RU2845971C1 - Method for replacing cicatricial skin defects on back surface of finger - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, particularly to traumatology, orthopaedics and reconstructive surgery, and can be used for skin cicatricial defect replacement on finger dorsal surface. Longitudinally oriented fascioadipodermal tongue-shaped flap with a distal base is formed with a ratio of the length and width of 3:1. Flap is folded into a stem; cicatrices are excised in a proximal portion of the cicatricially changed skin area on an area equal to a cross-sectional area of the formed stem, and the stem end is anchored. Two months later, an incision is made at a base of a proximal stem pedicle; a dorsal metacarpal artery and a saphenous vein are transected; the wounds are closed. Three weeks later, the proximal leg is dissected away; cicatrices are excised in a distal portion of the cicatricially changed skin area on an area equal to a cross-sectional area of the formed stem, and the stem end is anchored. Two months later, the stem is incised along the cicatrix to form an adipodermal flap which is sewn into the skin defect of the finger.

EFFECT: method enables replacing the defects of the dorsal surface of fingers, reducing a risk of tissue ischemia and providing higher functional activity ensured by a combination of surgical techniques and the most optimum operation modes.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely traumatology and orthopedics, and can be used in reconstructive hand surgery.

A method of replacing finger skin defects using a microstem according to Khitrov, formed on the hand, is known (E.V. Usoltseva, K.I. Mashkara. Surgery of diseases and injuries of the hand, 1986, Leningrad "Medicine", Leningrad branch, p.243, Fig.110). As can be seen from the figure, in the known method a U-shaped skin-fat flap with a proximal base is formed, the flap is rolled into a tube, the end of which is sutured to the defect, the donor wound on the hand is sutured.

Disadvantages of the method: 1) the size of the transferred skin flap is insufficient for significant defects, since the method involves primary suturing of the donor wound, which does not allow increasing the width of the flap, and accordingly its length (the ratio of the length and width of the flap cut to form the stem cannot be more than 2:1, which increases the number of stages of its migration and prolongs the treatment period); 2) the flap does not contain a main arterial vessel and a subcutaneous vein, which increases the likelihood of developing ischemic complications after the formation of the stem and at the stages of its migration (the absence of a main vessel in the stem can lead to a disruption of its blood circulation due to bending or twisting of the pedicle at the stages of migration and the need to increase the stages of plastic surgery).

A method is known for replacing a skin defect on the dorsal surface of a finger by moving a skin-fat metacarpal flap on a peripheral vascular pedicle (Belousov A.E. Plastic, reconstructive and aesthetic surgery, A.E. Belousov. - St. Petersburg: Gipppokrat, 1998, pp. 185-186). In the known method, an elliptical skin-fat flap is formed on a peripheral vascular pedicle, represented by the dorsal metacarpal artery included in the flap, with a rotation point located 0.5-1.0 cm proximal to the metacarpophalangeal joint. Then the flap is rotated 180 degrees and sutured into the tissue defect of the finger.

The method has the following disadvantages: 1) using this flap it is possible to replace only adjacent soft tissue defects (located next to it, in adjacent areas); 2) the method does not allow replacing tissue defects on the dorsal surface of the nail and middle phalanges due to the limited length of the vascular pedicle or the formation of necrosis of its distal part; 3) the development of vascular insufficiency of the flap is possible due to tension, bending, damage or compression of the feeding vessels; 4) there is a possibility of developing venous insufficiency of the flap, since subcutaneous veins are not included in it.

The objective is to develop a method for replacing cicatricial skin defects on the back of the finger, including in the case of finger contracture.

The technical result is an increase in the efficiency of replacing defects of the dorsal surface of the fingers and the prevention of ischemic complications.

