90
Fig. 4.30 Procedure 6: Distally, if the area 3–4 cm from the wrist is
dissected, several distal perforators will be naturally included in the
flap. The stem of the radial blood vessels is not severed
Fig. 4.31 Procedure 7: The fascial flap is turned over and confirmation
of bleeding made from the distal end (the most proximal area
anatomically). If there is no bleeding, an additional anastomosis is
performed to the volar artery after transfer
a
Fig. 4.32 (a, b) Procedure 8: The fascia flap is used to cover the
exposed bone and tendons
4 Degloving Injury
91
Fig. 4.33 Procedure 9: A split-thickness skin graft is conducted on top
of the adipofascial flap. In the case that the harvested fascia is large, it
can be difficult to directly suture the donor site due to swelling of the
flexor muscle group, so a skin graft should be conducted instead
Fig. 4.34 Procedure 10: Pressure is applied to the skin graft using
gauze and a bandage, and fixed in place with a plaster splint
b
Fig. 4.32 (continued)
Note For this case example, the thumb is inserted into an abdominal
subcutaneous pocket to reconstruct subsequently.
Reverse Flow Forearm Adipofascial Flap and Skin Graft (Level of Difficulty: 3)
92
a
b
Fig. 4.35 (a, b) Procedure 11: The thumb can be reconstructed using a pedicled abdominal flap, or a toe transplant can be performed
Note Photo shows final image. For this case, reconstruction of the thumb was conducted using a pedicled abdominal flap.
4 Degloving Injury
93
Extended Twisted Wrap-around (TWA) Flap (Level of Difficulty: 5)
Information
Vascular pedicle First dorsal metatarsal artery or dorsal artery of foot/comitant vein and cutaneous vein
Size Combined flap of TWA flap and dorsalis pedis flap, and a large area from the tip of the great toe/second toe to the
dorsalis pedis can be harvested
Advantage Useful for covering a degloving injury where the overall bone and tendons of the thumb have been retained,
for an aesthetic and functional thumb reconstruction.
Disadvantage Technically very difficult. Because the extensor tendons are exposed over a wide area of the dorsalis
pedis, it is difficult for the skin graft to take in one stage, and there is a possibility that it will need to be covered using
a free flap
Extended Twisted Wrap-around (TWA) Flap (Level of Difficulty: 5)
94
Operation Procedures
Refer to Section of “Reconstruction of dorsum of hand/Pedicled
abdominal flap” in Chap. 3
Fig. 4.37 Procedure 2: The right thumb is reattached, and the left
thumb is temporarily covered using a pedicled abdominal flap
Fig. 4.36 Procedure 1: Case of amputation of thumb on both hands,
with right thumb completely amputated and degloving injury to left
thumb. The tendon and bone have been retained
4 Degloving Injury
95
Fig. 4.38 Procedure 3: A combined TWA flap and dorsalis pedis flap
is designed on the right foot
Fig. 4.39 Procedure 4: A wrap-around flap is harvested distally
including the approximate lateral 1/3 of distal phalanx of great toe, and
a wrap around flap is also elevated from dorsal side of second toe. One
toe nerve is included in each flap. While securing the plantar toe artery,
the first dorsal metatarsal artery is dissected in the proximal direction
Note Care is taken not to include the plantar weight bearing areas of
the great toe and second toe.
Extended Twisted Wrap-around (TWA) Flap (Level of Difficulty: 5)
96
Fig. 4.40 Procedure 5: The flap is harvested with two cutaneous veins
included. For the artery, depending on the size of the flap, it is harvested
with either the first dorsal metatarsal artery or dorsal artery of the foot
Fig. 4.41 Procedure 6: After fixing the distal phalanx with a kirschner
wire, anastomosis of the arteries and veins is performed in the snuff box
Note If the anastomosis location is to be distal of the snuff box, then
the length of the first dorsal metatarsal artery will be sufficient. But if a
large dorsalis pedis flap is required, then the vascular pedicle will be the
dorsal artery of the foot and anastomosis location inside the snuff box.
