flaps hand - harsh amin
DESCRIPTION
HAND RECONSTRUCTIONTRANSCRIPT
Dr. HARSH AMIN
LOCO-REGIONAL FLAPS FOR HAND DEFECTS
INTRODUCTION
Hand is an organ where skin envelope covers multiple tendons, nerves, vessels, bones and joints
For proper function this envelope has to be elastic and non adherent and large enough to allow freedom of motion
Relevant anatomy
Problem
GOALS OF RECONSTRUCTION
Restoration of functional, sensate and aesthetically acceptable hand
Coverage always follows proper debridement & skeletal
stabilization
Achieve Primary wound healing (To minimize contracture and joint stiffness)
Palmar skin - Palmar defects require thick, sensate glabrous skin for resurfacing, to withstand pressure and friction while grasp and pinch
Dorsal skin - Thinner , more elastic and loose enough to allow flexion at joints
PRINCIPLES
Palmar Defect
Multiple septal fibers and Grayson and Cleland’s ligaments compartmentalize the fat pads and neurovascular bundles and mobilization of volar flaps require division of these
Patients with thick palmar skin are not ideal candidates for extensive volar dissection
Large pulp defects in the thumb and radial side of index may warrant heterodigital island flap for sensate reconstruction despite the donor morbidity.
Dorsal Defect
Skin grafting over the dorsum often results in adherence and limited finger flexion.
Dorsal transposition flaps are ideal for resurfacing.
Aesthetic considerations of color matching and contour can be important to the patient as this is the exposed surface of the hand.
Factors affecting planning
DefectDonor site
PatientDoctor
Site of the defect Size of defect Mechanism of injury Cleanliness of wound
Defect
Handedness occupation Age Sex Overall health Preference
Patient
Donor site
Availability
Doctor
Experience Set up/ team
RECONSTRUCTIVE OPTIONS
Options for coverage of Hand Defects
Amputation
Primary Closure
Secondary intension
Skin graft
STG
FTG
flap
Free
Pedicled
Local
Regional
Distant
Local flaps
Transposition
Random
Type 1
Type 2
Axial
Flag
FDMA (Kite/Foucher)
SDMA
Digital artery island flap
Rotation
Advancement
Moberg
V-Y
Atasoy
kutler
Regional flaps
Random
Cross Finger
Classic
Reversed
Innervated
Thenar
Axial
Neurovascular island flap
Fillet flap
Forearm flaps
Reverse radial forearm
Reverse ulnar forearm
Post. Interrosseous
Dorsal Ulnar
When flaps?
LOCAL FLAPS
Flaps that come from adjacent area to defect
Identical in quality
Requires only one procedure for completion
Transposition Flaps
(Random)
Type 1Requires STG for Donor
Type 2Donor is closed Primarily
Transposition Flaps
(Axial)
FDMA flap
Flag Flap
Digital Artery Island Flap
Dorsal metacarpal artery flap
Rotation Flap
Advancement Flap
REGIONAL FLAPS
Flap that is raised from area of the limb that is not adjacent to defect
May require 2 stages if not axial pattern
SELECTION OF FLAP
Fingertip reconstruction <0.5cm2 no bone exposed healing by epithelialization 0.5-1cm2 no bone exposed FTSG bone exposed VY plasty 1-2cm2 Homodigital island flap
Moberg flap for thumb 2-5cm2 Cross finger flap or reverse flow
digital island flap Heterodigital island flap for thumb
Dorsal finger resurfacing defect <2 cm2 Dorsal transposition flap distal defect 2-5cm2 Reverse dermis cross
finger flap proximal defect 2-5cm2 Dorsal metacarpal
artery perforator flap
Volar finger Resurfacing Defect <2 cm2 Intrinsic perforator based local
flaps Defect 2-5cm2 Cross finger flaps, dorsal metacarpal artery perforator flaps, heterodigital
island flaps Defect > 5cm Extrinsic pedicled flap (radial
forearm, posterior interosseous artery) or free flaps
POST OPERATIVE CARE
COMPLICATIONS
CONCLUSION
THANK YOU