Reconstruction of Finger Composite Defects with Perforator Free Flap from the Superficial Palmar Branch of Radial Artery.
Finger defects can be repaired with secondary healing, local or regional flaps, or distant or regional-free flaps. [1-10] The objective in reconstruction is to close the defect area, allowing tendon mobility, and recovery of sensory conduction of the repaired tissue.  In defects involving skin reconstruction, the reconstruction can be rapidly and easily accomplished using local and regional flaps. Despite its two advantages as cost-effectiveness and shortness of the procedure, there are also several disadvantages such as restricted flap advancement, inadequate flap size relative to the defective area, sensory dysfunction of the flap, joint rigidity, venous problems, neuroma formation, and donor site morbidities. [1,11] Therefore, regional and distant flaps have been described to be required for larger defects. Although a great number of alternatives are available for soft-tissue reconstruction in composite finger injuries (involving skin, bone, tendon, vessel, and nerve) free flaps to be used are harvested from lower extremities. [12,13] Because of the delay in healing of the donor site and initiation of the finger movements of the patient at a later stage and presence of a hypertrophic scar and the donor site morbidity, these flaps are preferred at a lower rate. 
Flaps elevated from the superficial palmar branch of the radial artery (SUPBRA) have passed through various stages of development from the pedicle thenar flap elevated with its sensory innervation to free flap. [14-19] Hairless donor site of the flap, its elevation as a composite flap (involving nerve, vessels, and tendon), and better tissue compliance makes it a good alternative in reparation of composite defects. [20,21]
In the this study, our main objective is to report short-and long-term outcomes of reperation of composite defects of fingers using free SUPBRA flaps.
MATERIALS AND METHODS
All patients were provided with information about the surgical techniques before operation, and their consent was obtained and maintained in accordance with the principles of the World Medical Association's Declaration of Helsinki for "Ethical Principles for Medical Research Involving Human Subjects" (amended in October 2013). This study examined 10 patients (three women and seven men) with ages ranging between 18 and 47 years who received free composite SUPBRA flaps between 2010 and 2013. All traumatic cases were due to workplace accidents. Injuries were classified as crushing (n = 4), degloving (n = 1) and uncontaminated injuries and clean cuts (n = 5). Defect sizes ranged from 2 cm x 3 cm to 3 cm x 5 cm. The patients were followed for 11.5 (6-18 months). The mean hospitalization period was three (2-5) days. The patients who underwent bone fixation were rehabilitated for 5 weeks, while those who did not were included in another rehabilitation program that lasted five weeks. All patients were evaluated using static and dynamic two-point discrimination tests, Semmes-Weinstein monofilament test, active total range of motion (ROM) of the injured fingers, cold intolerance, and neuroma development on donor site. Besides, the visual analog scale (VAS) was applied for the evaluation of flaps and donor sites. VAS scores of smaller than five, five-seven, and eight-ten points were evaluated as unacceptable, acceptable, and good outcomes, respectively. The Statistical Package for Social Sciences (IBM SPSS Inc.; 23.0, Chicago, IL, USA) was used for statistical analysis of all data. The data were assessed using descriptive statistics (frequency, percentage, mean, standard deviation, median, and min-max).
The size of the flap was delineated to be 3-5 mm larger than the defect diameter so as to cover the defects without tension. Before elevation of the flap under axillary block, we performed anesthesia and tourniquet application, debridement of the recipient site, fixation of soft tissues, preparation of one artery and two veins of the recipient site and preparation of the digital nerve for coaptation of nerves [Figure 1]. Superficial veins were identified following incision that was made distal to the volar wrist line. A more laterally placed radial artery was found, and dissection was extended distally to the artery. The origin of the SUPBRA was identified, and the dissection was extended further to include veins accompanying the pedicle in the flap. For the sensate flap, the palmar cutaneous branch of the median nerve was included in the flap. For reconstruction of the tendon or the ligament, following dissection of palmaris longus tendon and then veins toward the proximal part of the forearm which should occupy in the central part of the flap, superficial veins were also dissected from the distal to the volar wrist line toward the thenar region and included in the flap. If a long pedicled or a flow-through flap would be designed, incision on the thenar region was advanced further, and the artery was followed up to this region. Excluding the arterial pedicles, all anatomical structures were incised from their identified locations and tourniquets were removed. Under microscopic examination, anastomosis of one artery and two veins, nerve coaptation, tendon, and ligament repair was observed. Donor sites were closed primarily during operation; the patients received one cc (5000 IU) heparin (Nevparin, MN Pharma, Istanbul, Turkey) injections. During the 1st postoperative month, all patients received single doses of 100 mg acetylsalicylic acid (Aspirin, Bayer Pharma, Germany).
