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The Zitelli Bilobed Flap on Skin Coverage After Mucous Cyst Excision: A Retrospective Cohort of 33 Cases
SCIENTIFIC ARTICLE
The Zitelli Bilobed Flap on Skin Coverage After Mucous Cyst Excision: A Retrospective Cohort of 33 Cases Isidro Jiménez, MD,* Pedro J. Delgado, MD,* Ricardo Kaempf de Oliveira, MD†
Purpose To study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cysts using the Zitelli modified bilobed flap. Methods We surgically treated 33 patients from January 2006 to June 2015. We assessed demographic data, comorbidities, location and size of the cyst, time to wound healing, and complications. Results The most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. The mucous cyst recurred in 1 of 33 cases. There were no major complications. Conclusions The Zitelli bilobed flap can provide good-quality skin coverage over the distal interphalangeal joint in a short period. (J Hand Surg Am. 2017;-(-):1.e1-e5. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Bilobed, coverage, cyst, flap, mucous.
M
UCOUS CYSTS OF THE DIGITS ARE a frequent occurrence in hand surgery. The natural history of the mucous cyst has been widely debated and it is currently accepted that they are composed of a hernia sac that originates from osteoarthritic degeneration of the distal interphalangeal (DIP) joint. An underlying osteophyte is usually present.1e3 They are generally small but may cause discomfort.4 Numerous treatments have been reported ranging from simple aspiration to DIP joint arthrodesis to ensure prevention of cyst recurrence.1,2,5e10
From the *Hand and Upper Extremity Surgery Unit, Hospital Universitario HM Montepríncipe, Boadilla del Monte, Madrid, Spain; and †Instituto da Mão, Complexo Hospitalar Santa Casa and Hospital Mãe de Deus, Porto Alegre, RS, Brazil. Received for publication June 21, 2016; accepted in revised form March 8, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Pedro J. Delgado, MD, Hand and Upper Extremity Surgery Unit, Hospital Universitario HM Montepríncipe, Avda. Montepríncipe, 25, 28660 Boadilla del Monte, Madrid; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.03.013
Surgical management is not mandatory. In fact, nonsurgical management is the rule if the condition is asymptomatic, but excision may be necessary if the overlying skin is thinned or if the patient reports important symptoms. Some authors report healing of the thinned skin over the cysts; others report that even full-thickness skin defects can be left to heal secondarily,11 but this may take a protracted time until clinical resolution. The thinned skin may ulcerate, creating direct communication with the DIP joint and increasing the risk of septic arthritis, a complication that could be avoided with proper coverage.4 In addition, many authors believe that the risk of recurrence is also reduced by these flaps because they allow excision of mucous deposits invading the thin skin overlying the cyst.1,5,7 For this reason, many authors advocate skin excision and the use of local flaps to cover the resulting defect.2,6,12,13 Many flaps have been described to provide this skin coverage, including some bilobed flaps with different designs.14,15 In 1918, Esser reported a selfclosing bilobed flap for nasal tip skin injuries, later
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
ZITELLI FLAP AFTER MUCOUS CYST EXCISION
TABLE 1. Patients’ Gender, Comorbidities, Size of Cyst, Time to Wound Healing, and Complications (n [ 33) Patients’ data
Result
Gender, n (%) Female
24 (72.7%)
Male
9 (27.3%)
Comorbidities, n (%) Obesity
2 (6%)
Diabetes Mellitus
3 (9%)
Arterial hypertension
7 (21.2%)
Smoker
3 (9%)
Former smoker
3 (9%)
Cyst size, mm Average
7.1 x 5.8
Minimum
3x2
Maximum
12 x 11
Time to wound healing, d Average
14
Minimum
9
Maximum
19
FIGURE 1: Geometric landmarks for the bilobed flap design. r indicates the cyst radius; A, the center of flap rotation; line B, the axis of the cyst; and line C, the axis of the third lobe. The BC angle should be between 90 and 100 .
