COMBINED MEDIALIS PEDIS AND MEDIAL PLANTAR FASCIOCUTANEOUS FLAPS FOR COVERAGE OF SOFT TISSUE DEFECTS OF MULTIPLE ADJACENT FINGERS MITSUHIRO OKADA, M.D., PH.D.,1* HIDEHIKO SAITO, M.D., PH.D.,2 KENICHI KAZUKI, M.D., PH.D.,3 and HIROAKI NAKAMURA, M.D., PH.D.1
Soft tissue defects of adjacent multiple fingers covered by a single large flap require secondary separation of the flap into each finger. Such covering obstructs independent motion of injured fingers until the single large flap is separated. This report describes the technique of combined medialis pedis and medial plantar fasciocutaneous flaps for reconstructing soft tissue defects of multiple adjacent fingers. Three male patients (age range, 18–33 years) underwent soft tissue reconstructions of multiple adjacent fingers with combined flaps. Injuries involved three adjacent palmar fingers, two adjacent palmar fingers, and two adjacent dorsal fingers. Average sizes of the combined flaps were 4.2 3 4.0 cm for the medialis pedis flap and 3.0 3 1.8 cm for the medial plantar fasciocutaneous flap. All flaps survived without vascular complications, and donor sites healed uneventfully. All patients experienced excellent recovery of range of motion for the reconstructed fingers. In conclusion, combined flaps may offer an alternative for coverage of soft tissue defects that involve multiple adjaC 2014 Wiley Periodicals, Inc. Microsurgery 34:454–458, 2014. cent fingers. V
Conventional treatment for soft tissue defects of multiple adjacent fingers involves coverage with a single large skin flap and secondary separation into each finger after neovascularization is complete.1 Such reconstruction restricts the independent motion of individual injured fingers. Bifurcated flaps can cover soft tissue defects of multiple adjacent fingers independently. Such independence may facilitate postoperative exercise, allowing more satisfactory results for range of motion of the fingers. In addition, bulky flaps obstruct the postoperative range of motion of reconstructed fingers; therefore, thin flaps are desirable in soft tissue reconstruction.2 Combined medialis pedis and medial plantar fasciocutaneous flaps are nourished by different branches via a common vascular pedicle, enabling adjacent soft tissue defects to be covered separately.3 Moreover, the combined flaps have a skin texture similar to that of the fingers. These features may confer advantages in the treatment of multiple adjacent fingers with soft tissue defects when compared with other free or regional flaps. To the best of our knowledge, no reports focusing on treatment of soft tissue defects involving multiple adjacent fingers using combined medialis pedis and medial 1 Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan 2 Department of Orthopedic Surgery, Seirei Hamamatsu Hospital, Hamamatsu, Shizuoka, Japan 3 Department of Orthopedic Surgery, Osaka City General Hospital, Osaka, Japan *Correspondence to: M. Okada, M.D., PH.D; Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan. E-mail: [email protected] Received 13 June 2013; Revision accepted 17 December 2013; Accepted 26 December 2013 Published online 16 January 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22222
Ó 2014 Wiley Periodicals, Inc.
