flap modalities for hand and upper limb...

A G U S R O Y R H H A M I D , H E N D R A S A N J A Y A

S U B D I V I S I O N O F P L A S T I C , R E C O S T R U C T I V E A N D A E S T H E T I C S U R G E R Y , D E P A R T M E N T O F S U R G E R Y , S C H O O L O F M E D I C I N E , U D A Y A N A

U N I V E R S I T Y T H E 1 0 T H N A T I O N A L C O N G R E S S A N D 2 2 N D A N N U A L S C I E N T I F I C

M E E T I N G O F I N A P R A S B N D C C , B A L I - I N D O N E S I A

2 0 1 8

Flap Modalities for Hand and Upper Limb Defect

Introduction

What should we do ?

Introduction

• Flap is one modalities for cover hand defect problem

• Hand defect can be include exposed of the bone, muscle, tendon and tissue.

• We must to know what kind of the flap can be use for hand defect reconstruction from local until free flap.

Classification of the flap

If classified according to their location in relation to the defect alone, they can be grouped into 3 types of flaps :

Local flaps: harvested from the injured digit or tissue surrounding the injured zone of the hand

Regional flaps: harvested from adjacent noninjured digit or zone of the hand

Distant flaps: harvested away from the injured hand

Flap is piece of tissue which has got its own blood supply and does not depend upon the recipient bed for its survival.

A flap can be created from skin with its underlying subcutaneous tissue, fascia, or muscle, either nindividually or in some combination. Depending on the reconstructive requirements, even bone can be included in a flap.

Examples of wounds that require flap coverage include wounds with exposed bone, tendon, or other vital structure and large wounds over a flexion crease, for which a split thickness skin graft or secondary closure would result in tight scarring.

Local Flap –Term is used when tissue immediately adjacent to the open wound is used for coverage.

Regional Flap – Regional flaps derive from tissues not immediately adjacent to the primary defect but from its vicinity.

Thus, most regional flaps in the hand are raised from another part of the hand or forearm.

They are both random and axial pattern with respect to their blood supply. Regional axial flaps require only one surgical procedure, whereas regional random flaps require at least two stage operations. At the first operation, the flap is raised and applied to the primary defect. At the second, the pedicle is divided and inset.

Distant Flap –Term used when tissue is brought from an area away from the open wound from a different region.

Free Flap – Term is used when tissue with its vessels detached from its donor site and transferred to recipient site by micro vascular anastomosis.

Local Flaps of the Hand

Shady A. Rehim, MB ChB, MSc, MRCSa, Kevin C. Chung, MD, MSb,*

Hand Clin 30 (2014) 137–151

http://dx.doi.org/10.1016/j.hcl.2013.12.004

V-Y Advancement Flap for finger tip injury

Local Flaps of the Hand

Shady A. Rehim, MB ChB, MSc, MRCSa, Kevin C. Chung, MD, MSb,*

Hand Clin 30 (2014) 137–151

http://dx.doi.org/10.1016/j.hcl.2013.12.004

Finger tip Injury

4 weeks post

op

A Moberg flap was performed to reconstruct the

resultant defect. Note the digital nerves

incorporated within the flap (left bottom).

Local Flaps of the Hand

Shady A. Rehim, MB ChB, MSc, MRCSa, Kevin C. Chung,

MD, MSb,*

Hand Clin 30 (2014) 137–151

http://dx.doi.org/10.1016/j.hcl.2013.12.004

The vascular supply of the distally based DMCA perforator flap as described by Quaba and Davidson.

(Data from Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg 1990;43(1):28–

39.)

Local Flaps of the Hand

Shady A. Rehim, MB ChB, MSc, MRCSa, Kevin C.

Chung, MD, MSb,*

Hand Clin 30 (2014) 137–151

http://dx.doi.org/10.1016/j.hcl.2013.12.004

Dx : Skin & Soft Tissue Loss sisi Palmar Left IF

Tx : Deb + Heterodigital fasciocutaneous Island Flap +

Extensor Tendon Graft

A reverse homodigital island flap or heterodigital

Island Flap

Local Flaps of the Hand

Shady A. Rehim, MB ChB, MSc, MRCSa, Kevin C.

Chung, MD, MSb,*

Hand Clin 30 (2014) 137–151

http://dx.doi.org/10.1016/j.hcl.2013.12.004

Dx : Flexion Contracture Dig V Manus D

Tx : Release Contracture + Reverse Interdigital Island Flap

Posterior Interosseous Artery Island Flap

The reverse posterior interosseous artery (PIA) flap is based on reverse flow through the PIA via anastomosis with the anterior interosseous artery and the dorsal carpal arches near the wrist joint.

It is considered to be less reliable compared to the radial forearm flap because of variations in vascular anatomy. The distal reach of the PIA flap is also limited to the MCPJ of the fingers and the IPJ of the thumb.

Ahmed Hassan El-Sabbagh & Ahmed Abd El-Moaty Zeina & Al-Moddather El-Hadidy & Ahmed Bahaa El-Din, J Hand Microsurg (July–December 2011) 3(2):66–72

Dx : Bone Exposed & contracture PIP join 5 th Digit

Perfomed Debridement + PIA Island Flap

Dx : Necrotic Wound on Wrist Region after 3rd degree burn

Perfomed Debridement + PIA

Flap

Dx : Extension Contracture 4th & 5th Digits after Burn Injuries

Perfomed Released

Contracture + PIA Flap

Reverse Radial Forearm Island Flap

Flexor Carpi Radialis

Flexor Digitorum Superficialis

Flexor Carpi Ulnaris

Radial A & V (Cut)

Brachioradialis

Palmaris Longus

Palmaris Longus

Arthi Kruavit, MD, Vivat Visuthikosol, MD, FACS, Narong Punyahotra, MD Vichai Srimuninnimit, MD, Thai J Surg Jan. - Mar. 2004

Dx : Flexion Contracture on Palmar Region After Burn Injuries

Perfomed Release Contracture + Reverse Radial Forearm Island Flap

Groin and Abdominal Flap

Dx : Skin + Soft Tissue Loss + OF Humerus Gr III C ec Crush Injury

Tx : debridement + Abdominal Flap

20 y o F Dx : Crush Injury Right

Forearm Tx : Debridement + Groin

Flap

Dx : Fascitis nekrotican manus S Debridement +Groin flap

Extended Groin Flap

Groin Flap

Dx : Ring avulsion right 2nd digit ec crush injury

Debridement + groin flap

Free Flap

Replantation

Perforator Flap of the Hand and Upper Limb

A perforator flap is a flap consisting of skin and/or subcutaneous fat based on one or more vascular tributaries of a single source artery. Small vessels supplying blood to the flap are termed perforators. Perforators arise from a source vessel and pass either through (indirect) or between (direct) deeper tissues (ie, muscle) to supply the skin.

Radial artery perforator flap, ulnar artery perforator flap, posterior interosseous artery flap, lateral arm flap, first dorsal metacarpal artery perforator flap, Perforator-based propeller flap

Conclusion

Many flap can be used for cover defect of the hand and upper limb

From local, distance until free flap

Groin and abdominal flap is the one essier flap for cover small until large defect.

New perforator flap of the hand and upper limb is the one choice for cover hand defect DOPPLER

Thank You For Kind Attention