Local flaps of the hand

Abstract

A local flap consists of skin and subcutaneous tissue that is harvested from a site near a given defect while maintaining its intrinsic blood supply. Local skin flaps can be a used as a reliable source of soft tissue replacement that replaces like with like. Flaps are categorized based on composition, method of transfer, flap design, and blood supply, but flap circulation is considered the most critical factor for the flap survival. This article reviews the classification of local skin flaps of the hand and offers a practical reconstructive approach for several soft tissue defects of the hand and digits.

Keywords: Hand flaps; Reconstruction; Soft tissue coverage.

Figure 1

Demonstrating wrong design of rotation flap (A). Note that the length of the arc of the flap should be at least 3-4 times the diameter of the defect (B) to sufficiently rotate the skin flap into the defect (C).

Figure 1

Demonstrating wrong design of rotation flap (A). Note that the length of the arc of the flap should be at least 3-4 times the diameter of the defect (B) to sufficiently rotate the skin flap into the defect (C).

Figure 1

Demonstrating wrong design of rotation flap (A). Note that the length of the arc of the flap should be at least 3-4 times the diameter of the defect (B) to sufficiently rotate the skin flap into the defect (C).

Figure 2

Showing a skin lesion (basal cell carcinoma) on the dorsum of the hand (A) and an outline of rhomboid flap planned for coverage of post-excision skin defect. Note that the line of flap closure should lie within the relaxed skin tension lines to facilitate skin closure taking advantage of the skin laxity (B). Also note that the margins of the transposed flap have been curved or rounded off to avoid strangulation and necrosis of pointed triangular edges of the skin flap.

Figure 2

Showing a skin lesion (basal cell carcinoma) on the dorsum of the hand (A) and an outline of rhomboid flap planned for coverage of post-excision skin defect. Note that the line of flap closure should lie within the relaxed skin tension lines to facilitate skin closure taking advantage of the skin laxity (B). Also note that the margins of the transposed flap have been curved or rounded off to avoid strangulation and necrosis of pointed triangular edges of the skin flap.

Figure 3

Illustrating design of V-Y advancement flap to cover fingertip amputation (A). Note the flap is outlined and dissected off flexor tendon sheath incorporating digital vessels and then advanced to cover the defect (B-C).

Figure 3

Illustrating design of V-Y advancement flap to cover fingertip amputation (A). Note the flap is outlined and dissected off flexor tendon sheath incorporating digital vessels and then advanced to cover the defect (B-C).

Figure 4

A V-Y advancement flap was performed to resurface skin of a painful adherent scar resulting from a previous fingertip amputation of the index finger (top). Demonstrating excellent soft-tissue padding, contour, color, texture match and mobility nine months post-operatively (below).

Figure 5

A 20-year-old female patient who sustained a crush injury to the left index finger with soft tissue loss and necrosis. The necrotic skin was debrided, and thenar flap was then designed to cover the open area.

Figure 6

Showing results soft-tissue replacement of the same patient in figure 4 two months post-operatively.

Figure 7

A 49-year-old who suffered electric burn injury with entrance wound over the index and middle fingers. Following wound debridement the patient had an exposed flexor tendon that was covered with a cross-finger flap obtained from the dorsum of the middle phalanx of the adjacent long finger.

Figure 8

Showing results soft-tissue replacement with cross-finger flap of the same patient in figure 6 five months post-operatively.

Figure 9

Illustrating the reverse cross-finger flap. The skin over donor finger is reflected leaving part of deep dermis and subcutaneous tissue that is in turn swung over primary defect and covered with a full-thickness skin graft. Reflecting back the skin that was initially elevated closes the secondary defect created over the donor finger.

Figure 10

A reverse homodigital island flap.

Figure 11

A schematic illustration of the vascular supply of the distally based DMCA perforator flap as described by Quaba and Davidson.

Figure 12

Demonstrating elevation and inset of dorsal metacarpal artery flap as described by Quaba and Davidson to cover a defect over the dorsum of the finger.

Figure 13

A 34-year-old male patient who sustained a full-thickness electric burn injury over dorsum of his left index finger (A). Following wound debridement (B) a wound defect measuring 6×3 cm with an underlying exposed metacarpophalangeal (MCP) joint was created (C). A dorsal metacarpal artery flap was used to cover the wound (D).

Figure 14

Demonstrating an ellipse design of the skin paddle of the dorsal metacarpal artery flap, that can be stretched owing to skin elasticity to reach more distant defects on dorsum of the finger.

Figure 15

A 22-year-old male patient who had a crush injury to the left thumb with loss of tissue at the nail bed that was treated initially with primary closure and left him with thin sensitive skin over the tip of the thumb. Following scar excision, a Moberg flap was performed to reconstruct the resultant defect. Note the digital nerves incorporated within the flap (left bottom).

Figure 16

Illustrating harvesting (A) and transfer (B) of the first dorsal metacarpal artery flap to cover dorsal thumb defect.

Figure 16

Illustrating harvesting (A) and transfer (B) of the first dorsal metacarpal artery flap to cover dorsal thumb defect.

Figure 17

A dorsoradial thumb defect (A) covered by reverse dorsoradial flap (Moschella flap) of the thumb. The dorsoulnar flap (Brunelli flap) is performed in a similar fashion but elevated from the dorsoulnar side of the thumb (B). (From Germann G, Bidermann N Levin SL. Intrinsic Flaps in the Hand. Clin Plast Surg. Oct;38(4):729-38; with permission.)