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

ANATOMY
The fibula is triangular, about 1.5 to 2 cm in diameter, and 40 cm in length. It is composed of highly dense
cortical bone and a relative paucity of cancellous components. It supports one-sixth of our body weight. It
articulates with the tibia proximally and distally, and maintains the stability of the knee and ankle joints. Most
muscles that control foot motion originate from the fibula.
The peroneal artery supplies the fibula in two forms—periosteal and endosteal. The nutrient artery from the
peroneal artery gives the bone endosteal circulation through the nutrient foramen, which ranges from one to
three in number, usually one (69%), and in more than 70% of cases is located in the middle third of the fibula (3,
4). The fibula can be used with overlying skin in an osteocutaneous flap. The lateral skin of the lower leg is
supplied with cutaneous branches from the peroneal artery, ranging from three to eight in number. There are two
types of cutaneous branches, musculocutaneous and septocutaneous (4, 5, 6). The musculocutaneous
perforators are more numerous and more proximal than the septocutaneous perforators (4, 6).
The septocutaneous perforators, which pass through the posterior crural septum between the peroneal muscles
and soleus, are found along the posterior margin of the fibula and are distributed from the middle third to the
lower third of the fibula (4, 5). Although the reliability of the septocutaneous perforators is still controversial, Wei
et al. (5) reported excellent survival rates for the osteoseptocutaneous fibular flap. Even if the septocutaneous
perforator is absent, the musculocutaneous branch supplies adequate circulation to the same area.
FLAP DESIGN AND DIMENSIONS
Some technical points need to be stressed:
1. Preoperatively, a Doppler probe is used to mark the cutaneous perforator along the posterior margin of the
fibula. In thin individuals, the posterior crural septum may be palpable as a cleft in the fibular posterior margin.
2. To harvest the fibula, it is important to place the point between the upper and middle thirds of the fibula in the
center of the flap, to maximally contain the nutrient branch of the peroneal vessels; most of the nutrient
foramen is located in the upper two thirds of the fibula.
3. Obtaining a longer fibula than measured will allow for a longer pedicle and easier insetting of the flap in cases
with a different configuration of skin and bone defect.
4. Six to 8 cm of the proximal and distal fibula is preserved to maintain stability of the knee and ankle joints.
5. In order to obtain an osteocutaneous flap based on the septocutaneous perforators, the center of the skin
paddle is placed along the posterior margin of the middle third to distal third of the fibula (4, 5, 6).
6. Two or three cutaneous branches to the lateral skin of the leg, which have been marked along the posterior
border of the fibula with the Doppler, are included in the skin paddle. It is desirable that the design of the
cutaneous portion be larger than the defect size. Wei et al. (5) recommended that the skin paddle can be up to
25 cm in length and 14 cm in width, with one or two sizable septocutaneous branches, and that the
dimensions should be minimally 8 to 10 cm in length and 4 cm in width (7).
7. The donor site should never be closed by primary repair under severe tension but rather should be skin-
grafted.
OPERATIVE TECHNIQUE
Elevation of Osteocutaneous Fibula—Lateral Approach with Patient in Supine Position
A skin incision to the subcutaneous layer is made. The skin flap is elevated from the peroneal muscle anteriorly

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and the soleus muscle posteriorly in a subfascial plane. An alternative method involves elevating the skin flap
initially in the suprafascial level, and as the dissection approaches the posterior crural septum, the deep fascia
investing the peroneal and soleus muscles should be incised and included in the skin flap to prevent accidental
tearing of the cutaneous branches. The superficial peroneal nerve should be carefully protected because of its
subcutaneous position in the distal third of the lower leg. At this point, inspect the septum for inclusion of the
cutaneous perforator(s). Just one or two branches of the septocutaneous perforators secure the viability of the
skin paddle. If viability is suspect, dissect and clamp the musculocutaneous branch within the septum, release
the tourniquet, and check perfusion. After viability is confirmed, the musculocutaneous branch is cut and ligated.
If the septum contains no vessels, intramuscular dissection is continued to the origin of the musculocutaneous
branch to the skin flap. The peroneal muscle is dissected from the lateral border of the fibula, and dissection is
continued to the intermuscular septum between the lateral and anterior compartments and extensor digitorum
longus and extensor hallucis longus, carefully exposing the interosseous membrane, so as not to injure the
anterior tibial vessels and deep peroneal nerve. Also, by keeping the Metzenbaum scissors tight against the
bone, a minimal amount of muscle can be left on the fibula. The interosseous membrane is incised, and the
tibialis posterior is exposed. After a Gigli saw is used for the proximal and distal osteotomy, posterolateral traction
with a bone hook will allow for easy identification of the peroneal artery. At the posterior portion of the flap, the
soleus muscle is separated from the posterior crural septum; next, the flexor hallucis longus is dissected from the
fibula, exposing the peroneal pedicle between the posterior tibial muscle and flexor hallucis longus. Occasionally,
the peroneal vessels are within the flexor hallucis longus, requiring the harvest of a portion of the flexor hallucis
longus with the pedicle. The dissection is continued to the peroneal vessel bifurcation (Fig. 324.2). The elevated
osteocutaneous fibula can be osteotomized into a number of segments in situ as necessary.
FIGURE 324.2 Cross-section of dissection of fibula and skin paddle.

FIGURE 324.3 Drawing of inset of two fibula bone grafts and revascularization by the superficial palmar arch and
princeps pollicis and flow-through peroneal artery.
FIGURE 324.4 Postoperative radiograph.
Recipient Preparation
In case of two metacarpal defects, a small portion of the intervening central segment between either side
segments of the fibula can be resected subperiosteally, to snugly place the fibula segments into the missing
metacarpals. The osteotomized fibula segment is fixed to the remnant of the missing bone with miniplates or
screws. If the metacarpophalangeal joint or carpometacarpal joint is lost, arthrodesis can be performed. To
reconstruct the thumb metacarpal, it is extremely important to keep in mind that opposition and pinching action be
restored (Figs. 324.1, 324.3, and 324.4).
CLINICAL RESULTS
A very satisfactory aesthetic result can be obtained using a fibular osteocutaneous flap for composite
metacarpal-defect reconstruction. However, several factors should be considered in terms of functional
recovery. The degree of hand-mobility recovery will depend more on the extent of joint, tendon, intrinsic
muscle, and soft-tissue damage in the area of the injured metacarpal bone, rather than the missing
metacarpal bone defect length (2). Especially in a composite defect, intactness of the joint is a more

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important prognostic factor than other tissue damage. Thus, an intact thumb carpometacarpal joint, like the
metacarpophalangeal joint of the other digits, will allow for a more favorable result.
SUMMARY
The osteocutaneous fibula free flap provides many advantages in metacarpal reconstruction: (a) a good
size match for metacarpal bone, (b) multiple segments of the fibular strut for multiple metacarpal defects, (c)
more rapid and better bony union than the nonvascularized bone graft, (d) good flexibility of the
septocutaneous skin paddle for insetting and contouring the flap, (e) use as a flow-through system to
revascularize an injured digit, (f) one-stage reconstruction for composite defect, and (g) an excellent
aesthetic result.
References
1. Lee HB, Tark KC, Kang SY, et al. Reconstruction of composite metacarpal defects using a fibula free flap.
Plast Reconstr Surg 2000;104:1448.
2. Lin CH, Wei FC, Rodriguez ED, et al. Functional reconstruction of traumatic composite metacarpal defects
with fibular osteoseptocutaneous free flap. Plast Reconstr Surg 2005;116:605.
3. Mckee NH, Haw P, Vettese T. Anatomic study of the nutrient foramen in the shaft of the fibula. Clin Orthop
Rel Res 1983;184:141.
4. Yoshimura M, Shimada T, Hosokawa M. The vasculature of the peroneal tissue transfer. Plast Reconstr
Surg 1990;85:917.
5. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteocutaneous flap: anatomic study and clinical
application. Plast Reconstr Surg 1986; 78:191.
6. Schusterman MA, Reece GP, Miller MJ, Harris S. The osteocutaneous free fibula flap: is the skin paddle
reliable? Plast Reconstr Surg 1992;90:787.
7. Wei FC, Seah CS, Tsai YC, et al. The oteoseptocutaneous flap for reconstruction of composite
mandibular defects. Plast Reconstr Surg 1994; 93:294.