4 Degloving Injury
97
Fig. 4.42 Procedure 7: The toe nerves included in the flap are sutured
to the finger nerves. If possible, additional anastomosis is performed
with the plantar toe artery to the digital artery
Fig. 4.43 Procedure 8: Reconstruction of the donor site is commenced.
The dorsal artery of the foot and the cutaneous vein are secured
Extended Twisted Wrap-around (TWA) Flap (Level of Difficulty: 5)
98
Fig. 4.44 Procedure 9: The abdominal perforator flap is elevated, and
the fat resected while leaving the fat surrounding the vascular pedicle in
place
Refer to Section of “Reconstruction of forearm region/Free abdomi-
nal perforator flap” in Chap. 2
Refer to Section of “Reconstruction of dorsum of hand/Free abdomi-
nal perforator flap” in Chap. 3
Refer to Section of “Reconstruction of palm and wrist area/Free
abdominal perforator flap” in Chap. 5
Refer to Section of “Reconstruction of Achilles tendon area/Free
abdominal perforator flap” in Chap. 17
Fig. 4.45 Procedure 10: The thinned abdominal perforator flap is
harvested
Fig. 4.46 Procedure 11: The skin defect area is covered with the
abdominal perforator flap, and anastomosis is conducted of the deep
inferior epigastric artery and vein to the dorsal blood vessels of the foot
and cutaneous vein
4 Degloving Injury
99
Note If the skin flap is sufficiently thinned, the dorsalis pedis can be covered in one stage and it is still possible to obtain a pleasing aesthetic. As
a two stage surgery technique, artificial dermis can be temporarily placed over the dorsalis pedis and after granulation tissue is raised 2–3 weeks
later, a split-thickness skin graft is conducted.
(Some photos reproduced from Hirase, Y., et al.: Reconstruction of degloving injuries. Plastic Surgery Advance Series.
Plastic surgery for the limbs. Recent Progress, Editing: Kojima, T., pp134-142, Kokuseido Publishing, Tokyo, 2005)
a
b
Fig. 4.47 (a, b) Procedure 12: Final image of dorsalis pedis and both hands. Appearance three months after right thumb reattached, and left thumb
reconstructed using an extended TWA flap. In degloving injuries not accompanied by bone fractures, there is little bone resorption and a good
range of movement is maintained
Extended Twisted Wrap-around (TWA) Flap (Level of Difficulty: 5)
100
Information
Vascular pedicle Combination of a reverse flow radial blood vessel circulation and superficial epigastric blood vessel
circulation
Size The dorsum of the hand is covered by a large as possible reverse flow radial antebrachial flap, and for the volar
skin defect that cannot be covered, a thinned abdominal flap is used.
Advantage By combining two flaps it is possible to comfortably cover a large wound.
Reverse Flow Radial Forearm Flap and Pedicled Abdominal Flap (Level of Difficulty: 3)
4 Degloving Injury
101
Operation Procedures
a
b
Fig. 4.48 (a, b) Procedure 1: After conducting debridement, a large skin defect is present stretching from the dorsum of the hand to the tip of the
middle, ring and little fingers on the dorsal side. On the volar side a skin defect extends from the distal palm to the tips of the fingers
Fig. 4.49 Procedure 2: Using the technique described earlier, the
radial forearm flap is elevated with a reverse blood flow
Reverse Flow Radial Forearm Flap and Pedicled Abdominal Flap (Level of Difficulty: 3)
102
Fig. 4.50 Procedure 3: and the entire flap is transferred distally by
passing beneath the first compartment
Fig. 4.51 Procedure 4: After the flap is transferred distally, an
additional anastomosis is conducted using the cutaneous vein
Fig. 4.52 Procedure 5: A split-thickness skin graft is conducted on the
donor area. A light tie-over bolster dressing is applied
4 Degloving Injury
103
Fig. 4.54 Procedure 7. The dorsal side is completely covered using the
flap, however a skin defect remains on the volar side
Fig. 4.53 Procedure 6: The flap is used to cover the dorsal side of the
middle, ring and little fingers in a syndactyly form
Fig. 4.55 Procedure 8: A pedicled abdominal flap is elevated from the
abdomen as a tubal flap, and used to cover the volar skin defect area
Reverse Flow Radial Forearm Flap and Pedicled Abdominal Flap (Level of Difficulty: 3)
104
Fig. 4.56 Procedure 9: The abdominal flap is severed 2 weeks later,
and active and passive stretching exercises of the MP/PIP joint are
commenced immediately
Fig. 4.57 Procedure 10: Separation of the digital web spaces is
conducted in two stages, and a skin graft added to the skin defect area.
