Yuichi Hirase

Reverse vascular pedicle digital island flap

In 7 cases involving 8 fingers, amputation of the distal phalanx of the finger with defects of the pulp were covered by island flaps with the digital vessels acting as reverse vascular pedicles. The survival of the island flap was successful in all cases. The vascularisation of the island flap is derived from the digital palmar arch which is the anastomosis between the radial and ulnar sides of the finger. This method uses a single operative field and covers the defect with volar skin having similar qualities. However, due to problems in sensory recovery, we limit the indications for this method to the middle, ring and little fingers of the non-dominant hand.

Salvage of fingertip amputated at nail level: new surgical principles and treatments.

In this study, a new classification of fingertip amputation based on the surgical treatment is reported. Specifically, the necessity for special procedures to prevent venous congestion in fingertip replantation at the nail bed level was studied. There are some reports of successful replantations without venous anastomoses. In order to avoid technical factors, clinical cases operated on by a single surgeon were evaluated to determine what treatment is necessary for amputations at various levels to avoid necrosis due to venous congestion. During the 5-year period from October 1987 to October 1992, 150 replantations in 137 patients were performed, including 49 fingertip replantations in 45 patients who were operated on consecutively by a single surgeon. The distal phalanx (DP) of the finger was classified as zone DP-I, HA, KB, and III from distal to proximal. This classification was based not only on the amputation level but also on the difference in surgical treatment. For amputations of zone DP-I, which extends from the fingertip to the most distal dividing point of the digital artery, the amputated fingertip is attached without vascular anastomosis and the whole finger is wrapped in aluminium foil and cooled in ice water for 3 days. For amputations of zone DP-IIA and KB, anastomosis of the digital artery is performed in the central portion of the palmar region of the finger, but Kirschner wire fixation is not performed so as not to disturb the venous drainage through the medullary cavity. For amputations of zone DP-IIA, special treatment is not necessary for venous congestion, and for those of zone DP-IIB partial resection of the nail is done if necessary. For zone DP-I I amputations, venous anastomosis must be performed for salvage. All patients were operated on according to the procedures based on this classification and final survival rate was 91.5%.

Vascular anatomy of the finger dorsum and a new idea for coverage of the finger pulp defect that restores sensation

The cutaneous vascular anatomy of the finger dorsum was studied by dissection under loupe magnification of 71 fingers from 19 preserved cadaver hands. All specimens were injected with red latex or epoxy resin through a cannula in the brachial artery to identify the small vessels. The finger dorsum was supplied by the terminal branches from the dorsal metacarpal artery around the metacarpophalangeal joint. Other areas were nourished by the dorsal cutaneous branch from the proper palmar digital artery. There were two or three dorsal branches in the proximal phalangeal region and two in the middle phalangeal region. On the basis of these findings, we have developed a new method for one-stage reconstruction of finger pulp defect that restores sensation. Our innervated reverse vascular pedicle digital island flap includes the dorsal digital nerve and the proper palmar digital artery as a retrograde vascular pedicle. We have used the technique in three patients, with excellent results. The advantage of this procedure is that it provides a one-stage reconstruction of the pulp defect and restores sensation. The disadvantage is that the procedure requires neurorrhaphy.

Prefabricated sensate myocutaneous and osteomyocutaneous free flaps: an experimental model. Preliminary report.

Principles of neovascularization have been reported for the successful creation of a variety of muscle and bone free flaps. This study demonstrates a simple and effective technique for construction of prefabricated sensate myocutaneous and osteomyocutaneous free flaps in a rat model. These experiments were carried out in 20 Sprague-Dawley male rats. In half the animals, a sensate myocutaneous flap was constructed by sandwiching the superficial inferior epigastric vessels between a laterally based external abdominal oblique muscle flap and a laterally based skin flap served by an identified cutaneous nerve. A similar preparation included a piece of iliac crest bone. Two to three weeks later, now neovascularized by the sandwiched vessels, the flaps were harvested and transferred as free flaps with high reliability. An increased number of potential donor sites, the versatility of design, and the ability to customize flaps to the specific recipient-site needs are proffered.

