40
Fig. 3.13 Procedure 3: An incision is made in the anterior, superior
and posterior margin of the fascia fl ap, the fascia fl ap is dissected and
turned downwards. In between the two fascia fl aps is loose connective
tissue that can be easily removed with the fi ngers. Make sure that the
deep fascia isn’t removed at the same time
Note The fascia fl ap becomes narrower as it moves proximally, and
anterior of the ear it is made up of only the superfi cial temporal blood
vessels.
The vein often runs close to the ear while the artery is about 1 cm
posterior.
Fig. 3.14 Procedure 4: The fl ap is dissected up to the superior margin
of the zygomatic arch, the blood vessels confi rmed and the fascia fl ap
harvested
Note The auriculo-temporal nerve is harvested together with the tem-
poral blood vessels, however this doesn’t affect function.
When closing the donor site, a continuous suction drain must be
inserted. A minimal subcutaneous suture is conducted deep, while a
stapler suture is conducted for the surface of the skin.
3 Reconstruction of Dorsum of Hand
41
Fig. 3.15 Procedure 5: The photo shows the skin defect of dorsum of
right hand. Exposure of the extensor tendons present. (Photo repro-
duced from Hirase, Y., et al.: temporoparietal free fascial fl ap. Journal
of Japanese Society for Plastic and Reconstructive Surgery 10:649–
657, 1990)
Fig. 3.16 Procedure 6: Anastomosis is performed with the radial
artery and comitant vein (or cutaneous vein) in the snuff box, and the
exposed extensor tendons wrapped with the fascia fl ap. A split- thickness
skin graft is performed over the fascia, and a tie-over bolster dressing is
applied
Note A plaster splint is fi xed.
Free Temporal Fascia Flap (Level of Diffi culty: 4)
42
Tips
From the temporal region it is possible to elevate two fascial fl aps by one vascular pedicle (superfi cial temporal blood
vessels)
(Photo reproduced from Hirase, Y., et al.: temporoparietal
free fascial fl ap. Journal of Japanese Society for Plastic and
Reconstructive Surgery 10:649–657, 1990)
(Reproduced from Hirase, Y., et al.: Double-layered free
temporal fascial-fl ap as a two-layered tendon-gliding surface.
Plast Reconstr Surg 88:707–712,1991)
a
b
Fig. 3.17 ( a, b ) Procedure 7: The splint is removed at two weeks after
surgery, and active exercise commenced
3 Reconstruction of Dorsum of Hand
43
Dorsal Metacarpal Arterial Flap Using V-Y Plasty (Level of Diffi culty: 2)
Information
Vascular pedicle Multiple cutaneous branches from the dorsal metacarpal artery
Advantage Possible to achieve an excellent aesthetic effect as skin graft not required. Possible to reconstruct using
similar tissue, so excellent sensory functions also.
Disadvantage Only possible to transfer distance of 2–3 cm in horizontal direction
Caution Design must be made so that transfer is conducted in horizontal direction
(Photo supplied from operation conducted by Dr. Keizo Fukumoto)
Dorsal Metacarpal Arterial Flap Using V-Y Plasty (Level of Diffi culty: 2)
44
Operation Procedures
Fig. 3.18 Procedure 1. There is 3 cm wide scar on radial side of
dorsum of hand. V-Y skin fl ap is designed above the second, third and
fourth dorsal metacarpal arteries so it can be moved horizontally
Note The larger the fl ap can be designed, the more metacarpal arteries
can be included in the fl ap, and the greater the stability of the blood
fl ow.
Fig. 3.19 Procedure 2. The scar tissue is resected and an incision made
in the area surrounding the fl ap. Retaining the cutaneous vein, the fl ap
margin and area around the fl ap is dissected
3 Reconstruction of Dorsum of Hand
45
Fig. 3.20 Procedure 3. The wound is sutured closed starting from the
radial side of the fl ap
Tips
Cutaneous branches that supply the skin of the dorsum of the hand are always present
The dorsal metacarpal artery can at times be missing.
However, the cutaneous branches that supply nutrient to the skin of the dorsum of the hand are always present in the
vicinity of the MP joint, so for example, even if part of the dorsal metacarpal artery is missing, it is still no barrier to
moving a large section of skin of the dorsum of the hand as a fl ap.
