Reconstruction of volar skin and soft tissue defects of the digits including the pulp: experience with the free SUPBRA flap.

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e9

Reconstruction of volar skin and soft tissue defects of the digits including the pulp: Experience with the free SUPBRA flap Fortune C. Iwuagwu*, Sam K. Orkar, Aftab Siddiqui St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK Received 14 January 2014; accepted 24 August 2014

KEYWORDS SUPBRA; Free tissue transfer; Glabrous skin; Reconstruction; Digits

Summary Background: The ideal flap for volar defects on the digits should provide glabrous skin, maintain length, be sensate and supple enough to allow unimpeded motion of the joints. When local flap options are either inadequate or unavailable, this constitutes a challenge that usually requires free tissue transfer. We describe our experience of the use of the free transfer of glabrous skin based on the superficial palmar branch of the radial artery (SUPBRA) for digital (volar) reconstruction. Methods: Between May 2005 and June 2011, we used this flap to reconstruct digital defects in 13 patients with mean age of 40.1 years (range 18e68 years) and a follow up range from 0.7 to 3.5 years (mean 1.5 years). The dimension of the flaps ranged from 2 5cm to 2 10 cm. The indications for surgery included traumatic loss of tissue/amputation, severe pulp space infection, dog bite injury, crush injury/ischaemic loss and salvage of failed local flap. The donor site was closed directly in all cases. Results: There were no flap failures. All wounds healed with good functional outcomes with ideal tissue match, minimal donor site morbidity and return of protective sensation despite no neurorrhaphy performed except in one patient. Conclusion: The free SUPBRA flap has many advantages, approaching ideal replacement for the volar tissues of the fingers, excellent tissue match, minimal donor site morbidity with an excellent camouflaged scar in the mid palmar crease, one operation field, non sacrifice of a major vessel, can be made ‘sensory’, neurotises well and offers a single site for rehabilitation. We believe that the free SUPBRA flap is a very reliable and useful option in the armoury of the reconstructive hand surgeon. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex, CM1 7ET, United Kingdom. Tel.: þ44 1245516127; fax: þ44 1245 515223. E-mail addresses: [email protected], [email protected] (F.C. Iwuagwu). http://dx.doi.org/10.1016/j.bjps.2014.08.064 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Iwuagwu FC, et al., Reconstruction of volar skin and soft tissue defects of the digits including the pulp: Experience with the free SUPBRA flap, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.08.064

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Introduction Medium to large defects of the volar soft tissue of the fingers continue to present a therapeutic challenge.1 Small defects are usually managed by dressings only, skin grafts or with local flaps.2,3 Even for these smaller defects, improperly executed local flaps may fail creating larger defects that require salvage. According to the dictum of Harold Gilles which is replacing ‘like for like’,4,5 the ideal replacement for volar skin loss on the digits should provide padding or cushion, have a good colour and texture match, be sensate or have potential to be sensate, resilient, maintain length and not limit motion. Only glabrous skin can achieve this ideal but are plagued by problem of limited availability. Therefore skin for coverage of defects on the volar surface of the digits should ideally be imported from sources of ‘like tissue’ (i.e. glabrous skin) namely the same or adjacent digits, palm and soles of the feet. Glabrous skin can be provided by loco regional flaps,2,3,6,7 or free flaps from the foot and toes (toe pulp, toe web, medial plantar artery perforator flap using instep skin)8e13), or digits13,14 and palm.15e18 For the medium to large defects, pedicled homodigital3,6 or heterodigital flaps19 or pedicled flaps from the palm may be inadequate, limited in reach or compromise the function and cosmesis of the donor digits.7,13 Delayed donor site wound healing, hypertrophic scars, slower mobilisation of patient and questionable or low patient acceptance commonly complicate the use of the sole of the foot for free tissue transfer.1,13 Free tissue transfer from the palm is however non-limiting to the patient. Since the first report of the use of a free thenar flap based on the superficial branch of the radial artery in two patients by Kamei et al.,20 there have been occasional reports of this flap.15e18 We have previously reported a modification of this flap to enable the harvest of a longer flap and a more aesthetically placed donor site scar.21 This report describes in detail the surface markings, review of the anatomy, surgical technique and our long-term experience of the use of this flap in patients (n Z 13) for coverage of medium to large volar defects on the digits. Suggestion for a uniform nomenclature is also presented.

