The axial dorsal metacarpal V-Y advancement flap for the repair of distal forearm skin defects

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  • British Journalof Plastic Surgery (1!391), 44.214215 0 1991 The Trustees of British Association of Plastic Surgeons

    The axial dorsal metacarpal V-Y advancement flap for the repair of distal forearm skin defects

    Y. Maruyama and M. Yoshitake

    Department of Plastic and Reconstructive Surgery, Toho University Hospital, Tokyo, Japan

    SUMMAR Y. We demonstrate an extension of the range of cover of the second dorsal metacarpal flap to include the wrist and the distal forearm and discuss the value of an axial V-Y advancement flap iu reconstructive surgery.

    Dorsal metacarpal flaps based on the dorsal metacar- pal vessels have been shown to have a role in reconstructive hand surgery as normograde (Earley and Milner, 1987; Colville, 1989; Small and Brennen, 1990) or reverse (Maruyama, 1990; Quaba and Davison, 1990) flaps.

    Dorsal metacarpal flaps have a number of limita- tions but are suitable for covering relatively small defects on the hand. The donor site morbidity is acceptable, and although skin grafts are sometimes required, these settle down well.

    The area covered by second dorsal metacarpal flaps has been described by Earley and Milner (1987). It reaches the wrist joint on the dorsum of the hand.

    In this paper we demonstrate a further extension of the range of cover of the second dorsal metacarpal flap to the wrist and the distal forearm and discuss the value of an axial V-Y advancement tlap in reconstruc- tive surgery.

    Case history

    A 60-year-old female was admitted to our hospital for wide resection of a left forearm tumour and repair of the resultant defect.

    Initial resection of the tumour with close margins on her distal forearm had been carried out two weeks before at another hospital, and the pathological examination revealed a malignant eccrine spiradenoma.

    The area was widely excised and a second dorsal metacarpal flap was designed on the adjacent dorsum of the hand for V-Y advancement into the defect (Fig. 1A).

    The incision was started at the lateral side of the flap and carried down through the subcutaneous fat and the fascia over the dorsal interosseous muscles (Fig. lB, Fig. 2A).

    The second dorsal metacarpal vessels were identified lying deeply in the interosseous spaces and were included in the flap, the communicating artery with the palmar metacarpal being divided. Dissection of the flap and its pedicle was continued proximally (Fig. 2B). Following the dissection, we confirmed that the flap fitted in the defect. Then we confirmed the viability of the flap by fluorescein i.v. injection. Finally the flap was transposed to the distal forearm defect, and the donor site was closed in V-Y advancement fashion (Fig. lC, Fig. 2C).

    The postoperative course was uneventful and the flap survived completely. Ten months later, the result was satisfactory with a full range of movement and no sensory disturbance of the hand.

    Discussion

    The V-Y advancement flap is suitable and has been used for reconstruction of various soft tissue defects (Chan, 1988; Maruyama et al., 1990). It has the advantage of an excellent colour and texture match; the tissue can be used effectively and a skin graft is not required for the donor site. The subcutaneous pedicle V-Y advancement flap has limitations con- cerning its application because of its random blood supply however. The versatility of axial flaps is well- known, and there are many situations in which axial flaps can be transposed to a defect in islanded V-Y advancement fashion.

    Quaba and Davison (1990) mention that the arc of rotation of the distally based dorsal hand flap covers the dorsal metacarpal, web and dorsal phalangeal areas including the distal interphalangeal joint.

    Earley and Milner (1987) showed that the area of cover of the second dorsal metacarpal flap reaches the dorsal wrist crease proximally.

    We have shown here that a second dorsal metacarpal flap based on the second dorsal metacarpal vessels could be transposed to the distal region of the forearm in an islanded advancement fashion leaving a moder- ate-sized donor site which could be closed by V-Y closure.

    References

    than, S. T. S. (1988). A technique of undermining a V-Y subcutaneous island flap to maximize advancement. Britbh Journal of Plastic Surgery, 41,62.

    Colville, J. (1989). Syndactyly correction. British Journal of Plastic Surgery, 42, 12.

    Enrley, M. J. and MiIner, R. H. (1987). Dorsal metacarpal flaps. British Joumal of Plastic Surgery, 40,333.

    274

  • The Axial Dorsal Metacarpal V-Y Advancement Flar, for the ReDair of Distal Forearm Skin Defects 275

    Figure l--(A) The design of the dorsal metacarpal flap is shown after wide resection. (B) Elevation of the flap, the distal communicating artery ligated. (C) The island flap was advanced proximally, and the donor site was closed in V-Y fashion. (D) Ten months after the operation. Figure 2+A, B, C) Schemata.

    Marnyanta, Y. (1990). The reverse dorsal metacarpal flap. British Journal of Plastic Surgery, 43,24.

    Marnyama, Y., I~ahira, Y. and Ebihara, H. (1990). V-Y advance- ment flaps in the reconstruction of skin defects of the posterior heel and ankle. Plastic and Reconstructiw Surgery, 85,759.

    Qnaba, A. A. and Davidson, P. M. (1990). The distally-based dorsal hand flap. British Journaiof Plastic Surgery, 43,28.

    The Authors

    &mll, J. 0. and Brettnen, M. D. (1990). The second dorsal metacarpal artery neurovascular island flap. British Journal of Plastic Surgery, 43, 11.

    Ye Masstyanta, MD, Associate Professor and Head Michio Yosbitake, MD, Registrar

    Department of Plastic and Reconstructive Surgery, Toho University Hospital, 6-l l-l, Ohmori-nishi, Ohtakyu, Tokyo, Japan 143.

    Requests for reprints to Dr Maruyama.

    Paper received 12 October 1990. Accepted 11 December 1990.

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