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Microsurgical approach for a venous malformation of the thumb
MICROSURGICAL APPROACH FOR A VENOUS M A L F O R M A T I O N OF T H E T H U M B R. ADANI, R. BUSA and A. CAROLI
From the Hand Surgery Unit, University of Modena, Modena, Italy We report a case of a low-flow venous malformation of the thumb treated by microsurgical excision of the mass and a free toe pulp flap. Forty-two months after surgery the patient had a good cosmetic and functional result without any recurrence of the turnout.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 1." 30-31 Vascular malformations account for about 8% of all soft tissue tumours reported in the upper limb (Vandevender and Daley, 1995). Localized venous malformations are uncommon in the hand (Glanz, 1969; Glicenstein et al, 1988; Tropet et al, 1982). If the tumour is symptomatic, with pain, swelling and/or paraesthesia, surgical excision is the treatment of choice (Caroli et al, 1991; Glicenstein et al, 1988; Palmieri, 1987). In some cases the mass is localized to the pulp of a single digit, involving the dermal layer. In these cases excision of the tumour requires the removal of overlying skin. The problem of adequate resurfacing is particularly important when the thumb pulp is involved. We report a case of venous malformation of the thumb which was treated by microsurgical resection and pulp reconstruction by a free toe pulp flap.
suspected and clinical diagnosis of a low-flow vascular malformation was confirmed by echo-colour-Doppler, angiography and magnetic resonance (MR) examinations (Fig 2). He was treated by excision of the lesion. In a bloodless field, magnification was used to identify, ligate and then divide the feeding and drainage vessels of the malformation. The tumour was found to be connected with the ulnar neurovascular bundle. A deep infiltration of the subcutaneous and dermal layers of the pulp was evident, while the nailbed seemed to be uninvolved. Removal of the distal portion of the ulnar neurovascular bundle at the IP joint level and of the palmar and dorso-ulnar skin of the distal phalanx was necessary to allow complete excision. The residual defect measured about 4 x 3.5 cm and reconstruction was performed by means of a free pulp flap taken from the homolateral big toe. The transferred flap included the dorsalis pedis artery and vein and the plantar nerve, which were joined to the dorsal branch of the radial artery, the cephalic vein and the ulnar digital nerve respectively, at the recipient site. Histological examination confirmed the diagnosis of a venous malformation. Forty-two months after surgery the
CASE REPORT A 24-year-old, right-handed male student presented with a congenital soft mass involving the pulp of the right thumb (Fig 1). The mass had enlarged considerably over the previous 3 years and for some time it had caused the patient an unpleasant "pin-prick" feeling. No sensory deficit was evident. As well as functional limitation in fine prehension, he complained of cosmetic embarrassment. The vascular nature of the tumour was immediately
Fig 1
The mass involved the pulp and part of the dorso-ulnar aspect of the distal phalanx of the right thumb.
Fig 2
30
Tl-weighted sagittal section (TR/TE=400/20) of the thumb showing a hyperintense reticulate (adipose tissue) within a wide hypointense mass.
VENOUS M A L F O R M A T I O N
operated thumb showed a good aesthetic and functional result (Weber test on the reconstructed ulnar side of the pulp: 6 ram) without recurrence of the tumour (Fig 3). DISCUSSION Numerous treatments have been proposed for vascular malformations. Many of these methods cannot be used or are not successful in digits: the intralesional injection of sclerosant agents and radiation therapy often cause undesirable effects on the surrounding healthy tissues; cryotherapy gives poor results and the use of the Argon laser is not indicated for subcutaneous forms
31
(Glicenstein et al, 1988). The YAG laser is not suitable for treating localized forms that involve the dermal layer and does not always allow a radical excision (Apfelberg et al, 1990). Surgery seems to be the best treatment for these tumours. The subcutaneous localized forms are most easily treated with surgical excision, with a low recurrence rate (Palmieri, 1987). The traditional wide surgical resection in diffuse or in certain localized forms, can jeopardize important structures, such as vessels and digital nerves, and has a higher recurrence rate, usually due to the technical difficulty in removing the whole mass (Hill et al, 1993). Microsurgical dissection technique minimizes damage to important structures and can reduce the risk of recurrence. If the residual cutaneous defect after excision is small, it can be successfully skin grafted. For wider defects, a local flap (Glanz, 1969) or a neurovascular heterodigital island flap can be used (Caroli et al, 1991 ). Involvement of the whole pulp and part of the dorsum of the finger makes the problem of reconstruction more complex: a wide flap of thin and sensitive skin is required to restore the function and the contour of the thumb. A good solution to both problems was found by using a free toe pulp flap. Microsurgery is a well-established tool for the treatment of congenital arteriovenous fistulas of the hand (Koshima et al, 1993; Yamamoto et al, 1994) but only a small number of cases have been reported in which low-flow malformations of the upper limb have been treated by microsurgical excision and free flap coverage (Tropet et al, 1982).
