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The subcutaneous turn-over flap in the treatment of difficult wounds of the digits
THE SUBCUTANEOUS TURN-OVER TREATMENT OF DIFFICULT WOUNDS
FLAP IN THE OF THE DIGITS
P. C. CAVADAS and L. PUERTES-CORELLA
From the Division of Plastic, Reconstructive and Hand Surgery, Hospital Centro de Rehabilitati6n de Levante, Valencia, Spain A series of 18 cases of fasciosubcutaneous reverse flaps used to cover defects of the fingers is reported.
Journal o f Hand Surgery (British and European Volume, 1998) 23B: 4:472-475 Soft tissue defects of the digits with exposed bone or tendon are demanding problems, whose treatment calls for an experienced surgeon, familiar with the many possible techniques of treatment. Although a number of local flaps have been described, homodigital flaps have the advantage of permitting immediate motion of the digital joints, which is extremely important. The purpose of the present paper is to report on our experience in the use of a distally based subcutaneous turn-over flap to reconstruct complicated defects of the fingers. The flap was an extension of the adipofascial turn-over flap (Lai et al, 199l a).
ddbridement of infected nonunions, extra length was planned so that it could be placed into the defect. The length-to-width ratio was as high as 3 to 1 in some cases, with complete survival. Whenever possible, raising a flap from the dorsum of the metacarpophalangeal joint was avoided, as there is very little subcutaneous tissue in this area. The flap was skin grafted at the end of the procedure, and the donor wound was closed over a drain. RESULTS
All flaps but one survived completely with primary healing of the wounds. The partial tip necrosis occurred in a replanted finger with loss of the palmar skin, and the flap had a length-to-width ratio of 4 to 1. There was no recurrence of infection in the septic nonunions treated.
PATIENTS A N D M E T H O D S
Between June 1995 and March 1997, 18 patients were operated on for complicated wounds of the fingers, including acute and chronic defects. There were 17 men and 1 woman. Mean age of patients was 34 years (range, 17 58). The flap was used for 11 acute traumatic injuries, and as a reconstruction in seven infected phalangeal nonunions. The mean size of the flap was 33 mm x 12 mm (range, 25 x 8 to 45 x 15). Defects were in the middle phalanx in six cases (three dorsal, two lateral and one palmar), in the proximal interphalangeal joint in five cases (two dorsal, two lateral and one palmar), in the proximal phalanx in five cases (lateral or dorsal), and in the distal phalanx in two cases. The wounds were covered with a distally based turn-over subcutaneous flap. These flaps can be considered an extension of previously described flaps (Lai et al, 1991 a), with a higher lengthto-width ratio.
Representative cases
Case 1 A 17-year-old man had an infected n o n u n i o n of the neck of the proximal phalanx of the long finger (Fig 1). The wound was thoroughly d6brided, and the dead space was filled with a distally based turn-over subcutaneous flap 45 x 15 m m in length, and a skin graft was applied. The bone defect was grafted 4 weeks later. Case 2 A 52-year-old man had a traumatic loss of skin with exposure of the dorsoulnar aspect of the interphalangeal joint of the thumb (Fig 2). The joint was covered with a distally based turn-over subcutaneous flap 40 x 10 mm in size, and a skin graft was applied with primary healing of the wounds.
Surgical technique
Once the defect was defined, the flap was outlined as a distally based one, anywhere along the longitudinal axis of the involved ray, but always avoiding the palmar aspect. Dorsolateral design is preferred to dorsal flaps, as there is more subcutaneous substance in the former. N o special effort was made to include named vessels, and the only precaution taken was to leave at least 1 cm of undisturbed tissue between the defect and the base of the flap. The flaps were elevated under tourniquet control and included all tissue between the dermis and the paratenon but always sparing the digital neurovascular bundles. When used to obliterate the dead space resulting from
Case 3 A 47-year-old man had a traumatic loss of skin over the radial side of the distal interphalangeal joint of the index finger (Fig 3). The tuft of the distal phalanx was trimmed (5 ram) and the defect was covered with a distally based turn-over flap 25 x 8 mm in size and the remaining pulp tissue. 472
SUBCUTANEOUS TURN-OVER FLAP
Fig 1
473
(a) Infected nonunion of the proximal phalanx of the long finger. (b) The defect was covered with a reverse subcutaneous turn-over flap. (c) The flap is being transposed. Preservation of the head of the proximal phalanx had been attempted but recurrent drainage due to sequestrum required its resection, a flap readvancement to obliterate dead space, and delayed bone grafting. (d) Late postoperative view.
