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SURGICAL TECHNIQUE

Fascial Flaps for Hand Reconstruction

Amir H. Taghinia, MD, Matthew Carty, MD, Joseph Upton, MD

Free or pedicled fascial flaps to the hand provide an excellent reconstructive option in casesof exposed tendon, joint, or bone where soft tissue coverage is needed. They provide thin,broad, well-vascularized coverage and a gliding surface for tendons and joints. A fascial flapalso avoids an unsightly donor site that results from a fasciocutaneous flap. Because of thesecharacteristics, mobilization can be started early to avoid or minimize tendon adhesions andjoint and soft tissue contractures. In this report, we discuss the technique for harvesting andinsetting a pedicled reverse radial forearm adipofascial flap for a dorsal thumb defect. (JHand Surg 2010;35A:1351–1355. Copyright © 2010 by the American Society for Surgery ofthe Hand. All rights reserved.)

Key words Fascial flap, hand reconstruction, flap, fascia.

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ECONSTRUCTION OF COMPLEX hand wounds can beparticularly challenging because these woundstypically need thin, pliable, well-vascularized

overage with potential for sensibility and a glidingurface. With exposed tendons, bones, or joints, stan-ard skin grafts do not take well. Traditional pedicledasciocutaneous flaps such as the groin flap are bulkynd require prolonged attachment, preventing early re-abilitation. Free myocutaneous and many fasciocuta-eous flaps are also bulky and require multiple revisionrocedures.

Fascial flaps provide the advantages of being thinnd pliable and having well-vascularized soft tissueoverage. A fascial flap also avoids having to skin grafthe donor area, which often leaves a highly visible andnsightly scar if a fasciocutaneous flap is used. They arespecially desirable in the hand because they are thin,an be sensate, and provide a gliding surface for earlyendon and joint rehabilitation. Both pedicled and freeaps can be used.1 The most commonly used pedicledap is the reverse radial forearm adipofascial flap.2,3

ree flaps are technically more demanding and include

From the Division of Plastic Surgery, Beth-Israel Deaconess Medical Center, Harvard Medical School,Boston, MA.

Received for publication May 23, 2010; accepted in revised form May 23, 2010.

No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.

Corresponding author: Dr. Joseph Upton, 830 Boylston Avenue, Suite 212, Chestnut Hill, MA02467; e-mail: jupton3@gmail.com.

0363-5023/10/35A08-0026$36.00/0

wdoi:10.1016/j.jhsa.2010.05.015

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he temporoparietal fascia flap and the dorsalis pedisascia flap.4

In this article, we outline the technique and clinicalase for harvesting a reverse radial forearm adipofascialap for reconstruction of a dorsal thumb wound. Al-

hough free flap reconstructions can also be performed,he radial forearm flap does not require microsurgicalxpertise and is technically less demanding.

NDICATIONSndications for this type of reconstruction occur when aomplex hand wound presents as a result of trauma,nfection, tumor extirpation, or Dupuytren’s surgery, oruring reconstruction of congenital disorders. Skinrafts would not suffice, such as with exposed tendonith denuded or damaged paratenon, exposed boneithout periosteum, or exposed joint. These flaps arearticularly well suited for dorsal hand wounds, whichemand thin tissue and a gliding surface if tendons arexposed. The patient should be healthy and able toooperate with rehabilitation.

ONTRAINDICATIONSascial flaps are contraindicated in infected, dirtyounds. They should not be performed in ill patients orentally incapacitated patients who cannot complyith postoperative rehabilitation. The amount of tissue

hat flaps provide is somewhat limited, so large woundsannot be fully resurfaced with these flaps. If a freeascial flap is considered, one needs a microsurgeon

ith the appropriate microsurgical instruments and a

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microscope. If a pedicled flap is considered, one shouldconsider the integrity of the blood supply to that flap.An Allen test is critical to assess the patency of thepalmar arch, especially if a reverse radial forearm flap isconsidered.

SURGICAL ANATOMY AND TECHNIQUEIn this article, we discuss the anatomy and technique ofharvesting a pedicled reverse radial forearm adipofas-cial flap. The blood flow to this flap comes from theulnar artery, across the palmar arch, and then in areverse fashion into the radial artery. If the palmar archis disrupted or incomplete, this flap will not survive.