F.C. Iwuagwu et al. using a discriminator and Semmes Weinstein monofilament tests performed by the Hand therapists. Hand therapy was performed and ‘Table top flat test’ was performed on all patients at monthly intervals to monitor and confirm lack of postoperative palmar contracture. Records of range of motion at the metacarpophalangeal and interphalangeal joints in the Hand therapy notes were also collected.

Anatomy The flap is based on the superficial palmar branch of the radial artery (SUPBRA). The vascular and neural anatomy of the thenar eminence and the anatomical basis for vascularised free or island flap from this area have been elucidated by previous authors.17,22 The SUPBRA branches from the radial artery (RA) about 2.5 cm from the scaphoid tubercle. It then divides into a superficial and a deep (cutaneous or main20) branch (Figure 1a). The superficial branch supplies an area of skin over the thenar eminence which supplies the thenar flap as described by Kamei et al.20 The deep branch, which is included in some of our flaps (but ligated by Kamei et al.20), follows the axis of the mid palmar crease passing superficial to or through superficial fibres of the thenar musculature in our clinical observations peri-operatively. This deep branch sends branches into the skin (between the thenar muscle fibres) like a ‘mesentery’. It commonly ends in the superficial palmar arch or in perforators in the first web space. The pedicle is about 2 cm in length, with an average diameter of 1.4 mm (range 0.8e3 mm). In a subset of patients, the SUPBRA is larger in diameter than the continuation of the RA. Venous drainage is via the venae comitantes, superficial veins on the dorsal border of the thumb and superficial palmar veins continuing as distal forearm veins. The nerve supply is from the palmar cutaneous branch of the median nerve - PCBMN (100%), superficial radial nerve (90%) and the lateral cutaneous nerve of forearm (40%).22 In our series, it is probably only from the PCBMN.

Operative procedure

Patients and methods

Surface marking (Figure 1b and c)

From May 2005 to June 2011, 13 patients with defects on the volar aspect of the digits and/or the pulp were reconstructed with a free superficial palmar branch of the radial artery flap. We have used the flap in another 4 patients not included in this report because in these cases the flap was used for purposes other than wound cover and will be the focus of a future report. The mean age was 40.1 years (range 18e68 years) Table 1. The indications were traumatic loss of tissue and amputation (n Z 4), severe pulp space infection (n Z 3), dog bite injury with loss of pulp (n Z 1), crush injury and ischaemic loss (n Z 3), and salvage for a failed VeY flap (n Z 2). The dimensions of the flap raised ranged from 2 5cm to 2 10 cm. Neurorrapphy was performed only in one patient. Return of sensation was monitored by static 2PD

We have used various ways to surface mark or locate the SUPBRA and its continuation as the deep branch. Firstly on inspection, we have found a visible subcutaneous vein about 5e10 mm radial to the mid palmar crease to be along the line and direction of the branch (Figure 1b). A pulsation can be seen in some patients. Further still, in some of these patients, the tortuous vessel can be seen close to the origin as it traverses the distal wrist crease. Secondly on palpation, it can be felt as the ‘radial pulse’ distal to the scaphoid, as it traverses the radio carpal joint radial to the flexor carpi radialis tendon. This should not be confused with the continuation of the radial artery (terminal branch) as the latter turns dorsally towards and beneath the extensor pollicis longus (deep to the anatomical snuff box).


Summary of patient demographics and results.

