Hello and welcome! We have prepared an exciting session for you. Before we begin, we want to remind you that the material shown here is the property of ASPS or the presenters. Copying or distributing the content in these presentations without specific consent from ASPS is prohibited, including screenshots, photography, live streaming and video recordings. Also, please note that this session has a corresponding forum discussion taking place right now on the PSTM 23 conference platform. If you have questions for our faculty, please feel free to submit them there. Please note that chat records may be recorded. Thank you for your participation and enjoy! Hello and welcome to this session on My Favorite Flaps in the Hand. My name is Matt Iorio, and I'm a professor of surgery at the University of Colorado Hospital in Aurora, Colorado. I'm a hand and extremity microsurgeon, and I think we've prepared an exceptional panel and discussion for you today. Thank you very much for your participation and for your attention, and please enjoy! I'm Tim Doherty. I'm a hand surgeon at Southern Illinois University, and today I'll be talking about one of my favorite flaps, the dorsal metacarpal artery perforator flap, and I'll start by introducing a case. This is an 18-year-old male who rolled over his dirt bike, causing an injury to the dorsum of his right hand. He had full thickness friction burns to the dorsum of the fingers, with most of the injury affecting the long finger with exposed tendon. The problem with the distal upper extremity in the hand is that it's somewhat analogous to the distal one-third of the lower extremity, in that there are not a lot of good coverage options. So with traditional reconstructive options, could you close this primarily? Possibly, but that would not allow you to get the patient moving right away, and it would definitely be under significant tension. Could you skin graft? It probably won't be successful with the exposed tendon and certainly would also require mobilization. You could try a reverse cross finger for the knuckle, but in this case the adjacent digit donor sites are compromised, and it certainly wouldn't help you with coverage of the entire finger. You could do a distant axial flap, like a groin flap, or a random pattern thin flap with chest wall or abdominal skin, but this would require three weeks of connection prior to division and certainly immobilization as well. You could do a free flap. That might work, but it's a big surgery for this small defect if there's another good option. And amputation is always an option, but this definitely shouldn't be the go-to when reconstruction is a possibility. So I bring this up to show that the dorsal metacarpal artery perforator flap is a very versatile flap for finger coverage and is one of my favorite flaps to do in the hand. This was first described in the British Journal of Plastic Surgery in 1990 by Dr. Quaba, which is where this flap gets its eponym. Most flaps in the hand prior to this were a random pattern with traditional designs of rotation advancement or transposition. In this paper he shared some anatomy and technical pearls that I think still hold true to this day. So in contrast to the first dorsal metacarpal artery, which is a direct branch from the radial artery, the remaining dorsal metacarpal arteries are branches from the dorsal carpal arch, which is supplied by the dorsal branch of the radial artery. The great thing about the fingers is that they have very robust blood supply. So they're actually communicating vessels near the metadiaphysis of the metacarpals and the phalanges through which all of these vessels communicate, causing either a dual or triple supplementation of blood supply to the flap. The traditional dorsal metacarpal artery perforator or Quaba flap is based off of a skin perforator that goes to the skin near the location of a communicating vessel between the palmar metacarpal artery and the dorsal metacarpal artery, as shown with the asterisk, and the primary source of inflow is the deep palmar arch. There's a variation of the dorsal metacarpal artery perforator flap where it can be taken on the more distal communicating vessels around the proximal phalanx, as shown by the arrows. However, oftentimes a communicating vessel between the palmar metacarpal artery and the proper digital artery is absent, as shown here, meaning that semantics-wise, the flap based off of these perforators is not really a true DMAP flap, but more likely a proper digital artery perforator flap. And as shown in this image from Quaba's original paper, this is a true perforator flap rather than an axial pattern flap as the dorsal metacarpal artery is left intact between the extensor tendons. So back to our case, for the flap design, I usually mark the approximate location of the skin perforator with a dot approximately a half a centimeter to a centimeter from the metacarpophalangeal joint, and I typically don't use a Doppler in these cases. Then you design a longitudinal ellipse of skin centered over the skin perforator and in line with the corresponding dorsal metacarpal artery. I try not to extend the proximal extent of the flap beyond the