Thenar flap ppt.
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Thenar flapDr. Diyar A. Salih
Plastic Surgery ResidentFeb 17th, 2013
Kurdistan, Sulaimani
The thenar flap is composed of the palmar glabrous skin and its underlying subcutaneous tissue that is a used for resurfacing fingertip soft tissue defects.
Definition
Flap undersurface
Recipient defect
Indications
1. Volar pulp injuries (length preservation)2. Most applicable to index and middle finger3. Ring and little finger: less often indicated
and difficult technically in the small finger.4. Major distal phalangeal amputations.5. Amputations of any orientation on the
index, long, or ring fingers.
Relative contraindications
• Preexisting arthritis• Joint injury• Dupuytren contracture
Age is no contraindication (1)
Age
• Age is not a contraindication• Equal success 1-76 years • A review of 150 thenar flaps involving all age
groups revealed not one incident of joint restriction or other serious complication
Design1. Proximally base:
venous return high on the thenar eminence MCP skin crease Flap width:
a. equal the diameter: simple closure; flat appearance.
b. 1.5 times the diameter: restore the roundness.
2. Distally based
3. H-shaped: modifications most commonly used proximal flap cover the defect distal flap undermined in second stage and cover
donor defect to eliminate skin graft over thenar eminence.
Volar pulp Exposed bone
Case example
Flap designed on the radial aspect of the thenar eminence 1. Reduce PIP joint flexion2. Place the scar outside the palm
Marking
Lateral border designed at thethumb MCP joint crease ( protect NVB and flexor pollicis longus)
Donor site closed primarily or skin grafted
If flap designed centrally on the thenar eminence: causes painful scar in power gripping
Modification
Add fishtail dart if extended to the adductor space distally to prevent contracture.
Prepping
Recipient area preparation
Elevation
Skin and subcutaneous tissue
Inset
Tension-free closure
Hand positioning
1. MCP joint (of the recipient finger) fully flexed in a protective position
2. Minimizing PIP joint flexion. 3. DI joint flexion, further improves the
position of immobilization4. Thumb full palmar abduction or
opposition
Dressing
Advantages
Recipient1. Less conspicuous donor scar2. Avoiding a donor deficit (2)
Recipient:1. Thicker and more durable than skin graft or cross-finger
flap2. Better color and texture match3. Highly functional, durable, glabrous skin.4. Better subjective and objective sensory recovery and
cosmesis than did skin graft.5. Transferring thicker palmar skin (2)
Disadvantages and complications
• Limited amount of donor skin• Donor site scars: painful, tender, and sensitive
(reduced by donor site proper selection) that limiting function of the hand.
• Donor site skin grafting: tender and sensitive that limiting function of the hand.
• Two-stage procedure• Finger immobilization in flexion• Potential PIP joint stiffness and contracture:
Higher in older patients (above 30 years), joint diseases, men with thick, heavy hands, due to prolonged IP joint flexion
• Sensory results: good in younger patient and better than with the cross-finger flap.
• Flap ischemia and necrosis• However, in reported series of thenar flap,
patients did well with relatively fewer complications.
based on:Superficial palmar branch of radial arteryPalmar cutaneous branch of median nerve.Improved sensory recovery is raised.
Free thenar flap
Flap inset• After 10 to 14 days (1)• The base inset• Minimum surgical manipulation to maintain flap
viability• Active exercises to remobilize the hand
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