140
Column
The sense of loss.
I received a visit by a young man who had amputated his little fi nger in an accident. He asked me to make a new
little fi nger for him. Of course that is my specialty and I am confi dent I could make the best looking fi nger of anyone
in this country. But due to my contrarian nature, I couldn’t easily accept such a task. That is because the human body
doesn’t come equipped with spare parts. So that means if you want to create a little fi nger, then you will lose something
from somewhere else. A fi ngernail from another fi nger, a toe from a foot, the feeling from somewhere, and symmetry
from somewhere else. There will be considerable pain, and a loss of time and money as well.
Will that little fi nger be really worth all that sacrifi ce?
The young man lamented that he was no longer able to do the things he once could.
But there is nothing that a child who is born without their little fi nger cannot do. The worth of this young man could
not have changed just because he lost his little fi nger.
It would be strange if it were. But for humans, there is nothing more diffi cult to endure than the sense of loss. It is
far more diffi cult for a person to accept the misfortune of losing something they once had than the misfortune of never
obtaining something they longed for. It is not what was lost, but the experience of having lost something that is diffi cult
to accept. It is because the fi sh that got away was the fi sh that was lost (that would otherwise have been had) that makes
it so hard to bear.
I told the young man to go home and have a careful think about whether that little fi nger was really worth the sac-
rifi ce and risk.
Pity the patients with an attending surgeon with such a contrarian nature. Sometimes I think to myself that it is for
that reason alone, that the joy of successfully reconstructing a fi nger is so enormous.
5 Reconstruction of Palm and Wrist Area
141
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_6
Reconstruction of First Web Space Area
Basic Principles
When treating adduction contracture of the thumb, after cutting the adductor muscle and
widening the fi rst web space, there is a need to cover the skin defect area with a skin fl ap.
Although there are reports of inserting abdominal fl aps or reverse fl ow forearm fl aps, this
can cause dome like deformity and an aesthetic reconstruction is diffi cult.
With the skin fl ap reported by Spinner that is created from the radial side of the index
fi nger, there is no need to include major arteries and it is possible to create a comparatively
large fl ap with a very pleasing outcome aesthetically.
The fl aps created in this section can be used either as a rotation fl ap or a sliding fl ap.
Selectable Flaps and Surgical Procedures
Spinner fl ap • 4 & 5 Z plasty • Reverse fl ow radial forearm fl ap • Pedicled abdominal fl ap •
Free abdominal perforator fl ap • Free groin 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.
6
142
Spinner Flap (Level of Diffi culty: 1)
Information
Vascular pedicle No specifi c arteries are included
Size It is created in the middle of the radial index fi nger, however when creating skin fl aps exceeding a width of
20 mm, it is necessary to conduct a skin graft as reefi ng is diffi cult. The tip of the fl ap can extend as far as the PIP joint.
Advantage First choice surgical procedure for treating adduction contracture of the thumb. Simple with stable blood
fl ow. Specifi c arteries are not included, however there is no problem even if the width to length ratio exceeds 1:3. Apart
from use for the fi rst interdigital area, can also be rotated and transferred to the base of the thumb.
Disadvantage In cases where large soft tissue is required, a skin graft is required for the donor site which can become
somewhat obvious.
6 Reconstruction of First Web Space Area
143
Operation Procedures
Fig. 6.1 Procedure 1: A burn scar is present on the fi rst interdigital
area, and a localized fl ap surgery (4 Z plasty) was conducted, but there
was no improvement due to an implicit lack of skin
Fig. 6.2 Procedure 2: An incision is made in the fi rst interdigital area,
the subcutaneous fi brous cord is resected and the adduction contracture
of the thumb released
Spinner Flap (Level of Diffi culty: 1)
144
Fig. 6.3 Procedure 3: The fl ap is designed in the middle of the radial
side of the index fi nger
Fig. 6.4 Procedure 4: The fl ap is dissected above the fascia, but the
palmar/dorsal digital arteries/veins are not included in the fl ap. The fl ap
is dissected to the deep fi rst web space area, and in cases where there is
contracture of the adductor pollicis muscle, the required muscle is cut.
