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Free distal ulnar artery perforator flaps for the reconstruction of a volar defect in fingers
Accepted Manuscript Free distal ulnar artery perforator flaps for the reconstruction of a volar defect in fingers. Juan Liu , M.D Huaiyuan Zheng , M.D PII:
S1748-6815(14)00302-7
DOI:
10.1016/j.bjps.2014.05.060
Reference:
PRAS 4244
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 29 July 2013 Revised Date:
7 May 2014
Accepted Date: 29 May 2014
Please cite this article as: Liu J, Zheng H, Free distal ulnar artery perforator flaps for the reconstruction of a volar defect in fingers., British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.05.060. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE PAGE Full title: Free distal ulnar artery perforator flaps for the reconstruction of a volar
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defect in fingers.
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Author name(s) and final degree(s) :Juan Liu.M.D1. Huaiyuan Zheng.M.D1,2.
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1 Institution: Department of Hand Surgery, Wuhan Union Hospital, Tongji Medical
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College, Huazhong University of Science and Technology, China.
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Address: Jiefang Road No.1277, Wuhan, Hubei province, China.
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2 Institution: Department of Plastic Surgery and Hand Surgery, Klinikum
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Rechts der Isar, Technische Universität München
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Address: Ismaninger Strasse 22, 81675 München
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Corresponding Author: Huaiyuan Zheng
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E-mail Address: [email protected]
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Tel: +8613720252769
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SUMMARY
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Background: A volar defect in finger is a common manifestation in hand injuries, and
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proper volar coverage of fingers is of great significance for the hand function and
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cosmetic appearance.
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Purpose: Our study is to investigate the feasibility of reconstructing a volar defect
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infingers with the free ipsilateral distal ulnar artery perforator flap under the brachial
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plexus block.
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Methods: Eight free distal ulnar artery perforator flaps were used to reconstruct volar
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defects in 8 fingers. The involved fingers were 3 index fingers, 3 long fingers, one thumb
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and one ring finger. The sizes of flaps ranged from 3.0 ×4.0 to 3.0×11.0cm. All the flaps
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were harvested from the ipsilateral forearm of the injured fingers. The donor sites were
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primarily closed except in one case with a skin graft. The operation time ranged from 120
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to 150 minutes, with an average of 130 minutes. All the operations were performed under
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brachial plexus block.
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Results: All flaps survived completely without any complications during the 4 to 18
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months follow-up. All the patients were satisfied with the hand function and the cosmetic
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appearance.
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Conclusion: It might be a good workhorse flap to reconstruct the volar defects in fingers
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in hand surgery with the free distal ulnar artery perforator flaps.
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Key words: Free distal ulnar artery perforator flap; Finger; Microsurgery; Volar defects
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INTRODUCTION
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Volar defects in fingers after hand injuries require flap reconstruction due to exposed structures such as tendons and nerves
[1]
. Flap options include local flaps namely
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advanced flaps, cross-finger flaps, the dorsal metacarpal artery flaps and distant flaps
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such as abdominal flaps
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disadvantages.
[ 2 ][ 3 ][ 4 ]
. However, all these flaps have
advantages and
With the development of techniques in microsurgery, free perforator flaps have been
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widely used in plastic and reconstructive hand surgery. Several free perforator flaps have
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been developed: for example, free anterolateral thigh flap(ALT) , free paraumbilical
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flap(FPUF) and free medial sural artery perforator flap(FMSAPF)
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The donor sites of theseflaps locate on the trunk and lower extremities. As a result,
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general anesthesia is needed for flap harvest and transfer. Meanwhile, the flaps from the
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lower extremities always contain thicker subcutaneous tissues, which mismatch the
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texture of fingers and
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upper extremity can be a good candidate for the reconstruction of skin and tissue defects
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in fingers . Recently, some new free perforator flaps from the ipsilateral upper extremity
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of the injured hand have been reported, one of which is the free distal ulnar artery
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perforator flap [7][8][9].
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in hand injuries.
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[5][6]
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need second stage debulking procedures. Therefore, flap from the
The use of free distal ulnar artery perforator flaps to reconstruct finger defects was
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first reported by Inada [9]. The flap has the advantages including thinner adipose tissue,
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matching texture and similar vessel diameter with the recipient sites. Moreover, fewer
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variations of vascular anatomy and feasibility to be harvested under brachial plexus
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anesthesia favor it a good candidate flap for the reconstruction of volar defects in fingers.
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In this article, we present our experience of reconstructing volar defects in
fingers
in eight patients with the free distal ulnar artery perforator flaps.
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MATERIAL AND METHODS
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Patients Between September 2010 and December 2012, eight free distal ulnar artery
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perforator flaps were transferred for the treatment of volar skin defects after hand injuries.
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Informed consent was obtained from each patient. Five males and three females with a
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mean age of 32 years old (range 21 to 45 years) were enrolled. The involved fingers were
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3 index fingers, 3 long fingers, one thumb and one ring finger. Among these defects, four
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cases were skin defects after hand injuries, three were skin necrosis after trauma, and one
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skin defect was due to the removal of a overlying scar. The lengthof the defects exceeded
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one phalanx in 5 cases, and the width of defects in 3 cases were more than half of finger
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circumference, which rule out the possibility of coverage with a cross-finger flap or a
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local flap. The skin and tissue defects around the metacarpophalangeal joints was
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observed in 3 cases with complicated hand injuries, and the vascular supply to the dorsal
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metacarpal artery flap might be compromised. The operations of three patients were
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performed on admission; the other five received elective operations. All the operations
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were performed under tourniquet control and brachial plexus anesthesia. The sizes of
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flaps ranged from 3.0×4.0 to 3.0×11.0cm. All the flaps were harvested from the ipsilateral
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forearm. The donor sites of seven cases were closed primarily and the one that was 4.0cm
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in width was closed with a free skin graft. Arteries were anastomosed with the common
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digital artery in five cases, with the proximal digital artery in two cases and with the
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superficial palmar arch in one case on the recipient fingers or hands. Veins were
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anastomosed with the prepared dorsal or volar veins. The time of operation ranged from
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120 to 150 minutes, with an average time of 130 minutes (Table 1).