Complications, n (%) Donor area skin necrosis
1 (3%)
Superficial infection
2 (6%)
Recurrence
1 (3%)
and eroded skin over the cyst treated surgically using the Zitelli modified bilobed flap. Exclusion criteria were septic DIP arthritis and subungual cysts resulting in severe nail deformity.17 Minor nail deformities such as grooves or flattening and previous local procedures such as percutaneous drainage or cryotherapy were not considered exclusion criteria. The authors performed no punctures or injections before surgery, to avoid the risk of articular infection; 2 of them performed all procedures. In addition to demographic data and comorbidities, the location and size of the cyst were documented (Table 1). The period to wound healing and complications, such as nail deformity or cyst recurrence, were assessed throughout the follow-up period. Wound healing was defined as the skin incision being completely closed after removal of the stitches with no wound dehiscence during range of motion. All preoperative and follow-up examinations were performed and data were collected by all authors.
modified and popularized by Zimany.14 Its use for mucous cysts in the digits was first reported by Young and Campbell,12 who reported that its preoperative design was challenging. Zitelli16 reported a modified geometric design that facilitates flap drawing and reproducibility. It was first reported as a treatment for mucous cyst in 9 patients, with good outcome by Jager et al.2 The purpose of this study was to investigate the time to healing, recurrence rate, and aesthetic results achieved in the treatment of DIP joint mucous cysts using the Zitelli modified bilobed flap. MATERIALS AND METHODS After we obtained approval from the institutional review board at Hospital Universitario HM Montepríncipe, we identified a retrospective cohort of 33 digits in 31 patients surgically treated for a DIP joint mucous cyst using the Zitteli bilobed flap from January 2006 to June 2015. The diagnosis was made based on clinical findings and plain x-rays. Inclusion criteria were patients diagnosed with a DIP joint mucous cyst with thinned J Hand Surg Am.
Surgical technique The surgery was performed under a digital nerve block using 1% mepivacaine. A digital tourniquet was applied as described by Salem18 and optical loupes r
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ZITELLI FLAP AFTER MUCOUS CYST EXCISION
1.e3
FIGURE 2: Perioperative and follow-up views of a bilobed flap. A Skin resection is planned and the bilobed flap is designed according to the geometric planning. B The cyst and skin are excised and the flap is harvested. C Flap rotation. D Final operative view: self-closure of the donor site; no skin graft is required. E, F Final follow-up dorsal and lateral views: the cosmetic outcome is excellent.
rotating the flap and suturing it into place with a 6-0 nonabsorbable nylon monofilament. In some cases, complete skin closure could not be not achieved, which left a small area that was not located over the joint to heal by secondary intention (Fig. 2) (4 of 33 patients). In most cases complete closure of the defect was achieved (Fig. 3). The first dressing change was performed 5 to 7 days after surgery and an aluminum DIP immobilization orthosis was used for 2 weeks.
were used for magnification. Skin excision was planned creating a circular defect; the flap was then designed according to Zitelli’s modified technique.2 The first lobe should have the diameter of the defect, with the second lobe being slightly smaller in width but half a diameter longer. This second lobe covers the defect created by the first lobe. Its narrower design is better because during rotation of the flap, the surrounding skin tends to be stretched, turning the round defect created by the first lobe into a more oval shape. Finally, it is recommended to limit the angle formed by the axis of the first and the third lobes to 90 to 100 , to avoid dog ears around the pedicle and allow easier skin closure (Fig. 1). The whole cyst was excised, including the overlying skin. Distal interphalangeal joint capsulectomy was performed between the terminal tendon and the lateral ligaments. The stalk of the mucous cyst was identified and excised and any DIP osteophytes in the area were also excised. The circular skin defect was covered by J Hand Surg Am.
RESULTS There were 24 women and 9 men. Average age at surgery was 59 years (range, 40e87 years); median follow-up was 24 months (range, 12e120 months). All cysts were located between the DIP joint and nail fold and all were situated radially or ulnarly on the dorsal surface of the digit. Five cysts affected the interphalangeal joint of the thumb, 7 the DIP joint of the index finger, 16 the DIP joint of the middle finger, 1 the DIP joint of the ring r
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ZITELLI FLAP AFTER MUCOUS CYST EXCISION
FIGURE 3: Patient 17. Flap design. First dressing appearance and cosmetic result at the end of follow-up.
finger, and 4 the DIP joint of the little finger. Mean mucous cyst size was 7.1 5.8 mm. All flaps survived and the wounds healed in 14 days on average. There were no major complications, defined as DIP septic arthritis or flap necrosis, and no nail deformities developed after the surgery. In one case skin necrosis on the distal-most part of the first lobe occurred after surgery but it healed by secondary intention without the appearance of a synovial fistula at final follow-up. In 3 patients a superficial infection was diagnosed and treated successfully with oral antibiotics. There was one cyst recurrence (3%) at final follow-up.
