Kỹ Thuật Thực Hành Trong Phẫu Thuật Ghép Vạt Da

13/10/2026 • by Bs CKI Phẫu thuật tạo hình, tái tạo và thẩm mỹ Trương Hoài Anh •

Cẩm nang hướng dẫn thực hành ngoại khoa cực kỳ hữu ích về kỹ thuật bóc tách và chuyển vạt da. Cung cấp chỉ định lâm sàng, ưu nhược điểm của từng loại vạt và các mẹo giúp tăng tỷ lệ sống của vạt ghép.

📂 Chuyên mục: Tài liệu thẩm mỹ, Phẫu thuật tái tạo, Giải phẫu học

🏷️ Từ khóa: phẫu thuật ghép vạt, vạt da, phẫu thuật tái tạo, vi phẫu

📖 Xem bản dịch / Nội dung văn bản

Practical Techniques
in Flap Surgery
Yuichi Hirase
123

Practical Techniques in Flap Surgery

Yuichi Hirase
Practical Techniques in Flap
Surgery

Yuichi Hirase
Yotsuya Medical Cube
Chiyoda-ku
Tokyo
Japan
Original Japanese edition published by KOKUSEIDO CO., LTD, Tokyo, 2009
ISBN 978-4-431-56043-2 ISBN 978-4-431-56045-6 (eBook)
DOI 10.1007/978-4-431-56045-6
Library of Congress Control Number: 2016958142
© Springer Japan 2017
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer Japan KK

I have received support from many people, but above all, Dr. Harry J. Buncke
and Dr. Tadao Kojima, without whom I certainly would not be where I am
now. I dedicate this book to these two great masters.

vii
This book is the English version of Yasashii Hiben (Practical and Gentle Techniques in Flap
Surgery) published in Japanese by Kokuseido Co., Ltd. in 2009. It was created in response to
strong calls for the release of an English version after the Japanese version was published.
The present volume differs from conventional books on flap surgery in a number of respects.
First, it explains techniques not by type of flap surgery but by the area to be reconstructed. In
addition, it presents applicable flap surgery methods and explains each method in an easy-to-
understand manner by using photographs, following the steps of the surgical procedure.
Furthermore, it indicates the difficulty level of each surgical method in order to allow selection
of the one that suits the surgeon’s skills. Each chapter is followed by “Tips” that provide useful
information on treatment and a “Column” on the author’s ideas and experiences. The author
hopes that the book will serve as a helpful reference for readers.
The author would like to express his deep gratitude to Ms. Misuzu Yoshikawa, Erklären
Inc., for her enormous efforts in bringing this English version to press.
Chiyoda-ku, Tokyo, Japan
Yuichi Hirase
Autumn 2015
Preface

ix
Contents
1. Reconstruction of Upper Arm and Medial and Lateral Elbow�� 1
Pedicled Latissimus Dorsi Musculocutaneous
Flap (Level of Difficulty: 3)�� 2
Operation Procedures�� 3
2. Reconstruction of Forearm Region�� 9
Rotation Flap/Radial Forearm Flap (Level of Difficulty: 1)�� 10
Operation Procedures�� 11
Pedicled Abdominal Flap (Level of Difficulty: 3)�� 13
Operation Procedures�� 13
Free Abdominal Perforator Flap (Level of Difficulty: 4)�� 17
Operation Procedures�� 18
Free Groin Flap (Level of Difficulty: 4)�� 21
Operation Procedures�� 22
3. Reconstruction of Dorsum of Hand�� 29
Pedicled Abdominal Flap (Level of Difficulty: 3)�� 30
Operation Procedures�� 31
Free Temporal Fascia Flap (Level of Difficulty: 4) �� 38
Operation Procedures�� 39
Dorsal Metacarpal Arterial Flap Using V-Y
Plasty (Level of Difficulty: 2)�� 43
Operation Procedures�� 44
Reverse Flow Radial Forearm Flap (Level of Difficulty: 3)�� 46
Operation Procedures�� 47
Free Dorsalis Pedis Flap with Tendons (Level of Difficulty: 4)�� 53
Operation Procedures�� 54
Free Abdominal Perforator Flap (Level of Difficulty: 4)�� 60
Operation Procedures�� 61
Adipofascial Flap by the Dorsal Branch of Ulnar Artery (Level of Difficulty: 3)�� 66
Operation Procedures�� 67
4. Degloving Injury�� 71
Temporary Coverage: Abdominal Subcutaneous
Pocket Insertion (Level of Difficulty: 1)�� 72
Operation Procedures�� 73
Free Temporal Fascial Flap (Level of Difficulty: 4)�� 76
Operation Procedures�� 77
Reverse Flow Radial Forearm Flap (Level of Difficulty: 3)�� 80
Operation Procedures�� 81
Reverse Flow Forearm Adipofascial Flap + Skin
Graft (Level of Difficulty: 3) �� 87

