Tissue Surgery - part 3 docx

Advanced Concepts in Vascularized Tissue Transfer in the Hand 27 a b c Dorsal tissue loss Dermo-epidermal flap Subcutaneous flap Grayson’s ligament Cleland’s ligament Areas of pedicle release Split thickness skin graft Figure 3-5. Homodigital adipofascial palmar flap. (Voche P, Merle M. The homodigital subcutaneous flap for cover of dorsal finger defects. Br J Plast Surg. 1994;47(6): 435–439. Copyright (1994), with permission from The British Association of Plastic Surgeons.) 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Design of a reverse homodigital artery flap. 1 Advanced Concepts in Vascularized Tissue Transfer in the Hand 29 Thenar Flaps Based on the Superficial Palmar Branch of the Radial Artery I]Z XaVhh^X i]ZcVg ÒVe Vh V gVcYdb"eViiZgc ÒVe [dg gZXdchigjXi^c\ YZ[ZXih d[ i]Z ejae ^h lZaa`cdlcVcY ]VhWZZc YZhXg^WZYWncjbZg" djhVji]dgh# '!&&!&)!+)Ã,& >c& (!@VbZ^ZiVa#^cigd" YjXZY i]Z Å[gZZ i]ZcVg ÒVeÆ WVhZY dc i]Z hjeZgÑX^VaeVabVgWgVcX]d[i]ZgVY^VaVgiZgn# ,'  I]^h^cigdYjXi^dclVh[daadlZYWnkVg^djhkVh" XjaVg VcY cZjgd"VcVidb^XVa hijY^Zh ;^\jgZ ("-# &&!,(Ã,+ I]ZhZ hijY^Zh Xdch^hiZcian h]dlZY i]Vi i]Z hjeZgÑX^Va eVabVg WgVcX] d[ i]Z gVY^Va VgiZgn ]VhVcVkZgV\ZY^VbZiZgd[&#)bbVcYhjeea^Zh V XdchiVci VgZVd[h`^c dkZg i]Zegdm^bVa eVgih d[ i]Z VWYjXidg edaa^X^h WgZk^h VcY deedcZch edaa^X^h bjhXaZh# 6[iZg \^k^c\ d[[ V cjig^Zci WgVcX] id i]Z i]ZcVg bjhXaZ! i]Z hjeZgÑX^Va eVabVg VgiZgn WgVcX] gjch i]gdj\] i]Z WVhZ d[i]Zi]ZcVg[VhX^VVcYXdch^hiZcian\^kZheZg[d" gVi^c\ WgVcX]Zh id i]Z i]ZcVg [VhX^dXjiVcZdjh VgZV#I]ZeVabVgVheZXid[i]Zi]ZcVgZb^cZcXZ ^h Xdch^hiZcian ^ccZgkViZY Wn i]Z XjiVcZdjh WgVcX] d[ i]Z bZY^Vc cZgkZ! VcY i]Z gVY^Va VheZXi^h^ccZgkViZYWni]ZhjeZgÑX^VaWgVcX]d[ i]Z gVY^Va cZgkZ VcY i]Z aViZgVa VciZWgVX]^Va XjiVcZdjhcZgkZ# &&!,)!,*!,, <^kZci]ZVcVidbnYZhXg^WZYVWdkZ!V[VhX^d" XjiVcZdjh ÒVe XVc WZ gV^hZY i]Vi XVc Vahd WZ jhZY Vh Vc ^ccZgkViZY ÒVe# ,*!,,  I]Z aVg\Z Y^VbZiZg d[ i]Z kZhhZah Vaadlh ^ih jhZ Vh V [gZZ ÒVe# &&!,'Ã,*!,,!,- >ceVgi^XjaVgYZ[ZXih!hjX]VhbVhh^kZeVabVg YZ[ZXih VcY YZ\adk^c\ ^c_jg^Zh!VÒVeWVhZY dc i]ZhjeZgÑX^VaeVabVgWgVcX]d[i]ZgVY^VaVgiZgn XVcWZXdbW^cZYl^i]VgVY^Va[dgZVgb ÒVeWn ZmiZcY^c\ i]Z kVhXjaVg eZY^XaZ id i]Z gVY^Va VgiZgn# ,, >cVWdji+%d[VaaeZdeaZ!VY^hiVaXdc" cZXi^dcl^i]i]ZhjeZgÑX^VaeVabVgVgX]ZcVWaZh Figure 3-7. (above) Preoperative injury. Extensive injury to the radial side of the palm with damage to the radial digital artery of the index finger precludes har- vesting the heterodigital arterialized flap from the ulnar side of the index finger, as this would risk necrosis of the donor finger. As