Kỹ Thuật Thực Hành Trong Phẫu Thuật Ghép Vạt Da

191
Fig. 7.31 Procedure 3: A longitudinal incision is made medial of the
radial artery, and the path of the radial artery is confi rmed while detach-
ing from beneath the fascia
Fig. 7.32 Procedure 4: An incision is made on both sides of the fl ap
margin, and confi rmation is made that the perforators from the radial
artery are actually included in the fl ap
Fig. 7.33 Procedure 5: The vascular pedicle is completely dissected,
and the proximal radial artery is clumped using a blood vessel clip, the
tourniquet is released, and confi rmation made of whether there is good
reverse blood fl ow to the skin fl ap



Reverse Flow Radial Forearm Flap (Level of Diffi culty: 3)

192
Fig. 7.34 Procedure 6: The fl ap is turned over distally and transferred.
The epidermis of the excess skin of the proximal fl ap is resected
Fig. 7.35 Procedure 7: The fl ap is transferred and sutured to the sur-
rounding tissue
Note Here, if anastomosis is conducted with the veins included in the
distal fl ap to the cutaneous vein in the surrounding area, there is less
chance of congestion occurring post-operation.


7 Reconstruction of Finger Trunk

193
Reverse Flow Metacarpal Arterial Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Cutaneous branch from the dorsal metacarpal artery
Size Designed long and thin with a width that enables reefi ng between metacarpals
Caution Cutaneous branches from the dorsal metacarpal artery enter the fl ap at the proximal MP joint, so it is safer to
include this area and create a long thin fl ap. It is better to fi rst make an incision in only one margin of the fl ap and then
confi rm the location of the cutaneous branch before elevating the fl ap.


Reverse Flow Metacarpal Arterial Flap (Level of Diffi culty: 3)

194
Operation Procedures
Fig. 7.36 Procedure 1: Partial skin necrosis of the palmar side of the
index fi nger following reattachment
Fig. 7.37 Procedure 2: The skin fl ap is designed on the second and
third metacarpals
Note In order to be certain of including the required amount of cutane-
ous branch in the fl ap, the design is extended distally (proximal end of
fl ap).


7 Reconstruction of Finger Trunk

195
Fig. 7.38 Procedure 3: When the skin pedicle is detached from the
layer above the extensor tendons, it is possible to see the cutaneous
branch from the dorsal metacarpal artery at the proximal MP joint. The
stem of the dorsal metacarpal artery runs inside the dorsal interosseous
muscles, so this is dissected heading in the proximal direction, and con-
fi rmation is made that blood fl ow to the fl ap doesn’t change even when
normal fl ow circulation is interrupted using a blood vessel clip
Fig. 7.39 Procedure 4: The proximal metacarpal artery is ligated and
cut. Through this procedure the metacarpal artery has been detached to
a more distal position, and the pivot point for the fl ap is moved even
further distally from the MP joint. As long as a suffi ciently long fl ap for
covering the skin defect area has been elevated, then there is no require-
ment to detach the metatarsal artery, and the fl ap can be rotated with the
cutaneous branch close to the MP joint as the pivot point


Reverse Flow Metacarpal Arterial Flap (Level of Diffi culty: 3)

196
Fig. 7.40 Procedure 5: The skin fl ap is transferred to the palmar side of
the index fi nger
Fig. 7.41 Procedure 6: The skin fl ap donor site is sutured closed. (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)


7 Reconstruction of Finger Trunk

197
Tips
Designing a long skin fl ap is the key
A long fl ap is designed to enable the fl ap to be elevated with greater safety. When a large area fl ap pedicle
(rather than one with the vascular pedicle only) is detached from over the extensor tendons, then the cutaneous branches
are naturally included in the fl ap. This enables a normal fl ow fl ap to be elevated with the dorsal MP joint as a pivot
point without detaching the actual metacarpal artery. The normal fl ow fl ap with distal pedicle is transferred to the
fi nger.


