Usage of Reversed Radial Forearm Flap for Reconstruction of Hand and Wrist Defects

INTRODUCTION
Soft tissue defects of hand and wrist with exposed
tendons; joints, nerves and bones represent
a challenge to plastic surgeons. Such defects necessitate
early flap coverage to protect underlying
vital structures, preserve hand functions and to
allow for early rehabilitation [1].
While small defects can be closed with local
transposition flaps, reconstruction of larger defects
47
should be performed using distant flaps, free flaps
or pedicle flaps. Although the application of distant
flaps is a useful method, it may be uncomfortable
for the patient and several operations may be
required [2].
Free flaps provide excellent soft tissue coverage
and allow for early rehabilitation, but they have
the disadvantages of an extended operation time,
and requirements for special equipment and microsurgery
training. Pedicle flaps may be taken from
both the distal and proximal pedicles, and there is
no need for microvascular anastomosis during the
defect reconstruction [3].
The aim of this retrospective study was to
evaluate the midterm clinical and functional results
of 15 patients who underwent reconstructionusing
reverse flow radial forearm fasciocutaneous
flaps for hand and finger dorsal complex defects
due to avulsion injuries. We also evaluated whether
this method can be reliably applied without
microsurgery.
MATERIAL AND METHODS
This descriptive, experimental study was carried
out at the Department of Plastic & Reconstructive
Surgery, Tanta University Hospitals, from December
2017 to January 2019. Total 15 patients having
soft tissue defects of the dorsum of hand and fingers
arising from various etiologies including road
traffic accidents, mechanical trauma, and industrial
trauma and fireworks injuries were included. Age
ranges between 20-43 (mean 22.5) years.
Reverse radial forearm flap was found most
suitable option in all these cases. Allen's test was
performed preoperatively to confirm the continuity
of palmar arch. Conventional reverse radial flap
was used in all the cases.
During the operation, once the flap has been
raised, blood flow through palmar arch was confirmed
by applying clamp on the proximal end of
radial artery and only then the artery was divided
and flap rotated on an arc of 180 degree. In majority
of the cases flap was tunneled to the defect site.
Only in three of the cases where subcutaneous
tunnel was not found satisfactory, it was completely
opened. Donor site was covered with split skin
graft in 13 cases and direct closure in 2 cases.
RESULTS
Fifteen cases of hand and wrist trauma were
provided soft tissue cover with reverse radial
forearm flap from December 2017 to January 2019.
Eleven patients were males and 4 were females.
Age ranges between 22-43 (mean 22.5) years. Most
common soft tissue defects 7 cases were in the
area of dorsum of hand, in 3 cases this flap was
used for the coverage of palmar defects while 5
48 Vol. 44, No. 1 / Usage of Reversed Radial Forearm Flap for Reconstruction
cases for 1st web space and the index finger defects
each.
Web space defects were covered with this flap
in 5 cases and yet another required a big flap to
cover the soft tissue defects at palm and thumb.
Patients were followed for at least three months
post-operatively. There was partial loss of two flaps,
which was debrided, and skin grafting was done.
Superficial epidermolysis was found in only 1 case,
which was managed, conservative. Rest of all the
flaps in this series survived completely. Table (1)
skin graft was applied at donor site in 13 cases,
which was taken well and direct closure in 2 cases
with small defect. Three patients were not satisfied
with the color mismatch of the grafted area.
The difference of color at grafted areas improved
in the later follow-ups visits. There was no
difficulty in post op movement of the remaining
hand function and symptoms of post-operative
neuroma were absent.
Table (1): Patients' demographic characteristics of the patients, type of injury and accompanying defects.
Gender
FF
MMMMF
MMMF
MMMM
31
34
28
21
43
39
25
26
34
38
40
20
28
37
22
No Age
123456789
10
11
12
13
14
15
Location of defect
Dorsum of the hand
1st web space
Index finger
Dorsum of the hand
Palm of the hand
1st web space
Dorsum of the hand
Dorsum of the hand
Palm of the hand
1st web and thumb
Palm of the hand
Dorsum of the hand
1st web space
Dorsum of the hand
Dorsum of the hand
Size of the flab (CM)
7.2 X 6.3
3.3 X 3
10 X 7.4
8.1 X 6.4
5.3 X 7.6
6.6 X 7.8
6.1 X 8.2
9.1 X 8.2
8 X 7.3
9.1 X 7.7
3.5 X 3
8.3 X 7.7
6.1 X 4.2
8 X 7.7
6.6 X 8.1
Outcome
Survive
Survive
Survive
Survive
Survive
Survive
Survive
Partial necrosis
Survive
Survive
Survive
Survive
Survive
Partial necrosis
Survive
2nd procedure
–––––––
Debridement and graft
–––––
Debridement and graft
–
Fig. (1,2): A 28-year old, laborer presented with machine
injury of his left hand with severe crush injury of
index, middle and ring fingers.