Chapter 325
Dorsal Rectangular Skin Flap for Web Space Reconstruction
E. Z. BROWNE JR.
EDITORIAL COMMENT
This is the classic procedure for release of syndactyly. However, the editors emphasize that the flap needs
to be much longer than is depicted in the drawings in this chapter, probably halfway into the dorsum
between the PIP and DIP joints.
Although an interdigital web space collapses with adduction, it assumes a rectangular shape with abduction of
the fingers. Reconstructive procedures designed to restore the web space must result in a pliable, rectangular
structure with maximum distensibility along the volar edge of the web. Although inter-digitating flaps can be used
to restore the rectangle, it is difficult to create the appropriate slope from dorsal to volar edge, and pliability can
be limited by scarring within the rectangle. A single, dorsal proximally based, rectangular skin flap is preferable
for total web space reconstruction. This flap is passed between the fingers and set into an inverted T in the
palmar skin (Fig. 325.1).
INDICATIONS
The flap has application in instances where the entire web space has been obliterated, causing a true
syndactylism. It is not indicated in situations where only part of the web space is involved, such as a dorsal
adduction contracture sparing the volar edge. This may be treated satisfactorily with skin grafts or with
various modifications of Z-plasties (1, 2, 3).
FIGURE 325.1 Dorsal, proximally based rectangular flap, set into inverted volar T.
The dorsal rectangular skin flap can be adapted for use in a number of conditions, such as congenital
deformities (4), traumatic defects, and revision after reconstructive procedures such as distant flaps. It is
especially useful in the treatment of burn syndactyly (5), and has also been useful in improving prehension
by deepening scarred web spaces associated with partial amputation, especially with loss of a thumb (Fig.
325.2). In general, the flap has not been found to be as useful for release of the first web space as the four-
flap Z-plasty (6).
FLAP DESIGN AND DIMENSIONS

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This is a random skin flap, and it is elevated midway in a plane between dorsal and volar skin. The volar surface
is
split longitudinally and the flap is placed into an inverted “T” set into the palmar skin (Fig. 325.3). The defects
created along the sides of the fingers are skin-grafted. The base of the flap must extend proximally to the
metacarpal heads for flaps used between the fingers, and may extend back to the level of the middle of the first
metacarpal for reconstruction of the first web space. It is important to bring the volar T more proximal into the
palm than would be anticipated, in order to avoid a secondary contracture along the volar edge. The length-to-
width ratio has not been found to be critical, in spite of the nature of the scarred skin, and it is appropriate to use
the entire length of the skin available for the flap.
FIGURE 325.2 Use of flap to deepen first web space.
FIGURE 325.3 A: Markings before release. B: Flap inset with skin graft on the sides of the fingers. C: Volar
view of flap inset. D: Final result. (From Browne et al., ref. 5, with permission.)
OPERATIVE TECHNIQUE
In elevating the flap, care must be exercised to avoid the neurovascular structures, especially in congenital

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deformities. When the flap is used in the first web space, it is necessary to divide the fascia overlying the first
dorsal interosseous muscle, and to release any scar causing contracture of this fascia to the adductor pollicis. It
should be kept in mind that the radial artery may be encountered during this procedure. Unless the interval
between the interosseous and the abductor is opened widely, the first web space will not be effectively
deepened.
It is usually necessary to preserve as much flap length as possible, and marginal areas seem always to survive.
By setting the flap into an inverted “T” in the palmar skin, the principle of a double-opposed Z-plasty is used,
thus minimizing contracture along the volar edge.
CLINICAL RESULTS
In spite of the apparent disregard for length-to-width ratio, this flap has been very reliable, even in
circumstances such as burn syndactyly where the flap is composed of old skin graft. The flap has been
used in well over 70 instances of varying types of traumatic syndactyly, without loss of a single flap.
Although there has been loss, on occasion, of some of the skin grafts placed in the defects on the sides of
the fingers, it has been possible to regraft these, and there have been no instances of functional deficit
associated with the flap.
SUMMARY
The dorsal rectangular skin flap is an excellent means of reconstructing the web space, especially between
adjacent fingers.
References
1. Adamson JE, Crawford HH, Horton CE, et al. Treatment of dorsal burn adduction contracture of the hand.
Plast Reconstr Surg 1968;42:355.
2. Shaw DT, Li CS, Richey DWG, Nahigian SH. Interdigital butterfly flap in the hand: the double-opposing Z-
plasty. J Bone Joint Surg 1973;55A:1677.
3. Krizek TJ, Robson MC, Flagg SV. Management of burn syndactyly. J Trauma 1974;14:587.
4. Bauer TB, Tondra JM, Trusler HM. Technical modifications in repair of syndactylism. Plast Reconstr Surg
1956;17:385.
5. Browne EZ Jr, Teague MA, Snyder CC. Burn syndactyly. Plast Reconstr Surg 1978;62:92.
6. Woolf RM, Broadbent TR. The four flap Z-plasty. Plast Reconstr Surg 1972;49:48.

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Chapter 326
Lateral Digital Skin Flap for Web Space Reconstruction
P. COLSON
H. JANVIER
The lateral surface of the finger is often spared in burn injuries. It is therefore available to be used as a flap for
web space reconstruction (1). The technique will vary, depending on whether the burned skin is on the dorsal
(most frequent) or palmar aspect of the hand.
INDICATIONS
The lateral digital flap may be indicated in different instances: trauma, tumor excision, congenital
deformities, Dupuytren's contracture, and burn injuries (2, 3, 4, 5, 6, 7). In the latter circumstance,
experience shows that, apart from the functional results, the cosmetic appearance is very satisfactory. This
is a major psychological factor in early and complete rehabilitation.
FIGURE 326.1 A: A narrow “lateral digital” skin flap is raised from each side, so that the two flaps share the
same pedicle. These two flaps have been compared with two “rabbit's ears” (S. Bunnell). B: The two flaps
rotated 180° are inset into the dorsal defect. Each donor site is sutured with slight tension.
FLAP DESIGN AND DIMENSIONS
The technique of reconstruction will depend on the location and severity of the contracture (8, 9).
Dorsal Burns
In the patient who can still make a fist in spite of some skin blanching, such moderate interdigital webbing can be
satisfactorily dealt with by small lateral digital flaps.
A narrow tongue of unburned skin and subcutaneous tissue is designed on the fingers on each side of the web
(1). Both flaps will have the same pedicle at the base (Fig. 326.1A). The two tongues are detached, rotated 180°,
and brought into

contact—as two rabbit's ears—and sutured to each other and to the edges of the defect created by the dorsal
incision.
FIGURE 326.2 A: First stage in release of palmar burn contracture: the palmar longitudinal retracted scar is
entirely severed and the finger is extended. Thereafter, the laterodigital flap can be satisfactorily designed. One
flap is required to maintain release of the flexion contracture, as shown here. B: A second flap is designed at a
later stage, to release the web space contracture. Note the technical details to avoid both the shortening of the
interdigital space and the retraction of the palmar suture line.
If the flaps are small and the burned skin on the rest of the finger is not too extensive, the donor site can be
closed primarily.
In the patient who cannot completely flex the metacarpophalangeal joints and in whom there is a severe
contracture, a large flap is needed. The defect resulting from such a large flap must be covered with a split-
thickness skin graft.
Palmar Burns
In most cases of palmar burns, the contracture not only limits separation of the fingers with transverse retracted
webs, but also keeps the proximal phalanges in permanent flexion, with longitudinal contracted bands crossing
over the digitopalmar crease. For this reason, repair usually requires two lateral digital flaps cut from each
interdigital space and used in two stages. The first flap, rotated 90°, allows for extension of the flexed finger (Fig.
326.2A), and the second flap, rotated 180°, widens the commissural web (Fig. 326.2B).

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Thenar Web
Web space contractures of the thumb with mild adduction may be corrected by means of two lateral digital flaps
raised from the thumb and index finger. Split-thickness skin grafts are usually used to resurface the raw areas.
If the web space contracture is significant, a distant flap such as a brachial dermo-epidermal flap should be used
(see Chapter 307).
OPERATIVE TECHNIQUE
Careful attention to detail is most rewarding: the longitudinal incision on the dorsum of the hand must release not
only the retracted skin, but also the underlying fibrosed tissue, sometimes including the strong transverse
intermetacarpal ligament. The flap is cut as wide as good skin will permit, and the tip is designed to extend as
close to the distal interphalangeal joint as possible.
To free the flap, the neurovascular bundle is first identified under Cleland's ligament. The ligament is severed
along its entire length. The flap then carries with it some subdermal tissue and a few small vessels and nerves
issuing directly from the palm.
The flap is then rotated 180° and the tip is inserted into the proximal end of the dorsal longitudinal incision.
Sutured into the defect of the incised web, the flap will fit well if it is supple. Such a flap has very good viability,
even if cut long—less than 2% distal necrosis in our experience—provided it is not sutured into place under
tension. This is an important technical point, because the flap grows thinner from its base to its extremity. Its
blood supply moves mainly through the subdermal vascular plexus.
To avoid a straight line contracture along the flap donor site, the digital incision is prolonged to penetrate the
palm for a few millimeters, and a small triangular extension of the palmar skin is cut, rotated, and fitted into the
raw area near the digitopalmar crease (Fig. 326.2B).
SUMMARY
The lateral digital flap, when used with the proper indications, can successfully release interdigital and
thenar web space contractures in both dorsal and palmar burns.
References
1. Boyes JH. Bunnell's surgery of the hand, 4th ed. Philadelphia: Lippincott, 1964;190; Figs. 223, 224.
2. Colson P, Janvier H, Gangolphe M. Un procédé de S. Bunnell pour la refection de commissures digitales
par rotation de lambeaux. Ann Chir Plast 1960;5:205.
3. Tubiana R, Baux S, Kenesi C. À propos de trois cents brûlures thermiques récentes des mains. Ann Chir
1967;23:1387.
4. Vilain R, Michon J. Chirurgie plastique cutanée de la main. Paris: Masson, 1968;93.
5. Iselin M, Iselin F. Traité de chirurgie de la main. Brussels: Flammarion, 1967; 266-267.
6. Colson P, Janvier H. Brûlures du dos de la main: problèmes posés par la réparation secondaire de la

région des commissures. Ann Chir Plast 1970;15:14.
7. Morel-Fatio D. Chirurgie des pertes de substance cutanées. In: Encyclopédie médico-chirurgicale. Paris:
Editions Techniques; 8-10; Figs. 399, 400, 403.
8. Lister G. The theory of the transposition flap and its practical application in the hand. Clin Plast Surg
1981;8:115.
9. Beasley RW. Secondary repair of burned hands. Clin Plast Surg 1981;8:141.