The palmar side of the index fi nger is detached subcutaneously to make
it easier to close the donor site
6 Reconstruction of First Web Space Area
145
Fig. 6.5 Procedure 5: The fl ap is transferred and the donor site closed.
A skin graft is conducted if there is considerable tension
Fig. 6.6 Procedure 6: The fl ap is pulled deeply into the web space and
sutured
Spinner Flap (Level of Diffi culty: 1)
146
Fig. 6.7 Procedure 7: In cases with severe adduction contracture of the
thumb, the patient is Procedure made to wear a night brace for several
months to prevent recurrence
6 Reconstruction of First Web Space Area
147
4 & 5 Z plasty (Level of Diffi culty: 2)
Information
Vascular pedicle Subcutaneous vascular plexus
Size When creating for the fi rst interdigital space, the standard is 2–3 cm per side, and a 60°Z plasty. A small Z plasty
is not very effective.
Caution A 4-Z plasty has a considerable extension effect. For a 5 -Z plasty, part of the fl ap requires trimming.
4 & 5 Z plasty (Level of Diffi culty: 2)
148
Fig. 6.9 Procedure 2: A full thickness incision is made in the skin,
which is detached above the muscle. If there is contracture of the adduc-
tor pollicis muscle, the incision is made in the center, and suffi cient
interdigital space is secured
Note When Z plasty is conducted from both sides there is often an
excess of skin on both sides of the triangular fl ap (diagonal line part).
That area is trimmed off.
Fig. 6.10 Procedure 3: Appearance with the fl ap transferred and
sutured. Another Z plasty is added to the thumb
Operation Procedures
Fig. 6.8 Procedure 1: A 5 - Z plasty is designed in line with contracture
of the fi rst interdigital space. In the case example in the photo, an addi-
tional 1 Z plasty is designed on the base of the thumb
6 Reconstruction of First Web Space Area
149
Fig. 6.11 Procedure 4: Final image. Suffi cient interdigital space has
been secured
Note An artifi cial fi nger is fi tted to the index fi nger.
4 & 5 Z plasty (Level of Diffi culty: 2)
150
Information
Vascular pedicle Radial artery and perforators
Advantage Vascular pedicle is long and large. Often non-hair areas. It is possible to harvest thin fl aps of various sizes.
Disadvantage Harvested from exposed area, so a scar remains. Important blood vessels are sacrifi ced. If a reverse fl ow
fl ap is created congestion tends to occur. Bulge can tend to occur if inserted in the web space area.
Caution When intending to create a reverse fl ow fl ap, an Allen test should be conducted prior to the operation, and
confi rmation conducted that the ulnar artery is patent.
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)
6 Reconstruction of First Web Space Area
151
Fig. 6.12 Procedure 1: An incision is made in the fi rst web space area,
and when the contracted adductor pollicis muscle is cut, a deep skin and
tissue defect results
Fig. 6.13 Procedure 2: An forearm fl ap is designed above the radial
artery with the pivot point located on the medial wrist area
Operation Procedures
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)
152
Fig. 6.15 Procedure 4: A subcutaneous tunnel is created from the wrist
to the dorsum of the hand and the skin fl ap passed through it, moving
from the dorsal side to the fi rst web space area
Fig. 6.14 Procedure 3: A radial forearm fl ap is raised together with the
forearml fascia including the radial blood vessels, the vascular pedicle
is cut in the proximal position, and the fl ap transferred distally as a
reverse fl ow fl ap
6 Reconstruction of First Web Space Area
153
Fig. 6.16 Procedure 5: The skin fl ap is inserted into the interdigital
area, with part de-epithelized and inserted into the tissue defect of the
interdigital area. A drain tube is inserted in the margin of the skin fl ap
Note To prevent re-occurrence of contracture, it is advisable to tem-
porarily fi x the MP/CM joints of the thumb with Kirschner wires for
about 2 weeks.
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)
154
Free Groin Flap (Level of Diffi culty: 4)
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 1.5–2 cm
Size The width 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 large.
Caution When detaching 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.
