Abstract
To investigate the effect of free lateral tarsal artery perforator flap in the repair of the volar skin defect of the thumb. From January 2020 to December 2022, the free lateral tarsal artery perforator flap was used to repair the skin defect of the palmar side of the thumb in 11 cases. There were 9 males and 2 females with an average age of 45 years (range, 35–62 years). The causes of injury were mechanical injury in 8 cases, traffic accident in 3 cases, combined with different degrees of tendon and bone exposure and injury. The time from injury to operation was 1 to 4 hours, with an average of 2.5 hours. The size of the flap ranged from 3.0 cm × 3.0 cm to 5.5 cm × 5.0 cm, and the donor site was repaired with the skin graft. All the flaps and skin grafts survived successfully, and the wounds healed in the first stage. All patients were followed up for 6 to 24 months, with an average of 15 months. The appearance of the flap was good, with normal color, no pigmentation, and a soft texture. The 2-point discrimination of the flap was 6 to 11 mm, with an average of 8.5 mm at 6 months after operation. At the last follow-up, 8 cases were excellent and 3 cases were good according to the trial standard of upper limb function evaluation of the Chinese Society of Hand Surgery of the Chinese Medical Association, and the excellent and good rate was 100%. There was no significant effect on the sensation and function of the feet in the donor site, and the patient satisfaction was high. Free lateral tarsal artery perforator flap is a good choice to repair the skin defect of the palmar side of the thumb because of its simple operation, high survival rate and good sensory recovery of the recipient area.
Keywords: lateral tarsal artery perforator flap, microsurgery, skin defect
1. Introduction
The hand is an important motor and sensory organ of the human body, and the function of the thumb is particularly important. Thumb damage is not fatal, but it brings great pain to the victim, and the treatment is difficult and demanding, and it is easy to leave disability.[1,2] Because of its anatomical characteristics, when the volar skin defect of the thumb often can not be closed by itself, if it is allowed to heal naturally, it will form scars and cause hand dysfunction.[3] From the point of view of treatment, according to the local anatomical characteristics of the distal thumb, when the palmar skin of the distal thumb is missing 1/2, the wound is difficult to close by itself.[4]
With the development of microsurgical techniques, there are more and more methods to repair skin defects. Different repair methods have their advantages and disadvantages, and clinicians have their preferences.[5] Hand wounds often need flap transplantation from other parts because of dense skin texture and less subcutaneous soft tissue. The free lateral tarsal artery flap is a commonly used method to repair hand wounds in a clinic, which has the following advantages: the vascular pedicle of the flap is superficial, so it is not necessary to separate the muscle tissue deeply when cutting; The lateral tarsal artery flap has less subcutaneous tissue, is relatively thin, is close to the skin color and texture of the hand, has a satisfactory shape of the repaired finger, and does not need secondary plastic surgery. The flap with the lateral dorsalis pedis nerve has good sensory function, and the donor site is relatively hidden.[6,7] Therefore, when transplanting the skin defect of the hand, adequate evaluation should be carried out, and the lateral tarsal artery perforator flap should be used as far as possible when the wound area is small.[8]
In recent years, there are few clinical reports on the selection of a flap for the volar skin defect of the thumb to ensure coverage of the wound and complete nerve repair at the same time. In this study, the author completed 11 cases of free lateral tarsal artery perforator flap to repair the volar skin defect of the thumb from January 2020 to December 2022. Satisfactory results have been achieved.
2. Materials and methods
2.1. Clinical data
From January 2020 to December 2022 in the First Affiliated Hospital of Bengbu Medical College, free lateral tarsal artery perforator flaps were used to repair 11 patients with volar thumb skin defects. This study was approved by the institutional ethical review board of First Affiliated Hospital of Bengbu Medical College. There were 9 males and 2 females, with an average age of 45 years (range, 35–62 years). The causes of injury were mechanical injury in 8 cases, traffic accident in 3 cases, and combined with different degrees of exposure and injury of tendon and bone. The time from injury to operation was 1 to 4 hours, with an average of 2.5 hours. The size of the flap ranged from 3.0 cm × 3.0 cm to 5.5 cm × 5.0 cm, and the donor site was repaired with a skin graft.