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Chapter 327
Five-Skin Flap for Reconstruction of Web Space Contracture
M. ROUSSO
M. R. WEXLER
I. J. PELED
EDITORIAL COMMENT
This technique probably provides the widest first web space, compared with any other of the
reconstructions.
Web space contractures are most frequently caused by burns. Usually, one surface is spared. The clinical
features of web space contractures are distortion of the normal web concavity and the appearance of a
transverse interdigital scar that limits abduction. Sometimes, a dorsal or volar digitopalmar skin contracture is
present hyperextending or, on the contrary, flexing, metacarpophalangeal joints and proximal interphalangeal
joints.
Congenital, posttraumatic (including burns), and spastic contractures are amenable to release by the five-skin
flap technique (1, 2, 3, 4, 5).
INDICATIONS
Reconstruction can achieve several goals: (1) interdigital abduction, especially in the first web space; (2)
deepening of the web spaces, restoring them to their normal symmetric concavity and dihedral shape; and
(3) lengthening of the dorsal or volar digitopalmar skin, releasing longitudinal metacarpophalangeal or
proximal interphalangeal associated deformities.

FIGURE 327.1 A: The objectives of redistribution of skin tension. B: The geometric principles involved in
the five-skin flap technique. C: Release of the first web. D: Release of an interdigital web. (From Rousso,
ref. 2, with permission.)
The five-skin flap technique can achieve all three objectives. Different combinations and modifications can
be used, depending on the degree of severity.
FLAP DESIGN AND DIMENSIONS
The five-skin-flap technique involves two balanced opposed Z-plasties along the line of contracture, with a
transverse V-Y-plasty advancing deep into the middle of the reconstruction (Figs. 327.1B and 327.2).
FIGURE 327.2 A,B: Release of a first web space contracture using the standard technique.
If the skin contracture is not linear but occurs in two dimensions, the flap is modified as shown in Figure 327.3A.
This is especially useful for congenital, posttraumatic, or spastic contractures.
If the transverse dorsal scar is linear and neatly protruding, the dangers of transposing scarred flaps can be
completely avoided by a simplified technique that advances all flaps with minimal transposition or undermining
(Fig. 327.4A).

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The final result of the three variations is similar from a geometric point of view to that of Mustardé's method for
repair of congenital contractures of the inner palpebral angle (6).
FIGURE 327.3 Modification of the standard five-skin flap technique. A: Geometric principles of the modification.
B: Application to a first web space contracture. (From Rousso, ref. 2, with permission.)
FIGURE 327.4 Simplified technique for severely scarred linear contracture. A: Geometric principles. B: As
applied to an interdigital web. C: Note the healthy pocket of skin in the center of the commissure that is then
shaped into a V-Y-plasty and advanced without undermining proximally over the dorsum. D: Immediate
postoperative result. E: Late postoperative result. (From Rousso, ref. 2, with permission.)

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FIGURE 327.5 A: Multiple V-Y-plasties used for incomplete release. B: Postoperative result after five-skin-flap
technique. The three V-Y-plasties outlined. C: Postoperative result after three V-Y-plasties. (From Rousso, ref. 2,
with permission.)
FIGURE 327.6 Combinations of the five-skinflap technique (cross-hatching marks the contracture). A: For linear
contractures at different levels. B: For associated volar digitopalmar and interdigital web contracture. (From
Rousso, ref. 2, with permission.)
FIGURE 327.7 A: Release of multiple interdigital web skin contractures with associated digitopalmar skin
contractures. The interdigital contractures are alternately released in two stages. Note the five-skin-flap
technique used for a contracture across the wrist. B: Glove model to help design the five-skin-flap release. C:
Postoperative result after two stages completed. (From Rousso, ref. 2, with permission.)
If the results are incomplete, they can be improved 6 months later by multiple V-Y-plasties (Fig. 327.5A).

The five-flap principle can be applied to various locations and combinations of contractures. (Fig. 327.6).
If the injury results in a volar contracture of several adjacent webs, release of alternate webs in two stages is
indicated (Fig. 327.7).
CLINICAL RESULTS
The result is predictable. The Z-plasties and V-Y-plasties adapt easily to the most frequent skin
contractures. All flaps are smaller than when using a single Z-plasty, allowing scarred tissues to be elevated
without resulting in necrosis at their tips.
Healthy flaps are interposed within the scarred area, helping prevent recurrence of contracture.
Compression dressings or garments may be indicated postoperatively.
SUMMARY
The five-skin flap technique can be used to release many web space contractures. Further release can be
obtained at a later stage with five V-Y-plasties. Various combinations and modifications can be used to treat
particular cases.
References
1. Rousso M. Brûlures dorsales graves de la main: reconstruction de la commissure: technique à cinq
lambeaux: I. La premiere commissure. Ann Chir 1975;29:475.
2. Rousso M. Brûlures dorsales graves de la main: II. Reconstruction des commissures 2, 3, et 4:
modification à la technique à cinq lambeaux. Ann Chir 1975;29:1014.
3. Rousso M, Wexler MR. Secondary reconstruction of the burned hand. Prog Surg 1978;16:182.
4. Rousso M, Wexler MR. Management of the burned hand. In: Goldwyn RM, ed. Long-term results in plastic
and reconstructive surgery, Vol. 2. Boston: Little, Brown, 1980;892-907.
5. Rousso M, Wexler MR. Burns of the upper limb. In: Tubiana R, ed., The hand, Vol. 2. Philadelphia:
Saunders, 1981.
6. Mustardé JC. The treatment of ptosis and epicanthal folds. Br J Plast 1960; 12:252.

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Chapter 328
Transposition Flap for Soft Tissue Adduction Contracture of The
Thumb
M. SPINNER
EDITORIAL COMMENT
This and the subsequent chapter demonstrate excellent local flap techniques for first web-space
reconstruction. However, the dorsal thumb flap allows for a much wider release of the first web space and
uses an area that despite its relative insignificance from a functional standpoint, may be more apparent from
a cosmetic standpoint. Both of these flaps are innervated ones, and consequently the first web-space
widening is fully innervated. See also Chapter 329.
Loss of adduction of the thumb is a major handicap. Abdominal flaps of varying designs, local rotational flaps, Z-
plasty, diamond split-thickness and full-thickness grafts— all have been suggested for correcting an adduction
contracture of the thumb. A transposition flap from the index finger is an effective technique (1).
FLAP DESIGN AND DIMENSIONS
The adducted thumb is released by a planned incision that transposes skin from the radial aspect of the proximal
phalanx of the index finger to the first web space (Fig. 328.1). The amount of
contracture and release necessary is predetermined: the increased width desired determines the width of the
base of the transposition flap taken from the radial side of the index finger.
FIGURE 328.1 A: Adduction contracture of the thumb (X). B: Oblique view, demonstrating the triangular flap
based proximally on the dorsoradial aspect of the index finger. C: Volar aspect, demonstrating the thenar and
index finger incision. (From Spinner, ref. 1, with permission.)
The length of the flap is predetermined by the distance that is required for the apex of the flap to fit into the
thenar eminence. A 1:1.5 ratio is ordinarily used but can be increased, if necessary, to a 1:3 ratio. The triangle of
skin is outlined on the index finger.
OPERATIVE TECHNIQUE

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The web is opened by continuing the volar radial aspect of the triangle into the adducted first web space and
extending its midportion at right angles, into the volar aspect of the thenar eminence (Fig. 328.1C). The flap is
elevated. It should be noted that this flap is well innervated by a branch of the superficial radial nerve (see
Chapter 283). The underlying structures are easily visualized and the dorsal veins are preserved. The
contracted fascia between the first and second metacarpals is released, as is the adductor muscle. (The fascia
about the adductor is frequently scarred, and can be easily seen.)
The tailored flap is transposed into the defect created (Fig. 328.2). A split-thickness skin graft is used to cover
the defect on the radial side of the index finger and dorsal surface of the hand. The operative exposure gives
free access to the shaft of the thumb, the index finger, and the metacarpophalangeal joints—as well as the
adjacent contracted soft tissues.
FIGURE 328.2 A,B: Palmar and dorsal views. The adduction contracture has been released, and the
transposition flap and split-thickness skin graft have been sutured in place. (From Spinner, ref. 1, with
permission.)
CLINICAL RESULTS
Six hands have been treated with this procedure. In the cases treated, opponens transfer, arthrodesis of the
thumb, metacarpophalangeal joint operations, and other local secondary operative procedures have been
performed in conjunction with the release of the adducted thumb.
SUMMARY
A transposition flap for correction of soft-tissue adduction contracture of the thumb has two advantages.
First, local tissue is used to correct the adduction contracture of the thumb. Second, the exposure is
excellent for the simultaneous performance of other essential procedures, such as opponens plasty.
Reference
1. Spinner M. Fashioned transpositional flap for soft tissue adduction contracture of the thumb. Plast
Reconstr Surg 1969;44:345.