x
Extended Twisted Wrap-around (TWA) Flap (Level of Difficulty: 5)�� 93
Operation Procedures�� 94
Reverse Flow Radial Forearm Flap + Pedicled
Abdominal Flap (Level of Difficulty: 3)�� 100
Operation Procedures�� 101
5. Reconstruction of Palm and Wrist Area�� 107
V-Y Advancement Flap (Level of Difficulty: 1)�� 108
Operation Procedures�� 109
Free Medial Plantar Flap (Level of Difficulty: 4)�� 112
Operation Procedures�� 113
Free Medial Pedis Flap (Level of Difficulty: 4)�� 116
Operation Procedures�� 117
Free Abdominal Perforator Flap (Level of Difficulty: 4)�� 122
Operation Procedures�� 123
Ulnar Parametacarpal Flap (Level of Difficulty: 2)�� 128
Operation Procedures�� 129
Hand Relaxation Incision (Level of Difficulty: 1)�� 133
Operation Procedures�� 134
Reverse Flow Radial Forearm Flap (Level of Difficulty: 2)�� 136
Operation Procedures�� 137
6. Reconstruction of First Web Space Area�� 141
Spinner Flap (Level of Difficulty: 1) �� 142
Operation Procedures�� 143
4 & 5 Z plasty (Level of Difficulty: 2)�� 147
Operation Procedures�� 148
Reverse Flow Radial Forearm Flap (Level of Difficulty: 3)�� 150
Operation Procedures�� 151
Free Groin Flap (Level of Difficulty: 4)�� 154
Operation Procedures�� 155
7. Reconstruction of Finger Trunk�� 161
Z Plasty (Level of Difficulty: 1)�� 163
Operation Procedures�� 164
Digitolateral Flap (Level of Difficulty: 2)�� 167
Operation Procedures�� 168
Reverse Digitolateral Flap (Level of Difficulty: 2)�� 171
Operation Procedures�� 172
Heterodigital Arterial Flap (1) (Level of Difficulty: 3)�� 175
Operation Procedures�� 176
Heterodigital Artery Flap (2) – Transfer to Skin Defect
of Thumb (Level of Difficulty: 3)�� 179
Cross Finger Flap (Level of Difficulty: 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Spinner Flap (Level of Difficulty: 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Reverse Flow Radial Forearm Flap (Level of Difficulty: 3). . . . . . . . . . . . . . . . . . . 189
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Reverse Flow Metacarpal Arterial Flap (Level of Difficulty: 3) . . . . . . . . . . . . . . . 193
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Kite Flap (Level of Difficulty: 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Operation Procedures�� 199
Free Venous Flap (Level of Difficulty: 3)�� 203
Operation Procedures�� 204
Contents

xi
Free Hemi Pulp Flap Transfer (Level of Difficulty: 4). . . . . . . . . . . . . . . . . . . . . . . 207
Operation Procedures�� 208
Ulnar Parametacarpal Flap (Level of Difficulty: 3). . . . . . . . . . . . . . . . . . . . . . . . . 211
Operation Procedures�� 212
Dorsolateral Flap (Level of Difficulty: 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Operation Procedures�� 216
Modified Kleinert Method (Level of Difficulty: 2). . . . . . . . . . . . . . . . . . . . . . . . . . 219
Operation Procedures�� 220
Digital Arterial Adipofascial Flap and Skin Graft (Level of Difficulty: 2). . . . . . . . 223
Operation Procedures�� 224
Double-Opposing Digitolateral Flap (Level of Difficulty: 2). . . . . . . . . . . . . . . . . . 229
Operation Procedures�� 230
Bi-lobed Palmar Flap (Level of Difficulty: 1). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Operation Procedures�� 234
8. Reconstruction of Fingertip�� 237
Oblique Triangular Flap Modification (Level of Difficulty: 3) �� 238
Operation Procedures�� 239
Graft-on Flap Method by Oblique Triangular
Flap (Level of Difficulty: 3)�� 244
Operation Procedures�� 245
Extended Palmar Flap Advancement with V-Y and
Z Plasty (Level of Difficulty: 2)�� 251
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Heterodigital Finger Island Flap (Modified Littler Method)
(Level of Difficulty: 4)�� 256
Operation Procedures�� 257
Modified Heuston Flap (Level of Difficulty: 1). . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Reverse Flow Digital Arterial Flap (Level of Difficulty: 4). . . . . . . . . . . . . . . . . . . 265
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Reverse Flow Digital Arterial Flap with Adipose
Flap Attached (Level of Difficulty: 4) �� 271
Operation Procedures�� 272
Reverse Flow Digital Artery Cross Finger Flap (Level of Difficulty: 4)�� 276
Operation Procedures�� 277
Thenar Flap / van der Biezen Method (Palm Flap)
(Level of Difficulty: 2)�� 281
Operation Procedures�� 282
Hemi Pulp Transfer (Level of Difficulty: 4)�� 286
Operation Procedures�� 287
Tissue Banking by Insertion in Subcutaneous
Pocket (Level of Difficulty: 1)�� 293
Operation Procedures�� 294
Ulnar Parametacarpal Flap (Level of Difficulty: 3)�� 298
Operation Procedures�� 299
9. Toe Transfer�� 301
Thumb Amputation at Basal Phalanx Level: Twisted
Wrap-Around (TWA) Flap (Level of Difficulty: 5)�� 303
Operation Procedures�� 304
Thumb Amputation at Basal Phalanx Level: Great Toe
Transfer (Level of Difficulty: 4)�� 310
Operation Procedures�� 311
Contents

xii
Thumb Amputation at Metacarpal Level: Second Toe
Transfer (Level of Difficulty: 4)�� 316
Operation Procedures�� 317
Pollicization and Free Abdominal Perforator
Flap (Level of Difficulty: 5)�� 320
Operation Procedures�� 321
Finger Reconstruction (Basal Phalanx Amputation Case): Second Toe
Transfer (Level of Difficulty: 4)�� 324
Operation Procedures�� 325
Metacarpal Hand: Double Toe Transfer (Level of Difficulty: 4)�� 329
Operation Procedures�� 330
10. Nail Reconstruction �� 333
Split-thickness Nail Bed Graft (Level of Difficulty: 1) �� 335
Operation Procedures�� 336
Split-thickness Nail Bed Graft and Digital Arterial
Flap (Graft-on Flap Method) (Level of Difficulty: 3)�� 340
Operation Procedures�� 341
Distal Phalanx Amputation of Thumb: Wrap-around
Flap (Level of Difficulty: 4)�� 346
Operation Procedures�� 347
Distal Phalanx Amputation of Thumb: Volar Advancement
Flap & Wrap-around Flap (Level of Difficulty: 4)�� 350
Operation Procedures�� 351
Digital Arterial Flap and Partial Toe Transfer