Reverse Flow Metacarpal Arterial Flap (Level of Diffi culty: 3)

198
Kite Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Dorsal digital artery of dorsum of index fi nger and cutaneous vein
Size It is possible to harvest all skin from the dorsum of the proximal phalanx area of index fi nger
Caution The dorsal digital artery is thin and in some cases it is hard to identify. It is important that the vascular pedicle
of the fl ap is elevated with the entire subcutaneous adipose tissue from a wide area


7 Reconstruction of Finger Trunk

199
Operation Procedures
Fig. 7.43 Procedure 2: The fl ap is designed on the area from the dorsal
MP joint to the dorsal PIP joint of the index fi nger
Fig. 7.42 Procedure 1: A skin defect area is present on the palmar side
of the thumb following a toe transfer


Kite Flap (Level of Diffi culty: 3)

200
Fig. 7.44 Procedure 3: An incision is made in the margin of the fl ap
Fig. 7.45 Procedure 4: The fl ap is detached from above the extensor
tendon moving from the distal end of the fl ap
Note Care must be taken not to damage the paratenon on the extensor
tendon.


7 Reconstruction of Finger Trunk

201
Fig. 7.47 Procedure 6: The fl ap is transferred and sutured
Fig. 7.46 Procedure 5: On the dorsum of the hand, the skin is detached
from above the extensor tendon, with the fl ap pedicle created as thick
and wide as possible


Kite Flap (Level of Diffi culty: 3)

202
Fig. 7.48 Procedure 7: A mid-thickness skin graft is conducted on the
donor site, and a tie-over compression applied

7 Reconstruction of Finger Trunk

203
Free Venous Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Anastomosis is conducted of the cutaneous vein to the artery and vein
Size Two small cutaneous veins of a width that can be harvested. There is no defi nite size
Caution The fl ap is harvested from an area without a venous fl ap. If used for the fi nger, the medial wrist area is a good
donor site.
Disadvantage Blood fl ow may be instable in some cases, and may lead to congestion.
Progress is observed conservatively for 2 weeks


Free Venous Flap (Level of Diffi culty: 3)

204
Operation Procedures
Fig. 7.50 Procedure 2: The fl ap is designed with several adjoining
cutaneous veins from the medial forearm included
Fig. 7.49 Procedure 1: A skin defect is present on the dorsum of the
fi nger


7 Reconstruction of Finger Trunk

205
Fig. 7.52 Procedure 4: Anastomosis is conducted with one vein to the
digital artery
Fig. 7.51 Procedure 3: A full thickness fl ap is harvested


Free Venous Flap (Level of Diffi culty: 3)

206
Fig. 7.53 Procedure 5: Anastomosis is conducted with the other vein
to the cutaneous vein in the dorsum of the fi nger. If a good blood fl ow
can be obtained then the fl ap will turn pink
Note Temporary congestion with surface necrosis may occur on some
occasions, but in many cases, if observed for 2 weeks, epithelization
occurs without need for debridement.

7 Reconstruction of Finger Trunk

207
Free Hemi Pulp Flap Transfer (Level of Diffi culty: 4)
Information
Vascular pedicle First dorsal metatarsal artery or digital artery of the toe
Size From the medial great toe to the fi rst interdigital area
Caution The cutaneous vein of the dorsum of the great toe must be included in the fl ap.


Free Hemi Pulp Flap Transfer (Level of Diffi culty: 4)

208
Operation Procedures
Fig. 7.54 Procedure 1: A long and narrow skin defect accompanying
exposure of the fl exor tendon is present in the palmar side of the ring
fi nger
Fig. 7.55 Procedure 2: The fl ap is designed from the medial side of the
great toe to the fi rst interdigital area
Note The fl ap is designed to include the cutaneous veins of the dorsum
of the toe.
Refer to Section of “Reconstruction of the fi nger tip/Hemi pulp
transfer” in Chap. 8


7 Reconstruction of Finger Trunk

209
Fig. 7.57 Procedure 4: The toe nerve is sutured to the fi nger nerve and
anastomosis is conducted with the toe artery to the fi nger artery.
Anastomosis is conducted between the cutaneous veins in the dorsum
of the fi nger
Fig. 7.56 Procedure 3: The skin fl ap is harvested with the toe nerve,
toe artery and cutaneous vein of the dorsum of the great toe. Continuing
the incision to the fi rst interdigital area, the neurovascular pedicle can
easily be seen


Free Hemi Pulp Flap Transfer (Level of Diffi culty: 4)

210
Fig. 7.58 Procedure 5: If possible the donor site is directly sutured
closed, but if diffi cult it is better to conduct a skin graft
Note In the case that the bone is exposed, an artifi cial dermis is applied
and then a skin graft is conducted 2–3 weeks later under a local
anesthetic.