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Chapter 329
Dorsal Thumb Flap for The Thenar Web Space
B. STRAUCH
M. FOX
The specialized nature of the first web space that allows for a wide range of thumb mobility is severely
compromised when trauma or congenital deformity encroach on full web space expansion. Numerous
procedures, including free skin grafts, distant flaps, and local flaps, have been described for correction of an
adduction contracture of the first web space (1, 2, 3, 4, 5). Common to all of these procedures is a full release of
the web space from dorsal to volar fulcrum at the base of the first and second metacarpals. Also common to
these procedures is a residual area of less than normal sensation in the critical web space or key pinch contact
area.
INDICATIONS
A local transposition flap, elevated over the dorsum of the thumb, allows for complete release of first web
space contracture. This flap construction allows adequate visualization of underlying contracted tissues and
a closure that provides full-thickness sensory skin coverage over the entire web space and key pinch
contact area.
FLAP DESIGN AND DIMENSIONS
The flap is planned to encompass the entire dorsal skin of the thumb, from ulnar to radial midaxial lines (Fig.
329.1A). The distal extent of the flap is tapered and extends 3 to 4 mm beyond the interphalangeal (IP) joint. The
radial midaxial line extends proximally to the basilar crease of the thumb.
OPERATIVE TECHNIQUE
An ulnar incision widens at the metacarpophalangeal joint to the middorsal area of the first web space and
extends to the junction of the base of the first and second metacarpals. A volar incision is then extended from the
free border of the web proximally to the junction of the first and second metacarpals (Fig. 329.1B). The flap is
elevated at the level of the fascia, incorporating the superficial veins and the branches of the radial nerve into the
flap. Full exposure of the adductor brevis, the insertion of the volar thenar intrinsics, as well as the entire ulnar
side of the thumb, is attained. Fascial releases are accomplished after full integumentary release has been
achieved.
Following complete soft-tissue release, the thumb is then fully abducted. The elevated flap, having been
released from the thumb, now lies directly over the center of the first web space (Fig. 329.1C) and can be turned
over into the palmar surface to close the skin defect (Fig. 329.1D). The radial volar
side of the split web is rotated to close the defect on the thumb to a point dorsal to the midaxial line. A split-
thickness skin graft is used to close the remaining defect on the dorsum of the thumb (Fig. 329.2).

FIGURE 329.1 A: The flap encompasses the entire dorsal skin of the thumb. The distal end extends 3 to 4 mm
beyond the interphalangeal crease. The ulnar incision widens at the base to the middorsal area of the first web
space. B: The volar incision extends from the free border of the web to the junction of the first and second
metacarpals. (Continued)
FIGURE 329.1 (Continued) C: Elevation of the flap affords full exposure of the underlying tissues. Abduction of
the thumb leaves the flap properly oriented. D,E: Closure of the wounds and application of a split-thickness skin
graft on the dorsum of the thumb. (Adapted from Strauch, ref. 4, with permission.)

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FIGURE 329.2 A-D: A 6-year-old child with complete simple syndactyly of the first web space. Despite a
completely encircling mantle of skin, the thumb had reasonably good mobility and was of normal length. The
ulnar border of the flap was extended ulnarward, to compensate for the inability to extend the flap to the midaxial
line on the ulnar side of the thumb. Full release with a dorsal thumb flap. Entire first web space and key pinch
area covered with normally innervated full-thickness skin and soft tissue. (From Strauch, ref. 4, with permission.)
SUMMARY
A flap designed from the dorsum of the thumb can be used not only to completely release an adduction
contracture of the first web space but also to provide critical sensation.
References
1. Littler JW. The prevention and correction of adduction contracture of the thumb. Clin Orthop 1959;13:182.
2. Milford L. The hand, citing PW Brand. Evaluation of the hand and its function. Orthop Clin North Am
1973;4:1127. In: Edmonson AS, Crenshaw AH, eds. Campbell's operative orthopedics, 6th Ed. St. Louis:
Mosby, 1980;274.
3. Spinner M. Fashioned transpositional flap for soft tissue adduction contracture of the thumb. Plast
Reconstr Surg 1969;44:345.
4. Strauch B. Dorsal thumb flap for release of adduction contracture of the first web space. Bull Hosp Joint
Dis 1975;36:34.
5. Sandzen SC Jr. Dorsal pedicle flap for resurfacing a moderate thumb-index web contracture release. J

Hand Surg 1982;7:21.

Chapter 330
Dorsal Index Skin Flap for The Thenar Web
E. J. HALL-FINDLAY
B. STRAUCH
EDITORIAL COMMENT
The incorporation of the Z-plasty expands the Spinner flap potential of widening the first web space.
The use of the dorsal index skin as a flap for deepening a contracted web space was described by Brand for
patients with leprosy (1, 2, 3). See Chapter 283 for a further discussion of this flap applied to the thumb.
FLAP DESIGN AND DIMENSION
This flap is designed for the thenar web space. The donor site can be closed primarily or with a skin graft, if
more thumb abduction is required (Fig. 330.1).
If dorsal dissection alone is not sufficient to give a good web, a small Z-plasty may be added to give extra width
to the web (Fig. 330.2). Brand cautions that an over-wide web produced weakness in pinch in leprosy patients
since the web is necessary to stabilize the metacarpal when it is pushed by the index finger in the act of pinching
(4). If a Z-plasty is necessary, its central limb must run along the free margins of the web for about 2 to 3 cm. Its
dorsal limb will be the distal 2 to 3 cm of the dorsal incision already made and its ventral limb will run down the
palmar side of the web from the other side of the central limb.
OPERATIVE TECHNIQUE
The dorsal skin and fascia must be incised to release the web space contracture. An incision is made along the
full length of the index metacarpal starting from the index metaphalangeal (MP) joint and curving dorsally back
toward the wrist. The skin over the web is elevated. While the thumb is held in abduction and opposition, the
dorsal fascia is divided. In leprosy patients, Brand found it was not usually necessary, or indicated, to divide the
paralyzed muscle. However, to get adequate abduction, the origins of the adductor pollicis and first dorsal
interosseous muscles will often have to be divided.
A K-wire between the first and second metacarpals may be necessary to maintain some abduction during the
postoperative period. This wire can be removed at the end of 6 weeks.
Once sufficient abduction is obtained, the skin defect is covered with either a split-thickness or a full-thickness
skin graft.
CLINICAL RESULTS
The advantage of this particular method is that it places the skin grafted area over the dorsum of the hand
where it causes less disability. Care must be taken during elevation of the flap to leave the paratenon over
the extensor tendons (Fig. 330.3).
SUMMARY

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A dorsal index skin flap can be used to deepen the first web space.
FIGURE 330.1 A: The web has been released and the flap elevated. B: The apex of the flap (x) has been
shifted into the palm. C: The flap in place seen from the palmar surface. D: The donor site is covered with a
skin graft.

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FIGURE 330.2 A: Thumb web Z-plasty. A large posterior flap is created. B: The smaller palmar flap and the
distal end of the posterior flap are shown. C: The flaps transposed. D: The donor site is covered with a skin
graft.

FIGURE 330.3 A: This 12-year-old boy suffered total amputation of his thumb as a result of a motorcycle
accident. The results of microvascular replantation were excellent (this is a case of Dr. Frank Forshew,
Akron, OH), but the patient had a web space contracture of 38°. B,C: The dorsal flap has been transferred
after release of the contracture. D: Final result. (These figures were provided by Drs. F. James Rybka of
Carmichael, CA, and Frederick E. Pratt of Sacramento, CA (retired), for Chapter 283.)
References
1. Brand PW. Deformity in leprosy. In: Cochrane RG, ed. Leprosy in theory and practice, 2nd Ed. Bristol:
John Wright, 1964;485.
2. Brand PW. The reconstruction of the hand in leprosy. Ann R Coll Surg Eng 1952;11:350.
3. Brand PW. Hand reconstruction in leprosy. In: Brand PW, ed. British surgical practice: surgical progress.
London: Butterworths, 1954; 124-125.
4. Brand PW. Personal communication with B. Strauch, 1988.

