Fascial Flap Reconstruction of the Hand a Single.25[1]

HAND/PERIPHERAL NERVE

Fascial Flap Reconstruction of the Hand: ASingle Surgeon’s 30-Year Experience

Matthew J. Carty, M.D.Amir Taghinia, M.D.Joseph Upton, M.D.

Boston, Mass.

Background: The reconstruction of complex hand wounds is challenging dueto the requirements for thin and pliable coverage with a reliable vascular supply,potential for sensibility, and provision of a gliding surface. Fascial flaps representan excellent option for the reconstruction of these complicated defects.Methods: A retrospective review of fascial flap reconstructive procedures to thehand undertaken by a single microsurgeon was performed for operations oc-curring between 1979 and 2009. Both pedicled and free tissue transfer proce-dures were included in both pediatric and adult patients. Data were culled froma combination of patient charts, hospital records, radiographic studies, andclinical photographs.Results: Sixty fascial flap reconstructive procedures to the hand were analyzedin 60 patients from the defined 30-year period. The most common pathologicalprocess necessitating reconstruction was acute trauma (n � 32, 53 percent).Most of the soft-tissue injuries included in the study sample were located on thedorsal hand and wrist (n � 27, 45 percent). The most commonly utilizedreconstructive modality was the temporoparietal fascial flap (n � 35, 58 per-cent). Most reconstructions were completed as free tissue transfers (n � 46, 77percent). Perioperative complications were relatively minor; no flap losses wererecorded. All cases studied demonstrated excellent long-term coverage with noevidence of underlying tendon adhesion or contracture.Conclusion: Fascial flaps represent an excellent option for coverage of soft-tissue defects of the hand that are not amenable to reconstruction with skingrafting alone, particularly for localized defects with denuded tendons or ex-posed joints. (Plast. Reconstr. Surg. 125: 953, 2010.)

Complex hand wounds are characterized bysignificant soft-tissue loss with variable ex-posure of bones and/or joints, lacerated

tendons, and neurovascular structures. Althoughoften small in size and localized to a discrete an-atomic region, these defects are not amenable tosimple closure or skin grafting alone. Fascial flapsare well suited to meet these reconstructive needsbecause they provide a thin, pliable, and mobilereconstructive substrate with a reliable vascular

supply, potential for sensibility, and—most impor-tantly—a gliding surface to facilitate tendon andjoint mobility.

The advantages of fascial flap reconstructionto the hand are well recognized. No fewer than 10discrete fascial harvest sites have been delineatedfor both pedicled and free tissue transferreconstruction.1–9 Despite this fact, fascial flapsremain an infrequently utilized method of cover-age for complex hand reconstruction, with no re-ports of long-term patient outcomes published todate. This report seeks to reemphasize the poten-tial benefits of this surgical option by reviewing the30-year experience of a single surgeon performingfascial flap reconstruction for complex hand in-juries and to offer lessons learned from this lon-gitudinal perspective.

From the Department of Surgery, Brigham and Women’s/Faulkner Hospital, Harvard Medical School; Department ofSurgery, Children’s Hospital Boston, Beth Israel DeaconessMedical Center, Harvard Medical School; and Departmentof Surgery, Children’s Hospital Boston, Shriner’s HospitalBoston, Harvard Medical School.Received for publication May 27, 2009; accepted September15, 2009.Presented at the American Association of Plastic Surgeons88th Annual Meeting, in Rancho Mirage, California,March 23, 2009.Copyright ©2010 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181cc964c

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

www.PRSJournal.com 953

METHODSA retrospective review was performed of all

pedicled and free fascial flap procedures for up-per extremity reconstruction completed by thesenior author between 1979 and 2009. Both pe-diatric and adult patients were included in theanalysis; all procedures were performed in one ofthree academic institutions. Data were culled froma combination of patient charts, radiographicstudies, and clinical photographs and assessed todetermine general characteristics, as well as clin-ical, functional, and aesthetic outcomes andtrends. Data included patient age at the time ofreconstruction, anatomic location of injury, de-tails regarding the type of reconstructive proce-dure, and complications, both early and late. Onlypatients with compete follow-up data were in-cluded. The recorded reconstructive parametersincluded choice of donor tissue, recipient vessels,and all secondary procedures. Complications in-cluded early problems, such as hematoma or se-roma formation, delayed or problematic woundhealing, operative site infection, and anastomotsisfailure, as well as late issues, including scar con-tracture, tendon adhesion, neuroma formation,and contour problems.