(Level of Difficulty: 4)�� 356
Operation Procedures�� 357
Fingernail Reconstruction: Twisted Wrap-around (TWA)
Flap (Level of Difficulty: 5)�� 363
Operation Procedures�� 364
Vascularized Nail Bed Graft (Level of Difficulty: 4)�� 371
Operation Procedures�� 372
11. Reconstruction of Mediastinitis/Pyothorax/Abdominal
Incisional Hernia�� 375
Mediastinitis: Pectoralis Major Muscle Flap (Level of Difficulty: 2) �� 376
Operation Procedures�� 377
Mediastinitis: Rectus Abdominis Musculocutaneous
Flap (Level of Difficulty: 4)�� 380
Operation Procedures�� 381
Mediastinitis: Latissimus Dorsi Musculocutaneous
Flap (Level of Difficulty: 4)�� 386
Operation Procedures�� 387
Pyothorax: Latissimus Dorsi Musculocutaneous
Flap (Level of Difficulty: 4)�� 392
Operation Procedures�� 393
Abdominal Incisional Hernia: Components Separation Method
(Level of Difficulty: 3)�� 397
Operation Procedures�� 398
Abdominal Incisional Hernia: Tensor Fascia Latae
Musculocutaneous Flap (Level of Difficulty: 4)�� 400
Operation Procedures�� 401
Contents

xiii
12. Reconstruction of Inguinal Region�� 405
Rectus Abdominis Musculocutaneous Flap (Level of Difficulty: 4)�� 406
Operation Procedures�� 407
Rectus Femoris Muscle Flap (Level of Difficulty: 3)�� 411
Operation Procedures�� 412
13. Reconstruction of the Gluteal, Sacral, and Trochanteric Regions�� 417
Lumbosacral Back Flap (Level of Difficulty: 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Operation Procedures�� 419
Posterior Thigh Flap (Level of Difficulty: 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Operation Procedures�� 424
Gluteus Maximus Perforator Flap (Level of Difficulty: 3)�� 428
Operation Procedures�� 429
Tensor Fascia Lata Musculocutaneous Flap
(Level of Difficulty: 3)�� 431
Operation Procedures�� 432
14. Patella Region Reconstruction�� 435
Gastrocnemius Muscle Flap (Level of Difficulty: 3)�� 436
Operation Procedures�� 437
Saphenous Flap (Level of Difficulty: 3)�� 443
Operation Procedures�� 444
Free Latissimus Dorsi Musculocutaneous
Flap (Level of Difficulty: 4)�� 447
Operation Procedures�� 448
15. Anterior Lower Leg Reconstruction�� 449
Soleus Muscle and Skin Graft (Level of Difficulty: 3)�� 450
Operation Procedures�� 451
Soleus Muscle Flap and Gastrocnemius Muscle
Flap (Level of Difficulty: 3)�� 455
Operation Procedures�� 456
Free Latissimus Dorsi Musculocutaneous
Flap (Level of Difficulty: 4)�� 462
Operation Procedures�� 463
16. Reconstruction of Distal 1/3 of Lower Leg�� 467
Reverse Turn-Over Fascial Flap (Level of Difficulty: 2)�� 468
Operation Procedures�� 469
Reverse Flow Sural Artery Skin Flap (Level of Difficulty: 2)�� 472
Operation Procedures�� 473
Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)�� 477
Operation Procedures�� 478
Free Gastrocnemius Muscle Flap (Level of Difficulty: 4)�� 481
Operation Procedures�� 482
Free Latissimus Dorsi Musculocutaneous Flap (Level of Difficulty: 4) �� 487
Operation Procedures�� 488
Cross Leg Flap Method (Level of Difficulty: 2)�� 496
Operation Procedures�� 497
17. Reconstruction of Achilles Tendon Area�� 499
Lateral Calcaneal Flap (Conventional Method)
(Level of Difficulty: 2)�� 500
Operation Procedures�� 501
Lateral Calcaneal Sliding Flap (Level of Difficulty: 3)�� 504
Operation Procedures�� 505
Contents

xiv
Reverse Peroneal Flap (Level of Difficulty: 4)�� 508
Operation Procedures�� 509
Medial Pedis Flap (Level of Difficulty: 4)�� 512
Operation Procedures�� 513
Reverse Turn-Over Fascial Flap (Level of Difficulty: 2)�� 516
Operation Procedures�� 517
Free Latissimus Dorsi Musculocutaneous Flap
(Serratus Anterior Muscle Flap) (Level of Difficulty: 4)�� 520
Operation Procedures�� 521
Free Temporal Fascia Flap (Level of Difficulty: 4) �� 525
Operation Procedures�� 526
Free Abdominal Perforator Flap (Level of Difficulty: 4)�� 532
Operation Procedures�� 533
18. Reconstruction of Calcaneal Region/Lateral Plantar Region�� 537
Medial Plantar Flap (Level of Difficulty: 3)�� 538
Operation Procedures�� 539
Free Abdominal Perforator Flap (Level of Difficulty: 4)�� 545
Operation Procedures�� 546
19. Reconstruction of the Plantar Forefoot�� 549
Bi-lobed Scapular Flap (Level of Difficulty: 4)�� 550
Operation Procedures�� 551
Medial Plantar Flap (Level of Difficulty: 3)�� 555
Operation Procedures�� 556
Medial Plantar Flap and Free Abdominal Perforator (DIEP)
Flap (Level of Difficulty: 4)�� 560
Operation Procedures�� 561
Free Abdominal Perforator Flap (Level of Difficulty: 4)�� 563
Operation Procedures�� 564
20. Reconstruction of Dorsum and Amputated Foot Stump�� 569
Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)�� 570
Operation Procedures�� 571
Reverse Extensor Digitorum Brevis Muscle
Flap (Level of Difficulty: 3)�� 578
Operation Procedures�� 579
Reconstruction of Dorsum: Free Abdominal Perforator
Flap (Level of Difficulty: 3)�� 583
Operation Procedures�� 584
Groin Flap (Level of Difficulty: 4)�� 586
Operation Procedures�� 587
Reconstruction of Amputated Foot Stump: Free Abdominal
Perforator Flap (Level of Difficulty: 4)�� 589
Operation Procedures�� 590
Free Anterolateral Thigh Flap (Level of Difficulty: 5)�� 594
Operation Procedures�� 595
Free Scapular Flap (Level of Difficulty: 4)�� 598
Operation Procedures�� 599
Contents