Chapter 331
Arterialized Palmar Flap for First Web Space Reconstruction
L. O. VASCONEZ
Contracture of the thenar web space usually produces a disabling limitation of motion of the index finger and
thumb, preventing grasping of larger objects. Causes of thenar web contracture include trauma, burns, hand
infections, and systemic or local diseases, as well as paralysis in congenital malformations. Release of thenar
web contractures to be effective usually requires a resurfacing with soft, pliable flap tissue.
INDICATIONS
An arterialized palmar flap to resurface the release of a thenar web contracture is best applicable to
contractures secondary to burns of the dorsal skin, particularly when the index finger and thumb have
suffered full-thickness burns and are covered with skin grafts. In such cases one cannot use the excellent
“Brand flap” from the dorsum of the index finger (see Chapter 330) (1), and release by multiple Z-plasties is
risky. A transposition flap from the palmar aspect of the hand that extends to the metacarpophalangeal joint
of the index finger is most appropriate.
ANATOMY
A transposition palmar flap that is outlined adjacent to the defect on the thenar web space usually has its inferior
margin extending along the metacarpophalangeal crease to the index finger. It is an arterialized flap that is
supplied by cutaneous branches of the index digital artery as it crosses from the superficial arch toward the first
web space. One or two branches, significant to supply the skin and subcutaneous tissue of the flap, emerge from
the index digital artery in the thenar region.
FLAP DESIGN AND DIMENSIONS
The web contracture is first completely released and the index finger and thumb are held widely apart. A
transposition flap is then outlined adjacent to the defect and extending along the radial aspect in the finger up to
the metacarpophalangeal crease. The flap will lie over the course of the proper index digital artery and its base
will be proximally along the thenar region (Fig. 331.1).
OPERATIVE TECHNIQUE
The outlined flap is elevated superficial to the first lumbrical and adductor pollicis fascia and is raised sufficiently
to allow a 60° to 90° angle of transposition to the recipient area of the thumb web space. Care is taken to avoid
injury to the proper index digital nerve and artery. The flap is then sutured into the defect. The donor site, which
is located along the palmar aspect of the hand extending to the radial aspect of the index finger, is covered with
a split-thickness skin graft—preferably from the instep of the foot in black patients to avoid hyperpigmentation of
the graft.

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FIGURE 331.1 Outline of the flap in a normal hand. The arrow points to the metacarpophalangeal crease.
FIGURE 331.2 A: Dorsal aspect of burned hands with moderate thenar web contracture on the left hand. The
right hand thenar web contracture has been released with multiple Z-plasties. B: Released thenar web
contracture with a palmar flap. Dorsal view. C: Palmar view. Note the hyperpigmented skin graft in the palm.
CLINICAL RESULTS
This arterialized flap is reliable and well vascularized from the vertically oriented branches of the digital
artery. Recurrence of the contracture is unusual but a temporary splint may be needed for 2 to 3 months for
web molding. The skin graft on the palmar aspect of the finger is well tolerated, although it is unsightly in
black patients (Fig. 331.2).
SUMMARY
The arterialized palmar flap is a local flap that provides enough good quality skin to release most of the
moderate thenar web contractures.

Reference
1. Brand PW. Deformity in leprosy. In: Cochrane RG, ed. Leprosy in theory and practice, 2nd Ed. Bristol:
John Wright, 1964;485.

Chapter 332
First Web Space Pseudo-Kite Flap
P. LOREA
J. MEDINA
G. FOUCHER
EDITORIAL COMMENT
This is another good option for opening the first web space, particularly in patients with a congenital hand
defect. The vascularized flap, although relatively small (if one is to close the defect primarily), does open up
the web space for adequate functional rehabilitation.
Numerous flaps and plasties have been described to address functional limitations of the first web, which are
present in several congenital or posttraumatic conditions. These flaps, although not perfectly adapted to
congenital first-web deficiency, are dissected as islands from the web itself, the dorsal thumb or index finger, the
dorsum of the hand, or the dorsal or palmar forearm. Because appearance is a major concern in congenital
conditions, more so perhaps than in traumatic cases, a tetrahedral locoregional flap is described, which is
designed to enlarge or to create a first web. The flap is dorsoradially harvested from the index finger and based
on the axial vascularization of a kite flap. The donor site is closed primarily, avoiding the conspicuous scar of a
skin graft on the dorsum of the hand.
INDICATIONS
In congenital cases, the pseudo-kite flap is an intermediate solution between local z-plasties and regional
flaps from the dorsum of the hand (1), as well as distant flaps (e.g., posterior interosseous flap). We used
this flap mainly in such congenital conditions as thumb hypoplasia (Blauth II and III), Apert syndactyly,
amniotic band syndrome, and late-treated thumb in palm or symbrachydactyly (2), but we found it useful
also in some posttraumatic conditions, such as in the sequelae of crush injuries (3). However, we do not
use this flap after burn injury or in a Volkmann contracture, in which skin deficiency is sometimes too
extensive, or when scars are present on the dorsum of the index finger.
We do not advocate the use of the pseudo-kite flap in every congenital condition with first-web deficiency. It
is part of an armamentarium of flaps and plastic techniques, each of which is useful in selected conditions.
The choice is dependent on many factors, as the design of the malformed first web is not the same in each
patient (e.g., total absence, deficiency in length [distance between thumb and index metacarpophalangeal
(MP) joints], or deficiency in depth [relative length of the thumb]). However, the flap has the successful
ability to lengthen the first web without relative thumb lengthening (deepening of the web).
ANATOMY
The pseudo-kite flap is an axial-pattern flap perfused by the first dorsal interosseous artery, the axial vessel of
the kite flap described previously (4). Numerous anatomic variations have been described, but these are not
relevant in describing surgical technique (5). This artery consistently runs along the radial aspect of the second
metacarpal, most of the time superficial to the aponeurosis of the first dorsal interosseous, sometimes deep to

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the aponeurosis, and sometimes both configurations are present together. Most of the cutaneous perforators are
situated at the level of the neck of the second metacarpal, where the skin flap has its narrow skin bridge. During
the proximal distal dissection, care must be taken underneath the skin paddle not to injure the first dorsal
interosseous artery, which is tethered by a constant anastomotic circle around the neck of the second
metacarpal.
FLAP DESIGN AND DIMENSIONS
The pseudo-kite flap is a rhomboid-shaped flap, corresponding to the tetrahedral aspect of the first web (Fig.
332.1). It is designed on the radial side of the dorsum of the first phalanx and MP joint of the index finger. The
pivot point with a half-centimeter skin bridge is situated on the radial aspect of the neck of the second metacarpal
bone, to include the first dorsal interosseous artery. The incision ( AB) runs to the middle of the web ( B). This
incision continues straight on the palmar side ( A'). The BC side of the rhombus is along the midlateral radial line
of the index finger, with the length of BC usually equal to BA. The CD side is designed on the dorsal aspect of
the proximal phalanx of the index finger, and DE on the dorsum of the hand, with point E situated along the
second metacarpal some millimeters radial to point A, to preserve the narrow skin bridge. Dimensions vary
according to the patient's age.
FIGURE 332.1 Design of the flap.
Closure of the donor site is done by modification of a procedure described by Dufourmentel (6). BD and ED lines
are prolonged ulnarly, and DF is drawn by bisecting this BD- ED angle. The length of DF is equal to the other
sides of the rhombus. The last line ( FG) is perpendicular to the extended BD and starts from point F. If more skin
is necessary on the palmar aspect of the first web, a longer BA' line is possible; BC and DC lines may be
extended by placing C more distally.
OPERATIVE TECHNIQUE
The incision begins with line AB extending palmarly to A'. Any fibrous band, fibrous tissue, or muscle tethering
the first web is released by this exposure. The aponeurosis of the first dorsal interosseous and adductor muscles
is incised, with care taken to preserve the nutrient artery. The first web opening may be maintained by a
Kirschner wire. If necessary, this incision allows disinsertion of the first dorsal interosseous muscle from the first
metacarpal. We avoid proximal transfer of the adductor muscle, favoring its disinsertion from the second and
third metacarpals through a separate incision.
Lines BCDE are then incised to allow elevation of the flap. Care is taken to keep the dissection plane deep to the
aponeurosis of the first dorsal interosseous muscle, to ensure inclusion of the first dorsal interosseous artery. It

is not necessary to visualize the artery and is dangerous to skeletonize it. At the level of the metacarpal neck,
one must be aware of the anastomotic branch, and if necessary, dissection must go deeper in the muscle to
divide this branch and to avoid injuring the axial artery.
Elevation of a DFG flap is done in a more superficial plane, including only skin and subcutaneous tissue. The
transfer of the flap allows closure of point C to point A' (Fig. 332.2). Closure of the donor site is done by transfer
of the DFG triangle, F being sutured in the C position. Primary closure is possible when the index-finger MP joint
is maintained in extension. If closure has to be done in flexion, a skin graft may be needed. If the rhombus was
initially asymmetric, distal closure of the ABC angle is done in a V-Y fashion, until equalization of all sides of the
rhombus is reestablished.
FIGURE 332.2 Inset of the flap and closure of the donor site.
CLINICAL RESULTS
We reported previously on 16 flaps in 16 patients (2). Patient mean age at the time of surgery was 10
months (range, 6 months to 6 years). A split-thickness skin graft was necessary in five cases. A dynamic
flexion splint was necessary for the index finger in one case, and static night-splinting was used in 11
patients to maintain the first web opening. Complications included skin necrosis (one superficial), wound
dehiscence, and skin-graft slough.
The mean lengthening of the web fold was 205%, compared with preoperative values. The first
intermetacarpal angle was measured by radiograph, when available (seven patients), and increased from
11 degrees preoperatively (range, 6 to 17 degrees) to 75 degrees postoperatively (range, 54 to 89
degrees). Grasping ability was measured and compared with the normal side, with increasing-sized
cylinders in eight patients. The web size was equal to that of the other side in five patients, 1 cm smaller in
three patients, and 2 cm smaller in one. All patients (or families) were satisfied, and no patient needed
reoperation.
Our experience with traumatic cases is not so extensive and includes six cases. Distal skin grafting of the
donor site was required in three cases. No complications occurred, and patients were satisfied with the
functional results and aesthetic improvement.
SUMMARY
The pseudo-kite flap is a rhomboid (diamond-shaped), axial- pattern, fasciocutaneous flap, useful in some