S.no Patient Age/Sex Indication initials 58/F

2

JP

36/M

3

MC

42/M

4

NA

19/M

5

IH

30/M

6 7

JH JM

8 9 10 11 12 13

Severe terminal pulp space infection Volar distal phalanx, R middle finger Failed VeY fingertip reconstruction Volar distal phalanx, R index finger Severe infection post Volar R little finger flexor tenolysis and Y-Vs Complex injuries, index Volar-radial proximal and and middle fingers middle phalanx R thumb

2 10

6 mm

216

2.5

Debulking

26

6 mm/DPS

220

1

YeV contouring

28

8 mm/DLT

212

1.8

YeV contouring

28

Not measured as flap applied to side of digit 5e6 mm/DPS

92 (PIPJ and DIPJ fused)

2

Nil

90a

3.5

Not recorded DLT

245 219

0.7 2

175 Not recorded 260 188

1 1.5 1.2 0.9

Debulking y-v contouring Nil Debulking,y-v contouring Nil Nil Nil Nil

265 155

1 1.5

Debulking Nil

26

40/M 68/F

Amputated R thumb tip with exposed bone Traumatic pulp loss Failed VeY finger tip reconstruction

Volar distal phalanx L middle finger 2 6 Volar distal phalanx middle finger 27

PR LT JB PM

52/M 23/M 18/F 37/M

Dog bite injury Crush injury Amputation (radial volar oblique) Crush injury

Pulp loss on left index finger Pulp necrosis right ring finger Right index finger tip Pulp necrosis left little finger

DT SH

43/M 55/F

Crush injury Severe pulp space infection

25 6 mm/DPS 25 Not recorded 2.5 6.5 DPS 26 8 mm at 11 months Poor localisation Right middle finger pulp loss 25 DPS at 6 months Left middle finger pulp and middle 7 3 Not recorded phalanx skin loss

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GO

Flap size Sensation (S2pd/MF) AROM -degrees Follow Revision up -yr.

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Site of the defect

Reconstruction of glabrous skin defects of the digits

S 2 PD-static two point discrimination; MF e Semmes Weinstein monofilament test; DPS e diminished protective sensation (Filament markings 3.84e4.31) DLT-diminished light touch (Filament markings 3.22e3.61), Mean AROM 215.5 excluding thumb and fused joints. a Range of motion for the MCPJ and IPJ; AROM e total active range of motion e for the metacarpophalangeal eMCPJ, proximal and distal interphalangeal jointsdPIPJ and DIPJ; IPJ e interphalangeal joint).

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Table 1

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F.C. Iwuagwu et al.

Figure 1 Showing the arterial anatomy and surface marking the flap a) Schematic representation of the arterial anatomy showing the radial artery, SUPBRA and its branches. b) A visible subcutaneous vein about 5e10 mm radial to the mid palmar crease to be along the line and direction of the branch and a Doppler probe used in line of the radial pulse followed distally past the radiocarpal or wrist joint to mark out the vessel. c) Flap marked out as an oblong ‘leaf’ and subcutaneous veins on the distal forearm are marked.

Thirdly a Doppler probe in the line of the radial pulse followed distally past the radio carpal or wrist joint will mark out the vessel (Figure 1b). The flap is then designed as an ‘oblong leaf’ or curvilinear ellipse with the long axis in the direction of the mid palmar crease with a maximum width of 2 cm to enable direct closure (Figure 1c). Larger flaps can be raised but may require the use of skin grafts so in our series we have limited our design to 2 cm (except in one female patient with very supple palm) as suggested by Kamei et al.20 Finally subcutaneous veins on the distal forearm are marked out usually on the ulnar aspect of the skin paddle (Figure 1c).