surgery to expect slow resolution of the cyst.6,32 Cyst and skin excision with local flap coverage has reported to have a recurrence rate from 0% to 8%.2,8,13,15,33 In our series, the recurrence rate was 1 in 33 patient (3.3%), similar to previously published data. The treatment of DIP mucous cysts with thinned and eroded skin remains controversial.24 The rate of recurrence, with or without skin excision and local flap coverage, seems to be similar although further studies are needed. It has been noted that the thinned skin will heal, providing adequate skin coverage2,10; however, we believe the difference is not in the status at the final follow-up but in the time required for complete resolution of the cyst and skin wound healing. In our series, time to wound healing was 14 days; unfortunately, these data were not reported in most of published articles. Kleinert et al1 first described the use of rotation flaps after cyst excisions in 36 patients. Since that report, many flaps have been described. Final outcome is almost always excellent, but often at the cost of secondary healing of the donor site.15 Others flaps allow direct skin closure and are easy to perform but extensive dissection is required, as with the dorsal Hueston flap2 or the extended dorsal advancement flap described by Shin and Jupiter.34 Finally, other skin flaps allow smaller surgical dissection and direct skin closure but their designs are more complex and might be challenging even for an experienced surgeon.4,12,14 We believe that a benefit of the Zitteli modified flap is its simplicity, which improves its reliability.2,4 Our study has limitations. It is a descriptive, noncomparative study and the follow-up period is probably not long enough in all cases to assess the longterm recurrence rate.
DISCUSSION The usefulness of a bilobed flap to cover a skin defect is not new and its use has been widely reported in the literature at various anatomic areas including the face, trunk, foot, scalp, hand, and axilla.19e23 Surgical excision of DIP mucous cysts is necessary when the patient reports discomfort in daily activities, the cyst is causing a nail deformity, or the surrounding skin becomes fragile and thin, leading to pain and increasing the risk of joint infection.2,12,13,24 Recurrence rates vary depending on the surgical procedure. Needle puncture has a recurrence rate up to 100%.1 The recurrence rate after cryosurgical destruction ranges from 13% to 40%9,10 whereas surgical cyst excision without osteophyte excision has a recurrence rate from 9.5% to 28%.5,24,25 Cyst excision with DIP osteophyte excision is associated with a recurrence rate from 0% to 3.5%.1,7,26e31 Joint debridement without cyst excision has been reported to be associated with a recurrence rate of 0% and with residual nail deformity in 10% of cases, but patients must be educated after J Hand Surg Am.
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ZITELLI FLAP AFTER MUCOUS CYST EXCISION
The Zitelli bilobed flap after mucous cyst excision is simple and provides good-quality skin coverage over the DIP joint. It allows excision of the cyst and thinned skin with no added risk to the nail matrix.2,15 The final aesthetic result appears to be satisfactory.
16. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989;125(7):957e959. 17. Sommer NZ, Brown RE. The perionychium. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:333e354. 18. Salem MZA. Simple finger tourniquet (letter). BMJ. 1973;2:779. 19. Bouche RT, Christensen JC, Hale DS. Unilobed and bilobed skin flaps: detailed surgical technique for plantar lesions. J Am Podiatr Med Assoc. 1995;85(1):41e48. 20. Iida N, Ohsumi N, Tonegawa M, Tsutsumi Y. Reconstruction of scalp defects using simple designed bilobed flap. Aesthet Plast Surg. 2000;24(2):137e140. 21. Cerqueiro-Mosquera J, Fleming ANM. The bilobed flap: a new application in the reconstruction of congenital thumb deviation. J Hand Surg Br. 2000;25(3):262e265. 22. Karacalar A, Güner H. The axial bilobed flap for burn contractures of the axilla. Burns. 2000;26(7):628e633. 23. Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg. 2001;54(7):570e572. 24. Dodge LD, Brown RL, Niebauer JJ, McCarroll HR Jr. The treatment of mucous cysts: long-term follow-up in sixty-two cases. J Hand Surg Am. 1984;9(6):901e904. 25. Constant E, Royer JR, Pollard RJ, Larsen RD, Posch JL. Mucous cysts of the fingers. Plast Reconstr Surg. 1969;43(3):241e246. 26. Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst excision. J Hand Surg Br. 1997;22(2):222e225. 27. Kasdan ML, Stallings SP, Leis VM, Wolens D. Outcome of surgically treated mucous cysts of the hand. J Hand Surg Am. 1994;19(3): 504e507. 28. Eaton RG, Dobranski AI, Littler JW. Marginal osteophyte excision in treatment of mucous cysts. J Bone Joint Surg Am. 1973;55(3): 570e574. 29. Brown RE, Zook EG, Russell RC, Kucan JO, Smoot EC. Fingernail deformities secondary to ganglions of the distal interphalangeal joint (mucous cysts). Plast Reconstr Surg. 1991;87(4):718e725. 30. MacCollum MS. Mucous cysts of the fingers. Br J Plast Surg. 1975;28(2):118e120. 31. Newmeyer WL, Kilgore ES Jr, Graham WP III. Mucous cysts: the dorsal distal interphalangeal joint ganglion. Plast Reconstr Surg. 1974;53(3):313e315. 32. Athanasian EA. Bone and soft tissue tumors. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:2141e2196. 33. Baazil H, Dalemans A, De Smet L, Degreef I. Comparison of surgical treatments for mucous cysts of the distal interphalangeal joint. Acta Orthop Belg. 2015;81(2):213e217. 34. Shin EK, Jupiter JB. Flap advancement coverage after excision of large mucous cysts. Tech Hand Up Extrem Surg. 2007;11(2): 159e162.
REFERENCES 1. Kleinert HE, Kutz JE, Fishman JH, McCraw LH. Etiology and treatment of the so-called mucous cyst of the finger. J Bone Joint Surg Am. 1972;54(7):1455e1458. 2. Jager T, Vogels J, Dautel G. The Zitelli design for bilobed flap applied on skin defects after digital mucous cyst excision: a review of 9 cases. Tech Hand Surg. 2012;16(3):124e126. 3. Roulet S, Marteau E, Bacle G, Laulan J. Surgical treatment of mucous cysts by subcutaneous excision and osteophyte resection: results in 68 cases at a mean 6.63 years’ follow-up. Chir Main. 2015;34(4):197e200. 4. Imran D, Koukkou C, Bainbridge LC. The rhomboid flap: a simple technique to cover the skin defect produced by excision of a mucous cyst of a digit. J Bone Joint Surg Br. 2003;85(6):860e862. 5. Crawford RJ, Gupta A, Risitano G, Burke FD. Mucous cyst of the distal interphalangeal joint: treatment by simple excision or excision and rotation flap. J Hand Surg Am. 1990;15(1):113e114. 6. Gingrass MK, Brown RE, Zook EG. Treatment of fingernail deformities secondary to ganglions of the distal interphalangeal joint. J Hand Surg Am. 1995;20(3):502e505. 7. Rizzo M, Beckenbaugh RD. Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation. J Hand Surg Am. 2003;28(3):519e524. 8. Kanaya K, Wada T, Iba K, Yamashita T. Total dorsal capsulectomy for the treatment of mucous cysts. J Hand Surg Am. 2014;39(6): 1063e1067. 9. Esson GA, Holme SA. Treatment of 63 subjects with digital mucous cysts with percutaneous sclerotherapy using polidocanol. Dermatol Surg. 2016;42(1):59e62. 10. Bardach HG. Managing digital mucous cysts by cryosurgery with liquid nitrogen: preliminary report. J Dermatol Surg Oncol. 1983;9(6):455e458. 11. Budoff JE. Mucous cysts. J Hand Surg Am. 2010;35(5):828e830. 12. Young KA, Campbell AC. The bilobed flap in treatment of mucous cysts of the distal interphalangeal joint. J Hand Surg Br. 1999;24(2): 238e240. 13. Chen WS, Lin CC. Mucous cyst of the distal interphalangeal joint: treatment by simple excision or excision and rotation flap. J Hand Surg Br. 1991;16(1):118e119. 14. Zimany A. The bi-lobed flap. Plast Reconstr Surg (1946). 1953;11: 424e434. 15. Blanc S, Candelier G, Bonnan J, Faure P. Use of a bilobed flap for the treatment of mucous cysts. Chir Main. 2004;23(3):137e141.
