This document discusses various techniques for reconstructing soft tissue defects of the thumb. It begins with an overview of thumb anatomy and blood supply. Various local flap options are then described for small to moderate sized defects, including V-Y flaps, Moberg flaps, cross-finger flaps, and digital perforator flaps based on the radial or ulnar palmar arteries. Larger defects may be covered with pedicled flaps such as neurovascular island flaps or first dorsal metacarpal artery flaps. The document concludes by describing free flaps for thumb reconstruction, such as bipedicle flaps from the index finger or chimeric flaps based on the groin vasculature.

1. Nguyen Phuoc Thanh. MD

2. Congenital Deformities of the Hand and Upper Limb 2018
Wei Wang • Jianmin Yao

3. Thumb anatomy

5. Thumb function
https://www.mangore.com/player-anatomy-3-15-56

6. Blood supply of thumb
SPA: superficial palmar arch
DPA: deep palmar arch
UA: ulnar artery
RA: radial artery
UPDAT: ulnopalmar digital
artery of the thumb
UDDAT: ulnodorsal digital
artery of the thumb
RPDAT: radiopalmar digital
artery of the thumb
RDDAT: radiodorsal
digital artery of the thumb
FPMA: first palmar
metacarpal artery
FDMA: first dorsal
metacarpal artery
SPBRA: superficial palmar
branch of radial arteryArterial Supply of the Thumb – Systemic Review
Miletin J, Sukop A, Baca V, Kachlik D
doi: 10.1002/ca.22973

7. Blood supply of thumb
Arterial Supply of the Thumb – Systemic Review
Miletin J, Sukop A, Baca V, Kachlik D
doi: 10.1002/ca.22973

8. Blood supply of thumb
Atlas of Perforator Flap and Wound Healing_ Microsurgical Reconstruction and Cases-Springer Singapore (2019)
He-Ping Zheng, Jian Lin, Yong-Qing Xu, De-Qing Hu
Branches, distributions and anastomosis
of right thumb dorsal artery.
(a) Radial view, (b) Dorsal view.
1. Radial palmar thumb
artery
2. ulnar palmar thumb artery,
3. thumb dorsal artery,
4. dorsal perforator,
5. tendon of extensor pollicis longus,
6. tendon of extensor pollicis brevis,
7. tendon of abductor pollicis longus,
8. cutaneous nerve of radial dorsal thumb

9. Thumb softissue defects
• Amputations
• Dorsal defects
• Palmar tip defects
• Glove injury
• Absence of thumb = 40% disability of hand as a whole
http://www.wheelessonline.com/ortho/management_of_thumb_soft_tissue_defects_amputations

10. Full-thickness skin grap
• Defects up to 1.5 cm in diameter with no bone exposure can
be effectively treated with dressing changes. Daily dressing
changes with petroleum or bismuth-impregnated gauze are
relatively easy for patients.
• Defects > 1,5 cm with a stable base, however, require skin grafting.
Full-thickness grafts are usually preferred, as they are more durable
and stable, especially in the contact areas subject to pressure and
shear. Small full-thickness skin grafts can be harvested from the
hypothenar eminence or the volar wrist crease. Larger skin grafts,
however, are best harvested from the upper inner arm or groin
crease.

11. V-Y flap, Moberg flap
• When phalangeal
bone is exposed
at the thumb tip
• This flap can
easily cover a
defect of 1–2 cm2
CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
Plastic Surgery - Hand and Upper Extremity - Volume Six- Edition 4th
Chang J

12. Moberg flap
a Intraoperative picture of thumb-tip amputation
with Moberg advancement flap (MAF) elevation
in progress.
b Flexed thumb IP joint with MAF inset to cover
thumb-tip amputation.
cThumb appearance at 3 months with early
healing.
d Thumb appearance at 3 weeks showing
maintained first web space.
e Full IP joint extension 4 months following MAF
coverage.
f Satisfactory IP joint flexion 4 months following
MAF coverage
https://musculoskeletalkey.com/reconstruction-of-the-thumb-tip/