Pigmentation can occur after transfer
6 Reconstruction of First Web Space Area
155
Operation Procedures
Fig. 6.17 Procedure 1: Case of adduction contracture of the thumb due
to scar contracture. The fi rst web space is cut deeply, and while retain-
ing the digital arterial nerves heading toward the thumb, the scarred
adductor pollicis muscle is cut. The CM and MP joints were fi xed with
steel wires in the thumb opposition open position. Deep tissue defect is
present in the fi rst web space area
Fig. 6.18 Procedure 2: An inguinal fl ap is designed above the inguinal
ligament
Refer to Section of “Reconstruction of forearm region/Free groin fl ap”
in Chap. 2
Free Groin Flap (Level of Diffi culty: 4)
156
Fig. 6.19 Procedure 3: Confi rmation is made in the inguinal area of the
branch of the superfi cial circumfl ex iliac blood vessel from the femoral
artery
Fig. 6.21 Procedure 5: For the medial anterior superior iliac spine, if
detachment is conducted carefully so that the fascia from the lateral
margin of the sartorius muscle is included in the fl ap, it is possible to
confi rm whether the vascular pedicle (superfi cial branch of the superfi -
cial circumfl ex iliac artery) penetrates through the fascia and enters the
fl ap at the medial margin
Fig. 6.20 Procedure 4: An incision is made in the inferior margin and
distal end of the skin fl ap, and the skin fl ap is detached in the proximal
direction above the fascia latae
6 Reconstruction of First Web Space Area
157
Fig. 6.23 Procedure 7: The inguinal fl ap is harvested with the superfi -
cial circumfl ex iliac blood vessel and superfi cial inferior epigastric vein
attached
Fig. 6.22 Procedure 6: After detaching up to the medial sartorius mus-
cle, the superfi cial circumfl ex iliac artery branches into the deep branch
beneath the sartorius muscle, which is ligated and cut. Detachment is
continued further proximally, and the vascular pedicle is cut at the
branch from the femoral blood vessels. Based on the size of the fl ap, the
superfi cial inferior epigastric vein can be included in the fl ap
Free Groin Flap (Level of Diffi culty: 4)
158
Fig. 6.25 Procedure 9: Anastomosis is performed in the distal snuff
box with the radial artery and cutaneous vein. The skin fl ap is sutured
to the surrounding tissue and a drain tube inserted
Fig. 6.24 Procedure 8: The skin fl ap is sutured to the fi rst web space
area
6 Reconstruction of First Web Space Area
159
a
b
Fig. 6.27 ( a , b ) Procedure 11: Final image. Adduction contracture of the thumb is alleviated and a good thumb opposition position is obtained
Fig. 6.26 Procedure 10: Reconstruction of thumb opposition position
was performed 1 month later through transfer of the extensor digiti
minimi muscle
Note At the same time, skin abrasion is conducted to the pigmenta-
tion area.
Free Groin Flap (Level of Diffi culty: 4)
160
Tips
If pigmentation occurs, perform skin abrasion and apply whitening agent
In some cases pigmentation occurs when an inguinal skin fl ap is transferred to the hand. In such cases skin abrasion
should be performed down to the subdermal layer, and when the area has dried, whitening agent (hydroquinone) should
be continually applied.
6 Reconstruction of First Web Space Area
161
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_7
Reconstruction of Finger Trunk
Basic Principles
Reconstruction of the skin of the fi nger trunk area doesn’t require reconstruction of sensory
function, but it is preferable to use skin with similar quality, so the fi rst priority is to see if
reconstruction is possible using similar skin.
If it is not possible to elevate a fl ap from the same fi nger, then transfer of skin fl aps from
adjoining fi ngers or from other areas of the hand are considered.
It is possible to perform skin graft on the dorsum of the hand, however for reconstruction
of the skin on the palm side, a fl ap with suitable skin thickness is chosen.
Selectable Flaps and Surgical Procedures
Z plasty • Digitolateral fl ap • Heterodigital arterial fl ap • Cross fi nger fl ap • Spinner fl ap •
Reverse fl ow radial forearm fl ap • Reverse fl ow metacarpal arterial fl ap • Kite fl ap • Free
venous fl ap • Free hemi pulp fl ap transfer • Ulnar parametacarpal fl ap • Dorsolateral fl ap •
Modifi ed Kleinert method • Digital arterial adipofascial fl ap and Skin graft • Double-
opposing digitolateral fl ap • Bi-lobed palmar 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.
