
capillary filling and its temperature are important.
Postoperative care
Immediately after operation there may be changes in
the normal vasomotor system, and the flap may be
pale or slightly congested. It is possible to regulate
this flow by modifying the elevation of the limb. This
may be necessary several times during the day.
If the flap stays very pale, with no capillary filling,
a small incision may show no bleeding: this is proba-
bly an arterial thrombosis and the only treatment is
reoperation. If the flap shows congestion and
progressive appearance of purple spots, it is proba-
bly a venous thrombosis. It may be treated by opera-
tion or (in the case of a skin flap only) by the use of
leeches. These should be medical grade leeches and
used approximately four to six times a day (one at a
time). Between leech applications, the wound is left
bleeding. After 5-7 days they are no longer necessary.
Monitoring of the blood loss is mandatory, and blood
may need replacement.
In pedicle flaps the monitoring is different, as in
some island flaps with a long pedicle the flap may
stay pale for the first 24 hours. It is necessary to avoid
secondary venous congestion at the borders of these
flaps. The whole dressing must be changed every day
in order to observe the entire flap. If purple areas
appear at the borders, leeches must be applied to
avoid partial necrosis. Usually one or two leeches a
day for 2 or 3 days are enough.
Muscle flaps are difficult to monitor, especially if
they are covered with skin grafts. The colour and
bleeding are observed. In a free flap an anomaly may
lead to reoperation. In a pedicle flap we have no
effective treatment.
When the flap is on the upper extremity, the
patient may walk the next day. When the flap is on
the lower limb, the patient is kept in bed for a few
clays and is not allowed to walk for 2 weeks. For a
plantar flap the delay is 3 weeks.
Drainage under the flap is not routine and a drain
may be removed after 24 or 48 hours. The drainage
of the donor area, especially after a muscle flap
(soleus) operation in the leg, is very important and
must be maintained for 5-6 days.
When a lower extremity flap is healed, it is neces-
sary for the patient to wear an elastic bandage for 1
or 2 months to control oedema.
Secondary surgery or defatting procedures are
usually delayed for at least 12 months.

(Trang không có chữ)

4
Transfers from
the upper limb

Transfers from the upper limb
Arm and forearm
I ntroduction
The arm and forearm provide numerous island pedicle
flaps. The great advance in the 1980s was the design
of distally based flaps supplied by a retrograde arterial
flow. Initially described at the level of the hand by
using the reversed `Chinese' flap, this concept has
been extended to any level where a vascular anasto-
motic circle is constant. All the joint areas are
provided with anastomotic circles and constitute
pivotal sites for flaps which can be designed proximal
to the joint.
At the arm and forearm very few muscles can be
raised
without
great
functional
impairment.
Brachioradialis is an exception; flexor carpi ulnaris is
only used in tetraplegic patients. The little muscles of
the wrist and hand - quadrator pronatus, abductor
digiti quinti and the first interosseous muscles - are
not recommended.
Fasciocutaneous flaps are
more suitable than
muscle flaps at the upper limb, as they provide a
supple skin and a deep gliding surface for the under-
lying muscles and tendons.
Posterior arm flap
Introduction
The posterior arm flap, initially described as a free
flap, is here presented as a rotation flap. It is a
fasciocutaneous flap raised from the posterior aspect
of the arm with an axial pattern vascularization.
Indications
The posterior arm flap no longer has indications as a
free flap. Nonetheless, it is indicated as a rotation flap
in the axilla repair when latissimus dorsi is not
suitable and when the scapular flaps are not available.
The arc of rotation of the pedicle allows coverage
of the anterior aspect of the proximal third of the arm
and the armpit. The donor site can be primarily
closed if the width of the flap does not exceed 5 em.
The use of the flap is not advocated when the
subcutaneous tissue is very thick.
Vascular and nerve supply
The flap is supplied by the cutaneous branch of the
dominant artery devoted to the medial head of
triceps. This artery raises from either the branchial
artery or the profunda brachii. It gives off a muscu-
lar branch to the medial head of triceps. The
cutaneous branch enters the posterior aspect of the
arm at the angle between triceps and latissimus dorsi.
The artery is accompanied by venae comitantes and
the posterior cutaneous nerve of the arm. The
pedicle passes beneath a fibrous band which joins
triceps to latissimus dorsi and then runs parallel to
the long axis of the arm. The diameter of the artery,
at its origin, is about 1.5 mm. The length of the
pedicle is 4.5 cm.