An 18-year-old male patient had a bone defect at the back of the middle phalanx of the third finger of his right hand, dorsal ligament defect, and intrinsic extensor tendon defects [Figure 2a]. Debridement revealed a defect with a size of nearly 2.5 cm x 4.5 cm [Figure 2b]. Free SUPBRA flap was elevated together with palmaris longus tendon and skin island measuring 3 cm x 5 cm [Figure 2c]. Dorsal tendon system intrinsic extensor tendon defects were repaired using palmaris longus tendon. Pedicle of the flap was anastomosed to the digital artery. Palmar cutaneous branch of the median nerve was coapted to the digital nerve. Two veins from the superficial venous plexus were anastomosed to dorsal veins. The operation time lasted nearly 180 min. The patient was discharged on the 3rd postoperative day. Figure 2d and e show the appearance of the fingers in the 6th postoperative month.
A 28-year-old male patient had injured middle phalanx of the second digit of his right hand. He had a skin defect measuring 2.5 cm x 4 cm and a nearly 2-cm defect involving flexor digitorum profundus and radial side of the digital artery and digital nerve [Figure 3 a]. Distal and proximal-free SUPBRA flap was elevated together with a 3 cm x 4.5 cm skin island including the tendon of palmaris longus, the palmar cutaneous branch of the median nerve so as to achieve a flow-through flap [Figure 3b and c]. The tendon defect was repaired in the palmaris longus tendon. The digital nerve was repaired using a palmar cutaneous branch of the median nerve. The digital artery defect was repaired using an orthodromic (flow-through) island flap. Two superficial veins were anastomosed. Images of the finger at 8 months after initial surgery may be seen in Figure 3d-e.
All of the applied ten composite free flaps survived. The median value for the operation time was 194 min (180-260 min) and the patients returned to their work and their normal daily life in a median postoperative time of 5 months (4-8 months). No problem was observed. No problems or complications occurred in any of the primarily closed donor sites or in wrist movements. Donor site scars were evaluated as good (n = 3), acceptable (n = 5) and unacceptable (n = 2) by the patients. Median measurements in static and dynamic two-point discrimination tests were 7.9 mm (6-11 mm) and 6.1 mm (5-8 mm), respectively. The Semmes-Weinstein test results were determined as follows: normal (green: Two fingers), residual texture (blue: Four fingers), residual protective sensation (purple: Three fingers) and loss of protective sensation (one patient). Active ROM of the reconstructed fingers was evaluated as 71.6[degrees] (65[degrees]-80[degrees]) for the metacarpophalangeal joint, 83.2[degrees] (74[degrees]-94[degrees]) for the proximal interphalangeal joint and 70.5[degrees] (64[degrees]-77[degrees]) for the distal interphalangeal joint. Almost full active ROM was obtained in all the reconstructed fingers. Cold intolerance was not observed in six patients, while mild (n = 2), moderate (n = 1) and severe (n = 1) degrees of cold intolerance were seen in some patients. Neuroma development was not observed in any of the donor sites.
Reconstruction of the composite defects of fingers is still a challenging field in the field of hand surgery.  A local flap which may be used to repair composite defects involving bone, tendon or nerves is not available yet. For the repair of composite lower extremity defects involving bone, tendon and/or nerves, free flaps can provide a perfect support.  However, they have some disadvantages such as requirement of general anesthesia, donor site tissue incompatibility, and patient's delayed return to his/her daily activities.  However, SUPBRA flap is a good alternative in reconstruction of composite defects of the finger than a flap from the lower extremity due to similarity between tissues of the defect and flap with its better histocompatibility, application of this procedure under regional anesthesia, and earlier rehabilitation combined with minimal donor site disadvantage. 
