Engelhardt T O, Rieger U M, Baltaci M, Pierer G, Schwabegger A H
Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Medizinische Universität Innsbruck, Austria.
Handchir Mikrochir Plast Chir. 2011 Aug;43(4):255-61. doi: 10.1055/s-0030-1267914. Epub 2011 Aug 10.
Skin and soft-tissue architecture of the palm are unique. Coverage of extensive soft-tissue defects restoring the functional capacity of the palm remains a challenging task. Anatomic restoration with skin from another area is hardly possible. In manual labourers, reconstruction of mechanical soft-tissue stability is required in addition to sensation, range of motion and grip strength. Sensate fasciocutaneous flaps bear disadvantages of tissue mobility, shifting and bulkiness. Published criteria for defect-related flap selection are sparse.
Defect analysis (anatomy, units of tactile gnosis, individual parameters) provides information to weigh needs for sensation or tissue stability, influencing selection of most appropriate procedures. We distinguished 4 units: hypothenar (H), thenar (T) and central palm (Z). (Z) consists of a central palmar unit (c') and the distal palm (d'). Individual parameters (age, profession, dominant hand, psychosocial aspects) were also considered. Units (T) and (H), regions of secondary touch, demand protective sensation by applying sensate fasciocutaneous flaps. In labourers tactile gnosis in (Z) is of less, tissue stability of greater value. An extensive palmar defect (9×13 cm, affecting unit (Z), partially affecting units (T) and (H), of the dominant hand) with combined vessel, nerve, tendon injuries (male labourer, 21 years) was covered after defect analysis with a free gracilis muscle flap and a glabrous intermediate (0.5 mm) thickness skin graft from the instep region.
29 months postoperatively anatomic conditions of palmar soft tissue (Vancouver scar scale: 1), high mechanical soft-tissue stability including normal hand function were evident. Semmes Weinstein testing showed positive pressure sensation. Professional reintegration after 5 months was possible.
Defect coverage of the palm must not consist of merely providing sensate vascularised tissue. The most appropriate procedure can be derived from careful defect analysis focusing on the affection of units of tactile gnosis to achieve near to anatomic reconstruction. In labourers, patient- and defect-related demands need close correlation with the value of the selected flaps regarding the sensation and mechanical stability to be expected. In selected cases (mechanical irritation, affection of unit (Z), younger age) by combining microvascular muscle flaps with plantar intermediate thickness skin grafts promising functional results with early professional reintegration can be achieved by reconstructing like with like.
手掌的皮肤和软组织结构独特。修复手掌功能能力的大面积软组织缺损覆盖仍然是一项具有挑战性的任务。用身体其他部位的皮肤进行解剖修复几乎不可能。对于体力劳动者，除了感觉、活动范围和握力外，还需要重建机械性软组织稳定性。带感觉的筋膜皮瓣存在组织移动性、移位和臃肿等缺点。已发表的与缺损相关的皮瓣选择标准很少。
缺损分析（解剖结构、触觉识别单位、个体参数）为权衡感觉或组织稳定性需求提供信息，影响最合适手术方法的选择。我们区分了4个单位：小鱼际（H）、大鱼际（T）和手掌中央（Z）。（Z）由手掌中央单位（c'）和手掌远端（d'）组成。还考虑了个体参数（年龄、职业、优势手、心理社会因素）。（T）和（H）是次要触觉区域，需要通过应用带感觉的筋膜皮瓣来提供保护性感觉。对于体力劳动者，（Z）区域的触觉识别相对次要，组织稳定性更有价值。一名21岁男性体力劳动者，优势手出现大面积手掌缺损（9×13厘米，累及单位（Z），部分累及单位（T）和（H）），伴有血管、神经、肌腱联合损伤，在缺损分析后，采用游离股薄肌皮瓣和来自足背区域的无毛中间厚度（0.5毫米）皮肤移植进行覆盖。
术后29个月，手掌软组织的解剖状况良好（温哥华瘢痕量表：1级），机械性软组织稳定性高，包括手部功能正常。Semmes Weinstein测试显示正压力觉。5个月后能够重新回到工作岗位。
手掌的缺损覆盖不能仅仅是提供带感觉的血管化组织。最合适的手术方法可以通过仔细的缺损分析得出，重点关注触觉识别单位的受累情况，以实现接近解剖重建。对于体力劳动者，患者和缺损相关的需求需要与所选皮瓣在预期感觉和机械稳定性方面的价值密切相关。在某些特定病例（机械刺激、单位（Z）受累、年龄较轻）中，通过将微血管肌皮瓣与足底中间厚度皮肤移植相结合，可以通过同类重建实现良好的功能结果并早期重返工作岗位。
