- Email: [email protected]
Soft Tissue Reconstruction of the Hand
CURRENT CONCEPTS
Soft Tissue Reconstruction of the Hand Jeffrey B. Friedrich, MD, Leonid I. Katolik, MD, Nicholas B. Vedder, MD There are a number of insults that can compromise the soft tissue envelope of the hand. Soft tissue reconstruction seeks to restore both the aesthetic appearance and the function of the hand. The purpose of this review is to describe recent advances in hand soft tissue reconstruction. Skin grafts and skin substitutes both are useful reconstructive options for certain defects. Digital coverage continues to be subject to refinements that lead to better reconstructions. Flaps based on donor sites from the dorsal metacarpal artery system are finding continually expanding uses in hand reconstruction. Traditional notions of forearm-based donor tissue are being challenged, leading to better hand reconstructions with less donor morbidity. Finally, improvements in free tissue transfer enable the expansion of reconstructive possibilities available for hand coverage. (J Hand Surg 2009;34A:1148–1155. © 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Flap, skin graft, soft tissue.
HE SOFT TISSUE envelope of the hand is uniquely designed to provide tactile input from our environment and must also withstand substantial wear over a lifetime. There are many insults that can compromise the soft tissue of the hand, including trauma, thermal injury, infection, and malignancy. The unique functional design of the hand can be impaired when the soft tissue envelope is compromised. Where other body parts have ample skin, fat, and muscle, allowing easy primary or secondary closure, the hand’s neurovascular and musculotendinous structures are just beneath the skin’s surface. Therefore, soft tissue loss in the hand requires a thoughtful approach to coverage that enables simultaneous restoration of the aesthetic appearance and the function of the hand. Most hand surgeons use traditional soft tissue reconstruction methods, such as skin grafts, cross-finger flaps, thenar flaps, Moberg flaps, neurovascular island flaps, radial forearm flaps, and groin flaps. These techniques will always have a place in the field of hand
T
Current Concepts
From the Division of Plastic Surgery, University of Washington, Seattle, WA; and the Philadelphia Hand Center, P.C., Philadelphia, PA. Received for publication March 27, 2009; accepted in revised form April 23, 2009. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jeffrey B. Friedrich, MD, Division of Plastic Surgery, University of Washington,3259thAvenue,Box359796,Seattle,WA98104;e-mail:[email protected]. 0363-5023/09/34A06-0029$36.00/0 doi:10.1016/j.jhsa.2009.04.035
1148 䉬 © Published by Elsevier, Inc. on behalf of the ASSH.
reconstruction. However, improvements and refinements in the methods of hand soft tissue reconstruction have provided additional reconstructive techniques that can be merged with traditional procedures to create a large selection of reconstructive options. This review will provide a summary of current concepts pertaining to soft tissue reconstruction of the hand. FINGER RECONSTRUCTION Finger injuries are common, especially those of the fingertips. Injuries that result in loss of skin without bone exposure can be treated by regular cleansing and dressing changes. Subsequent healing by secondary intention yields good results in terms of appearance and sensation. However, the optimal treatment when bone is exposed becomes less clear. The patient’s work demands and the desire for restoration of appearance guide the choice of treatment. Revision amputation is certainly expeditious, and the functional results can be excellent. In some patients, presentation of digit length is more important than rapid recovery. In this situation, composite tissue (skin and fat) reconstruction is usually required. The cross-finger flap and thenar flap are excellent options, but digital stiffness and proximal interphalangeal (PIP) joint contractures can result from the immobilization. In many Asian cultures, digit length restoration and preservation are high priorities. Consequently, impressive advances in tip reconstruction have come from that
SOFT TISSUE RECONSTRUCTION OF THE HAND
1149
part of the world. Lim and colleagues described a spiral flap for digital tip defects.1 The flap is designed in a spiral shape, which is then extended to the fingertip in much the same way one would extend a spring with traction. The resultant proximal donor defect is covered with a skin graft. Impressively, this group reports normal range of motion, normal sensation, and no cold intolerance. In an application of free tissue transfer expertise on an extremely small scale, Lee and coworkers published a large series of fingertip defects that were reconstructed with pulp from the second toe2 (Fig. 1). In addition to the microvascular anastomoses, these flaps are neurotized by digital nerve coaptation to provide sensibility. Of the 854 flaps reported, only 3 were outright failures, and there was a minimal revision rate. The authors report that static 2-point discrimination averaged 8 mm. This 2-point discrimination is similar to that seen with healing by secondary intention or with skin grafting. Those procedures, however, are not possible with exposed bone, whereas the toe pulp transfer is an option. Lee’s group has a large enough experience with free tissue transfer that the surgical times are reasonable. However, for most surgeons, the time required for free tissue transfer may be unreasonable for digital tip preservation. Moving more proximally in the digit, there have been a number of flaps described for finger coverage. The cross-finger flap remains a reliable method of coverage of the palmar surface of the digits. The disadvantages of this flap are the immobilization for several weeks, requirement of a second procedure, and its preclusion if the adjacent digits have been injured. For small defects, Yam and colleagues recently described a
small axial flap for palmar defects on either side of the digit midline.3 Described as the “palmar pivot flap,” this transfer is based on the transverse digital artery. This flap is applicable only for small defects. Finger defect coverage using tissue perfused by the metacarpal artery system has become common in the past 2 decades. In 1990, Quaba and Davison reported a series of finger defects that were covered by island skin flaps from the dorsal hand.4 These flaps were nourished by the palmar– dorsal vascular connection in the hand at the level of the metacarpophalangeal joint, just distal to the extensor tendon juncturae. Since that time, there have been a number of refinements described for these flaps, thereby increasing their versatility. More recent cadaver studies have confirmed this important palmar– dorsal communication through the web space at the level of the metacarpal neck.5 Gregory et al. provide an excellent review of the evolution of flaps based on the metacarpal artery system and describe the variations of the flap.6 These include the extended dorsal metacarpal artery flap, which uses a more distal palmar– dorsal anastomosis at the level of the proximal phalanx base to enable a more distant reach of the flap (Fig. 2). This group demonstrates that it is possible to have the extended dorsal metacarpal artery flap reach as far distally as the nail bed. Like other fasciocutaneous flaps, the skin portion of the dorsal metacarpal artery flap can be eliminated so that it consists of fascia alone. In these cases, the donor site is closed primarily, and the flap is covered with a skin graft. This flap variation can be useful in burned hands where the skin portion of the flap is not pliable or reliable. In their metacarpal artery
JHS 䉬 Vol A, July–August
Current Concepts
FIGURE 1: A Unstable thumb pulp scar B, C reconstructed with innervated toe pulp flap from the great toe.
