Clinical Presentation
A 29-year-old White female had a thermal burn injury to her right hand. She sustained a large soft tissue open wound, measuring 9 × 6 cm, over her palmar hand with the underlying bones and flexor tendons exposed. The palmar wound also extended to the volar thumb. She was managed initially by the burn service and the plastic surgery service was consulted for soft tissue reconstruction ( Fig. 20.1 ). A preoperative Allen test confirmed an adequate blood supply to the right hand via the ulnar artery system.
Operative Plan and Special Considerations
Based on the location and size of the soft tissue defect over the palmar hand, a reverse radial forearm fasciocutaneous flap could also be a good option. The flap is reliable and has a long pedicle for an easy flap inset. It can provide durable soft tissue coverage to a palmar hand wound. The Allen test should be performed preoperatively to evaluate the ulnar artery system to ensure there is an adequate blood supply to the hand when the radial artery is sacrificed after the flap elevation. A suprafascial rather than subfascial flap dissection can be performed to improve donor site cosmesis after a skin graft procedure for the donor site closure.
Operative Procedures
Under general anesthesia, the entire palmar hand wound was debrided. A reverse radial forearm flap was designed and oriented horizontally. A large skin paddle, measuring 6 × 9 cm, was marked. The proximal incision was determined based on the flap’s arc of turnover to cover the entire palmar hand wound including the thumb ( Fig. 20.2 ). The flap dissection was performed under a tourniquet control.
Once the skin incision had been made to the fascia, suprafascial dissection was performed for elevation of the skin paddle. When the dissection was about 1 cm from the pedicle vessels in both medial and lateral directions, subfascial dissection was performed to free the pedicle vessels. The proximal radial artery and its venae comitantes and the cephalic vein were divided with hemoclips and the skin paddle was elevated freely. With a zigzag incision distal to the skin paddle, the dissection of the pedicle in the distal forearm was performed between the flexor carpi radialis and brachioradialis as far as to the wrist line. The flap was turned over, based on the radial vessels in a reverse fashion, through the skin bridge between the palmar hand defect and the distal forearm. The flap was easily inset into the palmar hand wound in a reverse fashion without any tension. The flap was approximated to the adjacent skin with interrupted 3-0 Monocryl sutures in half-buried horizontal mattress fashion. A Penrose drain was placed under the flap before the final closure ( Fig. 20.3 ).
