“Kite Flap” for Thumb Reconstruction: A Case Report

Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap.

Background. Subungual squamous cell carcinoma (SCC) of thumb is a rare disease. However, it is the most common malignancy affecting the nail bed. Early recognition is crucial and important for prompt diagnosis and effective treatment. Often this tumour needs to be treated surgically with wide local resection, which results in a defect in the thumb. If not handled appropriately, such defects render restriction in functionality of the involved thumb as well as a poor aesthetic outcome. In the worst-case scenario, it may result in a poor function of involved hand. Thus, reconstruction of the involved thumb is necessary. The main aim of reconstruction is to regain the hands' function and preserved the thumbs' sensation. Secondarily, to have an aesthetically pleasing hand. Our hands carry out delegate job and important duty for daily function. Especially, the thumb working together with the other fingers to carry out the hand function as one unit. Loss of thumb function affects the whole performance of the hand. Case descriptions. We report a case of recurrent subungual squamous cell carcinoma of thumb, which had wide local resection and subsequently underwent soft tissue coverage with an islanded first dorsal metacarpal artery (FDMA) perforator flap. One month after surgery, the patient was able to regain a good functional outcome of the hand. In this report, we discussed the procedures that had been done. Conclusion. The patient regained full functional hand after reconstruction with preserved sensation over distal thumb. The aesthetic outcome is satisfactory. The FDMA perforator flap is a very pliable and robust flap for reconstruction of distal thumb defect.

Objective: To present six cases treated with kite flap for thumb reconstruction and to discuss important aspects of the first dorsal metacarpal artery (FDMA) flap technique along with the pertinent literature.\nMethod: We evaluated the age, etiology, operation time, and postoperative flap necrosis of six patients who had undergone thumb reconstruction with FDMA flap between 2014 and 2017. All patients signed a written informed consent form. A) Relevant anatomy: The FDMA is a branch of the radial artery. It supplies the dorsal aspect of the index finger up to the proximal interphalangeal (PIP) joint. The artery is located in the groove between radial of the body of the second metacarpal bone and the ulnar head of the first interosseous muscle. B) Flap design and surgical technique: The proximal and distal borders of the flap were constituted from the metacarpophalangeal (MCP) and PIP joints, respectively. Flap elevation was performed from the distal to proximal direction and from the ulnar to radial side.\nResults: The average patient age was 46.8 years. Five patients underwent surgery due to trauma and one patient underwent surgery due to a painful scar on the tip of the thumb. For the five trauma patients, thea verage operation time was 1.4 days. The patient with the painful scar had sustained the trauma 15 years ago. Flap necrosis was not observed. The average postoperative follow-up duration was 1.6 years.\nConclusion: The FDMA flap is a safe and practical solution for thumb reconstruction provided that the anatomy of the FDMA is well known and proper technique is used. [Hand Microsurg 2018; 7(3.000): 143-148]

Routine closure of the donor site with a second dorsal metacarpal artery flap to avoid the use of a skin graft after harvest of a first dorsal metacarpal artery flap

Analysis of thumb pulp reconstruction based on different local flaps: A systematic review

