- •
When indicated, local hand flaps offer excellent coverage of soft tissue defects that replaces like with like.
- •
A variety of traditional and nontraditional local hand flaps can be used to cover most of small to moderate-sized defects of the hand.
- •
Although routinely used, the application of local hand flaps is an evolving field with multiple new flap designs and modifications being described based on the intricate vascular anatomy of the hand.
- •
Local hand flaps frequently result in optimum functional
Local Flaps of the Hand
Section snippets
Key points
General considerations
A careful patient history and mechanism of the injury are indispensible in assessing the potential structural involvement and previous interventions. This provide a framework in which to begin treatment. One of the most influential factors in consideration of any treatment is tissue loss, including defect size, site, depth, orientation, and composition. However, other factors, such as those related to patients and surgeons’ technical ability as well as the availability of resources, are of
Classification of skin flaps
A flap is skin with a varying amount of underlying tissue that is used to cover a defect and receives its blood supply from a source other than the tissue to which it is transferred to.10, 11 Skin flaps can be classified according to their method of transfer (eg, advancement, rotation, and transposition),11 composition (eg, cutaneous, fasciocutaneous, fascial, adipofascial, or compound flaps including bone and/or tendon),12 and geometric design (eg, rhomboid, bilobed). If classified according
Dorsum of the hand
Random pattern flaps such as rotation or transposition flaps are useful local skin flaps for coverage of a variety of soft tissue defects over the dorsal surface of the hand. By taking advantage of the skin laxity together with carefully measured geometric flap designs, clinicians can successfully move tissue around to close several skin defects. Furthermore, if used correctly, random pattern flaps can be applied throughout the hand and fingers. As a rule, clinicians should always perform a
The rotation flap
The name rotation flap refers to the vector of movement of the flap, which is usually curved or rotational. This flap can be thought of as the closure of a triangular defect by rotating adjacent skin around a rotation point (or fulcrum) into the defect (Fig. 1).18 After outlining the defect, the arc of the flap rotation should be designed at least 3 to 4 times larger than the diameter of the defect to allow sufficient rotation of the flap and closure without excessive tension. A common mistake
The rhomboid/Limberg flap
First described by Limberg in 1928, the rhomboid flap is a transposition flap that consists of an equilateral parallelogram with 2 angles of 120° and 2 of 60°.19 To execute this flap, first the defect is converted into a rhomboid. A line is extended that equals the height of the rhomboid. This line is then extended parallel to one side of the rhomboid (Fig. 2A). The flap is elevated and transposed into defect, whereas the secondary defect is closed directly. In practice, defects have different
Fingers
It is easier to consider reconstruction of finger injuries if the fingers are divided into 3 parts: distal to the proximal interphalangeal (PIP) joint, at the level of PIP joint, and proximal phalanx. In addition to the level of injury, the side of injury should also be considered. Defects over palmar and dorsal surfaces of the fingers require different reconstruction options, as follows.
The V-Y advancement flap
The V-Y advancement flap was first described by Tranquilli-Laeli in 1935 but was popularized by Atasoy and colleagues20 in the United States in 1970.21 Fingertip amputation is a common injury that frequently results in soft tissue defects with an exposed underlying bone of the distal phalanx that cannot be left to heal with secondary intention or covered by skin grafts. The availability of remaining adjacent soft tissue and the pattern of injury usually dictate the method of treatment. The V-Y
The thenar flap
Gatewood23 first described the technique of a thenar flap for coverage of fingertip injuries in 1926. This description was expanded on by Flatt24, 25 in 1957. The thenar flap is indicated for volar skin avulsions over the pulp of the finger (eg, volar oblique amputations); however, its use can also be extended to cover dorsal defects over the nail bed. Advantages of the thenar flap include inconspicuous donor site defect and good soft tissue padding, color, and texture match from the glabrous
The cross-finger flap
The cross-finger flap is a 2-staged flap reconstruction that was first described by Cronin26 in 1951. Volar soft tissue defects located on the middle or distal phalanx can be covered with this flap. Another indication of the cross-finger flap is for more distal defects in which more tissue is required for coverage than can be obtained from a local advancement flap such as V-Y flap. Akin to thenar flap, PIP joint stiffness caused by joint flexion and immobilization is a concern when using the
The homodigital island flap
Weeks and Wray28 in 1973 described the homodigital island flap that is based on the volar blood supply of the fingers, either the radial or ulnar digital artery and its venae comitantes. The flap can be harvested on a proximal (antegrade) or a distal (retrograde) pedicle.29 Proximally based flaps are used to cover more proximal defects, whereas reverse pedicle digital island flaps, described by Lai and colleagues,30 are used to cover more distal defects over PIP and DIP joints (Fig. 10). In
The dorsal metacarpal artery flap
In 1987, Earley and Milner31 first described the proximally based dorsal metacarpal artery flap based on the first and second dorsal metacarpal artery. In 1990, Quaba and Davison32 introduced another subset of flaps called the distally based dorsal metacarpal artery (DMCA) flap, which is not based on the dorsal metacarpal arteries but on a constant palmar-dorsal perforator present in the digital web space (Fig. 11). The DMCA flap became a popular flap for coverage of dorsal finger defects up to
