RU2146895C1 - Method for making plastic repair of hand and finger skin defects - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves using cutanofascial graft taken from utility finger. The graft has an artery, nerve and two veins. After fixing the graft, one artery, one or two veins are sutured and perineural suture of the utility graft finger nerve is carried out. EFFECT: provided full-valued cutaneous integument. 5 dwg

Description

 The invention relates to medicine, namely to microsurgery, traumatology and orthopedics.

 Among the injuries of the brush very often there are injuries accompanied by a soft tissue defect. Full replacement of defects is an actual problem of hand surgery (A.E. Belousov, S. S. Tkachenko, “Microsurgery in traumatology.” - L.: Medicine, Leningrad Department, 1988, pp. 131-133, 150-155; A. M. Volkova, "Hand Surgery" .- Yekaterinburg: Middle Ural Book Publishing House, 1991, p. 5).

 A skin defect is a wound whose edges cannot be stitched by simple stitching without tension.

When choosing a method for replacing a skin defect, the following requirements must be agreed upon:
the method of plastics should lead to the best cosmetic and functional result;
short healing time;
minimum number of operations;
minimal cosmetic defect in the donor site.

 Known plastic is a full-layer graft (grafts in the entire thickness of the skin), which was first described and applied by Bunger (Macburg) in 1923 (J. Zoltan, “Skin transplantation.” Publishing House of the Academy of Sciences of Hungary, 1984, pp. 14-16, 82- 83). The graft with a thickness of 0.8-1.1 mm is placed on the wound and is fixed with a pressure bandage.

The disadvantages of this method:
the transplant is prone to wrinkling, fibrosis;
the transplant is very whimsical, survives only in aseptic conditions, on the receiving bed with good blood supply;
a donor wound must be sutured or closed with plastic surgery;
unsatisfactory cosmetic and functional results with plastic of the palmar surface of the fingers.

 Known microsurgical transplantation of complex skin grafts for the hand and fingers. A lot of flaps are described, which are used for plasty of soft tissue defects in the free version. A scapular flap, a flap from the first interdigital space from the foot, venous flaps, etc. are used (A.E. Belousov, S.S. Tkachenko, "Microsurgery in Traumatology" .- L .: Medicine, Leningrad Department 1988, p. 131- 133, 150-155; A.E. Belousov, V.V. Kuzin, P.E. Kuprin, "Venous flaps in plastic surgery of the extremities." Herald of Surgery, N 1, Medicine, 1991, p. 74-77).

The disadvantages of these methods:
high probability of damage to nearby anatomical formations during the allocation of flaps;
the need to perform plastic surgery when replacing a defect at the site of the flap;
the presence of a defect in the donor site.

 A known method, selected as a prototype, to eliminate a skin defect in the palm of the hand (rarely on the back surface of the hand), in which the skin of a badly damaged finger is used. The skin of the little finger is removed from the tendons and bones using an incision made along the mid-lateral line of the elbow edge. The preparation is carried out, in fact, in the avascular layer. In a skin flap, neurovascular formations remain unaffected (J. Zoltan, “Skin Transplantation.” Publishing House of the Hungarian Academy of Sciences, 1984, p. 221).

The disadvantages of the prototype:
the use of this method is possible only with preserved vascular connections;
while maintaining vascular connections, the application of this method is impossible if there is a cicatricial process in the skin flap;
It is difficult for a psychologically ill patient to prepare for the loss of a finger.

 The objective of the invention is the reduction of treatment time, the creation of a full skin.

 The task is achieved by the fact that as a plastic material, a skin-fascial flap from a scrap finger is used, including an artery, a nerve and two veins, and after fixation of the flap, a suture of one artery, one or two veins and a perineural suture of the finger nerve of the scrap flap are performed.

 The novelty of the method.

 1. The use of a scrap flap. With multiple amputations of the fingers, when there is a crush of soft tissues in the mechanism, and there is also a combined damage, i.e. multi-fragmented phalangeal fractures, tendon, joint defect, restoration (replantation) of the 1st and 2nd fingers of the hand is shown. The same fingers, which even during replantation will be deliberately afunctional, and their engraftment is very doubtful, are considered scrap. They are used as bone-articular grafts or a stump is formed at the site of separation, or a narrow hand. Using a skin scrap flap, they achieve simultaneous operation, the possibility of reinnervation of the flap with a high degree of discriminatory sensitivity. The immobilization period is short, which allows for early development. All the feeding arteries of the hand are preserved, there is no defect in the donor bed, as when grafts are taken from other parts of the body.

 2. Stitching of the artery, veins and nerve provides nutrition and reinnervation of the scrap flap.

The method is illustrated by drawings, where:
FIG. 1 - shows a complete detachment of the 5th finger of the right hand, incomplete detachment of the 2nd to 4th fingers, skin defect on the volar surface of the hand;
FIG. 2 - a revision of the vessels of the donor zone;
FIG. 3 - the collected skin flap is fixed in the area of the defect;
FIG. 4 - a suture of blood vessels, digital nerve;
FIG. 5 - final view after flap correction.

