Sin-Daw Lin

The reverse digital artery flap for fingertip reconstruction

Reverse digital artery flaps were performed successfully to resurface the major fingertip defect in 10 patients and the volar defect of the middle phalanx in 1. This thin flap with its long vascular pedicle containing a digital artery and its perivascular cuff tissue has a wide arc of transposition. It can be used to reconstruct the defect located from the proximal phalanx to the fingertip of all fingers. No loss of the flap in this series was noted. The procedure is a time-saving, one-stage operation. Patients who received this procedure had no uncomfortable immobilization of the hand or long hospitalization. It also causes no disfigurement and no functional loss of the involved digit. Our clinical experience showed favorable results.

A versatile method for reconstruction of finger defects : reverse digital artery flap

Four types of the reverse digital artery flap--standard, extended, and innervated standard and extended--were developed for 52 finger defects. The arising pattern of the dorsal branch which was included in the innervated flap was studied and classified in cadaver dissections. Topographically, the described Lais line is a useful guide to locate the underlying digital artery. Refinements in flap design and surgical technique resulted in favourable functional and cosmetic results. The average two-point discrimination of the reconstructed fingertip was 6.8 mm and 3.9 mm in the noninnervated and innervated flaps, respectively. This versatile flap is an ideal and reliable option for one-stage reconstruction of various finger defects.

Adipofascial turn-over flap for reconstruction of the dorsum of the foot

Local adipofascial turn-over flaps with skin grafts were successfully used to reconstruct complicated skin defects over the dorsum of the foot in 7 patients. The blood supply of the flap comes from perforators in the base and from the surrounding subcutaneous and fascial plexuses. A new concept of base-to-flap area ratio is proposed to predict the survival of the turn-over flaps in addition to the conventional base-to-length ratio. This appears to be a valuable technique for difficult wounds of the dorsum of the foot.

Innervated reverse digital artery flap through bilateral neurorrhaphy for pulp defects

To provide sensation to the reverse digital artery (RDA) flap, both the dorsal branch from the proper digital nerve and the superficial sensory branch from the corresponding radial or ulnar nerve are sectioned at their proximal ends and included with the RDA flap. These are then anastomosed with the distal ends of both radial and ulnar digital nerves at the recipient wound. Three cases of pulp defects reconstructed by this technique achieved very favourable functional and cosmetic results. The RDA flap, innervated through bilateral neurorrhaphy, seems to be an excellent option for one-stage reconstruction of major pulp defects.

Microskin autograft with pigskin xenograft overlay: a preliminary report of studies on patients

Split-thickness pigskin graft (STPSG) was used to replace allograft skin for microskin grafting in 16 patients, nine of whom were burn patients, five suffered from traumatic defects and two from diabetic ulcers. The expansion ratios used in these patients ranged from 8:1 to 12:1. The STPSG preparation described was found to be safe for clinical application. The autogenous donor skin was excised from the inguinal area, and the donor site was primarily closed. There were no instances of donor site morbidity. The majority of the STPSG overlays adhered to the wound firmly. Histological examination showed that the microskin grafts proliferated actively immediately beneath the STPSG overlay. The time for the wound to be fully resurfaced varied from 13 to 21 days depending on the expansion ratio employed. There were only two episodes of pseudomonas infection and no further grafting was required in any of the patients. In this study the pigskin xenograft was found to provide a suitable environment for the epithelialization of microskin autografts. When allograft is not available, this is an alternative way of ensuring successful microskin grafting.

Adipofascial flap of the lower leg based on the saphenous artery

The adipofascial flap of the lower leg based on the saphenous artery is a modification of the saphenous artery flap. It has been used successfully in 5 patients for reconstruction of soft tissue defects around the knee and superior third of the tibia. The size of these flaps ranged from 5 x 12 cm to 5 x 18 cm. All flaps survived completely. These cases had minimal donor site morbidity because their donor sites were closed primarily with the preserved overlying skin.

Reconstruction of plantar heel defect using reinnervated, skin-grafted flexor digitorum brevis flap

Two cases with extensive plantar avulsion injuries had their heel defects resurfaced initially with full thickness skin grafts. Two months later, reinnervation presented in areas of grafted skin innervated by medial and lateral plantar nerves. No reinnervation was found in the plantar heel region originally innervated by the medial calcaneal nerve. Heel ulceration in the non-sensate, grafted skin occurred in the first case. Reinnervated, skin-grafted flexor digitorum brevis muscle flaps were then used for reconstructing the non-sensate plantar heels. There was no breakdown of skin during the follow-up period of 8 months and 6 months respectively. This method provides sensate and durable cover for extensive plantar heel defects.

The lateral calcaneal artery adipofascial flap.

The lateral calcaneal artery adipofascial flap is a modification of the lateral calcaneal artery skin flap. It has been used successfully in five patients. In comparison to the skin flap, it has the advantages of more versatile clinical applications, better aesthetic result of the donor site and sural nerve preservation.

Amnion overlay meshed skin autograft.

Meshed skin autografts are conventionally dressed with fine petrolatum gauzes. Pain and haemorrhage are a frequent sequel to changing dressings in the early days after grafting. We have explored the use of amnion to overlay the meshed autograft (3:1) in addition to the fine petrolatum gauze. Eleven patients with 24 burn wounds were treated. The amnion provided good protection to the underlying meshed autograft and the neoepithelium. It did not block the re-epithelialization and may have promoted the healing process. Most of the grafts had healed completely by 7 days after application. Pain and haemorrhage were markedly reduced. The non-antigenic nature, adherent quality and inexpensive cost makes amnion a promising biological dressing for meshed autografts.

Clinical application of adipofascial turn-over flaps for burn wounds

Local adipofascial turn-over flaps overlaid with skin grafts were used successfully to reconstruct nine deep burn wounds following electric injuries or contact burns in seven patients. Durable flap coverage of the exposed tendons, joints or bones can be achieved with a one-stage procedure. Appropriate length-to-width ratio and flap-to-base area ratio, and the tension-free insetting of the flap are essential for flap survival. The non-adherent characteristic of the adiposal component of the flap enables the underlying involved tendons or joints to glide through without adherence, and the rich vascular network in the fascia provides an ideal bed for the skin graft. The adipofascial turn-over flap is a reliable and simple technique for reconstruction of certain deep burn wounds if the surrounding soft tissue is available. The functional and cosmetic results in our series have been rewarding and satisfactory.