RU2821762C1 - Method for replacement of cicatricial defects of skin of back surface and adhesions of main phalanges of fingers - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to reconstructive surgery of hand, and can be used for replacement of cicatricial defects of skin of back surface and adhesions of main phalanges of fingers. Scars are excised and cicatricial adhesions in the area of interdigital space are eliminated; artificial syndactyly is performed; defect area is measured; tongue-shaped adipocutaneous flap is cut out on a dorsal metacarpal artery on a peripheral vascular pedicle including a dorsal saphenous vein. Flap is mobilized and moved into the skin defect; a cone-shaped flap is formed from excess skin formed as a result of displacement of a skin-fat flap. Two months later, artificial syndactyly is eliminated; excess skin of the flap in the form of a cone is dissected along a scar in a projection of an interdigital space, and a U-shaped flap with a proximal base is formed from it. Edges of the divided tongue-shaped flap are sutured together with the wound edges on the lateral surface of the finger. U-shaped flap is placed on the bottom of the interdigital space and its top is sutured with the edges of the skin wound on the palm, and the lateral sides are sutured with the edges of the divided skin flap. Palmar plaster splint is applied in a finger-apart position for 4 weeks.

EFFECT: method provides effective replacement of defects of dorsal surface of fingers due to formation of adequate interdigital space and restoration of authentic skin.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely to reconstructive hand surgery.

There is a known method of replacing a skin defect on the dorsal surface of a finger by moving a skin-fat flap on the dorsal metacarpal artery on a peripheral vascular pedicle (Belousov A.E. Plastic, reconstructive and aesthetic surgery, A.E. Belousov. - St. Petersburg: Hippocrates, 1998, pp. 185-186). The method has the following disadvantages: 1) it allows you to replace a skin defect of only one finger; 2) does not provide defect replacement with elimination of scar adhesions and restoration of adequate interdigital space; 3) there is a danger of damage, tension and bending of the vascular pedicle, which can lead to disruption of the blood supply to the flap.

There is a known method for replacing skin defects on the dorsal surface of the fingers by creating artificial syndactyly and covering the skin defect with an axial skin-fat flap on a feeding pedicle, followed by separation of the fingers (Method of skin grafting for multiple injuries of the palmar surface of the fingers, RF patent No. 2448656). The method has the following disadvantages: 1) there is a need for distant flap surgery, which increases the duration and invasiveness of the intervention; 2) the structure (structure) and properties of the skin and subcutaneous tissue from distant areas differs from the structure and properties of the skin on the dorsum of the hand, which reduces the functional and cosmetic results of the operation; 3) the method does not prevent the formation of scar adhesions and narrowing of the interdigital space when the proximal parts of the main phalanges are involved in the process and form an adequate interdigital space, which also reduces the results of the operation.

The purpose of the proposed invention is to form an adequate interdigital space and restore authentic skin.

The technical result is to increase the efficiency of replacing defects on the dorsal surface of the fingers.

The technical result is achieved by excising the scars and eliminating cicatricial adhesions in the area of the interdigital space; perform artificial syndactyly; measure the area of the defect; cut out a tongue-shaped skin-fat flap on the dorsal metacarpal artery on the peripheral skin-vascular pedicle with the inclusion of the dorsal saphenous vein; the flap is mobilized and moved into the skin defect; in close proximity to the end point of the arc of rotation, they form a skin duplication, forming an excess skin flap in the shape of a cone; after two months, artificial syndactyly is eliminated; cut the excess skin of the flap in the shape of a cone in the projection of the interdigital space and form an axial U-shaped skin-fat flap with a proximal base from it, sew the edges of the divided tongue-shaped flap onto the fingers with the edges of the wound on the lateral surface of the finger, the U-shaped flap is placed on the bottom of the interdigital gap and sew its top with the edges of the skin wound on the palm, and the sides with the edges of the divided skin flap; A palmar plaster splint is applied in the position of the fingers apart for a period of 4 weeks.

The method is illustrated by drawings, where:

Fig. 1 shows the hand before surgery;

in fig. 2 - hand after excision of scars on the back of the fingers, formation of artificial syndactyly and a tongue-shaped dorsal metacarpal skin flap on the dorsal metacarpal artery;

in fig. 3 - hand after moving the tongue-shaped flap into the skin defect of the fingers, a skin cone formed on the flap;

in fig. 4 - incisions on the skin cone;

figure 5 is an axial U-shaped skin-fat flap formed from a skin cone;

Fig.6 - hand after eliminating syndactyly and forming an interdigital space due to an axial U-shaped skin-fat flap.

The method is carried out as follows.