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Surgical technique A line was drawn between the pisiform and the medial condyle of the elbow
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indicating the axis of the flap. The most distal margin should not exceed the distal wrist
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crease to avoid scar formation on the joint.The perforators of the dorsal ulnar artery were
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detected and marked with a Doppler probe preoperatively on the ulnar side of the distal
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forearm, which were approximately 2 to 4 cm proximal from the pisiform and 1cm dorsal
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from the ulnar edge of the flexor carpi ulnaris muscle tendon (FCU). All the operations
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were performed under pneumatic tourniquet control and loupe magnification with
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brachial plexus block.
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After debridement, the common digital artery or superficial palmar arch was
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dissected at the recipient hand. Subcutaneous veins in the volar or dorsal aspect were
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prepared for end-to-end anastomosis because of no matching venae comitantes along the
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common digital artery or superficial palmar arch. Then the length, diameter, and location
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of the recipient vessels were confirmed. After exposing the recipient vessels, the flap size
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was designed according to the template prepared from the defect to make sure that the
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perforator was located at the center of the flap. For a longer flap, the proximal margin can
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be extended to the proximal two thirds of the forearm. While the flap was elevated, the
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incision was first made along the volar border of the flap. All of the incision and
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dissection were performed under the deep fascia. The FCU tendon was exposed and
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retracted radially (Fig1.FCU). Then the ulnar neurovascular bundle was identified
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(Fig1.UN, UA). Tracing along the ulnar artery, we could find the dorsal branch
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originating 2 to 4 cm proximal from the pisiform (Fig1.DUA) and coursing volarly and
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medially for 2-3 cm as a common trunk. The perforator to this flap derived from the
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dorsal branch and then bifurcated into ascending and descending branches. After the
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perforator had been identified, the dorsal medial border of the flap was incised and the
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whole flap was elevated with the pedicle connected. The pedicle consisting of one
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dorsoulnar artery and two venae comitantes should be carefully dissected. During the
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dissection, the fascia around the dorsoulnar bundles could be partially preserved to avoid
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twisting and avulsion. Either subcutaneous veins or venae comitantes of ulnar artery
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could be included for venous drainage (Fig1.SV). The venae comitantes of the pedicle
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was dissected retrogradely to one of the ulnar venae comitantes proximally to an
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anticipated length. More attention should be paid to the anatomical relationship between
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the perforator and the dorsoulnar sensory branch when separating the perforator from the
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dorsoulnar nerve (Fig1.DUN). After the flap had been elevated with only pedicle vessels
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connected, the pneumatic tourniquet was released and the blood circulation of the flap
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was confirmed. If vasospasm occurred during the surgery, local warm saline could be
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applied around the pedicle. The flap could be trimmed with microscissors
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withpreservation of more than 1.5cm wide fascia around the perforator if necessary.
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The donor sites of the flap were closed primarilyor with a full-thickness skin graft.
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The defect was covered by the flap and the vessels of both the donor site and recipient
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site were anastomosed respectively. The sites of anastomosis for each flap are
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summarized in the Table 1. The operation time ranged from 120 to 150 min, with an
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average time of 130 min. Smoking was absolutely prohibited from the onset of the injury
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to one month after the flap transfer to avoid vascular spasm and wound dehiscence.
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RESULTS
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All flaps survived completely and the skin graft in one case survived fully. There were no complications such as vascular crisis, flap necrosis or infection
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days of hospitalization. Rehabilitation exercises were carried out 2 weeks after surgery.
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All the patients were followed up from 4 to 18 months. Patients’ subjective assessments,
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including returning to previous occupations, the aesthetic appearance of the donor and
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recipient sites, and functional recovery—were evaluated with a visual analog scale
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ranging from 0 (completely disappointed) to 10 (completely satisfied) which were
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divided into 3 classes 9 (good, 10–8; fair, 7–5; poor,1-5)[ 10 ]. The mean subjective
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satisfaction score was 8 (5-10). The mean two-point discrimination was 9mm (8-11mm).
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5 of 8 experienced cold intolerance, 2 of 8 suffered poor hygiene of recipient sites and 1
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of 8 had minor pain , all of which subsided spontaneously. Two of 8 complained a bulky
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flap and were admitted again for a flap debulking procedure. Varying degrees of
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pigmentation were observed in each flap. The scars at the donor sites were concealed. No
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patients had complications at the donor sites. All patients returned to presurgical
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occupational status after wound healing. The patients’ outcomes are summarized in Table
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2. Representative clinical cases are reported below.
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Case Reports
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Case 1:
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during 10 to 14
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A 32-year-old man presented with skin and tissue defects on the proximal volar and
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bilateral sides of his left index finger after hand injury (Fig 2a). The defect involved the
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lateral side of the finger and a common digital artery was injured so that a local flap such
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as the cross-finger flap and the reverse second dorsal metacarpal artery flap were not
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indicated. The defect was resurfaced by a 8×4 cm free distal ulnar artery perforator flap
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which was harvested from the ipsilateral forearm
under brachial anesthesia (Fig
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2b,2c).The donor site was closed with a skin graft. The flap and skin graft survived
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evenly. The patient was satisfied with the function of the hand and the cosmetic
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appearance after nine months follow-up (Fig 2d,2e,2f).
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Case 3
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A 28-year-old man suffered tissue necrosis at the volar side of the proximal long
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finger and distal palm 3 weeks after right hand injury (Fig 3a). After debridement of the
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necrotic tissues, the underlying deep structures (tendon and nerve) were exposed (Fig 3b).