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cases of first-web insufficiency, mainly in congenital conditions. Most of the time, the donor site may be
closed primarily, minimizing the scars on the “social” side of the hand.
References
1. Buck-Gramcko D. Syndactyly between the thumb and index finger. In: Buck-Gramcko D, ed. Congenital
malformations of the hand and forearm. London: Churchill Livingstone, 1998;141.
2. Foucher G, Medina J, Navarro R, Khouri RK. Correction of first web space deficiency in congenital
deformities of the hand with the pseudokite flap. Plast Reconstr Surg 2001;107:1458.
3. Foucher G, Cornil C, Braga Da Silva J. Le lambeau “pseudo-cerf volant” de l'index avec plastie LLL dans
la reconstruction de la premiere commissure. Ann Chir Plast Esthet 1992;37:207.
4. Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr
Surg 1979;63:344.
5. Sheriff MM. First dorsal metacarpal artery flap in hand reconstruction: I. Anatomical study. J Hand Surg
1994;19A:26.
6. Dufourmentel C. La fermeteur des pertes de substance cutaneé limitées “Le lambeau de rotation en L
pour Losange.” Ann Chir Plast 1962;7:61.

Chapter 333
Multiple Dorsal Rotation Skin Flaps for The Thenar Web
A. E. FLATT
The multiple dorsal flap technique was originally designed for the congenital mitten hand in which the thumbnail
lies in the same plane as the fingers (1, 2).
INDICATIONS
The usual indication for the use of these flaps is the need to supply sufficient skin for the thumb web space,
to allow proper opposition of the thumb. The flaps can also be used to mobilize sufficient dorsal skin in a
distal direction, to provide coverage for the metacarpal heads of patients who have suffered traumatic
amputations at this level and who need strong protective coverage, either for the wearing of a prosthesis or
during their ordinary work.
The commonest indication for these flaps is in the congenital mitten or five-fingered hand syndromes. In
these patients there is not a true contracture of the web space, since the web space has never really
developed. The thumb is, in effect, trapped in an inadequate amount of skin, and its release by these flaps
allows it to abduct, rotate, and assume the normal posture of the thumb immediately.
FIGURE 333.1 A: Multiple dorsal rotation skin flap technique. The first flap (a) is based on the thumb and
rotated into the opened web space. The second flap (b) is rotated into the defect left from (a). The third flap
(c) is rotated into the defect left from (b). The defect from flap (c) is higher up on the forearm where there is
more loose skin, so it can be closed in a curvilinear fashion. B: A small, square palmar flap (d) based on the
index finger is used to cover the proximal radial portion of the index finger. (From Flatt and Wood, ref. 2,
with permission.) C: Flap ( a) rotated into the web space. Note that the palmar flap ( d) is used to cover the
index finger. D: Flap ( b) is rotated to cover the defect by ( a) and flap ( c) is rotated into the defect by ( b).
Note flap ( a) in position. E: Flaps ( a) and ( b) inset into position. A good release of the first web space can
be achieved.
Other causes of contracture in the web space such as burn, skin avulsion due to scar contracture, or
contracture due to neurologic disorder or to improper splinting, can also benefit from the use of these flaps.

When a contracture is present, scarring must be dealt with at the same time.
OPERATIVE TECHNIQUE
The first, most distal, wide dorsal flap is based on the radial side of the dorsum of the thumb (Fig. 333.1 [a]), so
that the venous drainage and radial nerve sensibility supply are intact. Next, a small square flap based on the
index finger is raised from the palmar aspect of the skin between the thumb and the index finger (Fig. 333.1 [d]).
This flap will provide coverage for the proximal and radial aspects of the index finger (Fig. 333.1).
The thumb web space can now be cleared of all tight fascia, the thumb can be widely abducted, and the dorsal
flap can be laid in place. Both the dorsal flap and the index finger flap should be sutured in place before the
second dorsal flap is raised. This second flap (Fig. 333.1 [b]) should be as wide as the others, but based on the
ulnar side of the wrist. It is then rotated distally into the defect on the dorsum of the hand.
FIGURE 333.2 (Above) In the child with a congenital mitten hand, the thumbnail lies in the same plane as the
fingers. (Below) Opposition of the thumb is possible after providing adequate skin for the thumb web space.
(From Flatt and Wood, ref. 2, with permission.)
A third and final dorsal flap (Fig. 333.1 [c]) fills the defect created by the rotation of the second flap. This third
flap is based radially on the most distal portion of the dorsal forearm. Undermining of the surrounding tissues and
lining up of the skin edges will allow total closure of the area, resulting in a final single lazy-S scar running from
the dorsal side of the index metacarpophalangeal joint to the lower portion of the forearm.
FIGURE 333.3 A: Preoperative appearance of a congenital mitten hand. B: Postoperative result. (From Flatt and
Wood, ref. 2, with permission.)

The use of these flaps can provide excellent web space coverage and freedom for a totally entrapped thumb
(Figs. 333.2 and 333.3). The flap can also be used when there is, in effect, some adduction contraction and
some definition of a true thumb. For instance, when the thumb is well developed distal to the interphalangeal
joint, the dorsal flaps can be rotated as described above; but on these occasions it may be possible to plan
proper coverage without the use of the small, secondary index finger-based flap.
CLINICAL RESULTS
If a child is born with a total mitten hand, I believe that the thumb should be freed as soon as is reasonable
and certainly by 6 months of age. Release of the thumb may not be delayed beyond 1 year, because by this
age the child's cortex is sufficiently developed to make use of the thumb. A thumb must therefore be
provided by this time.
Long-term results have been encouraging, and the flaps grow with the hand as the child increases in age.
The scar is not always cosmetically pleasing and, on occasion, secondary excision and even Z-plasty have
been needed to relieve particularly unpleasing, thickened scarring (Figs. 333.3 and 333.4).
SUMMARY
The multiple dorsal rotation skin flap technique as described here has worked well for selected cases. The
principles have also been extended to other situations, such as providing coverage for loss of skin on the
dorsum of the hand and metacarpophalangeal joints. This operation is not recommended as a panacea for
the deepening of all thumb web clefts. Each adducted thumb contracture demands a careful evaluation of
its specific problems and the selection of appropriate treatment from the many methods available.
FIGURE 333.4 Examples of multiple dorsal rotation skin flap results in two patients. Correction of the typical
adducted and unrotated thumbs of the hypoplastic mitten hand has been provided by the flaps. Scarring is
sometimes unattractive. (From Flatt and Wood, ref. 2, with permission.)
References
1. Brand PW. Deformity in leprosy. In: Cochrane RG, ed. Leprosy in theory and practice, 2nd Ed. Bristol:
John Wright, 1964;485.
2. Flatt AE, Wood VE. Multiple dorsal rotation flaps from the hand for thumb web contractures. Plast

Reconstr Surg 1970;45:258.

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Chapter 334
Cross-Arm Triangular Flaps for First Web Space Reconstruction
I. J. PELED
M. R. WEXLER
M. ROUSSO
Adduction contracture of the thumb is rather a frequent finding following trauma (lacerations, crush, burns), and
may present as an early or late complication. Early splinting and physiotherapy are advisable, although not
always feasible or effective.
The intrinsic muscles, adductor pollicis, and first dorsal interosseous, are contracted and are often included in
the scarred fibrous tissue. The palmar fascia can also be involved in deep injuries or following infection.
INDICATIONS
When conservative treatment fails to correct the adduction contracture, a surgical procedure is needed to
restore the proper relationship of the thumb to the fingers and palm. This is achieved by releasing the
scarred skin and the fibrosed subcutaneous tissue, as well as by performing a myotomy of the intrinsic
muscles to open the web space widely. During this procedure several important structures, such as the
median nerve, flexor tendons of the index finger, and palmar arteries, may be exposed in the diamond-
shaped defect that has been created.
Local flaps and Z-plasties may be used to close the defect in only a few cases. The local skin cover can
have poor circulation, especially in burns. Skin grafts may succeed when the skin is the only structure that
is contracted (1). In most cases the defect is large and deep, and distant flaps are the choice (2, 3, 4, 5, 6).
One possibility is the use of two oppositely based, triangular, cross-arm flaps (7).
The inner aspect of the arm is an excellent donor area for hand resurfacing (8, 9, 10, 11, 12). The skin is
thin, elastic, and scarce in adipose tissue and hair. The laxity and rich blood supply allow wide undermining
and primary closure of the donor area in most cases.

