73.1 Description

Volar advancement flaps allow for full-thickness soft tissue coverage for fingertip amputations. Two main types of volar advancement flaps exist: (1) the Moberg flap and (2) the V-Y volar advancement flap devised by Atasoy. ^{1 , 2} The Moberg flap addresses volar oblique soft tissue loss at the thumb. ³ It was historically performed on other digits; however, suboptimal outcomes can occur when performed on digits 2-5, leading most surgeons to restrict its use to soft tissue loss at the distal thumb. The V-Y advancement flap addresses transverse and dorsal oblique soft tissue loss on all digits. ³

73.2 Key Principles

Both the Moberg and V-Y volar advancement flaps allow for soft tissue coverage at areas of distal fingertip loss. Flap choice is based on the pattern of soft tissue loss, as the V-Y flap is best suited for transverse and dorsal-oblique-oriented defects, and the Moberg flap lends itself to volar oblique tissue defects. As flap success is predicated on full-thickness coverage, patterns that restrict full coverage, or large defects which may require the selection of another flap type (e.g., homodigital island flap) versus heterodigital reconstruction. Further, the neurovascular supply must be preserved to maintain flap viability.

73.3 Expectations

When indicated, volar advancement flaps provide full-thickness soft tissue coverage to distal fingertip amputations. Preservation of the flap’s neurovascular supply may allow for maintenance of two-point discrimination in the transposed tissue, although altered sensation is often an outcome. Cold intolerance has also been described.

73.4 Indications

73.5 Contraindications

73.6 Vascular Considerations

Understanding the vascular anatomy of the Moberg and V-Y advancement flaps affords informed flap selection. The thumb has significant contributions to its blood supply both volarly and dorsally. The dorsal contribution of the thumb emerges from the paired dorsalis pollicis arteries emanating from the first dorsal metacarpal artery off the dorsal carpal arch. These paired arteries supply the thumb’s distal phalanx, whereas the dorsal blood supply does not extend as far distally in digits 2 to 5. ⁴ Furthermore, the primary volar blood supply to the thumb emerges from paired arteries emanating from the princeps pollicis artery (a branch from the radial artery), which is located dorsally. For the other digits, the digital arteries serve as the main vascular supply to the digit volarly and the dorsum of the distal phalanx. As the Moberg flap may jeopardize the digital neurovascular bundles, digits 2 to 5 are at increased risk of flap and tip necrosis following the procedure. The thumb’s robust dorsal vasculature along with the dorsal location of its volar blood supply (from the princeps pollicis artery) protect it from this complication. ⁴

73.7 Special Instructions, Positioning, and Anesthesia

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  May be performed under local, regional, or general anesthesia

  
  
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  Visualization may be aided by the use of a forearm tourniquet for the Moberg or V-Y advancement flap; a digital tourniquet may be placed for V-Y advancement flap procedures.

  
  
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  The patient should be positioned supine with the use of a hand table.

  
  
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  Loupe magnification may assist with dissection about the neurovascular bundles.

73.8 Key Procedural Steps

73.8.1 Moberg Advancement Flap Technique

Incisions should be made midlateral along the radial and ulnar borders of the thumb, dorsal to the neurovascular bundle. Remaining dorsal will allow for advancement of the entire pedicle within the tissue. The flap is then dissected free of the flexor tendon sheath and subsequently advanced along its long axis in a proximal to distal direction. Advancement greater than 1.5 to 2 cm may require flexion at the thumb interphalangeal joint for distal coverage. The incisions are then closed primarily (► Fig. 73.1).

Related posts:

75 Thenar Flap 71 Full Thickness Skin Graft 76 Axial Flag Flap and First Dorsal Metacarpal Artery Flap (Kite Flap) 78 Radial Forearm Flap 74 Cross Finger (and Reverse) Flap 77 Z-plasty

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