Case 10 (2023): 1st dorsal intermetacarpal artery flap (Foucher flap)

Andrea Wenger; Volker J. Schmidt

Journal of Plastic, Breast & Reconstructive Surgery·Rapports de cas chirurgicaux en libre accès, évalués par les pairsÉvalué par les pairs · Libre accès

Case 10 (2023): 1st dorsal intermetacarpal artery flap (Foucher flap) · JPBRS

Rapport de cas

Case 10 (2023): 1st dorsal intermetacarpal artery flap (Foucher flap)

Andrea Wenger, Volker J. Schmidt

Publié 29 avril 2023138 vues5 min de lecture

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Résumé

Initially, the patient presented with a purulent tenosynovitis of the right thumb. Debridement was performed and antibiotics for streptococcus pyogenes administered. 3 weeks later we did another revision surgery because of infected necrose tissue at the pulp of the thumb and osteomyelitis of the terminal bone. After two more debridements this resulted in a soft tissue defect at the palm of the thu

Points clés à retenir

Conseils pratiques

Sensitive flap. Short immobilisation with good range of motion. Regional reconstruction of the tissue. Microsurgical experience is helpful. Preserve paratendineum at the donor site.

Écueils

Venous congestion – especially in cases of island flap design. (Partial) flap loss (

Patient history

Examination

General medical history: 62 year old otherwise healthy male patient with no history of comorbidities (e.g. diabetes), no allergies, non-smoker, no regular intake of any medication Profession: self-employed caretaker, right-handed Right Hand: Skin defect at the palm of the thumb, 2 x 3 cm with exposed bone, FPL tendon, radial and ulnar nerve. EPL and FPL function intact, thumb warm and blood flow intact, 2 point discrimination at the radial side not measurable, 5mm at the ulnar side. X-ray showing signs of osteomyelitis, the IP joint intact

Pre-operative considerations

Since the patient was young, healthy, right-handed and a self-employed manual worker, the need of a mechanically robust pulp was the reconstructive goal and amputation at the IP level was no option. 2 flaps would be an appropriate choice for closing this defect: a first dorsal intermetacarpal artery flap or a sensory heterodigital island flap (e.g. ulnar pulp of the ringfinger). Our choice against the latter was due to the history of infection and osteomyelitis with potential risk for further complications and the defect presenting mainly at the radial and therefore the non-dominant part of the pulp in precision grip. The first dorsal intermetacarpal flap (commonly known as Foucher flap) has been initially described by Hilgenfeldt, was designed as a racquet flap by Holevich and modified as an island flap by Foucher. For safety considerations we decided to take a small skin overlying the pedicle and include as many subcutaneous veins as possible in the flap.

Étape 1 — Flap planning

The surgery is done under plexus block, the patient in a supine position with the shoulder abducted and placed on an arm table. The 1st dorsal intermetacarpal artery is marked by Doppler ultrasound, the flap on the dorsal aspect of the proximal phalanx of the 2nd finger is planned according to the size of the defect. Incisions shouldn’t be extended over mediolateral lines, PIP joint distally and MC joint proximally respectively. The skin overlying the pedicle is included in the flap and the defect later closed primarily.

Références

Muyldermans T, Hierner R: First dorsal metacarpal artery flap for thumb reconstruction: a retrospective clinical study. Strat Traum Limb Recon 2009;4:27-33
Couceiro J, Sanmartín M: The Holevic flap revisited: a comparison with the Foucher flap, case series. Hand Surg 2014;19:469-474
Delokonstantinou IP, Gravvanis AI, et al: Foucher first dorsal metacarpal artery flap versus Littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects. Ann Plast Surg 2001;67:119-122
Saalabian A, Rab M, et al: Insellappenplastik der ersten dorsalen Mittelhandarterie nach Foucher. Operat Orthop Traumatol 2009;21:614-619
Kola N: Thumb reconstruction using Foucher’s flap. Opcen Access Macedonian J of Med Sciences 2016;4:70-73
Tränkle M, Germann G, et al: Neurokutaner Insellappen nach Foucher. Weichteildeckung undn Rekonstruktion der Sensibilität am Daumen. Chirurg 2004;75:996-1002