J Hand Surg Am.
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The Zitelli Bilobed Flap on Skin Coverage After Mucous Cyst Excision: A Retrospective Cohort of 33 Cases Isidro Jiménez, MD,* Pedro J. Delgado, MD,* Ricardo Kaempf de Oliveira, MD†
Purpose To study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cysts using the Zitelli modified bilobed flap. Methods We surgically treated 33 patients from January 2006 to June 2015. We assessed demographic data, comorbidities, location and size of the cyst, time to wound healing, and complications. Results The most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. The mucous cyst recurred in 1 of 33 cases. There were no major complications. Conclusions The Zitelli bilobed flap can provide good-quality skin coverage over the distal interphalangeal joint in a short period. (J Hand Surg Am. 2017;-(-):1.e1-e5. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Bilobed, coverage, cyst, flap, mucous.
M
UCOUS CYSTS OF THE DIGITS ARE a frequent occurrence in hand surgery. The natural history of the mucous cyst has been widely debated and it is currently accepted that they are composed of a hernia sac that originates from osteoarthritic degeneration of the distal interphalangeal (DIP) joint. An underlying osteophyte is usually present.1e3 They are generally small but may cause discomfort.4 Numerous treatments have been reported ranging from simple aspiration to DIP joint arthrodesis to ensure prevention of cyst recurrence.1,2,5e10
From the *Hand and Upper Extremity Surgery Unit, Hospital Universitario HM Montepríncipe, Boadilla del Monte, Madrid, Spain; and †Instituto da Mão, Complexo Hospitalar Santa Casa and Hospital Mãe de Deus, Porto Alegre, RS, Brazil. Received for publication June 21, 2016; accepted in revised form March 8, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Pedro J. Delgado, MD, Hand and Upper Extremity Surgery Unit, Hospital Universitario HM Montepríncipe, Avda. Montepríncipe, 25, 28660 Boadilla del Monte, Madrid; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.03.013
Surgical management is not mandatory. In fact, nonsurgical management is the rule if the condition is asymptomatic, but excision may be necessary if the overlying skin is thinned or if the patient reports important symptoms. Some authors report healing of the thinned skin over the cysts; others report that even full-thickness skin defects can be left to heal secondarily,11 but this may take a protracted time until clinical resolution. The thinned skin may ulcerate, creating direct communication with the DIP joint and increasing the risk of septic arthritis, a complication that could be avoided with proper coverage.4 In addition, many authors believe that the risk of recurrence is also reduced by these flaps because they allow excision of mucous deposits invading the thin skin overlying the cyst.1,5,7 For this reason, many authors advocate skin excision and the use of local flaps to cover the resulting defect.2,6,12,13 Many flaps have been described to provide this skin coverage, including some bilobed flaps with different designs.14,15 In 1918, Esser reported a selfclosing bilobed flap for nasal tip skin injuries, later
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
ZITELLI FLAP AFTER MUCOUS CYST EXCISION
TABLE 1. Patients’ Gender, Comorbidities, Size of Cyst, Time to Wound Healing, and Complications (n [ 33) Patients’ data
Result
Gender, n (%) Female
24 (72.7%)
Male
9 (27.3%)
Comorbidities, n (%) Obesity
2 (6%)
Diabetes Mellitus
3 (9%)
Arterial hypertension
7 (21.2%)
Smoker
3 (9%)
Former smoker
3 (9%)
Cyst size, mm Average
7.1 x 5.8
Minimum
3x2
Maximum
12 x 11
Time to wound healing, d Average
14
Minimum
9
Maximum
19
FIGURE 1: Geometric landmarks for the bilobed flap design. r indicates the cyst radius; A, the center of flap rotation; line B, the axis of the cyst; and line C, the axis of the third lobe. The BC angle should be between 90 and 100 .
