Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

FIGURE 306.3 A: Design of simultaneous groin and tensor fasciae latae flaps for sandwich repair of a
degloved hand. B: Simultaneous elevation of a tensor fasciae latae island flap and a groin flap. (The
territory of the groin flap overlies the base of the tensor fasciae latae flap.) C: Flaps in position, enveloping
a degloved hand. The groin flap envelops the thumb and thenar area. The tensor fasciae latae flap
envelops the hand and palm. Split-thickness skin grafts cover the remaining dorsum. D: Functioning mitten
that results from this repair. (After Watson and McGregor, ref. 2, with permission.)

FIGURE 306.4 Photograph of a patient with a degloved hand enveloped in a groin flap and a tensor fasciae
latae flap as noted in Figure 306.3 (From Watson and McGregor, ref. 2, with permission.)
References
1. Smith RC, Furnas DW. The hand sandwich: adjacent flaps from opposing body surfaces. Plast Reconstr
Surg 1976;57:351.
2. Watson ACH, McGregor JC. The simultaneous use of a groin flap and a tensor fasciae latae
myocutaneous flap to provide tissue cover for a completely degloved hand. Br J Plast Surg 1981;34:349.

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Chapter 307
Dermo-Epidermal Flap to The Hand
P. COLSON
H. JANVIER
EDITORIAL COMMENT
The design of the bipedicle demoepidermal flap should avoid crossing the antecubital fosse to prevent
flexion contractures across the elbow joint.
Defatting gave birth to the dermo-epidermal flap (1, 2, 3, 4). Initially it was used to cover small defects of the
fingers and then it was expanded to cover large defects of the hand (3). The dermo-epidermal flap can be raised
with a single pedicle or bipedicle from various parts of the body including the abdomen, thorax, and arm.
INDICATIONS
We have used the dermo-epidermal bipedicle brachial flap mainly for the repair of burned hands, and we
use the classic “crossed arms” position (5, 6). Our choice is explained, in part, by the quality of the tissues
(hairless skin, well suited to reinnervation) and also by the possibility of maintaining the hand and all its
fingers in a good functional position without the use of an apparatus.
FLAP DESIGN AND DIMENSIONS
A pattern of the same dimensions and shape as the defect is used to design the dermo-epidermal flap. It is
essential to design a flap that is larger than the defect.

FIGURE 307.1 Design of the bipedicle dermoepidermal flap with one pedicle based on the arm and the other
based on the forearm.
Before the operation, the patient should be examined standing and asked to hold the donor arm with the burned
hand, with the fingers on the anterior surface of the arm, while the thumb is extended on the posterior surface of
the arm. The elbow of the donor arm is flexed at a right angle, so that the ulnar aspect of the hand rests on the
forearm. It will then be possible to design the line of incision and to locate the two flap pedicles, one based on
the arm and the other based on the forearm (Figs. 307.1 and 307.2; also see Fig. 307.7).
FIGURE 307.2 After the flap is elevated, the donor site is covered with a moderately thick split-thickness skin
graft.
OPERATIVE TECHNIQUE
Bipedicle Flap: General Procedures

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The skin is incised with a scalpel, stopping when the lobules of fat begin to herniate. We have totally
abandoned rapid and imprecise blunt dissection. We feel it is preferable to be able to control the
progression of the blade and, at the same time, both to visualize and to feel our way.
In this plane, the subdermal plexus is visualized, the veins are bulging with blood, and they deflate on
section. Total defatting must be limited to only the surface necessary to cover the defect, and this technical
point is very important.
The base of the flap is raised at a deeper level to include the blood vessels that nourish the pedicle.
For the mobilization and fixation of the dermo-epidermal flap, it is useful to take precautions, as the blood
circulation on the dermal capillary plexus is susceptible to mechanical and other problems. The flap
possesses extensibility and spontaneous retraction much greater than certain of the classic flaps. This is
why the prudent surgeon does not exploit the elasticity of the flap by excessive stretching with a tight
closure. Rather, he makes the flap pedicle a little longer. The surgeon should also fix the flap carefully to
the defect edge, and should avoid applying the flap on a finger flexed at an acute angle. Knuckle
prominence on the deep surface is enough to produce an area of compromised circulation.
Dermo-Epidermal Bipedicle Brachial Flap
First Stage
On the operating table, the appropriate position of the hand on the donor arm is verified, and the initial flap
design is modified if necessary (Fig. 307.1).
FIGURE 307.3 The flap is sutured to the fingers, and the fingers are sutured to the arm to keep the flap well
immobilized. This is essential since the flap survives on the dermal-subdermal plexus in some areas, but in
others “takes” as a graft.
Because of the pliability of the flap, separation can be achieved under visualization, while a full-thickness flap
requires more laborious tunneling. After preparing the dermo-epidermal flap, the donor surface is covered with a
split-thickness skin graft of moderate thickness (Fig. 307.2).
All burned tissue is widely excised and the procedure is completed by tenolysis of the extensors and sometimes
by arthrolysis. We stress placing the fingers in optimal position, i.e., in a state of mild flexion, allowing them to
rest on the curvature of the donor arm. In cases of positional malalignment, where fingers are not easily movable,
the joints should be pinned with two small Kirschner wires. The hand is slid under the dermoepidermal flap and it
traverses the tunnel. If the pedicles have been well designed (one on the arm, the other on the forearm), and if
the elbow is held in flexion at a right angle, the hand is easily introduced without overly distending the flaccid
flap.

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FIGURE 307.4 A: Despite two attempts at skin grafting, this burn patient could not completely flex his fingers. B:
Flap in place. Note that one pedicle is from the arm and the other is from the forearm. Note also the discoloration
that occurs in the flap. C,D: Postoperative extension and flexion.
The hand is then firmly fixed to the arm, positioning the thumb and fingers by hooks glued to the nails, or even by
nonabsorbable good-sized sutures, going through the finger pulp and deeply into the arm skin, to ensure firm
fixation (Fig. 307.3). The fingers are separated from each other and fanned out, not only to maintain open
commissures, but also to increase the surface of the flap that will be available for covering the lateral surfaces of
the fingers. Immobility of the hand is important for adhesion formation and for “take” of the flap, which behaves
like a free graft (7). After the hand is fixed, the flap itself is sutured to the wrist skin, using an undulating or zigzag
pattern, and fine sutures are placed in each of the fingers to cover the growth plate of the nail and the nailbed
(Fig. 307.3).
The two elbows are attached to each other by nonextendable adhesive bandages, to prevent separation of the
arms and to alleviate pain in the digital pulps, which have been fixed with sutures. Small compresses
impregnated with a solution of cortisone are applied on all the raw surfaces and are slid under the flap between
the fingers. We do not risk compressive dressings.
The patient is placed in bed on his back, with arms resting horizontally on the bed and the forearm suspended
vertically. By now the dermo-epidermal flap, originally of a nice red color, has become violaceous across its width
and has multiple areas of beads of serosanguineous fluid (Fig. 307.4). This is a transitory state that disappears
in a few days. On the third postoperative day, the patient leaves bed and begins to use his fingers actively and
the donor arm for self-feeding. The degree of immobilization is reduced each day (Fig. 307.5).

FIGURE 307.5 A,B: Even with the forearms taped, there is enough mobility for shoulder exercises.
Second Stage
Fifteen to 20 days after the first procedure, pedicle division frees the hand. If sizeable raw surfaces remain in the
deep surface of the flap and on the lateral surfaces of the fingers, in spite of cortisone application, they may be
debrided. The finger webs are then bisected, stopping the incision 2 to 3 cm above the web, i.e., the
commissure. The little flaps thus created are sutured to the skin of the lateral edges of the fingers, following an
undulating line (Fig. 307.6). When the lateral surfaces of the fingers are completely denuded (quite rare, in our
experience), the distal ends of the little flaps reach the palmar surface. It is then advised to make a small Z-plasty
at the base of the digit, a preventive procedure to avoid retraction of the palmar suture line (see Chapter 326).
The surgeon has a certain amount of leeway in tailoring the free edge of the flap, since capillary circulation is
well supported at all the flap extremities. Between the thumb and the index finger we routinely rotate two
triangular flaps, one on the dermo-epidermal flap, the other on the palm, to ensure a large aperture for the first
commissure, i.e., the web space of the hand.
FIGURE 307.6 After the flap is divided, the areas between the fingers are debrided. The flap is then inset as
necessary, taking care to avoid straight line scars.
Over a period of several months, the flap changes its appearance, becoming supple and thin, and allowing for
decompression of the contracture on the surface of the hand.
Dermo-Epidermal Unipedicle Flap from the Abdomen
Since a dermo-epidermal flap can be taken from different parts of the body, it is possible to use the flap on two

P.829
surfaces of the hand at two separate times, employing the principles of pronation and supination (Fig. 307.7).
FIGURE 307.7 A: Unipedicle dermo-epidermal flap from the abdomen used in two stages to cover the dorsal,
radial, and palmar surfaces of the hand. B: Preoperative appearance. C: Postoperative result.
Dermo-Epidermal Unipedicle Flap from the Arm
We have adopted this technique for severe contractures of the thumb-index web space, to maintain a large
space between them without an apparatus.
CLINICAL RESULTS
Most often, negligence or error in the choice of patient or of operative technique has been responsible for
necrosis. Surgeons who have been trained to depend on flap thickness or on the existence of a deep
arterial-venous circuit appear hesitant to use the dermo-epidermal flap. When total defatting is proposed,
they also must change their habitual opinions.
Although there are multiple difficulties in using the flap, which vary from case to case, in our first published
series of 18 cases using bipedicle and cross-arm dermo-epidermal flaps, we had 15 cases yielding good
results without any necrosis; two cases with minimal necrosis at the margin along the suture line, which
scarred in after secondary resection of the necrotic border; and one case of necrosis appearing in the
center of a 6 × 2-cm dermo-epidermal flap, which was treated by excision and grafting and which caused
delayed healing, but without functional impairment. In respect to the donor arm, the appearance of the free
graft was quite acceptable, and the motion of the elbow was totally conserved.