Dorsal Metacarpal Arterial Flap Using V-Y Plasty (Level of Diffi culty: 2)
46
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Radial artery and its perforators
Advantage Vascular pedicle is long and thick. Often non-hair areas. It is possible to harvest thin fl aps of various sizes.
Can become donor area for complex tissue transplant comprising bone, nerve and tendon. It is also possible to use as
a fl ow through fl ap (bridge fl ap) for connecting to another fl ap. If passed beneath the fi rst compartment, the pivot point
can be moved from the distal medial forearm to distal of the snuff box.
Disadvantage Harvested from exposed area, so a scar remains. Important blood vessels are sacrifi ced.
3 Reconstruction of Dorsum of Hand
47
Operation Procedures
Fig. 3.21 Procedure 1. Case of loss of skin and extensor tendons from
dorsum of multiple fi ngers. The PIP joint is fi xed in the extension posi-
tion with steel wires inserted between the proximal phalanx area to
enable the fi ngers to be spread apart
Fig. 3.23 Procedure 3. The fl ap is elevated from the ulnar side,
however the proper fascia of the forearm group of muscles is retained,
and the forearm fascia is included in the fl ap
Fig. 3.22 Procedure 2. The fl ap is designed after fi rst conducting an
Allen test to determine if the ulnar artery is patent, but the pivot point is
placed distal of the snuff box, with the skin fl ap designed using the
distance from there
Refer to Section of “Degloving injury/Reverse fl ow radial forearm
fl ap” in Chap. 4
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)
48
Fig. 3.24 Procedure 4. Confi rmation is made that multiple perforators
are included in the fl ap from the radial blood vessels
Fig. 3.26 Procedure 6. The proximal radial blood vessels are severed
and the fl ap elevated. The proximal end of the cutaneous vein in the fl ap
is secured
Fig. 3.25 Procedure 5. Next, the fl ap is elevated from the radial side.
The cephalic vein and the superfi cial branch of the radial nerve are
retained, and care taken to avoid damaging them
Note The cutaneous nerve of the forearm is included in the fl ap.
3 Reconstruction of Dorsum of Hand
49
Fig. 3.28 Procedure 8. The entire fl ap is passed beneath the fi rst
compartment
Fig. 3.27 Procedure 7. The area beneath the fi rst compartment of the
extensor tendon group is dissected and a tunnel created, while the radial
blood vessels are also dissected to distal of the snuff box
Fig. 3.29 Procedure 9. The pivot point for the reverse fl ow skin fl ap
becomes distal of the snuff box
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)
50
Fig. 3.30 Procedure 10. The skin fl ap is sewn in syndactyly form
Fig. 3.31 Procedure 11. Additional anastomosis is conducted with the
cutaneous vein contained in the skin fl ap to the cutaneous vein of the
recipient site
Fig. 3.32 Procedure 12. A split-thickness skin graft is performed on
the donor site of the forearm. A tie-over bolster dressing is applied
3 Reconstruction of Dorsum of Hand
51
Fig. 3.33 Procedure 13. The fl ap remains in syndactyly form for about
two months, and during that time hand therapy is commenced to
improve the range of movement of the fi nger joints
Fig. 3.34 Procedure 14. The fi nger spaces are created and grafting
conducted over the skin defect area
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)
52
Tips
Create a fl ap containing tendons
It is possible to transfer a radial antebrachial fl ap with the palmaris longus muscle tendon attached, and reconstruct
the extensor tendons of the dorsum of the hand as a vascularized tendon graft.
3 Reconstruction of Dorsum of Hand
53
Free Dorsalis Pedis Flap with Tendons (Level of Diffi culty: 4)
Information
Vascular pedicle Dorsal blood vessels and cutaneous vein
Advantage It is possible to obtain a thin sensory skin fl ap. It is possible to include extensor tendons in the fl ap
Disadvantage The take ratio of skin grafts on the donor site is poor
Free Dorsalis Pedis Flap with Tendons (Level of Diffi culty: 4)
54
Operation Procedures
Fig. 3.35 Procedure 1. Skin defect on dorsum of middle, ring and little
fi ngers accompanying loss of tendons to ring and little fi nger
Fig. 3.36 Procedure 2. A dorsalis pedis fl ap is designed with the
extensor tendons of the third and fi fth toe attached
3 Reconstruction of Dorsum of Hand
55
Fig. 3.38 Procedure 4. Depending on the position of the required
extensor tendon, the fl ap can be elevated with the extensor digitorum
longus muscle tendon included. In that case, harvesting is concentrated
around the extensor tendons of the second to fourth toes
Fig. 3.37 Procedure 3. The skin fl ap is dissected from above the
extensor digitorum longus muscle tendon. The paratenon above the
extensor tendons is retained. Continuing dissection of the skin fl ap with
the dorsal artery included, after the point where the dorsal artery sends
out a communicating branch to the plantar at the base of the metatar-
sals, it becomes the fi rst dorsal metatarsal artery. The communicating
branch to the plantar is ligated and cut at the location of the branch, and
detachment is continued
Note The deep peroneal nerve runs in parallel to the fi rst dorsal meta-
tarsal artery and the dorsal artery of the foot so it is automatically
included in the fl ap.