plantar fasciocutaneous flaps to improve postoperative function of the reconstructed fingers have been published in the literature. The present article describes the technique of combined medialis pedis and medial plantar fasciocutaneous flaps for reconstructing soft tissue defects of multiple adjacent fingers, along with clinical results. PATIENTS AND METHODS
Between January 2003 and January 2006, three male patients (age range, 18–33 years) received soft tissue coverage with combined medialis pedis and medial plantar fasciocutaneous flaps (Table 1). All patients had palmar or dorsal soft tissue defects of multiple adjacent fingers, with exposure or defects of underlying tendons. In case 1, the right index, middle, and ring fingers were injured in a meat grinder, exposing the flexor tendons with defects to palmar soft tissue. In case 2, third-degree burns were suffered on the left ring and little fingers. The flexor tendons were exposed with palmar soft tissue defects after debridement. In case 3, the left middle and ring fingers were injured in a traffic accident. Soft tissue defects with defects of the extensor tendon were at the dorsal aspects of the middle and ring fingers. The extensor tendon of the middle finger was completely defective from the middle phalanx to the proximal phalanx via the proximal interphalangeal joint. The extensor tendon of the ring finger was partially defective and the finger joints were fully extended. OPERATIVE TECHNIQUE
Operations were performed under general anesthesia. Recipient vessels, a common digital artery, and a dorsal cutaneous vein were prepared after debridement of the injured fingers. For elevation of the combined medialis
Flaps for Multiple Defects of Fingers
455
Table 1. Patients’ Demographics and Results
Case
Age (year)
1
22
2
33
3
18
Size of flap (cm)
Flap survival
Complication
3.5 3 2
Survived
None
1
4.5 3 1.5
2.5 3 1.5
Survived
None
0
4 3 2.5
332
Survived
None
0
Injured fingers
M
Index, middle, ring (palmar fingers) Ring, little (palmar fingers) Middle, ring (dorsal fingers)
438
L
Number of operations of flap separations
%TAM Index Middle Ring Ring Little Middle Ring
83 70 75 90 100 80 100
M, medialis pedis flap; L, medial plantar fasciocutaneous flap; TAM, total active motion.
Figure 1. Surgical technique. A medialis pedis flap was elevated for a soft tissue defect after considering the length of vascular pedicle required. For elevation of a medial plantar fasciocutaneous flap, one of the perforators of the lateral branch was selected, confirming that the length from the perforator to the point of bifurcation from the medial plantar artery (x—y) was at least equal to the distance from the remaining soft tissue defect to the point of bifurcation of the common digital artery (a—b). MPA, medial plantar artery; M, medial branch of the medial plantar artery; L, lateral branch of the medial plantar artery; Abd, abductor hallucis; N, tubercle of the navicular; D, donor site for the medial plantar fasciocutaneous flap; x, point of bifurcation from the medial plantar artery; y, perforator vessel of the medial branch of the medial plantar artery; Asterisk, medial plantar fasciocutaneous flap; Triangle, medialis pedis flap; CDA, common digital artery; Shaded areas, soft tissue defects of multiple adjacent digits; a, point of bifurcation of the common digital artery; b, point of a soft tissue defect.
pedis and medial plantar fasciocutaneous flaps, an incision was made along the medial arch of the foot under tourniquet control. The medial branch of the medial plantar artery was then exposed by retracting the abductor hallucis muscle laterally. The medial branch was followed distally until the branch to the tubercle of the navicular was found. The medialis pedis flap was designed to fit the soft tissue defects of more than one finger, including the tubercle of the navicular. The medialis pedis flap was elevated by dissecting the medial branch proximally to the point of bifurcation from the medial plantar artery. Dissection was continued laterally on the abductor hallucis to find several perforators through the intermuscular septum between the abductor hallucis and flexor digitorum muscle. The abductor hallucis was detached near its origin to explore the lateral branch of the medial plantar artery. One of the perfora-
tors was selected in consideration of the length from the remaining soft tissue defects to the point of bifurcation from the common digital artery (Fig. 1). The length from the perforator vessel of the lateral branch to the point of bifurcation of the medial plantar artery was equal to or longer than that from the remaining soft tissue defects to the point of bifurcation of the common digital artery. The medial plantar fasciocutaneous flap was designed to fit the remaining soft tissue defects, including the selected perforator vessel. The medial plantar fasciocutaneous flap was elevated by dissecting the lateral branch proximally to the point of bifurcation of the medial plantar artery. The medial plantar artery and its accompanying vein were dissected proximally enough and divided to gain the length of donor vessels so that they could reach the point of bifurcation of the common digital artery and the dorsal cutaneous vein when the flaps were Microsurgery DOI 10.1002/micr
456
Okada et al.