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SUMMARY
The dermo-epidermal flap can be used to provide thin, pliable, yet durable coverage for the hand.
References
1. Morel-Fatio D, Lagrot F. Les réparations des pertes de substance cutanées. Proceedings of the 56th
annual meeting of the French Surgical Society. Paris: Hasson, 1954;76,130—131.
2. Baux S, Isclin F. Brûlure et écrasement de la main et des doigts: empochement immediat. Ann Chir Plast
1965;10:41.
3. Colson P, Houot R, Gangolphe M, et al. Utilisation des lambeaux degraissés en chirurgie réparatrice de la
main. Ann Chir Plast 1967;12:298.
4. Kelleher JC, Sullivan JG, Dean RK. Use of a tailored abdominal pedicle for surgical reconstruction of the
hand. J Bone Joint Surg 1970;52A:1552.
5. Bunnell S. Redundant fat. In: Surgery of the hand, 2d ed. Philadelphia: Lippincott, 1948;170-171,178; Fig.
138.
6. Iselin L, Iselin F. Trade de chirurgie de la main. Paris: Flammarion, 1967;248.
7. Smahel J. Biology of the stages of plasmatic imbibition. Br J Plast Surg 1971;24:133.

Chapter 308
Abdominal Bipedicle Flap for Dorsal Defects of The Hand
N. H. ANTIA
EDITORIAL COMMENT
A less bulky hand may be achieved by removing the hand early so that only subcutaneous tissue is retained
on the hand. The hand then does need to be skin grafted.
Extensive loss of the skin and contraction of the dorsum of the hand are often seen as results of neglect in the
treatment of burns and in some cases of trauma. Not only do hyperextension deformities of the
metacarpophalangeal joints occur as a result of skin shortage in the longitudinal axis, but also contraction in the
transverse axis, sometimes with reversal of the transverse metacarpal arch.
INDICATIONS
In a long-standing deformity, especially in the adult hand, metacarpophalangeal joint capsulotomy is often
required as a secondary procedure. This can be performed only if there is adequate skin cover over these
joints. The provision of an adequate amount of skin on the dorsum of the hand cannot be achieved by free
skin grafting, unless metacarpophalangeal capsulotomy is performed simultaneously—a difficult and
hazardous procedure.
A bipedicle abdominal flap (1) (Fig. 308.1) provides excellent skin cover, through which capsulotomy can be
undertaken safely at a later stage, when there is adequate skin to allow full flexion of the
metacarpophalangeal joint. Such a flap cover also avoids the recurrence of the deformity, which often
results because of contraction of skin grafts, especially when there is inadequate postoperative splinting
and physiotherapy.
ANATOMY
Unfortunately, the skin of a flap is bulkier than that of a free graft or the normal skin of the dorsum but, due to the
excellent blood supply from the epigastric and thoracoabdominal vessels, this flap can be thinned considerably
before it is applied to the dorsum of the hand (2).
FLAP DESIGN AND DIMENSIONS
Although there is wide disparity in length of the proximal and distal margins of the flap, i.e., 10 cm and 29 cm, this
is overcome by curving the distal incision. The hand, denuded of the scar, can fit comfortably into this abdominal
pocket (Fig. 308.1).

FIGURE 308.1 Diagrammatic representation of the hand positioned in the semilunar flap. (From Antia and
Pandey, ref. 1, with permission.)
FIGURE 308.2 A: Hand after excision of the scar, positioned above the flap raised on the abdomen. B: Flap
sutured on dorsum of hand. C,D: Final result. (From Antia and Pandey, ref. 1, with permission.)
OPERATIVE TECHNIQUE
The positioning of the hand and the suturing of the flap are simplified if narrow skin bridges are left between the
webs of the fingers and also for the thumb web. The hand can be separated from the abdomen in 10 to 14 days,
and the raw area of the abdominal wall covered with a split-thickness skin graft (Fig. 308.2).

SUMMARY
An abdominal bipedicle flap can be used to provide durable skin cover to the dorsum of the hand.
References
1. Antia NH, Pandey SD. Semilunar abdominal bipedicled flap for the cover of dorsal defects of the hand. Br
J Plast Surg 1976;29:129.
2. Kelleher JC, Sullivan JG, Dean RK. Use of a tailored abdominal pedicle for surgical reconstruction of the
hand. J Bone Joint Surg 1970;52A:1552.

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Chapter 309
First Dorsal Metacarpal Artery Flap
M. M. SHERIF
EDITORIAL COMMENT
This is a useful source of local donor tissue.The blood supply is reasonably reliable and good sensibility
can be provided within the flap.
The first dorsal metacarpal artery (FDMA) flap is an axial flap based on the first dorsal metacarpal artery and its
terminal dorsal digital branches, and it is harvested from the skin of the dorsal surface of the hand, index finger,
and thumb. It can be raised as a proximally or distally based fascial or fasciocutaneous flap; vascularized tendon,
periosteum, or bone can be included.
INDICATIONS
This flap is used mainly as a sensory flap for coverage of skin defects over the palmar surface of the thumb
(1, 2, 3, 4, 5, 6, 7, 8); for reconstruction of dorsal thumb skin defects (9); and for the reconstruction of the
first web space, especially in cases of severe contracture (10, 11). The flap can be raised from the dorsal
surface of either the thumb or index finger. A reversedflow flap allows the coverage of skin defects up to the
distal phalanx of the index finger (12).
The FDMA flap is especially indicated in severe first webspace contractures with irregular surfaces and
exposed blood vessels and nerves. Release of contracted fascia and muscles can thus be provided. As a
sensory flap, it can be used for reconstruction of the volar skin of the thumb (Fig. 309.1), and it is able to
cover the whole volar surface up to the thumb tip (10, 11). Despite a less than optimal restoration of thumb
sensation (9) and some question as to durability for thumb
coverage, the skin displays an excellent ability to withstand the wear and tear on the working surface of the
hand (11), and flap sensibility is comparable to that of Littler's flap (10).

FIGURE 309.1 A: Amputated thumb distal to the interphalangeal joint. B: One week after thumb
reconstruction with an island sensory FDMA flap. The flap is tapered proximally, and the skin on the lateral
side of the thumb is released to avoid compression of the pedicle in the interphalangeal area.
An FDMA can also be taken from the dorsal aspect of the thumb, to provide sensation to an index stump
(13). A reversed-flow fascial flap can be used to provide sensation to an index stump by neurotization of the
radial nerve to one of the severed digital nerves of the index finger (11, 12, 13).
The flap has commonly been used to replace the dorsal skin of the thumb and is considered by some (9) to
be irreplaceable for this indication. An extended version of the flap has been used to cover the proximal
phalanx of the thumb, both from its volar and dorsal surfaces (15).
An island flap can cover the dorsal surface of the carpus, the wrist, and the metacarpophalangeal (MCP)
joint of the little finger. It can reach most areas in the palm, either through the space between the two heads
of the first dorsal interosseous muscle, or around the free margin of this muscle and the adductor pollicis
(10).
An extensor tendon has been included in the flap as a vascularized tendon to bridge a defect in the thumb
or middle finger (11). In addition, a reversed-flow fasciocutaneous flap has been used to cover defects on
the index finger, with the ability to reach the distal phalanx of this finger (12). A reversed-flow fascial flap
can cover an exposed extensor tendon around the MCP joint or an exposed joint, after capsulotomy in a
postburn hand. The flap provides a suitable bed for skin grafting, instead of shifting to a distant flap. The
deep fascia on the dorsum of the hand, proximal to the level of the wrist, has been included with the flap;
this coverage can reach the proximal phalanx of the ring finger and the index distal interphalangeal (DIP)
joint.
Other uses have included vein-carrier flaps in cases of thumb replantation, to correct the loss of dorsal
veins; anastomoses are done between the distal veins of the flap and the dorsal veins of the replanted
thumb. The flap can also enhance arterial flow after insufficient restoration of circulation to the thumb (8).
The FDMA flap has also been used in pollicization of the index finger, as a single vascular supply to the
index finger after injury to both palmar digital arteries (16). As a bone flap from the neck of the second
metacarpal, the FDMA flap has been used in treating nonunion of the scaphoid (17).
Double FDMA flaps can be raised based on the double vascular supply of this area, one cutaneous and the

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other fascial (11); they can be used for coverage and lining of exposed extensor tendons.
ANATOMY (FIG. 309.2)
The FDMA is a constant branch (8, 14, 18, 19, 20, 21, 22, 23) that arises from the radial artery (RA) distal to the
extensor pollicis longus tendon, just before the artery dips between the two heads of the first dorsal interosseous
(DIO) muscle. The FDMA runs either over or within the DIO fascia. As the artery is completely fixed to this fascia,
the first DIO muscle is always exposed during dissection of the pedicle.
Some authors (9, 18) describe the presence of a second FDMA deep to the DIO fascia (the muscular or deep
fascial FDMA). Although the double system was detected in only 10% to 12% of their dissected hands,
meticulous dissection of this area has shown the presence of these two systems in all cases (14). However, it
appears that both systems are completely
separate, except at the MCP joint area, where they end at the anastomosis around this joint. As in other dorsal
metacarpal arteries, when the main branch of this dorsal system is small, it is usually replaced by a large
perforator connecting the palmar and dorsal systems of the hand (19).
FIGURE 309.2 Diagrams illustrating the anatomy of the FDMA and its anastomosis in the first web area. A:
FDMA embedded in the fascia of the first dorsal interosseous muscle with its three branches (radial, ulnar,
intermediate). Cutaneous nerve accompanying the radial nerve has been cut. B: First dorsal interosseous
muscle and intermediate branch of FDMA have been removed to expose the muscular branch inside the ulnar
head of the muscle and the anastomosis at the metacarpal neck area.