Flap elevation Dissection is carried out under tourniquet control after elevation. Dissection starts proximally identifying the RA and the SUPBRA through a short incision in the most distal forearm (Figure 2a). In the situations where the SUPBRA is large, the terminal RA can be confirmed as the other vessel deviating laterally into the anatomical snuffbox. The SUPBRA is then followed distally taking care to remain beneath the deep branch especially as it traverses the level of the distal wrist crease into the palm. The radial border of the flap is incised taking care to ligate subcutaneous veins on the thenar eminence. The

incision is deepened to the fascia over the thenar muscles and then lifted ulnar wards. On the proximal half of the ulnar border of the flap, only a superficial incision is made into the upper dermis taking care to identify and preserve the subcutaneous palmar veins leading into the subcutaneous distal forearm veins (Figures. 2b and 3a). The flap is raised staying beneath the veins and the artery. Sometimes it is necessary to go through the most superficial fibres of the thenar eminence in other to include and not damage the deep branch of the SUPBRA (Figure 2b). Vigilance must be always kept for the recurrent motor branch of the median nerve. The distal connection of the pedicle to the superficial palmar arch or to other vessels in the first web space is identified and clamped with a micro clamp and the tourniquet released to check perfusion. Further technical points are i) The deep branch of the SUPBRA gives branches all along its course to the overlying skin as a mesentery (Figure 1a). We therefore believe that by incorporating more distal branches, the longer the length of the flap that can be harvested. ii) the SUPBRA is ligated flush with the RA to maximise pedicle length. iii) a good length of distal forearm vein is dissected to enable an easier anastomosis to a more proximal and therefore larger vein close to the web space (Figures.


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Figure 2 Operative series a.) The terminal RA can be differentiated from a large SUPBRA as the vessel deviating laterally into the anatomical snuffbox. b.) Ulnar and radial borders incised. But along the ulnar proximal border made superficially in order to identify and preserve the subcutaneous palmar veins leading into the subcutaneous distal forearm veins. Deep branch is seen on the under surface of the flap. c) Flap detached showing the much longer distal forearm veins (used for their larger calibre and intention to anastomose them to more proximal and larger veins close to web space) peripherally and the SUPBRA/vena commitantes in the middle of the photograph.

2c and 3a,b). Usually the arterial anastomosis is done first and the vein with the most prominent back flow is used for the venous anastomosis. Other times, two veins are used. The recipient vessels were the digital artery and the proximal dorsal digital and distal dorsal hand veins in all cases. iv) When the tourniquet is released, the flap becomes engorged with blood. This often necessitates loose in setting of the flap and sometimes split skin graft from the hypothenar eminence over the loose fatty areolar tissue covering the pedicle.

Results The results are summarised in Table 1. There have been no flap losses. Four patients have required a de-bulking and refining of shape of the flaps. The mean follow up was 1.5 years (range 0.7e3.5 years). Aesthetically and functionally, all the reconstructions have been very satisfactory with all patients returning to premorbid activities with no restrictions. The mean total active range of motion was 215.50 (excluding the thumb and digits with fused joints).

We present three representative cases. Case 1 e Mrs GO was 58 years, diabetic, with severe terminal pulp space and volar soft tissue infection with skin and soft tissue loss over the distal and middle phalanges. The terminal phalanx and flexor tendons were exposed. She was referred from an orthopaedic unit following her refusal of an amputation, with a request of ‘is there anything you can do for her?’ She had further debridement and subsequent reconstruction with a free SUPBRA flap (2 10 cm). (Figure 4) Case 2 e Mr MC was a healthy forty-two years man, who underwent flexor tenolysis and release of contracture with YeV flaps. He developed severe infection with necrosis of the flaps. Following debridement, he was reconstructed with a free SUPBRA flap. (Figure 5) Case 3 e IH, a 30-year old man suffered amputation of the right thumb (at work) at the level of the proximal third of the distal phalanx. With exposed remnant of distal phalanx (circumferentially), a free SUPBRA flap and neuroraapphy of a branch of the palmar cutaneous branch of the median nerve to the radial digital nerve was used to preserve the length of the remaining thumb and avoid shortening the bone to achieve soft tissue cover (Figure 6).


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F.C. Iwuagwu et al.