Complications, n (%) Donor area skin necrosis
1 (3%)
Superficial infection
2 (6%)
Recurrence
1 (3%)
and eroded skin over the cyst treated surgically using the Zitelli modified bilobed flap. Exclusion criteria were septic DIP arthritis and subungual cysts resulting in severe nail deformity.17 Minor nail deformities such as grooves or flattening and previous local procedures such as percutaneous drainage or cryotherapy were not considered exclusion criteria. The authors performed no punctures or injections before surgery, to avoid the risk of articular infection; 2 of them performed all procedures. In addition to demographic data and comorbidities, the location and size of the cyst were documented (Table 1). The period to wound healing and complications, such as nail deformity or cyst recurrence, were assessed throughout the follow-up period. Wound healing was defined as the skin incision being completely closed after removal of the stitches with no wound dehiscence during range of motion. All preoperative and follow-up examinations were performed and data were collected by all authors.
modified and popularized by Zimany.14 Its use for mucous cysts in the digits was first reported by Young and Campbell,12 who reported that its preoperative design was challenging. Zitelli16 reported a modified geometric design that facilitates flap drawing and reproducibility. It was first reported as a treatment for mucous cyst in 9 patients, with good outcome by Jager et al.2 The purpose of this study was to investigate the time to healing, recurrence rate, and aesthetic results achieved in the treatment of DIP joint mucous cysts using the Zitelli modified bilobed flap. MATERIALS AND METHODS After we obtained approval from the institutional review board at Hospital Universitario HM Montepríncipe, we identified a retrospective cohort of 33 digits in 31 patients surgically treated for a DIP joint mucous cyst using the Zitteli bilobed flap from January 2006 to June 2015. The diagnosis was made based on clinical findings and plain x-rays. Inclusion criteria were patients diagnosed with a DIP joint mucous cyst with thinned J Hand Surg Am.
Surgical technique The surgery was performed under a digital nerve block using 1% mepivacaine. A digital tourniquet was applied as described by Salem18 and optical loupes r
Vol. -, - 2017
ZITELLI FLAP AFTER MUCOUS CYST EXCISION
1.e3
FIGURE 2: Perioperative and follow-up views of a bilobed flap. A Skin resection is planned and the bilobed flap is designed according to the geometric planning. B The cyst and skin are excised and the flap is harvested. C Flap rotation. D Final operative view: self-closure of the donor site; no skin graft is required. E, F Final follow-up dorsal and lateral views: the cosmetic outcome is excellent.
rotating the flap and suturing it into place with a 6-0 nonabsorbable nylon monofilament. In some cases, complete skin closure could not be not achieved, which left a small area that was not located over the joint to heal by secondary intention (Fig. 2) (4 of 33 patients). In most cases complete closure of the defect was achieved (Fig. 3). The first dressing change was performed 5 to 7 days after surgery and an aluminum DIP immobilization orthosis was used for 2 weeks.
were used for magnification. Skin excision was planned creating a circular defect; the flap was then designed according to Zitelli’s modified technique.2 The first lobe should have the diameter of the defect, with the second lobe being slightly smaller in width but half a diameter longer. This second lobe covers the defect created by the first lobe. Its narrower design is better because during rotation of the flap, the surrounding skin tends to be stretched, turning the round defect created by the first lobe into a more oval shape. Finally, it is recommended to limit the angle formed by the axis of the first and the third lobes to 90 to 100 , to avoid dog ears around the pedicle and allow easier skin closure (Fig. 1). The whole cyst was excised, including the overlying skin. Distal interphalangeal joint capsulectomy was performed between the terminal tendon and the lateral ligaments. The stalk of the mucous cyst was identified and excised and any DIP osteophytes in the area were also excised. The circular skin defect was covered by J Hand Surg Am.
RESULTS There were 24 women and 9 men. Average age at surgery was 59 years (range, 40e87 years); median follow-up was 24 months (range, 12e120 months). All cysts were located between the DIP joint and nail fold and all were situated radially or ulnarly on the dorsal surface of the digit. Five cysts affected the interphalangeal joint of the thumb, 7 the DIP joint of the index finger, 16 the DIP joint of the middle finger, 1 the DIP joint of the ring r
Vol. -, - 2017
1.e4
ZITELLI FLAP AFTER MUCOUS CYST EXCISION
FIGURE 3: Patient 17. Flap design. First dressing appearance and cosmetic result at the end of follow-up.
finger, and 4 the DIP joint of the little finger. Mean mucous cyst size was 7.1 5.8 mm. All flaps survived and the wounds healed in 14 days on average. There were no major complications, defined as DIP septic arthritis or flap necrosis, and no nail deformities developed after the surgery. In one case skin necrosis on the distal-most part of the first lobe occurred after surgery but it healed by secondary intention without the appearance of a synovial fistula at final follow-up. In 3 patients a superficial infection was diagnosed and treated successfully with oral antibiotics. There was one cyst recurrence (3%) at final follow-up.