 The essence of the method is as follows.

 An incision is made to the level of the distal interphalangeal joint along the lateral surface of the scrap finger in the projection of the neurovascular bundle or taking into account any tissue defect. At the level of the distal interphalangeal joint, the incision is circular. A skin flap is prepared and separated from the bone-tendon base with the mandatory inclusion of the digital arteries, nerves and dorsal veins. Fascia is also part of the flap. Then, using an operating microscope under an increase of 5-8 times, an audit of the digital arteries and dorsal veins is performed. To perform anastomosis, we prepare one artery (less damaged or having the longest length). We prepare either one back collector vein, or 2 veins. We make a fence of the digital artery and nerve, which we do not use. If the length of the neurovascular leg of the flap is insufficient, then these autografts are used as an insert. We remove adventitia from the digital artery and dorsal veins. Similarly, the vessels of the donor zone are prepared. We include the flap vessels in the dorsal veins of the hand or one of the dorsal veins from a neighboring finger. We prepare the digital or common finger artery. Variants of using various vessels are determined by the length of the vascular pedicle of the flap and the diameter of the anastomosing vessels. The flap is fixed in the area of the defect with several adaptive sutures. Considering that the flap tissue can be crushed and the boundary of the blood supply to the flap is still not clear, if there is an excess of flap area, its correction is performed only after inclusion in the bloodstream. We produce a suture of blood vessels using microsurgical techniques, optical magnification. Suture thread prolene 8./0-10/0. After inclusion in the bloodstream, provided the flap is well filled, an epiperineural suture of the digital nerve is performed (to perform the suture, we select either the digital finger or subepineurally divide the common finger nerve). Correction of soft tissue flap and fixation with rare sutures. Drainage by rubber graduates. Soft bandage. Plaster immobilization.

 Clinical example. Patient I., 60 years old, right-handed, was hospitalized in the clinic 02/13/97, with a diagnosis of complete detachment of the 5th finger of the right hand; incomplete detachment of the 2-4th fingers of the right hand with damage to all neurovascular formations, flexor tendons, defect of the metacarpophalangeal joint of the 2nd finger, skin defect of the voluntary surface of the hand, fingers. Surgery performed: primary surgical treatment of wounds of the hand. Revascularization of the 2-3-4th fingers of the right hand, primary arthroplasty of the metacarpophalangeal joint of the 2nd finger. Suture of the deep flexors of the 2-3-4th fingers, digital nerves and arteries. Replantation of a skin flap on the voluntary surface of the hand and fingers. Anesthesia is conductor. Produced economical excision of the edges of the wound. Finger arteries and nerves are highlighted.

 The resection of the destroyed head of the 2-metacarpal bone was performed. The 5-metacarpal bone was resected and arthroplasty of the metacarpophalangeal joint of the 2nd finger was performed due to the metacarpal phalangeal joint of the 5th finger. Superficial flexors of the 2-3-4th finger are excised. Suture of the tendons of the deep flexors of the 2-3-4th finger, superficial flexors are hemmed to the deep. Suture of the digital nerve and artery of the 2nd finger from the radial side. Suture of the common digital artery, nerve of the 2nd to 3rd finger. Plastic surgery on the radial side of the finger nerve and artery of the 4th finger with an autoset taken from the scrap 5th finger on the radial side 4.5 cm long. Suture with 9/0 thread. The blood flow has been restored, the game of blood vessels is distinct, the fingers are full. However, a defect was formed along the volar surface of the hand and 4th finger 8x5 cm in size. The flap from the scrap 5th finger was prepared from the bone-tendon base. The flap includes an artery, nerve, 2 veins. The flap is fixed in place of the defect (the bottom of which is the tendons, nerves, vessels) with adaptive sutures. The own artery of the 5th finger is included in the artery of the skin-fascial flap taken from the 5th finger. Suture of the digital nerve, suture of one vein. Plaster immobilization. In the postoperative period, bed rest was prescribed for 5 days, treatment with antiplatelet agents, angioprotectors and antibiotics was performed. The engraftment of the flap is complete. On the 14th day the seams were removed. The development of movements began on the 6th day after the operation. 5 weeks after surgery, a cylindrical grip was restored. The texture, color, and mobility of the flap are good.

Claims (1)

 A method for plasticizing a skin defect of a hand and fingers using a finger flap of this brush, characterized in that a plastic-fascial skin flap from a scrap finger, including an artery, a nerve and two veins, is used as a plastic material, and after fixing the flap a suture of one artery is performed, a suture one or two veins and the perineural suture of the digital nerve of the scrap flap.

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