1150
SOFT TISSUE RECONSTRUCTION OF THE HAND
FIGURE 2: Schematic representation of the blood supply to the dorsal metacarpal artery flap. A In the conventional version of the flap, the tissue is supplied by the dorsal–palmar connection at the metacarpal neck. B The “extended” version of the flap relies on a dorsal–palmar connection at the proximal phalanx level. DIP, distal interphalangeal; PIP, proximal interphalangeal; MC, metacarpophalangeal. 1, dorsal metacarpal artery; 2, deep palmar arch; 3, superficial palmar arch. [From Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg 2007;60:731–739. Reproduced with permission.]
Current Concepts
flap review, Gregory’s group also illustrates another variation of the flap such that it is designed with a long tapered tail.6 This appears to be a good solution to the problem of pedicle management. In the conventional reversed dorsal metacarpal artery flap, the pedicle must either be tunneled under a skin bridge or the skin bridge must be opened and the pedicle skin grafted. The cutaneous tail described by Gregory et al. can potentially eliminate these less-than-desirable situations when transferring a metacarpal artery flap. Although the first and second dorsal metacarpal arteries are commonly used for these flaps, the other metacarpal arteries are also reliable, with the exception of the fifth, whose presence is inconsistent. 6 Additionally, proximally based first dorsal metacarpal artery flaps are excellent options for thumb coverage, particularly on the dorsum of the thumb ray (Fig. 3). Finally, the adipofascial “turnover” flap is a reasonable option for coverage of full-thickness defects on the dorsum of the fingers.7 This flap is based on constant dorsal cutaneous perforating vessels arising from the proper digital arteries at the level of the PIP joint. The flap may be extended to offer durable coverage to the entire digit from the PIP joint to the dorsal fingertip. A fullthickness skin graft is applied over the flap, and the donor site may be closed primarily (Fig. 4).
HAND RECONSTRUCTION Skin grafts and skin substitutes When reconstructing the soft tissue of the hand, it would be ideal if it could be accomplished without using tissues from elsewhere in the body to avoid donor-site morbidity. Patients often inquire about “synthetic” or “artificial” skin. Although modern technology has not yet progressed to that point, currently available “skin substitutes” have moved us closer to that goal. Integra Dermal Regeneration Template (Integra Lifesciences, Plainsboro, NJ) is a bilaminar product that contains bovine collagen and shark chondroitin in the inner layer and silicone in the outer layer. When applied to a wound, tissue grows into the collagen/chondroitin scaffold, replicating the dermis of the skin. One to 3 weeks later, the silicone layer is peeled away, and a thin skin graft is applied (Fig. 5). The product was initially developed for burn treatment, and the reports on use in hand burns are encouraging. Using available motion metrics, such as the Kapandji thumb opposition scale and the Tubiana prehensile assessment, the motion after reconstruction is good.8 The regeneration of a neodermis may allow better motion in the reconstructed area and better tendon gliding underneath. There exist scattered case reports for reconstruction of the nonburned hand, which are encouraging.9 A similar collagen/ elastin construct is available in Europe and has been employed in 1 stage (collagen/elastin monolayer and skin graft simultaneously) with good results in small series.10 Regional flaps Forearm-based flaps continue to be an excellent donor for injured hands. Page and Chang’s review of forearm flaps in a previous issue of the Journal is especially helpful.11 The value of the radial forearm flap to the field of hand surgery cannot be overestimated. However, the original radial forearm flap has several disadvantages, including poor donor-site appearance, potential bulkiness, and sacrifice of the radial artery. This last factor eliminates the flap as an option in patients with an abnormal Allen test, indicative of deficient palmar arch circulation. The desire to address these problems has led to refinements of the radial forearm flap. A reason for the poor donor-site appearance is due to skin graft application directly to the forearm muscles. This led to the development of suprafascial harvest of the radial forearm flap, thereby sparing the volar forearm fascia and allowing a smoother skin graft recipient site.12 Schaverien and Saint-Cyr recently described their injection study, demonstrating the robust suprafascial circulation of the radial forearm flap.13 Another
JHS 䉬 Vol A, July–August
SOFT TISSUE RECONSTRUCTION OF THE HAND
1151
FIGURE 3: A First dorsal metacarpal artery flap based on antegrade flow used to reconstruct a tangential avulsion injury of the thumb. B, C Note that the flap comfortably reaches the thumb tip. The donor site is closed with a full-thickness skin graft.
option that allows better donor-site appearance is use of the radial forearm fascia-alone flap. This version is harvested through a linear forearm incision, and the inset flap is covered with a skin graft. This technique seems at odds with Schaverien and Saint-Cyr’s conclusions that the radial forearm fascia is not well perfused. However, the fascia-alone flap is reliable and eliminates some of the bulk of the flap (Fig. 6). In nearly all cases of radial forearm flap harvest, the loss of the radial artery contribution to the circulation of the hand does not appear to have any detrimental effects. Some hand surgeons, however, feel that this circulatory loss can contribute to cold intolerance, although there are no data that corroborate this contention. Additionally, patients with digit circulation that is dependent solely on the radial artery cannot have a
radial forearm flap transfer as it was originally described. The development of the radial artery– sparing forearm flap provides a potential solution to both of these problems. Hansen and colleagues describe a series of 5 patients in whom a forearm flap based on a radial artery perforator vessel (thus sparing the radial artery) was transferred to the hand with good results.14 The “perforator flap” technique is the basis for this method: Flaps that spare the principal artery and instead use a tributary vessel that perforates the overlying muscle or fascia are dubbed perforator flaps.15 Other groups have used the radial forearm perforator flap with good results in small series.16 Use of perforating vessels to supply upper-extremity flaps is not confined to tributaries of the radial artery. Flaps based
JHS 䉬 Vol A, July–August
Current Concepts
FIGURE 4: A Dorsal finger defect B, C reconstructed with an adipofascial turnover flap and skin graft. This flap is based on palmar-dorsal vessel anastomoses at the level of the PIP joint.