2.2. Preoperative management
After admission, emergency debridement, removal of necrotic skin tissue, internal fixation of fracture with Kirschner wire, suture and repair of ruptured tendon, anastomosis of ruptured proper digital artery, and perineurial suture of ruptured nerve were performed. The wounds were covered with continuous vacuum sealing drainage dressings, and the secondary flap repair was performed when the wounds were relatively clean 1 week later.
2.3. Operation method
The medial border of the flap was incised along the axis passing through the lateral tarsal artery, and the extensor digitorum brevis and extensor digitorum brevis were retracted medially to expose the lateral tarsal artery. The origin of the lateral tarsal artery was found at the proximal end of the dorsal pedis artery for dissection, and the lateral tarsal artery was dissected laterally at the outer edge of the extensor digitorum brevis to the base of the fifth metatarsal bone. After the cutaneous branch entered the flap, the blood vessel was protected and carefully dissected on the periosteal surface. The soft tissue around the vascular pedicle protected the cutaneous branch of the blood vessel and carried the lateral dorsal pedis cutaneous nerve. The lateral border of the flap was then incised, and the flap was carefully dissected retrogradely along the vascular pedicle. The flap and the blood vessels were dissected together from the lower part of the extensor digitorum tendon and through the submuscular tunnel to the dorsalis pedis artery at the origin of the lateral tarsal artery. The tourniquet was loosened and the vascular pedicle was disconnected after the blood supply of the flap was observed. The pedicle of the flap was cut off and moved to the recipient area of the finger to check whether there was blood leakage from the branches of the blood vessels. If there was, the flap was ligated to stop bleeding. The 2 lateral tarsal veins were anastomosed with the finger veins, the lateral tarsal artery was anastomosed with the main artery of the finger, and the lateral cutaneous nerve of the dorsum of the foot was anastomosed with the digital nerve of the finger. A full-thickness skin graft was taken from the abdomen and grafted to the donor site of the flap.
2.4. Postoperative management
Stay in bed strictly for 1 week. Anti-inflammatory, anticoagulant, anti-vasospasm drugs and blood-activating drugs were used for 5 to 7 days. Raise the affected limb and irradiate it with a baking lamp. The blood supply of the flap was closely observed after the operation. One week after the operation, the compression suture package of the foot donor site was opened, and 2 weeks after the operation, the suture was removed, and the wrist and finger function exercises were started after the plaster was removed.
2.5. Postoperative follow-up
All patients were followed up for 6 to 24 months (mean, 15 months). Contents of follow-up: investigate the satisfaction degree of patients to the flap; detect the pain sensation, temperature sensation and touch sensation of the flap; evaluate the appearance and grade the sensory function of the flap according to the trial standard of upper limb function evaluation of Chinese Medical Association Hand Surgery Association.[9]
3. Results
After operation, the skin flap and the skin graft of the donor site survived smoothly, and the wound healed by first intention. The appearance of the flap was good, with normal color, no pigmentation, and soft texture. The 2-point discrimination of the flap was 6 to 11 mm, with an average of 8.5 mm at 6 months after operation. All patients returned to normal life and work, and finger flexion and extension activities were satisfactory. At the last follow-up, 8 cases were excellent and 3 cases were good according to the trial standard of upper limb function evaluation of the Hand Surgery Society of the Chinese Medical Association,[9] and the excellent and good rate was 100%. Feet sensation and function in the donor site were not significantly affected. See Table 1 and Figure 1 for details.
Table 1.
Summarized data.
| Number of patient | Male | Female |
|---|---|---|
| 9 | 2 | |
| Median age (yr) | 45 (35–62) | |
| Etiology | Traffic accident | Machine damage |
| 3 | 8 | |
| Flap dimension (cm) | 3.0 × 3.0 – 5.5 × 5.0 | |
| Two point discrimination (mm) | 8.5 (6–11) | |
| Mean fap thickness (mm) | 8.0 (5–11) | |
| BMI | 24.8 (18–32) | |
| Follow up (mo) | 15 (6–24) |
BMI = body mass index.
Figure 1.
