soft tissue coverage hand

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this presentation helps selecting different reconstructive options for different soft tissue defects of the hand and upper extremity

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Soft Tissue Coverage of Hand and Upper Extremity:

Soft Tissue Coverage of Hand and Upper Extremity Dr. Falak Sher Malik FCPS(Plast) Hand Surgery Fellow National Orthopaedic Hospital Bahawalpur

Objective:

Objective Primary wound healing inflammation scar formation joint stiffening

Principles of Soft Tissue Replacement:

Principles of Soft Tissue Replacement Timing-as early as feasible Careful debridement Retain tissues of uncertain viability Have a second look Once loss is certain Excise and replace

Principles of primary treatment:

Principles of primary treatment Timing-as early as possible Careful debridement Relief of vascular complications Stabilization of skeleton Repair of nerves and tendons Prevention of infection Provision of skin cover Prevention of stiffness and fixed deformities(soft tissue equilibrium)

Reconstructive Options:

Reconstructive Options

Surgical Approaches:

Surgical Approaches Primary closure Skin grafts Local flaps Regional flaps Distant pedicled flaps Microvascular free tissue transfers

Choice of Treatment:

Choice of Treatment Mechanism of injury Size of defect Location of defect Status of wound Injuries to other parts of hand Patient’s age, sex, General health Occupation

Donor Site Selection:

Donor Site Selection Hand itself – superior Best tissue match Superior sensory recovery Easy care Distant donor sites Justify the use

Skin Grafts:

Skin Grafts

SKIN GRAFTS:

SKIN GRAFTS Dorsal skin is thin and loose enough so as not to restrict flexion, yet it must protect tendons and joints . Volar skin must be thicker and tougher, while still allowing motion, and requires sensibility Full-thickness grafts are used primarily for small defects . Split-thickness skin grafts are used for closure of major skin defects .

STSG:

STSG Advantages: Multiple potential donor sites Variable graft thickness and color Reliable graft take Ease of graft harvest Low donor site morbidity Ease of graft application Graft shrinkage that reduces defect size

Disadvantages: :

Disadvantages: Donor site scarring Lack o durability or stability in palmer and finger tips region Pigmentation or color mismatch Unattractive appearance following mesh expansion of the graft. Secondary contraction

FTSG:

FTSG Advantages: Better protection Better sensibility ( more epidermal appendages). Less contraction Disadvantages: Take less readily than a split thickness graft Requires a better wound bed for application More prone to infection

Recommendation For STSG:

Recommendation For STSG Most wounds- recommended 0.015 inches If graft survival at risk 0.010-0.012 inches Infants : never over 0.008 inches Adult male: 0.015 from thigh, 0.018 from abdomen and buttocks Adult female: if > 0.015 use lower abdomen and never use inner thigh. Elderly: treat as child’s skin.

Sites of FTSG:

Sites of FTSG The groin crease( lateral to hair) Hypothenar region Abdomen Medial arm Antecubital fossa If possible the donor and recipient morbidity should be localized to same extremity.

Common causes of FTSG failures:

Common causes of FTSG failures Improper immobilization- Better to immobilize for 10-14 days Inadequate defatting of the graft

STSG mesh:

STSG mesh Mesh ratio 1:1.5 recommended for use in hand Reduces hematoma and seroma formation If cosmesis is paramount - use unmeshed.

Split-Thickness Graft:

Split-Thickness Graft

Split-Thickness Graft:

Split-Thickness Graft

Glaborous Skin Graft:

Glaborous Skin Graft

Full-Thickness Graft:

Full-Thickness Graft

Flaps:

Flaps

Indications for Flaps:

Indications for Flaps Exposed bones, joints,tendons or cartilages Open fractures Exposed hardware Where less contracture is desirable Padding Secondary reconstruction

Common local flaps used for hand:

Common local flaps used for hand Cross finger flap Reversed cross finger flap Innervated cross finger flap Cross thumb flap Thenar flap Neurovascular island flap Fillet flap Z-plasty Dorsal metacarpal artery flaps Digital artery island flap V-Y advancement flaps Moberg flaps

Z-plasty:

Z-plasty Basic pattern: Z with limbs of equal length, with the peripheral limbs forming an angle of 60° with central limb

PowerPoint Presentation:

Campbell 2007 11th ed Vol 4

Multiple Z-platies:

Multiple Z-platies

Double opposing Z-plasty:

Double opposing Z-plasty

Multiple Y-V advancements:

Multiple Y-V advancements

Four flap Z-plasty:

Four flap Z-plasty

Common regional flaps used for hand:

Common regional flaps used for hand Radial artery forearm flap Reversed posterior interosseous artery flap Ulnar artery forearm flap Becker’s Flap

Volar Y-V Flap:

Volar Y-V Flap

Volar V-Y Flap:

Volar V-Y Flap

Cross-Finger Flap:

Cross-Finger Flap

Cross-Finger Flap:

Cross-Finger Flap

Cross-Finger Flap:

Cross-Finger Flap

Dorsal finger flag ( vilain) flap:

Dorsal finger flag ( vilain) flap

Volar cross finger flap:

Volar cross finger flap distal thumb amputation site best when the amputation is through the terminal phalanx of the thumb, it can also be used for amputations through the distal end of the proximal phalanx

Thenar Flap:

Thenar Flap

Neurovascular Island Flap:

