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CC BY-NC-ND 4.0 · J Reconstr Microsurg Open 2020; 05(02): e107-e114
DOI: 10.1055/s-0040-1721705
Original Article

Evaluation of Primary and Secondary Free Flap Desyndactylization Techniques in Hand and Digit Reconstruction: A Systematic Review

Michael B. Gehring
1   Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
,
Matthew L. Iorio
1   Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
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Abstract

Objective Injuries of the hand often require free flap reconstruction. To minimize flap loss, evidence exists to surgically syndactylize digits when repairing multiple injuries, with delayed flap division, or desyndactylization. However, evidence suggests that division of the flap at the time of inset can be accomplished with minimal negative effect. The purpose of this study was to evaluate outcomes, following hand reconstruction with free flaps utilizing either acute or staged desyndactylization techniques.

Methods A systematic review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Articles that described the use of a free flap for surgically syndactylized digits or multilobed flaps for coverage of multiple digits were included.

Results One hundred sixty-one articles were reviewed with 34 fulfilling inclusion criteria. One hundred seventeen patients underwent 145 free flap reconstructions. Traumatic avulsions (49%) were the most common injuries, followed by burns (11%). Twenty-one (62%) papers described surgical syndactylization of digits, which were later desyndactylized and five (15%) papers included reconstruction of more than one digit with multilobed free flaps. Eight papers (24%) described both techniques. Overall, 100% of included flaps survived. Total complication rate was 6%, with six complications (67%) occurring in flaps with primary syndactylization.

Conclusion Hand defects often require free flaps for reconstruction. Although free flaps for the reconstruction of digital defects is technically demanding, they result in better outcomes. With available evidence indicating complications rates less than those of staged desyndactylization, multidigit reconstruction with multilobed free flaps may be a more desirable technique.