References A P F E L B E R G D B, MASER M R, LASH H, WHITE D N (1990). YAG laser resection of complicated hemangiomas of the hand and upper extremity. Journal of Hand Surgery, 15A: 765 773. CAROLI A, ZANASI S, M A R C U Z Z I A, et al (1991). Gli emangiomi della mano. Chirurgia degli Organi di Movimento, 76: 317-325. G L A N Z S (1969). The surgical treatment of cavernous haemangiomas of the hand. British Journal of Plastic Surgery, 22:293 301. GLICENSTEIN J, O H A N A J, L E C L E R C Q C. Tumeurs vasculaires. In: Glicenstein J (Ed.): Tumeurs de la main. Berlin, Springer-Verlag, 1988: 150-167. H I L L R A, P H O R W H, K U M A R V P (1993). Resection of vascular malformations. Journal of H a n d Surgery, 18B: 17-21. K O S H I M A I, SOEDA S, M U R A S H I T A T (1993). Extended wrap-around flap for reconstruction of the finger with recurrent arteriovenous malformation. Plastic and Reconstructive Surgery, 91:1140-1144. PALMIERI T J (1987). Vascular tumors of the hand and forearm. H a n d Clinics, 3: 225-240. TROPET Y, M E R L E M, F O U C H E R G, V I C H A R D Ph, M I C H O N J (1982). Angiomes sous-cutan6s de la main. Annales de Chirurgie Plastique, 27: 68-71. VANDEVENDER D K, D A L E Y R A (1995). Benign and malignant vascular tumors of the upper extremity. H a n d Clinics, 11: 161- 181. Y A M A M O T O Y, O H U R A T, M I N A K A W A H, et al (1994). Experience with arteriovenous malformations treated with flap coverage. Plastic and Reconstructive Surgery, 94: 476-482.
Received: 18 March 1996 Accepted after revision: 3 June 1996 Dr R. Adani, Sez. Chirurgia delia Mano, Policlinico, Via del Pozzo 71, 41100 Modena, Italy. Fig 3
(a, b ) G o o d c o s m e t i c r e s u l t a t 42 m o n t h s f o l l o w - u p .
© 1997 The British Society for Surgery of the Hand
From the Hand Surgery Unit, University of Modena, Modena, Italy We report a case of a low-flow venous malformation of the thumb treated by microsurgical excision of the mass and a free toe pulp flap. Forty-two months after surgery the patient had a good cosmetic and functional result without any recurrence of the turnout.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 1." 30-31 Vascular malformations account for about 8% of all soft tissue tumours reported in the upper limb (Vandevender and Daley, 1995). Localized venous malformations are uncommon in the hand (Glanz, 1969; Glicenstein et al, 1988; Tropet et al, 1982). If the tumour is symptomatic, with pain, swelling and/or paraesthesia, surgical excision is the treatment of choice (Caroli et al, 1991; Glicenstein et al, 1988; Palmieri, 1987). In some cases the mass is localized to the pulp of a single digit, involving the dermal layer. In these cases excision of the tumour requires the removal of overlying skin. The problem of adequate resurfacing is particularly important when the thumb pulp is involved. We report a case of venous malformation of the thumb which was treated by microsurgical resection and pulp reconstruction by a free toe pulp flap.
suspected and clinical diagnosis of a low-flow vascular malformation was confirmed by echo-colour-Doppler, angiography and magnetic resonance (MR) examinations (Fig 2). He was treated by excision of the lesion. In a bloodless field, magnification was used to identify, ligate and then divide the feeding and drainage vessels of the malformation. The tumour was found to be connected with the ulnar neurovascular bundle. A deep infiltration of the subcutaneous and dermal layers of the pulp was evident, while the nailbed seemed to be uninvolved. Removal of the distal portion of the ulnar neurovascular bundle at the IP joint level and of the palmar and dorso-ulnar skin of the distal phalanx was necessary to allow complete excision. The residual defect measured about 4 x 3.5 cm and reconstruction was performed by means of a free pulp flap taken from the homolateral big toe. The transferred flap included the dorsalis pedis artery and vein and the plantar nerve, which were joined to the dorsal branch of the radial artery, the cephalic vein and the ulnar digital nerve respectively, at the recipient site. Histological examination confirmed the diagnosis of a venous malformation. Forty-two months after surgery the
CASE REPORT A 24-year-old, right-handed male student presented with a congenital soft mass involving the pulp of the right thumb (Fig 1). The mass had enlarged considerably over the previous 3 years and for some time it had caused the patient an unpleasant "pin-prick" feeling. No sensory deficit was evident. As well as functional limitation in fine prehension, he complained of cosmetic embarrassment. The vascular nature of the tumour was immediately
Fig 1
The mass involved the pulp and part of the dorso-ulnar aspect of the distal phalanx of the right thumb.