13. Cross-finger flap
• The cross-fnger flap from the index
fnger is an excellent
reconstructive technique for larger
volar and tip defects of the thumb,
up to 2–3 cm2
• A full-thickness skin graft is then
sutured to the dorsum of the index
fnger. A bulky thumb splint is
applied.
• At 2 or 3 weeks, the flap is divided
and the inset to the thumb is
completed After division,
aggressive
range-of-motion therapy for both
the thumb and index fnger should
begin.CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
Plastic Surgery - Hand and Upper Extremity - Volume Six- Edition 4th
Chang J

14. Cross-finger flap
CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
Plastic Surgery - Hand and Upper Extremity - Volume Six- Edition 4th
Chang J

15. Digital dorsal perforator flap
Atlas of Perforator Flap and Wound Healing_ Microsurgical Reconstruction and Cases-Springer Singapore (2019)
He-Ping Zheng, Jian Lin, Yong-Qing Xu, De-Qing Hu

16. Thumb radialis palmar artery perforator flap
Detect and select the appropriate perforators at proximal
end of thumb metacarpophalangeal joint of the hand and radial
edge using Doppler ultrasound, expose the vessels and nerve tract
on the radial thumb, and then further identify the radial palmar
artery perforator. Skin graft in full-thickness from inner forearm to
repair the donor site by free transplantation.
Atlas of Perforator Flap and Wound Healing_ Microsurgical Reconstruction and Cases-Springer Singapore (2019)
He-Ping Zheng, Jian Lin, Yong-Qing Xu, De-Qing Hu

17. Thumb radialis palmar artery perforator flap
Displaced thumb radialis palmar artery perforator flap in
repairing defects of thumb pulp skin and soft tissues
(surgical photos provided by Xiao Zhou). (a) Defect
wound, (b) design of the flap, (c) flap dissociation and
vessel pedicle exposure, (d) repair fnished, (e) thumb
appearance 2 months after operation, (f) thumb function
2 months after operation
Atlas of Perforator Flap and Wound Healing_ Microsurgical Reconstruction and Cases-Springer Singapore (2019)
He-Ping Zheng, Jian Lin, Yong-Qing Xu, De-Qing Hu

18. Thumb radialis palmar artery perforator flap
Displaced thumb radialis palmar
artery dorsal perforator flap in
repairing defects of the skin and
soft tissue on thumb pulp (surgical
photos provided by Zengbing Xia).
(a) Soft tissue defect and flap design
(b) exposure of dorsal vessel branch
(c) resection of the flap
(d) after flap transposition surgery
(e) appearance of donor site 5 days
after operation
(f) appearance of flap 5 days after
operation
Atlas of Perforator Flap and Wound Healing_ Microsurgical Reconstruction and
Cases-Springer Singapore (2019)
He-Ping Zheng, Jian Lin, Yong-Qing Xu, De-Qing Hu

19. Thumb ulnar palmar artery perforator flap
Displaced thumb ulnar palmar artery perforator
flap in
repairing thumb nail bed defect (surgical photos
provided by Xiao Zhou).
(a) Defect of left thumb nail bed and flap design,
(b) Flap dissection and vessel pedicle exposure,
(c) Repair fnished,
(d) Flap appearance 6 months after operation
Atlas of Perforator Flap and Wound Healing_ Microsurgical Reconstruction and Cases-Springer Singapore (2019)
He-Ping Zheng, Jian Lin, Yong-Qing Xu, De-Qing Hu

20. Thumb ulnar palmar artery perforator flap
Displaced dorsal thumb ulnar palmar artery perforator
flap for repairing defect wound of thumb tip (surgical
photos provided by Zengbing Xia).
(a) Right thumb tip defect accompanied by bone exposure,
(b) Design of flap
(c) Vessel exposure
(d) Resection of flap
(e) Appearance 16 days after flap transposition surgery
(f) Conditions of donor site and recipient area 16 days
after operation
Atlas of Perforator Flap and Wound Healing_ Microsurgical Reconstruction and
Cases-Springer Singapore (2019)
He-Ping Zheng, Jian Lin, Yong-Qing Xu, De-Qing Hu