transferred. Each flap was harvested. Each skin defect of multiple fingers was independently covered with either the medialis pedis or medial plantar fasciocutaneous flap. The medial plantar artery was anastomosed with the prepared common digital artery, and its accompanying vein was anastomosed with the prepared dorsal cutaneous vein. In cases in which multiple fingers were included together within a flap, the flap was divided into each finger after the completion of neovascularization. The donor sites of the foot were closed with split-thickness skin
grafts, after the abductor hallucis was reattached to its origin. Outcomes assessed in this report included flap size, number of flap separations, and complications. Range of motion was assessed by comparing the percentage total active motion (%TAM) with that of the contralateral side. RESULTS
Average sizes of the combined flaps were 4.2 3 4.0 cm in the medialis pedis flap and 3.0 3 1.8 cm in the medial plantar fasciocutaneous flap. Flap survival was complete. No vascular complications were encountered, and all donor sites healed uneventfully. In case 1, the right index and middle fingers were covered together with a medialis pedis flap, and the right ring finger was covered with a medial plantar fasciocutaneous flap. The medialis pedis flap was separated into the index and middle fingers 6 weeks after the previous operation. The other two patients required no flap separation. In case 3, the defective portion of the extensor tendon of the left middle finger was reconstructed with a free tendon graft. No cases required any additional interventions, such as tenolysis, for injured tendons. The function of the reconstructed fingers is shown in Table 1. CASE REPORT
Figure 2. Third-degree burns were present on the palmar ring and little fingers. A second-degree burn was present on the palmar middle finger.
A 33-year-old man suffered from third-degree burns on the left palmar ring and little fingers and a seconddegree burn on the left palmar middle finger (Fig. 2). Two weeks after the injury, surgery was performed under general anesthesia. The flexor tendons were exposed after debridement of the left ring and little fingers. The fat tissue underlying the burned skin on the left middle finger was still vital and the flexor tendon was not exposed.
Figure 3. Combined medialis pedis and medial plantar fasciocutaneous flaps (Left). Intraoperative view of reconstructed multiple adjacent fingers (Right). MPA, medial plantar artery; M, medial branch of the medial plantar artery; L, lateral branch of the medial plantar artery; Asterisk, medial plantar fasciocutaneous flap; Triangle, medialis pedis flap.
Microsurgery DOI 10.1002/micr
Flaps for Multiple Defects of Fingers
Combined medialis pedis and medial plantar fasciocutaneous flaps were harvested from the left foot (Fig. 3, left). The size of the medialis pedis flap was 4.5 3 1.5 cm and that of the medial plantar fasciocutaneous flap was 2.5 3 1.5 cm. The soft tissue defect on the left ring finger was covered with the medialis pedis flap, and that on the left little finger was covered with the medial plantar fasciocutaneous flap. The soft tissue defect on the left middle finger was covered with a split thickness skin graft (Fig. 3, right). Donor sites on the left foot were closed with a split-thickness skin graft. The combined flaps survived without vascular complications, and no other postoperative complications were encountered. Donor sites on the left foot healed uneventfully (Fig. 4). Two weeks postoperatively, active range of motion exercises were started for the reconstructed fingers. Covering the affected digits independently facilitated postoperative exercise without any interference between fingers. The final %TAMs of the ring and little fingers were 90% and
Figure 4. The donor site healed with a split-thickness skin graft.
457
100%, respectively, without any interventions for flexor tendons (Fig. 5).
DISCUSSION
Soft tissue reconstruction for multiple adjacent fingers along with exposure or defect of the tendons affects the postoperative function of the injured fingers. As far as we know, this report is the first to describe combined medialis pedis and medial plantar fasciocutaneous flaps for restoration of range of motion in adjacent injured fingers. Combined medialis pedis and medial plantar fasciocutaneous flaps can cover separated skin defects independently.3 The medialis pedis flap is nourished by the medial branch of the medial plantar artery, and the medial plantar flap is nourished by the lateral branch of the medial plantar artery. This bifurcation via one common pedicle enables the combined flaps to cover separated soft tissue defects independently. Independent coverage of soft tissue defects facilitates postoperative range of motion exercises for multiple adjacent fingers with exposure or defects of the tendons. From an anatomical perspective, the interphalangeal joint of the little finger is not level with those of the other fingers.4 Therefore, when the little and adjacent fingers are covered together with one flap, their motion is incapable of being synchronized; this problem can be avoided by independently covering the little finger with either a medialis pedis or a medial plantar fasciocutaneous flap. In addition, tendon injuries require intensive postoperative hand therapy.5 Independent coverage of soft tissue defects enables isolated care of each injured fingers, including splint application. The thinness of the combined flaps is another advantage in terms of enhancing the range of motion during
Figure 5. Postoperative status of the active range of motion of the fingers. (Left) Finger extension. (Right) Finger flexion. Asterisk, medial plantar fasciocutaneous flap; Triangle, medialis pedis flap.