The technical result is achieved by forming a longitudinally oriented skin-fascial-fat tongue-shaped flap with a distal base with a length-to-width ratio of 3:1 on the dorsal surface of the hand in the area of one of the intermetacarpal spaces adjacent to the defective finger, wherein the length and width of the flap exceed the dimensions of the cicatricial area by at least 1 cm; the flap is folded into a stem, scars are excised in the proximal part of the cicatricial area of the skin over an area equal to the cross-sectional area of the formed stem, and the end of the stem is sutured; after two months, a bordering incision is made at the base of the proximal leg of the stem, the dorsal metacarpal artery and saphenous vein are crossed, and the wounds are sutured; After three weeks, the proximal leg is cut off, in the distal part of the cicatricially altered area of the skin, scars are excised over an area equal to the cross-sectional area of the formed stem, and the end of the stem is sutured; after two months, the stem is dissected along the scar, a skin-fat flap is formed from it, which is sewn into the defect of the skin of the finger.

The method is illustrated by figures, where:

Fig. 1 – the hand before surgery with a cicatricially altered area of the skin on the dorsal surface of the third finger;

Fig. 2 – hand after formation of a longitudinally oriented skin-fascial-fat tongue-shaped flap on the dorsal metacarpal artery and inclusion of the subcutaneous vein into it;

Fig. 3 – a hand after formation from a tongue-shaped flap of skin stem and suturing its end to a scar-altered area of skin, replacing the donor defect with a free skin graft;

Fig. 4 – stem after surgical training;

Fig. 5 – the stem after moving its leg to the distal part of the cicatricially altered area of the skin;

Fig. 6 – the stem after forming a flap from it and replacing the scarred area of skin with it.

The method is carried out as follows.

On the dorsal surface of the defective finger (Fig. 1), the scar-altered area of skin (1) is measured. On the dorsal surface of the hand, in the area of the intermetacarpal space adjacent to the defective finger, a longitudinally oriented skin-fascial-fat tongue-shaped flap (2) is formed with a distal base with a length-to-width ratio of 3:1 so that the dimensions of the length and width of the flap exceed the dimensions of the scar-altered area by at least 1 cm. The base of the flap is located at the level of the metacarpophalangeal joint (Fig. 2). The flap includes the dorsal metacarpal artery (3), as well as the dorsal saphenous vein (4), which is ligated and crossed at the proximal edge of the flap. The lateral branches of the vein are ligated and crossed at the edges of the flap (Fig. 2). The flap (2) is mobilized in the distal direction to the level of the metacarpophalangeal joint and folded into a stem, suturing the edges of the flap together. The donor wound is closed with a full-layer skin graft (5) (Fig. 3). In the area of the proximal part of the cicatricially altered area of the skin, scars are excised over an area equal to the cross-sectional area of the formed stem. The end of the stem is sutured into the resulting tissue defect, which leads to the formation of a loop (Fig. 3). Two months later, a bordering incision is made at the base of the proximal pedicle of the stem along half its circumference. The dorsal metacarpal artery and saphenous vein are isolated and transected. The pedicle of the stem is sutured to its place (Fig. 4). Three weeks later, scars are excised in the area of the distal part of the cicatricially altered area of the skin over an area equal to the cross-sectional area of the formed stem. The proximal stalk of the stem is cut off and sutured into the resulting tissue defect (Fig. 5). After two months, the remaining scars on the back of the finger are excised, and the edges of the wound are mobilized. An incision is made along the scar on the ventral surface of the stem, which is unfolded, forming a flap. A stalk flap is sutured into the resulting skin defect (Fig. 6).

The method ensures the restoration of authentic skin on the back of the finger.

The presence of an axial vessel and a subcutaneous vein in the formed stem allows it to be cut with a length-to-width ratio of 3:1, rotated 180 degrees without the risk of developing vascular complications, and to reduce the number of stages of transposition (movement) of the stem to the cicatricial defect.

Surgical training of the stem ensures reliable prevention of ischemic complications at the stages of its migration.

Formation of a longer stem allows to increase the area of the transferred flap and replace tissue defects in the distal parts of the finger.

The use of a free skin graft for primary closure of the donor wound allows for an increase in the width and, consequently, the length of the flap and the replacement of larger tissue defects.