RESULTSA total of 60 consecutive reconstructive pro-

cedures performed in 60 separate patients wereanalyzed from the defined 30-year period (Table1). The sample population included 44 males (73percent) and 16 females (27 percent), with anaverage age of 35 � 19 years. The vast majority ofpatients included in the study sample were adults(�18 years of age) at the time of reconstruction(n � 50, 83 percent). The most common patho-logical process requiring hand reconstruction wasacute trauma (n � 32, 53 percent), followed bylate contracture following acute trauma (n � 10,17 percent), malignancy (n � 7, 12 percent), con-genital deformity (n � 4, 7 percent), thermal in-jury (n � 4, 7 percent), Dupuytren contracture(n � 2, 3 percent), and vascular malformation(n � 1, 2 percent). Most of the soft-tissue injuriesincluded in the study sample were located on thedorsal hand and wrist (n � 27, 45 percent), fol-lowed by the first webspace and/or thumb (n �19, 32 percent), volar hand and wrist (n � 11, 19percent), and central hand (n � 3, 5 percent).

Within the study patient population, the mostcommonly utilized reconstructive modality wasthe temporoparietal fascial flap (n � 35, 58 per-cent), followed by the radial forearm fascial flap

(n � 16, 27 percent), first dorsal metacarpal arteryfascial flap (n � 6, 10 percent), and tensor fasciaelatae flap (n � 3, 5 percent). Most reconstructionswere completed as free tissue transfers (n � 46, 77percent), while the remainder were performed aseither transposition or pedicled island flaps (n �14, 23 percent). Nearly all of the fascial flap re-constructions included an overlying split-thick-ness skin graft (n � 52, 87 percent), while theremainder incorporated a cutaneous island in theflap design (n � 8, 13 percent).

Short-term perioperative complications werenoted to be relatively minor and included minorwound dehiscence (n � 2, 3 percent) and delayedwound healing (n � 2, 3 percent). Although twopatients (3 percent) required emergent reopera-tion for venous occlusion of the vascular pediclewithin the first 48 hours postoperatively, flap sal-vage was achieved in both cases; no flap or skingraft losses were recorded. One patient (2 percent)suffered a pulmonary embolus approximately 1week after reconstruction that necessitated readmis-sion for heparinization and subsequent long-termanticoagulation. Three patients (5 percent) dem-onstrated scar widening and transient alopecia atthe flap harvest site, one of whom (2 percent)required eventual operative scar revision. All cases

Table 1. Summary of Results

Characteristic Value

Total no. of patients 60Male, n (%) 44 (73)Mean age, years (SD) 35 (19)Indication for reconstruction, n (%)

Acute trauma 32 (53)Late contracture following trauma 10 (17)Malignancy 7 (12)Congenital deformity 4 (7)Thermal injury 4 (7)Dupuytren contracture 2 (3)Vascular malformation 1 (2)

Location of reconstruction, n (%)Dorsal hand and wrist 27 (45)First webspace and/or thumb 19 (32)Volar hand and wrist 11 (19)Central hand 3 (5)

Type of reconstruction, n (%)Temporoparietal fascial flap 35 (58)Radial forearm fascial flap 16 (27)First dorsal metacarpal artery flap 6 (10)Tensor fasciae latae flap 3 (5)

Free tissue transfer, n (%) 46 (77)Skin graft included, n (%) 52 (87)Complications, n (%)

Alopecia 3 (5)Minor wound dehiscence 2 (3)Delayed wound healing 2 (3)Reoperation for venous occlusion 2 (3)Pulmonary embolus 1 (2)Flap loss 0 (0)Procedure-related death 0 (0)

Plastic and Reconstructive Surgery • March 2010

954

studied demonstrated excellent long-term cover-age, flap pliability, and contour with no evidenceof underlying tendon adhesion or contracture atthe flap site.

DISCUSSIONBoth large and strategically placed small, com-

plex open wounds of the hand may representunique reconstructive challenges. Beyond theconsideration for soft-tissue coverage, the surgeonmust recognize the complex functional concernsrelevant to the zone of injury and strive to includethese priorities in his or her operative plan. Theseare more than simple lacerations and includecomposite loss or injury to bone, joint, tendon,artery, vein, nerve, and skin. In addition, the spe-cialized nature of hand sensibility and joint mo-tion represent higher-order functional concerns.

