THUMB
RECONSTR
UCTION
- [Link] S
2ND YEAR RESIDENT
GANDHI MEDICAL COLLEGE
INTRODUCTION
• The thumb is the shortest but the most important of all
finger.
• It is responsible for 40% of the hand function.
• An ideal reconstruction of the thumb would replace “like
with like,” restoring both function and appearance
Factors that affect the choice of option include patient's age,
dominant hand, sex, occupation, and desire where the
donor site is.
Surgeon's familiarity with a specific flap is also an
important factor in flap choice
Additional assessment for the following needs to be done
Status of first web
Whether the complaints match the deficit
Are there Problems with other digits
Dysfunctional use
Patient expectations
GOALS OF
RECONSTRUCTION
1. Sensate and non tender thumb cover
2. Stability
3. Adequate length
4. Strength
5. Correct posture and positioning
6. Mobility
CLASSIFICATION OF
THUMB DEFECT
Thumb defect is classified into four groups by Lister:
1. acceptable length but poor soft tissue coverage,
2. subtotal amputation with uncertainty in length,
3. total amputation with basal joint, and
4. total amputation without basal joint.
CAMPBELL-REID
CLASSIFICATION OF THUMB
AMPUTATION
1. Amputation distal to the MCP joint, leaving an adequate
length
2. Amputation distal to or through the MCP joint ,leaving an
inadequate length
3. Amputation through the metacarpal, with preservaation of
some functioning thenar muscles
4. Amputation at or near the carpo-metacarpal joint
SOFT TISSUE
COVERAGE
Acceptable length with poor soft tissue coverage
The choice of reconstructive procedure for soft tissue
deficits over the distal thumb depends primarily on the
size of the defect.
When the loss of skin and subcutaneous tissue from the
terminal aspect of the distal phalanx is small (typically <1
cm2) and no exposed bone is present, reasonable
treatment options include
OPTIONS include
allowing spontaneous healing by secondary intention,
skin grafts,
lateral triangular advancement flaps
“V-Y” advancement flaps
M0BERG FLAP
Palmar advancement flap is based on both neurovascular
bundles in the thumb. It permits coverage for defects as
large as 1.5 cm in longitudinal diameter.
It provides immediate sensibility and glabrous skin while
preserving thumb length.
Palmar advancement flap may result in complication such
as flexion contracture of interphalangeal joint and limiting
thumb extension.
The palmar flap is elevated superficial to the flexor
tendon sheath including both neurovascular bundles with
subcutaneous tissue within the flap.
After flap elevation, any tension is checked by advancing
the flap tip over the defect site.
If there is difficulty in advancing the flap, one can
[Link] the mid-lateral incision proximally onto the
thenar eminence,
[Link] the interphalangeal joint, or
[Link] the flap as island by transverse incision at the flap
base with a full thickness skin graft to the secondary
defect.
The distal edge of the flap is trimmed to give a rounded tip.
CROSS FINGER FLAP
Loss of the entire palmar surface of the thumb distal to
the IP joint
With the thumb adducted,levelof flap is determined on
dorsal radial aspect of index finger
flap is raised in an ulnar-to-radial direction in the plane
just superficial to the extensor paratenon.
The flap can be safely divided after 14 to 21 days.
Disadvantages and complications include a potentially
unsightly defect over the dorsum of the index finger, with
digital joint stiffness or thumb web contracture
FDMA ISLAND FLAP
It is transferred as a pure island flap carrying the FDMA,
subcutaneous veins, and branches of the radial sensory
nerve in a single stage, thus eliminating the need for
prolonged immobilization and potential long-term
stiffness.
The FDMA island flap can reach the volar and dorsal
aspects of the distal thumb and is considered a
versatile workhorse flap for innervated distal thumb soft
tissue coverage
To avoid scar contracture, the proximal limit of the flap is
the MP joint, and the distal limit is the proximal IP joint
The flap is elevated in the loose areolar plane above
the extensor tendon paratenon.
Dissection generally moves from distal to proximal and
from the ulnar to the radial side.
