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Reconstruction of large palmar defects of the hand using free flaps
RECONSTRUCTION OF LARGE PALMAR DEFECTS HAND USING FREE FLAPS
OF THE
M. M. NINKOV[C, A. H. SCHWABEGGER, G. WECHSELBERGER and H. ANDERL
From the University ClinicJot Plastic and Reconstructive Surgery, Innsbruck, Austria The reconstruction of large palmar defects of the hand remains a difficult problem due to the specific anatomical structures and highly sophisticated function of the palm. The glabrous skin and subcutaneous tissue in the palm are perfectly adapted to serve ,the prehensile function. The particular aim must be that repairs to this functional structure are similar in texture and colour and are aesthetically acceptable. Restoration of sensibility is desirable. For smaller defects a great variety of local pedicled or island flaps can be applied. However, for larger defects with exposed tendons, nerves or other essential structures, free flaps remain as a reliable alternative. This paper reviews our approach of soft tissue reconstruction in 16 patients with large palmar defects using various kinds of free flaps. The advantages, disadvantages and current indications for free flap resurfacing of the palm are discussed. Journal of Hand Surgery (British and European Volume, 1997) 22B." 5." 623-630
Large and deep soft tissue defects of the palm of the hand are not very frequent but their reconstruction is extremely difficult due to the special anatomy required for function of the palm. The glabrous skin provides unique support and protection of the underlying structures. The high concentration of sensory mechanoreceptors increasing in number from palm to fingertip provides a high degree of sophisticated sensibility in the working surface of the hand. The ideal substitute for palmar defects must be sensate, durable, relatively immobile, hairless and thin (Upton et al, 1992). Small soft tissue defects of the palm can be left to epithelialize spontaneously, or may be covered with splitthickness hypothenar or plantar skin grafts. The immobility of palmar skin makes local flap techniques inapplicable. However, regional neurovascular island flaps are very popular for fingertip reconstruction. They provide adequate sensibility and can be effectively combined with other flaps to cover a larger defect. Furthermore, distant pedicled flaps and a great variety of free flaps have been used for soft tissue reconstruction of large palmar defects. The purpose of this paper is to review our experience and to draw conclusions about the advantages, disadvantages and current indications for different free flaps to resurface soft tissue defects of the palm.
They were treated with various fasciocutaneous free flaps (Table 2) Depending on the time of reconstruction we divided our patients into three groups (Table 3). Results
No flap failure occurred. A significant complication was seen only once, where thrombosis of the vein graft caused partial necrosis of fingers (Case 3, Fig 3d). Hospital stay ranged from 5 to 25 days with a mean of 14 days. Secondary procedures such as tenolysis (two patients), transplantation (one patient) or transposition (one patient) of tendons beneath the fasciocutaneous flaps were feasible. All patients regained protective sensibility within 6 to 12 months. In those in whom sensate flaps were applied (six patients), two-point discrimination ranged from 12 to 16 mm, and no flap remained insensate. CASE REPORTS Case 1 This 23-year-old piano player sustained an explosion injury 7 months before referral to our clinic. At the time of injury he lost the distal part of thumb, middle and ring finger and the complete index finger with subsequent ray amputation. Upon referral the hand was completely immobile due to severe scar contraction in the palm (Fig l a). Radical scar excision was performed and the resulting defect (Fig 1b) was covered with a free groin flap, anastomosed to the ulnar vessels end to side. In this case a lateral arm flap was impracticable due to hirsutism and a dorsalis pedis flap was not possible, since toes to hand transfer was performed in a two-stage thumb and middle and ring finger reconstruction within 2 months (Fig 1c,d). Slight flap debulking was done later. The patient regained sufficient protective sensibility in the palm. After changing his job from a piano player to a salesman, he is now well able to use the keyboard of his computer.
PATIENTS A N D M E T H O D S
Between 1986 and 1996, 71 patients with severe injuries of the upper extremity were treated with a free flap. Sixteen of them had extensive traumatic soft tissue defects of the palmar region of the hand, caused by traffic accidents, high voltage burns, explosions, circular saws or other machinery (Table 1). All patients were male, probably due to the nature of injury, which in 12 cases resulted from occupational accidents and four from an explosion or gunshot. The mean age was 37 years (range 16 61). 623
THE JOURNAL OF HAND SURGERY VOL. 22B No. 5 OCTOBER 1997
624 Table ImPatient data
Patient
Age
Side
Cause
Appearance
Freeflap
Secondary
Complications
Follow-up
1
23
R
Explosion
First web space and radial palm contracture
Groin
Toe to hand transfers, flap debulking
None
31 months
2
45
L
Traffic accident
Exposed nerve and tendons after scar resection
First web space foot
None
Delayed healing at donor site
Lost after 2 weeks
3
22
L
Roller crush
Degloved h a n d
Lateral a r m
5, excision of dead Partial finger tissue, flap division, necrosis split thickness skin graft
42 months
4
23
R
Traffic accident
Exposed tendons, nerves, and vessels
Instep
3, tendon repairs
None
30 months
5
41
L
Wood shaver
Avulsed thenar, exposed tendons and joints
Lateral a r m
None
None
6 months
6
26
L
High voltage burns
Scar contraction
Groin
8, for t h u m b function repair
None
14 years
7
44
R
Circular saw
T h u m b stump and thenar infection and necrosis
Lateral a r m
Late t h u m b Partial necrosis reconstruction with from infection vascularized iliac crest
68 months
8
34
L
Explosion
Scar contraction first web space and thenar
Lateral a r m
2, revisions
Venous thrombosis twice
54 months
9
51
L
Woodcutter
Transmetacarpal amputation
Lateral a r m
Flap trimming and tendolysis
Delayed healing donor site, STSG
41 months
10
24
R
Avulsion
First web contracture after pollicization
Lateral a r m
Flap trimming
None
76 months
11
21
L
Roller crush
Exposed tendons after decollement
2 lateral arm flapssandwich
2, excision of dead tissue
Marginal necrosis
37 months
12
41
L
Circular saw
Oblique transmetacarpal amputation
Lateral a r m
None
None
34 months
13
61
R
Rope
T h u m b and thenar avulsion
Serratus fascia and STSG
None
None
47 months
14
32
R
Explosion
First web space and radial palm contracture
Lateral a r m
None
None
20 months
15
48
L
Gunshot wound