The development of both pedicled and freeflaps incorporating fascial components has paral-leled the evolution of fasciocutaneous and myocu-taneous flaps. Well-described fascial flap options cur-rently include the radial forearm,10–13 serratusanterior,14–17 dorsal metacarpal,18–23 lateral arm,24–27

temporoparietal,28–30 dorsal ulnar forearm,31,32 ten-sor fasciae latae,33,34 dorsal thoracic,35,36 and pos-terior interosseous,37,38 each of which poses relativeadvantages and disadvantages (Table 2). Thesmooth, areolar quality of the specialized connectivetissue on the surface of fascia provides the idealsurface for tendon gliding and joint motion. Fascialstrength, thinness, and pliability produce coveragesuperior to more traditional composite flaps, whichrequire multiple secondary revisions, particularly inobese patients. Maximum pliability and thinness areoften achieved with the use of full-thickness or thicksplit-thickness skin grafts, glabrous for the palmarsurface, and nonglabrous for the dorsal surfaces.

The primary indication for use of these fascialflaps was to provide coverage for full-thickness skinloss, complex wounds with exposed hardware,fractures, denuded bones or joints, nerve, andtendon repairs and intrinsic muscles. Althoughtemporary vacuum-assisted closure dressings mayhave been used to improve the vascularity of thewound bed, simple autograft coverage and/orsubsequent contracture in these hands would re-quire later resurfacing and many secondary re-visions. Two-thirds of the transfers were per-formed within 2 weeks of the injury, while theremaining were completed as secondary re-constructions for congenital differences, Du-puytren dissections, and following releases ofdifficult joint contractures.

The major flaw of this type of clinical study isthat every clinical case is different and there are noprecise control groups in which other modalitiesfor coverage were used. All of the procedures wereperformed by the senior author, who during thesame period of time used most of the pedicled andfree transfers of fasciocutaneous, musculocutane-ous, and muscle flaps described in the literaturefor similar purposes. With fascial transfers, single-stage coverage is possible, and there is no adher-ence to underlying nerve, tendon vascular, or skel-etal repairs; the augmented yet thin contour andlow-friction interface provided by fascial flaps pro-vide a superior functional and aesthetic result.

For defects involving the dorsum of the handor palmar surfaces, our initial choice has been thefree temporoparietal fascial flap. This flap can beextended to cover the entire metacarpal portionof the hand (Fig. 1). Although critics of this tech-nique have correctly noted the technically de-manding dissection and unreliable peripheralmargins of this flap, we have found this to be oneof the most useful, robust, and versatile of all fas-cial flaps. The typical vascular anatomy of the tem-poroparietal fascial flap, as well as its variants, hasbeen well described and tends to provide a pre-dictably robust pedicle both in terms of caliberand length.39 In addition, the independently vas-cularized bilaminar nature of the temporoparietalfascia permits its use as a “sandwich” flap to pro-vide a circumferential gliding bed for exposedtendons in a manner offered by few other flapdesigns (Figs. 2 and 3).40 On the palmar surfaces,it can be used simultaneously for revascularizationand resurfacing of one or two digits. Careful har-vest of this tissue and meticulous attention to de-tail render the donor-site extremity inconspicuouswithin the hair-bearing scalp. Incision placementmust be more posterior in young boys likely todevelop male patterned baldness similar to theirbiologic fathers. Another distinct advantage of thescalp donor site in comparison with others listedis the distinct paucity of adipose tissue adjacent tothe fascial layers in both adults and children. Thesensory potential through the auriculotemporalnerve renders this tissue ideal on the glabroussurfaces of the palm or digit.

Depending on the size and nature of thewound, our favored options for first webspace andthumb soft-tissue reconstruction have been eitherthe first dorsal metacarpal artery flap or the re-verse-pedicled radial forearm fascial flap. Smallwounds within the first webspace or thumb basethat are not amenable to primary closure, Z-plasty,or skin grafting are well served by the first dorsal

Volume 125, Number 3 • Fascial Flap Reconstruction of the Hand

955

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956

metacarpal artery flap, which is easily dissectedand provides excellent vascularized local fascialtissue with minimal donor-site morbidity. Largerdefects or those involving the first dorsal meta-carpal artery territory, however, typically requirethe greater degree of coverage that is provided bythe radial forearm fascial flap (Fig. 4). As is welldescribed, the radial forearm fascial flap is char-acterized by a straightforward harvest dissection

that can be performed under operative tourniquetcontrol in 1 hour and offers the possibility of in-clusion of both neurosensory and tendon units tofacilitate true composite tissue reconstructiveefforts.41 Although our preference in the past hasbeen to reconstruct radial-sided inflow to the handfollowing either pedicled or free tissue transfer ofthe radial forearm fascial flap with an interposi-tion vein graft to limit donor-site morbidity, tech-

Fig. 1. Chronicle of first reported case utilizing temporoparietal fascial flap for hand reconstruction. (Above, left) A 56 year-old-manpresented with large dorsal hand squamous cell carcinoma. (Above, center) Resection resulted in large dorsal wound with exposedbone and extensor loss. (Above, right) A temporoparietal fascial flap was harvested. (Below, left) The flap was inset with an overlyingsplit-thickness skin graft. (Below, center and below, right) At 30-year follow-up, the patient demonstrates excellent flap contour andsuppleness.