The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps

Objective: To compare the surgical outcomes of patients who underwent full-thickness skin grafts (FTSG) versus split-thickness skin grafts (STSG) for the reconstruction of scalp defects. Background: A wide range of scalp defects may arise following oncologic resection of scalp malignancies and the reconstruction of such defects may be challenging for reconstructive surgeons. In larger surgical defects, skin grafts may be used to facilitate wound healing and decrease the complexity of wound care, especially when a lack of hair-bearing scalp is not a concern. The majority of literature on scalp reconstruction only describes the use of STSG and generally recommends it only on a well-vascularized wound bed with intact periosteum. There is also a general belief that FTSG have lower survival compared with STSG, although there are limited published data on the use of FTSG for scalp reconstruction or any data comparing the outcomes of these two methods in scalp reconstruction. This study seeks to provide the first objective comparison of surgical outcomes in FTSG versus STSG for the reconstruction of scalp defects. Methods: We performed a retrospective chart review of patients who underwent scalp reconstruction with skin grafts at a single-institution academic tertiary care center from 2011 and 2016. χ2 or Fisher exact tests were used to compare graft take and complication rates. The effects of graft type, defect type, graft size, and patient comorbidities on the likelihood of graft take and complications were analyzed using multivariate logistic regression. Results: 125 full-thickness and 93 split-thickness skin grafts were performed on 200 patients with scalp defects. FTSG required fewer average reconstructions compared with STSG (1.06 vs. 1.24, P = 0.002). 92.8% of FTSG had complete graft take compared to 78.5% of STSG (P = 0.002). This difference between complete graft take was more evident in defects with exposed calvarium (87.2% vs. 47.6%, P = <0.001). Despite higher rates of minor debridement, FTSG resulted in less postoperative bone exposure and wound breakdown compared to STSG on both intact pericranium and exposed calvarium defects. Preoperative radiation, immunosuppression and increased graft sizes were also significant predictors of graft outcomes. Conclusion: Skin grafts, especially full-thickness, provide a versatile, reliable and simple approach for reconstructing medium to large scalp defects in the appropriate patient. Even on defects with bare calvarium, FTSG can have excellent graft take when a vascularized recipient bed is prepared. Defects with exposed bone, larger graft sizes, preoperative radiation and immunosuppression may result in decreased graft take and increased complications. Citation Format: Xue Zhao, Scott Mclean. Comparison of full-thickness versus split-thickness skin graft reconstruction of scalp defects [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 24.

Objective. Thumb defects are a difficult problem for reconstructive surgeons, as this finger provides more than 50 % of the hand’s function. Options for closing defects of different localization of the first finger of the hand are proposed. The flap of the first dorsal metacarpal artery (in the literature it is called the “Kite flap”) allows to close the defects located between the anatomical snuffbox and the interphalangeal joint of the first finger. The article presents a clinical case: a 16-year-old boy with a long-term non-healing ulcer in the back of the First metacarpal joint. The formation was removed. A flap on the 1st dorsal metacarpal artery was used to close the defect. A satisfactory result was obtained. The flap was first described by G. Foucher and J.B. Braun in 1979, and later various modifications of this flap were proposed. The flap ensures that the defect is closed with minimal damage to the donor area. Thus, the use of a flap on the 1 st dorsal metacarpal artery is an effective method for closing defects at the base of the first finger of the hand.

BackgroundFor reconstructive surgeons, massive midface defects, including large, full-thickness wounds on the upper lip, can be very challenging. Although there are many methods for reconstruction of upper lip defects, it is difficult to obtain satisfactory restoration of oral functions and good cosmetic results.Case presentationThis case report presents a man with massive midface defects, including upper lip, left nose, and cheek defects. Over the previous 2 years, the patient had three reconstructions with sequential free flaps for the resection of recurrent tumors, the first of which was in March of 2016; this resulted in the patient having massive midface defects, including an upper lip defect, a defect on the left side of the nose, and one on the left cheek. The defects were reconstructed using a radial forearm free flap (RFFF), a facial artery musculomucosal (FAMM) flap, and a kite flap. In June 2016, he underwent a second reconstruction, this time of the left nose defect, using a left anterolateral thigh (ALT) flap. In March of 2017, the patient underwent a third reconstruction with the use of a free ALT on the left intraoral cheek and the defects on the neck. All flaps survived. No complications were encountered postoperatively. The patient regained good oral sphincter function with no reports of drooling. Although the patient underwent three surgeries, the reconstruction results were acceptable.ConclusionsFor massive midface defects, including large, full-thickness wounds on the upper lip, the combination of a FAMM flap, kite flap, and RFFF promotes the reconstruction of the complex midface structure and improves the resulting functionality.