First web space and radial palm contracture with osteitis of second metacarpal
Lateral a r m
None
None
16 months
16
51
R
Iron press
Crushed carpus with metacarpeal amputation of digits IIV
Lateral a r m
None, toe to hand planned
None
6 months
625
RECONSTRUCTIONOF PALMARDEFECTS Table 2--Distribution of free flaps used for palm reconstruction
First web space of the foot Serratus fascia flap and split thickness skin graft Instep flap Groin flap Lateral arm flap
1 1 1 2 11
scar was excised but this caused exposure o f tendons and nerves (Fig 2c), the m e t a c a r p o p h a l a n g e a l joint was fully extensible. Cover of the defect was done using a sensate first web space flap (Fig 2d) and resulted in a functionally and cosmetically excellent outcome. Unfortunately the patient was lost to follow-up, so no late result picture is available. However, this case is reported as a demonstration o f defect cover in this special region. /
Table 3--Time of palm reconstruction with free fasciocutaneous flaps Case 3
Emergency Delayed Late
Within 24 hours Within 7 days After 7 days
Seven patients Five patients Four patients
Case 2
After a traffic accident the little finger o f a 45-year-old priest was a m p u t a t e d through the metacarpal bone. The developing scar resulted in a flexion contracture o f the ring finger (Fig 2a,b). Twenty-three years after injury the
Fig 1
This 22-year-old patient sustained a severe avulsion injury o f the left h a n d t h r o u g h a roller crush (Fig 3a,b). After d6bridement the index, middle, ring and little finger were revascularized with interpositional vein grafts (Fig 3c) and defects on the dorsal and palmar site were covered with skin grafts. Ten hours later due to t h r o m b o sis o f the interpositional vein grafts a revision was done. Perfusion o f the revascularized fingers was achieved and the palmar defect was covered with an extended lateral a r m free flap. Further d6bridement was done on the
(Case 1) (a) Severe contracture of the mutilated hand seven months after explosion injury, showing maximal range of finger extension and thumb abduction. (b) Situation after release of contraction through radical scar excision. Note exposed flexor tendons. (c, d) Thirty-one months postoperatively with excellent reconstruction of palm contour after slight flap debulking. Additionally thumb, middle and ring finger were reconstructed by toe to hand transfer in two sessions.
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T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 5 O C T O B E R 1997
Fig 2
(Case 2) (a, b) Severe and functionally impairing contracture 20 years after explosion injury and ray amputation. Maximal range of finger extension shown. (c) Full range of extension after scar excision, exposed flexor tendons and nerves. (d) Harvesting the first web space flap from the contralateral foot. (e) Situation 2 weeks postoperatively, patient was lost from further follow-up.
Case 4
dorsal side of the hand and the soft tissue defect was covered with split thickness skin grafts. The flap was anastomosed end-to-side to the radial artery and end-to-end to the comittant vein. A few days later venous thrombosis developed again, causing partial finger necrosis (Fig 3d) Repeated excision of dead tissue was done. The viable flap could then be mobilized distally to cover the finger stumps. Five months later the part of the flap covering the fingers was divided and the remaining wounds covered with full thickness skin grafts (Fig 3e,f). Restoration of protective sensibility was adequate.
Five days before referral to our hospital this 23-year-old patient sustained a traffic accident causing a severe abrasion injury of the palm with subsequent inflammation and necrosis of almost all of the palm, underlying flexor tendons and several digital nerves. The necrotic mass was d6brided immediately, followed by high dose antibiotic therapy. Five days later repeated d6bridement was done (Fig 4a), and the remaining defect was covered with a sensate (medial plantar nerve) free instep flap (Fig 4b) after reconstruction of the tendons and nerves by interpositional grafts in the same session. The medial plantar nerve was also reconstructed by a sural nerve graft. Vascular anastomosis was done end-to-side to the radial vessels, the medial plantar nerve was coapted to the superficial branch of the radial nerve. Insufficient flexor function necessitated tenolysis and tendon transfers, which could be performed beneath the flap without any major surgical difficulties or complications (Fig 4d,e). Two-point discrimination in the reconstructed palm 24 months later was 6 to 7 mm.
RECONSTRUCTION OF PALMAR DEFECTS
Fig 3
627
(Case 3) (a, b) Extensive avulsion injury from a roller crush, only the thumb being uninjured and with vascular supply. (c) Immediate revascularization of all four fingers by vascular grafts. (d) Cover of palm defect was done with a lateral arm flap. Notice distal finger necrosis a few days after primary surgery and complete survival of the E L A E (e, f) Result after partial finger reconstruction through mobilization of the flap distally and separation 5 months later.
DISCUSSION A wide variety of flaps may be used for hand reconstruction, but not all possess the ability to resurface a palmar soft tissue defect successfully and reliably. Sensibility, skin thickness, texture, colour, durability, binding of the
flap to the underlying structures, donor site morbidity, possibility of secondary reconstructive procedures, the surgeon's experience and operative facilities must all be taken into consideration. General difficulties of palm reconstruction originate from specific anatomical and functional characteristics
628
THE JOURNAL OF HAND SURGERY VOL. 22B No. 5 OCTOBER 1997
Fig 4
of the palmar surface of the hand (Table 4) as well as from its cosmetic requirements as a communication tool. The ultimate functional use of a hand depends upon sensation in its working surfaces and gliding of tendons. Restoration of this function has been attempted (Daniel et al, 1974) with a neurovascular medial arm flap, and later (Inigo and Gargollo, 1992; Ohmori and Harii, 1976) with a sensory dorsalis pedis flap. The popular radial forearm flap (RFF), either pedicled or free (Foucher et al, 1984; Mfihlbauer et al, 1982), in our opinion has an unacceptable donor site morbidity with sacrifice of the radial artery. In addition, the palmar arterial arches may be damaged by a severe palm injury, which prohibits application of a pedicled R F E
(Case 4) (a) Situation after radical ddbridement of an abrasion injury with subsequent palm infection. Necrotic and excised flexor tendons and nerves already reconstructed by graft interpositions. (b) Harvesting of a free instep flap from the ipsilateral foot. (c, d, e) Excellent functional result 24 months after tendon transfers.