DISCUSSION Improper treatment of complicated skin defects of the fingers can lead to considerable morbidity. Skin defects are often associated with open fractures and/or tendon injuries, which make early articular mobilization essential. In this situation; the reconstruction of such defects with homodigital flaps is highly convenient. Many flaps have been described for use in the fingers, all of them with some advantages and disadvantages (Foucher and Khouri, 1997). The subcutaneous tissue has been recognized as a rather independent layer in terms of vascularity (Marty et al, 1984), thus allowing it to be mobilized in turn-over flaps. There are some excellent anatomical and clinical reports on the use of these flaps in the lower limb (Lai et al, 1991 b; Gumener et al, 1991), and in the hand and digits (Marty et al, 1984; Lai et al, 1991 a; Weinzweig et al, 1994). The use of a simple, expedient and easy flap to
cover the wound, instead of other more laborious island or free flaps is worth consideration. The cases we treated had soft tissue defects in the fingers, and the flaps used to cover them were based on the flaps previously described by Lai et al (1991 a), but using a much higher length-to-width ratio. The area of intact subcutaneous tissue between the defect and the pivotal point was about 10 mm, and except for one case, the flaps survived completely. The flap can be used either for coverage of the dorsum or the palmar surface. When used for the palmar side, tunnelling can be risky and incising the skin bridge is preferred to avoid tension. There is relatively little bulk in the reconstructed area and in any case the subcutaneous reverse flap is probably not the first choice in reconstruction of the palmar side of the fingers and fingertips, as there are better choices. It is, however, a good choice to cover the dorsal and lateral sides of the fingers, up to the distal phalangeal level.
474
Fig 2
THE JOURNAL OF HAND SURGERY VOL. 23B No. 4 AUGUST 1998
(a) Soft tissue defect over the interphalangeal joint of the thumb. The flap is outlined. (b) The subcutaneous flap has been elevated and is being transposed. (c) Postoperative view. Interphalangeal joint mobilization was started in the early postoperative period.
Although there is considerable freedom in the design of the flap, the vascular territories can overlap to some extent, and in this way, for instance, the turn-over adipofascial flap of the lateral and dorsolateral side of the fingers may not be very different from the previously described dorsocommisural skin island flap (Valenti et al, 1990), except that it does not include skin. The same may be true for the dorsoulnar side of the thumb (Brunelli et al, 1991). The versatility of the subcutaneous turn-over design over the skin island is self-evident. It is, however, surprising that subcutaneous reversed flaps have relatively little popularity despite their high reliability and simplicity. They can be used with confidence to obliterate heavily contaminated wounds, such as infected
nonunions after bone d~bridement, and provide a good alternative to the classic cross-finger flap whenever early motion is necessary.
SUBCUTANEOUS TURN-OVER FLAP
Fig 3
475
(a) Soft tissue defect over the r a d i a l side of the distal interp h a l a n g e a l j o i n t a n d distal p h a l a n x . The flap is outlined. (b) The flap is being transposed. The distal 5 m m o f the tuft o f the distal p h a l a n x were t r i m m e d to allow r o t a t i o n o f the r e m a i n i n g p u l p tissue. (c) Postoperative view.
References Brunelli F, Pegin Z, Cabral J (1991). Dorsal arterial supply to the thumb. Surgical and Radiologic Anatomy, 13: 240~42. Foucher G, Khouri RK (1997). Digital reconstruction with island flaps. Clinics in Plastic Surgery, 24: 1-32. Gumener R, Zbrodowski A, Montandon D (1991). The reversed fasciosubcutaneous flap of the leg. Plastic and Reconstructive Surgery, 88: 1034-1041. Lai C-S, Lin S-D, Yang C-C, Chou C-K (1991 a). The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger British Journal of Plastic and Reconstructive Surgery, 44:165 169. Lai C-S, Lin S-D, Yang C-C, Chou C-K (1991 b). Adipofascial turn-over flap for reconstruction of the dorsum of the foot. British Journal of Plastic and Reconstructive Surgery, 44: 170-174. Marty FM, Montandon D, Gumener R, Zbrodowski A (1984). The use of subcutaneous tissue flaps in the repair of soft tissue defects of the forearm and hand: an experimental and clinical study of a new technique. British Journal of Plastic and Reconstructive Surgery, 37: 95-102. Valenti P, Masquelet AC, Begue T (1990). Anatomic basis of a dorsocommisural flap from the 2nd, 3rd and 4th intermetacarpal spaces. Surgical and Radiolngic Anatomy, 12: 235-239.
Weinzweig N, Chen L, Chen ZW (1994). The distally based radial forearm fasciocutaneous flap with preservation of the radial artery: an anatomic and clinical approach. Plastic and Reconstructive Surgery, 94: 675-684.
