Britivh JoumalofPlmtic Surgery (Ml), 44,165-169 0 1991 The Trustees of Bri&h Association of Plastic Surgeons

The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger

C.-S. Lai, S.-D. Lin, C.-C. Yang and C.-K. Chou

Division of Plastic and Reconstructive Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical College, Taiwan, Republic of China

SUMMARY. Six cases of complicated dorsal skin defects of haads and two in fingers were successfully resurfaced with local adipofascial turn-over flaps. Flaps with a base-to-length ratio of 1: 1.0 to 1: 1.5 survived completely. The width of the attached base was 1.0 to 1.5 cm in hands and 0.5 cm in fingers.

Skin defects with exposure of bones or tendons on the dorsum of hands can be a difficult problem because immediate or early closure is of paramount importance to the preservation of the function of the involved tendons. This paper describes a new technique by which local adipofascial turn-over flaps were used successfully to reconstruct complicated dorsal skin defects of hands and fingers.

Materials and methods

Between April 1987 and December 1989 eight cases underwent this procedure to reconstruct skin defects in the dorsal aspect of hands (6) and fingers (2). The average age of the patients was 34.2 years (range 19- 59 years). Follow-up was from 4 months to 20 months (mean 11 months) (Table 1).

Surgical technique

The reconstructive procedures are illustrated in Figure 1. The size of the defect is measured and the required adipofascial flap, usually with a base-to-length ratio of 1: 1.0 to 1: 1.5, is marked. The skin overlying the flap is carefully incised down to the dermal layer in a zig-zag manner. The incised skin, without adipose component, is undermined adequately and held laterally with hooks. The adipofascial flap is then.

Table 1

dissected free from the underlying paratenon or muscles. The dissection of the flap is stopped about 1.0 to 1.5 cm in hands and 0.5 cm in fingers, before the edge of the defect is reached. The flap is turned back upon its attached base to reach the opposite end of the defect. A full thickness or split thickness skin graft is applied to the raw surface of the turn-over flap. The skin over the donor site of the flap is reapproxi- mated with two-layer sutures and a drain is placed in the dependent position if necessary. It is usually removed on the second postoperative day. An elastic bandage is applied snugly over a bolus of gauze on the grafted skin and the hand is immobilised by a splint.

Illustrative case reports

Case 2 (Fig. 2) A 59-year-old man was admitted with a post-traumatic skin defect over the dorsum of his left hand. Extensor tendons denuded of paratenon were exposed. A proximally-based adipofascial flap, measuring 6 x 4 cm with a 1.5 cm deep base, was raised to cover the defect. The raw surface of the turn-over flap was then resurfaced with a thick split thickness skin graft. The postoperative course was uneventful and long-term follow-up showed normal function of the hand with excellent pliability of the flap.

Case 2 (Fig. 3) A 30-year-old woman suffered a chronic ulcer on the dorsum of her right hand resulting from the extravasation of 5-

No. Sex Age (yr)

1 M 2 F 3 F 4 M

59 30 30 19

Dorsum of left hand Dorsum of right hand Dorsal DIP of left index Volar DIP of left middle finger

5 M 36 Dorsum of right hand 6 M 38 Dorsum of right hand I F 20 Dorsum of right hand 8 F 42 Dorsum of left hand

Site of Size of Size of lesion defect (cm) flap (4

4.5 x 4.0 2.5 x 2.5 0.8 x 1.0 1.0 x 1.2

3.4 x 3.0 4.0 x 3.5 3.5 x 3.4 4.5 x 4.0

6.0 x 4.0 Survived 3.6 x 2.5 Survived 1.4x 1.2 Survived 1.5 x 1.5 Survived

4.5 x 3.0 Survived 5.5 x 3.8 Survived 5.0 x 3.5 Survived 6.0 x 4.0 Survived

Result

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British Journal of Plastic Surgery

Fig. 1

Figure l-(A) The skin overlying the planned flap is incised down to the dermal layer in a zig-zag manner. (B) The incised skin is undermined adequately and the adipofascial flap, usually with a base-to-length ratio of 1: 1 .O to 1: 1.5, is readily freed from the underlying paratenon and muscles. (C) The flap is turned over to cover the defect and the raw surface is resurfaced with a skin graft; the donor wound is closed primarily.