dorsal wrist crease because it may be less reliable, and I choose the width based off of the size of the defect, with the goal being to achieve primary closure of the donor site. In this case, I chose to mark the flap out on the second intermetacarpal space because of the burnt skin on the adjacent finger. For this flap, there are some general tips that are useful to know. First, the dorsal metacarpal arteries diminish in caliber and incidence when you pass from radial to ulnar. They're very reliable for the second and third web space, but perhaps a little less reliable for the fourth web space. Secondly, the perforasomes and the extremities are longitudinal, so if you're deviating from this and marking an oblique or curved skin paddle flap, it is random blood supply and may be less reliable. Lastly, as I mentioned, there are consistent communicating branches for the second to fourth interspaces, but on the radial side of the index finger or the ulnar side of the small finger, perforators may or may not be present as there is no intermetacarpal artery here. Therefore, this is more of a freestyle flap. When raising the flap, you want to mark the veins so you know they're coarse and where to expect to clip or cauterize these. One potential problem with this flap is venous congestion, and typically to combat this, I usually try to save one vein that I can free up and chase this out laterally as much as possible. And I do this in order to keep it attached despite the rotation to augment the output rather than relying on the single small perforating skin vein. In doing this, I've never had an issue with outflow. When raising the flap, I like to loosely exsanguinate the extremity prior to inflation of the tourniquet so that the vessels are filled but you can actually see your pedicle. I begin by raising one side of the flap to look for the perforators, and I don't commit to the entirety of the skin flap. And I do this because I approach these flaps like a freestyle flap, like I'm searching for a perforator, and I've never been in a situation where I haven't seen a perforator at the expected location, but if you didn't, you certainly haven't hurt the patient by committing to your other side of the incision. And it certainly doesn't cost much to go searching for a perforator. Once the perforator's found, I commit to the other side and islandize it. It's just like any other propeller flap. You really need to free up the perforator from the fascial bands that could potentially kink it since you're doing a 180-degree rotation. So here's the flap after raising. You can see a shadow of the perforator in the flap even while the tourniquet is up. There's more soft tissue attachment around the pedicle than I would typically like. However, in this case, there was a small perforating vein on that proximal aspect that I wanted to preserve. And as you can see, it mobilized very nicely despite the attachments with no kinking. And here you can see the second dorsal metacarpal artery perforator and the dorsal arch. And then after inset, it looks very nice with good color. The second case is a somewhat similar case. It's a 50-year-old male who's five weeks out from a work-related conveyor belt injury resulting in a third-degree burn on the radial side of the index, long, ring, and small fingers. The soft tissue was initially allowed to declare to see what was viable, and then there ended up being exposed bone present. The adjacent fingers were treated with local flap and skin graft closure, but the index finger had a much larger defect. And after distal phalanx amputation and removal of the distal radial aspect of the middle phalanx, there was still exposed bone and joint that needed to be covered. So again, a dorsal metacarpal artery perforator flap was designed. And here I marked out the distal perforator around the metadiaphysial flare of the proximal phalanx in case I wanted to use that based off of the more distal perforator by the proper digital artery. And as I mentioned, I start with one incision before committing to both incisions. And here I am pointing to the pedicle, which is slightly hard to see in this photo because it's blanched. But here when I zoom in, you can see the pedicle with the arrow by it. Here it is immediately after release of the tourniquet, and the distal tip looks a little pale, which is normal. But give it some time because you'll always see the color return as shown here. One regret that I have about this case is not taking a wide enough flap proximally. The bone was covered, but we still had a small defect volarly, which we ended up placing a skin graft. Here he is six weeks later. And then eight weeks post-op with great range of motion of the digit without any hand therapy. Obviously, he's not achieving palm touchdown, but that's because he's lacking the distal phalanx, giving him that last bit of total active motion. The third case is a 65-year-old guy who was sent to me with a gunshot injury to the skin on the dorsum of the long finger. After cleaning it up and debriding the devitalized skin, there was an open wound on the dorsum of the finger with exposed tendon, and primary closure was not achievable. So