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Then a 11×3cm free distal ulnar artery perforator flap was transferred to cover the defect
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from the same forearm under brachial anesthesia (Fig 3c,3d). The donor site was closed
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directly. The flap survived completely (Fig 3e). The linear scar of the donor site was
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concealed (Fig 3f). Four months follow-up showed that the patient was satisfied with the
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function of the hand but complained of flap bulking, which might hinder the active and
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passive flexion of the middle finger. Subsequently, tissue reduction procedure was
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performed.
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DISCUSSION
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Volar defects in fingers with exposure of underlying structures such as tendons and
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neurovascular bundles are common sequelae in hand injuries, for which the
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reconstruction remains challenging. The goal of treatment is to resurface the defects with
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a pliable, sensitive, and cosmetically similar tissue that will allow adequate function.
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Surgical choices for small defects include homodigital island flaps, heterodigital island
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flaps or cross-finger flaps [1][11].Usually, the donor site needs to be grafted. Larger defects
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can be covered with reverse dorsal metacarpal artery flaps
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[12]
. However, when the
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extremity is subjected to extensive trauma, in which more than one phalanx involved or
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combined with adjacent tissue and vessel injuries, the safety of these flaps might be
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compromised and free flaps might be indicated. With the development of reconstructive microsurgery, free flap transfer is
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considered as a promising option for the coverage of volar finger defects. Recently,
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several free flaps have been transferred for volar reconstruction of fingersincluding free
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thenar flap, free posterior interossenous flap and partial second toe free flap [13][14][15]. The
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free thenar flap has advantages including a similar texture matching glabrous skin, color,
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and thickness while pedicle variation, size limitation and unpleasant scar formation might
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restrict its use. The free posterior interosseous artery perforator flap may be feasible to be
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transferred from the same forearm. However, the anatomical variation was observed by
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some authors and the donor site is not concealed. Some reports have considered the free
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skin flaps from the second toes as the optimal option in the reconstruction of volar
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defects. However, the operation should be performed under general anesthesia and
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skin graft is needed for the closure of the donor site , especially when the defect exceeds
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one knuckle. The skin graft on toes has a higher risk of necrosis than other donor sites
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and the scar might have poor wear resistance with an unpleasant appearance.
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The free distal ulnar artery perforator flap was first reported for the reconstruction of
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[9]
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severely injured digits by Inada in 2004
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finger pulp reconstruction and post-burn contracture release. No literature has been found
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on the usage of this flap for volar defects coverage. The study from Becker and Gilbert
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has indicated that the dorsal branch of the ulnar artery was constant on 100 fresh
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forearms
[16]
. Later there were two reports on this flap for
.This branch goes perpendicular to the skin after branching from the ulnar
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artery, making it detectable by a handheld Doppler. Therefore, the reliable operative
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landmark can be provided before surgery. In our series, we found the dorsoulnar vessel
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originated from the main trunk at the point 2 to 4 cm proximal to the pisiform as
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described. There was no variation of this perforator in our series. The diameters of the
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perforator arteries varied from 0.9 to 1.3 mm with an average 19mm pedicle length. This
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provided a good match with the vessels on the recipient digit or palm. Retrograde
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dissection of the ulnar venae comitantes will provide a larger venous caliber ranging from
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1.8mm to 2.5mm, while superficial veins can also be included in the flap to warrant
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venous drainage. We advocate anastomosing the veins on the dorsal hand through a
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subcutaneous tunnel for which may provide a larger caliber. As described above, the
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major part of a larger size flap located proximal from the perforator. The short arterial
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pedicle (mean 19mm) was considered as the main factor for the flap inset, which is
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placed close to the recipient artery to facilitate anastomosis. The length of both the
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superficial and deep vein which can be extended proximally is determined by the location
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of the recipient veins in the dorsal hand. The veins can be transferred to the dorsum for
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anastomosis through subcutaneous or inter metacarpal tunnel. If a superficial vein
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running in the flap is included for venous drainage, the proximal stump of the superficial
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vein locates on the opposite direction to the pedicle. Our experience is to isolate the
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superficial vein from the subcutaneous tissue of the flap distally abutting to the pedicle
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and one third of the length of the superficial vein in the flap is enough for the whole flap
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venous drainage (Figure 4).
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In our study, the cutaneous nerve of the flap was not dissected and coapted with the
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recipient nerve, but all the cases were satisfied with their sensation of flaps. The mean
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two-point discrimination was 9mm, which is a little larger than
the value in flaps
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transferred from the toes according to Wang’s study[17]. For the sensation of volar fingers
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is not as important as that of pulps, this flap could be acceptable for the volar defect
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without pulp involved.
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We summarize the advantages of the free distal ulnar artery perforator flap for the
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coverage of volar defects of fingers as follows: (1) the operation can be performed under
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brachial plexus block; (2) the flap could be trimmed before transfer; (3) matching vessels’
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diameter ; (4) the donor site can be closed primarily if the width is less than 3cm; (5)
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similar texture and color ; (6) the donor site is concealed; (7) it is more preferential if the
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extremity is subjected to extensive trauma in which local or pedicled flaps are not
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available.
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However, we also acknowledge some drawbacks for this flap: (1) an
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ultra-microsurgical technique is needed with a prolonged operation time;(2) the formation
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of a scar will sometimes occur at the donor site; (3) poorer sensation and aesthetic
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outcomes compared with the glabrous skin flaps from the toes. Thus, the use of the
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DUAP for small-size finger pulp reconstruction is not recommended. Some minor
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complications of the flap (e.g. poor hygiene, cold intolerance, and minor pain) resolved
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spontaneously without special treatment, and did not interfere with the normal activities
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in daily life.
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In conclusion, the free distal ulnar artery perforator flap could be a good workhorse
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flap for the coverage of the volar defects in fingers after hand injury under brachial
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anesthesia. According to our data, the indications of free distal ulnar artery perforator flap
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for reconstruction of volar defects include: (1) the length of defect exceeds one phalanx
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or the width of the defect is more than half of phalangeal circumference which can not be
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covered by cross-finger flap;; (2) the defect is combined with adjacent tissue and vessel
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injury in which the local or pedicled flaps might be compromised.; (3) the pulp is not
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involved in the defect.
