Omokawa S, Tanaka Y, Ryu J, Clovis N
Musculoskeletal Research Center, West Virginia University, and Ishinkai-Yao General Hospital, Morgantown, USA.
Plast Reconstr Surg. 2001 Dec;108(7):2020-5. doi: 10.1097/00006534-200112000-00029.
Primary soft-tissue coverage for large palmar defects of the fingers is a difficult problem for cases in which homodigital or heterodigital flaps cannot be used. The aim of this study was to explore the vascular and neural anatomy of the midpalmar area to assess the possibility of reverse island flaps from this area. In 24 cadaver hands perfused with a silicone compound, the arterial pattern of the superficial palmar arch and common palmar digital artery was examined. The cutaneous perforating arteries and nerve branches supplying the midpalmar area were dissected, and the number, location, and arterial diameter of these branches were measured. In six other specimens, the common palmar digital artery was injected to determine the skin territory supplied by the artery. The superficial palmar arch contained the three common palmar digital arteries and its terminal branch coursed along the radial margin of the index metacarpus. This terminal branch had three to six cutaneous perforators (diameter range, 0.1 to 0.5 mm) and supplied the radial aspect of the midpalmar area located over the ulnar half of the adductor pollicis muscles. The midpalmar area was divided into two regions-the proximal and distal-according to the vascular distributions. The proximal region contained dense aponeurosis and thin subcutaneous tissue, and the cutaneous perforators were rather sparse (between three and nine) and had a small diameter (0.1 to 0.3 mm). The distal region, which had loose aponeurosis and abundant subcutaneous tissue, had a rich vascular supply from the common and proper digital artery. Perforating arteries of this region coursed frequently in an oblique fashion and the number of perforators (between eight and 15) and their arterial diameters (diameter range, 0.1 to 0.5 mm) were higher than those of the proximal region. The area of skin perfused by the common palmar digital artery was 5 x 3 cm at the distal midpalmar region. There were three to five cutaneous nerve branches from the palmar digital nerve supplying the midpalmar area. From this study, two different reverse flaps were proposed. First, a 5 x 2 cm flap from the distal midpalmar region was elevated on the basis of the common and proper palmar digital artery. Measurement of the rotation arc revealed that the pivot point of this flap was located at the proximal interphalangeal joint level and could cover the finger pulp of the digits. The second flap candidate was that from the radial aspect of the midpalm, which was supplied by the terminal branch of the superficial palmar arch. In studies with cadaver hands, connection of this artery with the deep arterial system enabled this flap to reach the thumb pulp. These flaps may be a useful reconstruction option for significant palmar soft-tissue loss of the fingers.
对于无法使用同指或异指皮瓣的病例，手指大的掌侧缺损的一期软组织覆盖是一个难题。本研究的目的是探索手掌中部区域的血管和神经解剖结构，以评估从该区域切取逆行岛状皮瓣的可能性。在24只灌注了硅酮化合物的尸体手上，检查了掌浅弓和指掌侧总动脉的动脉走行。解剖了供应手掌中部区域的皮穿支动脉和神经分支，并测量了这些分支的数量、位置和动脉直径。在另外6个标本中，向指掌侧总动脉内注射染料以确定该动脉所供应的皮肤区域。掌浅弓包含三条指掌侧总动脉，其终末支沿示指掌骨的桡侧缘走行。该终末支有三到六支皮穿支（直径范围为0.1至0.5毫米），供应位于拇收肌尺侧半上方的手掌中部区域的桡侧部分。根据血管分布，手掌中部区域分为近端和远端两个区域。近端区域有致密的腱膜和薄的皮下组织，皮穿支相当稀疏（三到九支）且直径较小（0.1至0.3毫米）。远端区域腱膜疏松，皮下组织丰富，有来自指掌侧总动脉和指掌侧固有动脉的丰富血供。该区域的穿支动脉常以斜行方式走行，穿支数量（八到十五支）及其动脉直径（直径范围为0.1至0.5毫米）均高于近端区域。在手掌远端中部区域，指掌侧总动脉所灌注的皮肤面积为5×3厘米。有三到五支来自指掌侧神经的皮神经分支供应手掌中部区域。基于本研究，提出了两种不同的逆行皮瓣。首先，以指掌侧总动脉和指掌侧固有动脉为蒂，从手掌远端中部区域掀起一个5×2厘米的皮瓣。旋转弧测量显示，该皮瓣的旋转点位于近端指间关节水平，可覆盖手指的指腹。第二个皮瓣候选部位是手掌中部桡侧的皮瓣，由掌浅弓的终末支供应。在尸体手的研究中，该动脉与深部动脉系统的连接使该皮瓣能够到达拇指指腹。对于手指严重的掌侧软组织缺损，这些皮瓣可能是一种有用的重建选择。
