Advertisement

Reverse Neurocutaneous Flap Based on the Dorsal Branch of the Ulnar Artery for Palm Coverage in Children: Long-Term Results

  • Matthias E. Sporer
    Affiliations
    Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria

    Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Brasil
    Search for articles by this author
  • Jayme A. Bertelli
    Correspondence
    Corresponding author: Jayme A. Bertelli, MD, PhD, Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Department of Plastic Surgery, Joana de Gusmão Children Hospital, Rua Newton Ramos 70, apto 901, Florianópolis, Santa Catarina 88015395, Brazil.
    Affiliations
    Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Brasil

    Department of Plastic Surgery, Joana de Gusmão Children Hospital, Florianópolis, Brasil
    Search for articles by this author
Published:October 19, 2022DOI:https://doi.org/10.1016/j.jhsa.2022.09.001

      Purpose

      Although the palm is spared mostly in severe burn injuries, it often is affected in children and requires radical excision of contracting scar tissue to allow normal hand development. Since alternatives are limited for palmar coverage, we primarily use a reverse-perfused, neurocutaneous dorsal ulnar artery flap. We report here our long-term follow-up results.

      Methods

      We reviewed the long-term results of 10 postburn palmar contracture release and flap coverage procedures in 10 children. The applied flap was based distally on the dorsal branch of the ulnar artery and harvested along the ulnar aspect of the hand and wrist. The pivot point of the flap was located dorsally, close to the 4th and 5th metacarpal base. Patients were followed for a median period of 6 years (range, 4–20 years).

      Results

      Flap size ranged from 60–130 mm in length and 20–35 mm in width. This variation in flap dimensions resulted from different hand sizes, because of the various patient ages at surgery. All flaps survived, donor site healing was uneventful, and marginal flap necrosis occurred only once. Satisfactory restoration of range of motion without secondary contractures was observed. Moreover, we detected adequate progressive growth, adaptability and sensory recovery in all flaps. Over time, the flaps mostly become hairless and progressively flattened without debulking.

      Conclusions

      The importance of this flap lies in the potential for considerable tissue mobilization to cover palmar defects without sacrificing any major vascular axis. The adequate progressive growth of the flap facilitates functional hand development in children. The predictable vascular anatomy, wide range, and durable, thin, and pliable skin make the reverse neurocutaneous dorsal ulnar artery flap an appealing option for soft tissue reconstruction of the palm in children.