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ACKNOWLEDGMENT
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The authors thank Mark di Frangia for proofreading.
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The authors declare that they have no conflicts of interest or funding sources to disclose.
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Ethical Approval: Informed consent was obtained from the patients.
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Reference
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[1] Ozaksar K, Toros T, Sügün TS, Bal E, Ademoğlu Y, Kaplan I . Reconstruction of finger pulp defects using homodigital dorsal middle phalangeal neurovascular advancement flap.J Hand Surg Eur. Vol 2010;35:125–129. [2] Jackson IT, Brown GE. A method of treating chronic flexion contractures of the fingers. Br J Plast Surg. 1970;23:373–379. [3] Harrison DH, Newton J. Two flaps to resurface the basal flexion-crease of the finger area. J Hand Surg Br. 1991;16:78–83. [4] Joshi BB. Dorsolateral flaps froms the same finger to relieve flexion contractures. Plast Reconstr Surg. 1972;49:186–189. [5] Koshima I, Urushihara K, Inagawa K, Hamasaki, T, Moriguchi T. Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg.2001;107:1753-1758. [6] Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg.2001;108: 1197-1208 . [7] Tsai TM., Sabapathy SR, Martin D. Revascularization of a finger with a thenar mini-free flap.J Hand Surg Am .1991;16: 604-606. [ 8 ] Cavadas PC. Posterior interosseous free flap with extended pedicle for hand reconstruction. Plast Reconstr Surg .2001; 108: 897-901. [9] Inada Y, Tamai S, Kawanishi K, et al. Free dorsoulnar perforator flap transfers for the reconstruction of severely injured digits. Plast Reconstr Surg. 2004;114:411–420. [ 10 ] Hamdi M, Coessens BC. Distally planned lateral arm flap. Microsurgery 1996;17:375–379. [11] Adani R, Marcoccio I, Tarallo L, Fregni U. The reverse heterodigital neurovascular island flap for digital pulp reconstruction. Tech Hand Up Extrem Surg .2005;9:91–95.
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[12] Sebastin SJ, Mendoza RT, Chong AK, et al. Application of the dorsal metacarpal artery perforator flap for resurfacing soft-tissue defects proximal to the fingertip.Plast Reconstr Surg. 2011 ;128:166-178. [13] Sassu P, Lin CH, Lin YT, Lin CH. Fourteen cases of free thenar flap: a rare indication in digital reconstruction. Ann Plast Surg.2008;60:260–266. [14] Pan ZH, Jiang PP, Wang JL. Posterior interosseous free flap for finger re-surfacing. J Plast Reconstr Aesthet Surg.2010;63:832–837. [15] Lee DC, Kim JS, Ki SH, Roh SY, Yang JW, Chung KC. Partial second toe pulp free flap for fingertip reconstruction.Plast Reconstr Surg.2008;121:899–907. [16] Becker C, Gilbert A. The ulnar flap: description and applications. Eur J Plast Surg .1988;11:79. [17] Wang L, Fu J, Li M, Han D, Yang L. Repair of hand defects by transfer of free tissue flaps from toes. Arch Orthop Trauma Surg. 2013;133:141-146
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Figure legend
Figure 1. Anatomical illustration of distal ulnar artery perforator flap: FCU, flexor carpi ulnaris; DUA, dorsoulnar artery; SV, subcutaneous vein; UN, ulnar nerve; UA, ulnar artery; DUN, dorsoulnar nerve. Figure 2.
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(a) A 32-year-old man suffering traumatic tissue defects on the proximal volar and lateral sides of his left index finger, and a free distal ulnar artery perforator flap was planned. (b) Harvest of the flap.
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(c) The defect was covered with the free distal ulnar artery perforator flap and the donor
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site was closed with a skin graft. (d-f) Postoperative view at 9 months of the flap with good functionand The appearance of the donor site (f). Figure 3.
(a) A 28-year-old man suffered tissue necrosis at the volar side of the proximal middle finger and distal palm 3 weeks after right hand injury. (b) Trauma after debridement of necrotic tissue.
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(c) A free distal ulnar artery perforator flap was designed. (d) The defect was covered by the flap.
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(e-f) Postoperative view at 4 months of the flap and the linear scar on the donor site. Figure 4. A,B: Harvest of the deep vein.
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C,D: Isolation of the superficial vein.
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ACCEPTED MANUSCRIPT Table 1 Demography of the Patients Patient
Age
Gender
Flap
Operation
Recipient
Size
Time
Vessels
(cm)
(min)
Defect Location
(years)
21
Volar and lateral sides of left
4.0×
proximal index
8.0
Volar side of left proximal
3.0×
thumb
4.0
M
F
Volar side of right
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CDA/SV
120
CDA/SV
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2
32
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1
3.0×
3
28
proximal middle finger
M
130
SPA/SPV
130
CDA/SV
150
CDA/SV
125
CDA/SV
120
PDA/SV
130
PDA/SV
10.0
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and distal palm Volar side of proximal and
3.0×
4
27
F
middle phalanx of right index
8.0
finger
Volar side of proximal and
3.5×
35
M
middle phalanx of right
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5
7.0
middle finger
Volar and medial side of
28
M
3.0×
proximal interphalangeal
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7.5
joint of right ring finger
45
8
40
Volar side of right proximal
3.0×
index
5.0
M
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F
Volar side of right proximal 3.0× middle finger and 6.0 interphalangeal joint
F, female; M, male; CDA, common digital artery; SV, superficial vein; SPA, superficial palmar arch; SPV, superficial palmar vein; PDA, proximal digital artery.