Keywords

surgical syndactylization - multilobe free flaps - hand reconstruction

Supplementary Material



Publication History

Received: 22 September 2020

Accepted: 27 October 2020

Article published online:
18 December 2020

© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Saint-Cyr M, Gupta A. Indications and selection of free flaps for soft tissue coverage of the upper extremity. Hand Clin 2007; 23 (01) 37-48
    CrossrefPubMedGoogle Scholar
  • 2 Miller EA, Friedrich J. Soft tissue coverage of the hand and upper extremity: the reconstructive elevator. J Hand Surg Am 2016; 41 (07) 782-792
    CrossrefPubMedGoogle Scholar
  • 3 Gupta A, Lakhiani C, Lim BH. et al. Free tissue transfer to the traumatized upper extremity: Risk factors for postoperative complications in 282 cases. J Plast Reconstr Aesthet Surg 2015; 68 (09) 1184-1190
    CrossrefPubMedGoogle Scholar
  • 4 Chen HC, Buchman MT, Wei FC. Free flaps for soft tissue coverage in the hand and fingers. Hand Clin 1999; 15 (04) 541-554
    CrossrefPubMedGoogle Scholar
  • 5 Giessler GA, Erdmann D, Germann G. Soft tissue coverage in devastating hand injuries. Hand Clin 2003; 19 (01) 63-71 , vi
    CrossrefPubMedGoogle Scholar
  • 6 Slavin SA, Upton J, Kaplan WD, Van den Abbeele AD. An investigation of lymphatic function following free-tissue transfer. Plast Reconstr Surg 1997; 99 (03) 730-741 , discussion 742–743
    CrossrefPubMedGoogle Scholar
  • 7 Yu G, Lei HY, Guo S, Yu H, Huang JH. Treatment of degloving injury of three fingers with an anterolateral thigh flap. Chin J Traumatol 2011; 14 (02) 126-128
    PubMedGoogle Scholar
  • 8 Xie G, Hu Z, Miao C, Chen W, Mei L. The free triple chimeric dorsalis pedis flaps for repair of multifinger soft tissue defects: a report of two cases. Microsurgery 2013; 33 (08) 660-666
    CrossrefPubMedGoogle Scholar
  • 9 Trovato MJ, Brooks D, Buntic RF, Buncke GM. Simultaneous coverage of two separate dorsal digital defects with a syndactylizing venous free flap. Microsurgery 2008; 28 (04) 248-251
    CrossrefPubMedGoogle Scholar
  • 10 Cho BC, Lee JH, Weinzweig N, Baik BS. Use of the free innervated dorsalis pedis tendocutaneous flap in composite hand reconstruction. Ann Plast Surg 1998; 40 (03) 268-276
    CrossrefPubMedGoogle Scholar
  • 11 Eren F, Oksuz S, Karagöz H, Melikoğlu C, Ulkur E. Multi-digit contracture release using medial sural artery perforator flap with syndactylization-desyndactylization method. Hippokratia 2015; 19 (04) 366-368
    PubMedGoogle Scholar
  • 12 Tsai FC, Cheng MH, Chen HC, Wei FC. Microsurgical medialis pedis flaps for reconstruction of soft-tissue defects in the hand. Ann Plast Surg 2002; 48 (01) 41-47
    CrossrefPubMedGoogle Scholar
  • 13 Giessler GA, Schmidt AB, Germann G, Pelzer M. The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries. J Reconstr Microsurg 2011; 27 (09) 567-573
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Woo SH, Kim KC, Lee GJ. et al. A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: an 11-year experience. Plast Reconstr Surg 2007; 119 (06) 1823-1838
    CrossrefPubMedGoogle Scholar
  • 15 Zheng H, Liu J, Dai X, Schilling AF. Free conjoined or chimeric medial sural artery perforator flap for the reconstruction of multiple defects in hand. J Plast Reconstr Aesthet Surg 2015; 68 (04) 565-570
    CrossrefPubMedGoogle Scholar
  • 16 Agarwal JP, Agarwal S, Adler N, Gottlieb LJ. Refining the intrinsic chimera flap: a review. Ann Plast Surg 2009; 63 (04) 462-467
    CrossrefPubMedGoogle Scholar
  • 17 Yan H, Zhang F, Akdemir O. et al. Clinical applications of venous flaps in the reconstruction of hands and fingers. Arch Orthop Trauma Surg 2011; 131 (01) 65-74
    CrossrefPubMedGoogle Scholar
  • 18 Lai CL, Ou KW, Chiu WK. et al. Reconstruction of the complete loss of upper and lower lips with a chimeric anterolateral thigh flap: a case report. Microsurgery 2012; 32 (01) 60-63
    CrossrefPubMedGoogle Scholar
  • 19 Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535
    CrossrefPubMedGoogle Scholar
  • 20 Iñigo F, Gargollo C. Secondary coverage of the hand using a dorsalis pedis plus first web space free flap. J Reconstr Microsurg 1992; 8 (06) 461-465
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Inoue G, Suzuki K. Arterialized venous flap for treating multiple skin defects of the hand. Plast Reconstr Surg 1993; 91 (02) 299-302 , discussion 303–306
