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Soft Tissue Replacement in the Hand

- See:                                                               Co-authored by Edward J. Harvey MD FRCS(C)
      - Finger Tip Injuries
      - Phalangeal Injury
      - Skin Grafts: for hand defects
      - Thenar Flap
      - Thumb Defects
      - V-Y Local Advancement Flaps
      - Z-plasty

- Types of Flaps:
    - Flap coverage of damaged palmar and dorsal hand soft tissue should provide a durable surface, cosmetic contour, appropriate bulk,
            suitable bed for tendon gliding or grafting, & acceptable donor site;
    - Arterialized Venous Skin Flaps
    - Chinese Fasciocutaneous Radial Rorearm Flap
    - Crossed Finger Flap
    - Pedicle Flaps
    - Neurovascular Island Flap
    - Reverse Dorsal Metacarpal Flap
    - Serratus Anterior
    - Retrograde Radial Fascial Forearm Flap:
            - this flap removes only the fascia and fat layers of the forearm tissue and leaves the radial artery and forearm skin intact;
            - the flap is low profile and is not bulkly;
            - this flap may be elevated without transecting the main trunk of the radial artery;
            - flap is elevated from the proximal aspect of the forearm while leaving the distal attachment of the pedicle intact;
            - flap viability is maintained by the perforating vessels just proximal to the wrist;
                   - these vessels lie within 5-8 cm of the wrist and run directly upward from the radial artery;
            - technique:
                   - a standard curvi-linera forearm incision is made;
                   - two parallel longitudinal fat/fascia incisions are made on the radial side of the forearm;
                   - fat and the deep fascia of the forearm are developed as long rectangular flaps based distally, over the radial aspect of the 
                          - the interval between fat and fascia is not violated;
                   - proximally the fascia is elevated off of the forearm flexor muscles;
                   - a few small perforating arteries may be ligated;
                   - take care to identify the lateral antebrachial cutaneous nerve and the radial sensory nerve;
                   - after the flap is elevated, it may be turned distally, and may be twisted so that the fat side is down and the fascial side is up;
            - ref: The retrograde radial fascial forearm flap: surgical rationale, technique, and clinical application.

- Soft Tissue Reconstruction in the Digits:
    - palmer defects of the finger:
             - finger tip injuries
             - palmer defects distal to PIP joint are common injuries;
             - consider a regional flap;
             - in pts < 40 yrs of age, finger may safely be left in flexion for the necessary two weeks;
             - in males consider a crossed finger flap;
             - in female patients consider a thenar flap;
             - in pts older than 40 consider a neurovascular flap;
    - dorsal or transverse amputations distal to PIP joint:
             - V-Y aadvancement flap may be used for finger tip amputations which have more dorsal soft tissue loss than palmar loss);
             - if defect is large reversed cross finger flap may be used;
             - defects around the proximal interphalangeal joint are covered w/ crossed finger flap flaps, conventional for the palmar surface and 
                    reversed for the dorsal;
    - palmar skin:
             - palmar skin is attached to the underlying palmar fascia by septa, which anchor the skin to the fascia stabilizing the skin;
             - palmar fascia is attached to metacarpals thru vertical extensions;
             - palmar skin movement is thereby minimized to improve grasp;

- Dorsal Hand Coverage:
    - chinese fasciocutaneous radial forearm flap
    - dorsal ulnar flap:
          - based on the dorsal branch of the ulnar artery;
          - disadvantages:
                 - limited flap mobility and coverage due to short pedicle;
                 - requires large cutaneous harvest inorder to obtain a long pedicle;
                 - sacrifices normal skin between the donor defect and the pivot point;
          - references:
                 - The ulnar flap - description and applications. Becker C and Gilbert A. Eur J Plastic Surg. 1988;11:79-82.
                 - Island flap supplied by the dorsal branch of the ulnar artery.
    - subcutaneous pedicle ulnar flap:
          - based on the ascending branch of the dorsal branch of the ulnar artery;
          - flap is raised as a subcutaneous pedicle based around the ascending branch and associated veins;
          - because the artery length is typically 5 cm, there is a generous arc of rotation;
          - once flap is raised, it is tunneled subcutaneously underneath the normal skin bridge to reach the defect;
          - flap defect is closed primarly;
          - reference:
                 - Use of a subcutaneous pedicle ulnar flap to cover skin defects around the wrist.

- Burns of the hand:
    - full thickness or deep partial thickness burns of the hand can benefit from prompt excision and grafting to reduce edema formation and 
          permit early joint motion;
    - use of thick STSG or Full Thickness skin grafts will help to minmize joint contracture;

- Misc;
    - sine qua non for functional recovery is tendon is tendon gliding and joint suppleness;
    - free skin grafts applied to paratenon do not interfere with tendon gliding, but when the paratenon has been lost, vascularized flap 
           coverage is necessary;
    - exposed joints should be positioned to maximized soft tissue defect, and consequently maximize amount of vascularized tissue required

Blood supply of the upper extremity muscles as related to functional tendon transfers.

Vascular anatomy of the upper extremity muscles.

The proximal inset thenar flap for fingertip reconstruction.

The extended palmar advancement flap.

Alternative hand flaps for amputations and digital defects.

The protective value of a neurovascular island pedicle transfer in hands partially anesthetic due to ulnar denervation in leprosy.

Secondary coverage of the hand using a dorsalis pedis plus first web space free flap.

The distally based posterior interosseous island flap for the coverage of skin loss of the hand.

Sacrifice of the unsatisfactory hand.

The cross-finger flap. An established reconstructive procedure.

Free neurovascular flap from the first web of the foot in hand reconstruction.

Avulsion Injuries of the Thumb.

Closed Degloving Injuries: Results following Conservative Surgery.

Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part.

Posterior interosseous artery flap in traumatic hand injuries