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In about 10% of dissected cadaver hands (14), the FDMA gives off a small direct cutaneous branch that follows
the course of the superficial branch of the radial nerve. More commonly, this vessel arises from the radial artery
itself (14, 20). It rapidly divides into ascending and descending branches supplying the radial nerve and the skin
overlying it. Due to its small size, this vessel is very difficult to isolate and dissect. However, its size is inversely
proportional to the FDMA itself. When the descending branch is large, it anastomoses with branches of the
FDMA at the level of the MCP joint of the index finger.
The FDMA itself divides into three branches: a radial, an intermediate, and an ulnar branch (14, 21). They run
close to the first metacarpal bone, in the middle of the first interosseous space or close to the second metacarpal
bone, respectively. The size of these branches is variable, and one or more may arise separately from the RA.
The intermediate branch ends by anastomosing in continuity with the first palmar metacarpal artery. This branch
is well developed in only 15% to 18% of cases (14, 18, 19, 21). The radial and ulnar branches may continue as
the dorsal digital artery of the thumb or index fingers. More commonly, they terminate as a plexus dorsal to the
extensor tendon (8, 14, 18, 20). At the level of the neck of the second metacarpal bone, they anastomose with
the palmar and intermuscular vessels. Two other anastomoses are present at the level of the proximal phalanx—
one
at the dermal level (20) and the other deep to the extensor tendon (9, 23). A reverse-flow flap is supplied through
these anastomoses.
Branches arise from the FDMA or its divisions to supply the nearby tendons (9) and periosteum (9, 17). The
presence of multiple anastomotic channels in the area of the neck of the second metacarpal bone (9, 22) makes
it the most favorable donor site for a fascioperiosteal flap (17).
Two venae comitantes are present around the artery. They drain the flap and anastomose freely with the
superficial venous system. The flap is also drained by the superficial veins over the dorsal surface of the hand.
FLAP DESIGN AND DIMENSIONS
The FDMA flap can be raised as a proximally based fasciocutaneous flap. In cadaveric injection studies, the skin
overlying the dorsum of the hand from the radial side of the thumb to the third metacarpal bone is usually stained
(14). However, in clinical practice, the cutaneous territory of skin flaps is usually larger than in the injection study.
Similarly, the dorsal surface of the index and thumb are faintly stained (14), while, in clinical cases, the skin
overlying the index finger up to the DIP joint can be raised completely (22). The flap rotates around the point of
origin of the artery at the base of the first interosseous space (Fig. 309.3).
When utilized as a distally based fasciocutaneous flap, the flap is raised on the distal perforator at the level of
the metacarpal neck (9), or on the rich dermal plexus at the base of the index finger (12). The skin territory is
usually limited by the proximal boundary of the first metacarpal space. The flap can reach the proximal
interphalangeal (PIP) joint and the middle phalanx (Fig. 309.4).
The flap can also be raised as a distally based fascial flap. This flap is based at the MCP joint area on the
perforator connecting the palmar and dorsal metacarpal arteries. The fascia raised can include the deep fascia
of the hand up to the extensor retinaculum of the wrist.

FIGURE 309.3 Arc of rotation of the proximally based FDMA flap. A: Conventional version. B: Extended version.
FIGURE 309.4 Arc of rotation of the distally based FDMA fasciocutaneous flap. A: Based on the perforator
situated at the level of the neck of the metacarpal bone of the index finger. B: Based on the anastomosis distal to
the metacarpophalangeal joint and the subdermal anastomosis.
OPERATIVE TECHNIQUE
Although the vessel is constantly present in all cases, it is safer to check the pulsation of the FDMA against the
metacarpal bones before starting the operation. An ultrasonographic examination has been recommended (24)
before embarking on raising any dorsal metacarpal flap. This may not always be necessary in the first web
space, except in cases of congenital deformities or trauma to the area.
The dissection technique should take account of the anatomic variations in the location and the variable
dominance of the vessels. The pedicle should contain the interosseous aponeurosis to include the three
branches of the FDMA. The superficial dorsal veins should be preserved in the pedicle.
Pedicled Flap
The flap is drawn on the dorsum of the hand, index finger, or thumb, according to the position of the skin defect.

P.834
The flap is elevated from distal to proximal, starting superficial to the extensor tendon paratenon. At the level of
the metacarpal neck, a perforator is always present; this should be coagulated or ligated. To avoid first web-
space contracture, the skin over this space should not be included in the flap. If this skin is necessary to cover
the skin defect, the flap is extended ulnarly toward the third metacarpal, so that the web is again covered by a
flap and is not grafted. To rotate the flap, the dorsal interosseous fascia is incised from the metacarpal bones as
far as necessary.
Island Flap
This flap is drawn on the dorsum of the index proximal phalanx from the PIP to the MCP joint. The pedicle is
dissected to include
the interosseous fascia with the three branches of the FDMA, as well as the superficial veins, the superficial
radial nerve, and its accompanying artery. The latter is exposed through a dorsal S-shaped incision starting from
the base of the first interosseous space, and ending at the proximal edge of the flap. The skin over the
interosseous space is dissected just deep to the dermis, to include the dorsal veins and terminal branches of the
radial nerve in the flap pedicle. The flap is raised from distal to proximal at a plane superficial to the extensor
tendon paratenon. A constant perforator is coagulated at the neck of the metacarpal bone, and the interosseous
fascia is released from the metacarpal bones. The pedicle length can reach 7 cm in an adult (10), thus allowing a
wide arc of rotation. A wide subcutaneous tunnel is dissected, and the flap is rotated without twisting the pedicle.
If the flap is used for reconstruction of the palmar skin of the thumb, the pedicle will cross the side of the
interphalangeal joint where the skin is tight and the flap pedicle can be easily compressed; it is better to open the
lateral side of the finger proximally and elongate the skin island of the flap proximally (10, 11).
Care should be taken when including a tendon with the flap, to avoid disruption of the fine vessels supplying the
tendon.
Reversed-Flow Flap
The proximal part of the flap is incised first, and the FDMA is dissected. The artery is then ligated from its origin
from the radial artery. The incision around the flap is completed, and the dissection is taken down to the
interosseous fascia. The flap is raised from proximal to distal. The perforator can be ligated at the neck of the
second metacarpal, and the flap is thus nourished only by the dermal anastomosis (12). In these cases, the
pedicle should be freed with a large portion of dermal and subcutaneous tissue. The donor area is either closed
directly or skin grafted.
Reversed-Flow Fascial Flap
The interosseous fascia is exposed, as in the island flap. The FDMA is ligated at its origin from the radial artery,
and the interosseous fascia is dissected from the underlying muscle and both metacarpals. At the level of the
metacarpal neck, the anastomosis between the dorsal and palmar systems can be easily seen. One of these
perforators should be preserved, to allow the flap to rotate freely. The fascia can then be covered with a skin
graft, and the donor area closed directly.
CLINICAL RESULTS
Flap necrosis due to arterial or venous complications is rare. In 29 cases reported (25), there were only
three failures; two of them were due to technical error. Although venous congestion may be common in
reversed-flow flaps, only one case was reported in the literature of reversed-flow FDMAs (9). In this case,
about half the flap was lost due to excessive tension on the pedicle.

The donor area is usually covered by a split-thickness skin graft, although a full-thickness graft can be used
in females, so that a better color match with the dorsum of the hand is achieved. To avoid skin grafting, an
aponeurotic flap can be raised, taking the interosseous fascia and subcutaneous tissue of the index finger,
while leaving the skin intact. However, the defect left after raising the FDMA flap is minimal, and grafting on
the dorsal surface of the index finger is aesthetically satisfactory to both patient and observers (11); this
type of flap is rarely indicated (9).
Neuroma and sensory deficit in the radial-nerve area is liable to occur, especially in cases of neurotization;
however, this has not been reported in the literature. Hair growth in the palm was noted in one case after
thumb palmar- surface reconstruction. This was treated by electrical epilation (11).
SUMMARY
The FDMA flap is reliable and versatile, with rapid and easy dissection, and with a constant anatomy and
expendable artery. Use of the flap in hand reconstruction can decrease the need for many of the distant
pedicled or free flaps previously used in this area.
References
1. Hilgenfeldt O. Operativer Daumenersatz. Stuttgart: Enke Verlag, 1950.
2. Gaul JS. Radial innervated cross finger flap from the index finger to provide sensory pulp to injured thumb.
J Bone Joint Surg 1969;51A:1257.
3. Kuhn H. Reconstruction du pouce par le lambeau de Hilgenfeldt. Ann Chir Plast 1961;6:620.
4. Holevich J. A new method of restoring sensibility to the thumb. J Bone Joint Surg 1963;45B:496.
5. Adamson JE, Horton C, Crawford H. Sensory rehabilitation of the injured thumb. Plast Reconstr Surg
1967;40:53.
6. Rybka FJ, Pratt FE. Thumb reconstruction with a sensory flap from the dorsum of the index finger. Plast
Reconstr Surg 1979;64:141.
7. Lesavoy M. The dorsal index finger neurovascular island flap. Orthop Rev 1980;9:91.
8. Foucher G, Braun JB. A new island flap transfer from the dorsum of the index finger to the thumb. Plast
Reconstr Surg 1979;63:344.
9. Dautel G, Merle M. Direct and reverse dorsal metacarpal flap. Br J Plast Surg 1992;45:123.
10. Small JO, Bernnen MD. The first dorsal metacarpal artery neurovascular island flap. J Hand Surg
1988;13B:136.
11. Sherif MM. First dorsal metacarpal artery flap in hand reconstruction. II. Clinical application. J Hand Surg

1994;19A:32.
12. Schoofs M, Chambon E, Leps P, et al. The reverse dorsal metacarpal flap from the first web. Eur J Plast
Surg 1993;16:26.
13. Lie KK, Posch JL. Island flap innervated by radial nerve for restoration of sensation in an index stump.
Plast Reconstr Surg 1971;47:386.
14. Sherif MM. First dorsal metacarpal artery flap in hand reconstruction. I. Anatomical study. J Hand Surg
1994;19A:26.
15. Gebhard B, Meissl G. An extended first dorsal metacarpal artery neurovascular island flap. J Hand Surg
1995;20B:529.
16. Germann G, Hornung R, Raff T. Two new applications for the first dorsal metacarpal artery pedicle in the
treatment of severe hand injuries. J Hand Surg 1995;20B:525.
17. Burnelli F, Matboulin C, Saffar P. Greffon pedicule d'origine metacarpienne dans les pseudoarthroses du
scaphoid carpien. Communication au Symposium sur le Poignet, Paris, France, April 6-8, 1995.
18. Earley MJ. The arterial supply of the thumb, first web and index finger and its surgical application. J Hand
Surg 1986;11B:123.
19. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg
Gynecol Obstet 1961;113:409.
20. Dautel G, Merle M, Borrelly J, Michon J. Variation anatomique du reseau vasculaire de la premiere
commissure dorsal. Applications au lambeau cerf-volant. Ann Chir Main 1989;8:53.
21. Murakami T, Tayaka K, Outi H. The origin, course and distribution of arteries of the thumb with special
reference to the so-called artery princeps pollicis. Okajimas Folia Anat Jpn 1969;46:177.
22. Earley MJ, Milner RH. Dorsal metacarpal artery flaps. Br J Plast Surg 1987; 40:333.
23. Bonnel F, Teissier J, Allieu Y, et al. Arterial supply of ligaments of the metacarpophalangeal joints. J
Hand Surg 1982;7A:445.
24. Healy G, Mercer NSG, Earley MJ, Woodcock J. Focusable Doppler ultrasound in mapping dorsal hand
flaps. Br J Plast Surg 1990;3:296.
25. Braun MF, Merle M, Foucher G. Le lambeau cerf-volant. Ann Chir Main 1988;7:147.