957

Fig. 3. Same patient as shown in Figure 2. At 10-year follow-up, the pa-tient demonstrated normal extrinsic extensor glide and function.

Fig. 2. Sandwich temporoparietal fascial flap reconstruction of extensor retinaculum. (Left) A 32-year-old man presentedwith severe extensor tendon adhesions following traumatic injury several years earlier. Two prior tenolysis procedureshad failed. (Center) Extrinsic extensor system following extensive tenolysis. (Right) Template design for bilaminar tem-poroparietal fascial flap providing simultaneous volar gliding surface and extensor retinaculum reconstruction.


958

niques permitting preservation of the native radialsystem in the setting of pedicled flap harvesthave recently been described.42 Later in this se-ries, we used less temporoparietal fascial flaps inlieu of the radial forearm fascial, which is mucheasier to dissect and does not require microvas-cular expertise.

Specialized surfaces of the hand are ideallyreplaced with “like” tissue. Thick split-thicknessgrafts were usually harvested from nonglabroussurfaces on the anterior thigh or buttock regions,full-thickness grafts from the groin or inner armareas, and glabrous split-thickness grafts from thehypothenar regions of either the hand or the insetof the foot under special circumstances. The filmy,

areolar layer of the fascial surface was placed ad-jacent to the mobile tendon, joint, or nerve andthe outer layer covered with the skin graft. Sheet,nonmeshed grafts are preferred for both large andsmall surfaces. We recorded no cases of skin graftfailure. Laminated skin grafted fascial surfaceswere preferred to bulky, composite fasciocutane-ous flaps due to the thin, pliable characteristics ofthese surfaces. The latter, however, may be quiteacceptable in thin individuals with no subcutane-ous adipose tissue.

All of the carefully selected patients in thisseries demonstrated excellent functional and aes-thetic outcomes. Although joints were initially im-mobilized in the extremes of motion (i.e., full

Fig. 4. Pedicled radial forearm fascial flap reconstruction to thumb. (Above, left) A 57-year-old male carpenter sustained anindustrial router injury to the left thumb, including loss of dorsal skin and the majority of extensor pollicis longus, with exposureof the underlying proximal phalanx. (Above, second from left) A radial forearm fascial flap was harvested. (Above, second from right)The flap was inset over the pollicis longus interposition tendon graft reconstruction of the extensor pollicis longus. (Above, right)Appearance of the flap with the overlying split-thickness skin graft. (Below) Appearance at 8-month follow-up. The patient wasback to work within 6 weeks after reconstruction.


959

extension on the palmar surfaces and full flexionover the dorsal surfaces of the wrist, hand, or dig-its), restoration of adequate range of motion wasnoted to be readily achievable in time with ag-gressive postoperative occupational therapy. Verydurable skin coverage and more than satisfactorytendon gliding and joint mobility were recordedin almost all of these patients. The need for sec-ondary revisions of six of these patients was due to

extensive crushing injuries or the loss of anatomicstructures, such as bone, joints, tendons, andnerves, in the context of the original traumaticevent. There were no problems making incisionsthrough and dissecting beneath these flaps. Fi-nally, many of patients within this study sampleregained protective sensibility with a moving2-point discrimination of 8.0 mm. The return ofsensibility proceeded inward from the periphery

Fig. 5. Sensate temporoparietal fascial flap reconstruction to palm. (Above, left) A 24-year-old male printer sustained a severe roller press injury to right hand. (Above, right)Temporoparietal fascial flap harvest included the auriculotemporal nerve that was co-apted to the palmar cutaneous nerve. (Below, left) The flap was inset with an overlyingsplit-thickness skin graft. (Below, right) Appearance at 25-year follow-up. The patient hassince returned to work as a printer.


960

of the skin graft toward the center of the defect.When auriculotemporal nerve junctures were per-formed with the temporoparietal fascial flap, aproximal to distal reinnervation of the overlyingskin graft was observed (Fig. 5).