Thumb
The thumb represents 40% to 50% of hand function.39 Restoring thumb defects is essential for pulp-to-pulp and key pinch grip. The arterial supply of the thumb differs from that of other fingers. The volar side of the thumb is supplied by 2 palmar collateral arteries arising from the princeps pollicis artery, which in turn is derived from the radial artery at the first intermetacarpal web space.40 The dorsal blood supply of the thumb is independent from its volar circulation. The skin over the
The Moberg flap
The advancement neurovascular flap of the thumb was originally described by the Erik Moberg41 in 1964 hence it is best known today as the Moberg flap. The Moberg flap is indicated for coverage of small-to-medium sized defects over the volar aspect of the distal phalanx of the thumb without the need to shorten the length. This flap provides excellent soft tissue coverage with highly sensate, well-padded skin of similar color and texture. The main disadvantage of the Moberg flap is the tendency
The first DMCA flap (kite flap)
Foucher and Braun42 in 1979 described the first DMCA flap, also known as the kite flap because the flap is raised with the pedicle, which resembles a kite. The kite flap is a skin island flap harvested from the dorsal surface of the adjacent index finger. The constant first DMCA, a branch of the radial artery, nourishes the flap. The flap may also incorporate a branch of the superficial radial nerve. These characteristics make the kite flap a good choice for reconstructing all dorsal defects of
The dorsoulnar and dorsoradial collateral artery flaps
The reverse flow homodigital dorsoulnar and dorsoradial collateral artery flaps (Fig. 17) were described by Brunelli (1993)43, 44, 45 and Moschella and Cordova (2006),46, 47 respectively. These flaps are supplied by the ulnar dorsocollateral and radial dorsocollateral arteries, which arise from the radial artery at the level of the head of the first metacarpal bone and run on their respective sides to supply the skin over the dorsum of the thumb. Studies have shown the constancy of these
Summary
If there are no clinical restrictions, local flaps represent an ideal soft tissue cover for small and moderate soft tissue defects. A surgeon who is well versed in the vascular anatomy of the hand and different types of local flap reconstruction is able to treat a variety of defects without requiring more complex methods of soft tissue repair. Nonetheless, clinicians must also recognize the limitations of local flaps and be prepared to change the treatment plan if the necessity arises.
References (47)
- et al.
Scar contractures of the hand
Clin Plast Surg
(2011) - et al.
Refinements in hand coverage with microvascular free flaps
Clin Plast Surg
(1992) Flap reconstruction in hand surgery: the evolution of presently used methods
J Hand Surg Am
(1979)- et al.
Soft tissue reconstruction. Coverage of hand injuries
Orthop Clin North Am
(1993) - et al.
Soft tissue coverage in devastating hand injuries
Hand Clin
(2003) - et al.
Soft tissue reconstruction of the hand
J Hand Surg Am
(2009) Local flaps to the hand
Hand Clin
(1985)- et al.
A classification of fasciocutaneous flaps according to their patterns of vascularisation
Br J Plast Surg
(1984) - et al.
Axial and random pattern flaps
Br J Plast Surg
(1973) - et al.
The extended role of the deltopectoral flap
Br J Plast Surg
(1970)
The vascular territories (angiosomes) of the body: experimental study and clinical applications
Br J Plast Surg
The angiosomes of the body and their supply to perforator flaps
Clin Plast Surg
Anatomy of upper extremity skin flaps
Hand Clin
Local hand flaps
J Hand Surg Am
The reversed de-epithelialized flap
Ann Chir Main
Intrinsic flaps in the hand
Clin Plast Surg
Dorsal metacarpal flaps
Br J Plast Surg
The distally-based dorsal hand flap
Br J Plast Surg
The reverse dorsal metacarpal flap
Br J Plast Surg
Reverse dorsal metacarpal osteocutaneous flaps
Br J Plast Surg
The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps
J Plast Reconstr Aesthet Surg
Reconstruction of the thumb
Am J Surg
Arterial anatomy and clinical application of the dorsoulnar flap of the thumb
J Hand Surg Am
Cited by (57)
Reverse dorsoradial metacarpal artery flap for reconstruction of large finger skin defect: A case report
2023, International Journal of Surgery Case ReportsClinical application of an expanded reverse-island flap with two dorsal metacarpal arteries and dorsal metacarpal nerves in index- and middle-finger-degloving injury repair and amputation reconstruction
2023, Journal of Plastic, Reconstructive and Aesthetic SurgeryComparison of reading man flap and skin grafting for closure of resultant donor defects in homodigital reverse flow flaps
2023, Journal of Plastic, Reconstructive and Aesthetic SurgeryCoverage of soft tissue defects in the thumb: Essential flaps in daily practice
2021, Hand Surgery and RehabilitationFingertip injuries managed by a thenar flap: Follow-up and long-term outcomes of 32 cases
2021, Hand Surgery and RehabilitationCitation Excerpt :This newly designed thenar flap was our first choice for volar oblique and transverse fingertip injuries, affecting any digit other than the thumb – mainly the index or middle finger and unusually the ring or little finger – with subtotal or total pulp loss. According to the literature, the thenar flap can also be indicated to cover dorsal defects over the nail bed and when used in combination with a nail bed graft, it provides an excellent means of nail bed reconstruction [10,25]. The main disadvantage of this flap is the fact that this is a two-stage surgical technique.
Reconstruction of Thumb Pulp Defects Using Free Lateral Great Toe Flaps
2021, Journal of Hand Surgery
Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. This work was supported in part by grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute on Aging (R01 AR062066), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (2R01 AR047328-06), and a Midcareer Investigator Award in patient-oriented research (K24 AR053120) (K.C. Chung).