      Type of study/level of evidence

      Therapeutic V.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ülkür E.
        • Açikel C.
        • Eren F.
        • Celiköz B.
        Use of dorsal ulnar neurocutaneous island flap in the treatment of chronic postburn palmar contractures.
        Burns. 2005; 31: 99-104
        • MacDougall R.
        The significance of the human hand in the volution of mind.
        Am J Psychiatr. 1905; 16: 232-242
        • Fisher M.
        Pediatric burn reconstruction: focus on evidence.
        Clin Plast Surg. 2017; 44: 865-873
        • Benanti E.
        • De Santis G.
        • Leti Acciaro A.
        • Colzani G.
        • Baccarani A.
        • Starnoni M.
        Soft tissue coverage of the upper limb: a flap reconstruction overview.
        Ann Med Surg. 2020; 60: 338-343
        • Biswas D.
        • Wysocki R.W.
        • Fernandez J.J.
        • Cohen M.S.
        Local and regional flaps for hand coverage.
        J Hand Surg Am. 2014; 39: 992-1004
        • Quénu É.
        • Jars F.M.L.L.
        Étude Anatomique sur les Vaisseaux Sanguins des Nerfs.
        C. Hérissey, 1892
        • Salmon M.
        Les Arteres de la Peau.
        Masson, 1936
        • Masquelet A.C.
        • Romana M.C.
        • Wolf G.
        Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg.
        Plast Reconstr Surg. 1992; 89: 1115-11121
        • Bertelli J.A.
        • Khoury Z.
        Neurocutaneous island flaps in the hand: anatomical basis and preliminary results.
        Br J Plast Surg. 1992; 45: 586-590
        • Bertelli J.A.
        • Kaleli T.
        Retrograde-flow neurocutaneous island flaps in the forearm: anatomic basis and clinical results.
        Plast Reconstr Surg. 1995; 95: 851-859
        • Bertelli J.A.
        • Pagliei A.
        The neurocutaneous flap based on the dorsal branches of the ulnar artery and nerve: a new flap for extensive reconstruction of the hand.
        Plast Reconstr Surg. 1998; 101: 1537-1543
        • Gulgonen A.
        • Ozer K.
        The correction of postburn contractures of the second through fourth web spaces.
        J Hand Surg Am. 2007; 32: 556-564
        • Bertelli J.A.
        • Pagliei A.
        Direct and reversed flow proximal phalangeal island flaps.
        J Hand Surg Am. 1994; 19: 671-680
        • Mahmoud W.H.
        • Hawary Y.
        The use of dorsal ulnar artery flap in coverage of wrist defects.
        Egypt J Plast Reconstr Surg. 2017; 41
        • Uygur F.
        • Uygur M.
        • Ulkür E.
        • Sever C.
        Versatility of the reverse dorsoulnar fasciocutaneous flap in coverage of hand defects: clinical experience with 36 cases.
        J Hand Surg Am. 2009; 34: 1327-1333
        • Kelly E.J.
        • Terenghi G.
        • Hazari A.
        • Wiberg M.
        Nerve fibre and sensory end organ density in the epidermis and papillary dermis of the human hand.
        Br J Plast Surg. 2005; 58: 774-779
        • Bosley R.
        • Leithauser L.
        • Turner M.
        • Gloster Jr., H.M.
        The efficacy of second-intention healing in the management of defects on the dorsal surface of the hands and fingers after Mohs micrographic surgery.
        Dermatol Surg. 2012; 38: 647-653
        • Lawrence C.M.
        • Comaish J.S.
        • Dahl M.G.
        Excision of skin tumours without wound closure.
        Br J Dermatol. 1986; 115: 563-571
        • Paget J.T.
        • Izadi D.
        • Haj-Basheer M.
        • Barnett S.
        • Winson I.
        • Khan U.
        Donor site morbidity of the medial plantar artery flap studied with gait and pressure analysis.
        Foot Ankle Surg. 2015; 21: 60-66
        • Greene T.L.
        • Steichen J.B.
        Digital nerve grafting using the dorsal sensory branch of the ulnar nerve.
        J Hand Surg Br. 1985; 10: 37-40
        • Becker C.
        • Gilbert A.
        [The ulnar flap].
        Handchir Mikrochir Plast Chir. 1988; 20: 180-183
        • Tan O.
        • Kılıç M.
        Supercharged dorsoulnar island flap: a case report and review of the literature.
        Acta Orthop Traumatol Turc. 2011; 45: 53-57
        • Khan M.M.
        • Yaseen M.
        • Bariar L.M.
        • Khan S.M.
        Clinical study of dorsal ulnar artery flap in hand reconstruction.
        Indian J Plast Surg. 2009; 42: 52-57
        • Karacalar A.
        • Ozcan M.
        Preliminary report: the distally pedicled dorsoulnar forearm flap for hand reconstruction.
        Br J Plast Surg. 1999; 52: 453-457
        • Ülkür E.
        • Uygur F.
        • Karagöz H.
        • Celiköz B.
        Use of free dorsoulnar perforator flap in the treatment of postburn contractures of the fingers.
        Burns. 2006; 32: 770-775
        • Choupina M.
        • Malheiro E.
        • Guimarães I.
        • et al.
        Osteofasciocutaneous flap based on the dorsal ulnar artery: a new option for reconstruction of composite hand defects.
        Br J Plast Surg. 2004; 57: 465-468
        • Masquelet A.C.
        • Romana M.C.
        The medialis pedis flap: a new fasciocutaneous flap.
        Plast Reconstr Surg. 1990; 85: 765-772
        • Adani R.
        • Tarallo L.
        • Marcoccio I.
        • Cipriani R.
        • Gelati C.
        • Innocenti M.
        Hand reconstruction using the thin anterolateral thigh flap.
        Plast Reconstr Surg. 2005; 116 (discussion 474–477): 467-473
        • Hattori Y.
        • Harima M.
        • Yamashita S.
        • Iida T.
        • Niu A.
        Superthin thoracodorsal artery perforator flap for the reconstruction of palmar burn contracture.
        Plast Reconstr Surg Glob Open. 2020; 8: e2695
        • Vögelin E.
        • Langer M.
        • Büchler U.
        [How reliable is the posterior interosseous artery island flap? A review of 88 patients].
        Handchir, Mikrochir, Plast Chir. 2002; 34: 190-194