Tissue Surgery - part 3 docx

Advanced Concepts in Vascularized Tissue Transfer in the Hand 27
a
b
c
Dorsal tissue loss
Dermo-epidermal flap
Subcutaneous flap
Grayson’s ligament
Cleland’s ligament
Areas of pedicle release
Split thickness skin graft
Figure 3-5. Homodigital adipofascial palmar flap. (Voche P, Merle M. The homodigital subcutaneous flap for cover of dorsal finger defects. Br J Plast Surg. 1994;47(6):
435–439. Copyright (1994), with permission from The British Association of Plastic Surgeons.)
Variations of Random-Pattern Flaps
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28 Tissue Surgery
Antegrade and Retrograde Homodigital
Artery Flaps
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Retrograde
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Figure 3-6. Design of a reverse homodigital artery flap.
1
Advanced Concepts in Vascularized Tissue Transfer in the Hand 29
Thenar Flaps Based on the Superficial Palmar
Branch of the Radial Artery
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Figure 3-7. (above) Preoperative injury. Extensive injury to the radial side of the
palm with damage to the radial digital artery of the index finger precludes har-
vesting the heterodigital arterialized flap from the ulnar side of the index finger,
as this would risk necrosis of the donor finger. As the flap came from the noncon-
tiguous side of the ring finger, vein division was necessary to facilitate transfer of
the flap. (below) Postoperative healing. Both the flap and the full-thickness skin
graft have healed well. (Tay SC, Teoh LC, Tan SH, et al. Extending the reach of the
heterodigital arterialized flap by vein division and repair. Plast Reconstr Surg.
2004;114(6):1450–1456.)
30 Tissue Surgery
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Hypothenar Flaps Based on the Ulnar Palmar
Digital Artery
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a
bc
Figure 3-8. Variations of the superficial palmar branch of the radial artery. (Schmidt HM, Lanz U. Chirurgische Anatomie der Hand, New York: Georg Thieme Verlag,
2003.)
Superficial
palmar
branch
Radial
artery
Ulnar

artery
Superficial
palmar arch
Figure 3-9. Schematic drawing of a reverse flap from the thenar area. The super-
ficial palmar branch of the radial artery connects to the superficial palmar arch,
which enables reverse-flow island flaps to cover palmar defects.
Advanced Concepts in Vascularized Tissue Transfer in the Hand 31
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Extended Dorsal Metacarpal Artery Flaps
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gZXZcianYZhXg^WZYkVg^Vi^dcd[i]ZYdghVabZiV"
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.)
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[dgVidg kZhhZa ^c i]Z egdm^bVa e]VaVcm Vi i]Z
bdhiY^hiVaWVhZd[i]ZÒVe#I]^hkZhhZaVahd[dgbh
i]Z WVhZ d[ i]Z b^Ye]VaVc\ZVa ^haVcY ÒVe VcY
[ZZYh i]Z hjWXjiVcZdjh VgiZg^Va cZildg`# I]Z
Figure 3-10. Arterial anatomy of the little finger. (Schmidt HM, Lanz U. Chirur-
gische Anatomie der Hand. New York: Georg Thieme Verlag, 2003.)
Figure 3-11. Diagram of the reverse ulnar hypothenar flap. The flap is designed
over the distal half of the ulnar aspect of the hypothenar eminence. UPDA  ulnar
palmar digital artery; PP  pivot point of the reverse flap; SPA  superficial palmar
arch; DUN  dorsal branch of the ulnar nerve. (Omokawa S, Yajima H, Inada Y,
et al. A reverse ulnar hypothenar flap for finger reconstruction. Plast Reconstr Surg.
2000;106(4):828–833.)
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egdadc\ZY ^bbdW^a^oVi^dc# >i ^h V kZghVi^aZ ÒVe
lZaa hj^iZY [dg Xdbea^XViZY Ñc\Zg^c_jg^Zh l^i]
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Flaps Based on the Dorsal Metacarpal Network
I]ZYdghjbd[i]Z]VcY^h^cXgZVh^c\anjhZYVh
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32 Tissue Surgery
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hZ\bZci d[ hZkZgZ Xdbb^cji^dc d[ i]Z egdm^"
bVa e]VaVcm l^i] i]Z adhh d[ i]Z hZ\bZciVa
ZmiZchdg iZcYdc ^c i]Z ^cYZm Ñc\Zg# I]^h ÒVe
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
@V`^cd`^ Zi Va#