Fluoracil @Fu) for 3 months. At operation the non-viable tissue and dense scar tissue at the edge of the wound were excised, leaving a defect with exposure of extensor tendons. A proximally-based adipofascial flap, measuring 3.6 x 2.5 cm with a 1 .O cm deep base, was elevated to reconstruct the poorly vascularised defect.

Case 3 (Fig. 4)

A 30-year-old woman sustained a laceration of her left index finger with resultant skin defect and bone exposure over the dorsal aspect of the DIP joint. A small adipofascial flap, measuring 1.4 x 1.2 cm with a 0.5 cm deep base, was raised and turned over to cover the defect.

All flaps survived completely without loss of the overlying skin graft. Normal hand function was gained in all patients. However, desquamation occurred in the reapproximated skin in two cases and in the grafted skin in one case. No scar or any sequela caused by desquamation was noted.

Discussion

Various types of local flaps have been used to reconstruct dorsal skin defects on the hand. The use of local transposition, rotation and advancement flaps with randbm vascularity have a limited range of motion. Distally-based radial (Lu er al., 1982; Lin et al., 1984) and ulnar (Lovie et al., 1984; Li et al., 1989) forearm flaps are effective for extensive skin defects but carry the main disadvantage of leaving a large donor site scar. Local flaps for covering dorsal skin defects of digits include the flag flap (Iselin, 1973), the arterialised lateral finger flap (Russell ef al., 198 l), the digital artery flap (Rose, 1983), the reverse digital artery flap (Lai ef al., 1989), the reverse dorsal hand flap (Quaba and Davison, 1990) and the venous dorsal digital island flap (Foucher and Norris, 1988). With these techniques the flap skin matches well with the surrounding skin but the small vascular pedicle requires careful section.

Clodius and Smahel(l973) first used the derma-fat flap transposed from the calf of one leg to the sole of the other foot, and Pakiam (1978) reported the transfer

The Adipofascial Turn-over Flap for Complicated Dorsal Skin Defects of the Hand and Finger 167

Fig. 2

Figure 2-Case 1. (A) Post-traumatic skin defect with exposure of extensor tendons. (B) Wound debridement and dissection of the adipofascial flap. (C) The flap turned over the defect; a thick split thickness skin graft was then applied to the raw surface of the hand and the donor wound closed primarily. (D) Eighteen months after surgery, showing excellent pliability of the flap.

of the de-epithelialised turnover flap from the dorsum of one finger to reconstruct the defect of the neigh- bouring finger in a two-stage operation, while Thatte et al. (1982) used the same flap to resurface a complicated wound of the hand in a one-stage operation. Epithelial cysts and discharging sinuses may present as a problem in using buried de- epithelialised flaps. Since the development of the fasciocutaneous flap by Ponten in 198 1, a rich vascular plexus at the level of the fascia has been confirmed by several reports (Tolhurst et al., 1983 ; Cormack and Lamberty, 1984; Taylor and Palmer, 1987). On the other hand, a rich vascular network in the subcuta- neous tissue was also confirmed by Pearl and Johnson (1983), Marty et al. (1984) and Gumener et al. (1986). The adipofascial turn-over flap basically depends on a “random” type of vascularity. Flaps with a base-to- length ratio of 1: 1 .O to 1: 1.5 survive completely.

