ObjectiveTo explore the effectiveness and operation of repairing multiple soft tissue defects in hands with lateral arm lobulated flaps.
MethodBetween October 2013 and September 2015, 13 cases of multiple soft tissue defects in the hand with tendon or bone exposure were treated with lateral arm lobulated flaps. All patients were males with average age of 28 years (range, 23-45 years). Defects were caused by penetrating injury in 7 cases, traffic accident injury in 3 cases, and hot-crush injury in 3 cases. Six patients had skin defect of the left 2 fingers after opening finger amputation, and 7 patients had skin defect of the palm and the back after hand injury. The size of skin defects ranged from 6 cm×5 cm to 9 cm×6 cm. All patients underwent emergency debridement and two-stage repair; the duration from injury to operation was 5-9 days (mean, 7 days). The size of flap was 6 cm×5 cm-9 cm×6 cm.
ResultsAll flaps survived completely, with no vascular crisis. Primary healing was obtained at donor and recipient sites, and the grafted skin survived. All cases were followed up 3-24 months (mean, 12 months). The appearance and texture of the flaps were similar to those of adjacent skin. Bulky flap was observed in 4 cases, and second stage operation was performed to make the flap thinner at 3 months after operation. The sensation of flap reached S3-S4.
ConclusionsThe lateral arm lobulated flap based on the radial collateral artery has constant vascular anatomy, easy-to-harvest, and large rotation angle. It is an effective procedure to repair small and medium size skin defects of the hand with satisfied texture and sensory recovery.
ObjectiveTo investigate the effectiveness of modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries in repairing large skin defect of the hand. Methods Between September 2017 and March 2021, 15 cases of large skin defect of the hand were treated. There were 11 males and 4 females with an average age of 42 years (range, 24-66 years). The injury causes included machine twist injury in 6 cases, pound injury in 5 cases, and crush injury in 4 cases. The injured parts included 6 cases of finger skin defect and 9 cases of distal skin defect of palm and dorsum of hand, all of which had tendon, joint, and bone exposure. The interval from injury to operation ranged from 2 to 6 hours (mean, 4 hours). The defect sizes after thorough debridement ranged from 3.5 cm×3.0 cm to 8.0 cm×4.5 cm. The modified dorsal metacarpal artery reverse island flap with a range of 3.8 cm×3.3 cm to 9.0 cm×5.0 cm was used to repair the defect, and the flap donor site was repaired with full-thickness skin graft. ResultsAll the flaps survived successfully after operation, and the wounds in the recipient site and the skin grafts in the donor site healed by first intention. All patients were followed up 9-24 months, with an average of 14 months. The appearance of the flap was good, and its texture and color were similar to those of the surrounding normal tissue. There was no obvious scar contracture, depression, and pigmentation in the donor site. At last follow-up, the static two-point discrimination of the flap was 8-20 mm, with an average of 13.6 mm. According to the Michigan Hand Outcome Questionnaire, 5 patients were very satisfied with the appearance of the flap, and 10 patients were satisfied. Conclusion The modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries has reliable blood supply, larger harvested area, simple procedure, and minimal donor site damage, which is suitable for emergency repair of large skin defect of the hand.
ObjectiveTo investigate the effectiveness of dorsalis pedis flap series-parallel big toe nail composite tissue flap in the repairment of hand skin of degloving injury with tumb defect.
MethodsBetween March 2009 and June 2013, 8 cases of hand degloving injury with thumb defect caused by machine twisting were treated. There were 7 males and 1 female with the mean age of 36 years (range, 26-48 years). Injury located at the left hand in 3 cases and at the right hand in 5 cases. The time from injury to hospitalization was 1.5-4.0 hours (mean, 2.5 hours). The defect area was 8 cm×6 cm to 15 cm×11 cm. The thumb defect was rated as degree I in 5 cases and as degree II in 3 cases. The contralateral dorsal skin flap (9 cm×7 cm to 10 cm×8 cm) combined with ipsilateral big toe nail composite tissue flap (2.5 cm×1.8 cm to 3.0 cm×2.0 cm) was used, including 3 parallel anastomosis flaps and 5 series anastomosis flaps. The donor site of the dorsal flap was repaired with thick skin grafts, the stumps wound was covered with tongue flap at the shank side of big toe.