surgery to expect slow resolution of the cyst.6,32 Cyst and skin excision with local flap coverage has reported to have a recurrence rate from 0% to 8%.2,8,13,15,33 In our series, the recurrence rate was 1 in 33 patient (3.3%), similar to previously published data. The treatment of DIP mucous cysts with thinned and eroded skin remains controversial.24 The rate of recurrence, with or without skin excision and local flap coverage, seems to be similar although further studies are needed. It has been noted that the thinned skin will heal, providing adequate skin coverage2,10; however, we believe the difference is not in the status at the final follow-up but in the time required for complete resolution of the cyst and skin wound healing. In our series, time to wound healing was 14 days; unfortunately, these data were not reported in most of published articles. Kleinert et al1 first described the use of rotation flaps after cyst excisions in 36 patients. Since that report, many flaps have been described. Final outcome is almost always excellent, but often at the cost of secondary healing of the donor site.15 Others flaps allow direct skin closure and are easy to perform but extensive dissection is required, as with the dorsal Hueston flap2 or the extended dorsal advancement flap described by Shin and Jupiter.34 Finally, other skin flaps allow smaller surgical dissection and direct skin closure but their designs are more complex and might be challenging even for an experienced surgeon.4,12,14 We believe that a benefit of the Zitteli modified flap is its simplicity, which improves its reliability.2,4 Our study has limitations. It is a descriptive, noncomparative study and the follow-up period is probably not long enough in all cases to assess the longterm recurrence rate.
DISCUSSION The usefulness of a bilobed flap to cover a skin defect is not new and its use has been widely reported in the literature at various anatomic areas including the face, trunk, foot, scalp, hand, and axilla.19e23 Surgical excision of DIP mucous cysts is necessary when the patient reports discomfort in daily activities, the cyst is causing a nail deformity, or the surrounding skin becomes fragile and thin, leading to pain and increasing the risk of joint infection.2,12,13,24 Recurrence rates vary depending on the surgical procedure. Needle puncture has a recurrence rate up to 100%.1 The recurrence rate after cryosurgical destruction ranges from 13% to 40%9,10 whereas surgical cyst excision without osteophyte excision has a recurrence rate from 9.5% to 28%.5,24,25 Cyst excision with DIP osteophyte excision is associated with a recurrence rate from 0% to 3.5%.1,7,26e31 Joint debridement without cyst excision has been reported to be associated with a recurrence rate of 0% and with residual nail deformity in 10% of cases, but patients must be educated after J Hand Surg Am.
r
Vol. -, - 2017
ZITELLI FLAP AFTER MUCOUS CYST EXCISION
The Zitelli bilobed flap after mucous cyst excision is simple and provides good-quality skin coverage over the DIP joint. It allows excision of the cyst and thinned skin with no added risk to the nail matrix.2,15 The final aesthetic result appears to be satisfactory.
16. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989;125(7):957e959. 17. Sommer NZ, Brown RE. The perionychium. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:333e354. 18. Salem MZA. Simple finger tourniquet (letter). BMJ. 1973;2:779. 19. Bouche RT, Christensen JC, Hale DS. Unilobed and bilobed skin flaps: detailed surgical technique for plantar lesions. J Am Podiatr Med Assoc. 1995;85(1):41e48. 20. Iida N, Ohsumi N, Tonegawa M, Tsutsumi Y. Reconstruction of scalp defects using simple designed bilobed flap. Aesthet Plast Surg. 2000;24(2):137e140. 21. Cerqueiro-Mosquera J, Fleming ANM. The bilobed flap: a new application in the reconstruction of congenital thumb deviation. J Hand Surg Br. 2000;25(3):262e265. 22. Karacalar A, Güner H. The axial bilobed flap for burn contractures of the axilla. Burns. 