Microsurgery DOI 10.1002/micr
458
Okada et al.
exercise of the reconstructed fingers. The texture of the medialis pedis and medial plantar flaps matches that of the original fingers.3,6–9 Free flaps from other regions are too bulky for use in the fingers,2 where they interfere with finger motion and restrict the range of motion. Furthermore, both the medialis pedis flap and the medial plantar flap provide glabrous skin and reduce unsightly scarring on the donor site, which is preferable from an esthetic perspective.6,9 Combined medialis pedis and medial plantar fasciocutaneous flaps can lessen postoperative vascular complications. The combined flaps require anastomoses of only one artery and one vein of the medial plantar vessels with recipient vessels. Postoperative vascular complications did not arise in any case in this report. A free vascularized skin flap for each finger is another surgical option; however, this requires multiple anastomoses of arteries and veins with the attendant increases in operative time,10 and the added complexity may increase the risk of postoperative vascular complications. Pedicled flaps harvested from either the finger or the dorsum of the hand may be unsuitable for soft tissue defects of multiple adjacent fingers. Pedicled flaps from the finger simply will not suffice for soft tissue defects of multiple adjacent fingers.11–13 Moreover, pedicled flaps from the finger demand uninjured skin from an adjacent finger, or an uninjured vascular network within an affected finger. Pedicled flaps from the dorsum of the hand show anatomical variations in the vascular pedicle.14,15 Such variations may lead to difficulties in achieving soft tissue coverage for multiple adjacent soft tissue defects, particularly for ulnar-sided fingers. This report did have several limitations. First, we only analyzed a relatively small number of cases in our series. Second, we only reported the experience of a single surgeon specializing in hand and microsurgery. A larger size of cases, particularly those in which this technique is performed in a general orthopedic practice, might be helpful in revealing additional surgical problems and postoperative complications that were not encountered in this series. CONCLUSIONS
Combined medialis pedis and medial plantar fasciocutaneous flaps could offer a useful option in the soft tissue
Microsurgery DOI 10.1002/micr
reconstruction of multiple adjacent fingers. Thinness and bifurcation of the combined flaps facilitate restoration of the postoperative range of motion of reconstructed fingers while also reducing the risk of postoperative complications.