Free Dorsalis Pedis Flap with Tendons (Level of Diffi culty: 4)
56
Fig. 3.39 Procedure 5. In the example case, the extensor tendons
heading toward toes three and fi ve are resected, and the extensor tendon
for toe fi ve is sutured to the extensor tendon for toe four
Note The extensor digitorum longus muscle tendons from the great
toe to toe four also include the extensor hallucis/digitorum brevis mus-
cle tendons, so there is little loss to the donor site. However, the exten-
sor hallucis brevis muscle can be ruptured when harvesting the dorsalis
pedis fl ap, so the extensor hallucis brevis muscle tendon is not har-
vested. Also, the fi fth toe doesn’t have an extensor digitorum brevis
muscle, so when harvesting the extensor digitorum longus muscle ten-
don, the distal amputated end should be sutured to the extensor tendon
of the fourth toe.
Fig. 3.40 Procedure 6. The fl ap is elevated with only the required
lengths of the dorsal blood vessels and cutaneous veins detached
3 Reconstruction of Dorsum of Hand
57
Fig. 3.41 Procedure 7. The fl ap is transferred and the tendons are
transplanted and sutured. If possible an interlacing suture is applied
Fig. 3.42 Procedure 8. The fl ap is sewn to the hand in syndactyly form
and anastomosis of the dorsal blood vessels is performed with the dor-
sal branch of the radial blood vessels in the snuff box
Free Dorsalis Pedis Flap with Tendons (Level of Diffi culty: 4)
58
Fig. 3.43 Procedure 9. Two weeks after surgery, permission is given
for active movement and hand therapy is begun. Two months later, the
space between the fi ngers is separated
3 Reconstruction of Dorsum of Hand
59
Tips
Perform a secondary skin graft
Because it is diffi cult for a skin graft to take on the donor area, in recent cases, the author has chosen to place an
artifi cial dermis on the area fi rst, and then after granulation tissue is raised, a secondary skin graft is conducted
Free Dorsalis Pedis Flap with Tendons (Level of Diffi culty: 4)
60
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Deep inferior epigastric blood vessels and their perforators
Size It is possible to create a skin fl ap from the skin beside the naval region that can be reefed in any direction horizon-
tally, longitudinally and diagonally. It is easy to include multiple perforators if harvesting in a longitudinal direction.
It is possible to create the fl ap horizontally in order to hide the stitching beneath underwear, however this requires hol-
lowing the navel, detaching the skin in the surrounding area before closing the suture.
Advantage It is possible to retain the rectus abdominis muscle so there is less concern for the possibility of an abdomi-
nal hernia.
The skin fl ap can be freely created. Possible to remove fat and perform thinning.
Caution The perforators may be ruptured in patients who have had abdominal surgery, and in principle this method is
not indicated in such cases.
