J Reconstr Microsurg 2011; 27(9): 551-558
DOI: 10.1055/s-0031-1285987
© Thieme Medical Publishers

Visual Subunits of the Hand: Proposed Guidelines for Revision Surgery after Flap Reconstruction of the Traumatized Hand

James P. Higgins1 , Mitchel Seruya1
  • 1Curtis National Hand Center, Union Memorial Hospital, Baltimore, Maryland
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Publikationsverlauf

Publikationsdatum:
09. August 2011 (online)

ABSTRACT

The posttraumatic hand deformity remains a difficult challenge for reconstructive surgeons. Much has been written about the relative benefits of fasciocutaneous, fascial, and muscle flap reconstruction; however, the literature is devoid of guidelines for secondary surgery after flap reconstruction to improve the appearance of the hand. We introduce the concept of visual subunits of the hand in an effort to better guide restoration of natural hand form; thenar, hypothenar, midpalm, distal palm, dorsal hand, volar forearm, and dorsal forearm subunits are proposed. The visual subunit principle has been implemented in reconstruction of posttraumatic hand deformities. Management initially focused on reestablishment of hand function and provision of soft tissue coverage via local and free tissue transfer. Secondary procedures involved partial flap elevation, targeted debulking, and redefining topographic regions where possible. By designing asymmetric skin excision patterns, the resultant length and width discrepancies can be used to purposefully enhance topographic features while re-creating the appearance of natural crease lines bordering adjacent subterritories. No complications related to partial or complete flap loss were encountered.