7
162
7 Reconstruction of Finger Trunk
163
Z Plasty (Level of Diffi culty: 1)
Information
Vascular pedicle Subcutaneous vascular plexus
Caution Auxiliary incisions are made in the skin creases of the fi nger to avoid creating new contracture. Z plasty that
is too small doesn’t alleviate contracture and can actually cause new contracture. Z plasty of 1 cm is desirable
Z Plasty (Level of Diffi culty: 1)
164
Operation Procedures
Fig. 7.1 Procedure 1: Longitudinal scar contracture is recognized in
the palmar side of the ring fi nger
7 Reconstruction of Finger Trunk
165
Fig. 7.2 Procedure 2: Several successive 1 cm Z plasty are designed on
the fi nger
Note Auxiliary incisions are made so as to avoid cutting the skin
crease at right angles.
Fig. 7.3 Procedure 3: An incision is made and subcutaneous scar tissue
is resected, and the contracture released
Z Plasty (Level of Diffi culty: 1)
166
Fig. 7.4 Procedure 4: The small transferred fl ap is sutured
7 Reconstruction of Finger Trunk
167
Digitolateral Flap (Level of Diffi culty: 2)
Information
Vascular pedicle The digital artery is not included, but instead the subcutaneous vascular plexus of the middle of the
fi nger is the main circulation
Size When creating in the proximal phalanx area, the length can be up to the PIP joint crease, and if width is less than
10 mm, it is possible to directly suture the donor site closed. When creating in the middle phalanx area, the length can
be up to the DIP crease, however suturing the donor site closed is diffi cult and a skin graft is required.
Advantage Practical for use in covering skin defects due to releasing contracture in the palmar side of the fi nger base
or the PIP crease. Major vascular pedicles are not included, but it is possible to create a thin long fl ap, and there are no
restrictions on length to width ratio. The skin fl ap can be made normal fl ow or reverse fl ow, but the blood fl ow in
reverse fl ow fl aps is instable in some cases. There is also a method (Leuder’s fl ap) of transferring the normal fl ow (or
reverse fl ow) fl ap created in the middle phalanx area to cover a skin defect area on the dorsal DIP and PIP joints.
Digitolateral Flap (Level of Diffi culty: 2)
168
Operation Procedures
Fig. 7.5 Procedure 1: Due to scar contracture on the palmar side of the
ring/little fi nger, unable to suffi ciently extend PIP joint. A long scar
contracture is present from the base of the ring fi nger to the DIP joint
Fig. 7.6 Procedure 2: A digitolateral fl ap is designed from the ulnar
proximal phalanx area for the base of the ring fi nger, and from the radial
middle phalanx area for the PIP crease
Note Z plasty is designed for the little fi nger.
7 Reconstruction of Finger Trunk
169
Fig. 7.7 Procedure 3: The digitolateral fl ap is detached from above the
fascia or from above the fl exor tendons, however the digital arteries or
digital nerves are not included. A suffi cient amount of skin fl ap is
removed up to the base, rotated 90° and transferred to the palmar side
Fig. 7.8 Procedure 4: Appearance after transferring the skin fl ap. The
proximal phalangeal donor site can be sutured closed
Note In this case example, a middle phalangeal skin fl ap donor site
was also possible, so it was sutured closed.
Digitolateral Flap (Level of Diffi culty: 2)
170
Tips
Don’t use excessive force to close the donor site
When elevating a digitolateral fl ap from the lateral middle phalanx area, many cases require a skin graft in order to
be closed.
7 Reconstruction of Finger Trunk
171
Reverse Digitolateral Flap (Level of Diffi culty: 2)
Information
Vascular pedicle The digital artery is not included, but instead the subcutaneous vascular plexus of the lateral fi nger
is the main circulation
Siz: When creating in the proximal phalanx area with a distal pedicle, the length can be up to the length of the proximal
phalanx area of the fi nger, and if width is around 10 mm, it is possible to directly suture the donor site closed. When
creating in the intermediate phalanx area, the length can be up to the length of the middle phalanx area, however sutur-
ing the donor site closed is diffi cult and a skin graft is required.
