Anatomical And Clinical Study Of The Flaps For The Reconstruction Of Skin And Soft Tissue Defects In Different Types Of The Hand

Part one The anatomical and clinical study of the dorsal digital perforator flap for the reconstruction of skin and soft tissue defect in the fingerObjective: Through the anatomy of two fresh perfused hand specimens,the dorsal perforators of the proper digital arteries of 2nd-5th fingers were observed,so as to provide anatomical basis for the elevation and transfer of flaps in clinic.Through comparing the two groups of patients who received dorsal digital perforator flap and cross-finger flap,the relative merits of the two flaps were analyzed,and our clinical experiences were introduced.Methods: Two fresh hand specimens were perfused with red nature emulsion through the radial and ulnar arteries.The dorsal perforators of the proper digital arteries of 2nd-5th fingers were dissected,and their number,external diameter,course and communication anastomosis were recorded,and the differences between ulnar and radial sides were compared.Twenty one patients who received dorsal digital perforator flap and twenty two patients who received cross-finger flap were selected retrospectively from 2017 to2019.The differences in survival rate,postoperative finger movement,sensation,appearance and treatment time between the two groups were compared.Results: The proper digital arteries on both sides of 2nd-5th fingers constantly sent out dorsal perforators to support the skin on the back of the fingers.There was no significant difference in number and external diameter between the radial perforators of each finger and its ulnar perforators(P >0.05).There was no significant difference in survival rate,postoperative finger movement,sensation and appearance between the dorsal digital perforator flap group and the cross-finger flap group(P > 0.05).In terms of treatment time and coverage flexibility,the dorsal digital perforator flap group had an advantage.Conclusions: The blood supply of the dorsal perforators originated from the proper digital arteries is reliable and can be used to design and harvest flaps.The digital dorsal perforator flap with stable blood supply and short treatment period,can flexibly repair the defects of different positions of the finger,has a good aesthetic and functional effect,and is a good alternative for the reconstruction of finger defects.Part two The clinical study of the dorsal digital perforator flap combined with a cross-finger flap for the reconstruction of fingertip degloving injuryObjective: The reconstruction of fingertip degloving injury presents a functional and aesthetic challenge.We used the dorsal digital perforator flap combined with a cross-finger flap to reconstruct this type of injury.The purpose of this retrospective study was to evaluate the efficacy of the combined flaps and to present our clinical experience.Methods: From November 2016 to October 2019,16 patients(13 men and 3 women)with fingertip degloving injury were treated with the dorsal digital perforator flap combined with a cross-finger flap for the sensory reconstruction.The average age of the patients was 35.4 ± 6.8 years(range,21 to 49 years),Involved digits consisted of 8 middle fingers,5 ring fingers and 3index fingers.The average size of the defect was 8.2 ± 1.5 cm2.We used the sensory dorsal digital perforator flap for the reconstruction of the dorsal defect of the degloving fingertip,and the sensory cross-finger flap for the volar defect.The average sizes of the flaps were 4.9 ± 0.7 cm2(the dorsal digital perforator flap)and 5.4 ± 0.8 cm2(the cross-finger flap).Eighteen patients with fingertip degloving injury treated by an abdominal flap were selected in the comparison group.Results: All flaps and skin grafts survived completely without ischemia and venous congestion in the study group.All wounds and their donor sites healed primarily without exudation and infection.Patients were followed up with a mean time of 11.3 ± 1.9 months(range,9-15 months).At the final follow-up,the averaged total active motion(TAM)of the injured finger and donor finger was 256.4 ± 15.2°(range,215°-273°)and 258.2 ± 14.6°(range,223°-277°).The averaged static 2-point discrimination(2PD)on the cross-finger flap and the dorsal digital perforator flap was 6.1 ± 1.1 mm(range,5-9)and 7.3 ± 1.0 mm(range,6-10).According to the modified American Society for Surgery of the Hand guidelines,all flaps obtained excellent or good sensory(scored less than 10).According to the cold intolerance severity score(CISS)questionnaire,all flaps scored less than 25 and had a mild cold intolerance.According to the visual analog scale(VAS),13 patients had no pain,2 reported mild pain,and 1 experienced moderate pain.According to the Michigan hand outcome questionnaire(MHQ),ten patients were strongly satisfied(score 5)with the appearance of the reconstructed finger and the remain patients were satisfied(score 4).Compared with the comparison group,the combined flaps has obvious advantages in sensation and appearance(P < 0.001).Conclusions: The dorsal digital perforator flap combined with a cross-finger flap is an effective and reliable method for the reconstruction of fingertip degloving injury.Part three The anatomical and clinical study of a free anterolateral thigh deep fascia flap for the reconstruction of skin and soft tissue defects in the handObjective: To report our experience in the reconstruction of soft tissue defects in the hand with a free anterolateral thigh deep fascia flap and describe the clinical outcomes.To express the anatomical understanding of the supply vessels of the anterolateral thigh flap.Methods: This study was a retrospective trial.From November 2016 to January 2020,6 patients(4 men and 2 women)with soft tissue defects in the hand were included in this study.The average age of the patients was 33.7 ±12.7 years(range,20 to 50 years).All patients underwent reconstructions with free anterolateral thigh deep fascia flaps.Relevant clinical characteristics were recorded prior to surgery.The size and thickness of the deep fascia flap and the thickness of the skin were measured intraoperatively.The survival of the flaps and skin grafts and the occurrence of infection were recorded after the operation.At follow-up,donor site complications and postoperative effects were evaluated according to the outcome satisfaction scale.The pain in the injured hand was assessed using the visual analog scale.Results: The average body mass index(BMI)was 26.6 ± 1.7 kg/m2(range,23.9 to 28.7 kg/m2).The defect sizes ranged from 5 cm × 5 cm to 13 cm × 8 cm(average,53.1 ± 27.9 cm2).The six anterolateral thigh deep fascia flaps ranged from 7 cm × 6 cm to 14 cm × 9 cm in size(average,71.8 ± 29.1cm2).The thicknesses of skin ranged from 25 mm to 40 mm(average,32.5 ±4.8 mm),and the thicknesses of the deep fascia flaps ranged from 2 mm to 3mm(average,2.5 ± 0.5 mm).After the operation,the blood supply of the deep fascia flap was normal in all cases.The second-stage skin grafts of most patients survived completely.The skin graft in one case was partially necrotic and healed after a dressing change.No infection occurred.At follow-up(average,16.3 ± 6.9 months),there was only a linear scar and no loss of sensation at the donor site of each patient.According to the outcome satisfaction scale,the outcome satisfaction score ranged from 6 to 8(average,7.2 ± 0.9),all of which were satisfactory.Apart from one patient who reported mild pain,all the other patients reported no pain.Conclusions: The free anterolateral thigh deep fascia flap is suitable for the reconstruction of soft tissue defects in the hand,especially irregular defects in obese and/or female patients.It can provide very good outcomes both functionally and aesthetically.It is suggested that the supply vessels of the anterolateral thigh flap should be classified as the descending branch system,such as medial and lateral branches,instead of being classified and named separately.