Figure 3 Operative series a) Schematic representation of flap elevation. It shows a defect over the distal and middle phalanges of the middle finger, digital artery to be used for anastomosis, skin flap raised with the pedicle (SUPBRA and a distal forearm vein) in continuity. The distal forearm vein is freed by subcutaneous dissection and stepwise stab incisions and not by lifting a large flap of forearm skin as shown in the diagram. It is shown like this for the reader to appreciate the continuity of the proximal palmar veins in the flap, which continue into the distal forearm veins. b) Dorsum of the hand showing one of the larger calibre proximal dorsal digital veins (than the volar veins) for venous anastomosis. The long vein in the pedicle is easily passed subcutaneously to the dorsum. Usually a single triangular flap or a lazy ‘S’ incision is used to expose the dorsal veins. Here in this diagram, flaps are elevated to help the reader grasp the operative technique.

Discussion We have presented our experience so far with the free SUPBRA flap, which provides a very useful option for a difficult problem. Kamei et al.20 who described the first two cases termed it the free thenar flap. However, there is

confusion in the use of this term ‘free thenar flap’ in the nomenclature of palmar flaps raised from this arterial axis. There is an earlier report of a “free thenar flap” based on the radial artery of the thumb14 which is different from the free thenar flap based on the SUPBRA like our series.17,18,20 Similarly Sassu et al.18 reported on 14 cases of

Figure 4 CASE 1 a) Skin and soft tissue loss over the distal and middle phalanges with exposed terminal phalanx and flexor tendons b) The post operative appearance with darkened or ‘pigmented’ pulp is probably due to the fact that patient has a very pigmented skin (black patient).


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Figure 5 CASE 2 a) Wound debrided and flap marked out or designed as a ‘leaf’ or curvilinear ellipse with the long axis in the direction of the mid palmar crease. b) Volar view 13 months post operatively having also undergone secondary surgery (YeV flaps) to debulk flap.

free thenar flap but the review shows that in seven of those cases, the pedicle was an unnamed or independent branch of the radial artery about 2 cm proximal to the origin of the SUPBRA. Even in our series, the anatomical area of our skin paddle includes the ‘hypotheanar-thenar area’ and the palmar triangle. To reduce this confusion we have suggested that the flap is named based on the arterial supply rather than the anatomical area from which it has been raised hence the title of the paper23,24). Recently other authors have used similar eponyms to describe this flap.25 We have made some beneficial modifications. Firstly the use of the deep branch of the SUPBRA allows a much longer length of flap (if needed) to be used, than with previous reports using a maximum flap length of 2.5 cme6.5 cm18,20). Secondly, other authors used venae comitantes or volar superficial veins of the thenar eminence for the venous anastomosis18,20 but we have found them fragile and short. We prefer to use the proximal dorsal veins of the digits and distal veins on the dorsum of the hand as recipient veins. As our defects are primarily on the distal half of the digit, we harvested the longer and larger subcutaneous veins of the forearms.

Thirdly, our design of the flap is shaped like a ‘leaf’ (commonly oblong) with the rib of the leaf in the direction of the mid-palmar crease. This enables easy direct closure. Fourthly, we design the flap to be more ‘central’ and leave the donor site scar more central, similar to and in the normal axis of the mid palmar crease which creates a more aesthetically pleasing/positioned scar in the palm. In some cases the scar is barely perceptible (Figure 7). Other flap designs have been very radial leading to more obvious donor site scars on the thenar eminence.17,18 It is interesting that without neuroraapphy (except in one patient), there has been significant functional sensory recovery, as previously shown in pedicled thenar flaps27 and distal thenar perforator based island flap.28 This is as a result of neurotisation and is likely better because of the proximity of the donor site to the recipient bed with an excellent tissue match and a high density of nerve receptors on the tips of the digits. We therefore routinely do not find any nerve anastomosis essential both in free tissue transfer and in the pedicled version of the flap.29 A concern of possible palmar contractures was not borne out, with all patients able to perform the ‘Table top flat test’ (placing the palm fully flat on a table). This is

Figure 6 CASE 3 a) Amputation with loss of the amputate with exposure of the distal phalanx b) Thumb after debulking of the flap 13 months post operatively.