After an Allen test confirms patency of the palmararch, the path of the radial artery is determined with aDoppler probe and marked out on the forearm (Fig. 1).As it emerges between the brachioradialis (BR) and theflexor carpi radialis (FCR) in the mid-forearm, the ra-dial artery sends multiple perforators via a thin septumto the subcutaneous fat and skin. These perforators are

FIGURE 1: An Esmarch bandage was used to make a templateof the defect. A laparotomy pad was used to assess the mostproximal extent of tissue needed with the pivot point locatedat the distal wrist crease. With the most proximal point of theflap noted on the forearm, the Esmarch template is placed onthe forearm and the dashed lines are drawn around thetemplate, centering it on the previously drawn outline of theradial artery. X marks indicate Doppler-readable signals onthe radial artery.

reliable and will be the basis of the blood supply to the

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adipofascial flap. Thus, the most proximal limit of theflap on the forearm will be about 2 to 3 cm proximal tothe location where the muscle bellies of the BR andFCR cross (Fig. 2). Once this crossing is encountered,an additional 2 to 3 cm of adipofascial tissue can beharvested proximally based on random blood supply.The artery and its venae comitantes will be divided atthis crossing and raised from proximal to distal justabove its fascial bed.

A laparotomy pad can be used to assess whether theflap will reach. With one end of the pad held at the pivotpoint of the flap (the distal wrist crease), the other endof it can be rotated from proximal to distal to determinewhether the proximal aspect of the flap on the forearmwill reach its most distal target on the hand. A dottedline will determine the amount of subcutaneous tissueor fascia that will be harvested. This can also be tailoredto the defect by making a template of the defect with anEsmarch bandage.

Once the marks are established, an Esmarch bandageis applied, the limb is exsanguinated, and an arm tour-

FIGURE 2: The flap has been raised and transposed into thedefect (not tunneled yet). The extensor tendon reconstructionis nearly complete. Fasciocutaneous perforators from the radialartery are only present distal to the crossing junction of themuscle bellies of the FCR and BR (seen above). This pointrepresents the most proximal dissection of the vascular bundle(unless musculocutaneous perforators will be used). Anyadditional tissue harvested proximal to this point will have arandom blood supply.

niquet is inflated. A linear incision is made in the

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a split-thickness sheet graft with pie-crusting.

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forearm over the path of the radial artery, starting at theproximal wrist flexion crease to a point proximal to theintersection between the proximal and middle thirds ofthe forearm. Where the dotted lines are placed, the skinis lifted off the subcutaneous tissue, leaving a thin layerof fat on the skin to avoid damaging the subdermalvascular plexus. Once the dotted lines are reached, theskin is sutured back to provide exposure of the under-lying tissues. The edges of the adipofascial flap are thenmarked on the subcutaneous tissues and the radial andulnar edges are incised down to the deep fascia invest-ing the muscle and BR/FCR tendons. These tissues arethen lifted off radially and ulnarly until the radial edgeof the FCR and the ulnar edge of the BR are encoun-tered. The radial artery lies between these 2 tendons.Just at their intersection (typically musculotendinousarea), the dissection is taken deeper and the radial arteryand its associated veins are identified and ligated. Theentire flap along with the radial vessels is then liftedfrom proximal to distal all the way to the most distalpivot point (Fig. 2). Once this point is reached, the flapis transposed into the defect. The pedicle can usually betunneled under the skin—but extreme care is warrantedhere to avoid kinking the pedicle. Once tunneled andtransposed, the flap is inset into the defect using absorb-able sutures. The tourniquet is then deflated to assuregood vascularity of the flap (Fig. 3). Once this is en-

FIGURE 3: The flap has been inset and sutured in place. Withthe tourniquet down, vigorous, healthy bleeding is seen on thesurface of the flap.

sured with good pulsatile flow through the radial artery,

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FIGURE 4: Final intraoperative appearance after application of

FIGURE 5: Industrial router injury to the patient’s dominantthumb. Eighty percent of the width of the extensor tendon was

longitudinally avulsed. The interphalangeal joint was exposed.

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a skin graft is harvested and placed over the flap andcarefully inset using fine absorbable sutures (Fig. 4).The donor linear defect is closed with deep dermal andrunning intracuticular absorbable sutures over a smallsuction drain.