the flap came from the noncon- tiguous side of the ring finger, vein division was necessary to facilitate transfer of the flap. (below) Postoperative healing. Both the flap and the full-thickness skin graft have healed well. (Tay SC, Teoh LC, Tan SH, et al. Extending the reach of the heterodigital arterialized flap by vein division and repair. Plast Reconstr Surg. 2004;114(6):1450–1456.) 30 Tissue Surgery i]Z XgZVi^dc d[ gZkZghZ"Òdl ^haVcY ÒVeh [gdb i]Z i]ZcVg VgZV [dg gZXdchigjXi^c\ i]Z i]jbW dg [dg XdkZg^c\ eVabVg YZ[ZXih V[iZg gZhZXi^c\ 9jejnigZcÈhXdcigVXijgZ;^\jgZ(".# && Hypothenar Flaps Based on the Ulnar Palmar Digital Artery I]Zh`^cdkZgi]Z]nedi]ZcVgZb^cZcXZ^hcdjg" ^h]ZYWn bjhXjadXjiVcZdjh dg [VhX^dXjiVcZdjh eZg[dgVidg VgiZg^Zh! l]^X] eVhh i]gdj\] i]Z ]nedi]ZcVgbjhXaZhdg[VhX^V#I]ZY^hiVa]Va[d[ i]Z]nedi]ZcVgZb^cZcXZ]VhVXdchiVcikVhXj" aVghjeean[gdbi]Z jacVgeVabVg Y^\^iVaVgiZgn d[ i]Z a^iiaZ Ñc\Zg# >ccZgkVi^dc d[ i]^h VgZV ^h [gdbYdghVadgeVabVgXjiVcZdjhWgVcX]Zhd[i]Z jacVgcZgkZ;^\jgZ("&%# &%!,.Ã-& I]Z jacVg ]nedi]ZcVg ÒVe ^h YZh^\cZY dkZg i]ZjacVgVheZXid[i]ZY^hiVa]Va[d[i]Z]nedi]" ZcVgZb^cZcXZ!l]^X]^hadXViZYdkZgi]ZVWYjX" idg Y^\^i^ b^c^b^ bjhXaZ# I]Z ÒVe XVc ^cXajYZ bjai^eaZ[VhX^dXjiVcZdjheZg[dgVi^c\kZhhZahi]Vi Vg^hZ[gdbi]ZjacVgeVabVgY^\^iVaVgiZgnd[i]Z a^iiaZÑc\Zg# -'Ã-* Id XdkZg h`^c VcY hd[i i^hhjZ YZ[ZXih d[ i]Z a^iiaZÑc\Zg!i]ZÒVeXVcWZYZh^\cZYVcYigVch" [ZggZY ^cVgZigd\gVYZ [Vh]^dc# -'  >ci]ZhZ XVhZh! i]Ze^kdied^ci^hadXViZYVii]Zegdm^bVae]VaVc" \ZVa aZkZa# HZchdgn ^ccZgkVi^dc d[ i]Z VgZV ^h bV^can egdk^YZY Wn i]Z YdghVa WgVcX] d[ i]Z jacVgcZgkZ#>ci]ZhZchViZÒVe!i]Z^ccZgkVi^c\ cZgkZ^hhjijgZY idi]Z eVabVg Y^\^iVa cZgkZVi i]ZY^hiVae]VaVc\ZVa_d^ci;^\jgZ("&&# I]ZVgiZg^VaWaddYhjeeand[i]^hgZkZghZÒVe ^hZchjgZYWnXdbbjc^XVi^dcWZilZZci]ZgVY^Va a bc Figure 3-8. Variations of the superficial palmar branch of the radial artery. (Schmidt HM, Lanz U. Chirurgische Anatomie der Hand, New York: Georg Thieme Verlag, 2003.) Superficial palmar branch Radial artery Ulnar artery Superficial palmar arch Figure 3-9. Schematic drawing of a reverse flap from the thenar area. The super- ficial palmar branch of the radial artery connects to the superficial palmar arch, which enables reverse-flow island flaps to cover palmar defects. Advanced Concepts in Vascularized Tissue Transfer in the Hand 31 YZh^\c!VcY]ZcXZ i]Z kZghVi^a^in!d[ i]ZhZ adXVa ÒVeh;^\jgZ("&'# .%Ã.( >c& ,!ildbV_dgYZkZa" debZcih^ci]ZÒVelZgZgZedgiZY/ .% VcÅZmiZcYZY! gZkZghZ!YdghVabZiVXVgeVaVgiZgnÒVe!ÆYZh^\cZY Wn @VgVXVaVg Zi Va# .' 