Scars are excised on the dorsal surface of the main phalanges of the fingers, and cicatricial adhesions in the area of the interdigital space are eliminated (Fig. 1). The opposite adjacent edges of the resulting wounds on the fingers are sewn together, forming an artificial syndactyly and one common wound (Fig. 2, item 1). The area of the resulting general wound defect is measured. According to the size of the defect on the dorsal surface of the hand, a tongue-shaped skin-fat flap of the dorsal metacarpal artery is cut out on a peripheral cutaneous-vascular pedicle with the inclusion of the dorsal saphenous vein (Fig. 2, item 2). The flap includes the dorsal saphenous vein (Fig. 2, item 3) after its ligation at the apex of the flap and the dorsal metacarpal artery. The base of the flap is placed in the area of the metacarpophalangeal joints. The flap (2) is mobilized and moved into the skin defect on the fingers (Fig. 3). After moving the flap to one of its sides, in close proximity to the end point of the arc of rotation, a skin duplicator is formed, when the edges of the wounds are sutured, excess skin of the flap is formed in the shape of a cone (Fig. 3, item 4). The donor wound is sutured initially after mobilization of the wound edges (Fig. 3). Two months after the graft has been implanted, artificial syndactyly and the formation of an interdigital space are removed. In this case, the skin flap is dissected in the projection of the interdigital space, the fused skin of the fingers on their adjacent lateral surfaces is separated, and the commissural skin fold on the palm is crossed. Next, an incision is made along the postoperative scar on the skin cone, extending it along the distal semicircle of the cone at its base to the opposite edge of the flap and connecting with the previous incision (Fig. 4, item 4), the dorsal metacarpal artery is ligated and crossed (Fig. 5, item .3), included in the flap. The edges of the wounds on the skin cone (4) are mobilized while maintaining connections with the preserved part of the artery (3) and an axial U-shaped skin-fat flap is formed from it with a proximal base (Fig. 5, item 5). The edges of the divided tongue-shaped flap are sewn together on the fingers with the edges of the wound on the lateral surface of the finger. A U-shaped flap (5) is placed on the bottom of the interdigital space and its top is sutured with the edges of the skin wound on the palm, and the sides with the edges of the divided skin flap (Fig. 6). A palmar plaster splint is applied in the position of the fingers apart for a period of 4 weeks.

Clinical example.

Patient A., 59 years old, was admitted to the clinic due to cicatricial defects of the skin of the dorsal surface of the main and middle phalanges, extension contractures of the third, fourth, fifth fingers, cicatricial basal syndactyly of the third, fourth fingers, stumps of the nail phalanges of the second, third, fourth fingers of the right hand . From the anamnesis it is known that the patient received a burn from a brush flame on October 15, 2021. at home. Upon admission, a cicatricial skin defect measuring 2×4 cm is detected on the dorsal surface of the main and partially middle phalanges of the third finger, 2×4.5 cm in size on the fourth finger, and 1×3 cm in size on the fifth finger. In addition, there was cicatricial basal syndactyly of the third and fourth fingers. The function of flexion of 2-5 fingers in the interphalangeal joints is sharply limited, there is no extension of the third and fourth fingers. 06/22/2022 Scars were excised on the dorsum of the third and fourth fingers and in the area of the third interdigital space. An artificial syndactyly was formed by suturing nearby opposite edges of the wound. The size of the resulting general wound defect was 4×5 cm. On the dorsal surface of the hand, a tongue-shaped dorsal metacarpal skin-fat flap measuring 4x8 cm was formed on a peripheral feeding pedicle with the inclusion of the third dorsal metacarpal artery and saphenous vein. The flap was moved into the resulting tissue defect. The donor wound is sutured primarily after mobilization of its edges. After moving it, a skin fold formed on the outer side of the flap; when its edges were sutured, excess skin formed in the form of a cone. After the operation, the wounds healed by primary intention, and the flap was completely healed. The division of artificial syndactyly was performed on August 21, 2022, while the previously transplanted flap was dissected in the projection of the third interdigital space, and the fused skin of the fingers on the lateral surfaces was separated. The flap is cut at the distal edge of the skin cone. From the previously formed skin cone, a U-shaped axial skin flap measuring 2x2 cm was formed, which was placed at the bottom of the third interdigital space. Its top was sewn with the edges of the skin wound on the palm, and the sides - with the edges of the divided skin flap. On the third and fourth fingers, the edges of the divided flap were sewn with the edges of the wound on the lateral surface of the finger. On the dorsal surface of the 5th finger, the skin defect after excision of the scars was replaced using local skin grafting. Wound healing by primary intention and engraftment of all flaps was achieved. The patient was examined 6 months after surgery. The skin of the 3rd and 4th fingers and the interdigital commissure does not differ from the neighboring ones in color, displacement and structure, the function of spreading the 3rd and 4th fingers is restored, and the extensor contractures of the fingers are eliminated.

The method increases the efficiency of replacing defects of the main phalanges with skin and subcutaneous tissue identical in properties and structure. Along with the replacement of the skin defect on the dorsal surface of the main phalanges, their scar adhesions are eliminated, and an adequate interdigital space is formed. The formation of a wide skin-vascular pedicle ensures the prevention of compression and bending of the axial vessel, accompanying and saphenous veins, which ensures adequate blood supply to the flap. The formation of a U-shaped axial skin-fat flap ensures the prevention of ischemic complications when placing it in the area of the interdigital space. When implementing the method, no damage is caused to donor resources from remote areas.

Claims (1)

A method for replacing cicatricial defects in the skin of the dorsal surface and adhesions of the main phalanges of the fingers, characterized by the fact that scars are excised and cicatricial adhesions in the interdigital space are eliminated; perform artificial syndactyly; measure the area of the defect; cut out a tongue-shaped skin-fat flap on the dorsal metacarpal artery on the peripheral skin-vascular pedicle with the inclusion of the dorsal saphenous vein; the flap is mobilized and moved into the skin defect; from the excess skin resulting from the movement of the skin-fat flap, a cone-shaped flap is formed; after two months, artificial syndactyly is eliminated; the excess skin of the flap is cut in the shape of a cone along the scar in the projection of the interdigital space and a U-shaped skin-fat flap with a proximal base is formed from it, the edges of the divided tongue-shaped flap are sutured on the fingers with the edges of the wound on the lateral surface of the finger, the U-shaped flap is placed on the bottom interdigital space and stitch its top with the edges of the skin wound on the palm, and the sides with the edges of the divided skin flap; A palmar plaster splint is applied in the position of the fingers apart for a period of 4 weeks.