In our clinical practice the most useful free fasciocutaneous flap is the extended lateral arm flap (ELAF), which is thin distally with skin which is relatively well anchored to the underlying fascia (Moffett et al, 1991). Furthermore, the restoration of sensation is obtained after coaptation of the posterior cutaneous nerve of the forearm to a recipient nerve of the hand. With regard to donor site morbidity the E L A F is superior to any other innervated fasciocutaneous flap (Table 5). In addition to the scar on the lateral side of the distal part of the upper arm and the proximal part of the forearm, there is a small area of sensory disturbance in the lateral proximal part of the forearm. After raising the ELAF, the overlap of the sensory nerves in the forearm clinically results in an area of "different" sensation without an area of absolute sensory loss. Our patients accept this donor site morbidity very well. However, this flap is far from being perfect for palmar resurfacing due to its colour, texture, mobility, proximal subcutaneous bulk and transfer of
RECONSTRUCTION OF PALMAR DEFECTS
629
Table 4--The specific anatomical and corresponding functional characteristics of the palmar surface of the hand
Anatomy
Function
T h i c k , c o r n i f i e d , hairless, inelastic g l a b r o u s skin w i t h specialized fat p o c k e t s
Protection and support of underlying structures, cosmetic appearance, prehensile function
P a h n a r s k i n is rigidly a n c h o r e d to the d e e p s t r u c t u r e s w i t h f i b r o u s s e p t a a n d fat-free s k i n creases
R e s i s t a n c e to t e a r a n d d a m a g e
High concentration of mechanoreceptors
S o p h i s t i c a t e d tactile g n o s i s
Plenty of exocrine sweat glands
High hydration
S u p e r f i c i a l p a l m a r f a s c i a in the m i d - p a l m a r p o r t i o n
P r o t e c t i o n for flexor t e n d o n s a n d n e u r o v a s c u l a r b u n d l e s
F l e x o r t e n d o n s , nerves, a n d vessels s u p p l y i n g the fingers, i n t r i n s i c m u s c l e s
M o t i o n a n d fine f u n c t i o n o f f i n g e r s
Table 5--Criteria for free flap selection in resurfacing palmar defects of the hand
Flap
Dorsalis pedis D o r s a l i s pedis w i t h t e n d o n s Fascia and STSG Groin Instep Lateral arm Muscle and STSG Parascapular Radial forearm Scapula First web space foot
Sensibility
Skin thickness
Durability
Colour
Texture
+ + -
+ + + +~ + + +/ + +/ +
+ + +/+~ + +/ + +/+/ +/ . +
-
-
+ +/ -
+
-
-
+
+
.
.
Firm binding
+ + +/ -
. -
Donor site morbidity
Optional secondary surgical procedure
+ + +/ +/+ + + -
+ + + + + +/+ + + +
(+) Good; ( + / ) Acceptable; (-) Non-acceptable STSG = split thickness skin graft
hair in some patients. The soft tissue thickness of the LAF (Katsaros et al, 1984; Scheker et al, 1987; 1988) can be avoided in raising it as an ELAF from the proximal part of the lateral forearm region, including the septal blood supply emerging from the distal part of the upper arm. Large fasciocutaneous flaps such as the groin (Chow et al, 1986), peroneal (Nakashima et al, 1987; Yoshimura et al, 1989), parascapular~(Burns and Schlafly, 1986) or scapular flaps may also be used but with the disadvantages that they lack sensation and are bulky, whereas small fasciocutaneous free flaps show acceptable results (Ishikura et al, 1995; Thatte et al, 1986). The choice of the groin flap in case 1 (Fig 1) was based on the patient's very slim shape and the desire to avoid scars because of his profession as a piano player. The preferable foot donor region in this case was left as a source for further thumb, index and middle finger reconstruction (Fig lc,d). Long-term follow-up revealed excellent function and very good protective sensibility in the reconstructed palm, which may be explained through nerve growth into
the very thin flap from the underlying surface and through a very long zig-zag suture line. This flap may be an alternative flap for men with a hairy ELAF region or for slim women to avoid a scar on the arm. This flap is also suitable for very large defects extending from the palm to the lower arm. In spite of certain advantages in infected wounds, selected thin muscle flaps covered with split thickness skin grafts lack sensation, are often too bulky and undergo fibrosis and scarring (Wolff and Stiller, 1992), which complicates secondary surgical procedures. Because of these disadvantages, resurfacing of palmar defects with muscle flaps remains limited to very selected indications (Dautel and Merle, 1993; Gordon et al, 1993; Logan et al, 1988; Press et al, 1990). A satisfactory alternative for palmar coverage may be a fascial flap (Wintsch and Helaly, 1986) covered with skin grafts (Table 1, case 13), or other potential donor sites such as the temporoparietal fascia (Ueda, 1996; Upton et al, 1986), lateral thigh and posterior calf fascia. Fascia provides a thin vascularized bed for grafts and a
630
surrounding layer for tendon gliding. However, secondary reconstructive procedures are more difficult beneath fascia covered with skin graft than beneath a flap consisting of normal skin and subcutaneous tissue. Furthermore, limited size and thickness are the major disadvantages of free fascial flaps. In our experience, an ideal functional and cosmetic reconstruction of the palmar surface can be achieved with a free flap taken from the sole of the foot, due to the similar anatomical structures. In case 6 a large isolated full thickness palmar defect was reconstructed using an innervated free instep flap (Ninkovi~ et al, 1996). This flap provides an optimal cosmetic, functional and anatomical replacement of the palm with acceptable donor-site morbidity (except for marginal hyperkeratosis, Fig 4e). Small defects should be reconstructed using the first interdigital free flap from the foot (Fig 2) whereas the free instep flap should be reserved for complete palmar resurfacing. According to the time of free flap cover in severe upper extremity injury we divided our patients into three groups (Table 3). The timing of wound closure or reconstruction including radical ddbridement and, if possible, emergency free flap cover (Lister, 1988) is of fundamental importance, regardless of wound size (Ninkovi~ et al, 1995 a; 1995 b). Delayed or late reconstruction with a free flap increases the number of secondary operative procedures, prolonging hospital stay and affecting the final outcome (Ninkovi~ et al, 1995 a; 1995 b; Wood and Irons, 1983). References Burns J T, Schlafly B (1986). Use of the parascapular flap in hand reconstruction. Journal of Hand Surgery, 1 IA: 872-875. Chow J A, Bilos Z J, Hui P, Hall R F, Seyfer A E, Smith A C (1986). The groin flap in reparative surgery of the hand. Plastic and Reconstructive Surgery, 77: 421425. Daniel R K, Terzis J, Schwarz G (1975). Neurovascular free flaps. Plastic and Reconstructive Surgery, 56:13-20. Dautel G, Merle M (1993). Pronator quadratus free muscle flap for treatment of palmar defects. Journal of Hand Surgery, 18B: 576 578. Foucher G, Van Gnechten F, Merle N, Michon J (1984). A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap. British Journal of Plastic Surgery, 37:139-148. Gordon L, Levinsohn D G, Finkemeier C, Angeles A, Deutch H (1993). The serratns anterior free-muscle transplant for reconstruction of the injured hand: an analysis of the donor and recipient sites. Plastic and Reconstructive Surgery, 92: 97--101. Inigo F, Gargollo C (1992). Secondary coverage of the hand using a dorsalis pedis plus first web space free flap. Journal of Reconstructive Microsurgery, 8: 461465. Ishikura N, Heshiki T, Tsukada S (1995). The use of a free medialis pedis flap for resurfacing skin defects of the hand and digits. Plastic and Reconstructive Surgery, 95:100 107.