REFERENCES 1. Woo SH, Kim KC, Lee GJ, Ha SH, Kim KH, Dhawan V, Lee KS. A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: An 11-year experience. Plast Reconstr Surg 2007; 119:1823–1838. 2. Friedrich JB, Katolik LI, Vedder NB. Soft tissue reconstruction of the hand. J Hand Surg Am 2009;34:1148–1155. 3. Chai YM, Wang CY, Wen G, Zeng BF, Cai PH, Han P. Combined medialis pedis and medial plantar fasciocutaneous flaps based on the medial plantar pedicle for reconstruction of complex soft tissue defects in the hand. Microsurgery 2011;31:45–50. 4. Agur AMR, Dalley AF. Grant’s atlas of anatomy. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009. p 864. 5. Rockwell WB, Butler PN, Byrne BA. Extensor tendon: Anatomy, injury, and reconstruction. Plast Reconstr Surg 2000;106:1592–1603. 6. Gu JH, Jeong SH. Radical resection of a venous malformation in middle finger and immediate reconstruction using medial plantar artery perforator flap: A case report. Microsurgery 2012;32:148–152. 7. Huang SH, Wu SH, Lai CH, Chang CH, Wangchen H, Lai CS, Lin SD, Chang KP. Free medial plantar artery perforator flap for finger pulp reconstruction: Report of a series of 10 cases. Microsurgery 2010;30:118–124. 8. Ishikura N, Heshiki T, Tsukada S. The use of a free medialis pedis flap for resurfacing skin defects of the hand and digits: Results in five cases. Plast Reconstr Surg 1995;95:100–107. 9. Lykoudis EG, Seretis K, Lykissas MG. Free sensate medial plantar flap for contralateral plantar forefoot reconstruction with flap reinnervation using end-to-side neurorrhaphy: A case report and literature review. Microsurgery 2013;33:227–231. 10. Trovato MJ, Brooks D, Buntic RF, Buncke GM. Simultaneous coverage of two separate dorsal digital defects with a syndactylizing venous free flap. Microsurgery 2008;28:248–251. 11. Hashem AM. Salvage of degloved digits with heterodigital flaps and full thickness skin grafts. Ann Plast Surg 2010;64:155–158. 12. Huang YC, Liu Y, Chen TH. Use of homodigital reverse island flaps for distal digital reconstruction. J Trauma 2010;68:429–433. 13. Woon CY, Lee JY, Teoh LC. Resurfacing hemipulp losses of the thumb: The cross finger flap revisited: Indications, technical refinements, outcomes, and long-term neurosensory recovery. Ann Plast Surg 2008;61:385–391. 14. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 1961;113:409–424. 15. Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg 1990;43:28–39.
Soft tissue defects of adjacent multiple fingers covered by a single large flap require secondary separation of the flap into each finger. Such covering obstructs independent motion of injured fingers until the single large flap is separated. This report describes the technique of combined medialis pedis and medial plantar fasciocutaneous flaps for reconstructing soft tissue defects of multiple adjacent fingers. Three male patients (age range, 18–33 years) underwent soft tissue reconstructions of multiple adjacent fingers with combined flaps. Injuries involved three adjacent palmar fingers, two adjacent palmar fingers, and two adjacent dorsal fingers. Average sizes of the combined flaps were 4.2 3 4.0 cm for the medialis pedis flap and 3.0 3 1.8 cm for the medial plantar fasciocutaneous flap. All flaps survived without vascular complications, and donor sites healed uneventfully. All patients experienced excellent recovery of range of motion for the reconstructed fingers. In conclusion, combined flaps may offer an alternative for coverage of soft tissue defects that involve multiple adjaC 2014 Wiley Periodicals, Inc. Microsurgery 34:454–458, 2014. cent fingers. V
Conventional treatment for soft tissue defects of multiple adjacent fingers involves coverage with a single large skin flap and secondary separation into each finger after neovascularization is complete.1 Such reconstruction restricts the independent motion of individual injured fingers. Bifurcated flaps can cover soft tissue defects of multiple adjacent fingers independently. Such independence may facilitate postoperative exercise, allowing more satisfactory results for range of motion of the fingers. In addition, bulky flaps obstruct the postoperative range of motion of reconstructed fingers; therefore, thin flaps are desirable in soft tissue reconstruction.2 Combined medialis pedis and medial plantar fasciocutaneous flaps are nourished by different branches via a common vascular pedicle, enabling adjacent soft tissue defects to be covered separately.3 Moreover, the combined flaps have a skin texture similar to that of the fingers. These features may confer advantages in the treatment of multiple adjacent fingers with soft tissue defects when compared with other free or regional flaps. To the best of our knowledge, no reports focusing on treatment of soft tissue defects involving multiple adjacent fingers using combined medialis pedis and medial 1 Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan 2 Department of Orthopedic Surgery, Seirei Hamamatsu Hospital, Hamamatsu, Shizuoka, Japan 3 Department of Orthopedic Surgery, Osaka City General Hospital, Osaka, Japan *Correspondence to: M. Okada, M.D., PH.D; Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan. E-mail: [email protected] Received 13 June 2013; Revision accepted 17 December 2013; Accepted 26 December 2013 Published online 16 January 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22222
Ó 2014 Wiley Periodicals, Inc.
