The "Domino Flaps" Concept: Functional Composite Reconstruction for Traumatic Transmetacarpal Thumb Amputation.

Complex transmetacarpal thumb amputation remains a challenging reconstructive injury. Optimal reconstructive options aim to achieve a neo-thumb with optimal length, sensitivity, stability, and an aesthetically functional result. In cases when immediate replantation of the amputated digit is not possible, a temporary ectopic replantation with staged reconstruction can be deployed. We report our experience of a complex transmetacarpal thumb amputation managed with a staged "domino flap" concept. The first stage involved an ectopic replantation of the amputated digit with a second stage replantation 3 weeks later. Domino flap refers to the requirement of a further reconstruction due to the defect at the donor sites. In this case, the replant is accompanied by 2 domino flap reconstructions with the dorsalis pedis composite free flap to reconstruct the first metatarsal and an anterior tibial artery propeller perforator flap to reconstruct the composite flap donor site.

A Retrospective Study of an Updated and Traditional Surgical Approach of the Distally Based Sural Flap.

BACKGROUND: The distally based sural flap (DBSF) is one of the armamentarium in the lower limb reconstruction. However, the flap has not gained popularity due to concerns about its reliability and donor site morbidity. Based on the anatomy characterization, we combined and developed five modifications to improve the vascular supply and reduce donor site morbidity. PATIENTS AND METHODS: The authors performed a comparison of retrospective study that included patients who underwent either traditional distally based sural flap (tDBSF) or modified distally based sural flap (mDBSF) surgery approach for ankle, heel, and dorsal foot coverage between January 2007 and May, 2019. The five modifications developed to improve the reliability of the flap include: 1. shift the pivot point more proximally 7.0 cm above the lateral malleolus, 2. preserve the lesser saphenous vein and include branches that communicates with the flap, 3. harvest thinner fascial pedicle, 4. change the skin incision to "S" shape, 5. closure of the donor site with a propeller flap. RESULTS: Thirty-one patients underwent mDBSF, and 23 received tDBSF. There were no significant differences in the size of the DBSF. Mean pedicle width was significantly narrower in mDBSF (1.63 ± 0.52 cm vs. 3.81 ± 0.70 in tDBSF). The pivot point was also found to be higher in mDBSF (8.01 ± 0.63 cm vs. 5.46 ± 0.56 cm) above the lateral malleolus. In mDBSF, the size of the propeller flap required for donor site closure was 53.45 ± 19.06 cm2 (range 33-80 cm2). The rate of partial necrosis between mDBSF and tDBSF was significantly different (9.68 vs. 34.78%). While the other complications had no difference. CONCLUSION: The modifications applied to the harvesting of the DBSF have achieved higher survival rate, lower dehiscence rate, and shorter hospital stay time in comparison with traditional approach in our retrospective study.

Routine closure of the donor site with a second dorsal metacarpal artery flap to avoid the use of a skin graft after harvest of a first dorsal metacarpal artery flap.

AIM: Closure of the donor site on the index finger after raising a first dorsal metacarpal artery (DMA) flap harvest is challenging. The conventional choice is to use a full-thickness skin graft. However, this procedure is associated with several complications and a second donor site to harvest the skin graft is inevitable. The aim of this study was to design a modified incision to allow harvest of a first DMA flap without skin graft. METHODS: From 2015 to 2016, 18 patients with a soft tissue defect of the thumb had reconstruction of the defect using a first DMA flap. A modified incision was used and a relaying perforator flap pedicled on the second DMA was raised through the same incision to cover the donor site. Patient satisfaction, appearance of the injured hand, and the active range of motion (ROM) were assessed. The sensitivity was evaluated by the 2-point discrimination (2-PD) test. RESULTS: All flaps survived completely without complications. Good coverage was obtained with only one linear scar in the dorsum of the hand and no skin grafts. All patients recovered full range of movement in their fingers and regained sensitivity of the flaps. All patients were satisfied with their hand function according to the Michigan Hand Outcomes Questionnaire (MHQ). The mean cosmetic score for the appearance of the injured hand was 8.2 out of 10. CONCLUSIONS: Using our modified incision, it was possible to harvest a second DMA flap at the same time as a first DMA flap allowing simultaneous coverage of the donor defect on the index finger. This prevented the need for a skin graft with all of the associated disadvantages.

