Functional resurfacing of the palm: Flap selection based on defect analysis

Abstract

Extensive defect coverage of the palm and anatomical reconstruction of its unique functional capacity remains difficult. In manual laborers, reconstruction of sensation, range of motion, grip strength but also mechanical stability is required. Sensate musculo-/fasciocutaneous flaps bear disadvantages of tissue mobility with shifting/bulkiness under stress. Thin muscle and fascial flaps show adherence but preclude sensory nerve coaptation. The purpose of this review is to present our algorithm for reliable selection of the most appropriate procedure based on defect analysis. Defect analysis focusing on units of tactile gnosis provides information to weigh needs for sensation or soft tissue stability. We distinguish radial unit (r)-thenar, ulnar unit (u)-hypothenar and unit (c)-central plus distal palm. Individual parameters need similar consideration to choose adequate treatment. Unit (r) and unit (u) are regions of secondary touch demanding protective sensation. Restoration of sensation using neurovascular, fasciocutaneous flaps is recommended. In unit (c), tactile gnosis is of less, mechanical resistance of greater value. Reconstruction of soft tissue resistance is suggested first in this unit. In laborers, free fascial- or muscle flaps with plantar instep skin grafts may achieve near to anatomical reconstruction with minimal sensation. Combined defects involving unit (c) require correlation with individual parameters for optimal flap selection. Defect coverage of the palm should not consist of merely providing sensate vascularized tissue. The most appropriate procedure should be derived from careful defect analysis to achieve near to anatomical reconstruction. In laborers, defect related demands need close correlation with sensation and mechanical stability to be expected.

Enhancing Aesthetic Outcomes of Soft-Tissue Coverage of the Hand

“…68 Although muscle and fascial flaps covered with skin grafts may be suitable alternatives, muscle flaps are generally insensate and facial flaps may ulcerate due to shear stress. In an attempt of finding the ideal match for restoring palmar defects, Engelhardt and colleagues 69 devised an algorithm based on careful ‘defect-analysis’ of the functional units and subunits of the palm as described earlier. For areas where sensation is regarded essential such as the thenar and hypothenar subunits, the authors recommended the use of free and pedicled sensate faciocutaneous flaps such as radial forearm flap, dorsal pedis artery flap, lateral arm flap or medial plantar artery flap (instep flap).…”

Soft tissue reconstruction with omental free flap in complex upper extremity injuries: Report of 13 cases

“…This is important for the reconstruction of protective sensation of the palm. The free medial plantar artery flap is useful, however its utility is limited to reconstruction of small defects of the palm . Their disadvantages are that they do not fill dead space, do not provide great circulatory contributions, and some of them have short vascular pedicles …”

“…The fascial flaps as the free temporoparietal fascial flap or local pedicled radial forearm flap with instep skin graft are a good surgical treatment only when there is no severe trauma …”

Freie M. gracilis-Lappenplastik zur anatomischen Rekonstruktion nach gliedmaßen-erhaltender Weichteil-Sarkom Resektion

“…Die Defektanalyse erfolgte analog zu der Beschriebenen an der Hohlhand [13] und am Fuß [14]. Die Deckung des Muskels mit gemeshten (n = 4) oder ungemeshten (n = 4) Spalthauttransplantaten vom medialen oder lateralen Oberschenkel erfolgte in der gleichen Sitzung.…”

“…Für eine zufriedenstellende Defektdeckung steht heute eine Vielfalt an lokalen und freien Lappenplastiken zur Auswahl, sodass das bestmögliche individuelle Verfahren im Interesse des Patienten ausgewählt werden kann. Die vielfältigen Verfahren zur Defektdeckung wurden in verschiedenen Arbeiten bereits detailliert beschrieben und gegeneinander abgewogen[13,15]. Neben einer zuverlässigen Defektdeckung unter Berücksichti-gung von Sensibilität bzw.…”