plantar fasciocutaneous flaps to improve postoperative function of the reconstructed fingers have been published in the literature. The present article describes the technique of combined medialis pedis and medial plantar fasciocutaneous flaps for reconstructing soft tissue defects of multiple adjacent fingers, along with clinical results. PATIENTS AND METHODS
Between January 2003 and January 2006, three male patients (age range, 18–33 years) received soft tissue coverage with combined medialis pedis and medial plantar fasciocutaneous flaps (Table 1). All patients had palmar or dorsal soft tissue defects of multiple adjacent fingers, with exposure or defects of underlying tendons. In case 1, the right index, middle, and ring fingers were injured in a meat grinder, exposing the flexor tendons with defects to palmar soft tissue. In case 2, third-degree burns were suffered on the left ring and little fingers. The flexor tendons were exposed with palmar soft tissue defects after debridement. In case 3, the left middle and ring fingers were injured in a traffic accident. Soft tissue defects with defects of the extensor tendon were at the dorsal aspects of the middle and ring fingers. The extensor tendon of the middle finger was completely defective from the middle phalanx to the proximal phalanx via the proximal interphalangeal joint. The extensor tendon of the ring finger was partially defective and the finger joints were fully extended. OPERATIVE TECHNIQUE
Operations were performed under general anesthesia. Recipient vessels, a common digital artery, and a dorsal cutaneous vein were prepared after debridement of the injured fingers. For elevation of the combined medialis
Flaps for Multiple Defects of Fingers
455
Table 1. Patients’ Demographics and Results
Case
Age (year)
1
22
2
33
3
18
Size of flap (cm)
Flap survival
Complication
3.5 3 2
Survived
None
1
4.5 3 1.5
2.5 3 1.5
Survived
None
0
4 3 2.5
332
Survived
None
0
Injured fingers
M
Index, middle, ring (palmar fingers) Ring, little (palmar fingers) Middle, ring (dorsal fingers)
438
L
Number of operations of flap separations
%TAM Index Middle Ring Ring Little Middle Ring
83 70 75 90 100 80 100
M, medialis pedis flap; L, medial plantar fasciocutaneous flap; TAM, total active motion.
Figure 1. Surgical technique. A medialis pedis flap was elevated for a soft tissue defect after considering the length of vascular pedicle required. For elevation of a medial plantar fasciocutaneous flap, one of the perforators of the lateral branch was selected, confirming that the length from the perforator to the point of bifurcation from the medial plantar artery (x—y) was at least equal to the distance from the remaining soft tissue defect to the point of bifurcation of the common digital artery (a—b). MPA, medial plantar artery; M, medial branch of the medial plantar artery; L, lateral branch of the medial plantar artery; Abd, abductor hallucis; N, tubercle of the navicular; D, donor site for the medial plantar fasciocutaneous flap; x, point of bifurcation from the medial plantar artery; y, perforator vessel of the medial branch of the medial plantar artery; Asterisk, medial plantar fasciocutaneous flap; Triangle, medialis pedis flap; CDA, common digital artery; Shaded areas, soft tissue defects of multiple adjacent digits; a, point of bifurcation of the common digital artery; b, point of a soft tissue defect.