1152
SOFT TISSUE RECONSTRUCTION OF THE HAND
FIGURE 5: A In this patient with a fingertip defect, Integra Dermal Regeneration Template (Integra Lifesciences, Plainsboro, NJ) was used for resurfacing. B When the silicone portion of the bilayer is removed, the defect can be covered with a thin skin graft or allowed to heal by secondary intention if the wound is small.
FIGURE 6: A Dorsal hand wound with exposed extensor tendons. B This wound was reconstructed with a reversed radial forearm fascia-only flap, and the flap itself was covered with a split-thickness skin graft. C, D Note the linear donor-site scar, which can be considered an advantage of the fascia-only flap when compared with the fasciocutaneous version.
Current Concepts
on perforators from the ulnar artery appear to be just as feasible as radial artery– based flaps, and there are small clinical series demonstrating this reconstruction technique.16 Vergara-Amador employed a cadaver injection study to demonstrate the existence of a vascular arcade on the ulnar dorsal side of the wrist.17 Vergara-Amador applied this knowledge to perform a series of ulnar dorsal
flaps for hand coverage. This flap is a variation on the theme of ulnar artery– based perforator flaps. Useful forearm-based soft tissue donor sites are not confined to the volar side of the forearm. The posterior interosseus artery flap, like the radial forearm flap, relies on reversed circulation to supply skin territory on the dorsum of the forearm. The reversed circulation is provided by anastomoses between the anterior interos-
JHS 䉬 Vol A, July–August
SOFT TISSUE RECONSTRUCTION OF THE HAND
1153
seus and posterior interosseus arteries just proximal to the distal radioulnar joint. Unlike the radial forearm flap, the posterior interosseus flap does not require sacrifice of a major artery to the hand. Its chief drawbacks are that the arterial supply could be compromised if it is near the zone of injury, and the aesthetic appearance of the forearm donor site is not any better than that of the radial forearm flap. There are multiple series of posterior interosseus artery flaps that demonstrate good results.18,19 Nevertheless, some hand surgeons consider this flap to be unreliable, especially compared with the radial forearm flap. Like the radial forearm flap, the posterior interosseus flap can be used as a composite flap with the inclusion of bone (ulna) and/or tendon. Distant tissue transfer There are certainly situations in which hand- or forearm-based donor tissue simply will not suffice for reconstruction of a hand defect. In these instances, tissue from a distant source must be employed. The pedicled groin flap remains an excellent reconstructive technique and will likely never be entirely supplanted by free tissue transfer. The groin flap has distinct advantages including relatively constant vascular anatomy, ease of dissection, and rare flap loss. However, recent developments in microsurgical free tissue transfer and the types of donor tissue used have allowed considerable versatility in the choice of tissue for reconstruction of the hand. When performing free tissue transfer to the lower extremity, muscle flaps are quite useful. Despite their
initial bulk, the flaps generally atrophy with time, providing good contour. With the exception of small muscle flaps such as the serratus anterior, most free muscle flaps are too bulky for the hand, even with muscle atrophy. For this reason, fasciocutaneous flaps and fascia flaps covered with skin graft are better suited for the hand. When choosing a donor site for a fascia flap, skin color match is not a consideration, so the flap choice is dictated by donor site and surgeon preference. Common fascia flaps used for the hand include the radial forearm fascia (pedicled or free), temporoparietal fascia, and anterolateral thigh fascia flaps. Whereas a fascia flap with skin graft generally works well and provides a good gliding surface for tendons, the appearance of the overlying skin graft can be undesirable. Use of a thin fasciocutaneous free flap can improve the appearance compared with that of the fascia flap/ skin graft combination. In these cases, the choice of donor site becomes an important consideration for an appropriate skin match. Eo and colleagues published their experience with the free dorsalis pedis flap from the foot dorsum.20 Intuitively, this flap seems ideally suited for matching the hand, especially the dorsal surface. This flap can also be used in composite fashion, taking tendon or bone with the flap. Unfortunately, the donor site on the dorsal foot can be troublesome and require additional surgery to obtain wound closure. The lateral arm free flap has been used for coverage of hand wounds.21,22 The flap is based on the posterior
JHS 䉬 Vol A, July–August
Current Concepts
FIGURE 7: A Mangled hand after a motor vehicle accident. B The severely damaged first web space was reconstructed with a free lateral arm flap. The flap harvest was facilitated by use of the ipsilateral arm. This flap required 2 rounds of debulking, which is a disadvantage of the flap.
1154
SOFT TISSUE RECONSTRUCTION OF THE HAND
radial collateral artery, a branch of the profunda brachii. This flap is generally thin and can be neurotized with the posterior brachial cutaneous nerve. The harvest is fairly straightforward and can be taken from the ipsilateral arm. In most patients, secondary debulking is necessary, and the donor scar can be unsightly (Fig. 7). In terms of donor sites, the anterolateral thigh flap has become popular for use as a free tissue transfer. This flap is based on the descending branch of the lateral femoral circumflex artery.23 The pedicle is long, and the surface area can be large, allowing broad applicability in hand reconstruction.22 For hand and upper-extremity reconstruction, it is best harvested either as a fascia-only flap (and skin grafted) or as a suprafascial perforator flap. The fasciocutaneous version is usually too bulky for hand reconstruction. Recently, the notion that a free flap must contain a donor artery and at least 1 donor vein has been challenged. The advent of the venous free flap adds diversity to the donor sites available for hand reconstruction. These flaps contain a skin island and 2 veins, one of which becomes “arterialized” when it is anastomosed to a recipient artery.24 The other vein then becomes the outflow for the flap. These flaps are often harvested from the volar forearm in the suprafascial plane, allowing them to be very thin. A venous tourniquet is used to create venous distention. The “afferent” and “efferent” veins are marked, and the skin paddle is then centered over these veins. Published series have shown good results using the flaps for both digit and hand reconstruction. In large series, the flap failure rate appears to be comparable with that of other types of free tissue transfer.25 Venous congestion and partial flap necrosis are obviously possible with these flaps; however, they are uncommon. The allure of being able to rapidly harvest a free flap without violating a fascial plane is obvious. However, this technique requires more analysis prior to widespread use.