(Some photos reproduced from Hirase, Y., et al.: Reconstruction of
degloving injuries. Plastic Surgery Advance Series. Plastic surgery for
the limbs. Recent Progress, Editing: Kojima, T., pp134–142, Kokuseido
Publishing, Tokyo, 2005)
4 Degloving Injury
105
Tips
Hixson & Moore classification
Class I: Blood flow has been retained. There may be bone fracture or dislocation, but main issue is skin avulsion
wound. It is sufficient to repair just the soft tissue of the skin. Good treatment outcome.
Class II: Blood flow is interrupted. Not only injury to the skin, bone and nerves, but injury to the arteries and or the
veins as well. Requires reconstruction of circulation. If proper treatment conducted it is possible to retain hand
function.
Class III: Complete avulsion or complete amputation. Tissue lost through avulsion includes skin/nerve/blood vessels/
bone/tendon etc. Even if circulation can be reconstructed, there is limit to function that can be re-obtained.
Conventionally, functional prognosis for Class III was considered poor, however if it is covered with suitable tissue
at an early stage, in a limited number of cases, the functional prognosis is not as bad as previously considered. The
photo shows the final range of movement for the above-mentioned case.
Reverse Flow Radial Forearm Flap and Pedicled Abdominal Flap (Level of Difficulty: 3)
106
Hint!
How to use medical leeches
Medical leeches are used for alleviating congestion of transplanted tissue. They are not indicated for improving
blood flow in ischemic tissue.
1. A needle is used to prick a hole in the surface of skin flap where congestion is occurring to allow it to bleed.
2. The medical leech is picked up using forceps and attached to the bleeding point.
The end that moves a lot is the head, but they are able to suck from both ends.
3. A paper cup with the bottom removed is placed over the leech to prevent it from escaping.
4. After 20–30 min the engorged leech is removed and disposed in alcohol.
5. A saline gauze dressing containing heparin is placed over the bleeding area and changed every 2 h. Confirmation of
whether bleeding is continuous is made each time.
6. In principle, it will take several days for congestion to improve at a rate of one leech treatment per day. For severe
congestion several leeches could be used each session or several sessions could be conducted each day.
Due to the action of hirudin produced by the leeches, bleeding will continue for between 12 and 24 h.
4 Degloving Injury
107
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_5
Reconstruction of Palm and Wrist Area
Basic Principles
The palm of the hand is responsible for the important action of enclosing objects.
Therefore it is necessary to cover this area using tissue that is soft with suffi cient
thickness. It is not necessary to pro-actively pursue a sensory reconstruction, but if a similar
tissue is used for reconstruction, it is possible to obtain a protective sensation.
Small skin defects can be covered using localized fl aps. When creating localized fl aps on
the palm, the skin fl ap must be designed to be moved in a horizontal direction.
For large defect areas, although medial plantar fl aps were previously preferred, this can
lead to the formation of a sore on the donor area in the long term, and the use of a medial
pedis fl ap creates less problems. For larger areas, the use of a pedicled or free thinned
abdominal fl ap is practical.