Received: 3 September 1997 Accepted after revision:21 February 1998 R C. Cavadas MD, PhD, Division of Plastic, Reconstructiveand Hand Surgery,Hospital Centro de Rehabilitati6nde Levante,Valencia,Spain. © 1998The British Societyfor Surgeryof the Hand
FLAP IN THE OF THE DIGITS
P. C. CAVADAS and L. PUERTES-CORELLA
From the Division of Plastic, Reconstructive and Hand Surgery, Hospital Centro de Rehabilitati6n de Levante, Valencia, Spain A series of 18 cases of fasciosubcutaneous reverse flaps used to cover defects of the fingers is reported.
Journal o f Hand Surgery (British and European Volume, 1998) 23B: 4:472-475 Soft tissue defects of the digits with exposed bone or tendon are demanding problems, whose treatment calls for an experienced surgeon, familiar with the many possible techniques of treatment. Although a number of local flaps have been described, homodigital flaps have the advantage of permitting immediate motion of the digital joints, which is extremely important. The purpose of the present paper is to report on our experience in the use of a distally based subcutaneous turn-over flap to reconstruct complicated defects of the fingers. The flap was an extension of the adipofascial turn-over flap (Lai et al, 199l a).
ddbridement of infected nonunions, extra length was planned so that it could be placed into the defect. The length-to-width ratio was as high as 3 to 1 in some cases, with complete survival. Whenever possible, raising a flap from the dorsum of the metacarpophalangeal joint was avoided, as there is very little subcutaneous tissue in this area. The flap was skin grafted at the end of the procedure, and the donor wound was closed over a drain. RESULTS
All flaps but one survived completely with primary healing of the wounds. The partial tip necrosis occurred in a replanted finger with loss of the palmar skin, and the flap had a length-to-width ratio of 4 to 1. There was no recurrence of infection in the septic nonunions treated.
PATIENTS A N D M E T H O D S
Between June 1995 and March 1997, 18 patients were operated on for complicated wounds of the fingers, including acute and chronic defects. There were 17 men and 1 woman. Mean age of patients was 34 years (range, 17 58). The flap was used for 11 acute traumatic injuries, and as a reconstruction in seven infected phalangeal nonunions. The mean size of the flap was 33 mm x 12 mm (range, 25 x 8 to 45 x 15). Defects were in the middle phalanx in six cases (three dorsal, two lateral and one palmar), in the proximal interphalangeal joint in five cases (two dorsal, two lateral and one palmar), in the proximal phalanx in five cases (lateral or dorsal), and in the distal phalanx in two cases. The wounds were covered with a distally based turn-over subcutaneous flap. These flaps can be considered an extension of previously described flaps (Lai et al, 1991 a), with a higher lengthto-width ratio.
Representative cases
Case 1 A 17-year-old man had an infected n o n u n i o n of the neck of the proximal phalanx of the long finger (Fig 1). The wound was thoroughly d6brided, and the dead space was filled with a distally based turn-over subcutaneous flap 45 x 15 m m in length, and a skin graft was applied. The bone defect was grafted 4 weeks later. Case 2 A 52-year-old man had a traumatic loss of skin with exposure of the dorsoulnar aspect of the interphalangeal joint of the thumb (Fig 2). The joint was covered with a distally based turn-over subcutaneous flap 40 x 10 mm in size, and a skin graft was applied with primary healing of the wounds.
Surgical technique
Once the defect was defined, the flap was outlined as a distally based one, anywhere along the longitudinal axis of the involved ray, but always avoiding the palmar aspect. Dorsolateral design is preferred to dorsal flaps, as there is more subcutaneous substance in the former. N o special effort was made to include named vessels, and the only precaution taken was to leave at least 1 cm of undisturbed tissue between the defect and the base of the flap. The flaps were elevated under tourniquet control and included all tissue between the dermis and the paratenon but always sparing the digital neurovascular bundles. When used to obliterate the dead space resulting from
Case 3 A 47-year-old man had a traumatic loss of skin over the radial side of the distal interphalangeal joint of the index finger (Fig 3). The tuft of the distal phalanx was trimmed (5 ram) and the defect was covered with a distally based turn-over flap 25 x 8 mm in size and the remaining pulp tissue. 472
SUBCUTANEOUS TURN-OVER FLAP
Fig 1
473
(a) Infected nonunion of the proximal phalanx of the long finger. (b) The defect was covered with a reverse subcutaneous turn-over flap. (c) The flap is being transposed. Preservation of the head of the proximal phalanx had been attempted but recurrent drainage due to sequestrum required its resection, a flap readvancement to obliterate dead space, and delayed bone grafting. (d) Late postoperative view.