7 Reconstruction of Finger Trunk

211
Ulnar Parametacarpal Flap (Level of Diffi culty: 3)
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
circumstances 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 of the palm.
In adults this is normally 15–20 mm in width
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 vascularized fl ap.
Disadvantage The area of coverage is comparatively small


Ulnar Parametacarpal Flap (Level of Diffi culty: 3)

212
Operation Procedures
Fig. 7.60 Procedure 2: The fl ap is designed to a width in which it is
possible to reef to the ulnar side of the palm. The diagonal line of the
fl ap design indicates the position (lateral part of MP joint) of the subcu-
taneous pedicle that is to be retained
Fig. 7.59 Procedure 1: A skin defect is present on the lateral little fi nger
following an osteotomy with respect to malformation of the little fi nger
Refer to Section of “Reconstruction of Palm and Wrist Area/Ulnar
parametacarpal fl ap” in Chap. 5


7 Reconstruction of Finger Trunk

213
Fig. 7.61 Procedure 3: The digital artery on the ulnar side of the little
fi nger is retained
Fig. 7.62 Procedure 4: The skin fl ap is elevated with the fascia of the
abductor digiti minimi muscle of the hand included. A 1 cm diameter
section of the lateral MP joint is rotated 180° without detaching. The
main blood fl ow comes from the palmar side artery of the little fi nger,
so this part is not detached
Note The dorsal part of the fl ap can be detached.


Ulnar Parametacarpal Flap (Level of Diffi culty: 3)

214
Fig. 7.63 Procedure 5: The fl ap is transferred and the skin defect area
is covered. The skin fl ap donor site is sutured closed

7 Reconstruction of Finger Trunk

215
Dorsolateral Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Digital artery and dorsal branch.
Size The width of the fl ap is decided based on the diameter of the skin defect area.
Advantage Suitable for the reconstruction of skin defect area on the dorsal side of the fi nger from the DIP joint to the
tip. The technique is comparatively simple.
Caution The neurovascular pedicle for the fi nger is retained in the proximal/distal section of the fl ap, and is moved in
a dorsal direction together with the fl ap. If the width of the fl ap is too thin, then it will be hard for the dorsal branch
from the digital artery to fi t, so the width should be greater than 10 mm


Dorsolateral Flap (Level of Diffi culty: 3)

216
Operation Procedures
Fig. 7.64 Procedure 1: A mucous cyst was present in proximal of the
nail fold, with thinning of the skin occurring directly above it, and after
a simple tumor resection it would not be possible to close the wound
Fig. 7.65 Procedure 2: The fl ap is designed above the digital artery
based on the width of the mucous cyst
Fig. 7.66 Procedure 3: Appearance after the mucous cyst and spur
have been resected. A skin defect is created with a width of 12 mm
accompanying exposure of the extensor tendon and bone
Note The fl ap is created so that the auxiliary incision is in the lateral
center of the fi nger.



7 Reconstruction of Finger Trunk

217
Fig. 7.67 Procedure 4: While detaching the neurovascular pedicle of
the fi nger, the fl ap is detached/elevated above the extensor tendon
Fig. 7.68 Procedure 5: The fl ap is trimmed into a tear drop shape and
transferred to the dorsum of the fi nger and the wound closed
Note The fi nger arterial nerves distal of the fl ap are fully retained.