Advantage Practical for use in covering skin defects following release of contracture in the palmar side of the fi nger
base or the PIP crease. Major vascular pedicles are not included, but it is possible to create a long thin fl ap, and there
are no restrictions on length to width ratio. The blood fl ow in reverse fl ow fl aps is instable in some cases
Reverse Digitolateral Flap (Level of Diffi culty: 2)
172
Operation Procedures
Fig. 7.9 Procedure 1: A scar contracture is present in the longitudinal
direction at the palmar side of the fi nger PIP joint
Fig. 7.10 Procedure 2: A distal pedicle fl ap is designed in the lateral
side of the middle and proximal phalanx area
7 Reconstruction of Finger Trunk
173
Fig. 7.11 Procedure 3: A lateral incision is made along the DIP and
PIP crease and the contracture released. The fl ap is then elevated above
the periosteum and rotated 90° and transferred to the palmar side
Fig. 7.12 Procedure 4: The skin fl ap is sutured in place. The proximal
phalanx donor site is sutured closed. In many cases a skin graft is con-
ducted for the lateral middle phalanx donor site
Reverse Digitolateral Flap (Level of Diffi culty: 2)
174
Tips
Observe progress for 2 weeks without performing debridement
Occasionally digitolateral fl aps transferred to the distal pedicle are subject to surface necrosis at the edge of the fl ap,
but in many cases, if treated conservatively and progress is observed for 2 weeks, epithelization occurs without need
for debridement.
7 Reconstruction of Finger Trunk
175
Heterodigital Arterial Flap (1) (Level of Diffi culty: 3)
Information
Vascular pedicle Digital artery of adjoining fi nger and surrounding fi ne veins
Size From the skin above the digital artery to the dorsum of the fi nger
Caution A thick vascular pedicle including the fi ne veins surrounding the digital artery pedicle is harvested. It is a
requirement that the contralateral digital artery of the adjoining fi nger be retained.
Heterodigital Arterial Flap (1) (Level of Diffi culty: 3)
176
Operation Procedures
Fig. 7.13 Procedure 1: Skin defect present on dorsum of fi nger accom-
panying exposure of extensor tendons following re-attachment
Fig. 7.14 Procedure 2: The skin fl ap is designed from the lateral center
of the adjoining fi nger onto the dorsum of the fi nger
7 Reconstruction of Finger Trunk
177
Fig. 7.15 Procedure 3: The digital nerve is retained and a thick vascu-
lar pedicle including the digital artery and the surrounding fat tissue is
created and elevated. The skin fl ap is detached from above the extensor
tendon
Fig. 7.16 Procedure 4: The skin fl ap is transferred and a skin graft
conducted for the donor site. A tie-over bolster dressing is applied. (Part
of photos reproduced from Hirase, Y.: Reconstruction using vascular-
ized skin fl aps: Plastic Surgery for Injuries (edited by Anze, M.)
pp 121–126, Kokuseido, Tokyo, 2007)
Heterodigital Arterial Flap (1) (Level of Diffi culty: 3)
178
Tips
Use the distal part of the digital artery of the elevated fl ap for reconstructing circulation of the reconstructed
fi nger
By conducting anastomosis of the distal part of the vascular pedicle of the elevated heterodigital fl ap to the artery
in the recipient site, it is possible to simultaneously reconstruct blood fl ow of the reconstructed fi nger.
7 Reconstruction of Finger Trunk
179
Heterodigital Artery Flap (2) – Transfer to Skin Defect of Thumb (Level of Diffi culty: 3)
Information
Vascular pedicle Digital artery and surrounding small veins on ulnar side of middle fi nger or ulnar side of ring
fi nger.
Size From the skin above the digital artery to the dorsum of the fi nger.
Caution A thick vascular pedicle is harvested with inclusion of small veins surrounding the digital arterial pedicle. It
is a requirement that the digital artery of the contralateral fi nger to the donor fi nger be retained.