Operative procedure
A,B
The distal margin of the flap
lies at the junction of the middle
and distal thirds of the arm, and
the location of the pedicle marks
the proximal extent of the flap.
The entrance of the pedicle into
the flap is precisely located by the
small depression at the crossing of
the tendons of latissimus dorsi
and triceps. This landmark should
be included in the design of the
flap.
The flap is raised, beginning the
dissection distally and including
the deep fascia.
A
1 site of pedicle
2 outline of flap
B
1 triceps
2 vascular pedicle
3 aponeurosis of the flap
Posterior arm flap
1
2
3

Transfers from the upper limb
C The dissection is continued
proximally and medially until the
pedicle is identified, running
beneath the fibrous band. The
fibrous band is divided to release
the pedicle, the origin of which
can now be seen arising from the
branchial vessels. The muscular
mobilized to cover a defect of the
axilla following the release of a
contracture.
c
1
fibrous band from triceps to
latissimus dorsi tendon
2 neurovascular pedicle
branch to the medial head
of
triceps
should
be ligated
and
divided to increase the arc of
rotation.
D The
flap
can
now
be

Lateral arm flap
Introduction
The lateral arm flap was initially described as a free
flap. This fasciocutaneous flap is raised on the lateral
aspect of the arm and supplied by a `septal pattern'
vascularization.
I ndications
It can be used as a local flap to cover defects over the
shoulder and elbow and may have either a proximal
or a distal pedicle. With a proximal pedicle the flap
can reach to the corticoid area or the axilla. This
procedure may constitute an alternative to the poste-
rior arm flap or the scapular flap. Nonetheless, the
cosmetic prejudice at the donor site cannot be
regarded as negligible. With a distally based pedicle
the flap is an excellent procedure to resurface the
anterior or the posterior aspects of the elbow.
The free flap is chiefly used in hand surgery. The
flap can be raised on the ipsilateral limb. The length
and the diameter of the vessels ensure reliable micro-
surgical anastomoses; however, profuse hairiness can
sometimes be an inconvenience.
Vascular and nerve supply
Lateral arm flap
The flap is supplied by septal arteries arising from the
posterior descending branch of the profunda brachii,
which anastomoses with the posterior recurrent
interosseous artery in the subcutaneous tissue of the
lateral aspect of the elbow.
The anterior descending branch of the profunda
brachii is not suitable to provide the basis of the flap
because of its variation and the proximity of the radial
nerve, which runs in the groove between brachiora-
dialis and brachialis.
The posterior branch of the profunda brachii runs
downwards between brachialis and triceps.
The pedicle of the flap can be dissected practi-
cally as far as the origin of the profunda brachii on
the brachial artery. The length of the pedicle may
reach 7-8 cm and the diameter of the artery is 2-2.5
mm.
Two nerves should be considered in the pedicle: a
small nerve, arising directly from the radial nerve,
which supplies the territory of the flap; and the poste-
rior cutaneous nerve of the forearm, which passes
through the deep fascia proximal to the lateral
epicondyle and supplies the skin over the posterior
aspect of the forearm.

Transfers from the upper limb
The proximally
based flap
Operative procedure
The procedure is the same for a
pedicled flap or a free flap.
A The flap is outlined on the
distal third of the lateral aspect of
the arm. It can be extended over
the lateral condyle. The axis of the
flap and the proximal incision
needed to dissect the pedicle are
traced along a line between the
acromion and the epicondyle.
A
1
i ncision to expose the pedicle
2 design of the flap
B The deep fascia is incised in
line with the skin, and the poste-
rior half of the flap is released
from the underlying triceps
muscle until the septum is seen.
The septum is inserted on the
humeral bone. It separates the
anterior
and
the
posterior
compartments of the arm and
contains the posterior descending
branch of the profunda brachii.
B
1 septum containing posterior
descending branch of the deep
brachial artery
2 humerus
3 triceps

D
1 triceps
2 posterior antebrachial cutaneous
nerve
3 brachioradialis
4 biceps brachii
5 deltoid
5
The proximally based flap
C The same dissection is
performed for the anterior part of
the flap
from the underlying
muscles,
which are brachialis,
brachioradialis and the extensors.
C
1 septum containing the vessels
2 humerus
3 extensor carpi radialis longus
4 brachioradialis
5 brachialis
D
The proximal skin incision is
then achieved and the plane is
identified between the deltoid and
the triceps muscles.

Transfers from the upper limb
E The triceps and the deltoid
muscles are retracted to expose
the vascular pedicle of the flap
and the radial nerve.
The profunda brachii and its
venae comitantes are cautiously
separated
from the nerve. The
descending anterior branch of the
profunda brachii is ligated and
divided. The two nerves, one of
which supplies the flap and the
other of which passes through the
flap, are identified. The septum is
then incised close to the bone to
release the flap. The vessels are
ligated distal to the flap.
9
8
E
4
1 triceps
2 posterior antebrachial cutaneous
nerve
3 inferior lateral brachial cutaneous
nerve
4 extensor carpi radialis longus
5 brachioradialis
6 posterior descending branch of the
deep brachial artery
7 anterior descending branch of the
deep brachial artery, to be cut
8 biceps brachii and brachialis
9 radial nerve
10 deep brachial vessels
11 deltold

F
arc of rotation of proximally based
pedicled island flap
Lateral arm flap
F
Retraction
of
deltoid
and
triceps permits the exposure of
the origin of the pedicle. The arc
of rotation of an island pedicled
flap allows coverage of the shoul-
der.

