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ZHANG Gong-lin张功林*, CAI Guo-rong蔡国荣, ZHANG Ming章鸣, ZHENG Liang-jun郑良军 and ZHANG Yan 张燕. Department of Orthopaedics, Orthopaedics ...
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Chinese Journal of Traumatology 2008; 11(3):190-192

Case report

Coverage of soft tissue defect in palm with prefabricated flap ZHANG Gong-lin张功林*, CAI Guo-rong蔡国荣, ZHANG Ming章鸣, ZHENG Liang-jun郑良军 and ZHANG Yan 张燕

T

he coverage of large soft tissue defects in palm remains a challenge in the plastic reconstructive surgery. There are many local tissue transfers described for small-sized defects of hand, whereas large defect require regional flaps such as the radial forearm flap or free tissue transfer.1-5 We used prefabricated flap of the palmar skin to cover the palmar defect and obtained satisfactory clinical results.

CASE REPORT A 43-year-old man had the left palmar defect in a machine accident in May 2005. The palmar skin was avulsed from the palmar fascia, and the underlying tendons, palmar fascia, and neurovascular structure were exposed. The size of soft tissue defect in the palm was 6 cm×9 cm (Fig.1). The palmar skin was avulsed to three slices (Fig.2). Revascularization of the avulsed palmar skin with microsurgical technique was impossible because no vessels could be anastomosed. The three slices of palmar skin were stitched together and defatted to form full-thickness skin. Then it was grafted temporarily onto the surface of right fascia latae of anterolateral thigh region (Fig.3). The graft was fixed by a tie-over suture fixation. After thorough debridement, the wound was temporarily covered with wet dressing. The dressing of anterolateral thigh was removed 2 weeks later and the prefabricated flap of palmar skin survived. Then the prefabricated flap was harvested, including the arteries and veins of desending branch of the lateral circumflex femoral vascular vessels and lat-

Department of Orthopaedics, Orthopaedics and Traumatology Hospital of Taizhou, Wenling 317500, Zhejiang Province, China (Zhang GL, Cai GR, Zhang M, Zheng LJ and Zhang Y) *Corresponding author: Tel: 86-576-86193839, E-mail: [email protected]

eral cutaneous nerve of the thigh. The donor site was closed directly. The injured hand was reconstructed with prefabricated flap. The artery and vein of desending branch of the lateral circumflex femoral vascular vessels and the lateral cutaneous nerve of the thigh in the flap were anastomosed end-to-end to the artery and vein of the radial and medial antebrachial nerve respectively. The postoperative course was uneventful. Prefabricated flap of palmar skin had survived completely. In 28 months follow-up, the cosmetic appearance of the palmar side was good. Light touch sensation had restored and two-point discrimination was 6-9 mm. Sensation to hot and cold stimuli was also present with very satisfactory clinical results (Figs. 4-5). Mild scar hypertrophy affected the thigh donor site in the early postoperative period, but the scar appearance was satisfactory one year after surgery. There was no remarkable morbidity at donor site.

DISCUSSION The palmar skin is unique and can hardly be replaced by other tissues. It should be preserved when microsurgical replantation of avulsed palmar skin of hands cannot be performed. The ideal flap for reconstruction of palmar skin requires durable thick skin with protective sensation, thin and supple to avoid unnecessary at the same time.1-5 Ideal flap should be suitable for both the dorsal and palmar surface and the fingers should facilitate gliding of the tendons with adequate range of motion, and provide a satisfactory aesthetic result. Various cutaneous and fasciocutaneous flaps are described for the reconstruction of soft tissue defects of the hand. However, excessive bulk is the major problem in many flaps.4,5 The authors used prefabricated flap of palmar skin to cover the palm defect. Clinical results were very

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Chinese Journal of Traumatology 2008; 11(3):190-192

satisfactory. The advantages of the flap are as follows: 1. A unique tissue structure of the palmar skin can be preserved by prefabricated flap technique. 2. The flap is thinner, so there is no need to be thinned by second operation. The patients were satisfied with the function, suppleness of skin and cosmetic results in follow-up evaluation.

Fig.2. The palmar skin was avulsed to three slices.

3. The flap is nourished by the desending branch of lateral circumflex femoral artery. The flaps, which are highly vascularized, have a constant anastomy and a long vascular pedicle, so that the dissection of flaps could be accomplished easily.6-9 4. Sensation of the flap may be established and provides protective sensation by including the lateral cutaneous femoral nerve, which emerges from the deep fascia below the anterosuperior iliac spine and divides into two or three branches that lie along the deep fascia.7

Fig.3. The palmar skin of the hand was defatted to form fullthickness skin and grafted temporarily onto the surface of the left fascia latae of anterolateral thigh region.

5. There is no need to sacrifice major arteries of the donor limb. After the flap is harvested, the thigh donor site is directly closed and well-hidden, thus only a linear scar of the donor area can be obtained. The donor site does not leave any functional deficit. 6. The donor and recipient sites allow the two-team operation at the same time, which is good for the rational use of operative time and personnel. The anterolateral thigh region is an ideal donor site for the prefabricated flap of palm. However, a two-stage procedure is required, which is the main disadvantage.

Fig.4. Movement of adduction of the fingers.

Fig.5. Movement of flexion of the fingers.

Fig.1. Preoperative view of the soft tissue defect of the palm.

REFERNCES 1. Agir H, Sen C, Alagoz S, et al. Distally based posterior interosseous flap: primary role in soft-tissue reconstruction of the hand. Ann Plast Surg 2007;59(3): 291-296.

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branch of the lateral femoral circumflex vessel as a source of two

and ulnar arteries perforator-based adipofascial flaps for cover-

independent flaps. Plast Reconstr Surg 2006;117(6):2059-2063.

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8. Huang WC, Chen HC, Jain V, et al. Reconstruction of

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through-and-through cheek defects involving the oral commissure,

artery forearm flap. Plast Reconstr Surg 2007;119(7):2153-2160.

using chimeric flaps from the thigh lateral femoral circumflex

4. Ulkur E, Acikel C, Eren F, et al. Use of dorsal ulnar neurocutaneous island flap in the treatment of chronic postburn palmar contractures. Burns 2005;31(1): 99-104 5. Wang HJ, Chou TD, Tsou TL, et al. The application of

system. Plast Reconstr Surg 2002;109(2): 433-441; 9. Casey WJ 3rd, Rebecca AM, Smith AA, et al. Vastus lateralis motor nerve can adversely affect anterolateral thigh flap harvest. Plast Reconstr Surg 2007;120(1):196-201.

new biosynthetic artificial skin for long-term temporary wound coverage. Burns 2005;31(8):991-997. 6. Koshima I, Fujitsu M, Ushio S, et al. Flow-through anterior thigh flaps with a short pedicle for reconstruction of lower leg and foot defects. Plast Reconstr Surg 2005;115(1):155-162 7. Chou EK, Ulusal B, Ulusal A, et al. Using the descending

(Received November 23, 2007) Edited by LIU Jun-lan