FIGURE 334.1 Blood supply of the inner arm through the superior and inferior ulnar collateral branches of
the brachial artery.
ANATOMY
The rich blood supply of the inner arm is provided by two branches of the brachial artery: the superior and
inferior ulnar collateral arteries (Fig. 334.1). The superior ulnar collateral artery crosses the deep fascia together
with the ulnar nerve and supplies the brachialis anterior and triceps muscles and, by direct cutaneous branches,
the skin of the upper inner arm. It anastomoses with the posterior recurrent branch of the ulnar artery.
The inferior ulnar collateral artery divides into two branches at the lower third of the arm. The anterior branch
runs in front of the medial epicondyle and it anastomoses with the anterior recurrent branch of the ulnar artery.
The direct cutaneous branches irrigate the lower inner arm (13).
FLAP DESIGN AND DIMENSIONS
The flaps are drawn in the inner aspect of the contralateral arm according to the size of the defect. One
triangular flap is based superiorly and will cover the dorsal aspect of the web, and the other one is based
inferiorly and will cover the ventral half of the defect. The base of each flap equals the width of the web defect
(Fig. 334.2C).
OPERATIVE TECHNIQUE
The web is widely opened, incising and/or excising all the fibrous tissue and contracted muscle. The resulting
defect has a diamond shape, with one of the axes lying along the web and the other crossing it perpendicularly
from dorsal to palmar (Fig. 334.2B).
The flaps are raised in the plane of the loose areolar tissue space above the fascia. The two sides of the
triangles are sutured to the sides of the diamond while the hand grasps the arm (2, 14).
The donor area is closed primarily by undermining the skin edges (Fig. 334.2D and E). Separation of the flaps is
performed 10 to 14 days later, and the bases of the triangles are sutured to each other and form the arch of the
web. When necessary, a Z-plasty is used to lengthen this scar. The position of the hand, grasping the opposite
arm, is a good way of splinting and maintaining the abduction obtained by the release, without the need of
internal Kirschner wire fixation (FIg. 334.2E).
CLINICAL RESULTS
The triangular cross-arm flaps are reliable, thin flaps that cover the whole defect. There is no need for a
delay. The thumb is splinted in abduction by the grasping position on the arm. The only disadvantage is the
lack of sensation of the flap.
The results have been excellent and no complications have been found. Except for the remaining scar at
the donor area, there are no functional deficits (Fig. 334.2F and G). With modern microvascular techniques,
the same donor area can be used as a free flap (15, 16, 17), but conventional flaps are safe and may easily
be carried out.
SUMMARY
Triangular cross-arm flaps can provide the skin and soft tissue needed to release severe first web space

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adduction contractures. Sufficient release of the subcutaneous tissue and underlying fibrosed muscles can
be performed.
FIGURE 334.2 A: Adduction contracture of the first web following deep burns. B: Release of the first web.
C: Design of the contralateral triangular arm flaps. D: The opposed triangular flaps are raised and the
donor area is closed primarily by undermining the lateral flaps. E: The two triangular flaps sutured to the
created defect of the web. The hand grasps the contralateral arm. F: Dorsal view of the hands 1 year after
bilateral release of the first webs. G: Volar view. (From Yeschua et al., ref. 7, with permission.)
References
1. Flynn JE. Adduction contracture of the thumb. N Engl J Med 1956; 254:15.

2. Brown JB, McDowell F, eds. Skin grafting, 3d Ed. Philadelphia: Lippincott, 1958;108, 147.
3. Littler JW. The prevention and the correction of adduction contracture of the thumb. Clin Orthop
1959;13:182.
4. Flatt AE, Wood VE. Multiple dorsal rotation flaps from the hand for thumb web contractures. Plast
Reconstr Surg 1970;45:258.
5. Grabb WC, Myers MB, eds. Skin flaps. Boston: Little, Brown, 1975;489.
6. Peacock EE. Burns of the hand. In: Converse JM, ed. Reconstructive plastic surgery. Philadelphia:
Saunders, 1977;3376.
7. Yeschua R, Wexler MR, Neuman Z. Cross-arm triangular flaps for correction of adduction contracture of
the first web space in the hand. Plast Reconstr Surg 1977;59:859.
8. Teich-Alasia S, Ambroggio G, Oberto E, Liguori G. Are traditional pedicle flaps really obsolete? Chir Plast
1980;5:77.
9. Delbet JP, Wallich E. La place du cross-arm flap dans la chirurgie de la main. Ann Chir Plast 1964;9:3.
10. Colson P, Janvier H. Le dérgraissage primaire et total des lambeaux d'autoplastie à distance. Ann Chir
Plast 1966;11:11.
11. Rouvière H. Anatomie Humaine, 4th Ed, Vol. III. Madrid: Bailly-Baillière, 1956;148.
12. Teich-Alasia S, Barberis ML. The value of the “cross-arm” flap in reconstructive surgery of the hand. Chir
Plast 1972;1:134.
13. Sharpe C. Tissue cover for the thumb web: a review. Arch Surg 1972;104:21.
14. Gan KB. Inner arm flap for the reconstruction of nasal and facial defects. Ann Plast Surg 1981;6:277.
15. Dolmans S, Guimberteau JC, Baudet J. The upper arm flap. J Microsurg 1979;1:162.
16. Kaplan EN, Pearl RM. An arterial medial arm flap: vascular anatomy and clinical applications. Ann Plast
Surg 1980;4:205.
17. Newsom HT. Medial arm free flap. Plast Reconstr Surg 1981;67:63.

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Chapter 335
Microneurovascular Transfer on A First Web Space Skin Flap
B. STRAUCH
E. J. HALL-FINDLAY
EDITORIAL COMMENT
This flap allows for a very high innervation density, so that two-point discrimination in the range of normal
can be achieved.
The first web space skin flap from the foot may well be the ideal flap for providing sensory skin coverage to the
hand (1, 2, 3, 4). It can restore function to an anesthetic portion of a hand by supplying sensation with
appropriate cortical representation. It is a thin flap with good texture and surprisingly large dimensions, and it
results in minimal donor site morbidity.
INDICATIONS
Innervated flaps can be taken from other areas of the hand, depending on the nature of the injury, but the
patient has difficulty interpreting signals. However, the first web space flap from the foot not only provides
sensation, but sensation that has appropriate central representation. The texture of the flap is ideal, since
toe plantar skin is so similar to the skin on the volar surface of the fingers and hand. The flap also provides
skin of good stability, essential for an adequate grip.
ANATOMY
The arterial supply to the first web space of the foot comes from both the dorsal and the plantar interconnecting
arch systems (1, 2, 4). The first dorsal metatarsal artery, which leaves the dorsalis pedis artery as it passes
between the first and second metatarsals to join the plantar arch, is used as the donor artery. The first dorsal
metatarsal artery usually arises directly from the dorsalis pedis artery (in 88% of cases) (2). However, it may
branch off at any level, while the dorsalis pedis artery passes toward the plantar system. Depending on its origin,
the first dorsal metatarsal artery passes either superficial to or within the substance of the first dorsal
interosseous muscle; the latter case makes dissection more difficult.
Venous drainage is by both venae comitantes accompanying the arteries, but mainly by superficial veins that
drain into the saphenous system. Usually only one of these branches is used as the flap vein.