Current Concepts
OUTCOMES Functional outcome studies following up patients who have had hand soft tissue reconstruction are few and far between. This deficiency is likely due to several factors, including the fact that patients who have substantial hand soft tissue losses often have skeletal, tendon, or nerve injuries, making it difficult to compare outcomes. Functional outcome metrics specific to the hand, such as the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Michigan Hand Questionnaire strive to assess the hand function as a whole. These measures are unlikely to detect differences in type of tissue coverage used to reconstruct the soft tissue en-
velope. There are metrics specific to cutaneous scar outcome, chiefly the Vancouver scar scale. This scale has been used in reports after hand reconstruction.10 However, this scale involves some subjectivity in the appearance rating and does not assess function of the scarred area. REFERENCES 1. Lim GJ, Yam AK, Lee JY, Lam-Chuan T. The spiral flap for fingertip resurfacing: short-term and long-term results. J Hand Surg 2008;33A:340 –347. 2. 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. 3. Yam A, Peng YP, Pho RW. “Palmar pivot flap” for resurfacing palmar lateral defects of the fingers. J Hand Surg 2008;33A:1889 –1893. 4. Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg 1990;43:28 –39. 5. Vuppalapati G, Oberlin C, Balakrishnan G. “Distally based dorsal hand flaps”: clinical experience, cadaveric studies and an update. Br J Plast Surg 2004;57:653– 667. 6. Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg 2007;60:731–739. 7. Braga-Silva J. Anatomic basis of dorsal finger skin cover. Tech Hand Up Extrem Surg 2005;9:134 –141. 8. Dantzer E, Queruel P, Salinier L, Palmier B, Quinot JF. Dermal regeneration template for deep hand burns: clinical utility for both early grafting and reconstructive surgery. Br J Plast Surg 2003;56:764 –774. 9. Carothers JT, Brigman BE, Lawson RD, Rizzo M. Stacking of a dermal regeneration template for reconstruction of a soft-tissue defect after tumor excision from the palm of the hand: a case report. J Hand Surg 2005;30A:1322–1326. 10. Haslik W, Kamolz LP, Manna F, Hladik M, Rath T, Frey M. Management of full-thickness skin defects in the hand and wrist region: first long-term experiences with the dermal matrix Matriderm((R)). J Plast Reconstr Aesthet Surg 2008 (in press). doi: 10.1016/j.bjps.2008.09.026. Accessed February 1, 2009. 11. Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg 2006;31A:847– 856. 12. Lutz BS, Wei FC, Chang SC, Yang KH, Chen IH. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg 1999;103:132–137. 13. Schaverien M, Saint-Cyr M. Suprafascial compared with subfascial harvest of the radial forearm flap: an anatomic study. J Hand Surg 2008;33A:97–101. 14. Hansen AJ, Duncan SF, Smith AA, Shin AY, Moran SL, Bishop AT. Reverse radial forearm fascial flap with radial artery preservation. Hand (N Y) 2007;2:159 –163. 15. Sanapanichan K, Tu YK, Kraisarin J, Chalidapong P. Reconstruction of limb soft-tissue defects: using pedicle perforator flaps with preservation of major vessels, a report of 45 cases. Injury 2008; 39(Suppl 4):55– 66. 16. Ignatiadis IA, Mavrogenis AF, Avram AM, Georgescu AV, Perez ML, Gerostathopoulos NE, et al. Treatment of complex hand trauma using the distal ulnar and radial artery perforator-based flaps. Injury 2008;39(Suppl 3):S116 –S124. 17. Vergara-Amador E. Anatomical study of the ulnar dorsal artery and design of a new retrograde ulnar dorsal flap. Plast Reconstr Surg 2008;121:1716 –1724. 18. Lu LJ, Gong X, Lu XM, Wang KL. The reverse posterior interosseous flap and its composite flap: experience with 201 flaps. J Plast Reconstr Aesthet Surg 2007;60:876 – 882.
JHS 䉬 Vol A, July–August
SOFT TISSUE RECONSTRUCTION OF THE HAND
23. Wang HT, Erdmann D, Fletcher JW, Levin LS. Anterolateral thigh flap technique in hand and upper extremity reconstruction. Tech Hand Up Extrem Surg 2004;8:257–261. 24. Kong BS, Kim YJ, Suh YS, Jawa A, Nazzal A, Lee SG. Finger soft tissue reconstruction using arterialized venous free flaps having 2 parallel veins. J Hand Surg 2008;33A:1802– 1806. 25. Woo SH, Kim KC, Lee GJ, Ha SH, Kim KH, Dhawan V, et al. A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: an 11-year experience. Plast Reconstr Surg 2007; 119:1823–1838.
Current Concepts
19. Agir H, Sen C, Alagoz S, Onyedi M, Isil E. Distally based posterior interosseous flap: primary role in soft-tissue reconstruction of the hand. Ann Plast Surg 2007;59:291–296. 20. Eo S, Kim Y, Kim JY, Oh S. The versatility of the dorsalis pedis compound free flap in hand reconstruction. Ann Plast Surg 2008;61: 157–163. 21. Scheker LR, Kleinert HE, Hanel DP. Lateral arm composite tissue transfer to ipsilateral hand defects. J Hand Surg 1987;12A(5 Pt 1):665–672. 22. Yildirim S, Taylan G, Eker G, Akoz T. Free flap choice for soft tissue reconstruction of the severely damaged upper extremity. J Reconstr Microsurg 2006;22:599 – 609.