Clinical example

Patient K., 23 years old, was admitted to the clinic due to post-traumatic deformation of the third finger, stumps of the first and second fingers of the right hand at the level of the proximal third. On admission, flexion arthro-tenogenic contractures of the third finger were noted in the interphalangeal joints at an angle of 90 degrees and radial deviation in the proximal interphalangeal joint at an angle of 45 degrees. Pathological mobility of the finger was determined at the level of the proximal interphalangeal joint. On the dorsal and radial surfaces of the middle and proximal phalanges there were coarse scars fused with the underlying tissues, over an area of 2 × 7 cm. Radiographs of the hand showed extensive marginal defects of the proximal and middle phalanges. The first stage involved application of a transosseous distraction device to eliminate finger contractures (02.06.23), followed by gradual distraction and elimination of contractures in the interphalangeal joints, upon completion of which the phalanges were fixed with pins in the achieved position (17.01.24). On 29.03.24, to replace extensive scars on the dorsal surface of the third finger, a longitudinally oriented skin-fascial-fat tongue-shaped flap with a distal base at the level of the metacarpophalangeal joint of the third finger and a size of 3×9 cm was formed on the dorsal surface of the hand in the area of the third intermetacarpal space adjacent to the defective finger. The flap included the dorsal metacarpal artery and the dorsal saphenous vein with its lateral branches, which were ligated and crossed at the proximal edge of the flap. The flap was mobilized in the distal direction to the level of the metacarpophalangeal joint and folded into a stem. In the area of the proximal part of the cicatricially altered area of the skin, scars were excised over an area equal to the cross-sectional area of the formed stem, and the end of the stem was sutured. The donor wound on the back of the hand was replaced with a full-layer skin graft taken from the inner surface of the shoulder. The postoperative course was uneventful. The stem and graft engrafted completely. After 2 months (01.06.24), in order to prevent ischemic complications at subsequent stages of plastic surgery, surgical training of the formed stem was performed: a bordering incision was made at the base of the proximal stem pedicle along half its circumference; the dorsal metacarpal artery and saphenous vein were isolated and transected; the stem pedicle was sutured to its place. After the development of vascular insufficiency compensation mechanisms in the tissues, the proximal leg of the stem was migrated to the distal part of the cicatricial skin area. Three weeks later (23.06.24), the cicatricial skin area was excised in the distal part of the cicatricial skin area over an area equal to the cross-sectional area of the formed stem, the proximal leg of the stem was cut off, and the end of the stem was sutured into the resulting tissue defect. Two months later (25.08.24), the stem was unfolded to form a skin-fat flap, which was sutured into the finger tissue defect. The postoperative course was smooth, the flap fully engrafted. No ischemic complications were noted at the stages of stem migration.

Restoration of adequate skin on the dorsal surface of the finger improved its appearance and also allowed interventions to be performed on the bone base of the finger in order to improve its function.

Claims (1)

A method for replacing cicatricial skin defects on the dorsal surface of a finger, characterized in that a longitudinally oriented skin-fascial-fat tongue-shaped flap is formed on the dorsal surface of the hand in the area of the intermetacarpal space adjacent to the defective finger, with a distal base with a length-to-width ratio of 3:1, with dimensions no less than 1 cm greater than the length and width of the cicatricially altered area; the flap is folded into a stem, in the proximal part of the cicatricially altered area of the skin, scars are excised over an area equal to the cross-sectional area of the formed stem, and the end of the stem is sutured; after two months, a bordering incision is made at the base of the proximal leg of the stem, the dorsal metacarpal artery and saphenous vein are crossed, and the wounds are sutured; After three weeks, the proximal leg is cut off, in the distal part of the cicatricially altered area of the skin, scars are excised over an area equal to the cross-sectional area of the formed stem, and the end of the stem is sutured; after two months, the stem is dissected along the scar, a skin-fat flap is formed from it, which is sewn into the defect of the skin of the finger.