Selectable Flaps and Surgical Procedures
V-Y advancement fl ap • Pedicled abdominal fl ap • Free medial plantar fl ap • Free medial
pedis fl ap • Free abdominal perforator fl ap • Ulnar parametacarpal fl ap • Reverse fl ow radial
forearm fl ap • Hand relaxation incision
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.
5
108
V-Y Advancement Flap (Level of Diffi culty: 1)
Information
Vascular pedicle Perforators of cutaneous branch from palmar digital artery.
Size Size based on the width of the skin defect area that can be transferred horizontally.
Advantage Same quality skin and scar is not obvious.
Caution In principle, V-Y plasty of the palm is created in a horizontal direction.
5 Reconstruction of Palm and Wrist Area
109
Note This method enables for easy transfer of the skin fl ap.
Operation Procedures
Fig. 5.1 Procedure 1: The skin fl ap is designed in a horizontal
direction
Fig. 5.2 Procedure 2: An attempt is made to move the fl ap, and if there
is insuffi cient transfer distance, an additional incision is made in the
stretched palmar fascia
Note By designing a bigger skin fl ap there is more chance of multiple
cutaneous branches being included in the fl ap, and it is possible to get
more stretch out of the fl ap itself.
After fi rst making an incision in the margin of the fl ap, an incision
is then made in the palmar fascia.
Note In this case example, a digitolateral fl ap is inserted in the base of
the middle fi nger.
V-Y Advancement Flap (Level of Diffi culty: 1)
110
Fig. 5.3 Procedure 3: The wound is sutured closed from the distal part
of the fl ap
Fig. 5.4 Procedure 4: Fluffy gauze is placed over the skin fl ap and a
dressing applied with light pressure. There is no restriction of movement
of fi ngers
5 Reconstruction of Palm and Wrist Area
111
Tips
Flexion contracture tends to occur in triangular skin fl aps of the palm that are transferred longitudinally.
Although there is no problem with regard to circulation based on the direction triangular skin fl aps are created in
the palm, fl exion contracture of the fi ngers tends to occur when fl aps are transferred longitudinally. A V-Y skin fl ap
should only be created longitudinally when there is a long skin defect in a horizontal direction running parallel with
the palmar crease. It is also diffi cult to see the scar when the fl ap is transferred horizontally.
V-Y Advancement Flap (Level of Diffi culty: 1)
112
Free Medial Plantar Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Superfi cial branch of medial plantar blood vessels.
Size Aligning with the section of the instep arch, a width of 5 cm and a length of 10 cm is available. If the medial
pedis fl ap section is also included, the width can be increased by 3 cm.
Advantage Similar skin texture to the palm.
Disadvantage If the donor site is on a weight bearing area, tends to create a chronic sore. An arch support (worn in the
shoes) is required to be worn over a long period.
5 Reconstruction of Palm and Wrist Area
113
Operation Procedures
Fig. 5.5 Procedure 1: The fl ap is designed in line with the instep arch,
but when larger fl aps are required, the design is combined with the
medial pedis fl ap including above the scaphoid tubercle
Note If only harvesting the medial pedis fl ap, the fl ap is elevated with
the deep branch of the lateral plantar blood vessels, but when combin-
ing the medial plantar fl ap and the medial pedis fl ap, then there is no
issue with circulation if only using the superfi cial branch of medial
plantar artery.
Refer to Section of “Reconstruction of Calcaneal Region & Lateral
Plantar Region/Medial plantar fl ap” in Chap. 18
Fig. 5.6 Procedure 2: First, an incision is made in the posterior medial
malleolus of the tibia, and confi rmation is made of the posterior tibial
blood vessels, which are then separated from the nerves. The incision is
extended distally, with dissection continued down to the branching of
the medial/lateral plantar arteries. The blood vessels are dissected from
the reverse side while being careful to avoid cutting the abductor hal-
lucis muscle. An incision is then made in the distal margin of the fl ap
and dissection is made avoiding the toe nerves beneath the plantar fas-
cia. It becomes enabling confi rmation of the cutaneous branch of the
blood vessels that enter the fl ap
Fig. 5.7 Procedure 3: The blood vessels beneath the abductor hallucis
muscle are dissected and the deep branch of the medial plantar artery is
ligated and cut
Note The abductor hallucis muscle is not cut because doing so can
cause hallux valgus post surgery.