REFERENCES

  • 1 Kozin S H, Thoder J J, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures.  J Am Acad Orthop Surg. 2000;  8 (2) 111-121
  • 2 Tajima T. Treatment of open crushing type of industrial injuries of the hand and forearm: degloving, open circumferential, heat-press, and nail-bed injuries.  J Trauma. 1974;  14 (12) 995-1011
  • 3 Amadio P C, Wood M B, Cooney III W P, Bogard S D. Staged flexor tendon reconstruction in the fingers and hand.  J Hand Surg Am. 1988;  13 (4) 559-562
  • 4 Scheker L R, Langley S J, Martin D L, Julliard K N. Primary extensor tendon reconstruction in dorsal hand defects requiring free flaps.  J Hand Surg [Br]. 1993;  18 (5) 568-575
  • 5 Smith P, Jones M, Grobbelaar A. Two-stage grafting of flexor tendons: results after mobilisation by controlled early active movement.  Scand J Plast Reconstr Surg Hand Surg. 2004;  38 (4) 220-227
  • 6 Hsu W M, Wei F C, Lin C H, Chen H C, Chuang C C, Chen H T. The salvage of a degloved hand skin flap by arteriovenous shunting.  Plast Reconstr Surg. 1996;  98 (1) 146-150
  • 7 Nicolle F V, Woolhouse F M. Restoration of sensory function in severe degloving injuries of the hand.  J Bone Joint Surg Am. 1966;  48 (8) 1511-1518
  • 8 Swartz W M. Restoration of sensibility in mutilating hand injuries.  Clin Plast Surg. 1989;  16 (3) 515-529
  • 9 Weiland A J, Villarreal-Rios A, Kleinert H E, Kutz J, Atasoy E, Lister G. Replantation of digits and hands: analysis of surgical techniques and functional results in 71 patients with 86 replantations.  J Hand Surg Am. 1977;  2 (1) 1-12
  • 10 Brown D M, Upton J, Khouri R K. Free flap coverage of the hand.  Clin Plast Surg. 1997;  24 (1) 57-62
  • 11 Elliott R A, Hoehn J G, Stayman J W. Management of the viable soft tissue cover in degloving injuries.  Hand. 1979;  11 (1) 69-71
  • 12 Yildirim S, Taylan G, Eker G, Aköz T. Free flap choice for soft tissue reconstruction of the severely damaged upper extremity.  J Reconstr Microsurg. 2006;  22 (8) 599-609
  • 13 Carty M J, Taghinia A, Upton J. Fascial flap reconstruction of the hand: a single surgeon's 30-year experience.  Plast Reconstr Surg. 2010;  125 (3) 953-962
  • 14 Chen H C, el-Gammal T A. The lateral arm fascial free flap for resurfacing of the hand and fingers.  Plast Reconstr Surg. 1997;  99 (2) 454-459
  • 15 Chen H C, Tang Y B, Mardini S, Tsai B W. Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators.  Microsurgery. 2004;  24 (4) 270-280
  • 16 Chow J A, Bilos Z J, Hui P, Hall R F, Seyfer A E, Smith A C. The groin flap in reparative surgery of the hand.  Plast Reconstr Surg. 1986;  77 (3) 421-426
  • 17 Flügel A, Kehrer A, Heitmann C, Germann G, Sauerbier M. Coverage of soft-tissue defects of the hand with free fascial flaps.  Microsurgery. 2005;  25 (1) 47-53
  • 18 Parrett B M, Bou-Merhi J S, Buntic R F, Safa B, Buncke G M, Brooks D. Refining outcomes in dorsal hand coverage: consideration of aesthetics and donor-site morbidity.  Plast Reconstr Surg. 2010;  126 (5) 1630-1638
  • 19 Seitz I A, Williams C S, Wiedrich T A, Henry G, Seiler J G, Schechter L S. Omental free-tissue transfer for coverage of complex upper extremity and hand defects–the forgotten flap.  Hand (NY). 2009;  4 (4) 397-405
  • 20 Soutar D S, Tanner N S. The radial forearm flap in the management of soft tissue injuries of the hand.  Br J Plast Surg. 1984;  37 (1) 18-26
  • 21 Ulrich D, Fuchs P, Bozkurt A, Pallua N. Free serratus anterior fascia flap for reconstruction of hand and finger defects.  Arch Orthop Trauma Surg. 2010;  130 (2) 217-222
  • 22 Tubiana R. Functional Anatomy. 2nd ed. London: Martin Dunitz, Ltd.; 1996
  • 23 Gatti J E, LaRossa D, Brousseau D A, Silverman D G. Assessment of neovascularization and timing of flap division.  Plast Reconstr Surg. 1984;  73 (3) 396-402
  • 24 Farber G L, Taylor K F, Smith A C. Pedicled thoracoabdominal flap coverage about the elbow in traumatic war injuries.  Hand (N Y). 2010;  5 43-48
  • 25 Flatt A E. The thenar flap.  J Bone Joint Surg Br. 1957;  39-B (1) 80-85
  • 26 Heng D, Zhang C, Yao Y, Liu L, Chen Yi Y I. Experimental study on early division of cross-finger pedicle flap and its clinical application.  Chin J Traumatol. 2000;  3 (3) 159-162
  • 27 McGrath M H, Adelberg D, Finseth F. The intravenous fluorescein test: use in timing of groin flap division.  J Hand Surg Am. 1979;  4 (1) 19-22
  • 28 Burget G C, Menick F J. The subunit principle in nasal reconstruction.  Plast Reconstr Surg. 1985;  76 (2) 239-247
  • 29 Spear S L, Davison S P. Aesthetic subunits of the breast.  Plast Reconstr Surg. 2003;  112 (2) 440-447
  • 30 Hollenbeck S T, Woo S, Komatsu I, Erdmann D, Zenn M R, Levin L S. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers.  Plast Reconstr Surg. 2010;  125 (3) 924-934
  • 31 Furnas D W. Z-plasties and related procedures for the hand and upper limb.  Hand Clin. 1985;  1 (4) 649-665
  • 32 Hirshowitz B, Karev A, Rousso M. Combined double Z-plasty and Y-V advancement for thumb web contracture.  Hand. 1975;  7 (3) 291-293
  • 33 McGregor I A. The Z-plasty in hand surgery.  J Bone Joint Surg Br. 1967;  49 (3) 448-457
  • 34 Rose E H, Buncke H J. Selective finger transposition and primary metacarpal ray resection in multidigit amputations of the hand.  J Hand Surg Am. 1983;  8 (2) 178-182
  • 35 Posner M A. Ray transposition for central digital loss.  J Hand Surg Am. 1979;  4 (3) 242-257

James P HigginsM.D. 

Curtis National Hand Center, Union Memorial Hospital

3333 North Calvert Street, #200, Baltimore, MD 21212

eMail: jameshiggins10@hotmail.com

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