1155
JHS 䉬 Vol A, July–August
Soft Tissue Reconstruction of the Hand Jeffrey B. Friedrich, MD, Leonid I. Katolik, MD, Nicholas B. Vedder, MD There are a number of insults that can compromise the soft tissue envelope of the hand. Soft tissue reconstruction seeks to restore both the aesthetic appearance and the function of the hand. The purpose of this review is to describe recent advances in hand soft tissue reconstruction. Skin grafts and skin substitutes both are useful reconstructive options for certain defects. Digital coverage continues to be subject to refinements that lead to better reconstructions. Flaps based on donor sites from the dorsal metacarpal artery system are finding continually expanding uses in hand reconstruction. Traditional notions of forearm-based donor tissue are being challenged, leading to better hand reconstructions with less donor morbidity. Finally, improvements in free tissue transfer enable the expansion of reconstructive possibilities available for hand coverage. (J Hand Surg 2009;34A:1148–1155. © 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Flap, skin graft, soft tissue.
HE SOFT TISSUE envelope of the hand is uniquely designed to provide tactile input from our environment and must also withstand substantial wear over a lifetime. There are many insults that can compromise the soft tissue of the hand, including trauma, thermal injury, infection, and malignancy. The unique functional design of the hand can be impaired when the soft tissue envelope is compromised. Where other body parts have ample skin, fat, and muscle, allowing easy primary or secondary closure, the hand’s neurovascular and musculotendinous structures are just beneath the skin’s surface. Therefore, soft tissue loss in the hand requires a thoughtful approach to coverage that enables simultaneous restoration of the aesthetic appearance and the function of the hand. Most hand surgeons use traditional soft tissue reconstruction methods, such as skin grafts, cross-finger flaps, thenar flaps, Moberg flaps, neurovascular island flaps, radial forearm flaps, and groin flaps. These techniques will always have a place in the field of hand
T
Current Concepts
From the Division of Plastic Surgery, University of Washington, Seattle, WA; and the Philadelphia Hand Center, P.C., Philadelphia, PA. Received for publication March 27, 2009; accepted in revised form April 23, 2009. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jeffrey B. Friedrich, MD, Division of Plastic Surgery, University of Washington,3259thAvenue,Box359796,Seattle,WA98104;e-mail:[email protected]. 0363-5023/09/34A06-0029$36.00/0 doi:10.1016/j.jhsa.2009.04.035
1148 䉬 © Published by Elsevier, Inc. on behalf of the ASSH.
reconstruction. However, improvements and refinements in the methods of hand soft tissue reconstruction have provided additional reconstructive techniques that can be merged with traditional procedures to create a large selection of reconstructive options. This review will provide a summary of current concepts pertaining to soft tissue reconstruction of the hand. FINGER RECONSTRUCTION Finger injuries are common, especially those of the fingertips. Injuries that result in loss of skin without bone exposure can be treated by regular cleansing and dressing changes. Subsequent healing by secondary intention yields good results in terms of appearance and sensation. However, the optimal treatment when bone is exposed becomes less clear. The patient’s work demands and the desire for restoration of appearance guide the choice of treatment. Revision amputation is certainly expeditious, and the functional results can be excellent. In some patients, presentation of digit length is more important than rapid recovery. In this situation, composite tissue (skin and fat) reconstruction is usually required. The cross-finger flap and thenar flap are excellent options, but digital stiffness and proximal interphalangeal (PIP) joint contractures can result from the immobilization. In many Asian cultures, digit length restoration and preservation are high priorities. Consequently, impressive advances in tip reconstruction have come from that
SOFT TISSUE RECONSTRUCTION OF THE HAND
1149
part of the world. Lim and colleagues described a spiral flap for digital tip defects.1 The flap is designed in a spiral shape, which is then extended to the fingertip in much the same way one would extend a spring with traction. The resultant proximal donor defect is covered with a skin graft. Impressively, this group reports normal range of motion, normal sensation, and no cold intolerance. In an application of free tissue transfer expertise on an extremely small scale, Lee and coworkers published a large series of fingertip defects that were reconstructed with pulp from the second toe2 (Fig. 1). In addition to the microvascular anastomoses, these flaps are neurotized by digital nerve coaptation to provide sensibility. Of the 854 flaps reported, only 3 were outright failures, and there was a minimal revision rate. The authors report that static 2-point discrimination averaged 8 mm. This 2-point discrimination is similar to that seen with healing by secondary intention or with skin grafting. Those procedures, however, are not possible with exposed bone, whereas the toe pulp transfer is an option. Lee’s group has a large enough experience with free tissue transfer that the surgical times are reasonable. However, for most surgeons, the time required for free tissue transfer may be unreasonable for digital tip preservation. Moving more proximally in the digit, there have been a number of flaps described for finger coverage. The cross-finger flap remains a reliable method of coverage of the palmar surface of the digits. The disadvantages of this flap are the immobilization for several weeks, requirement of a second procedure, and its preclusion if the adjacent digits have been injured. For small defects, Yam and colleagues recently described a
small axial flap for palmar defects on either side of the digit midline.3 Described as the “palmar pivot flap,” this transfer is based on the transverse digital artery. This flap is applicable only for small defects. Finger defect coverage using tissue perfused by the metacarpal artery system has become common in the past 2 decades. In 1990, Quaba and Davison reported a series of finger defects that were covered by island skin flaps from the dorsal hand.4 These flaps were nourished by the palmar– dorsal vascular connection in the hand at the level of the metacarpophalangeal joint, just distal to the extensor tendon juncturae. Since that time, there have been a number of refinements described for these flaps, thereby increasing their versatility. More recent cadaver studies have confirmed this important palmar– dorsal communication through the web space at the level of the metacarpal neck.5 Gregory et al. provide an excellent review of the evolution of flaps based on the metacarpal artery system and describe the variations of the flap.6 These include the extended dorsal metacarpal artery flap, which uses a more distal palmar– dorsal anastomosis at the level of the proximal phalanx base to enable a more distant reach of the flap (Fig. 2). This group demonstrates that it is possible to have the extended dorsal metacarpal artery flap reach as far distally as the nail bed. Like other fasciocutaneous flaps, the skin portion of the dorsal metacarpal artery flap can be eliminated so that it consists of fascia alone. In these cases, the donor site is closed primarily, and the flap is covered with a skin graft. This flap variation can be useful in burned hands where the skin portion of the flap is not pliable or reliable. In their metacarpal artery
JHS 䉬 Vol A, July–August
Current Concepts
FIGURE 1: A Unstable thumb pulp scar B, C reconstructed with innervated toe pulp flap from the great toe.