    CrossrefPubMedGoogle Scholar
  • 22 Kantarci U, Cepel S, Gürbüz C. Venous free flaps for reconstruction of skin defects of the hand. Microsurgery 1998; 18 (03) 166-169
    CrossrefPubMedGoogle Scholar
  • 23 Kim KS, Kim ES, Kim DY, Lee SY, Cho BH. Resurfacing of a totally degloved hand using thin perforator-based cutaneous free flaps. Ann Plast Surg 2003; 50 (01) 77-81
    CrossrefPubMedGoogle Scholar
  • 24 Kim SW, Lee HJ, Kim JT, Kim YH. Multiple-digit resurfacing using a thin latissimus dorsi perforator flap. J Plast Reconstr Aesthet Surg 2014; 67 (01) 74-80
    CrossrefPubMedGoogle Scholar
  • 25 Lin YT, Henry SL, Lin CH. et al. The shunt-restricted arterialized venous flap for hand/digit reconstruction: enhanced perfusion, decreased congestion, and improved reliability. J Trauma 2010; 69 (02) 399-404
    CrossrefPubMedGoogle Scholar
  • 26 Lin TS. One-stage debulking procedure after flap reconstruction for degloving injury of the hand. J Plast Reconstr Aesthet Surg 2016; 69 (05) 646-651
    CrossrefPubMedGoogle Scholar
  • 27 Ninkovíc MM, Schwabegger AH, Wechselberger G, Anderl H. Reconstruction of large palmar defects of the hand using free flaps. J Hand Surg [Br] 1997; 22 (05) 623-630
    CrossrefPubMedGoogle Scholar
  • 28 Sakai S. Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers. Plast Reconstr Surg 2003; 111 (04) 1412-1420 , discussion 1421–1422
    CrossrefPubMedGoogle Scholar
  • 29 Shilov BL. Resurfacing of the damaged hand by the prefabricated free flap including serratus fascia: a case report. Microsurgery 1995; 16 (06) 370-372
    CrossrefPubMedGoogle Scholar
  • 30 Takeuchi M, Sakurai H, Sasaki K, Nozaki M. Treatment of finger avulsion injuries with innervated arterialized venous flaps. Plast Reconstr Surg 2000; 106 (04) 881-885
    CrossrefPubMedGoogle Scholar
  • 31 Wong SS, Wang ML, Su MS, Wei FC. Free medialis pedis flap as a coverage and flow-through flap in hand and digit reconstruction. J Trauma 1999; 47 (04) 738-743
    CrossrefPubMedGoogle Scholar
  • 32 Woo SH, Jeong JH, Seul JH. Resurfacing relatively large skin defects of the hand using arterialized venous flaps. J Hand Surg [Br] 1996; 21 (02) 222-229
    CrossrefPubMedGoogle Scholar
  • 33 Vogt PM, Mett TR, Bingoel AS, Jokuszies A, Krezdorn N. Reconstruction of basic hand function by a free osteocutaneous spare-part flap from the lower leg after septicemia: a case report. Hand (N Y) 2020;1558944720906499
    PubMedGoogle Scholar
  • 34 Xu L, Xu J, Shou K, Rui Y. Repair of avulsion injury of the whole hand with single-stage transfer of five combined tissues: case report. J Reconstr Microsurg 2003; 19 (02) 79-84 , discussion 85–86
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Chai YM, Wang CY, Wen G, Zeng BF, Cai PH, Han P. Combined medialis pedis and medial plantar fasciocutaneous flaps based on the medial plantar pedicle for reconstruction of complex soft tissue defects in the hand. Microsurgery 2011; 31 (01) 45-50
    CrossrefPubMedGoogle Scholar
  • 36 Chung KC, Tong L. Use of three free flaps based on a single vascular pedicle for complex hand reconstruction in an electrical burn injury: a case report. J Hand Surg Am 2001; 26 (05) 956-961
    CrossrefPubMedGoogle Scholar
  • 37 Tsai FC, Yang JY, Mardini S, Chuang SS, Wei FC. Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects. Plast Reconstr Surg 2004; 113 (01) 185-193 , discussion 194–195
    CrossrefPubMedGoogle Scholar
  • 38 Hung MH, Huang KF, Chiu HY, Chao WN. Experience in Reconstruction for Small Digital Defects With Free Flaps. Ann Plast Surg 2016; 76 (Suppl. 01) S48-S54
    CrossrefPubMedGoogle Scholar
  • 39 Tang L, Pafitanis G, Yang P. et al. Combined multi-lobed flaps: a series of 39 extensive hand and multi-digit injuries one-staged reconstructions using modified designs of ALT, DPA and chimeric linking flaps. Injury 2017; 48 (07) 1527-1535
    CrossrefPubMedGoogle Scholar
  • 40 Caulfield RH, Maleki-Tabrizi A, Birch J, Ramakrishnan V. Salvage of finger length in septicemic necrosis using 3 free flaps from a single anterolateral thigh donor site. Ann Plast Surg 2008; 60 (06) 623-625
    CrossrefPubMedGoogle Scholar
  • 41 Gao W, Hong J, Li Z, Chen X. Hand reconstruction with lobulated combined flaps based on the circumflex scapular pedicle. Microsurgery 2008; 28 (05) 355-360
    CrossrefPubMedGoogle Scholar