The use of innervated radial artery superficial palmar branch perforator free flap for complex digital injuries reconstruction.

Loco-regional flaps have been widely used for the reconstruction of digital injuries without requiring microvascular anastomosis, however, they result in scarring and compromised functional outcomes. This study demonstrates our experience utilizing the innervated radial artery superficial palmar branch (RASPB) perforator free flap for complex digital injury reconstruction. From May 2007 to March 2014, the innervated RASPB perforator free flap was used to reconstruct 79 distal complex hand and digital soft tissue defects of which 14 were used to re-vascularise the distal digit in a flow-through fashion. All free flaps were innervated by the palmar cutaneous branch of the median nerve. All 79 free flaps survived and all 14 digits re-vascularized successfully. One flow-through free flap developed distal skin necrosis which healed uneventfully without further procedure. The average follow-up was 21.5 months. Measurement of two-point discrimination ranged from 7 to 13 mm. All patients were satisfied with the aesthetic results. The innervated RASPB perforator free flap is a feasible and effective option for the reconstruction of complex digital defects and the flow-through concept, when utilized in cases with compromised vascularity, provides reliable re-vascularization. Level III, therapeutic study.

Distally based sural neuro-fasciocutaneous perforator flap for foot and ankle reconstruction: Surgical modifications for flap pedicle and donor site closure without skin graft.

BACKGROUND: The conventional procedure of the sural neuro-fasciocutaneous flap enables the supply of blood and venous drainage by increasing the width of the adipofascial tissue and preserving tiny venous return routes. Moreover, skin graft is a common method for donor site closure, which may lead to some complications and influence the aesthetic appearance. We report modifications for a distally based sural neuro-fasciocutaneous perforator flap and a relaying flap for donor site closure without skin graft. METHODS: Twelve patients undergoing the modified flap for foot and ankle reconstruction were included in this study between 2014 and 2016. A peroneal-based perforator, a superficial vein, and the vascular axis of the sural nerve were included in the pedicle. A Z-shape skin incision was performed to explore the perforator vessels and a relaying island perforator flap was used to close the donor site. RESULTS: All flaps survived completely without necrosis. The area of the flaps ranged from 16 × 8 cm to 30 × 15 cm. The diameter width of the pedicle ranged from 1.0 to 2.0 cm. A relaying perforator island flap was used in 10 cases for donor site closure and no skin graft was performed. There were no serious donor site complications. All patients were satisfied with the aesthetic outcome postoperatively at the final follow-up. CONCLUSIONS: The distally based sural neuro-fasciocutaneous perforator flap is considered a reliable method for foot and ankle reconstruction. The modification for flap pedicle and donor site closure method without skin graft should be recommended.

Reconstruction of combined thumb amputation at the metacarpal base level and index amputation at the metacarpal level with pollicization and bilateral double toe composite transfer.

BACKGROUND: This study aimed to describe the technique and report our experience with the reconstruction of combined proximal thumb amputations at the metacarpal base level and index finger amputation at the metacarpal level with pollicization and bilateral double toe composite transfer. METHODS: The technique consists of pollicization of the remnant index ray. Then a contralateral composite medial great toe pulp and vascularized second toe proximal interphalangeal joint flap are harvested to reconstruct the metacarpophalangeal joint of the thumb. Subsequently, an ipsilateral composite great toe wrap-around and second toe proximal interphalangeal joint flap are harvested to reconstruct the thumb interphalangeal joint and the distal thumb. A neurotized superthin anterolateral thigh flap is used to reconstruct the ipsilateral toe defect, while the bone defects of the bilateral second toes are reconstructed with corticocancellous iliac crest bone grafts. Between 2010 and 2014, eight patients underwent reconstruction. Four patients could be recalled for follow-up, with a mean duration of 22 months. RESULTS: All flaps survived. The contour and length of the reconstructed thumbs was similar to the contralateral one. The mean Michigan hand outcomes questionnaire score was 80.5. The mean disabilities of the arm, shoulder and hand score was 7.5. The mean foot and ankle disability index score was 94.2. CONCLUSIONS: Reconstruction of thumb amputations at the metacarpal base level with pollicization and double toe composite transfer results in excellent contour and functional outcome, with a natural-appearing thumb. In addition, all toes are preserved. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Combined multi-lobed flaps: A series of 39 extensive hand and multi-digit injuries one-staged reconstructions using modified designs of ALT, DPA and chimeric linking flaps.

