Reconstruction of totally degloved fingers: a novel application of the bilobed spiraled innervated radial artery superficial palmar branch perforator flap design provides for primary donor-site closure

Zhenglin Chi, Peng Yang, Dajiang Song, Zan Li, Liang Tang, Weiyang Gao, Yonghuan Song, Tingang Chu
Surgical and Radiologic Anatomy: SRA 2017, 39 (5): 547-557

INTRODUCTION: To investigate the results of resurfacing completely degloved digits using bilobed innervated radial artery superficial palmar branch (RASPB) perforator flap in a spiral fashion.

METHODS: A detailed anatomic study on 30 adult fresh frozen cadavers preinjected with silicone rubber compound to demarcate arterial anatomy documented locations, numbers, and diameters of arteries and skin perforators with surrounding nerves. The flap-raising procedure was performed using four fresh cadaver specimen. We reviewed the reconstruction of 12 digits by using a bilobed spiraled innervated RASPB free perforator flap after non-replantable degloving injury. Two skin paddles were marked out using standard points of reference. At least two separate cutaneous perforator vessels were identified using a hand-held Doppler and were dissected back to the RASPB in retrograde fashion. The skin paddles were then divided between the two cutaneous perforators to provide two separate paddles with a common vascular supply. The skin paddles were stacked in a spiral fashion on the flap inset, effectively increasing the width of the flap to cover the totally degloved finger while still allowing closure of the primary donor-site.

RESULTS: The RASPB was present within the flap in all cadavers. The direct perforator and the musculocutaneous perforator were available in 93.33 and 76.67 %, respectively, with neither of them in 6.67 % of the cases. The constantly present two perforators allowed the design of a new bilobed spiraled innervated radial artery superficial palmar branch perforator flap. We used the proposed flap to reconstruct completely degloved digits in 12 patients (mean age 28.6 years; range 17-35 years). With our proposed flap, no flap failure or re-exploration occurred and the donor site was closed primarily in all cases. All the flaps survived uneventfully. Total active motion ranged from 92° to 140° and 111° to 155° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2 point discrimination test varied from 6 to 11 mm. All the patients were satisfied with the overall results.

CONCLUSION: The bilobed flap is large enough to cover totally degloved finger defects and contain direct skin perforators, provides a bespoke cover for complex soft tissue defects of completely degloved digits while also improving morbidity and cosmesis of the donor site.

LEVEL OF EVIDENCE: Level IV, retrospective series.

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