1150
SOFT TISSUE RECONSTRUCTION OF THE HAND
FIGURE 2: Schematic representation of the blood supply to the dorsal metacarpal artery flap. A In the conventional version of the flap, the tissue is supplied by the dorsal–palmar connection at the metacarpal neck. B The “extended” version of the flap relies on a dorsal–palmar connection at the proximal phalanx level. DIP, distal interphalangeal; PIP, proximal interphalangeal; MC, metacarpophalangeal. 1, dorsal metacarpal artery; 2, deep palmar arch; 3, superficial palmar arch. [From Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg 2007;60:731–739. Reproduced with permission.]
Current Concepts
flap review, Gregory’s group also illustrates another variation of the flap such that it is designed with a long tapered tail.6 This appears to be a good solution to the problem of pedicle management. In the conventional reversed dorsal metacarpal artery flap, the pedicle must either be tunneled under a skin bridge or the skin bridge must be opened and the pedicle skin grafted. The cutaneous tail described by Gregory et al. can potentially eliminate these less-than-desirable situations when transferring a metacarpal artery flap. Although the first and second dorsal metacarpal arteries are commonly used for these flaps, the other metacarpal arteries are also reliable, with the exception of the fifth, whose presence is inconsistent. 6 Additionally, proximally based first dorsal metacarpal artery flaps are excellent options for thumb coverage, particularly on the dorsum of the thumb ray (Fig. 3). Finally, the adipofascial “turnover” flap is a reasonable option for coverage of full-thickness defects on the dorsum of the fingers.7 This flap is based on constant dorsal cutaneous perforating vessels arising from the proper digital arteries at the level of the PIP joint. The flap may be extended to offer durable coverage to the entire digit from the PIP joint to the dorsal fingertip. A fullthickness skin graft is applied over the flap, and the donor site may be closed primarily (Fig. 4).
HAND RECONSTRUCTION Skin grafts and skin substitutes When reconstructing the soft tissue of the hand, it would be ideal if it could be accomplished without using tissues from elsewhere in the body to avoid donor-site morbidity. Patients often inquire about “synthetic” or “artificial” skin. Although modern technology has not yet progressed to that point, currently available “skin substitutes” have moved us closer to that goal. Integra Dermal Regeneration Template (Integra Lifesciences, Plainsboro, NJ) is a bilaminar product that contains bovine collagen and shark chondroitin in the inner layer and silicone in the outer layer. When applied to a wound, tissue grows into the collagen/chondroitin scaffold, replicating the dermis of the skin. One to 3 weeks later, the silicone layer is peeled away, and a thin skin graft is applied (Fig. 5). The product was initially developed for burn treatment, and the reports on use in hand burns are encouraging. Using available motion metrics, such as the Kapandji thumb opposition scale and the Tubiana prehensile assessment, the motion after reconstruction is good.8 The regeneration of a neodermis may allow better motion in the reconstructed area and better tendon gliding underneath. There exist scattered case reports for reconstruction of the nonburned hand, which are encouraging.9 A similar collagen/ elastin construct is available in Europe and has been employed in 1 stage (collagen/elastin monolayer and skin graft simultaneously) with good results in small series.10 Regional flaps Forearm-based flaps continue to be an excellent donor for injured hands. Page and Chang’s review of forearm flaps in a previous issue of the Journal is especially helpful.11 The value of the radial forearm flap to the field of hand surgery cannot be overestimated. However, the original radial forearm flap has several disadvantages, including poor donor-site appearance, potential bulkiness, and sacrifice of the radial artery. This last factor eliminates the flap as an option in patients with an abnormal Allen test, indicative of deficient palmar arch circulation. The desire to address these problems has led to refinements of the radial forearm flap. A reason for the poor donor-site appearance is due to skin graft application directly to the forearm muscles. This led to the development of suprafascial harvest of the radial forearm flap, thereby sparing the volar forearm fascia and allowing a smoother skin graft recipient site.12 Schaverien and Saint-Cyr recently described their injection study, demonstrating the robust suprafascial circulation of the radial forearm flap.13 Another
JHS 䉬 Vol A, July–August
SOFT TISSUE RECONSTRUCTION OF THE HAND
1151
FIGURE 3: A First dorsal metacarpal artery flap based on antegrade flow used to reconstruct a tangential avulsion injury of the thumb. B, C Note that the flap comfortably reaches the thumb tip. The donor site is closed with a full-thickness skin graft.
option that allows better donor-site appearance is use of the radial forearm fascia-alone flap. This version is harvested through a linear forearm incision, and the inset flap is covered with a skin graft. This technique seems at odds with Schaverien and Saint-Cyr’s conclusions that the radial forearm fascia is not well perfused. However, the fascia-alone flap is reliable and eliminates some of the bulk of the flap (Fig. 6). In nearly all cases of radial forearm flap harvest, the loss of the radial artery contribution to the circulation of the hand does not appear to have any detrimental effects. Some hand surgeons, however, feel that this circulatory loss can contribute to cold intolerance, although there are no data that corroborate this contention. Additionally, patients with digit circulation that is dependent solely on the radial artery cannot have a
radial forearm flap transfer as it was originally described. The development of the radial artery– sparing forearm flap provides a potential solution to both of these problems. Hansen and colleagues describe a series of 5 patients in whom a forearm flap based on a radial artery perforator vessel (thus sparing the radial artery) was transferred to the hand with good results.14 The “perforator flap” technique is the basis for this method: Flaps that spare the principal artery and instead use a tributary vessel that perforates the overlying muscle or fascia are dubbed perforator flaps.15 Other groups have used the radial forearm perforator flap with good results in small series.16 Use of perforating vessels to supply upper-extremity flaps is not confined to tributaries of the radial artery. Flaps based
JHS 䉬 Vol A, July–August
Current Concepts
FIGURE 4: A Dorsal finger defect B, C reconstructed with an adipofascial turnover flap and skin graft. This flap is based on palmar-dorsal vessel anastomoses at the level of the PIP joint.