  • 42 Okada M, Saito H, Kazuki K, Nakamura H. Combined medialis pedis and medial plantar fasciocutaneous flaps for coverage of soft tissue defects of multiple adjacent fingers. Microsurgery 2014; 34 (06) 454-458
    CrossrefPubMedGoogle Scholar
  • 43 Pan ZH, Jiang PP, Xue S. Free iliac flap for treating multiple skin defects of the hand and digits. J Hand Surg Eur Vol 2013; 38 (09) 952-958
    CrossrefPubMedGoogle Scholar
  • 44 Pan ZH, Jiang PP, Xue S, Li H, Wang JL. Restoration of basic hand function following devastating hand injuries using a microsurgically fabricated chimeric iliac osteocutaneous flap. J Plast Reconstr Aesthet Surg 2017; 70 (06) 723-728
    CrossrefPubMedGoogle Scholar
  • 45 Ulrich D, Pallua N. Treatment of avulsion injury of three fingers with a compound thoracodorsal artery perforator flap including serratus anterior fascia. Microsurgery 2009; 29 (07) 556-559
    CrossrefPubMedGoogle Scholar
  • 46 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
    CrossrefPubMedGoogle Scholar
  • 47 Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 1992; 89 (03) 478-487 , discussion 488–489
    CrossrefPubMedGoogle Scholar
  • 48 Ofer N, Baumeister S, Megerle K, Germann G, Sauerbier M. Current concepts of microvascular reconstruction for limb salvage in electrical burn injuries. J Plast Reconstr Aesthet Surg 2007; 60 (07) 724-730
    CrossrefPubMedGoogle Scholar
  • 49 Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008; 28 (08) 632-634
    CrossrefPubMedGoogle Scholar
  • 50 Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period. J Trauma 2009; 67 (04) 752-757
    CrossrefPubMedGoogle Scholar
  • 51 Masquelet AC, Romana MC. The medialis pedis flap: a new fasciocutaneous flap. Plast Reconstr Surg 1990; 85 (05) 765-772
    CrossrefPubMedGoogle Scholar
  • 52 Chen HC, Tang YB, Mardini S, Tsai BW. Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators. Microsurgery 2004; 24 (04) 270-280
    CrossrefPubMedGoogle Scholar
  • 53 Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg 1989; 22 (06) 495-500
    CrossrefPubMedGoogle Scholar
  • 54 Lai CH, Lai CS, Huang SH, Lin SD, Chang KP. Free medial plantar artery perforator flaps for the resurfacing of thumb defects. Ann Plast Surg 2010; 65 (06) 535-540
    CrossrefPubMedGoogle Scholar
  • 55 Flatt AE. The thenar flap. J Bone Joint Surg Br 1957; 39-B (01) 80-85
    CrossrefPubMedGoogle Scholar
  • 56 Hastings II H. Dual innervated index to thumb cross finger or island flap reconstruction. Microsurgery 1987; 8 (03) 168-172
    CrossrefPubMedGoogle Scholar
  • 57 Shi SM, Lu YP. Island skin flap with neurovascular pedicle from the dorsum of the index finger for reconstruction of the thumb. Microsurgery 1994; 15 (02) 145-148
    CrossrefPubMedGoogle Scholar
  • 58 Inoue T, Kobayashi M, Harashina T. Finger pulp reconstruction with a free sensory medial plantar flap. Br J Plast Surg 1988; 41 (06) 657-659
    CrossrefPubMedGoogle Scholar
  • 59 Gu JH, Jeong SH. Radical resection of a venous malformation in middle finger and immediate reconstruction using medial plantar artery perforator flap: a case report. Microsurgery 2012; 32 (02) 148-152
    CrossrefPubMedGoogle Scholar
  • 60 Chuang DC, Colony LH, Chen HC, Wei FC. Groin flap design and versatility. Plast Reconstr Surg 1989; 84 (01) 100-107
    CrossrefPubMedGoogle Scholar
  • 61 Kimata Y, Uchiyama K, Ebihara S. et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997; 123 (12) 1325-1331
    CrossrefPubMedGoogle Scholar
  • 62 Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg 1998; 102 (05) 1517-1523
    CrossrefPubMedGoogle Scholar
  • 63 Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92 (03) 421-428 , discussion 429–430
    CrossrefPubMedGoogle Scholar
  • 64 Kimura N, Saitoh M. Free microdissected thin groin flap design with an extended vascular pedicle. Plast Reconstr Surg 2006; 117 (03) 986-992
    CrossrefPubMedGoogle Scholar
  • 65 del Piñal F, García-Bernal FJ, Studer A, Ayala H, Cagigal L, Regalado J. Super-thinned iliac flap for major defects on the elbow and wrist flexion creases. J Hand Surg Am 2008; 33 (10) 1899-1904
    CrossrefPubMedGoogle Scholar
  • 66 Hudak PL, Amadio PC, Bombardier C. The Upper Extremity Collaborative Group (UECG). Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. Am J Ind Med 1996; 29 (06) 602-608
    CrossrefPubMedGoogle Scholar
  • 67 Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg Am 1998; 23 (04) 575-587
    CrossrefPubMedGoogle Scholar