Aim: Numerous flaps have been described for the reconstruction of complicated defects of the fingertip. The aim of this study was to evaluate our experience on flaps that can be used in emergency settings, and analyze the outcomes of these procedures. Materials and Methods: A retrospective analysis of 81 patients, who presented to the emergency unit with complicated fingertip defects between 2009 and 2014 and in whom replantation was deemed unsuitable due to various reasons including crush or avulsion type of injury mechanism, absence of the amputated part, or unrepairable vascular injury in the amputate, was carried out. Results: Eighty-nine flaps were performed in 81 patients. The defects were repaired with V-Y advancement flaps in 57% (45 patients – 51 fingers) of the defects, kite flap in 15% (13 patients – 13 fingers), cross-finger flap in 12% (11 patients – 11 fingers), Kutler flap in 6% (4 patients – 5 fingers), digital artery perforator flap in 6% (4 patients – 5 fingers), and thenar flap in 4% (4 patients – 4 fingers) of the injuries. One patient operated with the digital artery perforator flap, and one other operated with the kite flap, developed partial flap necroses. There were no other complications. Conclusion: Functional and esthetic restoration of soft tissues in the fingers is possible with the use of appropriate flaps and meticulous surgical technique.

Abstract: Rhinophyma is a benign hypertrophic thickening and edema of the nasal pyramid skin caused by the growth of sebaceous glands, underlying connective tissue, and blood vessels. It is a fairly uncommon nasal disorder, affecting the nasal soft tissues and leading to nasal architecture disturbance, airway obstruction, and nasal aesthetic unit deformity. In cases of severe rhinophyma, surgical management is the first line of treatment, and full thickness skin graft (FTSG) is an additional option. This paper reports a nasal reconstruction with excision of rhinophyma, followed by FTSG as a defect reconstruction in Manado. A 53-year-old man complained about breathing, feeding, and nasal deformity problems for the last three years. About 25 years ago, the patient initially noticed a slowly thickening of the nose skin. Patient works for the army and gets a lot of sun exposure. Its bulk at presentation obstructed the nares (stage IV of rosacea) and insulted the appearance. The patient underwent surgical excision with a knife to shave off the aberrant tissue, with electrocauterization of the bleeding spots, followed by a FTSG from the left retroauricular as a donor site to cover the defect with good result. The diagnosis of rhinophyma was validated by histological analysis of the specimens. In conclusion, rhinophyma representing stage IV of rosacea, gives the nose and the rest of the face an unsightly appearance. It can be effectively treated with surgical excision and FTSG. Postoperative follow-up and supervision are necessary to ensure the optimal healing outcomes and that the patient is more confident with the result in concerns with functionality as well as appearance. Keywords: rhinophyma; nasal defect reconstruction; full-thickness skin graft

Objective To summarize the operative procedure and clinical efficacy of the first dorsal metacarpal artery flap for repair of the finger soft tissue defects with bone and tendon exposure by free transplantation. Methods From June 2014 to June 2017, 10 cases of the finger soft tissue defects with bone and tendon exposure were treated by the first dorsal metacarpal artery flap transplantation, and the sensation of the flap was reconstructed using the superficial branch of the radial nerve. The area of the flap ranged from 1.5 cm×4.5 cm to 5.2 cm×6.0 cm. The donor sites were closed directly or by skin graft. Results All the flaps survived successfully without vascular crisis. Primary healing of the flaps and donor sites was achieved. All the cases were follow-up for 6 to 20 months, with an average of 10 months. The shape and color of the flap were close to the healthy side, and the texture was soft. Two-point discrimination was 7 to 12 mm with an average of 8.5 mm. Hand function was evaluated by the total active range of motion of the fingers. The results were excellent in 6 cases, good in 3 cases and fair in 1 case. Conclusion The free first dorsal metacarpal artery flap, which selectively included the superficial branch of the radial nerve, is a reliable and simple procedure. It can effectively cover the wound with lighter injury in donor site and obtain an ideal appearance, function and sensory recovery. Key words: Finger injuries; Surgical flaps; Microsurgery; The first dorsal metacarpal artery