xv
21. Reconstruction of Dorsum of Toes �� 601
Reverse Extensor Digitorum Brevis Muscle
Flap (Level of Difficulty: 3)�� 602
Operation Procedures�� 603
22. Nerve Graft and Nerve Transfer�� 609
Non-vascularized Nerve Graft (Level of Difficulty: 3). . . . . . . . . . . . . . . . . . . . . . . 610
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
Vascularized Free Sural Nerve Graft (Level of Difficulty: 5). . . . . . . . . . . . . . . . . . 617
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
Nerve Transfer (Level of Difficulty: 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Operation Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
23. Transplantation of Bone and Joints �� 627
Vascularized Fibula Graft to Lower Leg (Level of Difficulty: 5)�� 628
Operation Procedures�� 629
Vascularized Fibula Graft to Forearm (Level of Difficulty: 4)�� 635
Operation Procedures�� 636
PIP Joint Transfer from Second Toe (Level of Difficulty: 4)�� 644
Operation Procedures�� 645
Vascularized Bone Graft from Radius (Level of Difficulty: 3)�� 652
Operation Procedures�� 653
24. Fat Graft �� 655
Free Vascularized Groin Fat Graft (Level of Difficulty: 4)�� 656
Operation Procedures�� 657
25. Muscle Graft�� 663
Free Vascularized Gracilis Muscle Graft (Level of Difficulty: 4) �� 664
Operation Procedures�� 665
References�� 669
Contents

1
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_1
Reconstruction of Upper Arm
and Medial and Lateral Elbow
Basic Principles
Exposure of blood vessels or nerves of the medial elbow, or exposure of the bone of the
lateral elbow must be covered using a skin flap. Although a number of either normal flow
or reverse flow vascularized flaps can be created in the elbow region, in many cases blood
vessel damage is also present, and there are often restrictions on the size of the flap, so
focusing only on the upper arm can make surgery more difficult. In spite of large dissection,
a vascularized latissimus dorsi flap is stable and practical.
With skin graft using negative pressure wound therapy, because the elbow is not required
to be fixed in place, there is less chance of contracture occurring, and even when graft con-
ditions are poor, there is a high ratio of the graft taking, making it extremely practical.
Selectable Flaps and Surgical Procedures
Pedicled latissimus dorsi musculocutaneous flap • Skin graft pressure method using negative
pressure wound therapy
The difficulty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Difficulty: 2). The levels range from
1 to 5, with level 1 indicating a preliminary level and level 5 indicating
a very advanced level.
1

2
Pedicled Latissimus Dorsi Musculocutaneous Flap (Level of Difficulty: 3)
Information
Vascular pedicle thoracodorsal blood vessel (the circumflex scapular artery is ligated and detachment continued up to
the subscapular blood vessels)
Size (muscle flap) width of 40 cm and length of 40 cm; if thoracolumbar fascia is included, it is possible to harvest the
entire 60 cm length
Advantage Good circulation, vascular pedicle is large and long, technique is comparatively easy. Can freely design
skin on muscle flap
Disadvantage Large dissection area, and large amount of blood loss. Cases with a thick layer of fat over the latissimus
dorsi muscle causes bulkiness preventing it from being used as a musculocutaneous flap, and therefore a skin graft is
required (1.5 times mesh skin graft)
Caution The muscle head is also cut, creating a complete muscle island flap. Do not use an electrical scalpel after
cutting the muscle ends. The space following removal of the latissimus dorsi muscle can cause a painful seroma, so
several continuous suction drains should be put in place.

1 Reconstruction of Upper Arm and Medial and Lateral Elbow

3
Operation Procedures
a
b
Fig. 1.1 (a, b) Procedure 1: Restriction in range of movement in the
elbow joint due to advanced scar contraction of medial elbow. Scar
resection expects skin defect on medial elbow due to elbow extension
Fig. 1.2 Procedure 2: After resecting the scar and conducting joint
mobilization surgery it was possible to extend the elbow, however a
skin defect and exposure of the medial nerves and blood vessels were
present
Pedicled Latissimus Dorsi Musculocutaneous Flap (Level of Difficulty: 3)

4
Fig. 1.5 Procedure 5: The skin defect area is covered with the mus-
cle flap. A bolster suture is done to pull the flap into the subcutane-
ous layer
Fig. 1.4 Procedure 4: The elevated latissimus dorsi musculocutane-
ous flap is transferred to the elbow via the subcutaneous pocket of the
upper arm
Fig. 1.3 Procedure 3: A latissimus dorsi musculocutaneous flap is
elevated. The distal end of the muscle is cut, and a complete island
musculocutaneous flap with only a neuro vascular pedicle is
created
Note The vascular intima can be damaged if an electric scalpel is used
after creation of the island musculocutaneous flap by cutting the proxi-
mal end of the muscle, so care is required. If a skin flap is required, it is
possible to elevate a latissimus dorsi muscle flap that has an island the
same size as the distance from the axillary fossa to the skin defect of the
elbow, however it is often bulky.
Refer to Section of “Reconstruction of Achilles tendon area/Free
latissimus dorsi musculocutaneous flap (serratus anterior musculocuta-
neous flap)” in Chap. 17
1 Reconstruction of Upper Arm and Medial and Lateral Elbow

5
a
b
Fig. 1.7 (a, b) Procedure 7: After surgery the range of motion of the
elbow has improved and full extension became possible
Fig. 1.6 Procedure 6: A split-thickness skin graft is conducted on top
of the muscle flap. A tie-over bolster dressing is applied
Pedicled Latissimus Dorsi Musculocutaneous Flap (Level of Difficulty: 3)

6
Tips
Can also be used for covering bone exposure of the lateral elbow
For use on the lateral elbow, if the flap is transferred with a skin island attached, it is appropriate for covering and
protecting the olecranon.