Chapter 310
The Free Vascularized Hemihamate Osteochondral Flap
WARREN M. ROZEN
VACHARA NIUMSAWATT
EDMUND W. EK
EDITORIAL COMMENT
A technically demanding procedure. It does allow for restoration of the cartilage-bearing articular surface of
the PIP joint.
INDICATIONS
The hemihamate osteochondral graft has been previously introduced as an option for comminuted or
unstable fracture dislocations of the proximal interphalangeal (PIP) joint (1, 2, 3). More recently, we
introduced the vascularized hemihamate osteochondral flap as an option seeking to optimize cartilage
preservation after transfer (4, 5). These PIP joint fractures are among the most difficult hand injuries to
treat, with multiple stabilizing structures of the joint often involved. In the setting of axial compression
injuries, the articular surface of the base of the middle phalanx is frequently comminuted, the joint unstable
and the complex biomechanics of the PIP joint disrupted. Various treatment options have been described in
the literature, ranging from static or dynamic traction splints to closed and/or open reduction with either
internal or external fixation. These are all associated with quite variable and often unsatisfactory results.
In this setting, utilization of the distal articular surface of the hamate to replace the comminuted base of the
middle phalanx was introduced by Hastings et al. (3), who suggested that an autogenous nonvascularized
osteochondral graft from the hamate most closely resembles the middle phalangeal base articular surface
due to its central ridge and bicondylar facet with articular contours (1, 2, 3). A significant limitation of this
technique is the need for the osteochondral fragment to survive as a nonvascularized graft; no studies have
evaluated this long-term survival. In fact, early resorption of the articular cartilage graft has been highlighted
in several studies investigating the longterm outcome of hemihamate osteochondral autografts,
demonstrating the early development of osteoarthritis with narrowing of the joint space and osteoarthritis in
up to 50% of patients in the longest follow-up study of 60 months (6, 7). Other studies of osteochondral
grafts have demonstrated histologically that instead of complete graft revascularization, there is a decrease
in hyaline cartilage, presence of subchondral bone necrosis, and nonintegration of autograft-host hyaline
cartilage over time (7, 8, 9). Given the dependence on successful revascularization for the success of the
hemihamate osteochondral graft, transferring the hemihamate fragment as a vascularized osteochondral
flap is a technique that may overcome these limitations.
ANATOMY
In cadaveric studies with radiographic imaging and dissection, we have been able to demonstrate consistent
vascular patterns in which there are three vascular networks that supply the dorsal carpal periosteum in
transverse arches: the radiocarpal (proximal), the intercarpal (middle), and the basal metacarpal (distal)
transverse arches (4, 5). These complex vascular networks are connected longitudinally at their medial and

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lateral aspects, and they are supplied from proximally by the radial and ulnar arteries and their dorsal branches,
as shown in Figures 310.1 and 310.2. The hamate, situated on the ulnar border of the distal carpal row, has the
middle transverse carpal arch and its branches on its dorsal surface (see Figs. 310.3 and 310.4). This arch is
approximately 1 mm in diameter itself (range 0.7 to 1.1 mm), with branches of the arch all less than 1 mm. The
arch is supplied on its ulnar side by the dorsal branch of the ulnar artery in all cases, always over 1 mm in
diameter. The volar supply to the hamate receives its blood supply from volar vessels via terminal branches of
the anterior interosseous artery and the ulnar recurrent artery, which branch and anastomose with the dorsal
branch of the ulnar artery.
FLAP DESIGN AND DIMENSIONS
The hamate has a wedge-shaped form and a hook-like process, which projects from its volar surface (2). The
proximal surface (apex) is narrow, convex, and smooth and articulates with the lunate. The distal surface
articulates with the fourth and fifth metacarpal bones, by concave facets, which are separated by a ridge. The
mean maximum hamate transverse width measurement is 16.62 mm (±2.04; 12.36 to 18.97), lateral width is
14.29 mm (±2.09; 10.59 to 16.66), and ridge height is 1.43 mm (±0.4; 0.78 to 1.88). The superior articular
surface is divided into two segments; radial condyle to ridge length is 10.06 mm (±3.11; 5.3 to 16.02) and ulnar
condyle to ridge is 12.39 mm (±1.05; 10.2 to 13.34).
The final dimensions of the defect after contouring are measured and used to template the required
osteochondral
flap from the dorsal hamate. Despite the need for precise measurements, the osteochondral flap taken is slightly
larger than the defect to allow for further contouring to the exact size and shape of the fracture fragment. Harvest
of the osteochondral flap is undertaken with preservation of the periosteal attachments of the joint capsule and
the vascular pedicle. The osteochondral flap dimensions are marked using the distal articular ridge of the hamate
between its articulations with the fourth and fifth metacarpals as the guide. This is of particular necessity for
reconstruction of the volar lip of the PIP joint, but other bony landmarks may be used depending on the defect.
FIGURE 310.1 Cadaveric radiograph showing arterial supply to the dorsal hamate (H). The ulnar artery (yellow
arrow) gives a dorsal branch (red arrow), which contributes to the dorsal intercarpal arch (blue arrow). Recurrent
flow is noted in the anterior interosseous and radial arteries. (Reproduced from Rozen WM, Niumsawatt V, Ross

R, et al. The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical
correlation. Surg Radiol Anat 2013;35(7):585-594, with permission.)
OPERATIVE TECHNIQUE
Exposure of the PIP joint is gained through Bruner incisions over the volar surface of the finger, extending from
the metacarpophalangeal crease to the distal interphalangeal flexion crease. Both neurovascular bundles are
identified and confirmed as suitable recipient vessels. An intraoperative digital Allen test is performed by using
microvascular clamps to occlude the recipient digital artery while checking for perfusion of the distal finger. The
flexor tendon sheath is incised, raising the A3 pulley as a radially based rectangular flap and the flexor digitorum
superficialis (FDS) and flexor digitorum profundus (FDP) tendons retracted to allow access to the volar plate and
the fractured volar surface of the base of the middle phalanx. Distal release of the volar plate and subperiosteal
release of the accessory collateral ligaments allow hyperextension of the PIP joint (“shotgunning”) to facilitate
broad access to the PIP joint and exposure of the fracture site (see Fig. 310.5). Bone fragments are excised with
an electric oscillating saw, used to prepare the bone surface to receive the hemihamate fragment (see Fig.
310.6). The dimensions of the defect are measured and used to template the required osteochondral flap.
FIGURE 310.2 Cadaveric dissection study displaying the injected arterial supply (blue) of the dorsal hand and
wrist, in particular the carpal bones and dorsal hamate. (Reproduced from Rozen WM, Niumsawatt V, Ross R, et
al. The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical
correlation. Surg Radiol Anat 2013;35(7):585-594, with permission.)
The hemihamate flap is harvested through a dorsal approach, as developed during our cadaveric studies. A
longitudinal incision is made overlying the fourth and fifth metacarpal bases and extended proximally. Superficial
nerve branches and extensor tendons are preserved, and the dorsal surface of the hamate is exposed. The
transverse carpal arch is identified, passing within the supracapsular plane (see Figs. 310.7 and 310.8). This is

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traced proximally to identify the main arterial and venous pedicles, which are assessed to be of suitable size for
microvascular anastomosis. The carpal arches are also followed distally, beyond the radial border of the hamate,
to identify the continuation of the artery for consideration of its use as a “flowthrough” flap. The joint capsule
over the distal hamate is then incised and reflected proximally to expose the carpometacarpal (CMC) joint
articulation. Careful dissection is then performed to preserve the periosteal attachments of the joint capsule while
the required bone segment is identified. The proximal dorsal capsule is then incised and elevated for a short
distance distally to expose the osteotomy sites, with the arteriovenous pedicles carefully protected. The afferent
and efferent limbs of the dorsal intercarpal arch and a single capsular vein are included within the flap. There are
multiple supracapsular veins identified that do not run in close proximity to the carpal arch that are amenable to
inclusion in the flap. The osteochondral flap dimensions are then marked, using the distal articular ridge of the
hamate between its articulations with the fourth and fifth metacarpals as the guide. The osteochondral flap is
taken slightly larger than the defect to allow for further contouring to the exact size and shape of the fracture
fragment. After elevation of the flap, bleeding from the subchondral bone is confirmed prior to division of the
pedicle (see Figs. 310.8 and 310.9). Hemostasis is achieved, and the bony defect filled with Surgicel. The
harvested segment of dorsal wrist capsule is reconstructed with a segment of extensor retinaculum graft,
secured with 3-0 TiCron sutures. The overlying soft tissues are closed in layers.
FIGURE 310.3 Same cadaveric specimen as Figure 310.2, with the tendon of extensor digiti minimi (E) displaced
ulnarly to expose the dorsal arterial supply to the hamate (H). The dorsal branch of the ulnar artery ( red arrow)
indirectly contributes to the dorsal intercarpal arch ( asterisk) and forms true anastomoses with ramifications of
the dorsal branch of the anterior interosseous artery. (Reproduced from Rozen WM, Niumsawatt V, Ross R, et
al. The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical
correlation. Surg Radiol Anat 2013;35(7):585-594, with permission.)