Neurovascular Island Flap

First Dorsal Metacarpal Artery Flap:

First Dorsal Metacarpal Artery Flap

PowerPoint Presentation:

Distally based Ulnar parametacarpal artery flap

Regional Flaps:

Regional Flaps Reverse flow Radial Artery Forearm Flap, Ulnar Artery Forearm Flap Posterior Interosseus Artery Flap Becker’s Flap

Regional Flaps:

Regional Flaps Advantages: Single Stage Good local match Favourable Hand Position for elevation

Regional Flaps:

Regional Flaps Disadvantages: Risky due to Compromised Vascularity Unavailable if involved in injury Technically demanding dissection Donor site requires Skin graft

Reverse Radial Forearm Flap:

Reverse Radial Forearm Flap

Reverse Radial Forearm Flap:

Reverse Radial Forearm Flap

Reverse Radial Forearm Flap:

Reverse Radial Forearm Flap

Reverse Radial Forearm Flap:

Reverse Radial Forearm Flap

Reverse Radial Forearm Flap:

Reverse Radial Forearm Flap

Reverse Radial Forearm Flap (Adipofascial variant):

Reverse Radial Forearm Flap (Adipofascial variant)

Reverse Radial Forearm Flap (Adipofascial variant):

Reverse Radial Forearm Flap (Adipofascial variant)

Posterior Interosseous Artery Flap:

Posterior Interosseous Artery Flap PIA runs between ECU and EDM Used as retrograde and antigrade flow 1.5cm above the Radioulnar joint pedicle Covers dorsum,thumb,first web space and palm limited up to MCPJ

Posterior Interossious Artery Flap:

Posterior Interossious Artery Flap

Posterior Interossious Artery Flap:

Posterior Interossious Artery Flap

Posterior Interossious Artery Flap:

Posterior Interossious Artery Flap

Posterior Interossious Artery Flap:

Posterior Interossious Artery Flap

Posterior Interossious Artery Flap (Adipofascial variant):

Posterior Interossious Artery Flap (Adipofascial variant)

Becker’s flap:

Becker’s flap

Beckers flap:

Beckers flap

Distant Pedicled Flaps :

Distant Pedicled Flaps Paraumbilical Perforator-based Abdominal Flap Groin Flap

Paraumbilical Perforator-based Abdominal Flap :

Paraumbilical Perforator-based Abdominal Flap Flap Design Area of thinning (dotted) 2 – 3 mm diameter Deep Inf. Epigastric Art.

Paraumbilical Perforator-based Abdominal Flap :

Paraumbilical Perforator-based Abdominal Flap Advantages Robust Vascularity Large size skin paddle to cover extensive defects with primary closure of donor site Can be thinned up to desirable thickness without risk of vascular compromise Hand in less dependent position

Paraumbilical Perforator-based Abdominal Flap :

Paraumbilical Perforator-based Abdominal Flap Disadvantages: Two Stage Limb immobilization Unsightly scar on front of abdomen

Abdominal Flap:

Abdominal Flap

Abdominal Flap:

Abdominal Flap

Groin flap:

Groin flap A fasciocutanous flap up to 25x10cm Superficial circumflex iliac artery and venae comitantes Can cover wrist, palm, dorsum and forearm wounds.

Groin Flap:

Groin Flap Advantages Robust vascularity, thin, pliable Hidden Donor site scar Disadvantages Two Stage Relatively smaller size of paddle Larger skin paddle requires skin graft for donor site Dependent Position of Hand Difficult to maintain personal hygiene

Groin Flap:

Groin Flap

Elbow coverage:

Elbow coverage

Lateral Arm Flap :

Lateral Arm Flap

Rotation Flap:

Rotation Flap

Complex Reconstruction in the arm:

Complex Reconstruction in the arm

Shoulder coverage:

Shoulder coverage

Microvascular free tisssue transfer:

Microvascular free tisssue transfer

Indications for Free Flaps:

Indications for Free Flaps Defect is too large Regional flaps are unsuitable Distant pedicled flaps are cumbersome Composite reconstruction desirable After ideal reconstruction Pt’s own choice Surgeon’s own wishes

Advantages of Free Flaps:

Advantages of Free Flaps Single stage Hand elevation possible Avoids joints stiffness Two team approach Complex reconstruction Ideal reconstruction Hidden donor site Avoids locoregional scarring

Disadvantages of Free Flaps :

Disadvantages of Free Flaps Long operating time Expensive Technically demanding Long learning curve Microsurgical expertise Microsurgical equipment Microsurgical team

Free Anterolateral Thigh Flap:

Free Anterolateral Thigh Flap

Anterolateral thigh free flap:

Anterolateral thigh free flap

Lateral arm free flap :

Lateral arm free flap Lateral Arm Flap

Free Microvascular Tissue Transfer :

Free Microvascular Tissue Transfer Lateral Arm Flap

Reconstruction under the flap:

Reconstruction under the flap

Cable Nerve Grafting:

Cable Nerve Grafting

Tendon Transfer:

Tendon Transfer

Tendon Transfer:

Tendon Transfer

Toe to Thumb Transfer:

Toe to Thumb Transfer

Take Home Message:

Take Home Message Early debridement and closure/cover as a rule Delay in cover invites fibrosis and stiffness Both function and cosmesis should be considered but priority goes to function Think about the future; secondary reconstruction and rehabilitation

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