Fig. (3): After debridement,
reversed radial forearm flap for
soft tissue coverage of the defect
of the index was done.
Fig. (4): The patient grasps a
pice of paper with the thumb and
the reconstructed index fingers
(functioning hand).
Egypt, J. Plast. Reconstr. Surg., January 2020 49
Fig. (5): Initial marking and incision of the flap. Fig. (6): Flap isolated after division of radial artery.
Fig. (7): (Immediate post-operative) shows grafting of the
donor site.
Fig. (8): (Immediate post-operative) shows inset of the flap
to cover the defect of the index finger.
Fig. (11): A 28-years old, presented with road traffic accident
with severe crush injury of 1st web space and the
base of the thumb.
Fig. (12): Flap inset at the defect after debridement.
Fig. (13): After 6 weeks of procedure
shows complete healing.
Fig. (9): A 35-years old, presented with road traffic accident
with severe crush injury of the thinner eminence.
Fig. (10): 2 weeks' post-operative shows covering of the defect
with the flap and primary closure of the donor site.
DISCUSSION
Soft tissue defects of hands require early coverage
so that physiotherapy can be commenced
as early as possible. Coverage is necessary to
replace missing skin and to protect exposed structures
[1].
Local flaps represent the first step on the reconstructive
ladder; however, the limited arc of
rotation and extensive zone of injury produced by
these injuries limits their use [4].
Distant flaps of the hand, including the groin
and inferior hypogastric flaps essentially have the
problems which include specific position of the
hand in dressing for minimum of 3 weeks, it is
two stage procedure resulting in prolong hospital
stay and effects patient financial status due to late
return of the patient to work, clinically patient
would have stiffness on the all joints of the hand
as well as edema which is secondary to prolong
immobilization which is necessary for this procedure
[5].
When the defect cannot be closed primarily,
cannot support STSG or FTSG, and local tissue is
not available or sufficient, distant axial pattern
flaps are the option of choice [6].
Although several types of flaps are available
for reconstructing dorsal hand defects, reverse
radial forearm flap is frequently used because of
including reliable and pliable tissue [7].
It can be raised as fasciocutaneous flap, suprafascial
or adiposofascial flap and provides robust
tissues for soft tissue reconstruction of the hand,
as it has constant anatomy, this flap also provide
a better contour and avoids the necessity of having
to thin the flap. This is a resourceful flap and
according to the dimensions of the defects it can
be raised in different sizes. Large defects can also
be covered and it is documented in the literature
that whole of the skin of the forearm can be raised
on radial artery leaving 2cm cuff of skin on ulnar
aspect dorsally [8].
Microvascular free flap we have various options
like anterolateral thigh flap, lateral arm flap, scapular
and para-scapular fasciocutaneous flap and
deep inferior epigastric flap. In addition to prolong
surgical time, requires technical expertise and
specialized instruments each free flap has its own
drawback. Anterolateral thigh flap, para-scapular
and scapular flaps can be extremely thick resulting
in poor contour of the hand and requires debulking
50 Vol. 44, No. 1 / Usage of Reversed Radial Forearm Flap for Reconstruction
later on. Lateral arm flap has a limitation of donor
site closure and if skin paddle is >6cm needs skin
grafting that produces unacceptable scar in the arm
[9].
Radial forearm flaps are extremely suitable for
reconstruction of medium to large size soft tissue
defects not only on the dorsum of the hand and the
palm injuries but also for the proximal of the finger
defects.
However, there are some disadvantages to these
flaps, the most significant of which is that one of
the main arteries of the hand is sacrificed In addition,
when the defect in the area from which it has
been taken cannot be closed primarily, it is necessary
to close the donor site with a skin graft and
from a cosmetic aspect; this is a disadvantage. One
of the most distressing complications of this flap
during harvesting; is the damage of superficial
sensory branch of radial nerve which can give rise
to neuroma formation as well as sensory loss to
anatomic snuff box area and care should be taken
to avoid these problems [10].
Conclusion:
We chose this flap for our patients because the
simple one-stage procedure with constant anatomy
requires no skill in microsurgery. Also, the flap
provide thin, pliable tissue for the hand and excellent
non-bulky cover of exposed structures, with a smooth surface for tendon gliding.