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^ci]Zegdm^bVae]VaVcmd[i]Zb^YYaZÑc\ZgWn
^chZgi^c\ V hbVaa e^ZXZ d[ i]Z ^ciZgdhhZdjh
bjhXaZhjeea^ZYWnVgZkZghZÒdld[i]ZhZXdcY
YdghVabZiVXVgeVaVgiZgn^cidi]ZWdcZbVggdl
heVXZ!V[iZggVY^XVaYWg^YZbZci#
Figure 3-12. Vascular network supplying dorsum of the hand: (1) rete carpi
dorsale, (2) dorsal carpal arch, (3) dorsal metacarpal artery (DMCA), (4) junctura
tendineae,(5) cutaneous perforator from DMCA,(6) continuation of DMCA to join
the confluence of common digital artery and digital arteries, (7) lateral terminal
branches of DMCA anastomosing (C) with dorsal branches of digital artery,
(8) deep palmar arch, (9) proximal communication perforator between DMCA
and palmar metacarpal artery (PMCA), (10) superficial palmar arch, (11) PMCA,
(12) distal communicating perforator between DMCA and PMCA, (13) common
digital artery, (14) digital artery to the neighboring finger, (15) digital artery to
the samefinger,(a-d) dorsal branchesof thedigital artery.(Vuppalapati G,Oberlin
C, Balakrishnan G. Distally based dorsal hand flaps: clinical experience, cadaveric
studies and an update.
Br J Plast Surg. 2004;57(7):653–667. Copyright (2004),
with permission from The British Association of Plastic Surgeons.)
Figure 3-13. Extended reverse dorsal
metacarpal artery flap. (Vuppalapati G,
Oberlin C, Balakrishnan G. Distally based
dorsal hand flaps:clinical experience,cadav-
eric studies and an update. Br J Plast Surg.
2004;57(7):653–667. Copyright (2004),
with permission from The British Associa-
tion of Plastic Surgeons.)
Advanced Concepts in Vascularized Tissue Transfer in the Hand 33
Free “Kite” Flap
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Oberlin C, Balakrishnan G. Distally based
dorsal hand flaps: clinical experience, cadav-
eric studies and an update. Br J Plast Surg.
2004;57(7):653–667. Copyright (2004),
with permission from The British Associa-
tion of Plastic Surgeons.)
34 Tissue Surgery
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Figure 3-15. Free kite flap. a. Defect on the palmar aspect of the index finger. Both flexor tendons and the neurovascular bundles are exposed.
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b. Results intraop-
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Advanced Concepts in Vascularized Tissue Transfer in the Hand 35
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dSRa
4th EC br
of 5th ECA
5th ECA
4th ECA
ODA distal ulna
UA
pAnt Int A
2nd EC br

of 2,3 IC SRA
2,3 IC SRA
1,2 IC SRA
dRCa
dICa
2nd EC br
of 1,2 IC SRA
Post Int A
Ant Int A
aAnt Int A
RA
Figure 3-16. Dorsal distal radius and ulna showing extraosseous vessels. aAnt
Int A  anterior division of the anterior interosseous artery; Ant Int A  anterior
interosseous artery; dlCa  dorsal intercarpal arch; dRCa  dorsal radiocarpal arch;
dSRa  dorsal supraretinacular arch; 2nd EC br of 1,2 IC SRA  second extensor
compartment branch of 1,2 intercompartmental supraretinacular artery; 2nd EC
br of 2,3 IC SRA  second extensor compartment of 2,3 intercompartmental
artery; 4th EC br of 5thECA  fourth extensor compartment branch of fifth exten-
sor compartment artery; 4th ECA  fourth extensor compartment artery; 5th ECA
 fifth extensor compartment artery; 1,2 IC SRA  1,2 intercompartmental
supraretinacular artery; 2,3 IC SRA  2,3 intercompartmental supraretinacular
artery; ODA, distal ulna  oblique dorsal artery of the distal ulna; pAnt Int A 
posterior division of the anterior interosseous artery; Post Int A  posterior inter-
osseous artery; RA  radial artery; UA  ulnar artery.
1
36 Tissue Surgery
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Figure 3-18. Intraoperative view: the 4th extensor compartment artery
(ECA) is ligated distal to the bone graft and centered proximal to the radiocar-
pal joint margin. It is elevated, including the overlying 4th ECA, based on an
orthograde 4th ECA pedicle with retrograde flow from the 5th ECA.
1
Figure 3-17. Vascularized pedicle bone graft based on the 1,2 intercompart-
mental supraretinacular artery.The incision is curvilinear,allowing wide exposure
for scaphoid vascular bone graft elevation and osteonecrosis visualization.
1
S
R
1,2 IC SRA
RA
Advanced Concepts in Vascularized Tissue Transfer in the Hand 37
References
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Subcutaneous Tissue Function: The Multimicrovacuolar
Absorbing Sliding System in Hand and Plastic Surgery
Jean Claude Guimberteau and Joseph Bakhach
Microanatomical Observations In Vivo
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during surgery. b) Searching for an epi-
tendinous plane. c) Network between the
tendon and the peripheral system: the
MVCAS. (A.D.F. Video-Productions with
special permission)
Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery 43
Microvacuola
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Figure 4-2. MVCAS under the electron
microscope. a) Histological and collagenous
continuity between the epitendon and
MVCAS. b) Sketch of this organization, in
vacuoles. c) 3D tissue supports. d) 3D
vacuola. (A.D.F. Video-Productions with
special permission)