British Journal of Plastic Surgery (1996), 49, 165-169 0 1996 The British Association of Plastic Surgeons

Transversely designed dorsal metacarpal V-Y advancement flaps for dorsal hand reconstruction

K. Onishi, Y. Maruyama and M. Yoshitake Department of Plastic and Reconstructive Surgery, Toho University Hospital, Tokyo, Japan

S UMMAR Y. Five successful cases of transversely designed dorsal metacarpal V-Y advancement flaps for reconstructing defects on the dorsum of the hand are reported. The flaps were supplied by dorsal metacarpal vessels. Proximally based flaps were used in 2 cases, one of which was supplied by two dorsal metacarpal arteries. Distally based flaps were used in 3 cases. All flaps survived completely.

An important factor to consider in repair of a soft tissue defect with a flap is the flap donor site. The V-Y advancement flap has the advantages of excellent colour and texture matching and primary donor site closure.‘,2 Maruyama and Yoshitake3 described the longitudinally designed, axial dorsal metacarpal V-Y advancement flap for the repair of distal forearm defects. The transversely designed dorsal metacarpal V-Y advancement flap has many advantages and wide applications for defects on the dorsum of the

hand. We report some of our clinical cases and discuss the usefulness of this flap.

Clinical cases

A transversely designed dorsal metacarpal V-Y advancement flap was used for reconstructing defects on the dorsum of the hand in 5 cases (Table 1, Fig. 1). In all cases, the size of the defects of skin

Table 1 Clinical cases

Case no. Ane (years) Sex Aetiolopv Defect size (mm i

Site of vascular aedicle

Dorsal metacarpal arterv Results

1 17 F 2 65 M 3 52 F 4 16 M 5 48 M

BUrlI Tumour Tumour Tumour Burn

30x20 42x35 3.5 x 30 30 x 30 33 x 25

Proximal 3rd Proximal 2nd & 3rd Distal 3rd Distal 3rd Distal 4th

Good Good Good Good Good

case 4 Fig. 1

case 5

Figure l-Illustration of the five flaps and their proximally or distally based vascular pedicles.

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Fig. 2

Figure 2-Case 2. (A) Defect and design of the dorsal metacarpal V-Y advancement flap, proximally based on the second and third dorsal metacarpal vessels. (B) The flap elevated. (C) Immediately after the operation. The flap donor site was closed in a V-Y fashion. (D, E) One year and 2 months after the operation. The result is excellent both functionally and cosmetically.

and soft tissue on the dorsum of the hand precluded primary closure. The flaps were supplied by dorsal metacarpal vessels adjacent to the defects. Proximally based flaps were used in 2 cases with defects at sites distal to the centre of the metacarpal bone, and distally based flaps were used in 3 cases with defects at sites proximal to the centre of the metacarpal bone. In one case with a relatively large defect of 42 x 35 mm (Case 2), a large flap including two dorsal metacarpal arteries was used to ensure its blood supply. All flaps survived completely with none of them showing even partial necrosis. The flap donor sites were closed primarily in all cases.

Case 2 (Fig. 2)

A 65-year-old man was referred to our hospital with a squamous cell carcinoma on the dorsum of his right

hand. The tumour was widely excised with a lo- 15 mm margin of the surrounding tissue, leaving a 42 x 35 mm soft tissue defect. A transversely designed dorsal metacarpal V-Y advancement flap, proximally based on the second and third dorsal metacarpal vessels, was elevated and transferred to cover the defect. The donor site was closed primarily by V-Y advancement. The flap survived completely and there was no tumour recurrence at one year and 2 months after the operation. The patient had no reduced function of the hand, such as difficulty with the grip. The result was also excellent from a cosmetic viewpoint.

Case 3 (Fig. 3)

A 52-year-old woman was referred with Bowen’s disease on the dorsum of her left hand. The tumour

Dorsal metacarpal V-Y advancement flaps 167

Fig. 3

Figure 3-Case 3. (A) Preoperative view. Bowen’s disease and design of the flap, distally based on the third dorsal metacarpal vessel. (B) One year and 1 month after the operation.

was excised with a 5 mm margin, leaving a 35 x 30 mm defect. During elevation of a transversely designed dorsal metacarpal V-Y advancement flap, distally based on the third dorsal metacarpal vessels, the third distal perforating artery penetrating the

palmar vascular system was preserved. The flap was transferred transversely to cover the defect and the donor site was closed by V-Y advancement. The postoperative course was uneventful and the flap survived completely.

Fig. 4

Figure 4-Case 4. (A) Defect and design of the dorsal metacarpal V-Y advancement flap, distally based on the third metacarpal vessels. (B) 3 months after the operation.

British Journal of Plastic Surgery

metacarpal region :

proximally or distally based flap

distal defect :

proximally based flap

Fig. 5

proximal defect :

distally based flap

Figure S-Basic design of the flaps.

Case 4 (Fig. 4)

A 76-year-old man was referred to our hospital with a suspected squamous cell carcinoma on the dorsum of his left hand. Excision of the tumour with margins of 5-10 mm resulted in a defect of 30 x 30 mm. Intraoperative histology showed a benign tumour. A transversely designed dorsal metacarpal V-Y advancement flap distally based on the third dorsal metacarpal vessels was elevated and transferred to cover the defect in the same manner as in Case 3. The flap survived completely.