ACCEPTED MANUSCRIPT Table 2 Outcomes of the patients Debulking
Follow Patient
Cold
SS
Two-point
Intolerance
score
Discrimination(mm) 9
Complications
up
Surgery
(months) +
10
2
6
None
-
9
3
12
Poor hygiene
+
7
4
4
None
+
8
5
8
Minor pain
+
7
6
18
None
+
8
7
10
Poor hygiene
-
9
8
6
None
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6
-
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None
10
-
9
+
11
+
9
-
8
-
8
-
8
-
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S1748-6815(14)00302-7
DOI:
10.1016/j.bjps.2014.05.060
Reference:
PRAS 4244
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 29 July 2013 Revised Date:
7 May 2014
Accepted Date: 29 May 2014
Please cite this article as: Liu J, Zheng H, Free distal ulnar artery perforator flaps for the reconstruction of a volar defect in fingers., British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.05.060. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE PAGE Full title: Free distal ulnar artery perforator flaps for the reconstruction of a volar
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defect in fingers.
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Author name(s) and final degree(s) :Juan Liu.M.D1. Huaiyuan Zheng.M.D1,2.
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1 Institution: Department of Hand Surgery, Wuhan Union Hospital, Tongji Medical
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College, Huazhong University of Science and Technology, China.
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Address: Jiefang Road No.1277, Wuhan, Hubei province, China.
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2 Institution: Department of Plastic Surgery and Hand Surgery, Klinikum
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Rechts der Isar, Technische Universität München
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Address: Ismaninger Strasse 22, 81675 München
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Corresponding Author: Huaiyuan Zheng
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E-mail Address: [email protected]
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Tel: +8613720252769
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SUMMARY
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Background: A volar defect in finger is a common manifestation in hand injuries, and
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proper volar coverage of fingers is of great significance for the hand function and
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cosmetic appearance.
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Purpose: Our study is to investigate the feasibility of reconstructing a volar defect
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infingers with the free ipsilateral distal ulnar artery perforator flap under the brachial
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plexus block.
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Methods: Eight free distal ulnar artery perforator flaps were used to reconstruct volar
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defects in 8 fingers. The involved fingers were 3 index fingers, 3 long fingers, one thumb
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and one ring finger. The sizes of flaps ranged from 3.0 ×4.0 to 3.0×11.0cm. All the flaps
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were harvested from the ipsilateral forearm of the injured fingers. The donor sites were
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primarily closed except in one case with a skin graft. The operation time ranged from 120
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to 150 minutes, with an average of 130 minutes. All the operations were performed under
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brachial plexus block.
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Results: All flaps survived completely without any complications during the 4 to 18
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months follow-up. All the patients were satisfied with the hand function and the cosmetic
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appearance.
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Conclusion: It might be a good workhorse flap to reconstruct the volar defects in fingers
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in hand surgery with the free distal ulnar artery perforator flaps.
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Key words: Free distal ulnar artery perforator flap; Finger; Microsurgery; Volar defects
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INTRODUCTION
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Volar defects in fingers after hand injuries require flap reconstruction due to exposed structures such as tendons and nerves
[1]
. Flap options include local flaps namely
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advanced flaps, cross-finger flaps, the dorsal metacarpal artery flaps and distant flaps
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such as abdominal flaps
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disadvantages.
[ 2 ][ 3 ][ 4 ]
. However, all these flaps have
advantages and
With the development of techniques in microsurgery, free perforator flaps have been
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widely used in plastic and reconstructive hand surgery. Several free perforator flaps have
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been developed: for example, free anterolateral thigh flap(ALT) , free paraumbilical
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flap(FPUF) and free medial sural artery perforator flap(FMSAPF)
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The donor sites of theseflaps locate on the trunk and lower extremities. As a result,
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general anesthesia is needed for flap harvest and transfer. Meanwhile, the flaps from the
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lower extremities always contain thicker subcutaneous tissues, which mismatch the
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texture of fingers and
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upper extremity can be a good candidate for the reconstruction of skin and tissue defects
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in fingers . Recently, some new free perforator flaps from the ipsilateral upper extremity
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of the injured hand have been reported, one of which is the free distal ulnar artery
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perforator flap [7][8][9].
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in hand injuries.
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[5][6]
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need second stage debulking procedures. Therefore, flap from the
The use of free distal ulnar artery perforator flaps to reconstruct finger defects was
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first reported by Inada [9]. The flap has the advantages including thinner adipose tissue,
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matching texture and similar vessel diameter with the recipient sites. Moreover, fewer
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variations of vascular anatomy and feasibility to be harvested under brachial plexus
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anesthesia favor it a good candidate flap for the reconstruction of volar defects in fingers.
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In this article, we present our experience of reconstructing volar defects in
fingers
in eight patients with the free distal ulnar artery perforator flaps.
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MATERIAL AND METHODS
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Patients Between September 2010 and December 2012, eight free distal ulnar artery
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perforator flaps were transferred for the treatment of volar skin defects after hand injuries.
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Informed consent was obtained from each patient. Five males and three females with a
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mean age of 32 years old (range 21 to 45 years) were enrolled. The involved fingers were
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3 index fingers, 3 long fingers, one thumb and one ring finger. Among these defects, four
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cases were skin defects after hand injuries, three were skin necrosis after trauma, and one
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skin defect was due to the removal of a overlying scar. The lengthof the defects exceeded
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one phalanx in 5 cases, and the width of defects in 3 cases were more than half of finger
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circumference, which rule out the possibility of coverage with a cross-finger flap or a
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local flap. The skin and tissue defects around the metacarpophalangeal joints was
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observed in 3 cases with complicated hand injuries, and the vascular supply to the dorsal
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metacarpal artery flap might be compromised. The operations of three patients were
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performed on admission; the other five received elective operations. All the operations
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were performed under tourniquet control and brachial plexus anesthesia. The sizes of
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flaps ranged from 3.0×4.0 to 3.0×11.0cm. All the flaps were harvested from the ipsilateral
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forearm. The donor sites of seven cases were closed primarily and the one that was 4.0cm
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in width was closed with a free skin graft. Arteries were anastomosed with the common
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digital artery in five cases, with the proximal digital artery in two cases and with the
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superficial palmar arch in one case on the recipient fingers or hands. Veins were
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anastomosed with the prepared dorsal or volar veins. The time of operation ranged from
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120 to 150 minutes, with an average time of 130 minutes (Table 1).