1 Reconstruction of Upper Arm and Medial and Lateral Elbow

7
Column
“Form ever follows function” LH Sullivan
During the reconstruction following the Great Fire of
Chicago, sky rise buildings began to emerge as a means of
effectively utilizing space. The pioneers of that movement
were the architects known as the Chicago School which
included names such as William Holabird, Dankmar
Adler and Frank Lloyd Wright, a famous architect in his
own right.
One of the key figures in this Chicago group was Louis
Sullivan. Sullivan asserted that both form and function were
equally important. This expression comes from the architec-
tural world, but it is just as important for a reconstructive
surgeon. When asked whether to “choose form or function”
the only answer is “to choose both.” That is because form is
also a part of function.
However, what is important is that it is not that func-
tion always follows form, but that form always follows
function. In other words, it is always form that follows,
and even though they go together, function is always one
step ahead. Whether it be the human body, or the home or
office where we live, when it boils down to it, the answer
is function. If architecture aims for “ease of use and with
good form also,” then reconstructive surgery aims for
“good form, little pain and ease of use,” but if we take this
one step further, it becomes “no pain, ease of use, and if
there is good form – even better.” This order must never
be confused.
Pedicled Latissimus Dorsi Musculocutaneous Flap (Level of Difficulty: 3)

9
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_2
Reconstruction of Forearm Region
Basic Principles
The proximal area of the forearm is rich with muscle tissue, and in many cases exposed
bone or tendons can be covered with muscle tissue, and can normally be covered with a skin
graft. If there are doubts about whether a skin graft will take in one stage, it is possible to
ﬁ rst place an artiﬁ cial dermis on the area and then perform skin grafting several weeks later.
Therefore, the main cases where the forearm needs to be reconstructed by covering with a
skin ﬂ ap involve the distal half of the forearm where tendons are easily exposed.
The skin of both the medial and lateral side of the distal end of the forearm is thin, and
exposure of tendons or bone/nerves are frequently encountered. In such cases it is necessary
to cover with a thin ﬂ ap. It is easier to avoid adhesion of tendons if a skin ﬂ ap that is rich in
adipose tissue with good blood ﬂ ow is used. Here, there is no need for sensory function. The
most practical ﬂ ap is the abdominal ﬂ ap, which is used either as a pedicled ﬂ ap or a free
ﬂ ap, and made thinner by removal of fat.
Selectable Flaps and Surgical Procedures
Rotation ﬂ ap/radial forearm ﬂ ap • Pedicled abdominal ﬂ ap • Free abdominal perforator ﬂ ap
• Free groin ﬂ ap • Pedicled latissimus dorsi muscle ﬂ ap • Free scapular ﬂ ap • Lateral upper
arm ﬂ ap (reverse ﬂ ow, normal ﬂ ow) • Skin graft and negative pressure wound therapy
• Anterolateral thigh ﬂ ap
The difﬁ culty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Difﬁ culty: 2). The levels range from
1 to 5, with level 1 indicating a preliminary level and level 5 indicating
a very advanced level.
2

10
Rotation Flap/Radial Forearm Flap (Level of Difﬁ culty: 1)
Information
Vascular pedicle Subcutaneous vascular plexus of forearm or radial artery perforator
Flap size It is possible to move the entire skin of the forearm
Advantage Simple with stable blood ﬂ ow
Caution The ﬂ ap is dissected above the proper fascia, and a fascial ﬂ ap is elevated using the forearm fascia. The skin
of the medial forearm can easily be rotated around the transverse axis, however extending it around the vertical axis
can lead to contracture.

2 Reconstruction of Forearm Region

11
Operation Procedures
a
b
Fig. 2.1 ( a , b ) Procedure 1: A rotation ﬂ ap is designed as a measure for moving the skin of the distal medial forearm. Dog ear correction is neces-
sary after rotation of a skin ﬂ ap at the end

Rotation Flap/Radial Forearm Flap (Level of Difﬁ culty: 1)

12
Fig. 2.2 Procedure 2: The distal end of the skin is dissected from
above the proper fascia, and the fascial ﬂ ap containing the forearm fas-
cia moved while being rotated, and the dog ear corrected

2 Reconstruction of Forearm Region

13
Pedicled Abdominal Flap (Level of Difﬁ culty: 3)
Information
Vascular pedicle Superﬁ cial epigastric blood vessels
Flap size A width for which direct closure can be conducted, normally 8–10 cm. Can be made over 25 cm extending
from pubic region
Advantage Stable blood ﬂ ow. Comparatively simple surgical technique. Rich amount of tissue. The tip can be made
thinner. By rolling the base of the skin ﬂ ap and creating a tubed ﬂ ap, there is no need to include lining for the ﬂ ap, and
because there is no raw surface, the patient can shower from an early stage. By creating a long tubed ﬂ ap, it is possible
to increase the level of freedom of the upper arm, preventing contraction of the shoulder joint
Disadvantage Surgery is conducted in two stages.

Operation Procedures
Note A skin ﬂ ap of at least 8 cm is required in order to create a tubed
ﬂ ap. If sufﬁ cient width is not secured at the base of the ﬂ ap where large
amounts of fat are present, the vascular pedicle will be pinched when in
the tube state, which can lead to circulation failure, so care is required.
The tip of the ﬂ ap can be made to the required width, however the skin
ﬂ ap is made longer in order to secure greater freedom for the upper arm.
Normally length is about double the width.
Refer to Section of “Reconstruction of dorsum of hand/Pedicled
abdominal skin ﬂ ap” in Chap. 3
Fig. 2.3 Procedure 1: A trapezium shaped skin ﬂ ap is designed on the
abdomen region on the same side as the affected hand with either an
upper pedicle or lower pedicle (the skin ﬂ ap can be located anywhere as
long as it is designed above the central axis of the lateral abdomen area,
so the position of the ﬂ ap should be determined according to the area
that is to be covered by the ﬂ ap)
Pedicled Abdominal Flap (Level of Difﬁ culty: 3)

14
Fig. 2.4 Procedure 2: The ﬂ ap is dissected at the layer above the exter-
nal oblique muscle. A broad area is dissected from the donor area and
sutured closed
Fig. 2.5 Procedure 3: The part of the ﬂ ap tip to be used for covering
the wound is thinned by removing fat, based on the condition of the
recipient site. A considerable amount can be removed as long as the
subcutaneous vascular plexus is retained
Note For the area to be used for the tube ﬂ ap, a large amount of fat is
resected around the margin of the ﬂ ap to ease tubing stress, but care
must be taken for resecting excess fat near the superﬁ cial epigastric
blood vessels.
Fig. 2.6 Procedure 4: The base of the ﬂ ap is sutured and the entire ﬂ ap
made into a tube shape
Note Here, if the ﬂ ap base is not wide enough, or the amount of fat is
too thick, the vascular pedicle will be pinched, so care is required.