THE JOURNAL OF HAND SURGERY VOL. 22B No. 5 OCTOBER 1997 Katsaros J, Schusterman M, Beppu M, Bannis J C, Acland R D (1984). The lateral upper arm flap: anatomy and clinical applications. Annals of Plastic Surgery, 12:489 500. Lister G D: Emergency free flaps. In: Green D P (Ed.): Operative hand surgery, 2nd edn. New York, Churchill Livingstone, 1988, Vol. 2:1127-1149. Logan S E, Alpert P S, Buncke H J (1988). Free serratus anterior muscle transplantation for hand reconstruction. British Journal of Plastic Surgery, 41: 639-643. Moffett T R, Madison S A, Derr J D, Acland R D (1991). An extended approach for the vascular pedicle of the lateral arm flap. Plastic and Reconstructive Surgery, 89: 259-267. Mfihlbauer W, Herndl E, Stock W (1982). The forearm flap. Plastic and Reconstructive Surgery, 70:336 344. Nakashima H, Araki Y, Nishikido E, Matzuda T, ltoh Y (1987). Free peroneal flap for wide skin defects of the foot and volar contracture of the hand. Journal of Reconstructive Microsurgery, 3:105 1 l 1. NinkovibM, Deetjen H, ¢)hler K, Anderl H (1995 a). Emergency free tissue transfer for severe upper extremity injuries. Journal of Hand Surgery, 20B: 53 58. Ninkovi~ M, Hussl H, Hefei L, Anderl H (1995 b). Timing of reconstruction in severe upper extremity injuries using free flaps. Handchirurgie, Mikrochirurgie, Plastische Chirurgie, 27: 297-306. Ninkovi~ M, Wechselberger G, Schwabegger A, Anderl H (1996). The instep free flap to resurface palmar defects of the hand. Plastic and Reconstructive Surgery, 97: 1489-1493. Ohmori K and Harii K (1976). Free dorsalis pedis sensory flap to the hand, with microneurovascular anastomoses. Plastic and Reconstructive Surgery, 58: 546 554. Press B H J, Chiu D T W, Cunningham B L (1990). The rectus abdominis muscle in difficult problems of hand soft tissue reconstruction. British Journal of Plastic Surgery, 43: 419M25. Scheker L R, Kleinert H E, Hanel D P (1987). Lateral arm composite tissue transfer to ipsilateraI hand defects. Journal of Hand Surgery, 12 A: 665-672. Scheker L R, Lister G D, Wolf T W (1988). The lateral arm flap in releasing severe contracture of the first web space. Journal of Hand Surgery, 13 B: 146 150. Thatte R L, Patil U A, Dhami L D (1986). The combined use of the superficial external pudendal artery flap with a flap of the anterior rectus sheath for the simultaneous cover of dorsal and volar defects of the hand. British Journal of Plastic Surgery, 39: 321-326. Ueda K, Harashina T, Inoue T, Ohba S (1996). Temporoparietal sandwich techniq ue in acute avulsion injury of the hand. Journal of Reconstructive Microsurgery, 12: 19-22. Upton J, Rogers C, Durham-Smith G, Swartz W M (1986). Clinical applications of fi'ee temporoparietal flaps in hand reconstruction. Journal of Hand Surgery, 11 A: 475483. Upton J, Havlik R J, Khouri R K (1992). Refinements in hand coverage with microvascular free flaps. Clinics in Plastic Surgery,/9: 841-857. Wintsch K, Helaly P (1986). Free flap of gliding tissue. Journal of Reconstructive Microsurgery, 2: 143-151. Wolff K D, Stiller D (1992). Functional aspects of free muscle transplantation: atrophy, reinnervation and metabolism. Journal of Reconstructive Microsurgery, 8: I37-142. Wood M B, irons G B (1983). Upper extremity free skin flap transfer: results and utility as compared with conventional distant pedicle skin flaps. Annals of Plastic Surgery, I 1:523 526. Yoshimura M, Shimada T, Matsuda M, Hosokawa M, lmura S (1989). Double peroneal free flap for multiple skin defects of the hand. British Journal of Plastic Surgery, 42:715 718.