0 VcY V ÅgZkZghZ YdghVa bZiVXVgeVa VgiZgn Xdbedh^iZ ÒVeÆ XdciV^c^c\ V kVhXjaVg hZ\bZci d[ WdcZ# KVg^djh Vji]dgh gZedgiZY Xdbedh^iZ ÒVeh ^cXajY^c\ iZcYdc hZ\bZcih# -,! 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Plast Reconstr Surg. 2000;106(4):828–833.) 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Vascular network supplying dorsum of the hand: (1) rete carpi dorsale, (2) dorsal carpal arch, (3) dorsal metacarpal artery (DMCA), (4) junctura tendineae,(5) cutaneous perforator from DMCA,(6) continuation of DMCA to join the confluence of common digital artery and digital arteries, (7) lateral terminal branches of DMCA anastomosing (C) with dorsal branches of digital artery, (8) deep palmar arch, (9) proximal communication perforator between DMCA and palmar metacarpal artery (PMCA), (10) superficial palmar arch, (11) PMCA, (12) distal communicating perforator between DMCA and PMCA, (13) common digital artery, (14) digital artery to the neighboring finger, (15) digital artery to the samefinger,(a-d) dorsal branchesof thedigital artery.(Vuppalapati G,Oberlin C, Balakrishnan G. Distally based dorsal hand flaps: clinical experience, cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653–667. Copyright (2004), with permission from The British Association of Plastic Surgeons.) Figure 3-13. Extended reverse dorsal metacarpal artery flap. (Vuppalapati G, Oberlin C, Balakrishnan G. Distally based dorsal hand flaps:clinical experience,cadav- eric studies and an update. Br J Plast Surg. 2004;57(7):653–667. Copyright (2004), with permission from The British Associa- tion of Plastic Surgeons.) 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Free kite flap. a. Defect on the palmar aspect of the index finger. Both flexor tendons and the neurovascular bundles are exposed. 9 b. Results intraop- erative and c) postoperative. 9 d. 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Dorsal distal radius and ulna showing extraosseous vessels. aAnt Int A  anterior division of the anterior interosseous artery; Ant Int A  anterior interosseous artery; dlCa  dorsal intercarpal arch; dRCa  dorsal radiocarpal arch; dSRa  dorsal supraretinacular arch; 2nd EC br of 1,2 IC SRA  second extensor compartment branch of 1,2 intercompartmental supraretinacular artery; 2nd EC br of 2,3 IC SRA  second extensor compartment of 2,3 intercompartmental artery; 4th EC br of 5thECA  fourth extensor compartment branch of fifth exten- sor compartment artery; 4th ECA  fourth extensor compartment artery; 5th ECA  fifth extensor compartment artery; 1,2 IC SRA  1,2 intercompartmental supraretinacular artery; 2,3 IC SRA  2,3 intercompartmental supraretinacular artery; ODA, distal ulna  oblique dorsal artery of the distal ulna; pAnt Int A  posterior division of the anterior interosseous artery; Post Int A  posterior inter- osseous artery; RA  radial artery; UA  ulnar artery. 