Resurfacing of the donor defect after wrap-around toe transfer with a free lateral forearm flap.

In thumb reconstruction, the wrap-around free flap has many advantages; however, delayed wound healing, pain, and skin ulcerations at the donor site can be a problem. In 5 patients, a free lateral forearm fasciocutaneous flap was successfully used for immediate resurfacing of the donor defect of the big toe during wrap-around procedures. This flap was selected after preliminary anatomic studies that showed that it could be safely raised if based on the anterior terminal division of the posterior radial collateral artery. The average follow-up period was 2 years. The time required for healing of the great-toe defect was less than 1 month. All patients were satisfied with the outcome of the procedure. The skin of this flap is very pliable and thin, and the subcutaneous tissue is about half the thickness of that of the lateral arm flap. This technique is especially indicated for closure of moderate to big skin defects at the great-toe level, whenever a larger than usual amount of skin is required, during wrap-around procedures for thumb reconstruction.

The lateral forearm flap: an anatomic study.

The anatomy of the lateral forearm flap has been studied in 12 fresh cadaver arms with methylene blue and latex injections and arteriography. The posterior radial collateral artery was found to divide constantly into two terminal branches, an anterior and a posterior division. The anterior division is the nutrient vessel of the flap. This artery extends significantly beyond the lateral epicondyle of the elbow into the lateral aspect of the forearm (range 13 to 18 cm, average 15 cm). This allows raising a fasciocutaneous flap in the proximal forearm with a much longer vascular pedicle than the classic lateral arm flap. Other advantages include very thin skin and subcutaneous tissue and less sensory deficit at the donor site. Based on these results, this newly designed lateral forearm flap has been used in 13 clinical cases. Its main indications are whenever soft, thin, pliable skin is needed for small to moderate-sized defects.

Prevention of neuroma in elective digital amputations by utilization of neurovascular island flap.

Following hand surgery, painful neuromas may impair the quality of the functional result. In planned, elective digital amputation, neuroma formation is quasi-unavoidable because the nerve is cut. Several techniques have been proposed to prevent the formation of neuroma but, in our opinion, the only logical way to avoid it, is not to cut the nerve. For this purpose, we proposed, in cases of planned, elective digital amputation, an intervention inspired by the technique described by Littler in 1956. This technique consists of isolating as an island, the pulp of the amputated finger while preserving nerve continuity of both collateral pedicles. Once the amputation is completed, in cases of distal amputation, the pulp flap is used to cover the proximal stump and, in cases of ray amputation, the nerve loop is buried after its deepithelialization between the adjacent metacarpals. Since 1990, this technique has been used for nine-planned, elective amputations in eight patients. Postoperatively, no patient has developed painful neuroma except one patient who had a painful finger preoperatively and in whom the symptoms remained unchanged postoperatively. This simple technique must be part of the therapeutic armamentarium of planned, elective digital amputations in cases with intact collateral nerves.