This study lends credence to the notion thatfascial flaps, either as pedicled or as free tissuetransfers, should be considered as the reconstruc-tive option of choice for many small or large com-plex defects of the hand. When first describedmore than 20 years ago, we did not think thesealternatives were applicable to most hand sur-geons. However, armed with a greater knowledgeof fascial anatomy, microvascular training, and theexperience and advice of older surgeons, ouryounger surgeons in training are now able to per-form these transfers—especially the pedicledtransfers—very reliably. These flaps offer the high-est probability of optimizing both functional andaesthetic outcomes for some very complexwounds. Fastidious preoperative planning and ad-herence to basic tenets learned through experi-ence should render flap failure a rare occurrence.Our lessons learned include the following:

1. Always convert a micro case to a macro case.The smallest donor or recipient vesselsshould not be smaller than 1.2 mm in diam-eter.

2. Wound stability must be achieved before re-construction, including debridement of alldevitalized tissues and restoration of handvascularity. Reconstruction need not neces-sarily be performed acutely but should ide-ally be completed within 10 to 14 days ofinjury.

3. Preoperative planning must include carefulconsideration of those tissues and functionsrequiring restoration, including assessmentof skin type (i.e., glabrous versus nongla-brous), sensibility patterns, and motion vec-tors.

4. Normal hand anatomic relations (e.g., re-lease of contractures) must be reestablishedbefore flap design is undertaken. The tissuecoverage requirement is almost alwaysgreater than initially expected and must in-corporate a three-dimensional conceptual-ization of the defect.

5. Meticulous dissection under loupe magnifi-cation is critical and should be performedunder operative tourniquet control, whenpossible, to avoid bloody staining of the op-erative field and target fascia.

6. Avoidance of flap dessication during harvest

is crucial to preventing marginal necrosis offlap edges in the postoperative period; keepthe donor tissue well-hydrated, particularlywhen it is under the heat of direct operativelighting.

7. When possible, the quality of grafted skinshould match that of the surrounding recip-ient surface (i.e., glabrous versus nongla-brous) and should ideally be placed as anonmeshed sheet graft to optimize long-term function and appearance.

8. Postoperative immobilization for 2 to 3weeks is crucial for appropriate flap andgraft incorporation.

9. Aggressive occupational therapy is necessaryfor mobilization of moving structures.

Matthew J. Carty, M.D.Brigham and Women’s Hospital Plastic Surgery at

Faulkner Hospital1153 Centre Street

Jamaica Plain, Mass. [email protected]

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musculocutaneous flap. Ann Plast Surg. 1978;1:372–379.2. Foucher G, Braun JB. A new island flap transfer from the

dorsum of the index to the thumb. Plast Reconstr Surg. 1979;63:344–349.

3. Song R, Song Y, Yu Y, et al. The upper arm free flap. Clin PlastSurg. 1982;9:27–35.

4. Reid CD, Moss LH. One-stage flap repair with vascularizedtendon grafts in dorsal hand injury using the “Chinese” fore-arm flap. Br J Plast Surg. 1983;36:473–479.

5. Upton J, Rogers C, Durham-Smith G, et al. Clinical applica-tions of the free temporoparietal flaps in hand reconstruc-tion. J Hand Surg (Am.) 1986;11:475–483.

6. Wintsch K, Helaly P. Free flap of gliding tissue. J ReconstrMicrosurg. 1986;2:143–151.

7. Becker C, Gilbert A. The ulnar flap. Handchir Mikrochir PlastChir. 1988;20:180–183.

8. Zancolli EA, Angrigiani C. Posterior interosseous island fore-arm flap. J Hand Surg (Br.) 1988;13:130–135.

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10. Jones NF, Jarrahy R, Kaufman MR. Pedicled and free radialforearm flaps for reconstruction of the elbow, wrist andhand. Plast Reconstr Surg. 2008;121:887–898.

11. Wilson IF, Schubert W, Benjamin CI. The distally basedradial forearm fascia-fat flap for treatment of recurrent deQuervain’s tendonitis. J Hand Surg (Am.) 2001;26:506–509.

12. Cherup LL, Zachary LS, Gottlieb L, et al. The radial forearmskin graft-fascial flap. Plast Reconstr Surg. 1990;85:898–902.

13. Chang SM. The distally based radial forearm fascia flap. PlastReconstr Surg. 1990;85:150–151.

14. Flugel A, Heitmann C, Kehrer A, et al. Defect coverage of thehand with the free serratus fascial flap. Handchir MikrochirPlast Chir. 2005;37:186–192.


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Fascial Flap Reconstruction of the Hand a Single.25[1]