DISCUSSION Improper treatment of complicated skin defects of the fingers can lead to considerable morbidity. Skin defects are often associated with open fractures and/or tendon injuries, which make early articular mobilization essential. In this situation; the reconstruction of such defects with homodigital flaps is highly convenient. Many flaps have been described for use in the fingers, all of them with some advantages and disadvantages (Foucher and Khouri, 1997). The subcutaneous tissue has been recognized as a rather independent layer in terms of vascularity (Marty et al, 1984), thus allowing it to be mobilized in turn-over flaps. There are some excellent anatomical and clinical reports on the use of these flaps in the lower limb (Lai et al, 1991 b; Gumener et al, 1991), and in the hand and digits (Marty et al, 1984; Lai et al, 1991 a; Weinzweig et al, 1994). The use of a simple, expedient and easy flap to
cover the wound, instead of other more laborious island or free flaps is worth consideration. The cases we treated had soft tissue defects in the fingers, and the flaps used to cover them were based on the flaps previously described by Lai et al (1991 a), but using a much higher length-to-width ratio. The area of intact subcutaneous tissue between the defect and the pivotal point was about 10 mm, and except for one case, the flaps survived completely. The flap can be used either for coverage of the dorsum or the palmar surface. When used for the palmar side, tunnelling can be risky and incising the skin bridge is preferred to avoid tension. There is relatively little bulk in the reconstructed area and in any case the subcutaneous reverse flap is probably not the first choice in reconstruction of the palmar side of the fingers and fingertips, as there are better choices. It is, however, a good choice to cover the dorsal and lateral sides of the fingers, up to the distal phalangeal level.
474
Fig 2
THE JOURNAL OF HAND SURGERY VOL. 23B No. 4 AUGUST 1998
(a) Soft tissue defect over the interphalangeal joint of the thumb. The flap is outlined. (b) The subcutaneous flap has been elevated and is being transposed. (c) Postoperative view. Interphalangeal joint mobilization was started in the early postoperative period.
Although there is considerable freedom in the design of the flap, the vascular territories can overlap to some extent, and in this way, for instance, the turn-over adipofascial flap of the lateral and dorsolateral side of the fingers may not be very different from the previously described dorsocommisural skin island flap (Valenti et al, 1990), except that it does not include skin. The same may be true for the dorsoulnar side of the thumb (Brunelli et al, 1991). The versatility of the subcutaneous turn-over design over the skin island is self-evident. It is, however, surprising that subcutaneous reversed flaps have relatively little popularity despite their high reliability and simplicity. They can be used with confidence to obliterate heavily contaminated wounds, such as infected
nonunions after bone d~bridement, and provide a good alternative to the classic cross-finger flap whenever early motion is necessary.
SUBCUTANEOUS TURN-OVER FLAP
Fig 3
475
(a) Soft tissue defect over the r a d i a l side of the distal interp h a l a n g e a l j o i n t a n d distal p h a l a n x . The flap is outlined. (b) The flap is being transposed. The distal 5 m m o f the tuft o f the distal p h a l a n x were t r i m m e d to allow r o t a t i o n o f the r e m a i n i n g p u l p tissue. (c) Postoperative view.
References Brunelli F, Pegin Z, Cabral J (1991). Dorsal arterial supply to the thumb. Surgical and Radiologic Anatomy, 13: 240~42. Foucher G, Khouri RK (1997). Digital reconstruction with island flaps. Clinics in Plastic Surgery, 24: 1-32. Gumener R, Zbrodowski A, Montandon D (1991). The reversed fasciosubcutaneous flap of the leg. Plastic and Reconstructive Surgery, 88: 1034-1041. Lai C-S, Lin S-D, Yang C-C, Chou C-K (1991 a). The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger British Journal of Plastic and Reconstructive Surgery, 44:165 169. Lai C-S, Lin S-D, Yang C-C, Chou C-K (1991 b). Adipofascial turn-over flap for reconstruction of the dorsum of the foot. British Journal of Plastic and Reconstructive Surgery, 44: 170-174. Marty FM, Montandon D, Gumener R, Zbrodowski A (1984). The use of subcutaneous tissue flaps in the repair of soft tissue defects of the forearm and hand: an experimental and clinical study of a new technique. British Journal of Plastic and Reconstructive Surgery, 37: 95-102. Valenti P, Masquelet AC, Begue T (1990). Anatomic basis of a dorsocommisural flap from the 2nd, 3rd and 4th intermetacarpal spaces. Surgical and Radiolngic Anatomy, 12: 235-239.
Weinzweig N, Chen L, Chen ZW (1994). The distally based radial forearm fasciocutaneous flap with preservation of the radial artery: an anatomic and clinical approach. Plastic and Reconstructive Surgery, 94: 675-684.
Received: 3 September 1997 Accepted after revision:21 February 1998 R C. Cavadas MD, PhD, Division of Plastic, Reconstructiveand Hand Surgery,Hospital Centro de Rehabilitati6nde Levante,Valencia,Spain. © 1998The British Societyfor Surgeryof the Hand