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Case Report/Case Series |

Local Fasciocutaneous Sliding Flaps for Soft-Tissue Defects of the Dorsum of the Hand

Joseph F. Sobanko, MD1; John Fischer, MD2; Jeremy R. Etzkorn, MD1; Christopher J. Miller, MD1
[+] Author Affiliations
1Division of Dermatologic Surgery and Cutaneous Oncology, Department of Dermatology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia
2Division of Plastic Surgery, Department of Surgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia
JAMA Dermatol. 2014;150(11):1187-1191. doi:10.1001/jamadermatol.2014.954.
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Importance  Appropriate coverage of defects that expose tendon, joints, and/or neurovascular structures is necessary to preserve optimal hand function. Local, random-pattern flaps and skin grafts may be inadequate because of the hand’s finite skin reservoir or the presence of a poorly vascularized and mobile wound bed. Described herein is a novel method of dorsal hand reconstruction.

Observations  A fasciocutaneous sliding flap and the underlying vascular anatomy of the dorsal hand are described. The flap takes advantage of the distinct fascial layers of the hand by raising the skin and fascia with bilevel undermining.

Conclusions and Relevance  The proposed single-stage, bilevel undermined fasciocutaneous sliding flap based on the perforating vessels running through fascial septae recruits pliable, easily mobilized skin, preserves neurosensory innervation, and facilitates early hand mobilization with reduced postoperative care. This flap, and its proposed variations, are ideal for use when paratenon is exposed and immobilizing the hand would be necessary for graft survival or when tension at the wound precludes reconstruction with primary closure or a traditional flap.

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Figure 1.
Flap Design and Execution

A, Note that the parallel limbs of the flap are longer than the diameter of the defect. The increased flap length increases the likelihood of including an adequate number of perforator vessels. B, The flap incised through skin and fat only on the ulnar and proximal sides, with dorsal superficial fascia intact; the radial side has been incised through the dorsal superficial and dorsal intermediate fascia to the level of the paratenon. C, Undermining in the dorsal deep lamina. The extensor pollicis brevis tendon is visible and the cotton-tipped applicator achieved blunt dissection. D, The fascial pedicle on the ulnar and proximal limbs has been preserved with undermining in the more superficial subcutaneous fat plane. E, The flap has undermined sufficiently. The extensor pollicis brevis and extensor pollicis longus tendons are visible. Perforators from the ulnar branch of the first dorsal intermetacarpal artery have been preserved in the space between the first and second carpal bones. F, The flap’s leading edge rotates easily to reach the distal end of the defect. G, Flap sutured into place. H, Six weeks after surgery.

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Figure 2.
Layers of the Dorsal Hand

Note the distinct layers of the dorsal hand and the important structures contained within the laminae.

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Figure 3.
Vascular Anatomy of the Dorsal Hand
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