
==== Front
Plast Reconstr Surg Glob Open
Plast Reconstr Surg Glob Open
GOX
Plastic and Reconstructive Surgery Global Open
2169-7574
Lippincott Williams & Wilkins Hagerstown, MD

GOX-D-24-00069
00048
10.1097/GOX.0000000000006170
3
Hand
Case Report
Dorsal Hand Reconstruction with Web Contracture Release Using Free Superficial Inferior Epigastric Artery Flap
Nomaguchi Matoku MD
Niimi Yosuke MD, PhD
Hasegawa Yuki MD, PhD
Matsumine Hajime MD, PhD
Sakurai Hiroyuki MD, PhD
From the Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University, Tokyo, Japan.
Yosuke Niimi, MD, PhD, Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan, E-mail: niimi.yosuke@twmu.ac.jp
9 2024
16 9 2024
12 9 e617021 1 2024
30 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Summary:

We present a case in which reconstruction of the dorsum of the hand and finger web space was carried out concurrently with the insertion of a superficial inferior epigastric artery flap into the interdigital spaces. This approach was taken to prevent the potential development of subsequent web space contracture. The patient, a 57-year-old woman, presented with a necrotizing soft tissue infection on the dorsum of her left hand, resulting in a full-thickness skin defect extending from the metacarpophalangeal joint to the wrist, with exposure of the extensor tendons. The reconstructive surgery involved raising a superficial inferior epigastric artery flap and transplanting it onto the tissue defect, to cover not only the dorsal defect but also the interdigital spaces after releasing web space contracture. Consequently, the surgery successfully released scar contractures on the dorsum of the hand and provided adequate interdigital space formation without requiring additional procedures, except defatting. At the 7-month postoperative follow-up, the patient had a good outcome with shoulder and hand (Quick Disabilities of Arm, Shoulder and Hand) score of 28.9 points. Interdigital scar contractures often lead to decreased fine motor skills and functional impairment, affect aesthetics, and require a prolonged period for social reintegration. This surgical technique involves simultaneous one-stage closure of the dorsal defect with a flap and interdigital reconstruction to prevent future scar contractures and functional impairments, and is a valuable approach for shortening the treatment duration.

OPEN-ACCESSTRUE
COUNTRYJAPAN
SDCT
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pmcSkin defects of the dorsum of the hand are frequently encountered in plastic surgery. The skin on the dorsum of the hand is thin and can easily expose tendons and bone structures. Therefore, reconstruction using flaps is a commonly chosen option.1 Although flap reconstruction is useful, simply filling the tissue defect with a flap may result in contraction and web space contractures, limiting the restoration of adequate functional mobility. Achieving flap coverage of the defect and addressing concerns regarding functional and aesthetic aspects is challenging. Here, we present a case of successful simultaneous reconstruction of the tissue defect following necrotizing soft tissue infection on the dorsal hand using a free flap, along with web space reconstruction.

CASE REPORT

The patient is a 57-year-old woman with no significant medical history. She sustained a right distal radius fracture and had a drip route on the left dorsal hand. The insertion site became infected, the previous physician diagnosed necrotizing soft tissue infection, and multiple debridement procedures were performed. Upon initial examination in our department, skin ulcers were observed from the metacarpophalangeal joint to the wrist joint on the back of the left hand, with exposure of the extensor tendons (Fig. 1).

Fig. 1. Findings at initial examination. A soft tissue defect extending from the metacarpophalangeal joint to the wrist on the dorsal side of the left hand was observed, along with exposure of the extensor tendons.

A surgical procedure was performed under general anesthesia for reconstructing this area 3 weeks after debridement. The superficial inferior epigastric artery (SIEA) flap was confirmed by multidetector computed tomography (MDCT) imaging (Fig. 2).

Fig. 2. Preoperative MDCT image. SIEA was confirmed by MDCT imaging (yellow arrow).

Debridement was performed with the aim of maximum preservation of the extensor tendons. Furthermore, the incision was extended from the tissue loss site on the dorsum of the hand to the interdigital space, sufficiently releasing the web contracture. A skin incision was made to identify the superficial circumflex iliac artery, SIEA, and deep circumflex iliac artery. The superficial circumflex iliac artery and SIEA branched separately from the femoral artery. Then, a free SIEA flap was elevated from the abdominal region with thinning under a microscope (Fig. 3). During the elevation, a thin flap was designed and included for insertion between each interdigital space to facilitate interdigital space formation. The superficial inferior epigastric vein (SIEV) was anastomosed with the radial vein, and the SIEA was anastomosed with the radial artery. Finally, a monitoring catheter2 was inserted into the branches of the SIEV flap for blood flow monitoring (Fig. 4). A passive and active exercise rehabilitation was initiated on postoperative day 6. At 7 months postoperatively, ROM of the thumb was 0–60 degrees for abduction and 0–90 degrees for palmar abduction, with a Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) score of 28.9, indicating a favorable outcome. ROMs of the index finger to little finger were approximately 10–80 degrees of the metacarpophalangeal joint 0–120 of the proximal interphalangeal joint and 0–80 of the distal interphalangeal joint. Aesthetic results were also satisfactory. Sufficient interdigital space was created along with the release of dorsal scar contracture. (See figure, Supplemental Digital Content 1, which displays the postoperative findings at month 7. At 7 months postoperatively, the morphology was good and the patient was satisfied in terms of aesthetics. After reconstruction, the patient had good results with 0–60 degrees of flexion abduction of the thumb, 0–90 degrees of palmar abduction, and a score of 28.9 on the QuickDASH. http://links.lww.com/PRSGO/D510.)