Received:29 October 1996 Accepted after revision:24 February 1997 Dr M. M Ninkovid,Universit/itsklinikffir Plastischeund Wiederherstellungschirurgie, Anichstrasse 35, A-6020Innsbruck, Austria © 1997The British Societyfor Surgeryof the Hand
OF THE
M. M. NINKOV[C, A. H. SCHWABEGGER, G. WECHSELBERGER and H. ANDERL
From the University ClinicJot Plastic and Reconstructive Surgery, Innsbruck, Austria The reconstruction of large palmar defects of the hand remains a difficult problem due to the specific anatomical structures and highly sophisticated function of the palm. The glabrous skin and subcutaneous tissue in the palm are perfectly adapted to serve ,the prehensile function. The particular aim must be that repairs to this functional structure are similar in texture and colour and are aesthetically acceptable. Restoration of sensibility is desirable. For smaller defects a great variety of local pedicled or island flaps can be applied. However, for larger defects with exposed tendons, nerves or other essential structures, free flaps remain as a reliable alternative. This paper reviews our approach of soft tissue reconstruction in 16 patients with large palmar defects using various kinds of free flaps. The advantages, disadvantages and current indications for free flap resurfacing of the palm are discussed. Journal of Hand Surgery (British and European Volume, 1997) 22B." 5." 623-630
Large and deep soft tissue defects of the palm of the hand are not very frequent but their reconstruction is extremely difficult due to the special anatomy required for function of the palm. The glabrous skin provides unique support and protection of the underlying structures. The high concentration of sensory mechanoreceptors increasing in number from palm to fingertip provides a high degree of sophisticated sensibility in the working surface of the hand. The ideal substitute for palmar defects must be sensate, durable, relatively immobile, hairless and thin (Upton et al, 1992). Small soft tissue defects of the palm can be left to epithelialize spontaneously, or may be covered with splitthickness hypothenar or plantar skin grafts. The immobility of palmar skin makes local flap techniques inapplicable. However, regional neurovascular island flaps are very popular for fingertip reconstruction. They provide adequate sensibility and can be effectively combined with other flaps to cover a larger defect. Furthermore, distant pedicled flaps and a great variety of free flaps have been used for soft tissue reconstruction of large palmar defects. The purpose of this paper is to review our experience and to draw conclusions about the advantages, disadvantages and current indications for different free flaps to resurface soft tissue defects of the palm.
They were treated with various fasciocutaneous free flaps (Table 2) Depending on the time of reconstruction we divided our patients into three groups (Table 3). Results
No flap failure occurred. A significant complication was seen only once, where thrombosis of the vein graft caused partial necrosis of fingers (Case 3, Fig 3d). Hospital stay ranged from 5 to 25 days with a mean of 14 days. Secondary procedures such as tenolysis (two patients), transplantation (one patient) or transposition (one patient) of tendons beneath the fasciocutaneous flaps were feasible. All patients regained protective sensibility within 6 to 12 months. In those in whom sensate flaps were applied (six patients), two-point discrimination ranged from 12 to 16 mm, and no flap remained insensate. CASE REPORTS Case 1 This 23-year-old piano player sustained an explosion injury 7 months before referral to our clinic. At the time of injury he lost the distal part of thumb, middle and ring finger and the complete index finger with subsequent ray amputation. Upon referral the hand was completely immobile due to severe scar contraction in the palm (Fig l a). Radical scar excision was performed and the resulting defect (Fig 1b) was covered with a free groin flap, anastomosed to the ulnar vessels end to side. In this case a lateral arm flap was impracticable due to hirsutism and a dorsalis pedis flap was not possible, since toes to hand transfer was performed in a two-stage thumb and middle and ring finger reconstruction within 2 months (Fig 1c,d). Slight flap debulking was done later. The patient regained sufficient protective sensibility in the palm. After changing his job from a piano player to a salesman, he is now well able to use the keyboard of his computer.
PATIENTS A N D M E T H O D S
Between 1986 and 1996, 71 patients with severe injuries of the upper extremity were treated with a free flap. Sixteen of them had extensive traumatic soft tissue defects of the palmar region of the hand, caused by traffic accidents, high voltage burns, explosions, circular saws or other machinery (Table 1). All patients were male, probably due to the nature of injury, which in 12 cases resulted from occupational accidents and four from an explosion or gunshot. The mean age was 37 years (range 16 61). 623
THE JOURNAL OF HAND SURGERY VOL. 22B No. 5 OCTOBER 1997
624 Table ImPatient data
Patient
Age
Side
Cause
Appearance
Freeflap
Secondary
Complications
Follow-up
1
23
R
Explosion
First web space and radial palm contracture
Groin
Toe to hand transfers, flap debulking
None
31 months
2
45
L
Traffic accident
Exposed nerve and tendons after scar resection
First web space foot
None
Delayed healing at donor site
Lost after 2 weeks
3
22
L
Roller crush
Degloved h a n d
Lateral a r m
5, excision of dead Partial finger tissue, flap division, necrosis split thickness skin graft
42 months
4
23
R
Traffic accident
Exposed tendons, nerves, and vessels
Instep
3, tendon repairs
None
30 months
5
41
L
Wood shaver
Avulsed thenar, exposed tendons and joints
Lateral a r m
None
None
6 months
6
26
L
High voltage burns
Scar contraction
Groin
8, for t h u m b function repair
None
14 years
7
44
R
Circular saw
T h u m b stump and thenar infection and necrosis
Lateral a r m
Late t h u m b Partial necrosis reconstruction with from infection vascularized iliac crest
68 months
8
34
L
Explosion
Scar contraction first web space and thenar
Lateral a r m
2, revisions
Venous thrombosis twice
54 months
9
51
L
Woodcutter
Transmetacarpal amputation
Lateral a r m
Flap trimming and tendolysis
Delayed healing donor site, STSG
41 months
10
24
R
Avulsion
First web contracture after pollicization
Lateral a r m
Flap trimming
None
76 months
11
21
L
Roller crush
Exposed tendons after decollement
2 lateral arm flapssandwich
2, excision of dead tissue
Marginal necrosis
37 months
12
41
L
Circular saw
Oblique transmetacarpal amputation
Lateral a r m
None
None
34 months
13
61
R
Rope
T h u m b and thenar avulsion
Serratus fascia and STSG
None
None
47 months
14
32
R
Explosion
First web space and radial palm contracture
Lateral a r m
None
None
20 months
15
48
L