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F.C. Iwuagwu et al. in almost all cases to 2 cm with the palm relaxed. It is possible to harvest larger (width) flaps and close directly in patients with supple skin or skin graft the donor site17,18 and may be excise the graft later. It avoids the ‘aesthetic morbidity’ from toe flaps especially in females or donor site morbidity from instep flaps. And will normally reserve this donor site (foot) as a second choice to the palm for these sizes of defects. We conclude that it is an excellent option to be considered for medium to large volar defects on the digits and is our preferred option for finger pulp reconstruction if free tissue transfer is indicated.

Ethical approval N/A. Figure 7 Aesthetically placed scar in the ‘mid palmar crease’ (patient in the operating theatre for debulking of flap 12 months post operatively by means of YeV plasties).

understandable as the skeleton being intact re-stretches the soft tissues of the palm. Scar treatments including the use of silicone gel sheet have been adequate as reported by others.26 There are however concerns with this flap. The short forearm incision leaves a more visible scar, which fortunately has settled well in our patients and is on the ‘hidden’ volar surface of the forearm. Potential injury to the recurrent motor branch of the median nerve and a short pedicle are also minuses. The bulkiness of the flap may necessitate debulking/contouring procedures. This bulkiness as is expected with any non-local flap to the digits, can interfere with mobilisation and range of motion afterwards in these patients who are already compromised from the severe injury, pain, swelling and immobilisation before the reconstruction. Hence adequate hand therapy post operatively cannot be overemphasised. Most of the recorded ranges of motion were taken in the early months postoperatively and patients continued to be followed up for more than 6 months after this record, without any further documentation of range of motion in the notes. All our patients were reported to have gone back to work or having a ‘full use of the hand’ in the hand therapy notes. Despite the above challenges, the free SUPBRA flap has many advantages, approaching ideal replacement for the volar tissues of the fingers. It provides excellent tissue match (colour and resilience), ample soft tissue restoring bulk and contour of pulp and volar aspect of digits, minimal donor site morbidity with an excellent camouflaged scar in the mid palmar crease which is ‘hidden’ in the palm (as opposed to the dorsum of the hand, which is the commonly exposed and visible part of the hand), one operation field, non sacrifice of a major vessel, can be made ‘sensory’,17 neurotises well and offers a single site for early rehabilitation (within a week). It can be moulded or inserted properly over the defect unlike the pedicled flaps with a limited reach or a need to flex the finger with consequent stiffness and contracture.27 This allows larger defects to be covered. In our series, all the donor sites were closed primarily limiting the flap width

Funding We declare that there is no role of study sponsors, in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Conflict of interest None.

Acknowledgements We are grateful to Mr. Niri Niranjan, Consultant Plastic and Reconstructive Surgeon, St Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford for the schematic drawings of the arterial anatomy and operative technique.

References 1. Garg R, Fung BK, Chow SP, Ip WY. A Free thenar flap e a case report. J Orthop Surg Res 2007;2:4. 2. Tranquilli-Leali E. Ricostruzione dell’apice delle falangi ungueali mediante autoplastica volare peduncolata per scorrimento. Infort Traum Lavaro 1935;1:186e93. 3. Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated fingertip with a triangular volar flap. A new surgical procedure. J Bone Jt Surg Am 1970; 52(5):921e6. 4. Sommerlad BC, McGrouther DA. Resurfacing the sole: long term follow up and comparison of techniques. Br J Plast Surg 1978; 31:107e16. 5. Levin LS, Seraffin D. Plantar skin coverage. Prob Plast Reconstr Surg 1991;1:156e84. 6. Venkataswami R, Subramanian N. Amputations of the fingertip and thumb. Plast Reconstr Surg 1980;66(2):296e300. 7. Seyhan T. Reverse thenar perforator flap for volar hand reconstruction. J Plast Reconstr Surg 2009;62:1309e16. 8. May Jr JW, Chait LA, Cohen BE, O’Brien BM. Free neurovascular flap from the first web of the foot in hand reconstruction. J Hand Surg 1977;2:387e93.