FIGURE 310.4 Cadaveric study showing the periosteal (blue arrow) and nutrient arterial (green arrows) supply
of the dorsal surface of the hamate. (Reproduced from Rozen WM, Niumsawatt V, Ross R, et al. The vascular
basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical correlation. Surg Radiol
Anat 2013;35(7):585-594, with permission.)
FIGURE 310.5 Clinical, intraoperative photograph demonstrating a comminuted fracture of the base of the
middle phalanx. The degree of comminution is shown during hyperextension of the proximal interphalangeal
(PIP) joint (“shotgunning”) used to expose the fracture site. (Reproduced from Rozen WM, Niumsawatt V, Leong
JC, et al. The vascular basis of the hemi-hamate osteochondral free flap. Part 2: surgical anatomy and clinical
application. Surg Radiol Anat 2013;35(7):595-608, with permission.)

FIGURE 310.6 The osteochondral defect after excision of the comminuted fragments with an electric oscillating
saw in preparation of the bone surface to receive the hemihamate fragment. The final dimensions of this defect
were measured and used to template the required osteochondral flap. (Reproduced from Rozen WM,
Niumsawatt V, et al. The vascular basis of the hemi-hamate osteochondral free flap. Part 2: surgical anatomy
and clinical application. Surg Radiol Anat 2013;35(7):595-608, with permission.)
FIGURE 310.7 Clinical, intraoperative photograph demonstrating the dorsal surface of the hamate and the
overlying transverse carpal arch (arrow), passing in the supracapsular plane. (Reproduced from Rozen WM,
Niumsawatt V, Ross R, et al. The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular
anatomy and clinical correlation. Surg Radiol Anat 2013;35(7):585- 594, with permission.)

FIGURE 310.8 Exposure of the carpometacarpal joint of the distal hamate, with elevation of the dorsal capsule
and the arterial supply of hamate. (Reproduced from Rozen WM, Niumsawatt V, Ross R, et al. The vascular
basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical correlation. Surg Radiol
Anat 2013;35(7):585-594, with permission.)
FIGURE 310.9 The free osteochondral flap of dorsodistal hamate, with attached arteriovenous pedicle
comprising an afferent and efferent limb of arterial dorsal carpal arch, and a single supracapsular vein (arrows).
(Reproduced from Rozen WM, Niumsawatt V, Leong JC, et al. The vascular basis of the hemi-hamate
osteochondral free flap. Part 2: surgical anatomy and clinical application. Surg Radiol Anat 2013;35(7):595-608,
with permission.)
The hemihamate flap is then transferred to the defect, and minor adjustments of contour made using a saw blade
and surgical bone file (see Fig. 310.10). Internal bony fixation is achieved with two 1.2-mm lag screws inserted in
a volar to dorsal direction (see Fig. 310.11). Preservation of the periosteal supply is achieved by placing the
screws lateral to the periosteal attachments of the flap. The joint is enlocated and fluoroscopic examination is
performed, demonstrating good position of the flap and restoration of joint surface congruity.
Revascularization of the flap is achieved by microsurgical anastomosis of each end of the transverse carpal arch
to cut ends of the ulnar digital artery to the finger, ensuring no sacrifice to a digital vessel and “flow-through”
arterial supply to the flap. A volar vein is used for venous drainage of the flap. Of note, while dorsal veins may be

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better developed, these would have issues of a separate incision, need for longer pedicle, and greater size
mismatch for anastomosis. As such, we feel a volar vein, if identified, may be a preferred option. End-to-end
anastomoses are performed with 10-0 nylon interrupted sutures. On release of the clamps, there is immediate
revascularization of the flap, with evidence of bleeding from
the overlaying periosteum and soft tissues. Joint stabilization is achieved with repair of the ulnar and radial
margins of the volar plate to the volar base of the middle phalanx. The radially based flap of flexor sheath is used
to reinforce this repair, taking care to avoid compression of the vascular pedicle. Skin incisions are closed and a
dorsal blocking splint placed to prevent hyperextension of the PIP joint. Discharge home is suitable on the same
day, and instructions given for immediate mobilization and early hand physiotherapy.
FIGURE 310.10 The hemihamate flap inset at the phalangeal base recipient site, demonstrating size and contour
match to the osteochondral defect. (Reproduced from Rozen WM, Niumsawatt V, Leong JC, et al. The vascular
basis of the hemi-hamate osteochondral free flap. Part 2: surgical anatomy and clinical application. Surg Radiol
Anat 2013;35(7):595-608, with permission.)
FIGURE 310.11 Internal bony fixation of the hemihamate flap to the phalangeal base was achieved with two 1.2-
mm lag screws inserted in a volar to dorsal direction. Preservation of the periosteal supply was achieved by

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placing the screws lateral to the periosteal attachments of the flap. (Reproduced from Rozen WM, Niumsawatt V,
Leong JC, et al. The vascular basis of the hemi-hamate osteochondral free flap. Part 2: surgical anatomy and
clinical application. Surg Radiol Anat 2013;35(7):595-608, with permission.)
CLINICAL RESULTS
Early postoperative assessments have demonstrated good range of motion of 0 to 70 degrees in all cases
to date, both actively and passively, and 3-monthly x-ray imaging has demonstrated maintenance of the joint
space. There have been no complications and minimal pain at either the donor or recipient sites described.
Longer-term results for comparison with nonvascularized osteochondral grafts are awaited.
Vascular imaging is performed on the 3rd postoperative day, with a view to early confirmation of intact
vascularization
of the flap. CTA and nuclear (radioisotope) bone scans of the osteochondral flap are performed. The bone
scan confirms perfusion of the osteochondral flap and the CTA confirms patency of the arterial
microvascular anastomoses.
FIGURE 310.12 Schematic representation of the vascularized hemihamate osteochondral flap for transfer to
the volar segment of the middle phalanx base as a vascularized flap. The arterial anatomy of the flap is
highlighted. (Reproduced from Rozen WM, Niumsawatt V, Ross R, et al. The vascular basis of the hemi-
hamate osteochondral free flap. Part 1: vascular anatomy and clinical correlation. Surg Radiol Anat
2013;35(7):585-594, with permission.)
SUMMARY

The vascular anatomy of the hamate is consistent and suitable for use in free tissue transfer as a
vascularized osteochondral flap of the hamate (see Fig. 310.12). In both cadaveric and clinical studies, the
middle intercarpal arch is uniformly present and of sufficient caliber to facilitate revascularization of the
hamate.
Given the success of the hemihamate to resurface the articular base of the middle phalanx, and the
evidence for vascularization to maintain articular cartilage in the long term, the vascularized hemihamate
osteochondral flap offers a novel and valid technique, which has the potential to meet all reconstructive
goals. By using the flap pedicle as a conduit, we can vascularize the flap without compromising an artery to
the digit. While technically challenging and requiring microsurgical skills, the dissection is feasible and the
flap can be elevated with no additional morbidity to the donor or recipient sites.
The free hemihamate flap may provide an improved technique with low donor site morbidity for
reconstruction of small joint comminuted fractures or for the reconstruction of other small osteochondral
defects.
References
1. Calfee RP, Kiefhaber TR, Sommerkamp TG, et al. Hemi-hamate arthroplasty provides functional
reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg 2009;34A:
1232-1341.
2. Williams RM, Kiefhaber TR, Sommerkamp TG, et al. Treatment of unstable dorsal proximal
interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg 2002;28A:856-865.
3. Hastings H, Capo J, Steinberg B, et al. Hemicondylar hamate replacement arthroplasty for proximal
interphalangeal joint fracture/dislocations (abstract). Presented at the 54th Annual Meeting of the American
Society for Surgery of the Hand, Boston, MA, 1999.
4. Rozen WM, Niumsawatt V, Ross R, et al. The vascular basis of the hemi-hamate osteochondral free flap.
Part 1: vascular anatomy and clinical correlation. Surg Radiol Anat 2013;35(7):585-594.
5. Rozen WM, Niumsawatt V, Leong JC, et al. The vascular basis of the hemi-hamate osteochondral free
flap. Part 2: surgical anatomy and clinical application. Surg Radiol Anat 2013;35(7):595-608.
6. Afendras G, Abramo A, Mrkonjic A, et al. Hemi-hamate osteochondral transplantation in proximal
interphalangeal dorsal fracture dislocations: a minimum 4 year follow-up in eight patients. J Hand Surg
2010;35E:627-631.
7. Harman BD, Weeden SH, Lichota DK, et al. Osteochrondral autograft transplantation in the porcine knee.
Am J Sports Med 2006;34:913-918.
8. Kleemann RU, Schell H, Thompson M, et al. Mechanical behaviour of articular cartilage after
osteochondral autograft transfer in an ovine model. Am J Sports Med 2007;35:555-563.
9. Tibesku CO, Szuwart T, Kleffner TO, et al. Hyaline cartilage degenerates after autologous osteochondral
transplantation. J Orthop Res 2004;22:1210-1214.