3 Reconstruction of Dorsum of Hand
61
Operation Procedures
a
b
Fig. 3.44 ( a, b ) Procedure 1. Large skin defect of dorsum of hand accompanying loss of extensor tendons, and skin defect in the hypothenar
region of the palm separated by unaffected skin
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
62
Fig. 3.46 Procedure 3. Several skin perforators are secured, with care
taken to avoid damaging the muscle fi bers of the rectus abdominis mus-
cle which are retained, and detachment continued up until the deep infe-
rior epigastric blood vessels
Fig. 3.45 Procedure 2. Skin fl ap designed longitudinally around the
naval lateral skin perforator area
Refer to Section of “Reconstruction of forearm region/Free abdomi-
nal perforator fl ap” in Chap. 2
Refer to Section of “Reconstruction of Achilles tendon area/Free
abdominal perforator fl ap” in Chap. 17
3 Reconstruction of Dorsum of Hand
63
Fig. 3.47 Procedure 4. Thinning is performed, leaving the fat sur-
rounding the perforators in place, and the fl ap can be thinned close to
the level of the subcutaneous vascular plexus
Fig. 3.48 Procedure 5. The fl ap is harvested with the deep inferior
epigastric blood vessels, with three skin perforators attached
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
64
Fig. 3.49 Procedure 6. De-epithelization is performed on part of the
harvested skin fl ap, and it is separated into two island fl aps, and sewn in
place
Fig. 3.50 Procedure 7. Anastomosis is conducted of the deep inferior
epigastric blood vessels as the vascular pedicle to the ulnar blood ves-
sels in the forearm. End-to-side anastomosis is conducted for the arter-
ies and side-to-side anastomosis for the veins
3 Reconstruction of Dorsum of Hand
65
Tips
Reconstruct function by combining with tendon graft or tendon transfer
In the above mentioned example, two months after skin transfer, reconstruction of the extensor tendons was con-
ducted by a free palmaris longus muscle tendon graft, and opponent plasty of thumb was performed by ring fi nger
fl exor digitorum superfi cialis muscle tendon transfer.
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
66
Adipofascial Flap by the Dorsal Branch of Ulnar Artery (Level of Diffi culty: 3)
Information
Vascular pedicle Dorsal branch of ulnar artery
Size: Length 10 cm, width 5 cm
Advantage Useful for covering palm, ulnar side of dorsum of hand. Important blood vessels are not sacrifi ced.
Operating time is short. Can harvest as a fascia fl ap
Disadvantage Thin and short vascular pedicle. When harvested as a skin fl ap, the skin graft on the donor site becomes
obvious
3 Reconstruction of Dorsum of Hand
67
Operation Procedures
Fig. 3.51 Procedure 1. Flap is designed for a scar on the ulnar side of
wrist. Firstly, confi rmation is made of the ulnar artery and ulnar margin
of the fl exor carpi ulnaris muscle tendon (FCU). The dorsal branch of
the ulnar artery is around 4 cm proximal from the pisiform bone, and
close to the medial border of the FCU
Fig. 3.52 Procedure 2. An incision is made in the skin, making the
FCU and fascia visible
Fig. 3.53 Procedure 3. When the medial border of the FCU is turned
over, the dorsal branch that has separated from the ulnar artery can be
identifi ed beneath the fascia. This is the vascular pedicle and also the
pivot point, so the vascular pedicle is not detached
Adipofascial Flap by the Dorsal Branch of Ulnar Artery (Level of Diffi culty: 3)
68
Fig. 3.54 Procedure 4. An adipofascial fl ap containing the appropriate
amount of fat beneath the fascia is dissected and elevated from the distal
end of the fl ap, and the fl ap is turned over with the dorsal branch of the
ulnar artery as the pivot point
Fig. 3.55 Procedure 5. The turned-over fascia fl ap is used to cover the
skin defect area, and a bolster suture is done to pull the fl ap into the
subcutaneous layer
Fig. 3.56 Procedure 6. A split-thickness skin graft is performed on top
of the fascia fl ap
3 Reconstruction of Dorsum of Hand
69
Fig. 3.57 Procedure 7. Appearance 6 months after surgery. An
improvement is seen in the indentation deformity
Tips
Secure the area around the vascular pedicle of the fascia fl ap as a broad pedicle
Although it is also possible to elevate this as a skin fl ap, the skin graft required for the donor site will be obvious. Although
the vascular pedicle is the dorsal branch of the ulnar artery, if it is dissected with only a thin vascular pedicle it will be hard
for the skin graft to take on top of that. In order to avoid obstructing the taking of the skin graft, in addition to securing the
vascular pedicle, it is important to secure a broad pedicle by retaining a wide area surrounding the vascular pedicle.
Adipofascial Flap by the Dorsal Branch of Ulnar Artery (Level of Diffi culty: 3)
70
Hint!
Practical method of continuous arterial infusion
Overview of continuous arterial infusion conducted by the author: Conducted for vascular pedicles that exhibit
repeated spasms
1. A small incision is made proximal of the vascular anastomosis location, the artery identifi ed and lifted from behind
using a vascular tube or drain tube. It is best to secure the artery at the elbow in the case of a hand reconstruction,
and at the knee in the case of a foot reconstruction. Keep in mind that the artery is behind the vein.