2 Reconstruction of Forearm Region

15
Fig. 2.7 Procedure 5: Case example of skin defect on medial forearm
following re-attachment of the wrist. Exposure of the tendons present
Fig. 2.8 Procedure 6: Appearance of ﬂ ap sutured to medial wrist. Care
must be taken for the wound not be left exposed. As there is no wound
exposure on the reverse side of the ﬂ ap, the patient can shower after
several days
Note Note that a long ﬂ ap is created.
Apart from bandaging up the wrist or forearm, the only other ﬁ xing
is made with an abdominal belt, and the shoulder joint is not ﬁ xed in
place.
Fig. 2.9 Procedure 7: If the blood ﬂ ow to the skin ﬂ ap is temporarily
blocked and the skin ﬂ ap remains a healthy color, it means that new
blood ﬂ ow has been created on the attachment surface of the wound,
and it is possible to separate the skin ﬂ ap. Normally the skin ﬂ ap is
separated at about 2 weeks later
Note In cases where the attachment area of the skin ﬂ ap is small, it
can take up to 3 weeks before the skin ﬂ ap is separated.

Pedicled Abdominal Flap (Level of Difﬁ culty: 3)

16
Tips
1. Temporarily block the blood ﬂ ow of the vascular pedicle
Regularly check that the base of the skin ﬂ ap isn’t bent due to postural change. Remove all dressings every 2 or 3
days, carry out movement of the elbow and shoulder, and have the patient take a shower. If there are no problems with
skin ﬂ ap circulation, from about day 10 onwards, cut off the blood ﬂ ow from the abdomen to the skin ﬂ ap pedicle for
about 10 min each day using an intestinal clamp or tourniquet to encourage new generation of blood vessels between
the ﬂ ap and the wound.

Tips
2. It is important to cut and suture in places that don ’ t apply stress to the margins of the ﬂ ap
When cutting the ﬂ ap, it is easy for the margin of the ﬂ ap to become necrotic due to thinning of the fat from the sepa-
rated ﬂ ap. It is important that incisions and suturing are conducted without applying stress to the margins of the ﬂ ap,
and that thinning is conducted secondarily, even if it results in the ﬂ ap becoming bulky (Fig. 2.15 ).

2 Reconstruction of Forearm Region

17
Free Abdominal Perforator Flap (Level of Difﬁ culty: 4)
Information
Vascular pedicle Deep inferior epigastric blood vessels and their perforators
Flap size No restriction as long as abdominal skin containing perforators is used
Advantage Few restrictions for the shape of the skin ﬂ ap. Possible to remove fat and make the skin ﬂ ap thinner. It is
possible to conduct primary closure of the donor site
Disadvantage High risk in cases of advanced obesity

Free Abdominal Perforator Flap (Level of Difﬁ culty: 4)

18
Operation Procedures
Fig. 2.12 Procedure 3: Several perforators emerging from the anterior
sheath of the rectus abdominis muscle are secured. The photo shows the
ﬂ ap turned-over in the longitudinal direction with the perforators
marked
Fig. 2.10 Procedure 1: Case of open fracture accompanying soft tissue
damage, and rupturing of all extensor tendons of the forearm.
Debridement is carried out of necrotic tissue
Fig. 2.11 Procedure 2: A few perforators are present beneath this
4 × 4 cm section beside the naval area. The ﬂ ap is designed in a horizon-
tal or longitudinal direction, with the perforators included, and an inci-
sion made in the margin of the ﬂ ap
Refer to Section of “Reconstruction of Achilles tendon area/Free
abdominal perforator ﬂ ap” in Chap. 17 and Section of “Reconstruction
of dorsum of hand/Free abdominal perforator ﬂ ap” in Chap. 3

2 Reconstruction of Forearm Region

19
Fig. 2.14 Procedure 5: The skin ﬂ ap is harvested with a long vascular
pedicle
Fig. 2.13 Procedure 4: Several perforators running longitudinally in
the direction of the rectus abdominis muscle ﬁ ber are selected, and the
anterior sheath of the rectus abdominis is cut and dissected up to the
deep inferior epigastric blood vessels. Apart from the area surrounding
the perforators, fat can be removed and the skin ﬂ ap which can be
thinned to the thickness of the subcutaneous vascular plexus (1 cm).
Thinning should be performed prior to severing the vascular pedicle
Note In order to prevent twisting of the vascular pedicle it is better to
include at least two perforators. Also, by securing perforators that run
in line with the muscle ﬁ ber, it is possible to minimize damage to the
tissue.
Fig. 2.15 Procedure 6: End-to-side anastomosis is conducted of the
long vascular pedicle to the radial artery. End-to-end anastomosis is
conducted for the comitant vein

Free Abdominal Perforator Flap (Level of Difﬁ culty: 4)

20
Fig. 2.16 Procedure 7: The anterior sheath of the rectus abdominis is
repaired and sutured closed. A continuous suction drain is inserted and
the wound closed
Tips
For infectious cases, tendon transfer is performed secondarily
In cases of multiple tendon injury and neuroparalysis it is theoretically possible to combine both free ﬂ ap and tendon
transfer. However for cases with infection present and for cases with long surgery times, covering properly with soft tissue
ﬁ rst, and then performing tendon transfer or tendon transplant later on enables quicker rehabilitation and produces a better
result. In the previously described example, tendon transfer was performed 2 months after attaching the skin ﬂ ap.
With regard to wrist-drop from injury to all extensor tendons, the ﬂ exor carpi radialis tendons of the wrist are trans-
ferred through the interosseous membrane to the extensor digitorum muscle tendons with interlacing suture. Flexor
digitorum suoerﬁ cialis tendon of the ring ﬁ nger is cut at the attachment area and pulled into the carpal tunnel, passing
beneath the median nerve/ﬂ exor tendon group/ﬁ rst compartment, and an interlacing suture is conducted to the extensor
pollicis longus muscle tendon distal to the wrist.
That result is shown at below.