Previously, superficial palmar branch of the radial artery flap might be elevated from the volar aspect of the wrist or from the thenar region vertical to the palmar fold. [13-16] The flap can be elevated reversely with its pedicle or used as a free flap in repairing finger defects. [15,18,19] It has the advantages of providing a hairless flap with a sensory innervation and elevation from the same region, in addition to its disadvantages including potential injury to the motor branch of the median nerve, presence of excess tissue which may require a thinning procedure as well as its short pedicle. [18,19] Besides, as in another application, it can be elevated from the flexor aspect of the wrist as a transverse skin island which includes the superficial palmar branch of the radial artery. A transverse flap is more appropriate for reconstructing composite defects. Together with a hairless and thinner flap, for reconstruction of the tendon, tendon of the palmaris longus, for arterial reconstruction a pedicled and a flow-through flap containing the superficial palmar artery and for reconstruction of the nerve, one may use a pedicle which includes palmar cutaneous branches of the median nerve, superficial radial nerve, and lateral antebrachial nerve. [20,21]
For repairing finger defects, previously, SUPBRA flap was elevated vertically. [15-17] In the year 2003, Sakai designed a transverse elevation method and used a free SUPBRA flap.  In some studies, the distance between the SUPBRA and volar wrist line was measured as 17-18 mm. [15,21-23] The diameter of the SUPBRA was found to vary between 0.9 and 1.4 mm. [15,20,23] The diameter of SUPBRA is suitable for digital arterial anastomosis. These measurements are closer to the diameter of the digital artery which makes SUPBRA an ideal free flap for repairing digital defects and facilitating anastomosis.
The superficial palmar branch of the radial artery flap is an ideal flap for flow-through arterial reconstruction. Its proximal and distal parts can be elevated.  If elevation of a longer pedicle is intended, distal SUPBRA can be dissected up to its junction with the superficial palmar arch. Since it is a reverse-elevated flap, both of these arteries can be utilized relatively safely for anastomosis. [18,19,22] At this site, venous flaps can be used as a flow-through alternative. However, venous valves may cause an increase in complication risks.  Flaps like posterior interosseous artery perforator or ulnar artery perforator flaps does not suitable for flow-through free flap reconstruction.  Therefore, we used SUPBRA flow-through flap in our study in five patients, and we did not observe any arterial complications.
The superficial palmar branch of the radial artery flap has two venous systems. One of them accompanies the arterial pedicle of the flap and the other consists of superficial veins. Based on the status of the recipient site, these two systems can be used simultaneously or separately. In our cases in general, two veins were used for a single artery, and the superficial vein at the midline was anastomosed to the vein accompanying the pedicle.
In cases where loss of soft-tissue damage is the main issue, arterialized venous flaps may be used alone or in combination with nerve and tendon flaps in a site with such an extensive venous network.  Despite higher success rates, observation of nutritional problems, inability to completely cover the bone defect, bulla formation and partial tissue necrosis observed with these flaps, SUPBRA flap offers a more durable alternative relative to these venous flaps. [10,25]
In reconstruction of defects involving tendons or ligaments, the tendon of palmaris longus can be included in the flap. [10,20] The positions of the skin defect and the tendon should be carefully adjusted when a vascularized tendon flap is used for the repair. When distal veins are used in venous flaps for anastomosis of the artery, placement of tendon elevated together with the flap restricts ROM.  Since both proximal and distal arteries can be used in SUPBRA, it is an ideal flap for tendon transfer. Therefore, in repairing defects measuring over 2 cm, it can be easily included in the tendon flap. 
Skin sensation was ensured by three different alternatives, namely, inclusion of the palmar cutaneous branch of the median nerve, lateral antebrachial branch of the cutaneous nerve, or sensory branch of the radial nerve in SUPBRA flap. [20,21,23] Inclusion of the palmar cutaneous branch of the median nerve in the flap impairs sensory functions of the wrist region and volar aspect of the wrist. Therefore, some studies have demonstrated elevating the flap from a more radial site that includes many other nerves in the flap.  In various studies where all three nerves were included in the flap, significant differences were not detected regarding skin sensation. [10,15,20,21] Neuroma formation is another problematic issue. Especially in cases where the palmar cutaneous nerve was not used, this possibility of complication is encountered more frequently. Therefore, in cases where other nerves are included in the flap, embedment of the proximal segment of the nerve in the donor site in the brachioradialis muscle was recommended.  In our study, we preferred using the palmar cutaneous branch of the median nerve. Consequently, we did not observe neuroma formation at the donor site of any patients. Excluding one case, the sensory functions of all of our all patients were recovered.