A patient with Thumb damage. (A) Preoperative condition. (B) Flap design. (C) The artery and accompanying vein were anastomosed with the affected part during operation. (D) Postoperative condition. (E) Six months after surgery. (F) Postoperative supply area.
4. Discussion
Because of physiological and anatomical reasons, the skin defect on the palm side of the thumb often can not be closed by itself. If it is allowed to heal naturally, it will form scars and cause hand dysfunction, and even fracture and tendon exposure in serious cases. Therefore, the wound surface is difficult to be repaired by skin grafting.[10] Therefore, skin flap repair is one of the main ways in the clinic. However, because of the variety of donor site selection and the different postoperative recovery effects, there is also a great clinical controversy.
At present, the main flap repair is the lateral tarsal artery flap repair. The main reason is that the anatomical position is relatively fixed, the lateral wall of the blood vessel has enough thickness to withstand long-term migration during the operation, and the vascular pedicle is ideal, which can be used as the main flap donor site for the foot defects.[11] At the same time, the flap has sensory nerves, which can effectively reconstruct the sensation of the defect and provide a more satisfactory tactile system, and has less impact on the flap area.[12]
The lateral tarsal artery is an extension of the dorsal pedis artery, which passes through the surface of the navicular bone, passes through the deep side of the extensor digitorum brevis, clings to the surface of the cuboid bone to the base of the fifth metatarsal bone, and anastomoses with the perforating descending branch of the fibular artery and the lateral calcaneal artery.[13] The refluxing veins of the flap are 2 concomitant veins, which are innervated by the lateral dorsal pedis cutaneous nerve.[14] The perforating point of the cutaneous branch of the lateral tarsal artery and the projection line on the body surface have obvious landmarks and are easy to find. It does not need deep separation during the operation, which can reduce the injury of the surrounding muscle tissue. At the same time, the immunity of the flap is generally 3.0 cm × 5.0 cm, which can meet intraoperative needs.[15]
The limitations of the study are the blood vessels of the flap branch are fine and can easily cause damage during free cutting; the scope of flap cutting is limited, so carefully repair large skin defects; the foot supply area has the risk of necrosis. Of course, patients with poor physical nutrition, poor vascular conditions and poor coagulation function should not advocate the emergency lateral tarsal flap repair, but should be treated in a relatively simple method.
In the course of the study, we found that many points in the operation are worth learning from: the course of the lateral tarsal artery is often not fixed and varies from person to person, so we should try our best to understand the patient’s condition before operation, and it is better to use color Doppler ultrasound to explore and determine the location of the blood vessel; The cutaneous branches of the lateral tarsal artery are widely distributed and easily injured, so it is difficult to dissect them during the operation. In the process of dissection, we should be careful and stable, and pay attention to protecting the lateral tarsal vessels. The cutaneous branches of the lateral tarsal vessels should be observed in time during the operation. If the needs of flap migration are not met, the extensor digitorum brevis myocutaneous flap should be removed in time, but it should not exceed the muscle flap too much, otherwise, the complication of distal epidermal necrosis will occur. At the same time, the lateral tarsal vessels should be protected during the operation to prevent insufficient blood supply to the flap after the operation. If a vasospasm occurs during the operation and the blood supply of the flap is insufficient after dissection, lidocaine can be added for local external application, and the operation can be continued after the spasm is relieved, and the flap can not be abandoned blindly.
5. Conclusions
To sum up, the free lateral tarsal artery perforator flap is a good choice for repairing the volar skin defect of the thumb because of its constant vascular anatomy, simple cutting, thin flap and good sliding, no need for secondary plastic surgery after the operation, and carrying sensory nerves.
Acknowledgments
We thank all colleagues in the Department of Microsurgery, the First Hospital Affiliated to Bengbu Medical College, for their help and support in this study.
Author contributions
Conceptualization: Changchun Zhang.
Funding acquisition: Changchun Zhang.
Investigation: Changchun Zhang, Kuankuan Zhang.
Methodology: Kuankuan Zhang, Haizhou Niu.
Project administration: Haizhou Niu.
Resources: Zhongbin Han.
Software: Haizhou Niu.
Supervision: Yangyang Liu.
Validation: Yangyang Liu.
Visualization: Yangyang Liu.
