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DOI: 10.1055/s-0030-1267914
© Georg Thieme Verlag KG Stuttgart · New York
M. gracilis Lappenplastik mit plantarem Spalthauttransplantat – Fallbericht und Literaturübersicht zur speziellen Anatomie der Hohlhand und ihrer funktionellen Rekonstruktion
Free Gracilis Muscle Flap with Plantar Intermediate Thickness Skin Graft – Case Report, Review of Anatomy and Functional Reconstruction of the PalmFunctional Resurfacing of the PalmPublication History
eingereicht 24.6.2010
akzeptiert 29.9.2010
Publication Date:
10 August 2011 (online)
![](https://www.thieme-connect.de/media/hamipla/201104/lookinside/thumbnails/10.1055-s-0030-1267914-1.jpg)
Zusammenfassung
Hintergrund: Die Weichteilarchitektur der Hohlhand ist einzigartig. Deckung ausgedehnter Weichteildefekte mit Rekonstruktion ihrer funktionellen Eigenschaften ist eine Herausforderung. Anatomische Wiederherstellung mit Geweben anderer Körperregionen ist fast unmöglich. Beim manuell Tätigen ist neben Bewegungsumfang und Sensibilität auch Stabilität und Widerstandsfähigkeit der Weichteile gegenüber mechanischer Beanspruchung gefordert. Sensible fasziokutane Lappenplastiken sind durch geringe Adhärenz, hohe Schichtdicke zweischneidig. Empfehlungen zur Selektion des Therapieverfahrens sind spärlich.
Material und Methode: Detaillierte Defektanalyse (anatomische, taktil-gnostische Einheiten der Hohlhand, individuelle Parameter) liefert wichtige Informationen zur Selektion der Lappenplastik. Unterschieden wurden 4 Einheiten: Thenar (T), Hypothenar (H) und zentrale Hohlhand (Z). Einheit (Z) wird gemeinsam von Einheit zentrale (c’) und distale (d’) Hohlhand gebildet. Einheiten (T) und (H) sind sekundäre Greifflächen und erfordern protektive Sensibilität durch Deckung mittels sensibler fasziokutaner Lappenplastik. Einheit (Z) hat geringere taktil-gnostische Bedeutung. Rekonstruktion der Weichteilstabilität dieser Einheit ist beim manuell Tätigen wesentlich. Bei einem 21-jährigen Schlosser wurde ein Defekt (9×13 cm) der dominanten Hohlhand (Gefäß-, Nerv-, Sehnenbeteiligung) nach Defektanalyse, Beteiligung (Z), partiell (T) und (H), mittels freier M. grazilis Muskel-Lappenplastik und dickem plantaren Spalthauttransplantat (Stärke 0,5 mm) gedeckt.
Ergebnisse: 29 Monate postoperativ zeigten sich anatomische Weichteilverhältnisse (Vancouver scar scale: 1), hohe mechanische Stabilität, seitengleiche Handfunktion (DASH score: 4). Semmes-Weinstein-Monofilament Test lieferte positive Druckempfindung. Berufliche Wiedereingliederung nach 5 Monaten.
Schlussfolgerung: Deckung von ausgedehnten Hohlhanddefekten erfordert die Entscheidung für Sensibilität oder Weichteilstabilität. Bei Voraussetzungen wie: mechanische Beanspruchung, Beteiligung von Einheit (Z) werden Weichteilstabilität und Widerstandsfähigkeit erstrangig. Defektanalyse ermöglicht zuverlässige Wahl des idealen Therapieverfahrens. Beim manuell Tätigen können durch Defektdeckung mittels Muskel-Lappenplastik und plantarem Spalthauttransplantat Gleiches mit Gleichem ersetzt und alle Therapieanforderungen erfüllt werden.
Abstract
Background: Skin and soft-tissue architecture of the palm are unique. Coverage of extensive soft-tissue defects restoring the functional capacity of the palm remains a challenging task. Anatomic restoration with skin from another area is hardly possible. In manual labourers, reconstruction of mechanical soft-tissue stability is required in addition to sensation, range of motion and grip strength. Sensate fasciocutaneous flaps bear disadvantages of tissue mobility, shifting and bulkiness. Published criteria for defect-related flap selection are sparse.
Material and Methods: Defect analysis (anatomy, units of tactile gnosis, individual parameters) provides information to weigh needs for sensation or tissue stability, influencing selection of most appropriate procedures. We distinguished 4 units: hypothenar (H), thenar (T) and central palm (Z). (Z) consists of a central palmar unit (c’) and the distal palm (d’). Individual parameters (age, profession, dominant hand, psychosocial aspects) were also considered. Units (T) and (H), regions of secondary touch, demand protective sensation by applying sensate fasciocutaneous flaps. In labourers tactile gnosis in (Z) is of less, tissue stability of greater value. An extensive palmar defect (9×13 cm, affecting unit (Z), partially affecting units (T) and (H), of the dominant hand) with combined vessel, nerve, tendon injuries (male labourer, 21 years) was covered after defect analysis with a free gracilis muscle flap and a glabrous intermediate (0.5 mm) thickness skin graft from the instep region.
Results: 29 months postoperatively anatomic conditions of palmar soft tissue (Vancouver scar scale: 1), high mechanical soft-tissue stability including normal hand function were evident. Semmes Weinstein testing showed positive pressure sensation. Professional reintegration after 5 months was possible.
Conclusion: Defect coverage of the palm must not consist of merely providing sensate vascularised tissue. The most appropriate procedure can be derived from careful defect analysis focusing on the affection of units of tactile gnosis to achieve near to anatomic reconstruction. In labourers, patient- and defect-related demands need close correlation with the value of the selected flaps regarding the sensation and mechanical stability to be expected. In selected cases (mechanical irritation, affection of unit (Z), younger age) by combining microvascular muscle flaps with plantar intermediate thickness skin grafts promising functional results with early professional reintegration can be achieved by reconstructing like with like.
Schlüsselwörter
freie Lappenplastiken - Hohlhanddefekt - Leistenhaut - Muskellappen - Fußsohle
Key words
free flap plasty - palm defect - skin graft - muscle flap - instep
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Korrespondenzadresse
Dr. Timm Oliver Engelhardt
Universitätsklinik für Plastische,
Rekonstruktive und Ästhetische
Chirurgie
Medizinische Universität
Innsbruck
Anichstraße 35
6020 Innsbruck
Austria
Email: timm.engelhardt@i-med.ac.at