(Trang không có chữ)

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Chapter 311
Lumbrical Muscle Flap of The Palm
H. KONCILIA
R. KUZBARI
A. WORSEG
M. TSCHABITSCHER
J. HOLLE
EDITORIAL COMMENT
These flaps have been used to successfully treat painful neuromas in continuity.
The coverage of the scarred and devascularized median nerve and its branches poses a challenging problem,
as it is often a sequel of multiple surgical procedures and causes disabling pain and numbness. We describe the
anatomy and clinical applications of the lumbrical muscle flap. Only the two radial lumbrical muscles are suitable
for flap transposition. Pedicled on branches originating in the superficial palmar arch (SPA) and from the common
palmar digital artery (CPDA), the lumbrical muscles can be transposed to reach the entire palm up to the proximal
flexion crease. Clinical use of the first and second lumbrical muscle flaps demonstrates the value of these flaps
for coverage of the median nerve and its branches in the palm.
INDICATIONS
To date, the blood supply of the lumbrical muscles has not been described and the muscles have not been
used surgically as pedicled flaps. The present study describes the blood and
nerve supply of the lumbrical muscles and demonstrates that the two radial lumbricals can be transposed as
proximal-based vascular island flaps. These flaps have a wide arc of rotation and a favorable shape,
enabling coverage of the median nerve and its branches in the palm.
ANATOMY
The lumbrical muscles, usually four in number, are cylindrical muscles located in the midpalmar dorsal to the
palmar aponeurosis. The muscles have a moveable origin, arising from the tendons of the flexor digitorum
profundus (FDP) muscles; the ulnar two are bipennate. Each lumbrical muscle passes to the radial side of the
corresponding finger and inserts into the radial lateral band of the extensor expansion (1, 2, 3, 4).
According to biomechanical and electromyographic studies (5, 6, 7, 8), the main function of the lumbrical muscles
is interphalangeal joint extension. Although the direct contribution to interphalangeal joint extension is small or
even nonexistent in flexed fingers, their indirect contribution to interphalangeal joint extension, by decreasing the
force of the flexor profundus, is pronounced (5, 6). The lumbrical muscles are minor metacarpophalangeal joint
flexors. However, in all their functions, the lumbrical muscles assist the much stronger synergistic interosseus
muscles (7).
The vascular and nerve supplies of the lumbrical muscles were investigated in 20 fresh human cadaver hands of

both sexes (12 to 20 hours postmortem). In all cadaver hands, the brachial artery was injected with a colored
latex-lead oxide solution, and the ulnar artery and superficial palmar branch of the radial artery were dissected at
the distal forearm and traced distally, carefully preserving all arterial branches. All vessels entering the lumbrical
muscles were dissected with the aid of an operating microscope (×10 magnification). The points of entry of the
vessels into the muscle bellies, and the diameter and length of the entering vessels, were measured using a
caliper. To visualize the filling of the internal muscle vasculature, the lumbrical muscles were isolated and then
examined radiologically after the arterial injection with the lead oxide solution. In addition, the nerves that entered
the muscles were dissected, and the points of nerve entry into the muscle bellies were marked and measured.
The origin and insertion of the lumbrical muscles were also investigated. Muscle length and width were
measured before and after removal of the epimysium. The arc of rotation of a proximal-based lumbrical muscle
island flap was determined after division of the minor vascular branches and complete detachment of the muscle
origin and insertion.
First and Second Lumbrical Muscles
The vascular supply of the first and second lumbrical muscles was consistent in all examined hands. The first
lumbrical was consistently supplied by one or two dominant arterial branches originating from the superficial SPA
and several nondominant minor branches from the radialis indicis artery (Fig. 311.1). The second lumbrical
muscle was consistently supplied by one or two dominant arterial branches, arising either from the SPA (67%) or
from the first CPDA (33%), and minor nondominant branches from the first CPDA (Fig. 311.2). In both lumbricals,
the dominant vessels typically entered the muscles on their radial-palmar surface at the junction of the proximal
and middle thirds of the muscle. The diameters of the dominant branches ranged from 0.45 mm to 1.92 mm
(mean: 1.22 mm); the length ranged from 15 to 22 mm (mean: 19 mm).
FIGURE 311.1 Dissection of the first lumbrical muscle showing the origin of the dominant pedicle, which consists
of two adjacent branches of the superficial palmar arch (SPA) (two vertical arrows and dark rubber). Note the
accompanying nerve branch (oblique arrow and light rubber) arising from the radial digital nerve to the index
finger. The SPA is marked by an asterisk.
As previously reported (9), a single branch of the radial digital nerve to the index finger supplied the first
lumbrical muscle in all examined hands. A single branch of the common digital nerve to the second web supplied
the second lumbrical muscle in 18 of the 20 hands. In two cadaver hands, the second lumbrical muscle was
supplied by two or more branches of the same nerve. In all hands, the motor nerves entered the muscle bellies,
together with the dominant vessels, at the junction of the proximal and middle thirds of the lumbricals. A common
neurovascular hilus was present in 90% of the first lumbrical muscles and in 40% of the second lumbricals. In the
remaining muscles, the nerve and vessels entered the muscles at different locations.

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FIGURE 311.2 Dissection of the second lumbrical muscle. The arterial blood supply is from one or two dominant
vessels (two oblique arrows) originating from the SPA (67%) and the first common palmar digital artery (CPDA)
(33%), respectively. Note the nondominant minor branch from CPDA (horizontal arrows). The SPA is marked by
an asterisk.
FIGURE 311.3 The first lumbrical muscle is shown schematically supplied by one or two dominant branches
arising from the SPA. The arc of rotation allows a 180-degree transposition of the flap for coverage of the median
nerve proximally to the wrist flexion crease.
FLAP DESIGN AND DIMENSIONS
The anatomic findings demonstrate that the first and second lumbrical muscles have a “type II” vascular pattern
according to the classification of Mathes and Nahai (10), with one or two dominant vessels entering and
supplying each muscle at the junction of its proximal and middle thirds, and two minor pedicles entering the distal
part of the muscles. The first two lumbricals can, thus, be transposed as proximally pedicled island muscle flaps
based on their dominant vascular pedicles. The arc of rotation of such proximally pedicled muscles reaches the
proximal palm to the level of the proximal flexion crease (Fig. 311.3). The first and second lumbrical muscles may
be raised together, in order to increase the width of the transposed muscle tissue.
The use of the third and fourth lumbrical muscles as pedicled flaps appears impractical, in view of the multiple
variations in length, width, and vascular supply of these muscles.

OPERATIVE TECHNIQUE
The surgical technique for the elevation of the first and second lumbrical muscle flaps is similar. Under tourniquet
control, the lumbrical muscle flap is elevated through a standard carpal-tunnel incision, which is extended to the
second interdigital web in a zig-zag pattern. The palmar aponeurosis is incised and elevated, and the lumbrical
muscle is identified, protecting the digital nerve to the index finger (it is superficial to the first lumbrical muscle).
The SPA is exposed proximally, and its branches that supply the lumbrical muscle are preserved. To facilitate the
separation of the lumbrical muscle from the FDP tendon, the lumbrical tendon is first identified distally, and the
muscle flap is dissected in a distal-to-proximal direction.
The dominant vascular pedicle is identified at the junction of the proximal and middle thirds of the muscle and
preserved. The minor pedicles entering the distal part of the muscle are ligated. The tendon of the lumbrical
muscle is then divided, raising a piece of tendon with the flap to facilitate the fixation of the lumbrical at the
recipient site. Finally, the muscle origin is sharply separated from the FDP tendon, to increase the arc of rotation
of the flap. The muscle island flap is allowed to perfuse before transposition. If needed, the epimysium is
removed, to increase muscle width and to allow the lumbrical muscle to fan out over the median nerve. When the
flap is used for defects in the palm, the muscle is covered with a skin graft. Postoperatively, a splint is applied for
10 days, maintaining the finger joints in intrinsic-plus position of metacarpophalangeal flexion and
interphalangeal extension. Elevation and transposition of the muscle flaps can be carried out in about 30 minutes
of tourniquet time.
SUMMARY
This study demonstrates that the first and second lumbrical muscles can be transposed as proximally
pedicled flaps. The constant and reliable vascular supply of these flaps originates from the SPA and the
CPDA, respectively (11). The lumbrical muscles are thin and easily accessible, and have a longitudinal
shape and an arc of rotation that easily reaches to the distal flexion crease of the wrist. To increase flap
width, the first and second lumbrical muscles may be transposed simultaneously, although this was not
needed in our clinical cases.
References
1. Basu SS, Hazary S. Variations of the lumbrical muscles of the hand. Anat Record 1960;136:501.
2. Schmidt R, Heinrichs HJ, Reissig D. Die Mm. Lumbricales an der Hand des Menschen, ihre Variation in
Ursprung und Ansatz. Anat Ariz 1963;113:414.
3. Metha HJ, Gardner WU. Study of lumbrical muscles in the human hand. Am J Anat 1961;109:227.
4. Braithwaite F, Channel GD, Moore FT, Whillis, J. The applied anatomy of the lumbrical and interosseus
muscles of the hand. Guy's Hospital Reports 1948;97:185.
5. Backhouse KM, Catton WT. An experimental study of the functions of the lumbrical muscles in the human
hand. J Anat 1954;88:133.
6. Eyler DL, Markee JE. The anatomy and function of the intrinsic musculature of the fingers. J Bone Joint
Surg (Am) 1954;36A:1.

7. Ranney D, Wells R. Lumbrical muscle function as revealed by a new and physiological approach. Anat
Record 1988;222:110.
8. Basmajian JV. Electromyography-dynamic gross anatomy: a review. Am J Anat 1980;159:245.
9. Lauritzen R, Szabo RM, Lauritzen DB. Innervation of the lumbrical muscles. Br J Hand Surg 1996;2113:57.
10. Mathes SJ, Nahai F. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982.
11. Koncilia H, Kuzbari R, Worseg A, Tschabitscher M, Holle J. The lumbrical muscle flap: anatomic study
and clinical application. J Hand Surg (Am) 1998;23:111.