POSTOPERATIVE CARE AND REHABILITATIONThe hand and wrist are immobilized for 1.5 to 2.0weeks, at which point protected rehabilitation is started.The suction drain is usually removed within 24 hours.Little wound care is required once the splint or cast isremoved. If earlier motion is necessary, healing of theskin graft may be compromised.

CLINICAL CASEThe case illustrations (Figs. 1–7) are of an otherwisehealthy man who sustained a dorsal thumb injury whileusing an industrial router. The injury claimed a majorportion of the extensor mechanism and shaved the dor-sal bone of the distal and proximal phalanges (Fig. 5).The interphalangeal joint was exposed. After the pa-tency of the palmar arch was confirmed, a reverse radialforearm adipofascial flap was planned for coverage.Once this flap was raised, a palmaris longus tendon

FIGURE 6: The extensor tendon reconstruction is complete.The flap has been tunneled into the defect and reflectedproximally. The course of the vascular bundle is seen on theundersurface of the flap. The forearm wound has been closed.

graft was harvested (through the same wound) and used

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to reconstruct the extensor mechanism. It was suture-anchored to the proximal aspect of the dorsal distalphalanx. The flap was then tunneled under the skin andinset into the defect (Fig. 6). Once good vascularity wasconfirmed, a split-thickness skin graft from the thighwas placed over the flap and sutured in place with fineabsorbable sutures. It was then pie-crusted for hemato-ma/seroma avoidance. The patient had a satisfactoryfinal outcome (Fig. 7).

PEARLS AND PITFALLSSeveral critical technical steps are necessary in theplanning and execution of these types of surgeries. Toavoid infection and minimize scarring, all devitalizedtissue must be meticulously debrided from the wound.A template of the defect, made initially using an Es-march bandage, allows one to take just the correctamount of tissue needed for resurfacing; no less and nomore. A preoperative Allen test ensures patency of thepalmar arch and perfusion to the hand and the flap.Without a patent arch, the flap would die and the handmay become ischemic. Septocutaneous vessels from the

FIGURE 7: Six-month postoperative view. The flap and skingraft are well contoured, soft, and pliable. Interphalangeal jointextension is full, but flexion is 45°. Nail deformity persists onthe radial side. The patient has returned to full duty at workand denies limitations in function.

radial artery start just distal to where the muscle bellies of

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the BR and the FCR start to diverge around the mid-forearm. This area of divergence can be variable and is thelimit of the proximal dissection of the radial artery. Theflap can be harvested a few centimeters proximal to thispoint with a random blood supply. The forearm skin flapsshould be raised with a pebbling of fat to ensure adequateblood supply and lack of wound breakdown in the donorsite. The paratenon of the FCR should be preserved in caseof donor site skin breakdown. If tunneling the flap, thesubcutaneous tunnel should be generous and care shouldbe exercised to avoid kinking of the pedicle. Once the flapis partially inset, the tourniquet should be taken down toassess vascularity of the flap. If the flap does not bleed,check the pedicle for kinking and tension and the tunnelfor tightness.

COMPLICATIONSFortunately, most complications are avoidable. Vascu-

lar compromise is rare in a healthy host with a patent

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arch and palpable pulses. Occasionally, kinking of thepedicle, tightness of the tunnel, or a hematoma maythreaten the blood supply of the flap. These can beavoided with meticulous, hemostatic dissection and at-tention to detail regarding transposition and inset of theflap. Other complications include partial skin graft loss,which is avoidable with adequate short-term immobili-zation.

REFERENCES

1. Jones NF, Jarrahy R, Kaufman MR. Pedicled and free radial forearmflaps for reconstruction of the elbow, wrist and hand. Plast ReconstrSurg 2008;121:887–898.

2. Cherup LL, Zachary LS, Gottlieb LJ, Petti CA. The radial forearmskin graft-fascial flap. Plast Reconstr Surg 1990;85:898–902.

3. Chang SM. The distally based radial forearm fascia flap. Plast Re-constr Surg 1990;85:150–151.

4. Brent B, Upton J, Acland RD, Shaw WW, Finseth FJ, Rogers C, et al.Experience with the temporoparietal fascial free flap. Plast Reconstr

Surg 1985;76:177–188.

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