In studies that compared free flaps elevated at the level of the forearm (venous flap, SUPBRA, posterior interosseous perforator flap, and ulnar artery perforator flap), authors have demonstrated SUPBRA flap to be superior to others with respect to recovery of sensory functions. Elevation of a thinner flap, which results in enhanced innervation supplied by surrounding tissues, was pointed out as the main reason for these successful outcomes.  Despite all advantages of SUPBRA flap, it has many disadvantages such as small size of the proximal pedicle, anastomosis performed at the traumatic recipient site, increase in the possibility of thrombus formation, deformation of the design of the distally based flap to be elevated, very large skin island, experience required for the flap elevation and anastomosis, as well as necessity of microsurgical instruments and visible scar on the wrist.
In composite defects of fingers, no technique for bone reconstruction has been described in the literature yet. It is difficult to harvest vascularized bone grafts from distant regions for reconstruction of digital defects. Besides, it might not be always possible to design the bone as a smaller anatomical structure and elevate it with technical vascularized bone grafts from the palmar carpal artery arising from the radial artery for repairing nonunion or malunion of scaphoid bones.  After leaving radial artery, SUPBRA gives branches to the carpal bones. It constructs an arterial network with the carpal arch and the palmar carpal artery overlying the radial bone, and from that artery, its branches extend up to the periosteum of the radial bone. 
Cosmetic appearance of the flap recipient and donor site carries the main importance. Transverse scar settles on the fold line of the volar aspect of the wrist and leads to a formation of a cosmetically better/tolerable scar. However, since this scar resembles a scar created by people who have attempted suicide (wrist-cutting), patients may feel uneasy. In our series, three patients found its scar as fine (n = 3), acceptable (n = 5), and unacceptable (n = 2). The latter two cases were young patients, and donor site scars were more conspicuous. Scar revision was offered to all patients; however, they declined further interventions. On the recipient site, when compared with other flaps, a thinner, hairless and easily-shaped flap on the recipient site offers better tissue compliance. Besides, this flap does not contain excess tissue and hence thinning procedure is not performed, making it both more time-and cost-effective, which does not incur additional costs.
The superficial palmar branch of the radial artery free flap can be elevated from the ipsilateral extremity under regional anesthesia. This flap can be easily used for reconstruction of composite defects involving various anatomical structures as skin-bone-nerve or tendon with an advantage of providing a relatively hairless and thinner coverage. Therefore, it can be considered as a good alternative for repairing composite tissue defects in hand surgery.
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Conflicts of interest
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Alper Aksoy, Emin Sir (1), Daghan Dagdelen (2), Meliha Kasapoglu Aksoy (3)
Department of Plastic, Reconstructive and Aesthetic Surgery Konur Hospital, (3) Department of Physical Therapy and Rehabilitation University of Health Science Bursa Yuksek ihtisas Training and Research Hospital, Bursa, (1) Plastic, Reconstructive and Aesthetic Surgeon, Private Practice, izmir, (2) Department of Plastic, Reconstructiveand Aesthetic Surgery, Balikesir State Hospital, Balikesir, Turkey
Address for correspondence: Dr. Alper Aksoy, Department of Plastic, Reconstructive and Aesthetic Surgery Konur Hospital, Bursa, Turkey.
How to cite this article: Aksoy A, Sir E, Dagdelen D, Aksoy MK. Reconstruction of finger composite defects with perforator free flap from the superficial palmar branch of radial artery. Turk J Plast Surg 2018;26:44-9.
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|Title Annotation:||Original Article|
|Author:||Aksoy, Alper; Sir, Emin; Dagdelen, Daghan; Aksoy, Meliha Kasapoglu|
|Publication:||Turkish Journal of Plastic Surgery|
|Date:||Apr 1, 2018|
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