Transfers from the upper limb
The distally based
pedicled flap
The
distal
design
is
usually
performed when coverage of the
arterior aspect of the elbow is
needed.
Operative procedure
G The flap is outlined on the
distal third of the lateral aspect of
the arm. A short distal incision
allows
the
mobilization
of the
distal pedicle.
H The posterior incision is
made first and deepened to
expose the triceps. Anteriorly, the
flap is dissected from brachioradi-
alis to expose the intermuscular
septum
within
which lies the
posterior descending branch
of
the profunda brachii.
H
1
biceps and brachialis
2 brachioradialis
G
1
proximal design
2 distal design

The distally based pedicled flap
I
The
posterior
descending
branch of the profunda brachii is
ligated at its origin. Another possi-
bility is to ligate the profunda
brachii proximal to its division
and the anterior descending
branch. The septum is released
from the humerus.
1 brachioradialis
2 recurrent radial artery
3 biceps and brachialis
4 radial nerve
5 ligature around the posterior
descending branch of profunda
brachii
6 triceps
7 posterior descending branch of
profunda brachii
J
A short fasciosubcutaneous
pedicle is dissected and mobilized
distal to the flap. It contains the
anastomoses
between the de-
scending
branch
of
profunda
brachii and the posterior recur-
rent interosseous artery
which
supply the flap. The flap can be
rotated anteriorly or posteriorly
for covering the elbow area.
J
1 distal vascular pedicle

Transfers from the upper limb
Other procedures
The fascial flap
This has the same rules of dissection. The flap is
exposed by a subdermal dissection, leaving subcuta-
neous tissue over the fascia and under the skin. The
size of the flap is limited by the risk of skin necrosis.
The osteocutaneous flap
A portion of cortical bone can be included in the flap.
In order to facilitate the dissection, a small cuff of
triceps and brachioradialis should be included in the
transfer.
Brachioradialis flap
I ntroduction
Brachioradialis is an accessory flexor of the elbow. It
can be raised as a pedicled transfer without functional
prejudice.
I ndications
Brachioradialis is only used as a pedicled flap. Its
principal indication is the coverage of the anterior
aspect of the elbow, especially when the joint is
exposed. The arc of rotation allows coverage of the
lateral aspect of the joint as far as the olecranon. It
can be used as a myocutaneous flap, including the
skin territory overlying the muscle. This procedure is
not advocated because the donor site would not be
primarily sutured.
The brachioradialis transfer has also been described
as a distally based island flap on the radial artery. This
is an interesting application, but it implies the sacri-
fice of the radial artery. Indications of this procedure
are not common, especially as numerous flaps are
available in the region.
Vascular and nerve supply
The brachioradialis flap is type II in the classification
of Mathes and Nahai. Blood supply is ensured by
several pedicles.
The proximal pedicle is the most important. It
arises from the anterior recurrent radial artery
in the bicipital groove, deep to the muscle.
This pedicle is sufficient to supply all of the
muscle.
Several smaller pedicles (2-4) arise from the radial
artery. They do not constitute a reliable vascular-
ization for the muscle when the proximal pedicle
is severed.
Nerve supply is derived from the radial nerve via
two or three small rami arising in the bicipital
groove.

Operative procedure
A The skin incision is outlined
on the radial border or the
forearm; it can be extended proxi-
mally in the bicipital groove.
A
1
skin incision
B
Brachioradialis flap
B The deep fascia is incised in
line with the incision.
Several transversal communicat-
ing veins should be ligated. Care
should be taken concerning the
cephalic vein and the anterior
nerve of the forearm.
1
brachioradialis
2 cephalic vein

Transfers from the upper limb
C The muscle and its distal
C
tendon are identified. The sensory
1 brachioradialis
branch of the radial nerve is
2 sensitive branch of radial
recognized on the lateral border
nerve
of the tendon.
3 radial artery
The tendon is isolated and
4 cephalic vein
divided.
D
7
6
5
4
3
1 brachioradialis
2 extensor carpi radialis brevis
3 radial artery
4 sensitive branch of radial nerve
5 extensor carpi radialis longus
6 flexor carpi radials
7 small pedicle from radial artery
3
4
3
D The muscle is progressively
released, distal to proximal, taking
care with the radial nerve. The
radial
artery
and its venae
comitantes are deeper.
Several small arteries issuing
from the radial artery to the
muscle should be cauterized or
ligated.

Brachioradialis flap
E
The rotation of the flap
permits coverage of the anterior
aspect or the lateral aspect of the
elbow.
The dissection can be extended
more proximally in the bieipital
groove to release the proximal
insertion of the muscle on the
humerus.