Heterodigital Artery Flap (2) – Transfer to Skin Defect of Thumb (Level of Diffi culty: 3)
180
Fig. 7.17 Procedure 1: Skin defect accompanied by exposure of the
fl exor pollicis longus muscle tendon at the base of the palmar side of the
thumb
Fig. 7.18 Procedure 2: A hetero-digital arterial fl ap is designed on the
ulnar side of the middle fi nger
Note The ulnar side of the ring fi nger can also be used as the donor
site.
7 Reconstruction of Finger Trunk
181
Fig. 7.19 Procedure 3: The digital nerve alone is retained/detached
and separated from the neurovascular pedicle of the fi nger and the fl ap
is elevated with only the vascular pedicle. Further distal of the proper
digital artery fl ap, the arterial pedicle is ligated and cut at two branch
locations to the palmar digital artery of the adjoining fi nger
Fig. 7.20 Procedure 4: A zig zag incision is made in the palm, and the
fl ap vascular pedicle is dissected up to the arterial arch
Heterodigital Artery Flap (2) – Transfer to Skin Defect of Thumb (Level of Diffi culty: 3)
182
Fig. 7.21 Procedure 5: The fl ap is transferred to the base of the thumb
and a skin graft is conducted on the donor site. A tie-over compression
is applied
7 Reconstruction of Finger Trunk
183
Cross Finger Flap (Level of Diffi culty: 2)
Information
Vascular pedicle Dorsal branch of digital artery
Disadvantage There is a problem with skin texture due to use of skin with different quality. Also, not a sensory fl ap.
Caution A long fl ap should be dissected, exceeding the lateral center of the contralateral fi nger, so that the fl ap doesn’t
bend over on itself. The hand is placed in syndactyly fashion for 2 weeks, and it is easy for the fi nger joints to develop
contracture, so active and passive exercise should be commenced soon after the fl ap is separated.
Cross Finger Flap (Level of Diffi culty: 2)
184
Operation Procedures
Fig. 7.22 Procedure 1: A skin defect is present with exposure of ten-
dons on the palmar side of the index fi nger
Fig. 7.23 Procedure 2: The fl ap on the dorsum of the fi nger is detached
to a good length above the extensor tendon and transferred to the pal-
mar side
Note The fl ap is detached nearly up to the palmar digital nerve/vascu-
lar pedicle before transfer, to prevent it from folding over on itself.
7 Reconstruction of Finger Trunk
185
Fig. 7.24 Procedure 3: A skin graft is conducted on the donor site, and
a tie-over compression applied. The fl ap is separated 2 weeks later
Cross Finger Flap (Level of Diffi culty: 2)
186
Spinner Flap (Level of Diffi culty: 1)
Information
Vascular pedicle No specifi c arteries are included
Size Created in the radial lateral side of the index fi nger, however when creating skin fl aps exceeding a width of
20 mm, it is necessary to conduct a skin graft as reefi ng is diffi cult.
The tip of the skin fl ap is made distal to the PIP joint
Advantage Simple with stable blood fl ow. Specifi c arteries are not included, however there is no problem if the width
to length ratio exceeds 1:3.
Disadvantage In cases where large soft tissue is required, skin graft is required for the donor site which can become
somewhat obvious.
7 Reconstruction of Finger Trunk
187
Operation Procedures
Fig. 7.25 Procedure 1: A skin defect is present at the base of the thumb
following dissection of the fl exor tendon
Fig. 7.26 Procedure 2: The fl ap is designed from the fi rst interdigital
space to the radial index fi nger. The length of the fl ap is set to the length
required, and the donor site is closed by direct suture
Spinner Flap (Level of Diffi culty: 1)
188
Fig. 7.27 Procedure 3: A thick skin fl ap is elevated above the fascia
Fig. 7.28 Procedure 4: The skin fl ap is inserted into the base of the
thumb and sutured. A drain is inserted in the donor site
7 Reconstruction of Finger Trunk
189
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Radial artery perforators
Size Can harvest from the entire medial forearm
Caution Congestion can tend to occur in reverse fl ow fl aps, so it is preferable that anastomosis is conducted with either
the cutaneous vein or radial artery comitant vein to the cutaneous vein in the recipient site.
Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)