21. Thumb ulnar palmar artery perforator flap
Displaced dorsal thumb ulnar palmar artery
flap for repairing thumb pulp defect
(surgical photos provided by Jian Lin).
(a) Defect of left thumb pulp
(b) Design of the flap
(c) Flap resection and vessel pedicle
exposure
(d) Flap survived completely 10 days after
operation
Atlas of Perforator Flap and Wound Healing_ Microsurgical Reconstruction
and Cases-Springer Singapore (2019)
He-Ping Zheng, Jian Lin, Yong-Qing Xu, De-Qing Hu

22. Neurovascular island flap
• It is rarely used as a primary
coverage flap, although it is
certainly possible to use it in that
manner. Rather, its most
common use is for the
restoration of sensation to the
thumb pulp following
reconstruction.
• The flap is based on the ulnar
neurovascular bundle of either
the middle or ring fnger. The
ulnar side
of the digit is chosen because its
loss will have minimal effect on
grip and pinch activities.CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
Plastic Surgery - Hand and Upper Extremity - Volume Six- Edition 4th
Chang J

23. First dorsal metacarpal artery flap
Sensate First Dorsal Metacarpal Artery Flap for Resurfacing Extensive Pulp Defects of the Thumb
Shun-Cheng Chang, MD, Shao-Liang Chen, MD, Tim-Mo Chen, MD, Chia-Jueng Chuang, MD, Tian-Yeu Cheng, MD, and Hsian-Jenn Wang, MD
DOI https://doi.org/10.1055/s-0038-1675369
• The artery runs over the fascial layer of
the first dorsal interosseous muscle and
divides into the radial branch to the
thumb, the intermediate branch to the
first web space, and the ulnar branch to
the index finger
• The ulnar branch usually courses distally
within the musculo-osseous groove,
between the ulnar head of the first
dorsal interosseous muscle and the radial
shaft of the second metacarpal bone,
until it reaches the metacarpophalangeal
(MP) joint

24. First dorsal metacarpal artery flap
• Dorsal defects
• Anatomical snuffbox: princeps pollices artery (radially) & FDMA
(unarly)
• From index-finger dorsum
• Must include subcutaneous fat and interossious muscle fascia with
the pedicle
• Thick fatty tissue with venea comitantes of artery (venous outflow)
• Flap tranpositioned via tunnering or direct incision
• Dornal site grafting

26. Differentiated three different vascular patterns
for the terminal fascial branches of the FDMA
• Type I was the most frequent (11 out of 18 specimens), with three
vessels, ulnar, intermediate, and radial originating from a common
trunk that arose from the radial artery.
• Type II was far less frequent (3 out of 18 specimens) it involved two
vessels originating from a common trunk, and one separate vessel
issuing from the radial artery.
• Type III (4 out of 18 specimens), three arteries originated directly
from the radial artery

27. Treatment of thumb soft-tissue defects using a bipedicle island flap of the index finger: anatomical basis and clinical application
Hong-lue Tan • De-yan Tan • Jin-kun Zhao DOI 10.1007/s00402-013-1704-y
• The size of the soft-tissue defects ranged from
2.2 cm x 1.6 cm to 3.5 cm x 2.2 cm (mean, 3.07
cm x 2.0 cm).
• The size of the flaps ranged from 2.5 cm x 1.8
cm to 3.7 cm x 2.5 cm (mean, 3.3 cm 9 2.2 cm).
• The mean length of the dorsal and palmar
pedicle were 7.1 cm (6.8–7.4 cm) and 5.0 cm
(4.8–5.2 cm)

28. Sensitive branches
• The terminal sensitive branches of the radial nerve
are present at the dorsum of the index finger, at the
area of the proximal phalanx, lying just beneath the
skin.
• In their dissections they always found a dorsal
branch of the digital nerve, which was deeper than
the radial nerve branches, lying just over the
extensor apparatus, and ending as three terminal
branches on the area of the middle phalanx.
• This dorsal nerve branch can be sacrificed to add
innervation to the flap if necessary.
Sensate First Dorsal Metacarpal Artery Flap for Resurfacing Extensive Pulp
Defects of the Thumb
Shun-Cheng Chang, MD, Shao-Liang Chen, MD, Tim-Mo Chen, MD, Chia-Jueng Chuang, MD, Tian-Yeu Cheng, MD,
and Hsian-Jenn Wang, MD
DOI https://doi.org/10.1055/s-0038-1675369