Gunshot wound
First web space and radial palm contracture with osteitis of second metacarpal
Lateral a r m
None
None
16 months
16
51
R
Iron press
Crushed carpus with metacarpeal amputation of digits IIV
Lateral a r m
None, toe to hand planned
None
6 months
625
RECONSTRUCTIONOF PALMARDEFECTS Table 2--Distribution of free flaps used for palm reconstruction
First web space of the foot Serratus fascia flap and split thickness skin graft Instep flap Groin flap Lateral arm flap
1 1 1 2 11
scar was excised but this caused exposure o f tendons and nerves (Fig 2c), the m e t a c a r p o p h a l a n g e a l joint was fully extensible. Cover of the defect was done using a sensate first web space flap (Fig 2d) and resulted in a functionally and cosmetically excellent outcome. Unfortunately the patient was lost to follow-up, so no late result picture is available. However, this case is reported as a demonstration o f defect cover in this special region. /
Table 3--Time of palm reconstruction with free fasciocutaneous flaps Case 3
Emergency Delayed Late
Within 24 hours Within 7 days After 7 days
Seven patients Five patients Four patients
Case 2
After a traffic accident the little finger o f a 45-year-old priest was a m p u t a t e d through the metacarpal bone. The developing scar resulted in a flexion contracture o f the ring finger (Fig 2a,b). Twenty-three years after injury the
Fig 1
This 22-year-old patient sustained a severe avulsion injury o f the left h a n d t h r o u g h a roller crush (Fig 3a,b). After d6bridement the index, middle, ring and little finger were revascularized with interpositional vein grafts (Fig 3c) and defects on the dorsal and palmar site were covered with skin grafts. Ten hours later due to t h r o m b o sis o f the interpositional vein grafts a revision was done. Perfusion o f the revascularized fingers was achieved and the palmar defect was covered with an extended lateral a r m free flap. Further d6bridement was done on the
(Case 1) (a) Severe contracture of the mutilated hand seven months after explosion injury, showing maximal range of finger extension and thumb abduction. (b) Situation after release of contraction through radical scar excision. Note exposed flexor tendons. (c, d) Thirty-one months postoperatively with excellent reconstruction of palm contour after slight flap debulking. Additionally thumb, middle and ring finger were reconstructed by toe to hand transfer in two sessions.
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T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 5 O C T O B E R 1997
Fig 2
(Case 2) (a, b) Severe and functionally impairing contracture 20 years after explosion injury and ray amputation. Maximal range of finger extension shown. (c) Full range of extension after scar excision, exposed flexor tendons and nerves. (d) Harvesting the first web space flap from the contralateral foot. (e) Situation 2 weeks postoperatively, patient was lost from further follow-up.
Case 4
dorsal side of the hand and the soft tissue defect was covered with split thickness skin grafts. The flap was anastomosed end-to-side to the radial artery and end-to-end to the comittant vein. A few days later venous thrombosis developed again, causing partial finger necrosis (Fig 3d) Repeated excision of dead tissue was done. The viable flap could then be mobilized distally to cover the finger stumps. Five months later the part of the flap covering the fingers was divided and the remaining wounds covered with full thickness skin grafts (Fig 3e,f). Restoration of protective sensibility was adequate.
Five days before referral to our hospital this 23-year-old patient sustained a traffic accident causing a severe abrasion injury of the palm with subsequent inflammation and necrosis of almost all of the palm, underlying flexor tendons and several digital nerves. The necrotic mass was d6brided immediately, followed by high dose antibiotic therapy. Five days later repeated d6bridement was done (Fig 4a), and the remaining defect was covered with a sensate (medial plantar nerve) free instep flap (Fig 4b) after reconstruction of the tendons and nerves by interpositional grafts in the same session. The medial plantar nerve was also reconstructed by a sural nerve graft. Vascular anastomosis was done end-to-side to the radial vessels, the medial plantar nerve was coapted to the superficial branch of the radial nerve. Insufficient flexor function necessitated tenolysis and tendon transfers, which could be performed beneath the flap without any major surgical difficulties or complications (Fig 4d,e). Two-point discrimination in the reconstructed palm 24 months later was 6 to 7 mm.
RECONSTRUCTION OF PALMAR DEFECTS
Fig 3
627
(Case 3) (a, b) Extensive avulsion injury from a roller crush, only the thumb being uninjured and with vascular supply. (c) Immediate revascularization of all four fingers by vascular grafts. (d) Cover of palm defect was done with a lateral arm flap. Notice distal finger necrosis a few days after primary surgery and complete survival of the E L A E (e, f) Result after partial finger reconstruction through mobilization of the flap distally and separation 5 months later.
DISCUSSION A wide variety of flaps may be used for hand reconstruction, but not all possess the ability to resurface a palmar soft tissue defect successfully and reliably. Sensibility, skin thickness, texture, colour, durability, binding of the
flap to the underlying structures, donor site morbidity, possibility of secondary reconstructive procedures, the surgeon's experience and operative facilities must all be taken into consideration. General difficulties of palm reconstruction originate from specific anatomical and functional characteristics
628
THE JOURNAL OF HAND SURGERY VOL. 22B No. 5 OCTOBER 1997
Fig 4
of the palmar surface of the hand (Table 4) as well as from its cosmetic requirements as a communication tool. The ultimate functional use of a hand depends upon sensation in its working surfaces and gliding of tendons. Restoration of this function has been attempted (Daniel et al, 1974) with a neurovascular medial arm flap, and later (Inigo and Gargollo, 1992; Ohmori and Harii, 1976) with a sensory dorsalis pedis flap. The popular radial forearm flap (RFF), either pedicled or free (Foucher et al, 1984; Mfihlbauer et al, 1982), in our opinion has an unacceptable donor site morbidity with sacrifice of the radial artery. In addition, the palmar arterial arches may be damaged by a severe palm injury, which prohibits application of a pedicled R F E
(Case 4) (a) Situation after radical ddbridement of an abrasion injury with subsequent palm infection. Necrotic and excised flexor tendons and nerves already reconstructed by graft interpositions. (b) Harvesting of a free instep flap from the ipsilateral foot. (c, d, e) Excellent functional result 24 months after tendon transfers.