Fig. 3. Intraoperative findings through SIEA flap elevation. A free SIEA flap was raised from the abdomen with thinning under a microscope, after performing a computed tomography angiography to confirm the depiction of the SIEA.

Fig. 4. Findings after skin flap suture. A skin flap was inserted and sutured in the interdigital space formation site. A skin flap blood flow monitoring catheter was inserted into the SIEV branch. Postoperative blood flow to the flap was good, and rehabilitation for both active and passive exercise was started on postoperative day 6.

DISCUSSION

The dorsum of the hand has thin, soft tissue, and for reconstruction of joint mobility, it is desirable to use thin tissues that can be adapted to the surrounding structures.1 Additionally, because deep tissues can easily become exposed, reconstruction using flaps may be necessary.3 Moreover, if contractures occur on the dorsum of the hand or between the fingers after trauma, it can lead to limitations in flexion and reduced fine motor skills, significantly impairing hand function.4 First web space contracture affects thumb function and grasping capacity. This pathology alters normal anatomy and results in decreased ability to use the hand.5

In recent years, reconstruction of the dorsum of the hand and interdigital spaces has been performed using thin flaps.6,7 Adani et al6 have advocated the use of anterolateral thigh flap as the primary choice for free flaps in dorsal hand reconstruction; although the anterolateral thigh flap is considered to be highly useful, they have reported the need for defatting under a microscope because of the flap’s thickness. Gousheh et al7 performed reconstruction of postburn scar contractures on the dorsum of the hand using a super-thin abdominal flap for distant flap reconstruction, achieving favorable hand function recovery and texture match. Nevertheless, there were drawbacks such as a prolonged postoperative resting period and the necessity for multiple procedures, including flap detachment.7 There are reports of anatomic variations in SIEA flaps,8 and Spiegel et al9 have shown that patients with arteries less than 1.5 mm in diameter are at increased risk of disturbance of blood flow, especially in breast reconstruction. We therefore performed a preoperative computed tomography angiography to evaluate SIEA. We chose the free SIEA flap because of the following advantages: (1) the abdominal skin is thin and soft; (2) the flap harvesting site has minimal scarring, and there is minimal donor site sacrifice because no muscle is harvested10; and (3) there is no need for positional changes during surgery, resulting in shortened surgery time. (See figure, Supplemental Digital Content 2, which displays the postoperative findings of donor site scar at year 3. At 3 years postoperatively, the morphology and scar were favorable without skin contracture. http://links.lww.com/PRSGO/D511.)

Furthermore, there are no reported cases of simultaneous reconstruction of dorsal tissue defects and interdigital space formation using the same flap. The advantages of simultaneously performing tissue defect reconstruction and interdigital formation with an SIEA flap include (1) a shorter rest period, enabling early rehabilitation initiation, (2) prevention of extensor tendon adhesions that can cause a reduced ROM, (3) achievement of satisfactory texture match, and (4) prevention of future interdigital contractures resulting from interdigital space formation. Given these factors, our approach allowed for the reconstruction of skin defects with a free flap and simultaneous web contracture release in a single stage, resulting in excellent outcomes in terms of aesthetics, functionality, and preventing contractures.

Limitations of this procedure include the potential for larger defect sizes in cases where the distance to the interdigital spaces is greater. Future studies should involve a higher number of cases and assess the impact on motor function.

This technique is considered a choice for the reconstruction of the dorsal hand and interdigital space formation.

CONCLUSION

Simultaneous reconstruction of the dorsal hand and interdigital space formation using SIEA flap is valuable from both an aesthetic and functional perspective.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ETHICAL APPROVAL

This study was carried out in accordance with the World Medical Association Declaration of Helsinki (June 1964) and subsequent amendments. The patients voluntarily gave written informed consent to participate in this study.

Supplementary Material

Published online 16 September 2024.

Disclosure statements are at the end of this article, following the correspondence information.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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