When the Chinese flap appeared in the 1980s it
undoubtedly opened a new chapter in reconstructive
surgery. Three main concepts were raised by the
Chinese flap:
1 A new mode of vascularization of flap. The forearm
flap was not an axial pattern flap because the
pedicle did not belong to the skin territory. This
type of flap is now called a flap with meso (loose
connective tissue), as the flap is nourished by small
arteries in a very thin membrane which links the
vascular axis and the flap.
2 A very wide range of applications, as the flaps
could be used in any way, pedicled or free.
3 Most surprisingly, the possibility of using this flap
with an arteriole retrograde flow. We have already
emphasized this point, which has revolutionized
the indications for the repair of hand defects.
The forearm flap is a versatile and reliable fascio-
cutaneous flap raised on the anterior aspect of the
forearm.
Indications
Indications for the forearm flap overlap with those for
reconstructive surgery of the limb.
The proximally based pedicle island flap can be
used for soft-tissue defect repair of the elbow.
The distally based pedicled island flap is used for
repairing defects of the hand and digits.
The free flap has many applications in head and neck
surgery, urology and limb reconstructive surgery In
a complex defect the radial artery can be utilized for
repairing a main vascular axis. A composite transfer
can be raised, including a piece of bone from the
radius, tendons, nerves and even brachioradialis.
The intensive use of the forearm flap over many
years has unmasked its drawbacks:
• A profuse hairiness in Caucasians which impairs
some recipient sites.
The sacrifice of the radial artery, resulting in a slight
lack of strength for the muscles of the forearm and
cold intolerance in the hand.
The cosmetic prejudice of the donor site.
Many procedures can palliate these drawbacks, but
for now the forearm flap tends to be supplanted
especially in hand surgery, by other, less problematic,
flaps.
Vascular and nerve supply
The flap is supplied by the radial artery, from which
arise many small arteries which perforate the anterior
brachial fascia. These small vessels are more abundant
in the distal third of the forearm than in the proximal
third. In the proximal third the skin is also supplied by
the arterioles arising from the underlying brachioradialis
muscle. A systematic description of the precise blood
supply cannot be given, as the number of arterioles is
variable. Nonetheless, three main branches are constant:
1 A proximal branch which arises near the origin of
the radial artery, or sometimes from the anterior
recurrent radial artery, and which can be consid-
ered as a long-course artery. It supplies a rather
long skin territory located on the anterolateral
aspect of the proximal half of the forearm.
2 A mid-course branch which arises 7-8 cm proximal
to the styloid process of the radius.
3 A distal branch which arises 2 cm proximal to the
styloid process runs beneath pronator quadrants
and supplies the metaphyseal region of the radius,
which can be included in the transfer.
Venous return is ensured by the venae comitantes
which have a diameter of more than 1 mm close to the
elbow, and by the superficial venous network of the
forearm. In the case of a distally based island pcxlicled
flap it is not necessary to include a superficial vein.
Sensibility is
mainly supplied by the anterior
cutaneous nerve of the forearm, but the discrimina-
tive sensibility is poor and the forearm free flap
cannot be considered as a true neurovascular flap.
Theoretically, all the skin of the forearm can be
raised on the radial artery. In practice, however, the
limits of the flap are the border of the ulna, medially,
and the midline of the dorsal aspect of the forearm,
laterally, including the volar skin.
Transfers from the upper limb
Forearm flaps
Introduction
•
•

Forearm flap with a
distal pedicle
Operative procedure
The patient is placed supine with
the arm abducted on a hand table.
Allen's test should be performed
before
surgical
procedure
to
assess the viability of the ulnar
artery.
B
Distally to the flap, the incision
is made over the radial vascular
axis to expose the pedicle. Proxi-
mally to the flap, a short incision
allows the control of the radial
artery. The superficial veins which
cross the flap are ligated.
B
Forearm flap with a distal pedicle
A
The flap is marked on the skin
approximately over the middle
third of the anterior aspect of the
forearm. The length of the pedicle
needed to allow the flap to cover
the defect is estimated. Two pivot
points can be defined for the
pedicle.
When the defect is
located on the dorsum of the
hand, the pivot point is at the
base of the thenar eminence just
proximal to the division of the
radial
artery.
When a longer
1
brachioradialis tendon
2 superficial vein, to be Ilgated
3 radial artery with venae comitantes
pedicle is needed, the pivot point
is at the apex of the first web,
which implies the inclusion of the
deep branch of the radial artery in
the
pedicle
and
passing
the
pedicle and the flap under the
tendons of the thumb.
A
1
pivot point of vascular pedicle in the
first web
2 design of the flap
3 course of the radial artery

Transfers from the upper limb
C Dissection is begun on the
ulnar side, including the fascia,
until it reaches the lateral border
of the flexor carpi radialis. The
muscle and its tendon are then
D
On the radial side, the flap is
released
from the
underlying
brachioradialis
muscle.
Care
should be taken with the sensory
retracted ulnar-wards to deepen
the dissection in order to spare
attachments of the meso and the
radial artery to the flap.
branch of the radial nerve. On the
medial border of brachioradialis
the dissection is deepened to pass
beneath the radial artery.
C
1 brachioradialis tendon
2 palmaris longus tendon
3 flexor carpi radialis
4 brachioradialis
5 radial artery and veins
rx uK•n yG
D
1 flexor carpi radials tendon
2 sensory branch of radial nerve
3 brachioradialis

E The radial artery and venae
comitantes are then clamped. The
tourniquet is released to verify the
vascularization of the flap and of
the hand. The tourniquet is then
reinflated and the vascular axis is
Forearm flap with a distal pedicle
divided proxirnal to the flap. The
flap and its vascular axis are pro-
gressively released from the under-
lying
flexor
muscles.
Diathermy
should be applied to the numerous
small arteries to the muscles.
F
The flap and the pedicle have
been completely released as far as
the base of the thenar eminence.
The flap reaches the first phalanx
of the fingers but cannot cover
the distal end of the digits.
E
1
flexor digitorum superficialis
2 flexor carpi radialis
3 brachioradialis

