0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Case Report/Case Series |

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

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.
Text Size: A A A
Published online

ABSTRACT

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.

Figures in this Article

INTRODUCTION

Because of the hand’s finite reservoir of skin and thin dermis and subcutaneous fat, random-pattern flaps have increased risk for necrosis or dehiscence from excessive tension. If tension precludes a random-patterned local flap, then a skin graft with prolonged immobilization of the hand may be necessary. For moderately sized defects of the dorsal hand not amenable to random-pattern flaps or grafting, we propose a sliding fasciocutaneous flap, whose blood supply derives from dorsal perforating arteries and which uses bilevel undermining at the dorsal superficial lamina and dorsal deep lamina for improved flap mobility. This novel reconstruction preserves both form and function and allows for quick recovery and return to daily activities.

REPORT OF A CASE

After resection of a squamous cell carcinoma on the dorsal hand of a woman in her 70s, a 3 × 2-cm defect extending to the dorsal intermediate fascia was repaired with a novel fasciocutaneous sliding flap based on the perforating arteries of the dorsal arterial system of the hand. The patient provided consent for this publication.

Flap Design

This flap may be used to repair superficial defects, as well as defects that extend down to tendon and bone that are situated on the dorsal surface of the hand between the metacarpophalangeal joints and the extensor crease of the wrist. Flap design should account for the size and site of the defect, as well as the mobility of the donor skin. The defect should be measured by instructing the patient to “make a closed fist.” This provides a conservative estimate of the size of the flap necessary to tolerate the anticipated postoperative tension generated with hand motion. The lateral borders of the flap may then be designed proximally off of the defect as 2 lateral limbs that arise from the widest portions of the defect. A third limb should connect the 2 lateral flap limbs. The length of the lateral limbs should be at least 1.5 to 2.0 times the defect diameter to incorporate a sufficient number of dorsal perforating arteries. These lateral flap limbs may parallel one another to create a rectangular flap, or they may gently diverge from one another so that an arciform or keystone shape is created. For defects that will be under tension, the keystone design allows for easier recruitment of skin with the V-Y closure at the proximal corners (Figure 1A). Because the abundance of the dorsal hand blood supply is derived from the dorsal metacarpal arteries and their perforators that run between the carpal bones, flaps designed centered over and incorporating multiple intercarpal spaces are more likely to have greater vascularity. Doppler ultrasound was not used in our clinical practice but may be helpful to locate perforators preoperatively.

Place holder to copy figure label and caption
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.

Graphic Jump Location
Surgical Technique

Once the flap is designed, all 3 flap limbs are gently incised through the dermis and superficial subcutaneous fat to the level of the dorsal superficial fascia (Figure 1B). This layer is readily identified by its glistening white color and the veins that it invests. To access the deeper undermining plane and gain additional mobility, 1, 2, or 3 limbs of the flap are further incised through the dorsal superficial and intermediate fascia to the level of the dorsal deep lamina immediately superficial to the paratenon and dorsal deep fascia (Figure 2). Frequently, only 1 lateral limb is incised to the deeper plane initially, undermining is performed, and flap mobility is assessed prior to incising through additional flap limbs. As more limbs of the flap are released, more mobility may be gained, but flap vascularity grows more tenuous, especially if the flap is not centered over a generous supply of perforating arteries.

Place holder to copy figure label and caption
Figure 2.
Layers of the Dorsal Hand

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

Graphic Jump Location

Undermining that occurs in the plane above the paratenon and dorsal deep fascia should be done bluntly to preserve perforator arteries when possible (Figure 1C). The perforating arteries have a small diameter of 0.1 to 0.3 mm, so they are not readily visible. However, their presence can often be intuited by a focal restriction on the ability to reflect the flap back or by a focal point of restriction on advancement of the flap. When perforator arteries are severed, the surgeon will note both bleeding and a sudden increase in flap mobility as a vertically oriented vascular “tether” is released.

