Thenar flap ppt.

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Thenar flap Dr. Diyar A. Salih Plastic Surgery Resident Feb 17 th , 2013

description

By Dr. Diyar A. Salih, a plastic surgery board trainee. Kurdistan, Sulaimani.It is a powerpoint presentation about reconstruction of finger tip injuries, using thenar flap. It includes definition of the flap, indications, relative contraindications, different designs, marking, operative technique, and complications. I hope you can get benefit from my work.

Transcript of Thenar flap ppt.

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Thenar flapDr. Diyar A. Salih

Plastic Surgery ResidentFeb 17th, 2013

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Kurdistan, Sulaimani

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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

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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.

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Relative contraindications

• Preexisting arthritis• Joint injury• Dupuytren contracture

Age is no contraindication (1)

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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

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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.

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Volar pulp Exposed bone

Case example

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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

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Modification

Add fishtail dart if extended to the adductor space distally to prevent contracture. 

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Prepping

Recipient area preparation

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Elevation

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Skin and subcutaneous tissue

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Inset

Tension-free closure

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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

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Dressing

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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)

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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.

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based on:Superficial palmar branch of radial arteryPalmar cutaneous branch of median nerve.Improved sensory recovery is raised.

Free thenar flap

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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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Thanks