Dorsolateral Flap (Level of Diffi culty: 3)

218
Tips
It is also possible to make a fl ap with just the digital arterial pedicle
This fl ap uses the skin adjoining the skin defect area and so has excellent skin texture and sensory function. However,
if the dissection of the nerve pedicle is insuffi cient, there is a possibility of numbness remaining in the fi ngertip post
operation. Therefore it is also possible to separate the nerve from the digital neurovascular pedicle and transfer the fl ap
with only the digital artery. However the technique is somewhat complex.


7 Reconstruction of Finger Trunk

219
Information
Vascular pedicle Dorsal branch of digital artery
Size The distal dorsal skin of the fi nger from the PIP joint


Modifi ed Kleinert Method (Level of Diffi culty: 2)
Modifi ed Kleinert Method (Level of Diffi culty: 2)

220
Fig. 7.69 Procedure 1: A mucous cyst is present on the DIP joint
Fig. 7.70 Procedure 2: An arc-shaped fl ap is designed from the DIP
joint to the PIP joint with the mucous cyst to be resected in a longitudi-
nal direction
Operation Procedures


7 Reconstruction of Finger Trunk

221
Fig. 7.71 Procedure 3: The mucous cyst and spur are resected
Fig. 7.72 Procedure 4: The skin fl ap is detached from above the exten-
sor tendon


Modifi ed Kleinert Method (Level of Diffi culty: 2)

222
Fig. 7.73 Procedure 5: The fl ap is rotated and the wound sutured
closed

7 Reconstruction of Finger Trunk

223
Information
Vascular pedicle Dorsal branch from digital artery
Size It is possible to use the entire dorsal side of the middle/proximal phalanx area of the fi nger
Caution The incision of the skin and the incision of the adipofascial fl ap is conducted in different directions, with
confi rmation made of the most distal dorsal branch before including it in the adipofascial fl ap.


Digital Arterial Adipofascial Flap and Skin Graft (Level of Diffi culty: 2)
Digital Arterial Adipofascial Flap and Skin Graft (Level of Diffi culty: 2)

224
Operation Procedures
Fig. 7.75 Procedure 2: An incision is made from the radial side, and
the subcutaneous layer is broadly dissected above the adipofascial fl ap
with the vein included. At that time, confi rmation is made of the radial
digital artery/nerve
Fig. 7.74 Procedure 1: Case of heat press injury on dorsal side of DIP
joint of middle fi nger. The DIP joint was fi xed in place, but a skin defect
is present on the dorsal side of the DIP joint


7 Reconstruction of Finger Trunk

225
Fig. 7.76 Procedure 3: Next the adipofascial fl ap is detached from the
ulnar side above the extensor tendon, moving toward the radial side,
and elevated
Fig. 7.77 Procedure 4: The base of the adipofascial fl ap is detached in
the distal direction on the radial side of the fi nger, from the most distal
area of the radial digital artery that can be confi rmed in the fascial fl ap,
to the area of the dorsal branch
Note Ordinarily, if a 1 cm fl ap fold is available, then the dorsal branch
can be included.
Either one of the adipofascial fl ap or the fold can be turned over.
Although an overlap is required, the procedure of turning over is techni-
cally easy.


Digital Arterial Adipofascial Flap and Skin Graft (Level of Diffi culty: 2)

226
Fig. 7.78 Procedure 5: The adipofascial fl ap is used to cover the
exposed area of the joint, and a bolster suture done to pull it into the
subcutaneous layer
Note The adipofascial fl ap donor site is sutured closed.

7 Reconstruction of Finger Trunk

227
Fig. 7.79 Procedure 6: A skin graft is conducted on the adipofascial
fl ap
Fig. 7.80 Procedure 7: A tie-over compression is applied. It is fi xed
with a splint


Digital Arterial Adipofascial Flap and Skin Graft (Level of Diffi culty: 2)

228
Fig. 7.81 Procedure 8:. The plaster splint is removed within 2 weeks
Note Photo is 4 weeks after surgery.

7 Reconstruction of Finger Trunk

229
Information
Vascular pedicle Subcutaneous vascular plexus.
Digital artery is not included
Size A width for which reefi ng is possible. The length is up to the PIP crease
Indication Conducted for the purpose of deepening fi nger space that has lost depth. Indicated in cases where there is
no damage to the lateral center of the fi nger or the fi nger space.


Double-Opposing Digitolateral Flap (Level of Diffi culty: 2)
Double-Opposing Digitolateral Flap (Level of Diffi culty: 2)

230
Operation Procedures
Fig. 7.83 Procedure 2: A slightly deeper fi nger space is designed for
the 2nd, 3rd and 4th fi nger spaces
Fig. 7.82 Procedure 1: Scar contracture at the base of the middle and
ring fi nger and web formation in the 2nd, 3rd and 4th fi nger space


7 Reconstruction of Finger Trunk

231
Fig. 7.84 Procedure 3: A digitolateral fl ap is designed in both sides of
the middle fi nger, both sides of the ring fi nger and the radial side of the
little fi nger
Fig. 7.85 Procedure 4: An incision is made in the margin of the fl ap
design


Double-Opposing Digitolateral Flap (Level of Diffi culty: 2)

232
Fig. 7.86 Procedure 5: The fl ap is raised above the fascia with a dorsal
pedicle without inclusion of the arterial nerve
Fig. 7.87 Procedure 6: The elevated fl ap is inserted into the newly cre-
ated fi nger spaces and sutured


7 Reconstruction of Finger Trunk

233
Information
Vascular pedicle Subcutaneous vascular plexus of the palm
Size A size that can be created in the area from the palmar fi nger crease of the base of the fi nger to the distal palmar
crease of the palm.
Advantage Technique is simple. Best suited for cases of small skin defects at the base of the fi nger, where it is not
possible to create a digitolateral fl ap due to the presence of an injury.
Caution The fl ap must be designed so that the reefi ng direction for the fl ap donor site is always horizontal.


Bi-lobed Palmar Flap (Level of Diffi culty: 1)
Bi-lobed Palmar Flap (Level of Diffi culty: 1)

234
Operation Procedures
Fig. 7.88 Procedure 1: With respect for a small skin defect from the
base of the ring fi nger to the fi nger space, a bi-lobed fl ap is designed on
the palm with two small longitudinal fl aps combined. The fi rst is a fl ap
the same size of the skin defect area, and the second is slightly smaller
Note The length of the fl aps is the same, but the width of b is slightly
smaller than a.
Fig. 7.89 Procedure 2: The two fl aps are rotated and transferred, and
primary closure of donor site b is conducted


7 Reconstruction of Finger Trunk

235
Tips
The easiest method is fi rst, the fl ap that is easy to transfer is created, and then the fl ap that is easy to cover that
wound is created.
In this method the fl ap itself is longitudinal, but the direction the fl aps are transferred is horizontal, so as stated
previously, the fl aps of the palm are easy to move horizontally.
Depending on the size of the skin defect area, a tri-lobed fl ap could also be considered.

Bi-lobed Palmar Flap (Level of Diffi culty: 1)

237
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_8
Reconstruction of Fingertip
Basic Principles
The fi rst choice procedure for reconstructing the thumb tip is a palmar advancement fl ap, and
by expanding the fl ap as far as the thenar, it is possible to cover an even larger skin defect.
For fi nger tip defects other than the thumb,
For transverse amputation, an oblique triangular fl ap or palmar fl ap advancement are indicated.
For oblique amputations on the palmar side, as long as the skin defect area doesn’t
exceed the DIP joint, a reverse fl ow digital arterial fl ap is indicated. For a large defect that
exceeds the distal phalanx area, either a hemi pulp transfer or reverse fl ow digital arterial
cross fi nger fl ap is indicated.
All palmar advancement fl aps include the nerves in the fl ap. For reverse vascular pedicle
digital island fl ap, thenar fl ap or hetero digital island arterial fl ap, because similar tissue is used,
it is not essential to include sensory function. The cross fi nger fl ap from the dorsum of the fi n-
ger replaces tissue with tissue of a different quality, so this cannot be a fi rst option. However,
when skin of a different quality must be used for the reconstruction of a fi ngertip, sensory func-
tion should be reconstructed at the same time (in the case of a cross fi nger fl ap, the dorsal
branch of the digital nerve in the fl ap is sutured to the digital nerve in the recipient site).
Selectable Flaps and Surgical Procedures
Palmar advancement fl ap of thumb • Hemi pulp transfer • Hetero digital arterial fl ap from ring
fi nger • Oblique triangular fl ap • Reverse fl ow digital arterial fl ap • Thenar fl ap • Hemi pulp
transfer • Reverse fl ow digital artery cross fi nger fl ap • Heuston’s fl ap modifi cation • Ulnar
parametacarpal fl ap • Graft-on fl ap method • Nail bed graft from great toe on fl ap • Tissue
banking using insertion in subcutaneous pocket
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.
8