In our clinical practice the most useful free fasciocutaneous flap is the extended lateral arm flap (ELAF), which is thin distally with skin which is relatively well anchored to the underlying fascia (Moffett et al, 1991). Furthermore, the restoration of sensation is obtained after coaptation of the posterior cutaneous nerve of the forearm to a recipient nerve of the hand. With regard to donor site morbidity the E L A F is superior to any other innervated fasciocutaneous flap (Table 5). In addition to the scar on the lateral side of the distal part of the upper arm and the proximal part of the forearm, there is a small area of sensory disturbance in the lateral proximal part of the forearm. After raising the ELAF, the overlap of the sensory nerves in the forearm clinically results in an area of "different" sensation without an area of absolute sensory loss. Our patients accept this donor site morbidity very well. However, this flap is far from being perfect for palmar resurfacing due to its colour, texture, mobility, proximal subcutaneous bulk and transfer of
RECONSTRUCTION OF PALMAR DEFECTS
629
Table 4--The specific anatomical and corresponding functional characteristics of the palmar surface of the hand
Anatomy
Function
T h i c k , c o r n i f i e d , hairless, inelastic g l a b r o u s skin w i t h specialized fat p o c k e t s
Protection and support of underlying structures, cosmetic appearance, prehensile function
P a h n a r s k i n is rigidly a n c h o r e d to the d e e p s t r u c t u r e s w i t h f i b r o u s s e p t a a n d fat-free s k i n creases
R e s i s t a n c e to t e a r a n d d a m a g e
High concentration of mechanoreceptors
S o p h i s t i c a t e d tactile g n o s i s
Plenty of exocrine sweat glands
High hydration
S u p e r f i c i a l p a l m a r f a s c i a in the m i d - p a l m a r p o r t i o n
P r o t e c t i o n for flexor t e n d o n s a n d n e u r o v a s c u l a r b u n d l e s
F l e x o r t e n d o n s , nerves, a n d vessels s u p p l y i n g the fingers, i n t r i n s i c m u s c l e s
M o t i o n a n d fine f u n c t i o n o f f i n g e r s
Table 5--Criteria for free flap selection in resurfacing palmar defects of the hand
Flap
Dorsalis pedis D o r s a l i s pedis w i t h t e n d o n s Fascia and STSG Groin Instep Lateral arm Muscle and STSG Parascapular Radial forearm Scapula First web space foot
Sensibility
Skin thickness
Durability
Colour
Texture
+ + -
+ + + +~ + + +/ + +/ +
+ + +/+~ + +/ + +/+/ +/ . +
-
-
+ +/ -
+
-
-
+
+
.
.
Firm binding
+ + +/ -
. -
Donor site morbidity
Optional secondary surgical procedure
+ + +/ +/+ + + -
+ + + + + +/+ + + +
(+) Good; ( + / ) Acceptable; (-) Non-acceptable STSG = split thickness skin graft
hair in some patients. The soft tissue thickness of the LAF (Katsaros et al, 1984; Scheker et al, 1987; 1988) can be avoided in raising it as an ELAF from the proximal part of the lateral forearm region, including the septal blood supply emerging from the distal part of the upper arm. Large fasciocutaneous flaps such as the groin (Chow et al, 1986), peroneal (Nakashima et al, 1987; Yoshimura et al, 1989), parascapular~(Burns and Schlafly, 1986) or scapular flaps may also be used but with the disadvantages that they lack sensation and are bulky, whereas small fasciocutaneous free flaps show acceptable results (Ishikura et al, 1995; Thatte et al, 1986). The choice of the groin flap in case 1 (Fig 1) was based on the patient's very slim shape and the desire to avoid scars because of his profession as a piano player. The preferable foot donor region in this case was left as a source for further thumb, index and middle finger reconstruction (Fig lc,d). Long-term follow-up revealed excellent function and very good protective sensibility in the reconstructed palm, which may be explained through nerve growth into
the very thin flap from the underlying surface and through a very long zig-zag suture line. This flap may be an alternative flap for men with a hairy ELAF region or for slim women to avoid a scar on the arm. This flap is also suitable for very large defects extending from the palm to the lower arm. In spite of certain advantages in infected wounds, selected thin muscle flaps covered with split thickness skin grafts lack sensation, are often too bulky and undergo fibrosis and scarring (Wolff and Stiller, 1992), which complicates secondary surgical procedures. Because of these disadvantages, resurfacing of palmar defects with muscle flaps remains limited to very selected indications (Dautel and Merle, 1993; Gordon et al, 1993; Logan et al, 1988; Press et al, 1990). A satisfactory alternative for palmar coverage may be a fascial flap (Wintsch and Helaly, 1986) covered with skin grafts (Table 1, case 13), or other potential donor sites such as the temporoparietal fascia (Ueda, 1996; Upton et al, 1986), lateral thigh and posterior calf fascia. Fascia provides a thin vascularized bed for grafts and a
630
surrounding layer for tendon gliding. However, secondary reconstructive procedures are more difficult beneath fascia covered with skin graft than beneath a flap consisting of normal skin and subcutaneous tissue. Furthermore, limited size and thickness are the major disadvantages of free fascial flaps. In our experience, an ideal functional and cosmetic reconstruction of the palmar surface can be achieved with a free flap taken from the sole of the foot, due to the similar anatomical structures. In case 6 a large isolated full thickness palmar defect was reconstructed using an innervated free instep flap (Ninkovi~ et al, 1996). This flap provides an optimal cosmetic, functional and anatomical replacement of the palm with acceptable donor-site morbidity (except for marginal hyperkeratosis, Fig 4e). Small defects should be reconstructed using the first interdigital free flap from the foot (Fig 2) whereas the free instep flap should be reserved for complete palmar resurfacing. According to the time of free flap cover in severe upper extremity injury we divided our patients into three groups (Table 3). The timing of wound closure or reconstruction including radical ddbridement and, if possible, emergency free flap cover (Lister, 1988) is of fundamental importance, regardless of wound size (Ninkovi~ et al, 1995 a; 1995 b). Delayed or late reconstruction with a free flap increases the number of secondary operative procedures, prolonging hospital stay and affecting the final outcome (Ninkovi~ et al, 1995 a; 1995 b; Wood and Irons, 1983). References Burns J T, Schlafly B (1986). Use of the parascapular flap in hand reconstruction. Journal of Hand Surgery, 1 IA: 872-875. Chow J A, Bilos Z J, Hui P, Hall R F, Seyfer A E, Smith A C (1986). The groin flap in reparative surgery of the hand. Plastic and Reconstructive Surgery, 77: 421425. Daniel R K, Terzis J, Schwarz G (1975). Neurovascular free flaps. Plastic and Reconstructive Surgery, 56:13-20. Dautel G, Merle M (1993). Pronator quadratus free muscle flap for treatment of palmar defects. Journal of Hand Surgery, 18B: 576 578. Foucher G, Van Gnechten F, Merle N, Michon J (1984). A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap. British Journal of Plastic Surgery, 37:139-148. Gordon L, Levinsohn D G, Finkemeier C, Angeles A, Deutch H (1993). The serratns anterior free-muscle transplant for reconstruction of the injured hand: an analysis of the donor and recipient sites. Plastic and Reconstructive Surgery, 92: 97--101. Inigo F, Gargollo C (1992). Secondary coverage of the hand using a dorsalis pedis plus first web space free flap. Journal of Reconstructive Microsurgery, 8: 461465. Ishikura N, Heshiki T, Tsukada S (1995). The use of a free medialis pedis flap for resurfacing skin defects of the hand and digits. Plastic and Reconstructive Surgery, 95:100 107.
