The digit is a challenging level at which to achieve good flap coverage when the wound
is large and extends the length of the digit. Smaller wounds can often be well-managed
by homodigital, heterodigital, or reverse flow metacarpal artery flaps. If a transposition
or pedicle flap is unable to accomplish the wound reconstruction, a free flap is required.
Free skin flaps can be directly innervated but are thicker than fascial flaps. Free
fascial flaps can contour much better around the convex surface of the cylindrical
digit. When placed on a flexor surface, a fascial flap can also fold to accommodate
digital flexion better than a bulkier skin flap.
A series was presented of free fascial flaps used to cover digits subjected to major
open combined trauma. The wounds were all judged too large or incorrectly located
for coverage by simpler techniques but did not include the volar pulp where an innervated
skin flap is preferred for discriminative sensibility. Ten male patients with a mean
age of 38.2 years (range: 9 to 60 years) underwent 9 lateral arm (posterior radial
collateral artery) and one serratus anterior (branch of thoracodorsal artery) free
fascial flaps with immediate split-thickness skin grafts, non-meshed. The mean defect
size was 4.4 cm × 7.6 cm (smallest, 4 × 4 cm and largest 7 × 15 cm). Eight cases were
individual digits and two cases were multiple digits. Four cases reconstructed the
volar surface of the digit, and 6 cases the dorsal surface (including the two multidigit
cases). The posterior radial collateral artery was used as a flow-through reconstruction
for digital salvage in two of the volar reconstruction cases. Reconstruction was of
one thumb, 5 index fingers, 5 long fingers, and one ring finger. The flaps covered
tendon repair sites in all cases, nerve grafts in the four volar reconstructions,
and skeletal fixation sites with hardware in 6 cases. The mechanism of injury was
5 roll-over motor vehicle accidents, 3 table saw injuries, and 2 industrial machine
crush injuries.
Table 1 Center Cases Showed Consistent Profits Over Two Years (M = $1,000,000):
| Year |
Cases |
Income |
Profit |
| I |
206 |
$1.5M |
$.49M |
| II |
182 |
$2.2M |
$.46M |
Table 2 Routine Cases Showed Marginal Profits or Losses:
| Year |
Cases |
Income |
Profit |
| I |
124 |
$0.3M |
$0.005M |
| II |
221 |
$0.4M |
($0.2M) |
Table 3 Inpatient Consults had Decreasing Losses:
| Year |
Cases |
Income |
Profit |
| I |
48 |
$1.1M |
($0.6M) |
| II |
32 |
$1.3M |
($0.1M) |
There were no complications in terms of non-union of the underlying osteosysnthesis
site, rupture of the underlying tendon repair site, or infection. All flaps were judged
at 100% survival, as were all of the immediately applied non-meshed skin grafts. Patients
entered hand rehabilitation within 72 hr of leaving the hospital, and none have required
additional surgical procedures.