INTRODUCTION: The use of multiple small flaps linked in a "chain-linked" flap microanastomosed chimeric system is recommended in distal hand and digital defects reconstruction. The aim of this study is to demonstrates our experience utilizing microsurgical fabrication, multi-lobed and linking combined flaps for the reconstruction of hand degloving injuries with complex multidigit soft tissue defects. METHODS: Microanastomosed chimeric flap systems using ALT and DPA modified designed flaps were combined in five selections to cover extensive soft tissue defects involving the hands and multiple digits of 39 patients (M:F - 36:3) from October 2009 to February 2013. Five different microsurgical combined chimeric flap systems utilised in extensive hand and multidigit injuries; innervated ALT flaps, multilobed DPA flaps, innervated ALT flap with multilobed DPA flap, innervated ALT flap with sensate ALT flap and bilobed ALT flap with multilobed DPA flap. All DPA donor sites were reconstructed using free ALT flap and anterior tibial artery propeller flap. RESULTS: Thirty-nine combined free flap extremities reconstructions on 39 patients (M:F - 36:3) with average age 28.5 (18-45) years sustained traumatic degloving injuries, 24 from road traffic accidents and 15 from industrial devices. Five different designs of combined multi-lobed flaps have be successfully used without any peri-operative complications. Average follow-up of 12 months, all flaps survived without complications. Operated extremities showed favorable functional recovery with restoration of the diminished protective sensation on the flap through reinnervation. All flaps survived uneventfully with coverage matching the texture and color of the recipients. Donor sites healed without complication. CONCLUSION: The microsurgical fabrication of chimeric ALT flaps and multilobed DPA flaps is a valuable alternative for the reconstruction of hand degloving injury with complex multidigit soft tissue defects. LEVEL OF EVIDENCE: Level IV, therapeutic study.

[Reconstruction of the donor area of distally based sural flap with relaying lateral gastrocnemius artery perforator propeller flap].

Objective: To investigate the clinical application of relaying lateral gastrocnemius artery perforator flap in reconstruction of the donor defect after distally sural flap transferring. Methods: Between January 2014 and January 2016, 12 cases with foot and ankle defects were treated. There were 10 males and 2 females with an average age of 23.4 years (mean, 14-52 years). The injury was caused by motorcycle accident in 7 cases and traffic accident in 5 cases. The injury located at left limb in 7 cases and right limb in 5 cases. The size of soft tissue ranged from 10 cm×4 cm to 12 cm×6 cm. The disease duration was 2-84 hours (mean, 26.2 hours). The foot and ankle defects were reconstructed by distally sural flaps, then the flap donor sites were reconstructed with relaying lateral gastrocnemius artery perforator flap at the same stage. The size of distally sural flap ranged from 11 cm×5 cm to 13 cm×7 cm. The size of relaying flap ranged from 7 cm×4 cm to 10 cm×6 cm. Results: All flaps survived uneventfully. All recipient sites and donor sites healed smoothly. No vascular crisis, wound dehiscence, or evident swelling occurred. All patients were followed up 6-14 months (mean, 12.4 months) with satisfied esthetic and functional results in recipient and donor sites. There were only linear scar on the donor sites. The color and contour was satisfying, the function of calf and foot were not affected. Conclusion: The relaying lateral gastrocnemius artery perforator flap combined with distally sural flap is an idea choice to reconstruct foot and ankle defect, which can avoid donor site skin grafting, minimize donor site morbidity.

Reconstruction of totally degloved fingers: a novel application of the bilobed spiraled innervated radial artery superficial palmar branch perforator flap design provides for primary donor-site closure.