1 36 Tissue Surgery VcVhidbdhZh l^i] i]Z YdghVa ^ciZgXVgeVa VcY gVY^dXVgeVaVgX]Zh#I]Z*i]:86^hi]ZaVg\Zhid[ i]Z[djgYdghVakZhhZah#>i^hadXViZY^ci]ZgVY^Va Òddgd[i]ZÑ[i]ZmiZchdgXdbeVgibZci!eVhh^c\ Vii^bZh i]gdj\] i]Z )!* hZeijb#I]^h kZhhZa ^h hjeea^ZYWni]ZedhiZg^dgY^k^h^dcd[i]ZVciZg^dg ^ciZgdhhZdjh VgiZgn VcY VcVhidbdhZh Y^hiVaan l^i]i]ZYdghVa^ciZgXVgeVaVgX]#>ihaVg\ZY^Vb" ZiZg! jacVg adXVi^dc VlVn [gdb gZfj^gZY XVe" hjadidbn ^cX^h^dch!VcY bjai^eaZ VcVhidbdhZh bV`Z ^i V YZh^gVWaZ hdjgXZd[ gZigd\gVYZ WaddY Òdl#I]ZYdghVagVY^dXVgeVaVgX]VcYi]ZYdghVa hjegVgZi^cVXjaVgVgX]egdk^YZ^bedgiVciVcVhid" bdi^XXdccZXi^dchidi]ZhZ[djgkZhhZah!Vaadl^c\ ZVX]idhZgkZVhVY^hiVaanWVhZYdggZkZghZ"Òdl eZY^XaZ\gV[i^YZci^XVa^ceg^cX^eaZidi]ZgVY^Va [dgZVgbÒVe#I]Z&!'>8HG6lVhi]ZbdhijhZ[ja [dg igZVi^c\ hXVe]d^Y cdcjc^dch VcY EgZ^hZgÈh Y^hZVhZ0 VcY i]Z *i] VcY )i]  :86 lVh i]Z WZhi eZY^XaZ \gV[i [dg igZVi^c\ @^ZcWX`Èh Y^hZVhZ ;^\jgZ("&-# Id Vkd^Y iZX]c^XVa e^i[Vaah VcY id ^begdkZ Xa^c^XVa djiXdbZ! Vaa kVhXjaVg^oZY eZY^XaZ WdcZ \gV[ihbjhi]VkZVeZY^XaZd[hj[ÑX^ZciaZc\i]id gZVX]i]ZgZX^e^Zcih^iZl^i]djiiZch^dc#I]ZkVh" XjaVgeZY^XaZh]djaYegZ[ZgVWan^cXajYZcjig^Zci kZhhZahi]VihjeeanWdi]Xdgi^XVaVcYXVcXZaadjh WdcZ# )+ >c@^ZcWX`Èh Y^hZVhZ!gZkVhXjaVg^oVi^dcl^i] VkVhXjaVgWjcYaZdgkVhXjaVg^oZYWdcZ\gV[iXVc WZeZg[dgbZYZkZc^cVYkVcXZYXVhZh!egdk^YZY i]ViVc ^ciVXiXVgi^aV\Z h]Zaa ^hegZhZcil^i]dji [gVXijgZ dg [gV\bZciVi^dc VcY cd Vgi]gdh^h ^h [djcY#GZkVhXjaVg^oVi^dc^hVad\^XVaVaiZgcVi^kZ id adVY"VaiZg^c\ egdXZYjgZh VcY ^h ZheZX^Vaan ViigVXi^kZ^cjacVg"cZjigVadg"edh^i^kZkVg^VcXZ XVhZhl]ZcgVY^Vah]dgiZc^c\^hXdcigV^cY^XViZY# 8dcigV^cY^XVi^dch^cXajYZhiV\Z >KY^hZVhZ VcY ajcViZ[gVXijgZhl^i]Zmigjh^dcdghZeVgVi^dcd[ i]Z[gV\bZcih# >c EgZ^hZgÈh Y^hZVhZ!kVhXjaVg^oZY WdcZ \gV[ih VgZXdcigV^cY^XViZY^clg^hihl^i]aZkZa>>dg>>> hXVe]d^Y cdcjc^dc VYkVcXZY XVgeVa XdaaVehZ HC68 VcY ^c lg^hih l^i] V gVY^dXVgeVa _d^ci Vgi]gdh^h# &**  HVjZgW^Zg VcY 7^h]de &&+ gZedgiZY ZmXZaaZciVcYegdb^h^c\gZhjaihl^i]i]^hbZi]dY i]Vi VgZ XdbeVgVWaZ id i]Z gZhjaih YZhXg^WZY VWdkZ# I]ZW^dad\nVcYZmeZg^bZciVabdYZahd[[gVX" ijgZ]ZVa^c\l^i]kVhXjaVg^oZYWdcZ\gV[ih]VkZ XaZVganh]dlci]ZVYkVciV\ZhdkZgXdckZci^dcVa \gV[i^c\# &'%  KVhXjaVg^oZY eZY^XaZY WdcZ \gV[ih [gdb i]Z Ydghjb d[ i]Z Y^hiVa gVY^jh d[[Zg i]Z VYY^i^dcVaVYkVciV\Zd[Vh^c\aZ^cX^h^dc[dg\gV[i ]VgkZhi VcY Ydcdg h^iZ egZeVgVi^dc! l^i]dji ediZci^Va^c_jgnidi]ZeVabVgXVgeVaa^\VbZcih# ;VhiZgjc^dci^bZhVcYi]ZVW^a^inidgZkVhXjaVg" ^oZ cZXgdi^X WdcZ! ^c VYY^i^dc id i]Z iZX]c^XVa ZVhZd[]VgkZhi!]VkZbVYZi]ZhZ\gV[ihVc^bedg" iVciidda[dg]VcYhjg\Zgn# Summary >ciZchZVcVidb^XVahijY^ZhVcYgZhjai^c\bdY^Ñ" XVi^dchd[igVY^i^dcVaÒVeh]VkZaZVYidZmX^i^c\ WgZV`i]gdj\]h^ci]ZXdcXZeihd[^cig^ch^XÒVeh VcY kVhXjaVg^oZY i^hhjZ igVch[Zgh ^c i]Z ]VcY# I]Z kVg^Zin d[ dei^dch cdl VkV^aVWaZ ]Vh hjW" hiVci^Vaan Zc]VcXZY i]Z gZXdchigjXi^kZ dei^dch! ZkZc^cXdbeaZmXa^c^XVah^ijVi^dch# Figure 3-18. Intraoperative view: the 4th extensor compartment artery (ECA) is ligated distal to the bone graft and centered proximal to the radiocar- pal joint margin. It is elevated, including the overlying 4th ECA, based on an orthograde 4th ECA pedicle with retrograde flow from the 5th ECA. 1 Figure 3-17. Vascularized pedicle bone graft based on the 1,2 intercompart- mental supraretinacular artery.The incision is curvilinear,allowing wide exposure for scaphoid vascular bone graft elevation and osteonecrosis visualization. 1 S R 1,2 IC SRA RA [...]... Concepts in Vascularized Tissue Transfer in the Hand References 37 38 Tissue Surgery Advanced Concepts in Vascularized Tissue Transfer in the Hand 39 40 Tissue Surgery 4 Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery Jean Claude Guimberteau and Joseph Bakhach Introduction Microanatomical Observations In Vivo 41 42 Tissue Surgery a b c “Microvacuola”... Microvacuolar Collagenic-Absorbing System Figure 4-1 a) Traction on the paratendon during surgery b) Searching for an epitendinous plane c) Network between the tendon and the peripheral system: the MVCAS (A.D.F Video-Productions with special permission) Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery Microvacuola Figure 4-2 MVCAS under the electron... MVCAS under the electron microscope a) Histological and collagenous continuity between the epitendon and MVCAS b) Sketch of this organization, in vacuoles c) 3D tissue supports d) 3D vacuola (A.D.F Video-Productions with special permission) 43 . VgiZg^Va cZildg`# I]Z Figure 3- 1 0. Arterial anatomy of the little finger. (Schmidt HM, Lanz U. Chirur- gische Anatomie der Hand. New York: Georg Thieme Verlag, 20 03. ) Figure 3- 1 1. Diagram of the reverse. IC SRA  second extensor compartment branch of 1,2 intercompartmental supraretinacular artery; 2nd EC br of 2 ,3 IC SRA  second extensor compartment of 2 ,3 intercompartmental artery; 4th EC. extensor compartment branch of fifth exten- sor compartment artery; 4th ECA  fourth extensor compartment artery; 5th ECA  fifth extensor compartment artery; 1,2 IC SRA  1,2 intercompartmental