ResultsVascular crisis occurred in 1 big toe nail composite tissue flap, margin necrosis occurred in 2 dorsalis pedis flap;the other flaps survived, and primary healing of wound was obtained. The grafted skin at dorsal donor site all survived, skin of hallux toe stump had no necrosis. Eight cases were followed up 4-20 months (mean, 15.5 months). All flaps had soft texture and satisfactory appearance;the cutaneous sensory recovery time was 4-7 months (mean, 5 months). At 4 months after operation, the two-point discrimination of the thumb pulp was 8-10 mm (mean, 9 mm), and the two-point discrimination of dorsal skin flap was 7-9 mm (mean, 8.5 mm). According to Society of Hand Surgery standard for the evaluation of upper part of the function, the results were excellent in 4 cases, good in 3 cases, and fair in 1 case. The donor foot had normal function.
ConclusionDorsalis pedis flap series-parallel big toe nail composite tissue flap is an ideal way to repair hand skin defect, and reconstructs the thumb, which has many advantages, including simple surgical procedure, no limitation to recipient site, soft texture, satisfactory appearance and function of reconstructing thumb, and small donor foot loss.
Objective To explore the effectiveness of the improved pedicled superficial iliac circumflex artery flap for repairing serious wound of the hand and forearm. Methods Between June 2008 and June 2011, 13 cases of serious wound of the hand and forearm were treated. There were 9 males and 4 females with a mean age of 41 years (range, 23-64 years). The disease causes included twist injury by machine in 2 cases, wire rope squeezed injury in 4 cases, traffic accident injury in 3 cases, crushing injury in 2 cases, high voltage electrical injury in 1 case, and snake bites in 1 case. There were 10 cases of fresh wounds and 3 cases of infection and necrosis wounds, and all had bone and tendon exposure. The skin and soft tissue defects ranged from 7 cm × 3 cm to 22 cm × 6 cm. The pedicled iliac artery flap was used in 8 cases, and pedicled iliac artery composite flap in 5 cases. The flap size ranged from 12 cm × 4 cm to 27 cm × 8 cm, with the flap pedicle of 2-4 cm wide strip and 3-5 cm wide fascia. Results The pedicle of flap was cut at 3 weeks in 12 patients, and at 4 weeks in 1 patient who had partial avulsion and hemorrhage at 1 week after operation. All flaps survived and incisions at donors and wounds healed by first intention. Eleven patients were followed up 6-36 months (mean, 20 months). The flap color and texture were good; 3 bulky flaps were observed, and satisfactory appearance was achieved after skin flap thinning. After 6 months, the protective sensation recovered in all cases; according to the Hand Surgery Society of Chinese Medical Association evaluation of upper extremity function trial standard for total active motion of the fingers, the results were excellent in 9 cases, good in 1 case, and poor in 1 case. Conclusion Improved fascia pedicled superficial iliac circumflex artery skin flap can repair serious hand and forearm injury, which is easy-to-operate and less injury at donor site.
Objective To investigate the effectiveness of the digital technology in repairing tiny hand wounds with superficial lateral sural artery perforator flap. Methods Between August 2013 and October 2016, 10 cases of tiny hand wounds were treated with the superficial lateral sural artery perforator flap. There were 6 males and 4 females, aged 19 to 47 years (mean, 31.2 years). The causes included crushing injury by machine in 6 cases, traffic accident injury in 3 cases, and electric burning injury in 1 case. The location of the soft tissue defect was the first web in 2 cases, the thumb pulp in 3 cases, the index finger pulp in 1 case, the dorsal palms in 3 cases, and the dorsum of finger in 1 case. The time from injury to hospitalization was 4 hours to 10 days (mean, 3.5 days). The size of wound was from 4 cm×3 cm to 8 cm×7 cm. All defects were associated with exposure of tendon and bone. CT angiography (CTA) from aortaventralis to bilateral anterior and posterior tibial arteries was performed before operation, and the appropriate donor site as well as perforator was selected. Then the CTA data were imported into the Mimics15.0 software to reconstruct the three dimensional structure of the perforator artery, bone, and skin; according to flap size, the flap design and harvesting process were simulated. The flap was obtained on the basis of preoperative design during operation. The size of flaps varied from 5 cm×4 cm to 10 cm×8 cm. The donor site was sutured directly in 9 cases and repaired with skin grafting in 1 case. Results Superficial medial sural artery peforator was cut in 3 patients whose superficial lateral sural artery was too narrow, and the flaps were obtained to repair defects smoothly in the others. Venous crisis occurred in 1 flap, which survived after exploration of the vessel, thrombus extraction, and thrombolysis; the other flaps survived successfully. All wounds and incisions healed by first intention. All cases were followed up 3-18 months (mean, 10 months). The flaps had good shape. At last follow-up, the results were excellent in 6 cases, good in 3 cases, and fair in 1 case according to total active motion (TAM). Conclusion The preoperative individualized design of the superficial lateral artery perforator flap can realize through CTA digital technology and Mimics15.0 software; it can reduce the operation risk and is one of better ways to repair the tiny hand wounds.