1152
SOFT TISSUE RECONSTRUCTION OF THE HAND
FIGURE 5: A In this patient with a fingertip defect, Integra Dermal Regeneration Template (Integra Lifesciences, Plainsboro, NJ) was used for resurfacing. B When the silicone portion of the bilayer is removed, the defect can be covered with a thin skin graft or allowed to heal by secondary intention if the wound is small.
FIGURE 6: A Dorsal hand wound with exposed extensor tendons. B This wound was reconstructed with a reversed radial forearm fascia-only flap, and the flap itself was covered with a split-thickness skin graft. C, D Note the linear donor-site scar, which can be considered an advantage of the fascia-only flap when compared with the fasciocutaneous version.
Current Concepts
on perforators from the ulnar artery appear to be just as feasible as radial artery– based flaps, and there are small clinical series demonstrating this reconstruction technique.16 Vergara-Amador employed a cadaver injection study to demonstrate the existence of a vascular arcade on the ulnar dorsal side of the wrist.17 Vergara-Amador applied this knowledge to perform a series of ulnar dorsal
flaps for hand coverage. This flap is a variation on the theme of ulnar artery– based perforator flaps. Useful forearm-based soft tissue donor sites are not confined to the volar side of the forearm. The posterior interosseus artery flap, like the radial forearm flap, relies on reversed circulation to supply skin territory on the dorsum of the forearm. The reversed circulation is provided by anastomoses between the anterior interos-
JHS 䉬 Vol A, July–August
SOFT TISSUE RECONSTRUCTION OF THE HAND
1153
seus and posterior interosseus arteries just proximal to the distal radioulnar joint. Unlike the radial forearm flap, the posterior interosseus flap does not require sacrifice of a major artery to the hand. Its chief drawbacks are that the arterial supply could be compromised if it is near the zone of injury, and the aesthetic appearance of the forearm donor site is not any better than that of the radial forearm flap. There are multiple series of posterior interosseus artery flaps that demonstrate good results.18,19 Nevertheless, some hand surgeons consider this flap to be unreliable, especially compared with the radial forearm flap. Like the radial forearm flap, the posterior interosseus flap can be used as a composite flap with the inclusion of bone (ulna) and/or tendon. Distant tissue transfer There are certainly situations in which hand- or forearm-based donor tissue simply will not suffice for reconstruction of a hand defect. In these instances, tissue from a distant source must be employed. The pedicled groin flap remains an excellent reconstructive technique and will likely never be entirely supplanted by free tissue transfer. The groin flap has distinct advantages including relatively constant vascular anatomy, ease of dissection, and rare flap loss. However, recent developments in microsurgical free tissue transfer and the types of donor tissue used have allowed considerable versatility in the choice of tissue for reconstruction of the hand. When performing free tissue transfer to the lower extremity, muscle flaps are quite useful. Despite their
initial bulk, the flaps generally atrophy with time, providing good contour. With the exception of small muscle flaps such as the serratus anterior, most free muscle flaps are too bulky for the hand, even with muscle atrophy. For this reason, fasciocutaneous flaps and fascia flaps covered with skin graft are better suited for the hand. When choosing a donor site for a fascia flap, skin color match is not a consideration, so the flap choice is dictated by donor site and surgeon preference. Common fascia flaps used for the hand include the radial forearm fascia (pedicled or free), temporoparietal fascia, and anterolateral thigh fascia flaps. Whereas a fascia flap with skin graft generally works well and provides a good gliding surface for tendons, the appearance of the overlying skin graft can be undesirable. Use of a thin fasciocutaneous free flap can improve the appearance compared with that of the fascia flap/ skin graft combination. In these cases, the choice of donor site becomes an important consideration for an appropriate skin match. Eo and colleagues published their experience with the free dorsalis pedis flap from the foot dorsum.20 Intuitively, this flap seems ideally suited for matching the hand, especially the dorsal surface. This flap can also be used in composite fashion, taking tendon or bone with the flap. Unfortunately, the donor site on the dorsal foot can be troublesome and require additional surgery to obtain wound closure. The lateral arm free flap has been used for coverage of hand wounds.21,22 The flap is based on the posterior
JHS 䉬 Vol A, July–August
Current Concepts
FIGURE 7: A Mangled hand after a motor vehicle accident. B The severely damaged first web space was reconstructed with a free lateral arm flap. The flap harvest was facilitated by use of the ipsilateral arm. This flap required 2 rounds of debulking, which is a disadvantage of the flap.
1154
SOFT TISSUE RECONSTRUCTION OF THE HAND
radial collateral artery, a branch of the profunda brachii. This flap is generally thin and can be neurotized with the posterior brachial cutaneous nerve. The harvest is fairly straightforward and can be taken from the ipsilateral arm. In most patients, secondary debulking is necessary, and the donor scar can be unsightly (Fig. 7). In terms of donor sites, the anterolateral thigh flap has become popular for use as a free tissue transfer. This flap is based on the descending branch of the lateral femoral circumflex artery.23 The pedicle is long, and the surface area can be large, allowing broad applicability in hand reconstruction.22 For hand and upper-extremity reconstruction, it is best harvested either as a fascia-only flap (and skin grafted) or as a suprafascial perforator flap. The fasciocutaneous version is usually too bulky for hand reconstruction. Recently, the notion that a free flap must contain a donor artery and at least 1 donor vein has been challenged. The advent of the venous free flap adds diversity to the donor sites available for hand reconstruction. These flaps contain a skin island and 2 veins, one of which becomes “arterialized” when it is anastomosed to a recipient artery.24 The other vein then becomes the outflow for the flap. These flaps are often harvested from the volar forearm in the suprafascial plane, allowing them to be very thin. A venous tourniquet is used to create venous distention. The “afferent” and “efferent” veins are marked, and the skin paddle is then centered over these veins. Published series have shown good results using the flaps for both digit and hand reconstruction. In large series, the flap failure rate appears to be comparable with that of other types of free tissue transfer.25 Venous congestion and partial flap necrosis are obviously possible with these flaps; however, they are uncommon. The allure of being able to rapidly harvest a free flap without violating a fascial plane is obvious. However, this technique requires more analysis prior to widespread use.