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Reconstruction of glabrous skin defects of the digits 9. Minami A, Usui M, Katoh H, Ishii S. Thumb reconstruction by free sensory flaps from the foot using microsurgical techniques. J Hand Surg 1984;9B:239e44. 10. Zuker RM, Manktelow RT. The dorsalis pedis free flap: technique of elevation, foot closure and flap application. Plast Reconstr Surg 1986;77:93e102. 11. Kato H, Ogino T, Minami A, Usui M. Restoration of sensibility in fingers repaired with free sensory flaps from the toe. J Hand Surg 1989;14A:49e54. 12. Morrison WA, O’Brien BM. Thumb reconstruction with a free neurovascular wrap around flap from the big toe. J Hand Surg 1980;5:575e83. 13. Turner A, Ragowannsi R, Hanna J, Teo TC, Blair JW, Pickford MA. Microvascular soft tissue reconstruction of the digits. J Plast Reconstr Aesthet Surg 2006;59:441e50. 14. Tsai TM, Sabapathy SR, Martin D. Revascularisation of a finger with a thenar mini-free flap. J Hand Surg Am 1991;16(4):604e6. 15. Kamei K, Shimada K, Kimura T, et al. Substantial volar defects of the fingers treated with free thenar flaps. Scand J Plast Reconstr Surg Hand Surg 1997;31:87e90. 16. Pilz SM, Valenti PP, Harguindeguy ED. Free sensory or retrograde pedicled fasciocutaneous thenar flap: anatomic study and clinical application. Handchir Mikrochir Plast Chir 1997; 29:243e6 [German]. 17. Omokawa S, Mizumoto S, Iwai M, et al. Innervated radial thenar flap for sensory reconstruction of the fingers. J Hand Surg Am 1996;21:373e80. 18. Sassu P, Lin CH, Lin YT, Lin CH. Fourteen cases of free thenar flap: a rare indication in digital reconstruction. Ann Plast Surg 2008;60(3):260e6. 19. Gurdin M, Pangman J. The repair of surface defects of fingers by transdigital flaps. Plast Reconstr Surg 1950;5(4):368e71.

9 20. Kamei K, Ide Y, Kimura T. A new free thenar flap. Plast Reconstr Surg 1993;92(7):1380e4. 21. Iwuagwu Fortune C, Orkar Sam K, Siddiqui Aftab. Free superficial palmar branch of the radial artery flap for the reconstruction of defects of the volar surface of the digits, including the pulp. Plast Reconstr Surg February 2013;131(2):308ee9e. 22. Omokawa S, Ryu J, Tang JB, et al. Vascular and neural anatomy of the thenar area of the hand: its surgical applications. Plast Reconstr Surg 1997;99:116e21. 23. Orkar K, Iwuagwu F. Free thenar flap for the reconstruction of defects on the volar surface of the digits. Winter meeting. London: BAPRAS, The Royal College of Surgeons; 5e7 December 2007. 24. Iwuagwu F. Palmar flap based on the superficial palmar branch of the radial artery for reconstruction of digital defects, British Society for Surgery of the Hand Autumn Meeting, Nottingham, 12e13 November 2009. 25. Lee TP, Liao CY, Wu IC, Yu CC, Chen SG. Free flap from the superficial palmar branch of the radial artery (SPBRA flap) for finger reconstruction. J Trauma 2009;66(4):1173e9. 26. Kim KS, Hwang JH. Radial midpalmar island flap. Plast Reconstr Surg 2005;116:1332e9. 27. Melone Jr CP, Beasely RW, Carstens Jr JH. The thenar flap: an analysis of its use in 150 cases. J Hand Surg 1982;7:291e7. 28. Kim KS, Kim ES, Hwang JH, Lee SY. Thumb reconstruction using the radial midpalmar (perforator based) island flap (distal thenar perforator based island flap). Plast Reconstr Surg 2010; 125:601e8. 29. Iwuagwu F, Siddiqui A. Pedicled (antegrade) SUPBRA flap e for wound cover on volar aspect of thumb. J Plast Reconstr Aesthet Surg May 2012;65(5):678e80.


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