2. A hole is opened in the blood vessel using a 25–27G needle, and an epidural catheter tube is inserted with reverse
fl ow. It is inserted for about 15 cm and the tube fi xed in place with tape. If bleeding is occurring around the insertion
area then it is stopped by the application of pressure. If properly inserted in the artery then a reverse pulse will be
present inside the catheter.
3. This is fi tted to an extension tube fi lled with a physiological saline solution, and then connected to a 20 cc piston fi lled with
the same physiological saline solution, and the backward fl ow arterial blood is lightly held in check and maintained.
4. Then, 5,000 units of heparin, 60,000 units of Urokinase and 20 mcg Prostaglandin are dissolved in low molecular
weight dextran® to a total of 40 ml, and fi lled in a 50 cc piston as a 12 h dose.
5. The injection rate is set at 3.3 ml per hour, and connected to the extension tube inserted in the artery.
6. Administration of antibiotics and rehydration following surgery are conducted using intravenous infusion.
7. Continuous arterial infusion is continued for around one week. In cases of major blood vessel pain, Prostandin® is
excluded from the content of the intraarterial injection. In cases where a blood clot occurs in the artery, the arterial
infusion is stopped and a switch made to intravenous administration.
3 Reconstruction of Dorsum of Hand
71
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_4
Degloving Injury
Basic Principles
Avulsion and degloving injuries of the finger and hand where the skin is stripped off large
areas are accompanied by exposure of bone and tendons, and how fast repair of the skin can
be carried out is the key to recovering function post-surgery. For the reconstruction method,
it is best to combine different methods based on the level of the injury.
It is important to reconstruct the skin defect area by combining various methods, and to
commence hand therapy as soon as possible after surgery to prevent contracture of the
finger joints.
Selectable Flaps and Surgical Procedures
Abdominal subcutaneous pocket insertion • Abdominal flap • Free temporal fascial flap
• Reverse flow radial forearm flap • Extended twisted wrap-around flap
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.
4
72
Temporary Coverage: Abdominal Subcutaneous Pocket Insertion (Level of Difficulty: 1)
Information
First, comprehensive debridement is carried out to the crush wound, and necrotic and infected tissue resected.
A subcutaneous pocket is created in the abdomen, the crushed finger or hand inserted inside and the surrounding area
sutured closed. The purpose of this surgery is not to cover the wound using the skin of the abdominal wall, but only to
conduct temporary tissue banking.
This can be done under local anesthetic.
4 Degloving Injury
73
Operation Procedures
Fig. 4.1 Procedure 1: Re-attachment was conducted for a degloving
injury, however progression of necrosis continued
Fig. 4.2 Procedure 2: Debridement is conducted under local anesthetic
and necrotic soft tissue completely resected
Temporary Coverage: Abdominal Subcutaneous Pocket Insertion (Level of Difficulty: 1)
74
Fig. 4.3 Procedure 3: The entire thumb is inserted into the abdominal
subcutaneous pocket
Fig. 4.4 Procedure 4: Appearance after removing one week later. The
progression of necrosis of the bone and tendon tissue has been
stopped. A twisted wrap-around flap was then used to cover the skin
defect area
4 Degloving Injury
75
Tips
Prior to reconstructing a hand or finger, another option is to temporarily cover the area using a pedicled abdominal
flap
If there is insufficient soft tissue on the graft bed, a large sacrifice is made by the foot when a toe transplant is con-
ducted. For cases with large skin defects, it is a practical measure to conduct a vascularized abdominal flap as a prelimi-
nary treatment to conducting a toe transplant.
Temporary Coverage: Abdominal Subcutaneous Pocket Insertion (Level of Difficulty: 1)
76
Free Temporal Fascial Flap (Level of Difficulty: 4)
Information
Vascular pedicle Superficial temporal blood vessels
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 fascial flaps
Disadvantage Hemorrhagic. Requires careful attention to stop bleeding. If dissection layer is too superficial can lead
to hair loss. Harvesting of deep fascia is somewhat complex. Too thin to be suited to reconstruction of the palmar
finger tip.
Indication When an area needs to be covered using thin tissue (mainly reconstruction of dorsum of hand)
(Hirase, Y., et al.: Reconstruction of degloving injuries. Plastic Surgery Advance Series. Plastic surgery for the limbs.