Free Medial Plantar Flap (Level of Diffi culty: 4)
114
Fig. 5.8 Procedure 4: The posterior tibial blood vessels are severed
with the required length, and the fl ap harvested with the vascular
pedicle passed beneath the abductor hallucis muscle
Fig. 5.9 Procedure 5: The fl ap is sutured in place and anastomosis
conducted with the posterior tibial blood vessels to the radial blood
vessels
Note If possible, end-to-side anastomosis is performed for the
arteries.
A drain tube is inserted in the margin of the fl ap.
5 Reconstruction of Palm and Wrist Area
115
Tips
A split-thickness skin graft is performed on the donor site, and a compression dressing applied.
The patient is instructed to walk with an arch support in their shoes for several months following surgery.
Tips
The biggest problem of medial plantar fl aps is in the donor site.
Even if the fl ap is created so as to avoid the weight bearing area, if the patient stops wearing the arch support, then
they tend to develop a sore. It is necessary to get the patient to understand that arch supports for the shoes should be
worn at all times. Also, for patients employed in jobs that require them to walk on gravel roads or similar, it is best to
avoid selecting this fl ap.
Photo is of sore that still re-occurs 5 years after surgery.
Free Medial Plantar Flap (Level of Diffi culty: 4)
116
Free Medial Pedis Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Medial branch of deep branch of medial plantar artery.
Size Width of around 3 cm and length of around 7 cm centered around the scaphoid tubercle.
Advantage Comparatively thin, fl exible and suitable for small skin defects of the palm.
Possible to retain the lateral plantar blood vessels and use only the medial plantar arteries. Patient not required to wear
an arch support.
Disadvantage Cannot be a sensory fl ap. Not suited to covering a large area on the palm.
5 Reconstruction of Palm and Wrist Area
117
Operation Procedures
a
b
Fig. 5.10 ( a , b ) Procedure 1: Scar on palm is resected and a free nerve transplant harvested from the forearm was performed. Skin defect present
from palm to fi rst web space area
Fig. 5.11 Procedure 2: The skin fl ap is designed with scaphoid tubercle
at center
Free Medial Pedis Flap (Level of Diffi culty: 4)
118
Refer to Section of “Reconstruction of the Achilles tendon area/
Medial pedis fl ap” in Chap. 17
a
b
Fig. 5.12 ( a , b ) Procedure 3: An incision is made in the inferior border
of the skin fl ap and the abductor hallucis muscle pulled downwards,
exposing the deep branch of the medial plantar blood vessels, which are
dissected in a proximal direction
Fig. 5.13 Procedure 4: Dissection of the deep branch of the medial
plantar blood vessels continues in a proximal direction, with the super-
fi cial branch ligated and severed along the way. Retaining the lateral
plantar blood vessels and severing the medial plantar artery, the vascu-
lar pedicle comes to a length of about 5 cm. If a longer vascular pedicle
is required, or if the diameter of the medial plantar artery is too small,
the lateral plantar blood vessels can be ligated and severed and dissec-
tion continued on toward the posterior tibial blood vessels
5 Reconstruction of Palm and Wrist Area
119
Fig. 5.14 Procedure 5. When the necessary length of vascular pedicle
is secured, the vascular pedicle is ligated and severed and the fl ap
harvested
Fig. 5.15 Procedure 6. The skin fl ap is set in place, and anastomosis is
performed between the vascular pedicle and the radial blood vessels in
the distal snuff box. A drain tube is inserted
Free Medial Pedis Flap (Level of Diffi culty: 4)
120
a
b
Fig. 5.16 ( a , b ) Procedure 7. The abductor hallucis muscle is lifted up
and the scaphoid tubercle covered
Fig. 5.17 Procedure 8. and a split-thickness skin graft conducted
over it
5 Reconstruction of Palm and Wrist Area
121
Fig. 5.18 Procedure 9. A tie-over dressing is applied and pressure
applied to the skin graft via either a bolster dressing or negative pres-
sure wound therapy. (Part of photos reproduced from Hirase, Y.:
Reconstruction using free fl aps: Plastic Surgery for Injuries (edited by
Anze, M.) pp 121–127, Kokuseido, Tokyo, 2007)
Tips
Skin texture and the size of the reconstruction site are the deciding factors for fl ap selection when reconstructing
the palm.