A versatile one-stage neurovascular flap for fingertip reconstruction : the dorsal middle phalangeal finger flap

The dorsal middle phalangeal finger flap is an extremely reliable flap that is indicated for fingertip injuries which require sensory reconstruction. This flap originates from the dorsum of the middle phalanx of the finger and is elevated with a vascular pedicle of the digital artery and the dorsal branch of the digital nerve. After transfer of the flap to the injured site, epineural neurorrhaphy is done between the digital nerve and the dorsal sensory branch of the flap. This flap can be thought of as an island flap of the innervated cross-finger flap that provides excellent sensory recovery and aesthetic improvement. We used this flap in a series of eight consecutive patients and were able to follow up seven patients for longer than 6 months (mean follow-up time 10.7 months). All patients achieved measurable two-point discrimination, with an average of 4.9 mm in the moving two-point discrimination. In this study, we report our consecutive series of the dorsal middle phalangeal finger flap and its versatile utility.

Creation of neovascularised free flaps using vein grafts as pedicles: a preliminary report on experimental models

In a rat model, based on the concept of neovascularisation, an interposition vein-grafted arterial-venous fistula pedicle was used to create neovascularised skin, muscle, and bone free flaps. The important feature of these flaps is that neovascularisation of the selected flap tissues was achieved with a vein graft, unlike earlier studies using local arteries and veins as pedicles. Within a few weeks sufficient neovascularisation developed to support free transfer of the flaps based on the implanted vein graft pedicle. After successful transfer these flaps were harvested for histological examination. The implications of the clinical application of this technique are discussed.

Double-layered free temporal fascia flap as a two-layered tendon-gliding surface

We report the use of a two-layered free fascial flap consisting of temporoparietal and deep temporal fascia based on a single vascular pedicle, the superficial temporal artery and vein. The flap was used to reconstruct an extensive degloving injury of the dorsum of the hand, in which multiple intact extensor tendons lay fully exposed on all sides, with exposed bone beneath them. By sandwiching the tendons between the layers of vascularized fascia, gliding surfaces were provided, both superficial and deep to the exposed tendons. The single-stage reconstruction was completed with a split-thickness skin graft. The patient returned to heavy manual work within 12 weeks of injury. He obtained an excellent range of movement without the need for tenolysis.

Postoperative cooling enhances composite graft survival in nasal-alar and fingertip reconstruction

A simple method using ice-water and aluminium foil for enhancing composite graft survival is reported. Cooling the entire recipient site retards cellular degeneration in the graft until neovascularisation occurs. The success of this technique in nasal reconstruction using auricular chondrocutaneous tissue and nonmicrosurgical fingertip reattachment is presented. The potential application to thicker skin grafts is also discussed.

Aesthetic fingertip reconstruction with a free vascularized nail graft : A review of 60 flaps involving partial toe transfers

&NA; Microsurgical toe transfer is an established procedure for functional reconstruction of fingers. However, even if the functional loss is minimal, the fingertip defect is often a large problem for patients for not only functional reasons but also aesthetic reasons. In these patients, although the normal appearance of the fingertip is very important, total toe transfer is not acceptable because of resection of an entire toe. With this background, partial toe transfer techniques have greatly progressed. On the other hand, various types of innervated finger flaps also have been developed in hand surgery. Based on this progress, we developed the combined technique of innervated finger flaps in the hand and osteo‐onychocutaneous flaps from the toe. This technique provides better aesthetic results in fingertip reconstruction, thus broadening the indications for vascularized nail grafts. We have now experienced 60 flaps in partial toe transfer. In this report, a review of 60 consecutive flaps is presented, and the indications, technique, and postoperative treatment are discussed. (Plast. Reconstr. Surg. 99: 774, 1997.)

Secondary reconstruction by temporoparietal free fascial flap for ring avulsion injury.

We report the secondary reconstruction of an amputated finger following a ring avulsion injury using a temporoparietal fascial flap (TPFF). There have been reports of preserving degloved fingers using a cross-finger flap and an abdominal flap, but it is difficult to obtain good results with these procedures. The TPFF is an ideal, thin flap that gives excellent results, preserving movement of the phalangeal joint.