Recent Progress, Editing: Kojima, T., pp 134–142, Kokuseido Publishing, Tokyo, 2005)
4 Degloving Injury
77
Operation Procedures
Fig. 4.5 Procedure 1: Degloving injury of hand accompanying
wide-area crushing injury
Fig. 4.6 Procedure 2: An incision is made in the temporal area in line
with the path of the superficial temporal artery, and after broadly dis-
secting the upper fascia, the required fascia is flap is severed. The tem-
poral fascia flap peels off easily by using fingers, so following the
superficial temporal artery in the proximal direction, the temporal fascia
flap is completely elevated and harvested
Refer to Section of “Reconstruction of Dorsum of Hand/Free tempo-
ral fascia flap” in Chap. 3
Free Temporal Fascial Flap (Level of Difficulty: 4)
78
Fig. 4.7 Procedure 3: The exposed bone and tendon are covered with
the temporal fascial flap, and anastomosis is performed with the
superficial temporal blood vessels to the radial blood vessels in the
snuff box
Fig. 4.8 Procedure 4: A split-thickness skin graft is conducted on top
of the fascia flap
4 Degloving Injury
79
Fig. 4.9 Procedure 5: Appearance 3 weeks after surgery. (Part of
photos reproduced from Hirase, Y: Reconstruction using free flaps.
Plastic Surgery for Injuries. pp 127–132, Kokuseido, Tokyo, 2007)
Free Temporal Fascial Flap (Level of Difficulty: 4)
80
Reverse Flow Radial Forearm Flap (Level of Difficulty: 3)
Information
Vascular pedicle Reverse blood flow of the radial blood vessels and the anastomotic cutaneous vein
Size Excluding the skin directly above the ulnar artery, possible to use almost all of the skin on the forearm
Advantage Skin is flexible and thin. There are few restrictions on the design, and it is possible to harvest flaps in a
range of shapes. The vascular pedicle is large, and because it is possible to perceive the palpitations through the skin,
flap design can be conducted accurately. Can also be used as an adipofascial flap without inclusion of the skin.
It is also possible to include tendon or part of the bone in the flap.
Disadvantage A skin graft scar will be seen on the exposed section. Circulation from the radial artery will be sacrificed
4 Degloving Injury
81
Operation Procedures
Fig. 4.11 Procedure 2: Elevation begins from the ulnar margin of the
flap. With the antebrachial fascia attached to the flap, detachment and
elevation is conducted above the proper fascia
Fig. 4.10 Procedure 1: The design is created with the pivot point of the
blood flow for the flap placed distal of the snuff box
Fig. 4.12 Procedure 3: Confirmation is made of the radial artery
entering the flap at the intermuscular septum where the antebrachial
fascia becomes thicker
Refer to Section of “Reconstruction of the dorsum of the hand/
Reverse flow radial forearm flap” in Chap. 3
Note Because the antebrachial fascia is not actually involved in the
blood flow for the flap, the flap can be elevated with it on the tendon
side, however the technique is complex.
Note In the area surrounding the intermuscular septum, fascia of
around 2–3 cm in width must be included in the flap.
Reverse Flow Radial Forearm Flap (Level of Difficulty: 3)
82
Fig. 4.14 Procedure 5: With the radial blood vessels included, the
intermuscular septum is detached from the periosteum. During the
procedure conducted up until now, it is possible to confirm several
cutaneous branches from the radial artery
Fig. 4.13 Procedure 4: An incision is made in the radial margin, and
the flap is detached from above the proper fascia with the antebrachial
fascia included in the flap. The cutaneous vein is included in the flap,
with care taken that the dorsal branch of the radial nerve and the thick
radial cutaneous vein is retained without being damaged
Fig. 4.15 Procedure 6: When the full length of the radial blood vessels
are detached, the flap is separated from the forearm, and attached only
to the vascular pedicle. The cutaneous vein in the flap is secured so that
it can be used for anastomosis later on
4 Degloving Injury
83
Fig. 4.16 Procedure 7: Case: Skin defect present on volar side of right
thumb and degloving injury to index and middle finger
Fig. 4.17 Procedure 8: Under a local anesthesia, the index and middle
fingers are placed in an abdominal subcutaneous pocket, and the skin
defect of the thumb is covered with a local skin flap
Note The MP joints are temporarily fixed with a steel wire so that
they don’t flex.