Transfers from the upper limb
G In order to increase the
length of the pedicle, an incision
is made over the snuffbox as far
as the apex of the first web.
H
The deep branch of the radial
artery is identified and released
from the floor of the snuffbox as
far as the apex of the first web,
where it plunges between the two
heads of the first interosseous
muscle. ligaion of the superficial
G
branch is necessary. Sometimes,
ligation of the branch to the
carpus and the first dorsal inter-
metacarpal artery is needed. Care
should
be
taken
with
the
branches of the radial nerve.
The tendons of abductor polli-
cis longus and extensor brevis are
isolated and their sheath is slightly
released from the styloid process
of the radius to allow the passage
of the flap. The flap and the
pedicle are also passed beneath
extensor pollicis longus.
H
1 abductor pollicis longus
and extensor pollicis
brevis tendons
2 superficial palmar
branch of the radial
artery
3 radial artery
4 sensitive branches
from radial nerve
5 dorsal carpal arterial
arch
6 radial artery (deep
branch)
7 extensor pollicis longus
tendon

I
The provided arc of rotation
allows the flap to cover the
extremities
of the digits. The
donor site is covered by a split-
thickness
skin
graft
after
the
Forearm flap with a
proximal pedicle
The
operative
procedure is
similar
to
that
for
a
distal
pedicle. The flap is marked on
the skin over the distal third of
the
forearm.
A short distal
Forearm flap with a distal pedicle
tendons of flexor carpi radialis
and brachioradialis are brought
together. A cast immobilization is
required
to
obtain
the
graft
healing.
incision is made to ensure the
control
of the radial artery.
Proximally, the pedicle can be
dissected up to its origin from
the brachial artery. The flap is
mobilized
on
the
proximal
pedicle and the radial artery and
its venae comitantes are ligated
distal to the flap.

Transfers from the upper limb
Other procedures
The fascial flap
The fascial flap is obtained by a subdermal dissection,
leaving subcutaneous tissue on the fascia. The size of
the flap is limited by the risk of skin necrosis.
The osteocutaneous flap
The distally based flap may include a piece of bone
raised in the diaphysometaphyseal region of the
radius. A cuff of pronator quadratus should be
included in the transfer to protect the vascularization.
Posterior interosseous flap
Introduction
The posterior interosseous flap is a fasciocutaneous
flap supplied by the posterior interosseous artery; it
is raised on the dorsal aspect of the forearm. The
posterior interosseous flap can be considered as the
paradigmatic septocutaneous flap, as the posterior
interosseous artery is contained in a true fibrous
septum.
Indications
The flap is used most frequently with a distal pedicle
to cover soft-tissue defects on the dorsum of the hand.
Areas which can be covered by this flap depend on
the size of the flap and the length of the pedicle: the
bigger the flap, the shorter the pedicle. When a flap
of moderate size (5 x 4 cm) is raised, the pedicle will
allow it to reach the first web space and the whole
of the dorsal and palmar aspect of the hand.
The flap can reach the proximal phalanges of the
digits. The posterior interosseous flap can, on rare
occasions, be used with a proximal pedicle. Small
defects over the olecranon can be covered with this
flap.
Vascular supply
The common interosseous artery arises from the ulnar
artery at the level of the radial tuberosity and divides
into the posterior and anterior interosseous arteries.
The posterior interosseous artery runs deep to supina-
tor and enters the posterior compartment of the
forearm. The surface marker of its point of entry is
the junction of the middle and proximal thirds of a
line drawn from the lateral epicondyle to the distal
radio-ulnar joint. The artery is accompanied by the
posterior interosseous nerve, which soon divides into
sensory and motor branches. A small sensory branch
and two venae comitantes accompany the artery as
far distally as the wrist.
The pedicle enters the septum between extensor
digiti minimi and extensor carpi ulnaris. Along its
course, the posterior interosseous artery gives off
several cutaneous arteries, numbering between 7 and
14. The largest of these arteries is proximal. At the
wrist, the artery anastomoses with the perforating
branch of the anterior interosseous artery, the dorsal
carpal arch and the vascular plexus surrounding the
ulnar head.

Operative procedure
A
The elbow is flexed to a right
angle and the lateral epicondyle
and distal radio-ulnar joint are
marked on the skin. The line
which joins these two points is
the axis of the flap. The vascular
pedicle is located just distal to the
junction of the middle and proxi-
mal thirds of this line. If a small
flap is required, the flap should be
raised predominantly distal to the
vascular pedicle.
A huge flap can be raised,
extending as far proximally as the
elbow. Theoretically, it is possible
to raise all the dorsal skin of the
forearm on this vascular pedicle.
When the flap is raised with a
distal
pedicle,
the
pedicle is
dissected on the distal radio-ulnar
joint and the flap is rotated
around this point to its desired
position.
B An incision is made on the
posterolateral border of the flap
and is extended distally as far as
the distal radio-ulnarjoint in order
to expose the vascular pedicle.
The intermuscular septum is
defined by identification of the
septa( arteries that pass through
the deep fascia to the skin.
A
1
lateral epicondyle
2 outline of flap
3 emergence of the pedicle
4 distal radio-ulnar joint
B
1 extensor digitorum communis
2 cutaneous pedicle within the
septum
3 aponeurosis
Posterior interosseous flap
2
3

