15 Local and Regional Hand Flaps

10.1055/b-0038-161083

15 Local and Regional Hand Flaps

Dariush Nikkhah, Mo Akhavani

15.1 Atasoy V-Y flap

The length of the digit should be preserved and in many cases one can avoid terminalization of the digit. The V-Y flap described by Atasoy is appropriate for dorsal oblique and transverse amputations of the fingertip. To avoid a minimal advancement, it is important to release fibrous septa and detach the flap from the underlying flexor sheath. Through the following illustrations, it is described how to avoid the V-V flap (Fig. 15‑1, Fig. 15‑2, Fig. 15‑3, Fig. 15‑4, Fig. 15‑5, Fig. 15‑6, Fig. 15‑7).

Fig. 15.1 Dorsal oblique amputation of fingertip with exposed bone.

Fig. 15.2 Curvilinear markings, the flap width should be the width of the nailbed.

Fig. 15.3 Incision of the skin under digital tourniquet.

Fig. 15.4 Detachment from flexor sheath.

Fig. 15.5 Division of fibrous septa facilitates advancement. The vessels are more elastic in contrast to the fibrous septae.

Fig. 15.6 **(a,b)** Sufficient advancement achieved to provide a well-padded tip.

Fig. 15.7 **(a,b)** Flap advanced 6 mm, inset with 6.0 Vicryl Rapide, and perfused once digital tourniquet is released.

15.2 Cross Finger Flap

This robust flap is useful in patients who are smokers and have significant comorbidities that could compromise the blood supply of islanded flaps. It is useful for large volar oblique defects of the fingertip and can be divided at 2 weeks. The shortcoming is the poor donor site and ensuing stiffness that can particularly result in adult patients (Fig. 15‑8, Fig. 15‑9, Fig. 15‑10).

Fig. 15.8 **(a,b)** Markings for cross finger flap on exposed volar tendon and neurovascular bundle after flexor sheath infection and flap necrosis.

Fig. 15.9 **(a)** Final result on table with index and middle finger sutured together. **(b)** Donor site full-thickness skin grafted and quilted.

15.3 Venkataswami Flap

This flap is suited to volar oblique defects and involves islanding the flap on its neurovascular pedicle (Fig. 15‑11, Fig. 15‑12, Fig. 15‑13, Fig. 15‑14, Fig. 15‑15, Fig. 15‑16). It is often necessary to divide branches from the artery that supply the flexor tendon. For larger defects, more advancement is needed and one must perform the dissection down to the base of the digit.

The Evans flap is a variation which involves creating steps instead of a straight line. This theoretically reduces the chances of scar contracture although it is harder to design.

Fig. 15.11 The eponychial flap was not performed in this patient who had an oblique distal tip amputation with bone exposure. Reconstruction with a Venkataswami flap was performed.

Fig. 15.12 Marking for Venkataswami flap in the same patient.

Fig. 15.13 Flap dissection should begin on the side away from the pedicle. The flexor sheath should be hugged and the neurovascular pedicle should be visualized as the flap is being raised away. Incomplete exsanguination of the digit will help in identification of the artery.

Fig. 15.14 **(a,b)** Branches from the digital artery to the tendon should be divided to allow advancement.

Fig. 15.15 **(a,b)** Flap advanced nearly 1 cm to provide padded coverage over distal phalanx.

Fig. 15.16 **(a–c)** Early outcome of reconstruction with normal contour to the fingertip.

15.4 Moberg Flap

Thumb length should be preserved at all costs. To preserve length in volar oblique defects of the thumb tip, a Moberg flap can be performed. This volar advancement flap is raised using two mid-axial incisions and is based on both neurovascular bundles of the thumb, which run closer to the midline than compared to the digits.

In the original description of this flap, the thumb was simply flexed at the interphalangeal joint (IPJ) to gain flap coverage; however, subsequent modifications have involved islanding the flap to gain greater advancement. These include a V-Y plasty over thenar crease (Fig. 15‑17, Fig. 15‑18, Fig. 15‑19), or a transverse proximal incision, which is then skin grafted.