Writing – original draft: Zhongbin Han.
Writing – review & editing: Zhongbin Han.
Footnotes
This study was supported by the Anhui Provincial Natural Science Project (no. 1908085MC90) and Bengbu Medical College Natural Science Project (no. BYKY17107) and the Key natural science project of Bengbu Medical College (2020byzd175).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Han Z, Zhang K, Niu H, Liu Y, Zhang C. Free lateral tarsal artery perforator flap for repair of volar skin defect of thumb. Medicine 2023;102:34(e34833).
Contributor Information
Zhongbin Han, Email: 153994311@qq.com.
Kuankuan Zhang, Email: 523344274@qq.com.
Haizhou Niu, Email: 229693275@qq.com.
Yangyang Liu, Email: 418825501@qq.com.
References
- [1].Zhuang YQ, Xiong HT, Fu Q, et al. Functional pectoralis minor myocutaneous flap transplantation for reconstruction of thumb opposition: an anatomic study with clinical applications. Asian J Surg. 2018;41:389–95. [DOI] [PubMed] [Google Scholar]
- [2].Mi S, Teng Y, Liang G, et al. Effectiveness of combined tissue transplantation to repair serially damaged injuries on radial side of hand. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2021;35:601–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Zhao M, Wu J, Yuan Z, et al. Application of radial-lateral forearm free perforator flap on repairing of soft tissue defects in finger. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2019;33:586–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4].Lin J, Zhang TH, Hu DQ, et al. Clinical effects of dorsal perforator fascia pedicle flap of the deep palmar arch in the repair of skin and soft tissue defects of finger web area. Zhonghua Shao Shang Za Zhi. 2019;35:490–4. [DOI] [PubMed] [Google Scholar]
- [5].Nambi GI, Salunke AA, Pathak S, et al. “Repair and Flap technique”: a retrospective analysis of single stage reconstruction method for treatment of chronic open achilles tendon defect with proximal turndown flap and reverse sural flap. Indian J Orthop. 2020;55(Suppl 1):149–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Niu HZ, Wu M, Guan JZ, et al. The perforator flap of the free lateral tarsal artery repaired the wound of the finger. Chin J Repair Reconstruct Surg. 2022;36:257–9. [Google Scholar]
- [7].Feng TC, Huang YH, Liu FG, et al. Comparison of lateral tarsal flap and adjacent finger flap for repair of finger skin defects. Chin J Orthopaedic Surg. 2017;25:1086–90. [Google Scholar]
- [8].Zhang HY, Wang BY, Niu J, et al. Lateral tarsal artery flap repaired skin soft tissue defect of the terminal hallux toe in 13 cases. J Zhengzhou University (Medical edition). 2017;52:223–5. [Google Scholar]
- [9].Pan DD, Gu YD, Shi D, et al. Trial standard for the society of hand surgery of Chinese medical association. Chin J Hand Surg. 2000;16:130–5. [Google Scholar]
- [10].Wu XJ, Huang J, Qiu ZW, et al. Local flap application in the repair of hand tissue defect. Modern Diagnosis Treatment. 2015;26:2201–2. [Google Scholar]
- [11].Xu SH, Gao WY, Lu SW, et al. Lateral tarsal artery flap transplantation repaired forefoot and hand skin defects in 31 cases. Hainan Med. 2016;27:304–5. [Google Scholar]
- [12].Shen LL, Lin CX, Sun ES, et al. Clinical application of perforator flap of lateral tarsal artery to repair the wound area of hallux flap. Qilu Med J. 2015;30:42–3. [Google Scholar]
- [13].Li JW, Feng L, Sun HB, et al. Clinical response of lateral tarsal flap for repair of dorsal foot skin defect. Chin Disability Med. 2012;20:8–9. [Google Scholar]
- [14].Zhong SX, Li JR, Li L, et al. Lateral tarsal artery flap graft to repair hand and foot skin defects. J Qiqihaer Med College. 2012;33:316–7. [Google Scholar]
- [15].Teng LC, Chen T, Huang S, et al. Lateral tarsal artery flap graft repaired hand and foot skin deficiency. Huaxia Med Sci. 2011;24:324–6. [Google Scholar]