Local hand flaps
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Local Hand Flaps. Summer Anatomy Lab July 25, 2013 Jennifer Klok. Reconstructive Ladder. Healing by secondary intention Primary closure Skin graft Local flap Regional flap Free flap. Cross-Finger Flap. Design: Skin and subcutanous tissue

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Local Hand Flaps

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Local hand flaps

Local Hand Flaps

Summer Anatomy Lab

July 25, 2013

Jennifer Klok


Reconstructive ladder

Reconstructive Ladder

  • Healing by secondary intention

  • Primary closure

  • Skin graft

  • Local flap

  • Regional flap

  • Free flap


Cross finger flap

Cross-Finger Flap

  • Design:

    • Skin and subcutanous tissue

    • Designed over dorsal aspect middle phalynx

  • Vascular supply:

    • Dorsal digital artery

    • Digital perforators


Cross finger flap1

Cross-Finger Flap

  • Clinical Applications

    • Coverage of volar aspect of adjacent digits’ middle phalangeal area

    • Distal digital tip coverage

    • Volar oblique fingertip amputations with exposed bone or tendon


Anatomy

Anatomy

  • Dorsal Digital Artery (1mm)

    • Dorsal skin distal to the distal proximal phalynx depends on perforating branches from digital arteries

    • Course through Cleland’s ligament

    • Supplies the flap

  • Digital Perforators passing dorsally around finger (0.2-0.3mm)


Design and markings

Design and Markings

  • Designed with base adjacent to injured finger

    • Proximal and distal flap marked transversely

    • Connect these with a longitudinal line just dorsal to mid-axis of dorsum of finger

    • 3-sided rectangle

  • Incisions made to encompass whole surface of middle phalynx


Volar finger defects

Volar finger defects


Dissection

Dissection

  • Incise skin based on markings down to SC fat until loose areolar plane

  • Elevate flap in this plane, taking care to leave the paratenon behind

  • Dissect to Cleland’s ligament; may need to divide ligament to increase pedicle length

  • Cover donor site with skin graft

  • Inset flap

  • Divide flap 2-3 weeks later


Fingertip defects

Fingertip Defects


Reverse cross finger flap

Reverse Cross-Finger Flap

  • For adjacent dorsal digital wound coverage

    • Elevate flap in subdermal plane

    • Adipofascial flap to cover dorsal defect


Thenar flap

Thenar Flap

  • To cover defects on the index and long fingers

  • Green’s:

    • “Use where preservation of length is considered important and other techniques that have less potential for complications are not applicable”


Thenar flap1

Thenar Flap


Thenar flap2

Thenar Flap

  • Donor site found by taking tip of index or ring finger and placing it against thenareminance

  • Draw circle around area of contact

  • Draw H or curved incision at this point

  • Elevate flaps in subcutaneous plane

  • Inset flap

  • Divide in 10-14 days

    • For the H flap, the proximal flap covers the finger defect and distal flap advanced to cover donor


Points about the thenar flap

Points about the Thenar Flap

  • To avoid potential for joint stiffness or unsightly scar in donor area:

  • Design flap near the MP crease of the thumb; avoid the midpalmar area

  • Fully flex the MP joint with whatever amount of flexion is required in the IP joints of the recipient finger

  • Detach pedicle 10-14 days post-op and start immediate AROM


First dorsal metacarpal artery flap

First Dorsal Metacarpal Artery Flap

  • Classification:

    • Type A fasciocutaneous flap

    • From dorsal skin over proximal phalynx (FDMA)

  • Clinical Applications:

    • For defects in the thumb


Local hand flaps

FDMA

  • Dominant Pedicle:

    • First dorsal metacarpal artery (FDMA)

  • Minor Pedicle:

    • Cutaneous perforators of the FDMA

  • Nerve Supply:

    • Dorsal sensory branches of the radial and ulnar nerves


Anatomy1

Anatomy

  • Dorsal metacarpal arteries

    • From dorsal carpal arch formed from dorsal carpal arteries

    • Gives rise to 4 dorsal metacarpal arteries

      • These course over dorsal interosseous muscles

      • Communicates with deep palmar arch

    • Proximal to web space divides into 2 dorsal digital branches

    • Then divide into terminal branches midway along proximal phalynx


Anatomy2

Anatomy

  • The first dorsal metacarpal artery (FDMA) tends to be a discrete terminal branch of the radial artery rather than arising directly from that dorsal carpal arch

    • Found in the first intermetacarpal space, just distal to the extensor pollicislongus tendon

  • Supplies the dorsum of the thumb and radial side of the index finger


Flap markings

Flap Markings

  • From MCP joint to the PIP joint of index

  • Radial & ulnar borders 1st the midlateral lines on either side of digit


Flap dissection

Flap Dissection

  • Incision in 1st dorsal web space, down to FDMA

  • Elevate flap distal to proximal, just above paratenon

  • Fascia and fat adjacent to 2nd metacarpal kept intact to protect vessels

  • Transfer and inset flap

  • Cover donor with skin graft


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