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Surgical technique A line was drawn between the pisiform and the medial condyle of the elbow
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indicating the axis of the flap. The most distal margin should not exceed the distal wrist
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crease to avoid scar formation on the joint.The perforators of the dorsal ulnar artery were
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detected and marked with a Doppler probe preoperatively on the ulnar side of the distal
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forearm, which were approximately 2 to 4 cm proximal from the pisiform and 1cm dorsal
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from the ulnar edge of the flexor carpi ulnaris muscle tendon (FCU). All the operations
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were performed under pneumatic tourniquet control and loupe magnification with
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brachial plexus block.
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After debridement, the common digital artery or superficial palmar arch was
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dissected at the recipient hand. Subcutaneous veins in the volar or dorsal aspect were
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prepared for end-to-end anastomosis because of no matching venae comitantes along the
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common digital artery or superficial palmar arch. Then the length, diameter, and location
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of the recipient vessels were confirmed. After exposing the recipient vessels, the flap size
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was designed according to the template prepared from the defect to make sure that the
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perforator was located at the center of the flap. For a longer flap, the proximal margin can
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be extended to the proximal two thirds of the forearm. While the flap was elevated, the
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incision was first made along the volar border of the flap. All of the incision and
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dissection were performed under the deep fascia. The FCU tendon was exposed and
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retracted radially (Fig1.FCU). Then the ulnar neurovascular bundle was identified
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(Fig1.UN, UA). Tracing along the ulnar artery, we could find the dorsal branch
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originating 2 to 4 cm proximal from the pisiform (Fig1.DUA) and coursing volarly and
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medially for 2-3 cm as a common trunk. The perforator to this flap derived from the
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dorsal branch and then bifurcated into ascending and descending branches. After the
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perforator had been identified, the dorsal medial border of the flap was incised and the
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whole flap was elevated with the pedicle connected. The pedicle consisting of one
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dorsoulnar artery and two venae comitantes should be carefully dissected. During the
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dissection, the fascia around the dorsoulnar bundles could be partially preserved to avoid
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twisting and avulsion. Either subcutaneous veins or venae comitantes of ulnar artery
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could be included for venous drainage (Fig1.SV). The venae comitantes of the pedicle
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was dissected retrogradely to one of the ulnar venae comitantes proximally to an
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anticipated length. More attention should be paid to the anatomical relationship between
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the perforator and the dorsoulnar sensory branch when separating the perforator from the
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dorsoulnar nerve (Fig1.DUN). After the flap had been elevated with only pedicle vessels
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connected, the pneumatic tourniquet was released and the blood circulation of the flap
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was confirmed. If vasospasm occurred during the surgery, local warm saline could be
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applied around the pedicle. The flap could be trimmed with microscissors
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withpreservation of more than 1.5cm wide fascia around the perforator if necessary.
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The donor sites of the flap were closed primarilyor with a full-thickness skin graft.
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The defect was covered by the flap and the vessels of both the donor site and recipient
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site were anastomosed respectively. The sites of anastomosis for each flap are
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summarized in the Table 1. The operation time ranged from 120 to 150 min, with an
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average time of 130 min. Smoking was absolutely prohibited from the onset of the injury
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to one month after the flap transfer to avoid vascular spasm and wound dehiscence.
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RESULTS
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All flaps survived completely and the skin graft in one case survived fully. There were no complications such as vascular crisis, flap necrosis or infection
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days of hospitalization. Rehabilitation exercises were carried out 2 weeks after surgery.
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All the patients were followed up from 4 to 18 months. Patients’ subjective assessments,
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including returning to previous occupations, the aesthetic appearance of the donor and
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recipient sites, and functional recovery—were evaluated with a visual analog scale
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ranging from 0 (completely disappointed) to 10 (completely satisfied) which were
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divided into 3 classes 9 (good, 10–8; fair, 7–5; poor,1-5)[ 10 ]. The mean subjective
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satisfaction score was 8 (5-10). The mean two-point discrimination was 9mm (8-11mm).
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5 of 8 experienced cold intolerance, 2 of 8 suffered poor hygiene of recipient sites and 1
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of 8 had minor pain , all of which subsided spontaneously. Two of 8 complained a bulky
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flap and were admitted again for a flap debulking procedure. Varying degrees of
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pigmentation were observed in each flap. The scars at the donor sites were concealed. No
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patients had complications at the donor sites. All patients returned to presurgical
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occupational status after wound healing. The patients’ outcomes are summarized in Table
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2. Representative clinical cases are reported below.
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Case Reports
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Case 1:
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A 32-year-old man presented with skin and tissue defects on the proximal volar and
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bilateral sides of his left index finger after hand injury (Fig 2a). The defect involved the
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lateral side of the finger and a common digital artery was injured so that a local flap such
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as the cross-finger flap and the reverse second dorsal metacarpal artery flap were not
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indicated. The defect was resurfaced by a 8×4 cm free distal ulnar artery perforator flap
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which was harvested from the ipsilateral forearm
under brachial anesthesia (Fig
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2b,2c).The donor site was closed with a skin graft. The flap and skin graft survived
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evenly. The patient was satisfied with the function of the hand and the cosmetic
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appearance after nine months follow-up (Fig 2d,2e,2f).
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Case 3
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A 28-year-old man suffered tissue necrosis at the volar side of the proximal long
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finger and distal palm 3 weeks after right hand injury (Fig 3a). After debridement of the
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necrotic tissues, the underlying deep structures (tendon and nerve) were exposed (Fig 3b).
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Then a 11×3cm free distal ulnar artery perforator flap was transferred to cover the defect
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from the same forearm under brachial anesthesia (Fig 3c,3d). The donor site was closed
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directly. The flap survived completely (Fig 3e). The linear scar of the donor site was
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concealed (Fig 3f). Four months follow-up showed that the patient was satisfied with the
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function of the hand but complained of flap bulking, which might hinder the active and
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passive flexion of the middle finger. Subsequently, tissue reduction procedure was
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performed.