2 Reconstruction of Forearm Region

21
Information
Vascular pedicle Superﬁ cial circumﬂ ex iliac blood vessel (at distal end branches into the superﬁ cial branch and deep
branch, and superﬁ cial branch enters the ﬂ ap). Length is 2 cm.
Flap size The width of the ﬂ ap that can be sutured closed is around 10–15 cm centered around the inguinal ligament,
and the length is up to about 25–30 cm, two times the length from the femoral artery to the anterior superior iliac spine.
Advantage Donor site can be sutured closed primarily and isn’t obvious. Skin ﬂ ap is comparatively thin, and large skin
ﬂ ap can be harvested.
Disadvantage There are often variations in the path of the superﬁ cial circumﬂ ex iliac artery. The vascular pedicle is
short and small (1.5 mm). Fat tissue in the medial side of the ﬂ ap (medial side of the femoral artery) is thick
Caution When dissecting the medial side of the anterior superior iliac spine, if going too deep, the lateral cutaneous
nerve of the thigh can be damaged, so care is required.

Free Groin Flap (Level of Difﬁ culty: 4)
Free Groin Flap (Level of Difﬁ culty: 4)

22
Operation Procedures
a
b
Fig. 2.17 ( a , b ) Procedure 1: Scar tissue is resected from the dorsal
part of the forearm and the ruptured extensor tendon group are dissected
and identiﬁ ed

2 Reconstruction of Forearm Region

23
a
b
Fig. 2.18 ( a , b ) Procedure 2: The fascia latae is harvested, and
wrapped and connected to the ruptured muscle group
Fig. 2.19 Procedure 3: A mark is placed 2.5 cm distally from the
inguinal ligament on the skin above the femoral artery, indicating the
head of the superﬁ cial circumﬂ ex iliac artery. A line is drawn from here
to the anterior superior iliac spine indicating the path of the superﬁ cial
circumﬂ ex iliac artery, and this is used as the central axis of the ﬂ ap
design

Free Groin Flap (Level of Difﬁ culty: 4)

24
Fig. 2.20 Procedure 4: Dissection is performed in the proximal part of
the skin ﬂ ap, the vascular pedicle from the femoral blood vessels are
conﬁ rmed and evaluation is made as to whether it is appropriate for a
free tissue transplant. If necessary the design of the ﬂ ap is changed. The
ﬂ ap is dissected above the deep fascia from the distal area of the ante-
rior superior iliac spine. If dissection is performed carefully, including
the fascia from the lateral margin of the sartorius muscle, it is possible
to conﬁ rm in the medial margin of the sartorius muscle that the vascular
pedicle (superﬁ cial branch of the superﬁ cial circumﬂ ex iliac artery)
penetrates through the fascia and enters the ﬂ ap
a
b
Fig. 2.21 ( a , b ) Procedure 5: After dissecting to the medial sartorius
muscle, the superﬁ cial circumﬂ ex iliac artery branches into the deep
branch beneath the sartorius muscle, and is ligated to cut

2 Reconstruction of Forearm Region

25
Fig. 2.22 Procedure 6: As dissection progresses further, it is possible
to conﬁ rm the superﬁ cial circumﬂ ex iliac artery emerging directly from
the femoral artery. The comitant vein of the vascular pedicle can be
seen emerging directly from the comitant vein of the femoral artery, and
this is detached
Fig. 2.23 Procedure 7: The ﬂ ap is completely elevated, and conﬁ rma-
tion made that the blood ﬂ ow is stable. The superﬁ cial circumﬂ ex iliac
vessels are dissected as long as possible to ligate at the place they
emerge from the femoral blood vessels and the ﬂ ap harvested
Note It is often possible to conﬁ rm whether the superﬁ cial inferior
epigastric vein is included in the ﬂ ap during the detachment of the ﬂ ap.
The superﬁ cial inferior epigastric vein at times merges with the superﬁ -
cial circumﬂ ex iliac vein, and at times emerges separate from the femo-
ral vein. In the case that it emerges independently from the femoral
vein, it is harvested as the second vein.

Free Groin Flap (Level of Difﬁ culty: 4)

26
a
b
Fig. 2.24 ( a , b ) Procedure 8: Because the vascular pedicle is thin and
short, an end-to-side anastomosis is performed to the radial or ulnar
artery. Anastomosis of the comitant vein and superﬁ cial inferior epigas-
tric vein is performed to the radial vein and cutaneous vein

2 Reconstruction of Forearm Region

27
Hint!
When the ﬂ ap is pale
There are many measures that can be taken, such as:
1. Is the vascular pedicle twisted?
2. Check the area of anastomosis and re-conduct anastomosis
3. Resect the adventitia
4. Warm with a warm saline towel
5. Administer PGE1, heparin
6. Lidocaine drip to the vascular pedicle
7. Administer albumin preparation
8. Conduct continuous intraarterial injection
However, if the vascular pedicle is not twisted and there isn’t a blood clot at the area of anastomosis, then the best
thing that can be done is to apply a warm saline towel to warm up the skin ﬂ ap, and then to take off your operating
gown and gloves and take a break. The biggest enemies of ﬂ ap surgery are spasms to the blood vessels and when the
surgeon loses their cool. Taking a short break can ﬁ x both of those problems.

Free Groin Flap (Level of Difﬁ culty: 4)

29
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_3
Reconstruction of Dorsum of Hand
Basic Principles
The dorsum of the hand has numerous extensor tendons and can be easily exposed. It is
possible to use an artiﬁ cial dermis to raise granulation tissue and then conduct a skin graft,
however this tends to lead to adhesion of the tendons and contracture of the MP joints.
Covering this area using a skin ﬂ ap requires a thin skin ﬂ ap, however it is not necessary to
reconstruct sensory function. A ﬂ ap is chosen that can become a tendon gliding surface.
Both pedicled and free abdominal ﬂ aps are practical because they can be thinned.
If the thinner skin ﬂ ap is required, the temporal fascia ﬂ ap can be used.
Thinning of the groin ﬂ ap is difﬁ cult, and they are difﬁ cult to use except covering amputation
stumps. The blood ﬂ ow of the reverse ﬂ ow posterior interosseous ﬂ ap is unstable.
Use of negative pressure wound therapy is indicated for a skin graft.
Selectable Flaps and Surgical Procedures
Pedicled abdominal ﬂ ap • Free temporal fascia ﬂ ap • Dorsal metacarpal arterial ﬂ ap • Reverse
ﬂ ow radial forearm ﬂ ap • Free dorsalis pedis ﬂ ap with tendons • Free abdominal perforator ﬂ ap
• Adipofascial ﬂ ap by dorsal branch of ulnar artery • Free or pedicled groin ﬂ ap • Reverse ﬂ ow
posterior interosseous ﬂ ap • Skin graft pressure method using negative pressure wound therapy
The difﬁ culty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Difﬁ culty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
3