Discussion

There are various reconstructive procedures for the repair of defects on the dorsum of the hand. The advent of reverse flow flaps and dorsal metacarpal flaps has revolutionised reconstructive hand sur- gery.3-1’ When defects are large, reverse flow flaps such as the reverse radial forearm and reverse pos- terior interosseous flaps are generally the procedure of choice. An alternative procedure is the combined use of reverse flow fascial flaps and skin grafts. If the defect is small or moderate in size, however, a dorsal metacarpal flap is the method of choice. In 1987, Earley and Milner4 described dorsal metacarpal flaps based on the first and second dorsal metacarpal vessels, while Quaba and Davison’ reported on dis- tally based dorsal hand flaps. These flaps are useful for dorsal hand reconstruction but require skin grafts at the donor site if the flap is large.

V-Y advancement flaps have been used for recon- structing various soft tissue defects.‘,z~‘z In 1991, Maruyama and Yoshitake3 described the axial dorsal metacarpal V-Y advancement flap, which made it possible to reconstruct distal forearm defects by transposing the flap longitudinally. We have trans- ferred dorsal metacarpal flaps transversely and have found many advantages. The flap can be prepared at any site on the dorsum of the hand and a large flap can be elevated safely by including more than one artery. The flap can also be elevated with either a proximal or distal base because the dorsal metacarpal

vessels have branches communicating with the palmar and digital vascular systems. The transversely designed dorsal metacarpal V-Y advancement flap is extremely useful for reconstructing defects in the metacarpal region. In general, flaps, including an adjacently running dorsal metacarpal artery as a nutrient vessel, are elevated from the side adjacent to the defect where there is available skin. Both proxi- mally and distally based flaps can be used for defects in the metacarpal region. The procedure is easier when proximally based flaps are used for cases with defects at sites distal to the centre of the metacarpal bone, and distally based flaps are used for cases with defects at sites proximal to the centre of the metacar- pal bone (Fig. 5). Obliquely designed flaps may, however, be used as distally based flaps for cases with defects at sites distal from the centre of the metacarpal bone and as proximally based flaps for cases with defects at sites proximal to the centre of the metacar- pal bone (Fig. 6). This surgical procedure is thus applicable to a variety of cases. The defect at the donor site can be closed easily in a V-Y fashion. The flap has an excellent colour and texture because of

distal defect :

distally based flap

Fig. 6

proximal defect :

proximally based flap

Figure 6-Flap variations. Oblique flap designs increase the range of clinical applications.

Dorsal metacarpal V-Y advancement flaps 169

the proximity of the donor and recipient sites. In addition, the procedure is simple and easy to use. The transversely designed dorsal metacarpal V-Y advancement flap can therefore be very useful for reconstructing defects on the dorsum of the hand.

References 1. Barron JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast

Surg 1965; 18: 51-78. 2. Blair JW, Bainbridge LC, Knight SL. Double V-Y advance-

ment flaps in the reconstruction of skin defects of the anterior lower limb. Br J Plast Surg 1993; 46: 644-6.

3. Maruyama Y, Yoshitake M. The axial dorsal metacarpal V-Y advancement flap for the repair of distal forearm skin defects. Br J Plast Surg 1991; 44: 274-5.

4. Earley MJ, Milner RH. Dorsal metacarpal flaps. Br J Plast Surg 1987; 40: 333-41.

5. Small JO, Brennen MD. The second dorsal metacarpal artery neurovascular island flap. Br J Plast Surg 1990; 43: 17-23.

6. Maruyama Y. The reverse dorsal metacarpal flap. Br J Plast Surg 1990; 43: 24-7.

7. Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg 1990; 43: 28-39.

8. Dautel G, Merle M. Direct and reverse dorsal metacarpal flaps. Br J Plast Surg 1992; 45: 123-30.

9. Reid CD, Moss ALH. One-stage flap repair with vascularised tendon grafts in a dorsal hand injury using the Chinese forearm flap. Br J Plast Surg 1983; 36: 473-9.

10. Soutar DS, Tanner NSB. The radial forearm flap in the management of soft tissue injuries of the hand. Br J Plast Surg 1984; 37: 18-26.

11. Costa H, Soutar DS. The distally based island posterior interosseous flap. Br J Plast Surg 1988; 41: 221-7.

12. Maruyama Y, Iwahira Y, Ebihara H. V-Y advancement flaps in the reconstruction of skin defects of the posterior heel and ankle. Plast Reconstr Surg 1990; 85: 759-64.

The Authors

Kiyoshi Onishi MD, Associate Professor Yu Maruyama MD, Professor and Chairman Michio Yoshitake MD, Registrar

Department of Plastic and Reconstructive Surgery, Toho University Hospital, 6-l l-l Omorinishi, Ota-ku, Tokyo 143, Japan.

Correspondence to Dr Onishi.

Paper received 31 August 1995. Accepted 8 November 1995, after revision.