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DISCUSSION
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Volar defects in fingers with exposure of underlying structures such as tendons and
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neurovascular bundles are common sequelae in hand injuries, for which the
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reconstruction remains challenging. The goal of treatment is to resurface the defects with
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a pliable, sensitive, and cosmetically similar tissue that will allow adequate function.
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Surgical choices for small defects include homodigital island flaps, heterodigital island
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flaps or cross-finger flaps [1][11].Usually, the donor site needs to be grafted. Larger defects
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can be covered with reverse dorsal metacarpal artery flaps
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[12]
. However, when the
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extremity is subjected to extensive trauma, in which more than one phalanx involved or
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combined with adjacent tissue and vessel injuries, the safety of these flaps might be
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compromised and free flaps might be indicated. With the development of reconstructive microsurgery, free flap transfer is
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considered as a promising option for the coverage of volar finger defects. Recently,
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several free flaps have been transferred for volar reconstruction of fingersincluding free
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thenar flap, free posterior interossenous flap and partial second toe free flap [13][14][15]. The
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free thenar flap has advantages including a similar texture matching glabrous skin, color,
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and thickness while pedicle variation, size limitation and unpleasant scar formation might
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restrict its use. The free posterior interosseous artery perforator flap may be feasible to be
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transferred from the same forearm. However, the anatomical variation was observed by
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some authors and the donor site is not concealed. Some reports have considered the free
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skin flaps from the second toes as the optimal option in the reconstruction of volar
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defects. However, the operation should be performed under general anesthesia and
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skin graft is needed for the closure of the donor site , especially when the defect exceeds
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one knuckle. The skin graft on toes has a higher risk of necrosis than other donor sites
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and the scar might have poor wear resistance with an unpleasant appearance.
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The free distal ulnar artery perforator flap was first reported for the reconstruction of
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[9]
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severely injured digits by Inada in 2004
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finger pulp reconstruction and post-burn contracture release. No literature has been found
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on the usage of this flap for volar defects coverage. The study from Becker and Gilbert
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has indicated that the dorsal branch of the ulnar artery was constant on 100 fresh
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forearms
[16]
. Later there were two reports on this flap for
.This branch goes perpendicular to the skin after branching from the ulnar
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artery, making it detectable by a handheld Doppler. Therefore, the reliable operative
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landmark can be provided before surgery. In our series, we found the dorsoulnar vessel
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originated from the main trunk at the point 2 to 4 cm proximal to the pisiform as
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described. There was no variation of this perforator in our series. The diameters of the
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perforator arteries varied from 0.9 to 1.3 mm with an average 19mm pedicle length. This
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provided a good match with the vessels on the recipient digit or palm. Retrograde
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dissection of the ulnar venae comitantes will provide a larger venous caliber ranging from
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1.8mm to 2.5mm, while superficial veins can also be included in the flap to warrant
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venous drainage. We advocate anastomosing the veins on the dorsal hand through a
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subcutaneous tunnel for which may provide a larger caliber. As described above, the
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major part of a larger size flap located proximal from the perforator. The short arterial
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pedicle (mean 19mm) was considered as the main factor for the flap inset, which is
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placed close to the recipient artery to facilitate anastomosis. The length of both the
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superficial and deep vein which can be extended proximally is determined by the location
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of the recipient veins in the dorsal hand. The veins can be transferred to the dorsum for
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anastomosis through subcutaneous or inter metacarpal tunnel. If a superficial vein
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running in the flap is included for venous drainage, the proximal stump of the superficial
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vein locates on the opposite direction to the pedicle. Our experience is to isolate the
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superficial vein from the subcutaneous tissue of the flap distally abutting to the pedicle
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and one third of the length of the superficial vein in the flap is enough for the whole flap
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venous drainage (Figure 4).
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In our study, the cutaneous nerve of the flap was not dissected and coapted with the
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recipient nerve, but all the cases were satisfied with their sensation of flaps. The mean
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two-point discrimination was 9mm, which is a little larger than
the value in flaps
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transferred from the toes according to Wang’s study[17]. For the sensation of volar fingers
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is not as important as that of pulps, this flap could be acceptable for the volar defect
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without pulp involved.
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We summarize the advantages of the free distal ulnar artery perforator flap for the
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coverage of volar defects of fingers as follows: (1) the operation can be performed under
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brachial plexus block; (2) the flap could be trimmed before transfer; (3) matching vessels’
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diameter ; (4) the donor site can be closed primarily if the width is less than 3cm; (5)
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similar texture and color ; (6) the donor site is concealed; (7) it is more preferential if the
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extremity is subjected to extensive trauma in which local or pedicled flaps are not
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available.
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However, we also acknowledge some drawbacks for this flap: (1) an
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ultra-microsurgical technique is needed with a prolonged operation time;(2) the formation
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of a scar will sometimes occur at the donor site; (3) poorer sensation and aesthetic
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outcomes compared with the glabrous skin flaps from the toes. Thus, the use of the
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DUAP for small-size finger pulp reconstruction is not recommended. Some minor
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complications of the flap (e.g. poor hygiene, cold intolerance, and minor pain) resolved
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spontaneously without special treatment, and did not interfere with the normal activities
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in daily life.
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In conclusion, the free distal ulnar artery perforator flap could be a good workhorse
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flap for the coverage of the volar defects in fingers after hand injury under brachial
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anesthesia. According to our data, the indications of free distal ulnar artery perforator flap
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for reconstruction of volar defects include: (1) the length of defect exceeds one phalanx
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or the width of the defect is more than half of phalangeal circumference which can not be
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covered by cross-finger flap;; (2) the defect is combined with adjacent tissue and vessel
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injury in which the local or pedicled flaps might be compromised.; (3) the pulp is not
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involved in the defect.
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ACKNOWLEDGMENT
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The authors thank Mark di Frangia for proofreading.