Extreme care must be taken at the radial border of the
MP joint because this is where the FDMA enters the
flap’s subcutaneous network.
Potential complications include flap vascular compromise
and index finger donor site morbidity, such as stiffness,
cold intolerance, hypertrophic scarring, and neuroma.
HETERODIGITAL
NEUROVASCULAR ISLAND
FLAP
The Littler flap is a flap transferred from the ulnar aspect
of the middle finger or radial aspect of the ring finger to
the thumb tip.
The flap is harvested from the hemipulp of the respective
finger and transferred on the neurovascular pedicle after
dissection through the palm
SUBTOTAL AMPUTATION WITH
QUESTIONABLE REMAINING
LENGTH
Phalangization
Small web space deepening:-
1. Skin grafting
2. Z plasty
Large web space deepening:-
3. dorsal hand flap,
4. RAFF, PIA
DORSAL HAND FLAP
OSTEOPLASTIC
RECONSTRUCTION
Osteoplastic reconstruction, or thumb reconstruction by
means of a bone graft covered with a pedicled flap, was
first attempted by Nicoladoni.
Osteoplastic reconstruction consists of three
components.
1. skeletal reconstruction,
2. soft tissue covering, and
3. sensory flap for the pulp
For skeletal reconstruction, one of iliac bone, ulna, or
radius can be selected depending on the size of bone
defects.
STAGE 1
STAGE
2
COMPOSITE RADIAL
FOREARM ISLAND
FLAP
This procedure has the advantage of providing a well-
vascularized skin and bone flap and, with the addition of
an extended neurovascular island pedicle flap, avoiding
the staging necessitated by conventional osteoplastic
methods.
DISTRACTION
OSTEOGENESIS
Distraction osteogenesis is an option when the toe- to-finger
procedure is likely to be difficult or the donor toe is limited.
The main advantage of using this method is to maintain
native innervation.
Before distraction osteogenesis, it is necessary to predict the
condition of the soft tissue on the bone stump after
lengthening.
This procedure can extend length by about 3 cm, but at
least two thirds of the metacarpal bone must remain
ON TOP PLASTY
If the defect on the thumb occurs with the damage of
other fingers, on-top plasty can be performed using the
remaining amputated index, in the form of pollicization or
spare-part surgery
POLLICIZATION
Consists of surgically migrating the index finger to the
position of the thumb
This procedure is the only satisfactory means of basal
joint reconstruction and results in extensive physiologic
sensory restoration
TOTAL LOSS WITH
DESTRUCTION OF
BASAL JOINT
Second-Toe Transfer
Second-toe transfer has been used as an alternative to
reconstruct these proximal thumb amputations when
pollicization is not an option due to injury to the index finger.
As much as 5 cm of thesecond metatarsal may be required to
provide adequate length but this has limited donor site
morbidity
TOE-TO-THUMB
RECONSTRUCTION
Great-Toe Transfer
Great-toe transfer involves isolating the great toe on the
FDMTA. Flap harvest is limited to the proximal phalanx of
the hallux, preserving at least the entire head of the first
metatarsal to avoid uneven plantar weight distribution and
unsteady gait
MODIFICATIONS
Wrap-Around Great-Toe Transfer
The wrap-around toe-transfer is a modification of the
great toe flap to preserve all or most of the hallux to
avoid donor site morbidity and create a more normal size
and contour to the reconstructed thumb.
The flap is harvested as an onychocutaneous flap and can
include a portion of the distal phalanx
Trimmed Great-Toe Transfer
• Designed to improve the appearance of the reconstructed
thumb
The medial skin and dissected off the trimmed-toe flap
and a longitudinal osteotomy were performed to remove
2 to 4 mm of the medial phalanges and 4 to 6 mm of the
medial prominence at the IP joint
TRIMMED TOE
TRANSFER
Toe Pulp and Distal Trimmed Toe-Transfer
Sensate cutaneous flaps can be harvested
from the great and second toes to reconstruct
isolated thumb pulp defects. Most often the
lateral great toe pulp and medial second toe
are selected.
TOE PULP TRANSFER
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