30
Pedicled Abdominal Flap (Level of Difﬁ culty: 3)
Information
Vascular pedicle Superﬁ cial epigastric blood vessels
Size A width for direct suture closure is normally 8–10 cm. Can make longer than 20 cm from lower abdominal region
Advantage Stable blood ﬂ ow. Simple operating technique. Rich amount of tissue. The end can be made thinner. By
rolling the base of the skin ﬂ ap and creating a tubed ﬂ ap, there is no need for lining of the ﬂ ap, and the patient can
shower from an early stage because there is no raw surface. And by creating a long tubed ﬂ ap, it increases the level of
freedom of the upper arm, preventing contracture of the shoulder joint
Disadvantage Surgery is performed in two stages

3 Reconstruction of Dorsum of Hand

31
Operation Procedures
Fig. 3.1 Procedure 1: The abdominal ﬂ ap is created from the lower
abdomen to the upper abdomen, along the center of the lateral abdomen
in line with the path of the superﬁ cial epigastric artery. The height of the
ﬂ ap is decided by placing the wounded hand against the abdomen
region
Note A ﬂ ap base of between 8 and 10 cm is required for creating a
tube out of the ﬂ ap. The length of the ﬂ ap is set to two times the length
of the area to be covered.
The end of the ﬂ ap becomes dog eared and so is resected.
Refer to Section of “Reconstruction of forearm region/Pedicled
abdominal ﬂ ap” in Chap. 2
Fig. 3.2 Procedure 2: The skin ﬂ ap is dissected at the layer above the
anterior sheath of the rectus abdominis (fascia of external oblique mus-
cle of the abdomen)

Pedicled Abdominal Flap (Level of Difﬁ culty: 3)

32
Fig. 3.3 Procedure 3: The skin ﬂ ap donor site is sutured closed
directly. If necessary, a continuous suction drain is inserted
Fig. 3.4 Procedure 4: A large amount of fat is removed from the
margins of the ﬂ ap. If an insufﬁ cient amount of fat is resected, the
superﬁ cial epigastric artery for the tubed pedicle ﬂ ap will be pinched,
causing circulatory insufﬁ ciency, so as much fat is removed as
possible
Note If circulatory insufﬁ ciency occurs to the ﬂ ap, the ﬂ ap becomes
pale and blisters appear on the tube. In such a case the stitches should
be removed.

3 Reconstruction of Dorsum of Hand

33
Fig. 3.5 Procedure 5: For the base of the ﬂ ap, enough fat is removed
without damaging the superﬁ cial epigastric artery. The end of the ﬂ ap
used for covering the wound of hand is made even thinner
Note For the end of the ﬂ ap, as long as the subcutaneous vascular
plexus has been retained it is possible to remove fat down to around a
thickness of 1 cm.
Fig. 3.6 Procedure 6: The base of the ﬂ ap is sutured and made into a
tube shape

Pedicled Abdominal Flap (Level of Difﬁ culty: 3)

34
a
b
Fig. 3.7 ( a, b ) Procedure 7: The wound of the hand is covered by the ﬂ ap
Note The suturing should be done tightly.
In particular, conﬁ rmation should be made that the stitching between
the posterior side of the ﬂ ap and the hand is tight to avoid making a
ﬁ stule.

3 Reconstruction of Dorsum of Hand

35
Fig. 3.8 Procedure 8: A towel should be placed between the elbow and
the axilla, and the upper arm is ﬁ xed in place
Note The only bandaging for the upper arm is applied to the wrist.
Fig. 3.9 Procedure 9: The entire upper arm is loosely tightened using
an abdominal belt. Make it possible for the patient to move their elbow
and shoulder within the abdominal belt

Pedicled Abdominal Flap (Level of Difﬁ culty: 3)

36
Fig. 3.10 Procedure 10: The ﬂ ap is separated two weeks later. Care
must be taken not to apply stress to the ﬂ ap margins for wound closure

3 Reconstruction of Dorsum of Hand

37
Tips
A toe transplant is the best option for making a metacarpal hand a functioning hand
If trying to obtain an aesthetic hand, then an artiﬁ cial hand prosthesis is the best option (Photo left. Appearance of
an artiﬁ cial hand prosthesis attached to photo for 10 above), but if the goal is to make a metacarpal hand a functioning
hand, a toe transplant is the best option (Photo right. Separate case).
Refer to Section of “Toe transfer/Metacarpal hand : Double toe transfer” in Chap. 9

Pedicled Abdominal Flap (Level of Difﬁ culty: 3)

38
Free Temporal Fascia Flap (Level of Difﬁ culty: 4)
Information
Advantage Extremely thin. Useful for covering exposed tendons and bones of hands and feet. Donor scar isn’t obvious
on haired area. Possible to harvest two temporal fascia ﬂ aps
Disadvantage Hemorrhagic. Requires careful attention to stop bleeding. If dissecting layer is too superﬁ cial can lead
to hair loss. Harvesting of deep fascia is somewhat complex

3 Reconstruction of Dorsum of Hand

39
Operation Procedures
Fig. 3.11 Procedure 1: The hair is not cut. All hair is ﬁ rst washed in
isodine liquid, which is then washed out with distilled water. Rubber
rings are attached to Pean forceps and the hair on both sides of the inci-
sion line is twisted by the forceps, and the rings released to bind the hair
Fig. 3.12 Procedure 2: An incision is made in line with the hair stream,
and the area above the temporal fascia is dissected. This area is hemor-
rhagic, so bleeding is carefully stopped using a bi-polar apparatus
Note When dissecting, care is taken to avoid a large amount of hair
root being exposed in the scalp.
The temporal branch of the facial nerve runs along a line about 1 cm
below the tragus to a point 1.5 cm lateral of the eyebrow, so this point
should be marked.
When dissecting the anterior section of the fascia, attention must be
paid to the path of the temporal branch of the facial nerve, being careful
not to go over the line marked on the skin.

Free Temporal Fascia Flap (Level of Difﬁ culty: 4)