Transfers from the upper limb
C The fascia is incised on both
sides of the septum. Extensor carpi
ulnaris is retracted towards the
ulna,
and extensor digiti minimi
and extensor indicis proprius are
retracted to the radial side. This
allows exposure of the posterior
interosseous artery distal to the
flap. The flap is then raised with
the
deep fascia, beginning the
dissection on the radial side. The
septum between extensor digito-
rum communis and extensor digiti
minimi should be divided. One
must take care not to divide the
intermuscular
septum,
between
extensor digiti minimi and exten-
sor carpi ulnaris, which contains
the skin arterioles.
The plane of the dissection is
defined between the two above
muscles and extensor digiti quinti
is gently retracted.
D It is sometimes necessary to
release the deep arch of extensor
digitorum communis in order to
obtain a clear view of the artery
as it emerges from deep to supina-
tor.
D
1
emergence of the posterior
interosseous artery
2 anastomosis of the posterior
i nterosseous artery with the
posterior perforating branch of the
anterior interosseous artery
c
1
extensor carpi ulnaris
2 posterior interosseous artery with
venae comitantes
3 extensor indicis proprius
4 interosseous membrane
5 extensor digiti minimi
6 extensor digitorum communis
5
2
3
4
2

E
Proximally, the artery must be
dissected
from
the
posterior
interosseous nerve, which lies on
its lateral side. Optical magnifica-
tion
and
microsurgical instru-
ments should be used at this
stage. Sometimes the motor nerve
to
extensor carpi ulnaris runs
superficial to the artery, which
should be ligated distal to this
most important motor nerve.
The ligature of the posterior
interosseous
artery should be
performed just proximal to the
first arteriole to the flap.
E
1
supinator
2 posterior interosseous nerve
3 proximal ligature of the posterior
interosseous artery
4 extensor carpi ulnaris
5 extensor indicis proprius
6 abductor pollicis longus
7 extensor digiti minimi
F
The medial border of the flap
overlying extensor carpi ulnaris is
then incised and the pedicle
within the septum is dissected
from the ulnar shag The distal
vascular anastomotic arch is also
released
from the interosseous
membrane.
F
1 ulnar shaft
Posterior interosseous flap

Transfers from the upper limb
G The ligature of the mmus
perforans of the anterior inter-
osseous artery allows the pivot
point of the pedicle to be placed
more distally on the vascular
network of the wrist. This proce-
dure increases the arc of rotation
of the pedicle.
G
1 ulna
2 extensor carpi ulnaris
3 anastomotic vascular arch
6 extensor Indicis propros
4 vascular network of the wrist
7 extensor dlgiti quinti
5 ramus perforans (posterior) of
8 extensor pollicis longus
anterior interosseous artery
9 extensor digiforum
H
The flap can now be mobilized
to reach the dorsal aspect of the
hand, including the first web space.
The dorsal aspect of the proximal
phalanx can be covered.
The donor site can be covered
by an immediate split-thickness
skin graft when a primary suture
is not possible.
8
7
6
5

Other procedures
The fascial flap
As for the forearm flap, a fascial flap of modest size
can be raised by a subdermal dissection.
The osteocutaneous flap
Theoretically, it is possible to include in the flap a
piece of cortical bone from the ulna. A small cuff of
muscle from extensor carpi ulnaris should be included
to protect the vascularization of bone. However, the
cortical bone is not easy to raise, because the ulna is
Posterior interosseous flap
rather thin. Moreover, the blood supply from the
posterior interosseous artery to ulnar bone is not
reliable. This procedure is not recommended.
The proximally based island pedicled flap
This is an interesting procedure to cover small defects
over the olecranon. The flap is designed on the distal
part of the forearm proximal to the distal radio-ulnar
joint. The pedicle is isolated until its emergence. It
may be possible by a proximal dissection to divide
supinator in order to increase the length of the
pedicle.

Transfers from the upper limb
Distal ulnar artery flap
Introduction
The distal ulnar artery flap is a fasciocutaneous flap
raised an the ulnar side of the wrist and forearm. Its
axial pattern vascularization is based on a cutaneous
branch of the ulnar artery.
I ndications
'the flap is chiefly used to resurface defects over the
anterior aspect of the wrist, especially when well-
vascularized tissue is needed to cover the median
nerve which may be surrounded by dense scar tissue
following previous injury or surgery. In these indica-
tions, it may be preferable, if the skin is of suitable
quality, to use a fascial flap which can be wrapped
around the nerve in order to protect and to supply it.
The distal ulnar artery flap can also be used to reach
the dorsal aspect of the wrist and hand. The small
length of the pedicle, constituted by the origin of the
cutaneous branch, limits the are of rotation of the flap.
Vascular supply
The main trunk of the pedicle is called the ulnodor-
sal artery which arises from the ulnar artery at a
distance of 2-5 cm proximal to the pisiform. The
artery passes beneath flexor carpi ulnaris and divides
into three branches:
The proximal branch supplies the distal portion of
flexor carpi ulnaris.
The middle branch is devoted to the skin and
divides into two small arterioles which pass through
the fascia. The ascending one runs between the ulna
and flexor carpi ulnaris and supplies the skin of the
medial side of the lower forearm. The descending
one accompanies the dorsal branch of the u1nar
nerve and gives off several arterioles to the skin.
The distal branch is devoted to the pisiform and
constitutes the pedicle of the vascularized pisiform
transfer to replace the Innate.
The flap can extend over the whole distal half of
the forearm. It averages 20 cm in length and 9 cm in
breadth. The pedicle is the common trunk. The
length of the pedicle is no more than 3 cm. The ulna
constitutes the median axis of the flap.