It is quite hard to define clearly the amount of attached base required for flap survival with an accurate mathematical method but a base with a depth of 1.0 to 1.5 cm in hands and 0.5 cm in fingers was quite safe in our series. Theoretically, any location around the defect can be used as the base of the flap. There is little bleeding from the dissected surface between the fascia and the underlying intact paraten- ons and muscles except for some perforators. Under- mining of the overlying skin of the donor flap is relatively safe as abundant dermal plexuses exist for the survival of the undermined skin flap. Only

desquamation was noted to occur in the reapproxi- mated skin. The gliding motion of involved tendons was restored uneventfully because the paratenons underlying the donor flap were kept intact and the exposed tendons of the defect area were faced with the adipose component of the turn-over flap, which will not impede their gliding motion.

Local adipofascial turn-over flaps for soft tissue coverage in hands provide several advantages which include (1) simplicity and rapidity of the procedure, (2) one-stage operation, (3) no necessity for de- epithelialisation, (4) thinness and good pliability, and (5) minimal donor site deformity. The flap is consid- erably easier to transpose than any other local or distant flap. Less skin graft is needed than in the case of a de-epitheliahsed turn-over flap. Epithelial cysts and discharging sinuses are also avoided because there is no dermal component in the flap. The cutaneous sensory nerves lie between the dermis and the adipose tissue can be preserved with meticulous dissection, whereas in performing a traditional derma-fat or derrna-fat-fascial flap cutaneous nerves are sacrificed to enable the flap to reach the defect.

Because the hand performs a unique mechanical function, good soft tissue cover is imperative. Lesavoy (1990) emphasised that the ideal flap for covering soft tissue defects of the hand must (1) provide subcuta- neous fat that tendons can glide through, (2) supply enough subcutaneous tissue for cover of vital neural, vascular, bone and joint structures, and (3) be

168 British Journal of Plastic Surgery

Fig. 3

Fig. 4

Figure >&se 2. (A) Chronic ulcer caused by the extravasation of 5-FU. (B) Non-viable tissue and dense scar tissue have been debrided, leaving a defect with exposure of extensor tendons; skin flaps retracted over site of adipofascial flap. (C) The adipofascial flap turned over to fit into the defect; the fascial surface of the flap was then covered with a full thickness skin graft. (D) Follow-up at 8 months after surgery. Figure &-Case 3. (A) Skin defect with exposure of bone resulting from knife wound; the skin overlying the adipofascial flap is already incised. (B) Small flap dissected and turned over to cover the defect; a full thickness skin graft was then applied on the raw surface of the flap. (C)Follow-up at 4 months.

The Adipofascial Turn-over Flap for Complicated Dorsal Skin Defects of the Hand and Finger 169

aesthetically pleasing. The local adipofascial tum- over flap full& these criteria, It allows immediate or early closure of difficult wounds of hands and fingers in an easy way and is especially indicated for small to medium-sized defects.

References

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Cormack, G. C. and Lamberty, B. G. H. (1984). A classification of fascia-cutaneous flaps according to their patterns of vascularisa- tion. British Journal of Plastic Surgery, 37,80.

Foucber, G. nnd Norris, R. W. (1988). The venous dorsal digital island flap or the “neutral” flap. Britbh Journal of Plastic Surgery, 41,337.

G-r, G., Montandon, D., Marty, F. and Zbrodowski, A. (1986). The subcutaneous tissue flap and the misconception of fasciocu- taneous flaps. Scandinavian JoumaI of Plastic and Reconstmctive Surgery, 2Q, 65.

IS&I, F. (1973). The tlag flap. Plasticand Reconstructive Surgery, 52, 374.

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The Authors

Chung-e Lai, MD, Associate Professor &-Daw Lin, MD, Professor chin-Cl&tug Yang, MD, Associate Professor Cl&-Kang Cbou, MD, Assistant Professor

Division of Plastic and Reconstructive Surgery, Chung-Ho Memo- rial Hospital, Kaohsiung Medical College, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan.

Requests for reprints to Dr C.-S. Lai at the above address.

Paper received 17 May 1990. Accepted 29 June 1990.