Chapter 312
Groin Skin Flap
I. A. McGREGOR
D. SOUTAR
EDITORIAL COMMENT
This is the classic description that gave rise to the whole field of axial-type flaps. The use of fluorescein
intraarterially to demarcate the extent of the primary territory was very helpful in determining the extent of
the flap, although it always underestimated it.
Until the early 1970s, it was generally accepted that strict rules governing length-to-width ratio had to be
acknowledged when raising a single pedicled flap on the trunk or limbs without prior delay. The deltopectoral flap
(1) with a length-to-width ratio in excess of 2:1 appeared to break these rules. To explain this anomaly, it was
postulated (2) that the flap contained an anatomically recognizable arteriovenous system running in its long axis.
On the basis of this hypothesis, a search was instituted for comparable axial arteriovenous systems in other sites
on which skin flaps could be based, with characteristics similar to those of the deltopectoral flap. The search
resulted in description of the groin flap. This concept of raising a flap based on a specific vascular pattern is, in
fact, a rediscovery (3, 4, 5, 6, 7).
Flaps with such an arteriovenous system were termed axial pattern flaps (8), and the concept not only
revolutionized pedicle flap design in general (9) but opened up the whole field of free tissue transfer using
microvascular anastomosis (10).
INDICATIONS
The standard groin skin flap has been used to resurface the hand and forearm, to substitute for the
standard abdominal tubed pedicle flap, and as a local transposition flap. Resurfacing the hand and forearm
is probably the main use of the flap (11). Defects of the elbow cannot readily be reconstructed because the
length of the flap required is not entirely safe.
FIGURE 312.1 Vascular anatomy of the groin showing the “cartwheel” of arteries and veins.
The abdominal tube pedicle is now rarely used. The 6-week period of maturation of the classically designed

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tube can be eliminated by using the groin flap. This can be raised, tubed, and attached to a wrist carrier in a
single stage. Transfer to the wrist in a single stage not only saves time, but has the advantage of being
technically easier because of the absence of previous surgery in the vicinity of the flap. The long pedicle
allows the flap to be attached to either the radial or the ulnar side of the wrist, whichever is appropriate for
the next stage.
ANATOMY
The skin of the groin and hypogastrium is supplied by a cartwheel of arteries arising from the femoral artery, just
below the inguinal ligament, and it is drained by a corresponding cartwheel of veins draining into the saphenous
opening (Fig. 312.1). It seems likely that any flap based on this arteriovenous cartwheel will survive, its safe
length depending on
the length of the particular “spoke of the cartwheel” (12). Intraarterial fluorescein studies of this cartwheel
demonstrate it to be an ellipse rather than a circle, with its long axis in the line of the groin flap and its short axis
in the line of the hypogastric flap (Fig. 312.2). This suggests that the length of the “cartwheel spoke” in the axis
of the groin flap is considerably longer than that in the axis of the hypogastric flap.
FIGURE 312.2 Shape of the territory of the arterial “cartwheel” of the groin in two patients, showing the outline to
be elliptical rather than circular, with the long axis in the line of the groin flap and the short axis in the line of the
hypogastric flap.
The anatomy of the superficial circumflex iliac artery was initially thought to be fairly constant (12), and in
practice its constancy is certainly adequate for the flap as originally described and used. The variations (Fig.
312.3) that have been reported (10) following studies on 100 cadaveric dissections become relevant when the
flap is used as a free flap. Similar variations have been reported by other authors (13, 14) who, in fact, found four
instances, in a series of 86 flaps, in which no trace of vessels large enough to nourish the flap were found.
When the groin flap is used as a standard single pedicled axial pattern skin flap, the takeoff point of its vascular
axis, i.e., the center of the “cartwheel,” is the most important point of reference, and this point is 2 to 3 cm below
the midinguinal point. From there the axial artery, the superficial circumflex iliac, passes laterally parallel to the
inguinal ligament as far as a point below the anterior superior iliac spine (Fig. 312.4). There it divides into three
branches that anastomose with branches of the deep circumflex iliac artery, the superior gluteal artery, and the
ascending branch of the lateral circumflex femoral artery.

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FIGURE 312.3 Variations in the arterial anatomy in the groin, based on the findings in 100 cadaver dissections.
(From Taylor and Daniel, ref. 10, with permission.)
At its origin from the femoral artery, the vessel lies deep to the deep fascia; and it pierces this structure near the
medial border of the sartorius muscle, coming then to lie in the subcutaneous tissue. As it passes laterally, it
becomes more superficial. The medial border of the sartorius is a key point in raising the flap and isolating its
vascular pedicle. There it is tethered by branches that pass deep to the sartorius and also by the lateral
cutaneous nerve of the thigh that crosses the vessel at this point.
The flap has a rich venous drainage; witness its extreme pallor when raised and transferred and the absence of
significant
edema immediately following its transfer. It has, in fact, two venous systems, deep and superficial. The dominant
system is superficial and comprises the superficial circumflex iliac vein, either as a single vessel or as a group of
veins, and the superficial epigastric vein. Together, the superficial system has a total diameter of some 3 to 6 mm
and it terminates in the saphenous bulb. The deep system comprises the venae comitantes that accompany the
artery and drain into the femoral vein. In some cases both systems terminate in the saphenous bulb, but in our
experience both have invariably been present, although separated by a layer of subcutaneous fat.
FIGURE 312.4 Course of the superficial circumflex iliac artery in relation to the underlying structures of the groin.
FLAP DESIGN AND DIMENSIONS
The line of the inguinal ligament is marked on the skin, the femoral artery is identified, and the point of origin of

the superficial circumflex iliac artery is marked on it 2.5 to 3 cm below the line of the inguinal ligament. From this
point, a line drawn laterally parallel to the inguinal ligament marks the course of the axial vessel of the flap. The
sartorius, curving downward from the anterior superior iliac spine, is drawn on the skin, with particular attention
to its medial border that is a key line in mobilizing the flap. The flap is designed around the axial vessel (Fig.
312.5) and, although an attempt is usually made to keep this axis in a central position, failure to do this
accurately appears to make little difference.
The width of the flap is dependent on the clinical problem; it has varied between 5 and 19 cm. Although a wider
flap is theoretically possible, it has not yet been required in our experience. Most commonly, a flap of
approximately 10-cm width is sufficient and allows easy tubing of the pedicle, if this is required.
The maximum length of the flap that can be raised is more difficult to define, depending as it does on the lateral
extent of the territory of the axial artery. Dissection has shown that the vessels lateral to the anterior superior iliac
spine rapidly “disappear” as they anastomose with the arteries in the vicinity. When the length of the territory as
established by intraarterial fluorescein studies is compared with the length of flap that has been found empirically
to be safe, the latter exceeds the former. By trial and error, it has been found safe to add a 1:1 flap to the end of
the truly axial component. It would appear that this addition is in the nature of a random flap. In clinical practice
the flap can safely be extended beyond the anterior superior iliac spine by a distance equal to the width of the
flap.
FIGURE 312.5 Outlines of groin and hypogastric flaps, with the relevant anatomic landmarks marked on the skin.
When used for resurfacing of the hand and forearm, the flap has the considerable advantage that reverse
planning is not necessary, since the pliable pedicle can be manipulated readily. The flap can be applied to either
surface of the hand or forearm and, in practice, the pedicle of the flap is usually tubed to eliminate all raw
surfaces.
OPERATIVE TECHNIQUE
Donor Site
The technique for raising a groin flap depends on whether it is being used as a standard skin flap or as a free
flap transfer. In raising it as a standard skin flap, it is rarely if ever necessary to visualize the vascular pedicle. In
a free groin flap transfer, it is this vascular pedicle and venous drainage system that are of paramount
importance, and they must consequently be visualized at an early stage in the dissection.
The flap is raised in its entirety with no delay of any kind. The correct dissection plane, ensuring that the flap
contains its axial vessels, is most easily found if the upper skin incision is made first. This incision divides the
superficial epigastric artery and its branches; if the flap is raised in a plane deep to these vessels, it will certainly

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include the superficial circumflex iliac arteriovenous systems, since both it and the superficial epigastric system
lie in the same plane. The flap is raised until the lateral border of the sartorius is reached.
At this point the fascia covering the muscle is incised and included in the flap, dissection thereafter proceeding
directly over the muscle. At the medial border of the sartorius, the flap will be found to be tethered by branches
passing into the underlying muscles and by the lateral femoral cutaneous nerve of the thigh that crosses the
arterial pedicle. Elevation of the flap should stop along this line. Although the deep branch of the artery can be
ligated at this point to allow mobilization of the pedicle further, it is safer to leave it undisturbed. If greater length
of flap is required, it is wiser to add the necessary centimeters at the distal end of the flap.
How safe it is to thin the flap remains a difficult problem. Increasing experience indicates that it is probably safe
to thin it quite radically toward its distal end. It has been shown (15) that surprisingly large flaps raised with
virtually no subcutaneous fat can survive, apparently entirely on a subdermal plexus. Provided that care is taken
to avoid damaging recognizable axial vessels, thinning of the flap is reasonably safe. However, if there is the
least doubt, it is certainly wiser to postpone thinning until transfer is complete.
The secondary defect of most groin flaps can be closed directly, although it may be necessary to flex the hip to
reduce tension on the wound during suture. Only defects of exceptional width require split-thickness skin
grafting. It is certainly preferable, where possible, to use direct closure. Not only does it simplify the whole
operative procedure and postoperative management, but it leaves virtually no functional loss and the scar is
hidden within the bikini area.
Recipient Site
In practice, the pedicle of the flap is usually tubed to eliminate all raw surfaces. Continuous suction, using a large
bore
catheter with extra holes cut along its length, is provided by introducing the catheter along the length of the tube.
The ability both to tube the pedicle and to close the donor defect provides a long pedicle that permits freedom of
movement without embarrassing the blood supply.
FIGURE 312.6 Division of a groin flap applied to the hand 3 weeks following application (A), completion of
insetting 1 week later (B). (From McGregor, ref. 16, with permission.)
Movement should be restricted during the immediate postoperative period, particularly during recovery from the
anesthetic, and the use of elastic adhesive strapping is generally sufficient. Thereafter there is no need for
elaborate immobilization. The extent of immobilization depends on the state of the wound but can usually be
quickly discarded.
The position taken by the arm is a relatively comfortable one and has been termed “the hand in pocket” position.
The patient is actively encouraged to move the joints of the upper limb through as wide a range as possible. In
particular, the length of the pedicle allows adequate mobility of the wrist and fingers.

The ability to mobilize the upper limb early appears to be of considerable importance in preventing the
development of edema fluid that might otherwise collect in the dependent hand; it more than adequately offsets
the effect of gravity.
Subsequent Stages
When cover of the defect by the flap is virtually complete, the flap is divided in its entirety at the end of 3 weeks,
but is not inset (Fig. 312.6). Final insetting is postponed for a further week. The handling is basically similar to
that of an ordinary direct flap. It is well recognized that rim necrosis, often following division and immediate
insetting of a flap (17), can be avoided by postponing insetting for a week.
When the flap is being transferred on a wrist carrier, the situation calls for greater care, because of the need to
be certain that there is enough blood flow through the attachment to sustain the flap. The presence in the flap of
a preexisting, efficient arteriovenous system through its groin attachment means that there is little to encourage
the development of an effective vascular flow through the wrist carrier attachment.
FIGURE 312.7 Use of a delay stage 3 weeks after transfer, to ensure survival of the bridge segment prior to final
division, and the use of the bridge segment to resurface the palm of the hand. (From McGregor, ref. 16, with
permission.)
The way to encourage the development of adequate vascular flow through the wrist attachment is to reduce the
efficiency of the already present arteriovenous system by formally ligating and dividing the feeding artery (18,
19). Because of this, a delay stage should be made a formal part of the procedure, with careful search for, and
division of, the superficial circumflex iliac artery (Fig. 312.7).
It is important also to appreciate that once the axial vessel is divided, the flap loses the characteristics it
previously possessed by being an axial pattern flap. After delay, therefore, it must be managed in the same way
as a standard abdominal tubed pedicle.
CLINICAL RESULTS
Used as a conventional axial pattern skin flap, the groin flap has proved safe and reliable. Necrosis has
generally been the result of obvious technical error or the use of a flap that extended too far beyond the
territory of the axial artery. This happened mainly during the period of initial exploration of the flap potential
and before the need to observe the 1:1 ratio of its terminal random segment was fully appreciated.
SUMMARY
The groin flap is a reliable, efficient flap for covering hand and forearm defects.