FIGURE 335.1 Donor site preparation of the first web space skin flap. Note the deep peroneal nerve. The donor
site is covered with a split-thickness skin graft.
The first web space is innervated by both the deep peroneal nerve and the plantar nerves. The deep peroneal
nerve lies adjacent to the first dorsal metatarsal artery. The plantar digital nerves are branches of the medial
plantar nerve and therefore arise in the sole of the foot. They supply the medial surface and pulp of the second
toe and the lateral surface and pulp of the big toe.
FLAP DESIGN AND DIMENSIONS
The dimensions of the flap can be unexpectedly large: 14 cm (medial to lateral) × 7.5 cm (plantar to dorsal) (4).
The flap can also be extended in a dorsal direction to include all or part of the dorsalis pedis flap, depending on
recipient site requirements. The skin with the greatest potential for good sensibility lies in the first web space
itself (5 to 15 mm two-point discrimination in situ vs. 20 to 30 mm for the dorsalis pedis flap) (2, 4) (Figs. 335.1
and 335.2).
FIGURE 335.2 The first web space flap used to provide sensory cover to the hand.
The dorsalis pedis artery should be examined by palpation. The first dorsal metatarsal artery can be evaluated
by both Doppler and lateral (preferably magnification type) arteriograms. Sensory testing, including two-point
discrimination, should be assessed in situ. After making a pattern from the recipient site, one should outline the

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flap on the foot. The superficial veins are then mapped out, with the use of a tourniquet if necessary.
FIGURE 335.3 The first web space flap can be used to provide sensation to the prehensile area in a hand that
has been previously covered with an insensate flap. Note that the deep peroneal nerve and both digital nerves
are being anastomosed to appropriate recipient nerves in the hand.
OPERATIVE TECHNIQUE
The flap dissection is begun dorsally, under tourniquet control and with the aid of loupe magnification. A
curvilinear incision is made over the dorsalis pedis artery, carefully preserving all superficial veins. Once the
dissection is in progress, the best donor vein can be selected, and the remaining veins ligated. (Some of these
may be used for vein grafts later, if deemed necessary.)
The dorsalis pedis artery is identified and dissected distally until the origin of the first dorsal metatarsal artery is
identified. All four branches (two plantar and two dorsal) of the first dorsal metatarsal artery should be carried
with the flap. The deep peroneal nerve should also be found at this stage, lying adjacent to the first dorsal
metatarsal artery. It is followed proximally until an adequate length can be obtained (Fig. 335.3) (1, 2, 3, 4).
Once the arterial anatomy has been clearly defined, the deep branch of the dorsalis pedis artery that passes to
the plantar arch can be ligated, as can the arcuate artery that passes laterally to supply the remaining dorsal
metatarsal arteries.
The plantar digital nerves can be identified either through the incision made at the plantar border of the flap or
while dissecting the skin flap away from the fascia of the toes as the dissection progresses in a dorsal to plantar
fashion. At some point the dissection should be done from the plantar aspect, to dissect the nerves as far
proximally as necessary, allowing tensionless recipient site anastomoses.
If the dorsalis pedis flap is to be included, the dissection should begin proximally, with careful preservation of the
dorsalis pedis artery within the flap (2, 4). In this case the superficial peroneal nerve should be included with the
flap.
CLINICAL RESULTS
Surprisingly, these flaps often develop better two-point discrimination on the hand than was ever present on
the foot (2, 4). This has not yet been adequately explained, but it could be the result of any of several
hypotheses. First, the flap contracts after elevation, moving sensory receptors closer together. Also, the
recipient site nerves are larger and may respond differently than nerves in the foot, or they may just have
more axons available. The brain itself may play a role, as the cortical area representing the hand is larger

than the area for the foot, and may therefore be able to discriminate impulses from the flap better than
impulses from the foot.
The donor site is covered with split-thickness skin grafts, resulting in minimal morbidity. In some cases the
graft becomes keratotic and forms irregularities that can be difficult to maintain from a hygienic viewpoint. If
the dorsalis pedis flap is included, there may be some discomfort while wearing shoes. Weight bearing and
walking are otherwise not adversely affected.
SUMMARY
Even when used for a small area, such as coverage for a thumb or pinching surface, this flap can turn a
neglected hand into a functionally useful hand.
References
1. Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. In: Daniller AT,
Strauch B, eds. Symposium on microsurgery. St. Louis: Mosby, 1976.
2. May JW Jr, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977; 2:387.
3. Morrison WA, O'Brien BM, MacLeod AM, Gilbert A. Neurovascular free flaps from the foot for innervation
of the hand. J Hand Surg 1978;3:235.
4. Strauch B, Tsur H. Restoration of sensation to the hand by a free neurovascular flap from the first web
space of the foot. Plast Reconstr Surg 1978; 62:361.

Chapter 336
Extensor Carpi Ulnaris and Flexor Digitorum Profundus Muscle
Flap Coverage of The Proximal Ulna
B. E. COHEN
With this procedure the flexor digitorum profundus muscle belly is freed and advanced and the extensor carpi
ulnaris is transposed as a distally based muscle flap. The muscles remain in continuity distally and their
neurovascular supply is not disrupted, thereby achieving single-stage coverage with no loss of hand function (1).
INDICATIONS
Coverage of the proximal ulna can be effected by two local forearm muscles without functional loss.
ANATOMY
The flexor digitorum profundus is a wide muscle in the deepest plane of the volar forearm muscles (Fig. 336.1). It
arises from, and is the muscle most closely attached to, the anterior aspect of the ulna and the interosseous
membrane. Its medial or ulnar portion is supplied by branches of the ulnar nerve and artery that enter its anterior
(superficial) surface. There are no neurovascular structures between the muscle and the underlying ulna. The
anterior interosseous nerve, a branch of the median nerve, supplies the lateral or radial portion of the muscle
with branches that also enter anteriorly.
The extensor carpi ulnaris arises from the lateral epicondyle of the humerus and the posterior aspect of the ulna
(Fig. 336.2). The main hilum, where branches of the posterior interosseous nerve and artery enter, is located on
the deep aspect of the muscle, 8 cm distal to the olecranon. Although one or two small vessels may enter more
proximally, the major pedicle can easily support the entire muscle belly.
OPERATIVE TECHNIQUE
The flexor digitorum profundus is freed from the ulna with sharp dissection and the use of a periosteal elevator
over a length of 8 to 10 cm (Figs. 336.3B and 336.4B). This maneuver is safe, as there are no neurovascular
structures between the muscle and the ulna. Once freed, the muscle may be easily advanced over the exposed
portion of the ulna (Fig. 336.3C). The needed mobility may be obtained without dissecting over as far as the
anterior interosseous vessels. The muscle is held in place with sutures to available soft tissue along the margin
of the bone.
The extensor carpi ulnaris is approached distally where the intervals between the dorsal muscles are apparent.
The radial border of the muscle is dissected free in a distal to proximal direction, up to the lateral epicondyle,
from which it is now detached. The underside of the muscle is then freed from the ulna in a proximal to distal
direction, until the main neurovascular pedicle is encountered, approximately 8 cm below the olecranon (Figs.
336.3B and 336.4B). The well-vascularized muscle belly can now be readily transposed and fixed to the adjacent
soft tissue, thereby providing a second layer of coverage over the previously advanced flexor digitorum
profundus (Figs. 336.3D and 336.4C).
Mobilization of the forearm skin on either side may be adequate to cover the transposed muscles (Fig. 336.4D). If
not, skin grafts are applied to the muscles. A small suction drain may be used in the wound. To prevent pulling
away of the muscle bellies, the extremity is splinted for 2 weeks in a neutral position, with the fingers in a

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functional position.
CLINICAL RESULTS
In using this technique, one should be aware that transposition of the extensor carpi ulnaris leaves the
radiohumeral joint in a subcutaneous position (this has not been a problem), and that it does not appear to
be capable of covering the olecranon. Choosing to use this, rather than an abdominal flap, shortens the
hospitalization period and obviates the need for a second operation. Furthermore, there is no abdominal
scarring and, if the skin can be closed over the muscles, one avoids a patchlike effect on the forearm
surface.
FIGURE 336.1 Anatomy. The flexor digitorum profundus muscle is depicted in this anterior view of the right
forearm. The ulnar portion of the muscle takes origin from the underlying ulna, while the neurovascular
supply enters the muscle belly on its superficial surface. (From Cohen, ref. 1, with permission.)
FIGURE 336.2 Anatomy. The extensor carpi ulnaris muscle is shown on this dorsal view of the right

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forearm. The muscle arises from the lateral epicondyle of the humerus and the dorsal surface of the ulna. Its
neurovascular supply enters its deep surface 8 cm distal to the olecranon. (From Cohen, ref. 1, with
permission.)
FIGURE 336.3 A-D: Surgical technique. The operative steps for coverage of the proximal ulna by the
extensor carpi ulnaris (ECU) and flexor digitorum profundus (FDP) are shown in this right forearm view from
the ulnar aspect.

FIGURE 336.4 A: A deep defect of the right ulna covered with thin epithelium and skin grafts. B: Thin
coverage removed from ulna. The extensor carpi ulnaris and flexor digitorum profundus muscles have been
elevated but not yet transposed (as in Fig. 336.3B). C: Muscles advanced and transposed over ulna
(extensor carpi ulnaris superficial to flexor digitorum profundus) are sutured into place (as in Fig. 336.3D).
Skin is mobilized for closure over muscle. D: Result at 1 year. (From Cohen, ref. 1, with permission.)
SUMMARY
With this technique the proximal portions of the flexor digitorum profundus and extensor carpi ulnaris are
moved without disturbing the vascular supply, the innervation, or the distal tendinous portions of these
muscles. A portion of the origin is maintained, and the transposed portion is allowed to reattach in its new
location. One-stage coverage of the proximal ulna is achieved, complete function is preserved, and an
aesthetically pleasing result is obtained.
Reference
1. Cohen BE. Local muscle flap coverage of the proximal ulna without functional loss. Plast Reconstr Surg
1982;70:745.