pedis and medial plantar fasciocutaneous flaps, an incision was made along the medial arch of the foot under tourniquet control. The medial branch of the medial plantar artery was then exposed by retracting the abductor hallucis muscle laterally. The medial branch was followed distally until the branch to the tubercle of the navicular was found. The medialis pedis flap was designed to fit the soft tissue defects of more than one finger, including the tubercle of the navicular. The medialis pedis flap was elevated by dissecting the medial branch proximally to the point of bifurcation from the medial plantar artery. Dissection was continued laterally on the abductor hallucis to find several perforators through the intermuscular septum between the abductor hallucis and flexor digitorum muscle. The abductor hallucis was detached near its origin to explore the lateral branch of the medial plantar artery. One of the perfora-
tors was selected in consideration of the length from the remaining soft tissue defects to the point of bifurcation from the common digital artery (Fig. 1). The length from the perforator vessel of the lateral branch to the point of bifurcation of the medial plantar artery was equal to or longer than that from the remaining soft tissue defects to the point of bifurcation of the common digital artery. The medial plantar fasciocutaneous flap was designed to fit the remaining soft tissue defects, including the selected perforator vessel. The medial plantar fasciocutaneous flap was elevated by dissecting the lateral branch proximally to the point of bifurcation of the medial plantar artery. The medial plantar artery and its accompanying vein were dissected proximally enough and divided to gain the length of donor vessels so that they could reach the point of bifurcation of the common digital artery and the dorsal cutaneous vein when the flaps were Microsurgery DOI 10.1002/micr
456
Okada et al.
transferred. Each flap was harvested. Each skin defect of multiple fingers was independently covered with either the medialis pedis or medial plantar fasciocutaneous flap. The medial plantar artery was anastomosed with the prepared common digital artery, and its accompanying vein was anastomosed with the prepared dorsal cutaneous vein. In cases in which multiple fingers were included together within a flap, the flap was divided into each finger after the completion of neovascularization. The donor sites of the foot were closed with split-thickness skin
grafts, after the abductor hallucis was reattached to its origin. Outcomes assessed in this report included flap size, number of flap separations, and complications. Range of motion was assessed by comparing the percentage total active motion (%TAM) with that of the contralateral side. RESULTS
Average sizes of the combined flaps were 4.2 3 4.0 cm in the medialis pedis flap and 3.0 3 1.8 cm in the medial plantar fasciocutaneous flap. Flap survival was complete. No vascular complications were encountered, and all donor sites healed uneventfully. In case 1, the right index and middle fingers were covered together with a medialis pedis flap, and the right ring finger was covered with a medial plantar fasciocutaneous flap. The medialis pedis flap was separated into the index and middle fingers 6 weeks after the previous operation. The other two patients required no flap separation. In case 3, the defective portion of the extensor tendon of the left middle finger was reconstructed with a free tendon graft. No cases required any additional interventions, such as tenolysis, for injured tendons. The function of the reconstructed fingers is shown in Table 1. CASE REPORT
Figure 2. Third-degree burns were present on the palmar ring and little fingers. A second-degree burn was present on the palmar middle finger.
A 33-year-old man suffered from third-degree burns on the left palmar ring and little fingers and a seconddegree burn on the left palmar middle finger (Fig. 2). Two weeks after the injury, surgery was performed under general anesthesia. The flexor tendons were exposed after debridement of the left ring and little fingers. The fat tissue underlying the burned skin on the left middle finger was still vital and the flexor tendon was not exposed.
Figure 3. Combined medialis pedis and medial plantar fasciocutaneous flaps (Left). Intraoperative view of reconstructed multiple adjacent fingers (Right). MPA, medial plantar artery; M, medial branch of the medial plantar artery; L, lateral branch of the medial plantar artery; Asterisk, medial plantar fasciocutaneous flap; Triangle, medialis pedis flap.
Microsurgery DOI 10.1002/micr
Flaps for Multiple Defects of Fingers
Combined medialis pedis and medial plantar fasciocutaneous flaps were harvested from the left foot (Fig. 3, left). The size of the medialis pedis flap was 4.5 3 1.5 cm and that of the medial plantar fasciocutaneous flap was 2.5 3 1.5 cm. The soft tissue defect on the left ring finger was covered with the medialis pedis flap, and that on the left little finger was covered with the medial plantar fasciocutaneous flap. The soft tissue defect on the left middle finger was covered with a split thickness skin graft (Fig. 3, right). Donor sites on the left foot were closed with a split-thickness skin graft. The combined flaps survived without vascular complications, and no other postoperative complications were encountered. Donor sites on the left foot healed uneventfully (Fig. 4). Two weeks postoperatively, active range of motion exercises were started for the reconstructed fingers. Covering the affected digits independently facilitated postoperative exercise without any interference between fingers. The final %TAMs of the ring and little fingers were 90% and
Figure 4. The donor site healed with a split-thickness skin graft.