Reconstruction of sensory function is not really needed when reconstructing the palm area. Therefore skin texture
and the size of the reconstruction site are the two most important elements for selecting a fl ap. When the skin defect of
the palm is comparatively small, a medial pedis fl ap should be chosen, and when it is large, a medial plantar fl ap should
be chosen. In cases where a larger fl ap is required or it is not possible to harvest from the foot, an abdominal perforator
fl ap should be chosen.
Free Medial Pedis Flap (Level of Diffi culty: 4)
122
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Perforators of deep inferior epigastric blood vessels.
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 or 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. It is possible to conduct thinning by removing fat.
Caution The perforators may be ruptured in patients who have had abdominal surgery, and in principle this method is
not indicated in such cases.
5 Reconstruction of Palm and Wrist Area
123
Note Although it is suffi cient to have one perforator for the circulation
of the skin fl ap, inclusion of multiple perforators avoids most problems
caused by twisting of the vascular pedicle on transfer of the fl ap.
Operation Procedures
a
b
Fig. 5.19 ( a , b ) Procedure 1: Due to scar contraction from the fi rst web
space area to the palm following re-attachment, patient unable to
suffi ciently conduct autonomous extension of the MP joint
Fig. 5.20 Procedure 2: The skin fl ap is designed in a longitudinal
direction on the rectus abdominis muscle. An incision is made in the
lateral side of the skin fl ap, and dissected above the external oblique
fascia and anterior sheath of the rectus abdominis. Of the multiple per-
forators passing through the anterior sheath of the rectus abdominis
lateral to the naval, two or three comparatively large perforators run-
ning parallel to the muscle fi ber of the rectus abdominis muscle are
chosen
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
124
Fig. 5.22 Procedure 4: and then the multiple selected perforators are
elevated together with the deep inferior epigastric blood vessels on the
reverse side of the muscle tissue
Fig. 5.21 Procedure 3: A small incision is made into the anterior
sheath of the rectus abdominis in the vicinity of the perforators, and the
perforators are detached from the muscle tissue
Note Here, the dissection of the rectus abdominis muscle is performed
in parallel to the muscle fi ber, with horizontal cuts avoided wherever
possible in order to retain the muscle tissue.
5 Reconstruction of Palm and Wrist Area
125
a
b
c
Fig. 5.23 ( a – c ) Procedure 5: Thinning is performed of the subcutaneous
fat, leaving the area surrounding the perforators in place
Note Thin areas can be thinned down to around a 1 cm thickness, how-
ever it is important that the subcutaneous vascular plexus is retained.
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
126
Fig. 5.24 Procedure 6: The skin fl ap is sutured to the skin defect run-
ning from the fi rst interdigital area to the palm, and anastomosis is con-
ducted of the deep inferior epigastric blood vessels to the radial artery
and comitant vein (or cutaneous vein) in the distal forearm. End-to-side
anastomosis should be used for arteries. The skin fl ap is sutured to the
surrounding tissue and a drain tube inserted
a
b
Fig. 5.25 ( a , b ) Procedure 7: If the circulation of the skin fl ap is stable,
active movement can be commenced several days after surgery
5 Reconstruction of Palm and Wrist Area
127
Tips
As long as the 4 cm square area lateral of the naval is included in the design, the skin fl ap can be designed to any shape.