To investigate the effectiveness of modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries in repairing large skin defect of the hand. Between September 2017 and March 2021, 15 cases of large skin defect of the hand were treated. There were 11 males and 4 females with an average age of 42 years (range, 24-66 years). The injury causes included machine twist injury in 6 cases, pound injury in 5 cases, and crush injury in 4 cases. The injured parts included 6 cases of finger skin defect and 9 cases of distal skin defect of palm and dorsum of hand, all of which had tendon, joint, and bone exposure. The interval from injury to operation ranged from 2 to 6 hours (mean, 4 hours). The defect sizes after thorough debridement ranged from 3.5 cm×3.0 cm to 8.0 cm×4.5 cm. The modified dorsal metacarpal artery reverse island flap with a range of 3.8 cm×3.3 cm to 9.0 cm×5.0 cm was used to repair the defect, and the flap donor site was repaired with full-thickness skin graft. All the flaps survived successfully after operation, and the wounds in the recipient site and the skin grafts in the donor site healed by first intention. All patients were followed up 9-24 months, with an average of 14 months. The appearance of the flap was good, and its texture and color were similar to those of the surrounding normal tissue. There was no obvious scar contracture, depression, and pigmentation in the donor site. At last follow-up, the static two-point discrimination of the flap was 8-20 mm, with an average of 13.6 mm. According to the Michigan Hand Outcome Questionnaire, 5 patients were very satisfied with the appearance of the flap, and 10 patients were satisfied. The modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries has reliable blood supply, larger harvested area, simple procedure, and minimal donor site damage, which is suitable for emergency repair of large skin defect of the hand.

Objective To evaluate the surgical methods and clinical effects of the reconstruction of soft tissue defect in distal thumbwith dorsal thumb neurocutaneous vascular flap. Methods From January, 2014 to December, 2016, 32 patients with soft tissue defects of distal thumb were repaired with dorsal thumb neurocutaneous vascular flaps, including left thumbs in 11 cases and right thumbs in 21 cases. They were including 7 cases of nail bed defects, 9 cases of pulp defects under nails, 16 cases ofthe defects of tips or stump of fingers; skin and soft tissue defects range of 1.5 cm×1.0 cm-3.5 cm×3.2 cm; Flap cutting areas range of 2.0 cm×1.5 cm-4.0 cm×3.5 cm. If the donor areas could be sutured directly, be sutured; if they could not, be covered with intermediate split thickness skin grafts. All patients were followed up when they were reviewed in outpatient department, and to be evaluated the shape, texture, sensation, flexion and extension function, and donor site of the flaps. Results One case of flaps blood circulation disordereddue to tight suture, and eased after the removal of part of the sutures; One case of flaps atrophied, and the phalangette was exposed after 3 months, so we removed the end part of bone and the wound was closed; other flaps were survived, with primary wound healing. In the total 32 patients, they were followed up range of 3 to 36 months,with an average of 12 months. Eighteen cases were followed up at least 6 months, which were 4 of the 7 cases of nail bed defects, 5 of the 9 cases of pulp defects under nail and 9 of the 16 cases of the defects of tip or stump of fingers. The appearances and textures of flaps were good, protective sensations were restored, and skin flap two-point discrimina-tionswere 8-10 mm. According to the Trial Standard for Evaluation of Upper Limb Function of Chinese Society of Hand Surgery, it was excellent in 11 cases, good in 17 cases and moderate in 4 cases, with the excellent and good rate of 87.5%. Conclusion It has advantages of simple operation, low risk, high success rate and satisfactory curative effects of the use of dorsal thumb neurocutaneous vascular flap for repair of distal thumb defect of skin and soft tissue. It is not only suitable for the hospital with good technical and equipment, but also suitable for the primary hospital. Key words: Finger injury; Thumb; Neurocutaneous vascular flap; Microsurgical operation

The radial forearm free flap (RFFF) is one of the most widely used and versatile fasciocutaneous free flaps in head and neck reconstruction because of its qualities--the consistent vascular anatomy; the thin and pliable nature; the minimal hair presence; and the possibility of harvesting and transferring it as a composite tissue flap, with bone, tendon, and nerve. The RFFF provides a method of single-stage reconstruction of wide residual defects after excision of advanced cancer (T3-T4) in the head and neck region. We present our ten-year experience with RFFF and the good results obtained with some refinements, which allowed us to verify the efficacy of the oral competence using the palmaris gracilis tendon as a sling. We also present the possibility of harvesting long segments of radius (up to 18 cm), and the discovery that use of antithrombotic or anticoagulant therapy is not necessary for the flap survival. This treatment does not guarantee a complete recovery, but it can improve the quality of the patient's life.