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The authors declare that they have no conflicts of interest or funding sources to disclose.
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Ethical Approval: Informed consent was obtained from the patients.
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Reference
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[1] Ozaksar K, Toros T, Sügün TS, Bal E, Ademoğlu Y, Kaplan I . Reconstruction of finger pulp defects using homodigital dorsal middle phalangeal neurovascular advancement flap.J Hand Surg Eur. Vol 2010;35:125–129. [2] Jackson IT, Brown GE. A method of treating chronic flexion contractures of the fingers. Br J Plast Surg. 1970;23:373–379. [3] Harrison DH, Newton J. Two flaps to resurface the basal flexion-crease of the finger area. J Hand Surg Br. 1991;16:78–83. [4] Joshi BB. Dorsolateral flaps froms the same finger to relieve flexion contractures. Plast Reconstr Surg. 1972;49:186–189. [5] Koshima I, Urushihara K, Inagawa K, Hamasaki, T, Moriguchi T. Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg.2001;107:1753-1758. [6] Kimura N, Satoh K, Hasumi T, Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg.2001;108: 1197-1208 . [7] Tsai TM., Sabapathy SR, Martin D. Revascularization of a finger with a thenar mini-free flap.J Hand Surg Am .1991;16: 604-606. [ 8 ] Cavadas PC. Posterior interosseous free flap with extended pedicle for hand reconstruction. Plast Reconstr Surg .2001; 108: 897-901. [9] Inada Y, Tamai S, Kawanishi K, et al. Free dorsoulnar perforator flap transfers for the reconstruction of severely injured digits. Plast Reconstr Surg. 2004;114:411–420. [ 10 ] Hamdi M, Coessens BC. Distally planned lateral arm flap. Microsurgery 1996;17:375–379. [11] Adani R, Marcoccio I, Tarallo L, Fregni U. The reverse heterodigital neurovascular island flap for digital pulp reconstruction. Tech Hand Up Extrem Surg .2005;9:91–95.
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[12] Sebastin SJ, Mendoza RT, Chong AK, et al. Application of the dorsal metacarpal artery perforator flap for resurfacing soft-tissue defects proximal to the fingertip.Plast Reconstr Surg. 2011 ;128:166-178. [13] Sassu P, Lin CH, Lin YT, Lin CH. Fourteen cases of free thenar flap: a rare indication in digital reconstruction. Ann Plast Surg.2008;60:260–266. [14] Pan ZH, Jiang PP, Wang JL. Posterior interosseous free flap for finger re-surfacing. J Plast Reconstr Aesthet Surg.2010;63:832–837. [15] Lee DC, Kim JS, Ki SH, Roh SY, Yang JW, Chung KC. Partial second toe pulp free flap for fingertip reconstruction.Plast Reconstr Surg.2008;121:899–907. [16] Becker C, Gilbert A. The ulnar flap: description and applications. Eur J Plast Surg .1988;11:79. [17] Wang L, Fu J, Li M, Han D, Yang L. Repair of hand defects by transfer of free tissue flaps from toes. Arch Orthop Trauma Surg. 2013;133:141-146
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Figure legend
Figure 1. Anatomical illustration of distal ulnar artery perforator flap: FCU, flexor carpi ulnaris; DUA, dorsoulnar artery; SV, subcutaneous vein; UN, ulnar nerve; UA, ulnar artery; DUN, dorsoulnar nerve. Figure 2.
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(a) A 32-year-old man suffering traumatic tissue defects on the proximal volar and lateral sides of his left index finger, and a free distal ulnar artery perforator flap was planned. (b) Harvest of the flap.
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(c) The defect was covered with the free distal ulnar artery perforator flap and the donor
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site was closed with a skin graft. (d-f) Postoperative view at 9 months of the flap with good functionand The appearance of the donor site (f). Figure 3.
(a) A 28-year-old man suffered tissue necrosis at the volar side of the proximal middle finger and distal palm 3 weeks after right hand injury. (b) Trauma after debridement of necrotic tissue.
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(c) A free distal ulnar artery perforator flap was designed. (d) The defect was covered by the flap.
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(e-f) Postoperative view at 4 months of the flap and the linear scar on the donor site. Figure 4. A,B: Harvest of the deep vein.
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C,D: Isolation of the superficial vein.
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Age
Gender
Flap
Operation
Recipient
Size
Time
Vessels
(cm)
(min)
Defect Location
(years)
21
Volar and lateral sides of left
4.0×
proximal index
8.0
Volar side of left proximal
3.0×
thumb
4.0
M
F
Volar side of right
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CDA/SV
120
CDA/SV
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32
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3.0×
3
28
proximal middle finger
M
130
SPA/SPV
130
CDA/SV
150
CDA/SV
125
CDA/SV
120
PDA/SV
130
PDA/SV
10.0
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and distal palm Volar side of proximal and
3.0×
4
27
F
middle phalanx of right index
8.0
finger
Volar side of proximal and
3.5×
35
M
middle phalanx of right
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5
7.0
middle finger
Volar and medial side of
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M
3.0×
proximal interphalangeal
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7.5
joint of right ring finger
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8
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Volar side of right proximal
3.0×
index
5.0
M
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F
Volar side of right proximal 3.0× middle finger and 6.0 interphalangeal joint
F, female; M, male; CDA, common digital artery; SV, superficial vein; SPA, superficial palmar arch; SPV, superficial palmar vein; PDA, proximal digital artery.
ACCEPTED MANUSCRIPT Table 2 Outcomes of the patients Debulking
Follow Patient
Cold
SS
Two-point
Intolerance
score
Discrimination(mm) 9
Complications
up
Surgery
(months) +
10
2
6
None
-
9
3
12
Poor hygiene
+
7
4
4
None
+
8
5
8
Minor pain
+
7
6
18
None
+
8
7
10
Poor hygiene
-
9
8
6
None
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6
-
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None
10
-
9
+
11
+
9
-
8
-
8
-
8
-
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