2000;26(7):628e633. 23. Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg. 2001;54(7):570e572. 24. Dodge LD, Brown RL, Niebauer JJ, McCarroll HR Jr. The treatment of mucous cysts: long-term follow-up in sixty-two cases. J Hand Surg Am. 1984;9(6):901e904. 25. Constant E, Royer JR, Pollard RJ, Larsen RD, Posch JL. Mucous cysts of the fingers. Plast Reconstr Surg. 1969;43(3):241e246. 26. Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst excision. J Hand Surg Br. 1997;22(2):222e225. 27. Kasdan ML, Stallings SP, Leis VM, Wolens D. Outcome of surgically treated mucous cysts of the hand. J Hand Surg Am. 1994;19(3): 504e507. 28. Eaton RG, Dobranski AI, Littler JW. Marginal osteophyte excision in treatment of mucous cysts. J Bone Joint Surg Am. 1973;55(3): 570e574. 29. Brown RE, Zook EG, Russell RC, Kucan JO, Smoot EC. Fingernail deformities secondary to ganglions of the distal interphalangeal joint (mucous cysts). Plast Reconstr Surg. 1991;87(4):718e725. 30. MacCollum MS. Mucous cysts of the fingers. Br J Plast Surg. 1975;28(2):118e120. 31. Newmeyer WL, Kilgore ES Jr, Graham WP III. Mucous cysts: the dorsal distal interphalangeal joint ganglion. Plast Reconstr Surg. 1974;53(3):313e315. 32. Athanasian EA. Bone and soft tissue tumors. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:2141e2196. 33. Baazil H, Dalemans A, De Smet L, Degreef I. Comparison of surgical treatments for mucous cysts of the distal interphalangeal joint. Acta Orthop Belg. 2015;81(2):213e217. 34. Shin EK, Jupiter JB. Flap advancement coverage after excision of large mucous cysts. Tech Hand Up Extrem Surg. 2007;11(2): 159e162.
REFERENCES 1. Kleinert HE, Kutz JE, Fishman JH, McCraw LH. Etiology and treatment of the so-called mucous cyst of the finger. J Bone Joint Surg Am. 1972;54(7):1455e1458. 2. Jager T, Vogels J, Dautel G. The Zitelli design for bilobed flap applied on skin defects after digital mucous cyst excision: a review of 9 cases. Tech Hand Surg. 2012;16(3):124e126. 3. Roulet S, Marteau E, Bacle G, Laulan J. Surgical treatment of mucous cysts by subcutaneous excision and osteophyte resection: results in 68 cases at a mean 6.63 years’ follow-up. Chir Main. 2015;34(4):197e200. 4. Imran D, Koukkou C, Bainbridge LC. The rhomboid flap: a simple technique to cover the skin defect produced by excision of a mucous cyst of a digit. J Bone Joint Surg Br. 2003;85(6):860e862. 5. Crawford RJ, Gupta A, Risitano G, Burke FD. Mucous cyst of the distal interphalangeal joint: treatment by simple excision or excision and rotation flap. J Hand Surg Am. 1990;15(1):113e114. 6. Gingrass MK, Brown RE, Zook EG. Treatment of fingernail deformities secondary to ganglions of the distal interphalangeal joint. J Hand Surg Am. 1995;20(3):502e505. 7. Rizzo M, Beckenbaugh RD. Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation. J Hand Surg Am. 2003;28(3):519e524. 8. Kanaya K, Wada T, Iba K, Yamashita T. Total dorsal capsulectomy for the treatment of mucous cysts. J Hand Surg Am. 2014;39(6): 1063e1067. 9. Esson GA, Holme SA. Treatment of 63 subjects with digital mucous cysts with percutaneous sclerotherapy using polidocanol. Dermatol Surg. 2016;42(1):59e62. 10. Bardach HG. Managing digital mucous cysts by cryosurgery with liquid nitrogen: preliminary report. J Dermatol Surg Oncol. 1983;9(6):455e458. 11. Budoff JE. Mucous cysts. J Hand Surg Am. 2010;35(5):828e830. 12. Young KA, Campbell AC. The bilobed flap in treatment of mucous cysts of the distal interphalangeal joint. J Hand Surg Br. 1999;24(2): 238e240. 13. Chen WS, Lin CC. Mucous cyst of the distal interphalangeal joint: treatment by simple excision or excision and rotation flap. J Hand Surg Br. 1991;16(1):118e119. 14. Zimany A. The bi-lobed flap. Plast Reconstr Surg (1946). 1953;11: 424e434. 15. Blanc S, Candelier G, Bonnan J, Faure P. Use of a bilobed flap for the treatment of mucous cysts. Chir Main. 2004;23(3):137e141.
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