B
Fascial flap
Operative procedure
A
The incision is outlined on the
medial side of the wrist and
forearm over the tendon of flexor
carpi
ulnaris.
The pisiform is
identified. The pedicle emerges
between 2 and 5 cm from the
pisiform.
A
1
pisiform
2 emergence of the pedicle (2-5 cm
from the pisiform)
B
A subdermal dissection allows
the
exposure
of
the
fascia.
Subcutaneous tissue should be left
on the fascia.
1 flexor carpi ulnaris tendon
2 subdermal dissection
Fascial flap
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E
A simple rotation of the flap
permits
the
coverage
of the
midpalm of the hand.
E
1
pedide of the flap
Fascial flap

Transfers from the upper limb
Fasciocutaneous flap
Operative procedure
F
The flap is outlined on the
medial side of the forearm and
wrist.
The landmark of the
emergence of the pedicle is
included in the design.
F
1 pisiform
2 outline of flap
G
The deep fascia is included in
the flap. The dissection begins
anteriorly
and
the
vascular
pedicle is identified. When the
flap is raised, it can be rotated
G
1 vascular pedicle
2 flexor carpi ulnaris
3 ulnar shaft
4 extensor carpi ulnaris
through 180 ° on the axis of the
pedicle without jeopardizing the
blood supply. The donor site is
covered
with a split-thickness
skin graft.

Hand and digits
Introduction
The aim of this section is not to describe all the proce-
dures for covering defects of the hand and digits.
Tissue loss at the fingertips constitutes a whole surgi-
cal world and would require an entire treatise, as the
techniques are numerous and controversial. This
section is limited to the local and regional flaps which
can be raised on a well-defined pedicle.
Reconstruction of the digits sometimes requires
partial free revascularized transfers which are elevated
from the foot. The indications and techniques of these
reconstructions are highly specialized and are not
included in this book.
The kite flap
I ntroduction
The kite flap is raised from the dorsum of the first
phalanx of the index finger, including the metacar-
pophalangeal (MP) joint. It is considered to be a
sensory flap.
I ndication
Hand and digits
The main indication for the kite flap is the resurfac-
ing of the dorsal aspect of the thumb. It is also used
for the reconstruction of the first web when the
defect is limited after release of a contracture.

Transfers from the upper limb
Vascular and nerve supply
A The flap is based on a true
neurovascular bundle. The artery
is the dorsal metacarpal artery of
the first space, arising from the
deep branch of the radial artery.
This artery has many anatomical
variations, but they are without
implications
for
the
surgical
procedure. In
most cases, the
artery follows the axis of the
second metacarpal bone. It may
A
1
first interosseous, superficial head
2 arterial branch to the dorsum of
the thumb
3 radial artery in the snuffbox
4 radial sensory nerve, anterior
branch
5 superficial dorsal metacarpal artery
be located superficial or deep to
the aponeurosis of the first dorsal
interosseous
muscle.
Whatever
the situation, there is always an
important vascular anastomotic
circle at the level of the neck of
the second metacarpal bone with
the radial palmar collateral artery
of the index finger and the palmar
metacarpal artery.
Sometimes two arteries are
present, one superficial and the
other deep to the aponeurosis.
6 first interosseous, deep head
7 fascia
8 deep dorsal metacarpal artery
9 anastomoses. between dorsal and
palmar systems
1 0 radial collateral artery of the index
finger
Thus from a surgical point of
view, it is important to include the
aponeurosis in the pedicle. The
artery is accompanied by one or
two venae comitantes.
The nerve is one branch of the
sensory
branch
of the radial
nerve. It is located in the subcu-
taneous tissue and supplies the
dorsal aspect of the MP joint and
the proximal two-thirds of the
dorsum of the first phalanx.

C
The two skin edges are gently
retracted by a subdermal dissec-
tion, exposing the subcutaneous
tissue which contains the branch
of the radial nerve and the artery.
The neurovascular bundle should
not
be
dissected
and should
remain included in the subcuta-
neous tissue.
The flap is raised from the
underlying extensor tendon. The
thin areolar vascularized tissue
which covers the tendons should
be spared. The veins that cross
the flap are ligated.
C
1
branch of sensory radial nerve
2 superficial dorsal metacarpal artery
3 superficial vein
The kite flap
Operative procedure
B The flap is outlined on the
dorsum of the MP joint and the
first phalanx of the index finger.
The incision to expose the
pedicle is a reversed S, starting
from the tip of the web. The distal
portion of the incision is gently
curved on the radial aspect of the
second
metacarpal
bone,
and
reaches the radial side of the flap.
B
1
design of the flap
2 incision to expose the pedicle