For flaps on the dorsal hand, the midpoint between the carpal bones should be preserved whenever possible because the underlying dorsal metacarpal artery and its perforators emerge along this line. For flaps based on the second through fourth web spaces, the area immediately distal to the juncturae tendinum, which is approximately 1 cm proximal to the metacarpal heads, should be preserved to protect the Quaba’s perforators. The fascial pedicles of the bipedicled and sling variations of this flap may provide sufficient random blood supply, even if the perforators under the flap have been severed.

Once the flap has been adequately released to the paratenon on the desired limb(s), the remaining attached limbs are undermined in a more superficial plane immediately in the subcutaneous fat to mobilize the fascial pedicle (Figure 1D). Once the flap has been sufficiently released and undermined, it should easily move into the defect without undue tension (Figure 1E and 1F). A layered repair should be able to secure the flap in a tension-free manner with preserved function and range of motion just after closure (Figure 1G and 1H).

DISCUSSION

Successful reconstruction of hand defects must allow patients to avoid postoperative hand dysfunction and quickly return to daily activities and work. Second intention healing may desiccate vital tissue such as tendon, and layered side-to-side repairs may compromise hand function because of closure tension. In the absence of a well-vascularized bed in defects that expose bony prominences and tendon, skin grafts are unreliable and fail to provide a gliding surface for the underlying mobile structures.1 Adhesions and fibrosis may ensue, potentially compromising tendon motion.2 Commonly used local cutaneous flaps for reconstruction of larger defects on the dorsal hand may be limited by a finite reservoir of adjacent donor skin and can lead to substantial donor site morbidity, prolonged rehabilitation, or ischemia.1,3

A novel approach to repairing dorsal hand soft-tissue defects is proposed whereby the distinct anatomic layers of the dorsal hand anatomy are mobilized to create a vascularized sliding flap. The strategy for mobilization of this flap and other variations was extrapolated from the anatomic investigation of cadaver hands of Bidic et al.4 They elegantly described the distinct fascial layers and accompanying structures via anatomic dissection, Doppler ultrasound, and lead oxide injections. Whereas Bidic et al4 sought to improve cosmetic hand rejuvenation, we believe that their findings are particularly salient for reconstruction after skin cancer resection. The reliable and reproducible fasciocutaneous sliding flaps may be implemented to cover defects with exposed tendon and reduce the likelihood of ischemia that may be seen with grafts and random-pattern cutaneous flaps. In addition to preservation of hand neurosensory function, use of adjacent tissue allows sensory discrimination to remain intact through the avoidance of skin grafting. This novel flap is ideally suited for moderately sized defects with a wound bed that is mobile with hand movement, increasing the risk of graft failure, or where tension is high and full flexion would have a high risk for dehiscence of a linear closure.

Axial, paddled flaps of the dorsal hand and wrist that are based on perforators of the dorsal metacarpal artery are often used to cover defects on the dorsum of the hand and fingers. These flaps and their corresponding blood supply have been reviewed comprehensively elsewhere.5,6 The sliding fasciocutaneous flaps described herein are not truly axial, but their blood supply is robust. Consistent cutaneous perforator vessels from the parallel arrangement of the dorsal arterial network permit these sliding flaps to be raised and mobilized with a reduced risk of ischemia when compared with random-pattern flaps based on the dermal plexus. Often, there is a communication between the palmar and dorsal systems, which may further reinforce blood flow to these flaps.68

The fasciocutaneous sliding flaps derive their primary blood supply from a series of perforating arteries from the dorsal and palmar arterial systems of the hand (Figure 3). The skin of the proximal two-thirds of the hand is supplied by the dorsal metacarpal arteries, which run parallel to the metacarpal bones within the fascia of the dorsal interosseous muscles deep to the extensor tendons.5,9 Each of the dorsal metacarpal arteries supplies blood to the dorsal skin of the hand via 4 to 8 cutaneous perforator vessels (diameter, 0.1-0.3 mm) that arise along its length.9 The number and diameter of perforators are larger at the level of the distal third of the metacarpal compared with the proximal and central thirds.9