Current Concepts
OUTCOMES Functional outcome studies following up patients who have had hand soft tissue reconstruction are few and far between. This deficiency is likely due to several factors, including the fact that patients who have substantial hand soft tissue losses often have skeletal, tendon, or nerve injuries, making it difficult to compare outcomes. Functional outcome metrics specific to the hand, such as the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Michigan Hand Questionnaire strive to assess the hand function as a whole. These measures are unlikely to detect differences in type of tissue coverage used to reconstruct the soft tissue en-
velope. There are metrics specific to cutaneous scar outcome, chiefly the Vancouver scar scale. This scale has been used in reports after hand reconstruction.10 However, this scale involves some subjectivity in the appearance rating and does not assess function of the scarred area. REFERENCES 1. Lim GJ, Yam AK, Lee JY, Lam-Chuan T. The spiral flap for fingertip resurfacing: short-term and long-term results. J Hand Surg 2008;33A:340 –347. 2. 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. 3. Yam A, Peng YP, Pho RW. “Palmar pivot flap” for resurfacing palmar lateral defects of the fingers. J Hand Surg 2008;33A:1889 –1893. 4. Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg 1990;43:28 –39. 5. Vuppalapati G, Oberlin C, Balakrishnan G. “Distally based dorsal hand flaps”: clinical experience, cadaveric studies and an update. Br J Plast Surg 2004;57:653– 667. 6. Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg 2007;60:731–739. 7. Braga-Silva J. Anatomic basis of dorsal finger skin cover. Tech Hand Up Extrem Surg 2005;9:134 –141. 8. Dantzer E, Queruel P, Salinier L, Palmier B, Quinot JF. Dermal regeneration template for deep hand burns: clinical utility for both early grafting and reconstructive surgery. Br J Plast Surg 2003;56:764 –774. 9. Carothers JT, Brigman BE, Lawson RD, Rizzo M. Stacking of a dermal regeneration template for reconstruction of a soft-tissue defect after tumor excision from the palm of the hand: a case report. J Hand Surg 2005;30A:1322–1326. 10. Haslik W, Kamolz LP, Manna F, Hladik M, Rath T, Frey M. Management of full-thickness skin defects in the hand and wrist region: first long-term experiences with the dermal matrix Matriderm((R)). J Plast Reconstr Aesthet Surg 2008 (in press). doi: 10.1016/j.bjps.2008.09.026. Accessed February 1, 2009. 11. Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap. J Hand Surg 2006;31A:847– 856. 12. Lutz BS, Wei FC, Chang SC, Yang KH, Chen IH. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg 1999;103:132–137. 13. Schaverien M, Saint-Cyr M. Suprafascial compared with subfascial harvest of the radial forearm flap: an anatomic study. J Hand Surg 2008;33A:97–101. 14. Hansen AJ, Duncan SF, Smith AA, Shin AY, Moran SL, Bishop AT. Reverse radial forearm fascial flap with radial artery preservation. Hand (N Y) 2007;2:159 –163. 15. Sanapanichan K, Tu YK, Kraisarin J, Chalidapong P. Reconstruction of limb soft-tissue defects: using pedicle perforator flaps with preservation of major vessels, a report of 45 cases. Injury 2008; 39(Suppl 4):55– 66. 16. Ignatiadis IA, Mavrogenis AF, Avram AM, Georgescu AV, Perez ML, Gerostathopoulos NE, et al. Treatment of complex hand trauma using the distal ulnar and radial artery perforator-based flaps. Injury 2008;39(Suppl 3):S116 –S124. 17. Vergara-Amador E. Anatomical study of the ulnar dorsal artery and design of a new retrograde ulnar dorsal flap. Plast Reconstr Surg 2008;121:1716 –1724. 18. Lu LJ, Gong X, Lu XM, Wang KL. The reverse posterior interosseous flap and its composite flap: experience with 201 flaps. J Plast Reconstr Aesthet Surg 2007;60:876 – 882.
JHS 䉬 Vol A, July–August
SOFT TISSUE RECONSTRUCTION OF THE HAND
23. Wang HT, Erdmann D, Fletcher JW, Levin LS. Anterolateral thigh flap technique in hand and upper extremity reconstruction. Tech Hand Up Extrem Surg 2004;8:257–261. 24. Kong BS, Kim YJ, Suh YS, Jawa A, Nazzal A, Lee SG. Finger soft tissue reconstruction using arterialized venous free flaps having 2 parallel veins. J Hand Surg 2008;33A:1802– 1806. 25. Woo SH, Kim KC, Lee GJ, Ha SH, Kim KH, Dhawan V, et al. A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: an 11-year experience. Plast Reconstr Surg 2007; 119:1823–1838.
Current Concepts
19. Agir H, Sen C, Alagoz S, Onyedi M, Isil E. Distally based posterior interosseous flap: primary role in soft-tissue reconstruction of the hand. Ann Plast Surg 2007;59:291–296. 20. Eo S, Kim Y, Kim JY, Oh S. The versatility of the dorsalis pedis compound free flap in hand reconstruction. Ann Plast Surg 2008;61: 157–163. 21. Scheker LR, Kleinert HE, Hanel DP. Lateral arm composite tissue transfer to ipsilateral hand defects. J Hand Surg 1987;12A(5 Pt 1):665–672. 22. Yildirim S, Taylan G, Eker G, Akoz T. Free flap choice for soft tissue reconstruction of the severely damaged upper extremity. J Reconstr Microsurg 2006;22:599 – 609.
1155
JHS 䉬 Vol A, July–August