Innervated radial thenar flap combined with radial forearm flap transfer for thumb reconstruction

A radial thenar flap combined with radial forearm flap was used for the reconstruction of the ipsilateral thumb in four patients. Vascular supply of the combined flap was based on the radial artery and extending the vascular pedicle to the superficial palmar branch of the radial artery. The flap was sensated by the palmar branch of the superficial radial nerve. The size of the flap averaged 15 x 5 cm and the innervated region of the thenar eminence was an area approximately 5 x 3 cm located over the proximal parts of the abductor pollicis brevis and opponens pollicis muscles. The flap was transferred as a free flap in three patients and as an advancement flap in one patient. The flaps survived completely without complications. Satisfactory restoration of sensation was achieved in the flap area, as shown by 6 mm of average moving two-point discrimination. This combined flap may be a feasible reconstructive option for large palmar defects of the fingers such as degloving injuries.     

Pollicization for thumb reconstruction in severe pediatric hand burns

Our experience in pollicization of the index ray for severely burned hands in children is reviewed with attention to severity of burn, functional impairment, age at pollicization, procedure used, operative time, length of hospital stay, and long-term functional results. Fifteen pollicizations were performed in 11 patients with an average follow-up of over 5 years. Indication for pollicization was lack of prehension due to total loss of the thumb with the presence of a transposable index ray. The bipedicle flap method was used in two cases and the neurovascular pedicle technique was employed in all others. Skin grafts were necessary in all cases. Results were graded according to presence or absence of tip pinch, key pinch, grasp, and opposition. Significant functional improvement was seen in 14 of 15 cases (94 percent). Four patients (27 percent) developed complications requiring secondary procedures. In our experience, pollicization provides the most rapid and effective means of restoration of thumb function in the severe pediatric hand burn with multiple digit loss.     

Microsurgical transfer of the second toe for congenital deficiency of the thumb

Twelve second-toe transfers have been performed to substitute for thumbs congenitally deficient through constriction ring syndrome, symbrachydactyly, and true transverse arrest. The children were on average 3 years of age, and the youngest was undertaken at 10 months. Anatomic variations were the rule in the six cases of transverse absence and the three cases of symbrachydactyly, requiring nerves, tendons, and vessels in the toe be connected to whatever appropriate structure could be located. All transfers survived, and only one required exploration. Sensation appeared good in the 11 seen in later review, but interphalangeal motion was achieved in only 3. However, good use was made of the digit by all except one patient, an early patient in whom there was not an adequate skeleton on which to base the transfer. This small series suggests that in appropriate cases toe transfer can be undertaken early for congenital deficiency with little fear of encountering microsurgical problems unique to the infant.     

Simple method for reconstruction of the cleft hand with an adducted thumb.

We describe a new, simple method for reconstruction of a cleft hand. Ulnar transposition of the index ray followed by creation of a thumb web space is an effective way to get sufficient abduction of the thumb. This procedure is simpler than the traditional "translocation of the flap," and also it produces no circulatory troubles to worry about.     

Reconstruction of the thumb with a trimmed-toe transfer technique

The trimmed-toe transfer is a new modification of the existing great-toe transfer technique for thumb reconstruction. This procedure was devised to circumvent patient concerns regarding overly large reconstructed digits following total great-toe-to-hand transfer. This technique involves reduction of both the bony and soft-tissue elements along the medial aspect of the transferred great toe in order to produce a more normal sized thumb. Follow-up of the initial 20 patients from 1983 to 1986 demonstrates good stability, grip strength, and pinch strength. Although compared with total great-toe transfer a modest reduction in joint motion of trimmed toes has been observed, the overall appearance and usefulness of the reconstructed thumbs have been excellent.     

A new island flap transfer from the dorsum of the index to the thumb.

We describe here a new island flap from the dorsum of the index finger, transferred on the first dorsal metacarpal artery with one or two veins and the terminal branches of the radial nerve. This vascular bundle is a reliable one, for we have had no necrosis in 12 consecutive cases. The quality of its venous outflow and the use of a dorsal donor site give it advantages over the Moberg-Littler island flap, unless a dorsal vein from the latter flap is preserved and sutured to a vein in the recipient site. The arterial vascularization without any skin pedicle makes this "kite" flap a more practical one than the "flag" flaps of Vilain or Holevitch or Kuhn. Finally, a one-stage transfer is usually preferable to a two-stage one (e.g. Adamson, Braillar). In a single operation, this transfer provides composite resurfacing of the thumb while bringing in new blood and nerve supply.     

Custom-made free vascularized compound toe transfer for traumatic dorsal loss of the thumb

Dorsal compound traumatic thumb loss can be reconstructed in selected young and well-motivated patients with a custom-made partial great toe transfer. The transfer, including the nail complex and vascularized piece of bone, can be fashioned by longitudinally cutting the distal phalanx to approach the appearance of the opposite thumb and to allow for more normal nail appearance. Ten patients illustrate this technique and emphasize its reconstructive potential as well as cosmetic acceptance.     

Transplantation of an osteoarthrotendinous allograft with autogenous soft-tissue coverage for thumb reconstruction

A fresh-frozen thumb osteoarthrotendinous allograft and autogenous coverage were used to reconstruct a thumb. Immunosuppressants were not used. The components of the composite allograft are present and functioning 1 year post-operatively. Host cells have replaced and are replacing bone and tendinous structures. The "survival" of this osteoarthrotendinous allograft may have important implications in the treatment of patients with previous digital amputations, congenital absence of digits, and amputated digits that have failed replantation or are not replantable because of severely damaged vessels.     

Double-paddle peroneal tissue transfer for oromandibular reconstruction

The double-paddle peroneal tissue transfer is a useful technique for reconstructing the extensive and complex defect that results after ablative surgery for oral cancer. It can facilitate the design and inset of the skin paddle and avoid the need for a second free flap. The two skin paddles can be based on either two cutaneous perforators of the peroneal vessels or two branches of a single cutaneous perforator. The authors report their experience with double-paddle peroneal tissue flaps (10 fasciocutaneous and five osteocutaneous) in 15 patients. The largest double paddle used was (16 x 9) (15 x 6) cm, and the smallest one was (7 x 5.5) (4.5 x 4) cm. All flaps were used for both intraoral and extraoral defect reconstruction. There was one single skin paddle necrosis caused by erroneous manipulation of the flap 1 week after the operation; however, the skin paddle had survived completely before the manipulation. All other flaps survived completely, with a good to excellent appearance, and no patient had a significant gait disturbance after the operation.