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Flaps hand - harsh amin
- 2. INTRODUCTION Hand is an organ where skin envelope covers multiple tendons, nerves, vessels, bones and joints For proper function this envelope has to be elastic and non adherent and large enough to allow freedom of motion
- 5. Problem
- 6. GOALS OF RECONSTRUCTION Restoration of functional, sensate and aesthetically acceptable hand
- 7. PRINCIPLES Coverage always follows proper debridement & skeletal stabilization Achieve Primary wound healing (To minimize contracture and joint stiffness) Palmar skin - Palmar defects require thick, sensate glabrous skin for resurfacing, to withstand pressure and friction while grasp and pinch Dorsal skin - Thinner , more elastic and loose enough to allow flexion at joints
- 8. Palmar Defect Multiple septal fibers and Grayson and Cleland’s ligaments compartmentalize the fat pads and neurovascular bundles and mobilization of volar flaps require division of these Patients with thick palmar skin are not ideal candidates for extensive volar dissection Large pulp defects in the thumb and radial side of index may warrant heterodigital island flap for sensate reconstruction despite the donor morbidity.
- 9. Dorsal Defect Skin grafting over the dorsum often results in adherence and limited finger flexion. Dorsal transposition flaps are ideal for resurfacing. Aesthetic considerations of color matching and contour can be important to the patient as this is the exposed surface of the hand.
- 10. Factors affecting planning Defect Donor site Patient Doctor
- 11. Defect Site of the defect Size of defect Mechanism of injury Cleanliness of wound
- 12. Handedness occupation Age Sex Overall health Preference Patient
- 13. Donor site Availability Doctor Experience Set up/ team
- 15. Options for coverage of Hand Defects Secondary intension Amputation Primary Closure Skin graft STG FTG flap Pedicled Free Local Regional Distant
- 16. Local flaps Transposition Random Type 1 Type 2 Axial Flag FDMA (Kite/Foucher) SDMA Digital artery island flap Rotation Advancement Moberg V-Y Atasoy kutler
- 17. Regional flaps Random Cross Finger Classic Reversed Innervated Thenar Axial Neurovascular island flap Fillet flap Forearm flaps Reverse radial forearm Reverse ulnar forearm Post. Interrosseous Dorsal Ulnar
- 18. When flaps?
- 19. LOCAL FLAPS Flaps that come from adjacent area to defect Identical in quality Requires only one procedure for completion
- 20. Transposition Flaps (Random) Type 1 Requires STG for Donor Type 2 Donor is closed Primarily
- 23. FDMA flap
- 25. Flag Flap
- 27. Digital Artery Island Flap
- 33. Dorsal metacarpal artery flap
- 38. Rotation Flap
- 46. REGIONAL FLAPS Flap that is raised from area of the limb that is not adjacent to defect May require 2 stages if not axial pattern
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- 82. SELECTION OF FLAP
- 85. Fingertip reconstruction <0.5cm2 no bone exposed healing by epithelialization 0.5-1cm2 no bone exposed FTSG bone exposed VY plasty 1-2cm2 Homodigital island flap Moberg flap for thumb 2-5cm2 Cross finger flap or reverse flow digital island flap Heterodigital island flap for thumb
- 86. Dorsal finger resurfacing defect <2 cm2 Dorsal transposition flap distal defect 2-5cm2 Reverse dermis cross finger flap proximal defect 2-5cm2 Dorsal metacarpal artery perforator flap
- 87. Volar finger Resurfacing Defect <2 cm2 Intrinsic perforator based local flaps Defect 2-5cm2 Cross finger flaps, dorsal metacarpal artery perforator flaps, heterodigital island flaps Defect > 5cm Extrinsic pedicled flap (radial forearm, posterior interosseous artery) or free flaps
- 88. POST OPERATIVE CARE
- 89. COMPLICATIONS
- 90. CONCLUSION
- 91. THANK YOU
Editor's Notes
- If away and donor with short pedicle require vein graft or a-v loop OR flow through flap