238
Oblique Triangular Flap Modifi cation (Level of Diffi culty: 3)
Information
Vascular pedicle Digital arterial neuro pedicle
Size The distal skin fl ap is the same width as the longitudinal axis (short pedicle) of the fi nger amputation stump, and
length extends to the PIP joint.
Indication The fl ap transfer distance is 10–15 mm
Caution In the conventional design, the width of the fl ap was made the same as the transverse diameter of the amputa-
tion stump, and the fl ap was simply advanced distally. Using this method, the nerve end was located at the distal end
of the fi nger, and patients complained of stump pain post operation. In this modifi cation, the width of the fl ap is the
longitudinal diameter of the fi nger amputation stump, and a long narrow fl ap is used to cover the fi nger amputation
stump while being rotated (rotate advancement).
Also, regardless of the size of the area to be covered, by dissecting a long neurovascular pedicle for the fl ap down to the
base of the fi nger, it is possible to remove tension and reduce numbness and pain of the fi nger tip following surgery.
Because the path of the arterial neuro pedicle of the fi nger is moved forward following transfer of the fl ap, it is neces-
sary to dissect a suffi cient amount of the subcutaneous tissue in the volar center of the fi nger so that the neurovascular
pedicle can be transferred to the volar center without being pulled tight.


8 Reconstruction of Fingertip

239
Operation Procedures
Fig. 8.1 Procedure 1: A transverse amputation of the nail bed area of
the left index fi nger
Note In order to includSe a nerve in the skin fl ap, elevation of a skin
fl ap from the radial side of the index fi nger, the radial side of the middle
fi nger, or the ulnar side of the little fi nger, should be avoided.
Fig. 8.2 Procedure 2: First, a line is drawn along the full length of the
mid-lateral line of the fi nger, and the width of the distal end of the fl ap
is decided by the longitudinal diameter of the fi nger amputation stump.
From that point a line is drawn diagonally to the PIP joint, and a long
narrow fl ap is designed


Oblique Triangular Flap Modifi cation (Level of Diffi culty: 3)

240
Fig. 8.4 Procedure 4: The digital neurovascular pedicle is identifi ed in
the distal area of the fl ap and broadly dissected, with the surrounding fat
included. Also, the fl ap is broadly dissected subcutaneously moving
from the fl ap margin to the center of the fi nger
Fig. 8.3 Procedure 3: An incision is made in the margin of the fl ap. A
deep incision is made in the line along the mid-lateral line of the fi nger
down to the periosteum, and a shallow incision is made subcutaneously
along the diagonal line
Note Because the path of the neurovascular pedicle of the fi nger is
moved forward following transfer of the fl ap, it is necessary to dissect a
suffi cient amount of the subcutaneous tissue in the center of the fi nger
so that the neurovascular pedicle can be transferred without being
pulled tight.
Fig. 8.5 Procedure 5: The fl ap is dissected from the layer above the
tendon sheath. When the fl ap is turned over it is possible to identify the
vascular pedicle on the reverse side, and dissection is continued using
that as a guide
(Part of photos reproduced from Hirase, Y. Secrets to successful
graft on fl ap: plastic surgery – Knacks and pitfalls of hand surgery.
pp 282–284, Bunkodo, 2007)



8 Reconstruction of Fingertip