Reverse adipofascial flap for hand wounds offers positive results but raises questions

Although the procedure was reported as simple and effective, one physician has several criticisms.

SAN FRANCISCO — A reversed adipofascial flap in conjunction with skin grafting is an effective technique for the reconstruction of complex hand wounds, according to a study presented here.

D. Nicole Deal, MD, of Wake Forest University in Winston-Salem, N.C., presented her findings at the 2009 Combined Annual Meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapists. She said, free tissue transfer — often seen as a necessity in complex hand wounds with exposed tendon or bone — has been associated with technical difficulty, prolonged postoperative hospital stay and donor site morbidity.

“The purpose of our study was to demonstrate the utility of the adipofascial flap in coverage of defects that were larger than 1 to 2 cm² of the dorsum of the hand and finger,” Deal said.

Study parameters

The study was retrospective in nature and looked at 13 patients — 11 men and 2 women — with traumatic dorsal degloving injuries located from the wrist crease to the dorsum of the middle phalanx. Patients underwent soft tissue reconstruction using a reversed adipofascial flap and skin grafting over a 35-month period.

Injuries included three gunshot victims, four deglovings, one table saw injury, three chain saw injuries, one thumb avulsion injury and one crush injury with subsequent infection.

According to the study, wounds involving web space were treated with a flap divided into twin flaps inset into the radial and ulnar web space, with the flap sizes overall varying from 2 cm x 5 cm to 10 cm x 18 cm. These involved the dorsum of the hand in four patients, the thumb in two patients, the index finger in one patient, the long finger in three patients, the long and ring fingers in one patient and the web space in two patients.

Necrosis of the finger is shown following wound infection.

Here, the skin flaps are elevated.

The adipofascial flap tunnel under a skin bridge is shown here.

Patient 8 weeks after surgery. Images: Deal DN

“A useful option”

Deal reported a 100% rate of skin graft survival in 12 patients, with one patient reporting a poor result. This patient had a below-elbow amputation for nonhealing wounds secondary to generalized poor health and ultimately died of sepsis from unrelated medical conditions.

Deal’s team reported no donor-site complications. All patients were reportedly satisfied with the surgery, and Laser Doppler fluxmetry measurements demonstrated excellent cutaneous perfusion of the grafted skin comparable to the neighboring normal skin.

“This is a retrospective review in a small case series, but we feel this is a useful option for larger dorsal hand and finger coverage,” Deal said. “It can be done as a one-stage procedure, it is less challenging than many other flaps, it can require no or minimal hospital stay and you don’t need to anticoagulate the patient after the procedure.”

Moderator criticisms

Moderator L. Scott Levin, MD, had a number of criticisms regarding the paper’s content — including the purported difficulty and the abstract’s concept of a “random flap” — and though he ultimately acknowledged the adipofascial flap’s use, he did not praise it as a replacement for existing procedures.

“The adipofascial flap in my opinion is not the first I’d ask to be used, but it is one that I would add to our reconstructive armamentarium,” he said.

For more information:

• D. Nicole Deal, MD, is an assistant professor with the Department of Orthopaedic Surgery at the University of Virginia. She can be reached at Box 800159 HSC, Dept Orthopaedic Surgery, University of Virginia, Charlottesville, VA 22908; 434-243-5432; e-mail: ndeal@wfubmc.edu. She has no direct or financial interest in any company or product mentioned in this article.
• L. Scott Levin, MD, FACS, is chair of the Department of Orthopedic Surgery of Penn Medicine at Penn University. He can be reached at the Hospital of the University of Pennsylvania, 2 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104; 1-800-789-7366; e-mail: scott.levin@uphs.upenn.edu. He has no direct or financial interest in any company or product mentioned in this article.

Reference:

• Deal DN, Barnwell J, Li Z. Soft tissue coverage of complex dorsal hand and finger defects using the turn over adipofascial flap. Paper HS-58. Presented at the 2009 Combined Annual Meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapists. Sept. 2-5, 2009. San Francisco.