29. Treatment of thumb soft-tissue defects using a bipedicle island flap of the index finger: anatomical basis and clinical application
Hong-lue Tan • De-yan Tan • Jin-kun Zhao . DOI 10.1007/s00402-013-1704-y

30. Treatment of thumb soft-tissue defects using a bipedicle island flap of the index finger: anatomical basis and clinical application
Hong-lue Tan • De-yan Tan • Jin-kun Zhao DOI 10.1007/s00402-013-1704-y

31. Goin flap
CHIMERIC GROIN FREE FLAPS: DESIGN AND CLINICAL APPLICATION
WAI-NANG CHAO, M.D.,1,2,3 PO-HUI WANG, M.D., Ph.D.,1 BING-REN CHEN,
M.D.,4 and SHIUAN-CHIH CHEN, M.D., Ph.D.1,5*
DOI: 10.1002/micr.22442
A: Anatomy of the groin.
AL,adductor longus muscle; ASIS, anterior
superior iliac spine; FA, femoral artery; FV,
femoral vein; G, gracilis muscle; IL, inguinal
ligament; PT, pubic tubercle; RF, rectus
femoris muscle; S, Sartorius muscle; SCIa,
superficial circumflex iliac artery; SEa,
superficial epigastric artery; TFL, tensor
fasciae latae muscle; VL, vastus lateralis
muscle.
B: The types of chimeric groin flaps.
C-C, cutaneous–cutaneous;
O-C, osteo-cutaneous;
M-C, musculo-cutaneous;

32. Vascular anatomy of groin flap. Variations
identified in arterial pedicle supplying ilioinguinal
region.
FA, Femoral artery;
IL, ilioinguinal ligament;
SCIA, superficial circumflex iliac artery;
SIEA, superficial inferior epigastric artery
Chapter 63: Microsurgery – Campell’s Operative Orthopaedics 13e

33. Interrelated origins of superficial circumflex iliac (C)
and superficial inferior epigastric (E) arteries from
femoral artery (FA) or another parent artery (P).
1, Common origin;
2, compensatory superficial circumflex iliac with
absent superficial inferior epigastric;
3, separate origins;
4, origin from parent vessel other than femoral
artery
1: 48%
2: 35%
3,4: 17%
Chapter 63: Microsurgery – Campell’s Operative Orthopaedics 13e

34. Goin flap
CHIMERIC GROIN FREE FLAPS: DESIGN AND CLINICAL APPLICATION
WAI-NANG CHAO, M.D.,1,2,3 PO-HUI WANG, M.D., Ph.D.,1 BING-REN CHEN, M.D.,4 and SHIUAN-CHIH CHEN, M.D., Ph.D.1,5*
DOI: 10.1002/micr.22442

35. Goin flap
Postoperatively, both flaps were divided after 4 weeks
The Split Pedicle Groin Flap: New Refinement in Groin Flap Application and
Technique for Combined Thumb and Dorsal Hand Defects
Dr. Miranda DOI: 10.1097/PRS.0b013e31823af1e5

36. Goin flap
https://musculoskeletalkey.com/reconstruction-of-the-thumb-tip/

38. Sumary
Defect Flap
Tip 1-2cm2 no bone exposure Full-thickness skin graft
Tip 1-2cm2 bone exposure V-Y flap, Moberg flap, cross finger flap,
neurovascular island flap
Tip 2-3cm2 no bone exposure Full-thickness skin graft
Tip 2-3cm2 bone exposure Cross finger flap, digital dorsal perforator flap,
first dorsal metacarpal artery flap,
neurovascular island flap
Dorsal no bone, tendon exposure Full-thickness skin grap
Dorasal bone, tendon exposure Digital dorsal perforator flap. First dorsal
metacarpal artery flap
Larger, complex defect, alvusion
injury
Goin flap