THE JOURNAL OF HAND SURGERY VOL. 22B No. 5 OCTOBER 1997 Katsaros J, Schusterman M, Beppu M, Bannis J C, Acland R D (1984). The lateral upper arm flap: anatomy and clinical applications. Annals of Plastic Surgery, 12:489 500. Lister G D: Emergency free flaps. In: Green D P (Ed.): Operative hand surgery, 2nd edn. New York, Churchill Livingstone, 1988, Vol. 2:1127-1149. Logan S E, Alpert P S, Buncke H J (1988). Free serratus anterior muscle transplantation for hand reconstruction. British Journal of Plastic Surgery, 41: 639-643. Moffett T R, Madison S A, Derr J D, Acland R D (1991). An extended approach for the vascular pedicle of the lateral arm flap. Plastic and Reconstructive Surgery, 89: 259-267. Mfihlbauer W, Herndl E, Stock W (1982). The forearm flap. Plastic and Reconstructive Surgery, 70:336 344. Nakashima H, Araki Y, Nishikido E, Matzuda T, ltoh Y (1987). Free peroneal flap for wide skin defects of the foot and volar contracture of the hand. Journal of Reconstructive Microsurgery, 3:105 1 l 1. NinkovibM, Deetjen H, ¢)hler K, Anderl H (1995 a). Emergency free tissue transfer for severe upper extremity injuries. Journal of Hand Surgery, 20B: 53 58. Ninkovi~ M, Hussl H, Hefei L, Anderl H (1995 b). Timing of reconstruction in severe upper extremity injuries using free flaps. Handchirurgie, Mikrochirurgie, Plastische Chirurgie, 27: 297-306. Ninkovi~ M, Wechselberger G, Schwabegger A, Anderl H (1996). The instep free flap to resurface palmar defects of the hand. Plastic and Reconstructive Surgery, 97: 1489-1493. Ohmori K and Harii K (1976). Free dorsalis pedis sensory flap to the hand, with microneurovascular anastomoses. Plastic and Reconstructive Surgery, 58: 546 554. Press B H J, Chiu D T W, Cunningham B L (1990). The rectus abdominis muscle in difficult problems of hand soft tissue reconstruction. British Journal of Plastic Surgery, 43: 419M25. Scheker L R, Kleinert H E, Hanel D P (1987). Lateral arm composite tissue transfer to ipsilateraI hand defects. Journal of Hand Surgery, 12 A: 665-672. Scheker L R, Lister G D, Wolf T W (1988). The lateral arm flap in releasing severe contracture of the first web space. Journal of Hand Surgery, 13 B: 146 150. Thatte R L, Patil U A, Dhami L D (1986). The combined use of the superficial external pudendal artery flap with a flap of the anterior rectus sheath for the simultaneous cover of dorsal and volar defects of the hand. British Journal of Plastic Surgery, 39: 321-326. Ueda K, Harashina T, Inoue T, Ohba S (1996). Temporoparietal sandwich techniq ue in acute avulsion injury of the hand. Journal of Reconstructive Microsurgery, 12: 19-22. Upton J, Rogers C, Durham-Smith G, Swartz W M (1986). Clinical applications of fi'ee temporoparietal flaps in hand reconstruction. Journal of Hand Surgery, 11 A: 475483. Upton J, Havlik R J, Khouri R K (1992). Refinements in hand coverage with microvascular free flaps. Clinics in Plastic Surgery,/9: 841-857. Wintsch K, Helaly P (1986). Free flap of gliding tissue. Journal of Reconstructive Microsurgery, 2: 143-151. Wolff K D, Stiller D (1992). Functional aspects of free muscle transplantation: atrophy, reinnervation and metabolism. Journal of Reconstructive Microsurgery, 8: I37-142. Wood M B, irons G B (1983). Upper extremity free skin flap transfer: results and utility as compared with conventional distant pedicle skin flaps. Annals of Plastic Surgery, I 1:523 526. Yoshimura M, Shimada T, Matsuda M, Hosokawa M, lmura S (1989). Double peroneal free flap for multiple skin defects of the hand. British Journal of Plastic Surgery, 42:715 718.
Received:29 October 1996 Accepted after revision:24 February 1997 Dr M. M Ninkovid,Universit/itsklinikffir Plastischeund Wiederherstellungschirurgie, Anichstrasse 35, A-6020Innsbruck, Austria © 1997The British Societyfor Surgeryof the Hand