Fig 2
30
Tl-weighted sagittal section (TR/TE=400/20) of the thumb showing a hyperintense reticulate (adipose tissue) within a wide hypointense mass.
VENOUS M A L F O R M A T I O N
operated thumb showed a good aesthetic and functional result (Weber test on the reconstructed ulnar side of the pulp: 6 ram) without recurrence of the tumour (Fig 3). DISCUSSION Numerous treatments have been proposed for vascular malformations. Many of these methods cannot be used or are not successful in digits: the intralesional injection of sclerosant agents and radiation therapy often cause undesirable effects on the surrounding healthy tissues; cryotherapy gives poor results and the use of the Argon laser is not indicated for subcutaneous forms
31
(Glicenstein et al, 1988). The YAG laser is not suitable for treating localized forms that involve the dermal layer and does not always allow a radical excision (Apfelberg et al, 1990). Surgery seems to be the best treatment for these tumours. The subcutaneous localized forms are most easily treated with surgical excision, with a low recurrence rate (Palmieri, 1987). The traditional wide surgical resection in diffuse or in certain localized forms, can jeopardize important structures, such as vessels and digital nerves, and has a higher recurrence rate, usually due to the technical difficulty in removing the whole mass (Hill et al, 1993). Microsurgical dissection technique minimizes damage to important structures and can reduce the risk of recurrence. If the residual cutaneous defect after excision is small, it can be successfully skin grafted. For wider defects, a local flap (Glanz, 1969) or a neurovascular heterodigital island flap can be used (Caroli et al, 1991 ). Involvement of the whole pulp and part of the dorsum of the finger makes the problem of reconstruction more complex: a wide flap of thin and sensitive skin is required to restore the function and the contour of the thumb. A good solution to both problems was found by using a free toe pulp flap. Microsurgery is a well-established tool for the treatment of congenital arteriovenous fistulas of the hand (Koshima et al, 1993; Yamamoto et al, 1994) but only a small number of cases have been reported in which low-flow malformations of the upper limb have been treated by microsurgical excision and free flap coverage (Tropet et al, 1982).
References A P F E L B E R G D B, MASER M R, LASH H, WHITE D N (1990). YAG laser resection of complicated hemangiomas of the hand and upper extremity. Journal of Hand Surgery, 15A: 765 773. CAROLI A, ZANASI S, M A R C U Z Z I A, et al (1991). Gli emangiomi della mano. Chirurgia degli Organi di Movimento, 76: 317-325. G L A N Z S (1969). The surgical treatment of cavernous haemangiomas of the hand. British Journal of Plastic Surgery, 22:293 301. GLICENSTEIN J, O H A N A J, L E C L E R C Q C. Tumeurs vasculaires. In: Glicenstein J (Ed.): Tumeurs de la main. Berlin, Springer-Verlag, 1988: 150-167. H I L L R A, P H O R W H, K U M A R V P (1993). Resection of vascular malformations. Journal of H a n d Surgery, 18B: 17-21. K O S H I M A I, SOEDA S, M U R A S H I T A T (1993). Extended wrap-around flap for reconstruction of the finger with recurrent arteriovenous malformation. Plastic and Reconstructive Surgery, 91:1140-1144. PALMIERI T J (1987). Vascular tumors of the hand and forearm. H a n d Clinics, 3: 225-240. TROPET Y, M E R L E M, F O U C H E R G, V I C H A R D Ph, M I C H O N J (1982). Angiomes sous-cutan6s de la main. Annales de Chirurgie Plastique, 27: 68-71. VANDEVENDER D K, D A L E Y R A (1995). Benign and malignant vascular tumors of the upper extremity. H a n d Clinics, 11: 161- 181. Y A M A M O T O Y, O H U R A T, M I N A K A W A H, et al (1994). Experience with arteriovenous malformations treated with flap coverage. Plastic and Reconstructive Surgery, 94: 476-482.
Received: 18 March 1996 Accepted after revision: 3 June 1996 Dr R. Adani, Sez. Chirurgia delia Mano, Policlinico, Via del Pozzo 71, 41100 Modena, Italy. Fig 3
(a, b ) G o o d c o s m e t i c r e s u l t a t 42 m o n t h s f o l l o w - u p .
© 1997 The British Society for Surgery of the Hand