INTRODUCTION: To investigate the results of resurfacing completely degloved digits using bilobed innervated radial artery superficial palmar branch (RASPB) perforator flap in a spiral fashion. METHODS: A detailed anatomic study on 30 adult fresh frozen cadavers preinjected with silicone rubber compound to demarcate arterial anatomy documented locations, numbers, and diameters of arteries and skin perforators with surrounding nerves. The flap-raising procedure was performed using four fresh cadaver specimen. We reviewed the reconstruction of 12 digits by using a bilobed spiraled innervated RASPB free perforator flap after non-replantable degloving injury. Two skin paddles were marked out using standard points of reference. At least two separate cutaneous perforator vessels were identified using a hand-held Doppler and were dissected back to the RASPB in retrograde fashion. The skin paddles were then divided between the two cutaneous perforators to provide two separate paddles with a common vascular supply. The skin paddles were stacked in a spiral fashion on the flap inset, effectively increasing the width of the flap to cover the totally degloved finger while still allowing closure of the primary donor-site. RESULTS: The RASPB was present within the flap in all cadavers. The direct perforator and the musculocutaneous perforator were available in 93.33 and 76.67 %, respectively, with neither of them in 6.67 % of the cases. The constantly present two perforators allowed the design of a new bilobed spiraled innervated radial artery superficial palmar branch perforator flap. We used the proposed flap to reconstruct completely degloved digits in 12 patients (mean age 28.6 years; range 17-35 years). With our proposed flap, no flap failure or re-exploration occurred and the donor site was closed primarily in all cases. All the flaps survived uneventfully. Total active motion ranged from 92° to 140° and 111° to 155° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2 point discrimination test varied from 6 to 11 mm. All the patients were satisfied with the overall results. CONCLUSION: The bilobed flap is large enough to cover totally degloved finger defects and contain direct skin perforators, provides a bespoke cover for complex soft tissue defects of completely degloved digits while also improving morbidity and cosmesis of the donor site. LEVEL OF EVIDENCE: Level IV, retrospective series.

[Predictive value of radiological parameter for re-displacement of conservative treatment of distal radius fracture].

OBJECTIVE: To analyze the radiological parameters of the conservatively in treating distal radius fracture and investigate whether the final re-displacement can be predicted after primary reduction. METHODS: From January 2013 to June 2014,212 patients with distal radial fracture conservatively were treated in our hospital, 107 patients of them were excluded because of their incomplete radiological parameters;the remaining 105 patients were available for radiological were assessed after injury, there were 56 male patients and 49 female patients in this study, the average age of the patients was 51 years old (ranged from 22 to 80 years). According to AO classification, there were 47 cases of type A2 and C1, and 58 cases of type A3, C2, C3. All patients were treated by closed reduction and below-elbow cast immobilization for 4 to 6 weeks. All patients were followed up for 3 to 6 months (means 4.5 months) by X-ray, all fractures were healed. Standard AP and lateral radiographic examination was conducted before reduction and after reduction and bony consolidation,the dorsal angulation and the radial angle were measured at each time point. The linear regression was used for the analysis to find out whether the final re-displacement can be predicted after primary reduction. RESULTS: Among 105 patients,the significant correlations were found for the dorsal angulation between the reduction time and the end time (r = 0.82) and for the radial angulation between the reduction time and end time (r = 0.85). CONCLUSION: The dorsal angulation and the radial angulation after complete healing can be predicted from linear the regression functions. Due to the possibility of predicting the end result, whether the fracture should receive further conservative treatment or surgical treatment can be decided immediately.

[Reconstruction of totally degloved fingers with a spiraled parallelogram medial arm free flap ].

Objective: To investigate the therapeutic results of completely degloved digital injury using a parallelogram free flap from the medial arm in a spiral fashion. Methods: From January 2011 to June 2013,13 defects in 13 patients with non-replantable degloved digital injury were treated with a parallelogram free flap from the medial arm in a spiral fashion.The longitudinal axis of the flap was along the line from the axilla to the medial humeral epicondyle.The medial brachial cutaneous nerve of the arm was harvested for sensory restoration.The non-replantable degloved finger was reconstructed with the medial arm flap in a spiral fashion.The digital artery and dorsal veins were prepared as the recipient pedicle,and the medial brachial cutaneous nerve was sutured to the digital nerve stump.All the wounds at the donor sites were closed directly. Results: The dimension of the flaps ranged from 5.0 cm × 2.0 cm to 7.5 cm × 4.0 cm.Excetp for one partial flap loss,all the other flaps survived uneventfully with conservative therapy.The static 2-point discrimination test varied from 6 to 13 mm.No linear scar contracture was recorded in these patients.All the patients were satisfied with the overall results. Conclusion: Resurfacing the defect in a spiral fashion is a valuable and reliable technique for the reconstruction of complete finger degloved injuries.The medial arm flap is a good option for this procedure,with satisfactory functional recovery and good aesthetic restoration.