Transfers from the upper limb
D
E
The vascular pattern of the
dorsum of the first web permits
us to perform a distally based
island pedicled kite flap. The flap
is outlined over the upper part of
the first web. The deep branch of
the radial artery is identified by
retraction of the tendons, and the
dorsal metacarpal artery is ligated
at its emergence. Then a subcuta-
neous fascal pedicle is raised as
far as the pivot point at the level
of the neck of the second
metacarpal bone or just distal to
it.
E
1
origin of dorsal metacarpal artery, to
be divided
2 the radial artery in the snuffbox
3 superficial dorsal metacarpal artery
D The key point of the proce-
dure is to include the fascia of the
first interosseous muscle.
The arc of rotation allows
coverage of all the dorsum of the
thumb, the first web and the
palmar aspect of the first phalanx;
it is not indicated for restoring the
pulp. The donor site is covered by
a full-thickness skin graft, and the
index finger is immobilized with
the MP joint flexed to ensure a
good healing of the graft.
1
2

F
The arc of rotation allows
coverage of a defect of the dorsal
or the palmar aspect of the two
first phalanges of the index finger.
This
procedure is particularly
useful for covering the palmar
aspect of PI when a cross finger
flap is not possible.
F
1
dorsal arterial branch to the thumb
2 radial artery in the snuffbox
2

Transfers from the upper limb
I sland flaps from
the digits
I ntroduction
The principle of a digital island
flap is based on the elevation of a
skin territory from the palmar or
the dorsolateral aspect of a finger
supplied
by the homolateral
digital artery. The digital nerve
can be included in the pedicle to
provide sensation to the flap. This
procedure results from a unified
theory of the treatment of the
distal defects of the long fingers
(thumb excluded).
Vascular anatomy
A The fingers are supplied by
two main palmar digital arteries.
One should remember two impor-
tant points: first, the palmar radial
digital artery of the index finger
and palmar ulnar digital artery of
the fifth finger are of small diame-
ter, and second, each finger is also
supplied
by two small digital
dorsal arteries arising from the
dorsal
interosseous
network
(these two arteries only supply
the dorsum of the first phalanx).
The digital vascular system is
almost entirely founded on the
palmar arteries, which are accom-
panied by the digital nerve and a
venous adventitial network. The
pedicle is anterior to Cleland's
ligament
and
posterior
to
Grayson's ligament.
Each palmar digital artery gives
off several collateral branches. We
can distinguish:
• Numerous superficial palmar
branches, very small and short,
that supply the palmar subcuta-
neous tissue.
• A few dorsal branches that
supply the dorsal aspect of the
second and third phalanx.
A
1
radial artery
2 median nerve
3 princeps pollicis artery
4 proper palmar digital
artery
5 common palmar digital
artery
6 superficial arterial arch
7 deep arterial arch
8 ulnar nerve
9 ulnar artery
• Deep palmar branches that
constitute anastomotic arcades
at the level of the first and
second phalanx.
The position of the anastomoses
between the two palmar digital
arteries is the basis of the surgical
procedures:
• The distal anastomoses are
located midway between the
distal
interphalangeal
(DIP)
joint and the finger tip.
• The retrotendinous
vascular
circles are located just proximal
to the proximal interphalangeal
(PIP) and DIP joints.
Two techniques are described
here:
• The homodigital flap.
• The heterodigital flap.

The homodigital flap
I ndication
The homodigital flap is used for
the
restoration
of
fingertip
injuries. It
is
supplied by the
collateral digital artery and the
corresponding digital nerve, and
the release of the pedicle allows
the advancement of the flap.
Operative procedure
B The procedure is carried out
on the radial or the u1nar side of
the finger, according to the donor
side chosen.
C The outline of the flap is
made over the lateropalmar aspect
of the third phalanx just proximal
to the loss of substance.
C
1
design of the flap
2 incision
The homodigital flap
s

Transfers from the upper limb
D The pedicle is progressively
released until the middle of Pl.
The nerve branch issuing from the
digital nerve at this level should
be spared.
Other
dorsal
arteriole
and
nervous branches distal to the PIP
joint
can
be divided
without
prejudice.
D
1 digital artery and nerve
2 dorsal branch of the digital nerve
E The medialization of the
pedicle and a slight flexion of the
finger permits the advancement of
the flap, which is raised from the
sheath of the tendon and the
periosteum of the phalanx. The
donor site is covered with a full-
thickness skin graft. It can also be
left to heal spontaneously.
A distally based pedicle island
flap can be raised on the lateral
aspect of PI distal to the dorsal
branch of the digital n ve. The
reverse flow is ensured by the DIP
joint
anastomoses
with
the
contralateral digital artery.
When the defect is dorsal, the
digital nerve should be spared and
separated from the artery and its
venae comitantes. When a recon-
struction of the pulp is needed,
the nerve is included in the eleva-
tion and can be sutured to the
controlateral nerve.
90

The heterodigital
flap
Operative procedure
F
The aim of this procedure is to
raise a sensitive and vascularized
hemipulp to restore the sensibility
of the thumb.
The ulnar side of the third
finger or the radial side of the
fourth finger can be raised. It is
better to raise the third finger
because the innervation comes
from the median nerve. The
release of the pedicle is done by a
volar zig-zag incision.
G
F
The heterodigital flap
G The design of the flap
comprises the palmar and the
dorsolateral aspect of the hemi-
pulp.