Place holder to copy figure label and caption
Figure 3.
Vascular Anatomy of the Dorsal Hand
Graphic Jump Location

The skin of the distal third of the hand and proximal digits is supplied by perforating arteries from the palmar arterial system. The common digital arteries, which arise from the superficial palmar arch, branch at the web space to connect with the dorsal metacarpal arterial system. The palmar metacarpal arteries, which arise from the deep palmar arch, also anastomose with the dorsal metacarpal artery at the web space and give off perforators to the dorsal skin.5 Skin perforators, called the Quaba perforators, consistently arise 1 cm proximal to the metacarpal head immediately distal to the juncturae tendinum, then ramify in retrograde fashion to supply blood to the skin of the distal dorsal hand.

Our proposed flap design has several distinct advantages compared with other methods of dorsal hand reconstruction. First, the bilevel undermining creates a highly vascularized flap based on both vertical perforating arteries and a vascularized sling pedicle. This robust vascular supply facilitates rapid, reliable wound healing and reduced postoperative care restrictions, which allows early hand mobilization with prompt return to unrestricted hand function. Second, the broad flap design benefits from mobilizing distant tissue reservoirs situated circumferentially around the wound; this permits diffuse distribution of the tension vectors necessary for wound closure and allows for recruitment of skin from several distinct tissue reservoirs that are less likely to “compete” with one another. This flap design broadly distributes the secondary motion required for flap closure, so limitations on joint mobility are less pronounced. Third, this single-stage reconstruction produces minimal donor site morbidity and delivers nearby pliable skin with good color and texture match to the recipient area. Using adjacent tissue with an intact neurovascular supply and avoiding skin grafts or dermal substitutes allows the defect to be repaired with sensate tissue, thereby preserving sensory discrimination.

Over the past 18 months, 2 of us (J.F.S., C.J.M.) have performed a variation of this flap on 15 dorsal hand defects. We categorize the 4 versions of the dorsal fasciocutaneous sliding flap as follows: (1) bipedicled bridge, (2) 2-sided sling, (3) 1-sided sling, and (4) keystone. All 4 variations similarly take advantage of the distinct fascial layers of the hand by raising the skin and fascia with bilevel undermining (Table and eFigures 1-3 in the Supplement). The complication rate for this flap is low. Patients often experience transient, self-resolving distal hand edema. Distal edge ischemia occurred in 2 patients. We believe that this can be minimized by observing the following precautions: (1) designing the flap 1.5 to 2.0 times the defect diameter when the hand is closed as a fist; (2) centering the flap over the intercarpal spaces, where perforating arteries abound; and (3) limiting the number of flap limbs that are deepened to the dorsal deep lamina.

Table Graphic Jump LocationTable.  Review of Fasciocutaneous Hand Flaps

CONCLUSIONS

A variety of local and regional flaps exist for soft-tissue defects of the dorsal hand, many of which can lead to substantial donor site morbidity and prolonged healing. Ideal reconstruction of soft-tissue hand defects should allow patients to avoid postoperative hand dysfunction, quickly return to daily activities, and preserve sensory discrimination. The proposed novel bilevel undermined fasciocutaneous sliding flaps based on the dorsal intermediate lamina and its investing fascial layers create highly vascular and mobile tissue for reliable coverage of soft-tissue defects on the dorsal hand. These flaps 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.

ARTICLE INFORMATION

Corresponding Author: Joseph F. Sobanko, MD, Hospital of the University of Pennsylvania, Dermatology, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 1-330S, Philadelphia, PA 19104 (joseph.sobanko@uphs.upenn.edu).

Accepted for Publication: April 18, 2014.

Published Online: July 30, 2014. doi:10.1001/jamadermatol.2014.954.

Author Contributions: Drs Sobanko and Miller had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Sobanko, Etzkorn, Miller.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Sobanko, Fischer, Etzkorn.

Study supervision: Sobanko.

Conflict of Interest Disclosures: None reported.