[Characteristics and replantation of degloving injury of distal finger].

OBJECTIVE: To explore clinical characteristics and replantation methods of degloving injury of distal finger. METHODS: From 2004 to 2009,18 cases of 19 distal finger degloving were admitted, and included 14 males and 4 femals with an average age of 31 years old ranging from 18 to 51 years old. The distal finger degloving injury was divided into 3 types according to the different levels of degloveing digital artery and skin involving 6 fingers of type I, 10 fingers of type II, 3 fingers of type III. Among them, 3 cases of 4 fingers were failed to be replantaed due to severed injured digital artery, and 15 cases of 15 distal finger degloving injury were replanted with microsurgical technique. RESULTS: Among 15 patients (15 fingers) conpleted the reimplant operation, 13 fingers were survived, 2 fingers were necrosis after operation. Thirteen survived fingers were followed up from 6 to 24 months (averaged 14 months). The appearance of injured fingers and nails obtained satisfactory results. According to Chinese Hand Surgery Society Criteria for function assessment replantation, the results were excellent in 9 cases, good in 3 cases and poor in 1. CONCLUSION: Replantation of distal degloving injury is effective and it should strive for replantation.

Digital pulp reconstruction with free neurovascular toe flaps.

UNLABELLED: Finger pulp defects are commonly encountered in clinical settings and their treatment remains a consistent challenge for plastic and hand surgeons. Reconstruction should restore, as much as possible, the contour of the pulp as well as discriminating sensibility. Following the prime reconstructive principle of replacing "like with like," the free neurovascular toe pulp flap seems to be the optimal choice for digital pulp reconstruction because of the natural similarity of the digital pulp both anatomically and physically. However, after about 30 years of experience with this procedure, it is still controversial because it is technically demanding, involves donor site morbidity, and its reliability is questionable. With other small free flaps available, the application of this flap has been challenged and reconsidered. In this review we specifically focus on the reconstruction of soft tissue defects of digital pulp using the free neurovascular toe flap, aiming to investigate its advantages and drawbacks and obtain a comprehensive understanding of this procedure. The latest reconstruction concerns and technical refinements are also discussed. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.

Finger pulp reconstruction with free flaps from the upper extremity.

Although never exceeding a few square centimeters, finger pulp defects are reconstructive challenges due to their special requirements and lack of neighboring tissue reserve. Local flaps are the common choice in the management of this injury. However, the development of microsurgery and clinical practice have greatly boosted the application of different free flaps for finger pulp reconstruction with excellent results, especially when local flaps are unsuitable or impossible for the coverage of large pulp defects. These flaps are all located in the same operation field and can be performed under one tourniquet; therefore, they are more convenient with better patients' compliance in clinical setting. Nonetheless, there is still no consensus about which type of these flaps should be preferred among various finger pulp reconstructive options. In this article, we attempt to review articles describing finger pulp reconstruction using free flaps from the upper extremity from the literature. We summarize the clinical applications of these free flaps and detail their advantages and drawbacks, respectively. The algorithm of flap selection for finger pulp reconstruction based on our experience and literature review is also discussed.

Reconstruction of totally degloved fingers with a spiraled parallelogram medial arm free flap.

PURPOSE: To investigate the results of resurfacing completely degloved digits using a parallelogram free flap from the medial arm in a spiral fashion. METHODS: We reviewed the reconstruction of 26 digits in 21 patients with a parallelogram free flap from the medial arm in a spiral fashion following a non-replantable degloving injury. RESULTS: The sizable perforator was observed consistently in the medial arm with 13 of 21 (62%) originating from the superior ulnar collateral artery, 6 of 21 (29%) directly from the brachial artery, and 2 of 21 (9%) from the superficial brachial artery. All the flaps but one, which sustained partial flap loss, survived uneventfully. Total active motion ranged from 93° to 145° and 112° to 154° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2-point discrimination test varied from 6 to 13 mm. No scar contracture was recorded in these patients. All the patients were satisfied with the overall results. CONCLUSIONS: Resurfacing the defect in a spiral fashion is a valuable and reliable technique for the reconstruction of complete finger degloving injuries. The medial arm flap is a good candidate for this procedure, with satisfactory functional recovery and good aesthetic restoration. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.