457
100%, respectively, without any interventions for flexor tendons (Fig. 5).
DISCUSSION
Soft tissue reconstruction for multiple adjacent fingers along with exposure or defect of the tendons affects the postoperative function of the injured fingers. As far as we know, this report is the first to describe combined medialis pedis and medial plantar fasciocutaneous flaps for restoration of range of motion in adjacent injured fingers. Combined medialis pedis and medial plantar fasciocutaneous flaps can cover separated skin defects independently.3 The medialis pedis flap is nourished by the medial branch of the medial plantar artery, and the medial plantar flap is nourished by the lateral branch of the medial plantar artery. This bifurcation via one common pedicle enables the combined flaps to cover separated soft tissue defects independently. Independent coverage of soft tissue defects facilitates postoperative range of motion exercises for multiple adjacent fingers with exposure or defects of the tendons. From an anatomical perspective, the interphalangeal joint of the little finger is not level with those of the other fingers.4 Therefore, when the little and adjacent fingers are covered together with one flap, their motion is incapable of being synchronized; this problem can be avoided by independently covering the little finger with either a medialis pedis or a medial plantar fasciocutaneous flap. In addition, tendon injuries require intensive postoperative hand therapy.5 Independent coverage of soft tissue defects enables isolated care of each injured fingers, including splint application. The thinness of the combined flaps is another advantage in terms of enhancing the range of motion during
Figure 5. Postoperative status of the active range of motion of the fingers. (Left) Finger extension. (Right) Finger flexion. Asterisk, medial plantar fasciocutaneous flap; Triangle, medialis pedis flap.
Microsurgery DOI 10.1002/micr
458
Okada et al.
exercise of the reconstructed fingers. The texture of the medialis pedis and medial plantar flaps matches that of the original fingers.3,6–9 Free flaps from other regions are too bulky for use in the fingers,2 where they interfere with finger motion and restrict the range of motion. Furthermore, both the medialis pedis flap and the medial plantar flap provide glabrous skin and reduce unsightly scarring on the donor site, which is preferable from an esthetic perspective.6,9 Combined medialis pedis and medial plantar fasciocutaneous flaps can lessen postoperative vascular complications. The combined flaps require anastomoses of only one artery and one vein of the medial plantar vessels with recipient vessels. Postoperative vascular complications did not arise in any case in this report. A free vascularized skin flap for each finger is another surgical option; however, this requires multiple anastomoses of arteries and veins with the attendant increases in operative time,10 and the added complexity may increase the risk of postoperative vascular complications. Pedicled flaps harvested from either the finger or the dorsum of the hand may be unsuitable for soft tissue defects of multiple adjacent fingers. Pedicled flaps from the finger simply will not suffice for soft tissue defects of multiple adjacent fingers.11–13 Moreover, pedicled flaps from the finger demand uninjured skin from an adjacent finger, or an uninjured vascular network within an affected finger. Pedicled flaps from the dorsum of the hand show anatomical variations in the vascular pedicle.14,15 Such variations may lead to difficulties in achieving soft tissue coverage for multiple adjacent soft tissue defects, particularly for ulnar-sided fingers. This report did have several limitations. First, we only analyzed a relatively small number of cases in our series. Second, we only reported the experience of a single surgeon specializing in hand and microsurgery. A larger size of cases, particularly those in which this technique is performed in a general orthopedic practice, might be helpful in revealing additional surgical problems and postoperative complications that were not encountered in this series. CONCLUSIONS
Combined medialis pedis and medial plantar fasciocutaneous flaps could offer a useful option in the soft tissue
Microsurgery DOI 10.1002/micr
reconstruction of multiple adjacent fingers. Thinness and bifurcation of the combined flaps facilitate restoration of the postoperative range of motion of reconstructed fingers while also reducing the risk of postoperative complications.
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