REFERENCES

Davami  B, Porkhamene  G.  Versatility of local fasciocutaneous flaps for coverage of soft tissue defects in upper extremity. J Hand Microsurg. 2011;3(2):58-62.
PubMed   |  Link to Article
Rahoma  AH.  Use of local sliding flaps to manage deep localized burns of the hand. J Hand Microsurg. 2011;3(2):45-50.
PubMed   |  Link to Article
Germann  G, Biedermann  N, Levin  SL.  Intrinsic flaps in the hand. Clin Plast Surg. 2011;38(4):729-738.
PubMed   |  Link to Article
Bidic  SM, Hatef  DA, Rohrich  RJ.  Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126(1):163-168.
PubMed
Vuppalapati  G, Oberlin  C, Balakrishnan  G.  “Distally based dorsal hand flaps”: clinical experience, cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653-667.
PubMed   |  Link to Article
Yang  D, Morris  SF.  Vascular basis of dorsal digital and metacarpal skin flaps. J Hand Surg Am. 2001;26(1):142-146.
PubMed   |  Link to Article
Quaba  AA, Davison  PM.  The distally-based dorsal hand flap. Br J Plast Surg. 1990;43(1):28-39.
PubMed   |  Link to Article
Bailey  SH, Andry  D, Saint-Cyr  M.  The dorsal metacarpal artery perforator flap: a case report utilizing a Quaba flap harvested from a previously skin-grafted area for dorsal 5th digit coverage. Hand (N Y). 2010;5(3):322-325.
PubMed   |  Link to Article
Omokawa  S, Tanaka  Y, Ryu  J, Kish  VL.  The anatomical basis for reverse first to fifth dorsal metacarpal arterial flaps. J Hand Surg Br. 2005;30(1):40-44.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
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.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Layers of the Dorsal Hand

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

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Vascular Anatomy of the Dorsal Hand
Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Review of Fasciocutaneous Hand Flaps

References

Davami  B, Porkhamene  G.  Versatility of local fasciocutaneous flaps for coverage of soft tissue defects in upper extremity. J Hand Microsurg. 2011;3(2):58-62.
PubMed   |  Link to Article
Rahoma  AH.  Use of local sliding flaps to manage deep localized burns of the hand. J Hand Microsurg. 2011;3(2):45-50.
PubMed   |  Link to Article
Germann  G, Biedermann  N, Levin  SL.  Intrinsic flaps in the hand. Clin Plast Surg. 2011;38(4):729-738.
PubMed   |  Link to Article
Bidic  SM, Hatef  DA, Rohrich  RJ.  Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126(1):163-168.
PubMed
Vuppalapati  G, Oberlin  C, Balakrishnan  G.  “Distally based dorsal hand flaps”: clinical experience, cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653-667.
PubMed   |  Link to Article
Yang  D, Morris  SF.  Vascular basis of dorsal digital and metacarpal skin flaps. J Hand Surg Am. 2001;26(1):142-146.
PubMed   |  Link to Article
Quaba  AA, Davison  PM.  The distally-based dorsal hand flap. Br J Plast Surg. 1990;43(1):28-39.
PubMed   |  Link to Article
Bailey  SH, Andry  D, Saint-Cyr  M.  The dorsal metacarpal artery perforator flap: a case report utilizing a Quaba flap harvested from a previously skin-grafted area for dorsal 5th digit coverage. Hand (N Y). 2010;5(3):322-325.
PubMed   |  Link to Article
Omokawa  S, Tanaka  Y, Ryu  J, Kish  VL.  The anatomical basis for reverse first to fifth dorsal metacarpal arterial flaps. J Hand Surg Br. 2005;30(1):40-44.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Supplement.

eFigure 1. Bipedicled Bridge Flap Design

eFigure 2. Keystone Flap Design

eFigure 3. One-Sided Sling Flap Design

Supplemental Content

Some tools below are only available to our subscribers or users with an online account.

970 Views
0 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
[Clinical application of radial mid-forearm perforator fasciocutaneous flap]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2014;28(11):1368-71.
Management of soft tissue defects of the hand. J Hand Surg Am 2015;40(6):1237-44; quiz 1245.
Jobs