For the cutaneous branches of the abdominal perforator fl ap, several perforators emerge from the rectus abdominis
muscle, however there are several very large perforators present in the 4 cm square area lateral of the naval. As long as
this area is included, any shaped fl ap can be designed.
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
128
Ulnar Parametacarpal Flap (Level of Diffi culty: 2)
Information
Vascular pedicle There are several cutaneous branches that extend from the palmar digital artery of the little fi nger to
the lateral side of the palm, and it is possible to elevate the fl ap with any of the branches, however under normal cir-
cumstances the fl ap is elevated using the cutaneous branch to the ulnar MP joint of the little fi nger.
Size Created to a width that allows reefi ng along the boundary between the palm and the dorsum of the hand on the
ulnar side. In adults this is normally 15–20 mm.
Advantage Can cover from the area near the ulnar side of the palm to the tip of the little fi nger. It is possible to elevate
an island fl ap as a pedicled fl ap.
Disadvantage The area of coverage is comparatively small.
5 Reconstruction of Palm and Wrist Area
129
Operation Procedures
Fig. 5.27 Procedure 2: A 10–15 mm diameter subcutaneous pedicle is
designed on the ulnar MP joint of the little fi nger, and a spindle shaped
fl ap with a width that enables reefi ng (20 mm or less) is drawn along the
border between the palm and the dorsum of the hand
Fig. 5.26 Procedure 1: Following resection of the palmar fascia due to
progressive Dupuytren contracture, Z plasty was conducted and the
wound sutured closed, however a skin defect was present on the palm
Ulnar Parametacarpal Flap (Level of Diffi culty: 2)
130
Note If the fl ap is created too far on the dorsal side then the dorsal
branch of the ulnar nerves can be damaged so care is required.
Fig. 5.28 Procedure 3: The skin fl ap is elevated with the fascia of the
abductor digiti minimi muscle of the hand included. The 10–15 mm
diameter area on the ulnar MP joint of the little fi nger is not detached
Fig. 5.29 Procedure 4: It is not necessary to confi rm cutaneous
branches to the fl ap, but confi rmation should be made that the palmar
digital artery of the little fi nger has been retained
5 Reconstruction of Palm and Wrist Area
131
Fig. 5.30 Procedure 5: The skin fl ap is rotated to cover the skin defect
area and reefi ng is conducted on the donor site to close it. A drain is
inserted in the palm subcutaneously
Note Immediately after transfer, the color of the skin fl ap is often pale,
but as long as excessive strain is not being applied to the edges of the
skin fl ap, color should improve with time.
a
b
Fig. 5.31 ( a , b ) Procedure 6: The skin texture of the skin fl ap is similar to the surrounding skin and so isn’t obvious. (Photos reproduced from Hirase, Y.,
et al.: Usefulness of ulnar metacarpal fl ap for covering ulnar side of the hand. Journal of Japanese Society for Surgery of the Hand 24: 120–123, 2007)
Ulnar Parametacarpal Flap (Level of Diffi culty: 2)
132
Tips
Cutting the margins of the fl ap and creating an island fl ap makes it easier to rotate.
If the skin defect area of the palm is in a slightly distal position, and it is necessary to rotate the skin fl ap 90° or
more, it is easier to rotate the fl ap if an incision is made around the entire margin of the spindle shaped fl ap and an
island fl ap is created.