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References
1. Bakamjian VY. A two stage method for pharyngo-esophageal reconstruction with a primary pectoral skin
flap. Plast Reconstr Surg 1965;36:173.
2. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
3. Wood J. Case of extreme deformity of the neck and forearm from the cicatrices of a burn, cured by
extension, excision and transplantation of skin, adjacent and remote. Med Chir Trans 1863;46:149.
4. Aymard JL. Nasal reconstruction. Lancet 1917;2:888.
5. Joseph J. Nasenplastik and sonstige Gesichtsplastik nehst einem. Anhang ueber Mammaplastik and
einige weitere Operationen aus dem Gebiete der aeusseren Koerperplastik. Leipzig: Curt Kabitzsch, 1931.
6. Shaw DT, Payne RL. One stage tubed abdominal flaps. Surg Gynecol Obstet 1946;83:205.
7. Khoo BC. John Wood and his contribution to plastic surgery: the first groin flap. Br J Plast Surg 1977;30:9.
8. McGregor IA, Morgan RG. Axial and random pattern flaps. Br J Plast Surg 1973;26:202.
9. Smith PJ. The vascular basis of axial pattern flaps. Br J Plast Surg 1973; 26:150.
10. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243.
11. Lister GD, McGregor IA, Jackson IT. The groin flap in hand injuries. Injury 1973;4:229.
12. Smith PJ, Foley B, McGregor IA, Jackson IT. The anatomical basis of the groin flap. Plast Reconstr Surg
1972;40:41.
13. Harii K, Ohmori K, Torii S, et al. Free groin skin flaps. Br J Plast Surg 1975; 28:225.
14. Ohmori K, Harii K. Free groin flaps: their vascular basis. Br J Plast Surg 1975;28:238.
15. Colson P, Houot R, Gangolphe M, et al. Use of thinned flaps (flap grafts) in reparative hand surgery. Ann
Chir Plast 1967;12:298.
16. McGregor IA. The groin flap. In: Grabb WC, Myers MB, eds. Skin flaps. Boston: Little Brown, 1975.
17. Stark RB, Kernahan DA. Reconstructive surgery of the leg and foot. Surg Clin North Am 1959;39:469.
18. Stranc WE. The delay procedure and its effect on blood now in tubed pedicle flaps. In: Sanvenero-
Rosselli G, Boggio-Robutti G, eds. Transactions of the Fourth International Congress of Plastic and

Reconstructive Surgery. Amsterdam: Excerpta Medica, 1969:1190.
19. Stranc MF, Labandter H, Roy A. A review of 196 tubed pedicles. Br J Plast Surg 1975;28:54.

Chapter 313
Hypogastric (Shaw) Skin Flap
T. BARFRED
EDITORIAL COMMENT
Since the superficial epigastric vessel courses just on top of Scarpa's fascia, the flap should be elevated
just under Scarpa's fascia, in order to maintain the safe vascularity of the flap. This will also result in a
relatively thin flap. It is not necessary to extend it down to the deep fascia or then to the rectus sheath.
Since 1973, when a choice between the groin flap and the hypogastric flap became possible, I have used the
hypogastric flap in about half of my cases (1). When both flaps seem equally comfortable, the groin flap is
chosen because of the texture of the flap and the position of the donor site (2, 3, 4, 5, 6, 7, 8).
INDICATIONS
The flap is suitable for any defect of the hand, either palmar or dorsal, but especially for the latter (Fig.
313.6). If several fingers are to be covered, an artificial syndactyly is created for one regular defect (Fig.
313.6B). In subsequent syndactyly operations, the flap is defatted and the cosmetic result is satisfactory.
The flap has been used for primary or secondary defects or for defects created in reconstructive
procedures, with equally good results. The tube itself has even been used as a flap for another defect on
the same hand or on the opposite hand.
Secondary reconstructive procedures (Fig. 313.5) can be performed easily under the flap at a later stage.
ANATOMY
In a study of 100 dissections of the iliofemoral region (9), the superficial circumflex iliac and superficial inferior
epigastric arteries had a common origin from the femoral artery in 48%. In 17% the two vessels had a separate
origin, and in the remaining 35%, the superficial inferior epigastric artery was absent and was replaced by
smaller branches from the superficial circumflex iliac artery. They found that the superficial inferior epigastric
artery, when present, covered a fan-shaped area from the border of the rectus abdominus muscle to the iliac
crest.
FLAP DESIGN AND DIMENSIONS
The hypogastric flap should be based just proximal to the ipsilateral inguinal ligament, centered over the femoral
artery and vein (Fig. 313.1). The flap should be directed slightly lateral and designed to the defect in the proximal
part. Distally, a width of 7 to 8 cm is generally necessary to tube this fairly abundant part of the flap. Most flaps
are 16 to 18 cm long. There has been no verified use of extraordinarily long flaps of this type, but the anatomic
studies indicate that a groin flap should be chosen for coverage of very large defects.

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FIGURE 313.1 The hypogastric (Shaw) flap.
FIGURE 313.2 The raw area of the flap can be directed laterally by staggering the incision at the base of the
tube.
A preoperative positioning test is most important, to decide which flap will give the best possibilities for
positioning and moving the hand and arm, when attached to the trunk.
OPERATIVE TECHNIQUE
Proximally, the flap is raised at the level of the deep fascia, but it may be thinned in its peripheral random pattern
part. Distally, the flap is raised just superficial to Scarpa's fascia. The donor defect is closed primarily. When
tubing the base of the flap, it is important to decide the best direction for the raw area of the flap (Fig. 313.2). It
can be easily directed medially, laterally, or facing upward, depending on the most relaxed position of the hand.
Transition between the tube and flap is facilitated if a reverse flap from the hand can be created (Fig. 313.3).
FIGURE 313.3 The transition from the tube to the hand is facilitated by a reverse flap from the hand.

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Until the tube is divided, every effort must be made to maintain movement in the shoulder, elbow, wrist, and
fingers (Fig. 313.4). If a contralateral flap is used, shoulder movement is difficult, but this may be the primary
choice if an ipsilateral hypogastric flap or groin flap is contraindicated.
Ten to 12 days after the first stage, the tube is clamped with a pliable intestinal forceps for 5 to 30 minutes, to
observe the vascular reaction in the flap. It is possible that some “training effect” is obtained at the same time.
The flap is routinely divided after 3 weeks. If part of the tube must be used, a delay operation to divide the axial
vessels is advised.
CLINICAL RESULTS
Thirty-three flaps have been performed on 31 patients between 1956 and 1981. One flap was totally lost
because of severe hemorrhage from the flap, simultaneous with severe hematemesis. One flap included an
appendectomy scar and was partially lost, resulting in reamputation of the thumb. One flap had only a
partial loss, but the severely burned hand had to be amputated because of increasing necrosis.
Ten cases had partial necrosis of the flap. Six of these healed spontaneously. In two cases, the flap was
detached, the necrosis excised, and the flap reapplied, without further complications. One patient had minor
necrosis, and a large tear had to be grafted later. One patient had a total skin loss, but the subcutaneous
flap tissue survived and allowed coverage of the defect with a full-thickness skin graft, using the crane
principle (10). Thus, in only two of 33 flaps did the intended result not occur.
The skin color of the flap is generally somewhat darker than normal skin, and the hair growth more ample.
Quite a few patients developed a slight sensation for touch. One patient gained weight after the operation,
to almost double his original, without increasing the subcutaneous tissue of the flap. No complications were
found in 14 subsequent reconstructions and eight defatting procedures.
SUMMARY
The hypogastric flap remains an alternative procedure to the groin flap for hand reconstruction. The needs
of the individual patient will determine which flap is the more appropriate.
FIGURE 313.4 A,B: The range of movement possible with a hypogastric flap in place in a short-armed
patient.

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FIGURE 313.5 Flexion and extension after a hypogastric flap and secondary reconstruction of all the
extensor tendons to the fingers.
FIGURE 313.6 A: Defect of the index and long fingers with bone and tendon injuries. B: The hypogastric
flap applied after artificial syndactyly to create one defect.
References
1. Barfred T. The Shaw abdominal flap. Scand J Plast Reconstr Surg 1976; 10:56.
2. Wood J. Case of extreme deformity of the neck and forearm from the cicatrices of a burn, cured by
extension, excision, and transplantation of skin, adjacent and remote. Med Chir Trans 1863;46:149.
3. Shaw DT, Payne RL. One stage tubed abdominal flaps. Surg Gynecol Obstet 1946;83:205.
4. Bunnell S. Surgery of the hand, 2d Ed. Philadelphia: Lippincott, 1948; 194-195.
5. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
6. Li CS, Nahigian SH, Richey DWG, Shaw DT. Primary application of the one stage abdominal tubed
pedicle. Hand 1972;4:184.
7. Kojima T. One stage tubed abdominal flap for the hand. Jpn J Plast Reconstr Surg 1973;16:300.
8. Baudet J, Lemaire JM. Le lambeau abdominal en chirurgie de la main. Ann Chir Plast 1975;20:215.
9. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243.

10. Millard DR, Cooley SGE. A solution to coverage in severe compound dorsal hand injuries. Plast Reconstr
Surg 1972;49:215.