Fig. 4.18 Procedure 9: After 10 days, the fingers are removed from the
subcutaneous pocket and the flap of the thumb is cut
Reverse Flow Radial Forearm Flap (Level of Difficulty: 3)
84
Fig. 4.20 Procedure 11: The dorsal branch of the radial blood vessels
is sufficiently dissected from beneath the first compartment. The palmar
branch of the radial artery is ligated and cut
Fig. 4.19 Procedure 10: A reverse flow radial antebrachial flap is
elevated according to the procedure explained
Fig. 4.21 Procedure 12: The flap is extracted distally from beneath the
first compartment
4 Degloving Injury
85
Fig. 4.22 Procedure 13: The flap is completely extracted, and if it can
be passed beneath the dorsal branch of the radial nerve, it is possible to
move the pivot point event further distally
Fig. 4.23 Procedure 14: The flap is used to cover the index and middle
fingers in a syndactyly form. Anastomosis of at least one subcutaneous
vein should be made between the recipient site and the flap in order to
prevent congestion. A split-thickness skin graft is conducted on the
donor site
Fig. 4.24 Procedure 15: From one week onwards it is possible to
conduct active movement of the MP joint. One month later, the finger
web space was created between the index and middle fingers
Note A hemi pulp transfer was performed for the thumb.
(Part of photos reproduced from Hirase, Y.: Reconstruction using
vascularized skin flaps: Plastic Surgery for Injuries (edited by Anze, M.)
pp 121–127, Kokuseido, Tokyo, 2007
Reverse Flow Radial Forearm Flap (Level of Difficulty: 3)
86
Tips
Being able to conduct anastomosis of one cutaneous vein when the flap is transferred, is useful for preventing
congestion postoperatively.
Use of a reverse flow radial antebrachial flap can occasionally cause severe congestion and edema. If anastomosis
is conducted between the graft bed and a cutaneous vein when the flap is transferred it is possible to avoid such
problems.
4 Degloving Injury
87
Reverse Flow Forearm Adipofascial Flap and Skin Graft (Level of Difficulty: 3)
Information
Vascular pedicle Radial blood vessel perforators
Size It is possible to harvest the entire medial forearm, passing the elbow joint and also extending proximally, but in
that case it is preferable to secure the proximal perforators and perform an additional anastomosis with the arteries after
transferring the fascia flap
Advantage The stem of the radial blood vessels is retained.
Caution Fat is also elevated in addition to the fascia. Because the circulation is in the fat tissue above the fascia, if the
fascia is taken without the fat, then the flap won’t take.
Reconstruction of the thumb and reconstruction of the index through to the little finger is conducted separately, with
sufficient margin for the first web space.
Reverse Flow Forearm Adipofascial Flap and Skin Graft (Level of Difficulty: 3)
88
Fig. 4.25 Procedure 1: Wide-area degloving injury accompanying
amputation of all fingers
Fig. 4.26 Procedure 2: The subcutaneous layer of the medial forearm
is detached across a wide area from the proximal wrist to the area
around the elbow joint
Note Even if going a few centimeters beyond the elbow it is still pos-
sible to elevate a fascial flap. If an additional anastomosis is conducted
with the proximal perforators to the graft bed, it is possible to transfer an
even larger adipofascial flap.
4 Degloving Injury
89
Fig. 4.27 Procedure 3: The proper fascia of the forearm muscle group
are left in place, and the forearm adipofascial flap is dissected/elevated
from the ulnar side. Close to the wrist it is possible to confirm several
thin perforators from the radial artery through the fascia. Close to the
elbow it is possible to confirm the large perforator from the radial
artery, and this is retained
Fig. 4.28 Procedure 4: Distally the radial blood vessel stem are now
shown, and proximally the perforators are shown
Fig. 4.29 Procedure 5: The proximal perforators are secured, severed
and the fascia flap elevated with the distal pedicle. Here, confirmation is
made as to whether bleeding occurs from the most distal position to the
fascia flap
Note Care is taken to avoid damaging the median nerve in the vicinity
of the elbow joint. Also, the paratenon of the tendon should not be
directly touched with the gloves, but handled atraumatically using
saline gauze dressing.
Note If bleeding cannot be confirmed, an additional anastomosis of
the secured perforators is conducted to the distal artery in the graft bed.
Reverse Flow Forearm Adipofascial Flap and Skin Graft (Level of Difficulty: 3)