5 Reconstruction of Palm and Wrist Area
133
Hand Relaxation Incision (Level of Diffi culty: 1)
Information
(Case example from operation performed by Dr. Tadao Kojima)
Vascular pedicle Cutaneous branch from the thenar muscle or subcutaneous blood circulation
Size Created as a bi-pedicle fl ap the size of the thenar muscle
Advantage It is possible to cover the carpal tunnel using the same quality of skin
Hand Relaxation Incision (Level of Diffi culty: 1)
134
Operation Procedures
Fig. 5.32 Procedure 1: A relaxation incision is made from the carpal
tunnel to the forearm, to open up the carpal tunnel. An incision is also
made in the lateral hypothenar
Fig. 5.33 Procedure 2: A relaxation incision is also made in the
dorsum of the hand, with an incision made in the interosseous fascia
Fig. 5.34 Procedure 3: An incision is made beneath the fascia on the
radial thenar muscle, dissection performed, and the skin of the thenar
region transferred as a bi-pedicle fl ap to cover the carpal tunnel
5 Reconstruction of Palm and Wrist Area
135
Fig. 5.35 Procedure 4: An artifi cial dermis patch is placed on the skin
defect area
Fig. 5.36 Procedure 5: A continuous suction tube is inserted
subcutaneously in the forearm, and a tie-over bolster dressing applied to
the artifi cial dermis
Tips
Wait for edema to subside before performing skin graft.
It is often possible to close by direct suture the artifi cial dermis patch area once the tissue edema has subsided after 2
or 3 weeks. A split-thickness skin graft is performed only on the areas that can’t be closed by direct suture.
Hand Relaxation Incision (Level of Diffi culty: 1)
136
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 2)
Information
Vascular pedicle Perforators of cutaneous branch from radial artery.
Size Possible to use almost all skin of medial forearm.
Advantage Technique is simple. Blood fl ow is stable.
Disadvantage Sacrifi ces a main artery. A scar remains on the forearm.
Caution Before the operation, carry out the Allen test to confi rm whether the radial artery is dominant or not.
5 Reconstruction of Palm and Wrist Area
137
Operation Procedures
Fig. 5.38 Procedure 2: The skin fl ap is dissected from above the fl exor
tendons on the ulnar side and the skin perforators from the radial artery
confi rmed. Another incision is made from the radial side of the fl ap and
the fl ap is elevated
Fig. 5.37 Procedure 1: Skin defect due to crushing injury stretching
from the palm side of the wrist to the medial forearm. Skin defect
accompanying exposure of median nerve following debridement. Skin
fl ap designed above radial artery
Note A large number of skin perforators are present in the distal 1/3 of
the forearm.
Note The photo shows the skin perforators from the radial artery as
seen from the radial side.
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 2)
138
Note If the fl ap can reach the graft bed with the perforators from the
radial artery to the forearm subcutaneous tissue as the pedicle, it is not
necessary to cut the radial artery in the proximal position. In that case
the blood fl ow of the fl ap is normal.
Fig. 5.39 Procedure 3: Normal blood fl ow is temporarily interrupted
using a blood vessel clip on the proximal radial blood vessels, and
confi rmation made that there is no change in color. It is then ligated and
severed and the fl ap elevated as a reverse fl ow fl ap
Fig. 5.40 Procedure 4: The fl ap is used to cover the exposed median
nerve and tendons and a drain inserted. A split-thickness skin graft is
conducted on the donor site. A tie-over bolster dressing is applied to the
skin-graft area
5 Reconstruction of Palm and Wrist Area
139
Fig. 5.41 Procedure 5: The medial wrist area is covered by the radial
forearm fl ap and there is a good texture match with the surrounding area
Note The solid arrow indicates the radial antebrachial fl ap and the dot-
ted arrow indicates the transferred abdominal perforator fl ap.
Tips
The perforators are used as the pedicle in order to retain the radial artery.
Skin perforators are densely located in the distal 1/3 of the medial forearm. If a large skin fl ap can be designed
and arranged so that this section is included, it will be possible to rotate and transfer the fl ap with the perforator
vessels as the pedicle. Using this method it is possible to transfer the fl ap without severing the radial artery.
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 2)