under local anesthesia with the patient wide awake and no tourniquet, I elevated the ulnar side of the flap and was able to isolate and mobilize the perforator to do a rotation advancement flap based off of the dorsal metacarpal artery perforator. Here he is at three weeks and is mostly healed. At the six-week post-op visit, he has great range of motion again without any hand therapy and good motion on the lateral view. And in the last case, I'll highlight that this is a good flap for volar soft tissue coverage of the fingers and for coverage after oncologic surgery. This is a 23-year-old female who had a pigmented lesion at the base of her right long finger. This was excisionally biopsied by another surgeon and then sent to me with a diagnosis of malignant melanoma, and it had a Breslow depth of two millimeters. I discussed her care with a tumor board, and they agreed that the finger didn't necessarily need to be amputated, as the traditional teaching is, but because of the location of the biopsy, which was right over the radial digital nerve and the Breslow depth, I told her that this would need to sacrifice the radial digital nerve for good oncologic margin and for the risk of neurovascular invasion. So I resected the skin with two-centimeter margins, as well as the radial digital nerve, and was left with this defect. So I temporized it with allograft while waiting for negative margins. This went on to scar in and heal by secondary intent, causing a slight MP joint contracture. So after the margins were confirmed as negative, I took her back, excised the scarred allograft to recreate the defect and identify both the nerve ends. I reconstructed the radial digital nerve with allograft, and then I reconstructed with a dorsal metacarpal artery perforator flap from the second web space. Here is a video showing that after the tourniquet is taken down, it has great capillary refill. The patient has gone on to heal with good soft tissue coverage over the vular finger and good reliable coverage over the allograft. And now she has an advancing tenil beyond the flap. And in these images, you can see that she has no restricted range of motion. And again, this is without any formal hand therapy because I let them move right away. In this photo, you can see that she's still got a portion of the flap attached showing on the dorsum. And I actually offered to excise the remaining portion of the flap now that she's healed, but she chose not to and says that it reminds her as part of her journey with cancer. So in summary, this is a great flap with very versatile applications in hand surgery. Remember the vascular anatomy and try to approach it from one side prior to committing to the flap design, especially as you approach the ulnar side of the hand. And then lastly, I'll finish with this photo of another patient that I did an index finger replant and a quaba flap for coverage of an open fraction of the long finger. And then he came back to the clinic with this clever T-shirt that I thought was pretty funny. So thank you very much. Good morning. My name is Livia Halawal and I'm a plastic hand surgeon at Brigham Women's Hospital in Boston. Today I'll be talking to you about cross finger and reverse cross finger flaps and we'll also touch briefly on both homodigital and heterodigital islet flaps. For each of these flaps, we'll touch briefly on indications, anatomy, technique, and outcomes. We'll also go through some example cases. So our first case is a 33-year-old male who sustained a left-hand table saw injury. He had a complete bolar ulnar oblique distal small finger amputation just proximal to the DIP joint. He is otherwise healthy and a non-smoker. His clinical photos can be seen here with the obvious small finger distal amputation. His plane frames are shown here. The small finger amputation occurred just proximal to the DIP joint, but distal to the FDS tendon insertion. Replantation may be an obvious initial first thought, but unfortunately the piece did not come with the patient. So what are your next steps? To touch briefly on fingertip reconstruction, your goals are generally to maintain as much function as possible, potentially restore sensation, and maintain length. There are obviously many reasons a patient may require fingertip reconstruction and these may affect the type of reconstruction you choose, whether the amputation is oblique or not, and the direction of that obliquity can also affect your options. For this patient, there are numerous options one could consider. These can include replantation, but not in this case, shortened and closed, skin graft and tag graft, wound care, cross-finger flap, homodigital island flap, heterodigital island flap, free tissue transfer, and potentially reverse cross-finger flap. In this patient, obviously, replantation is an option, given the missing piece. Any of the others might be reasonable. I would avoid shortening and closing in this patient in order to preserve FDS function. Skin graft and or tag graft could work, but would give less robust coverage. Same with wound care. A reverse cross-finger flap is really more for dorsal injuries, as we will discuss later. However, a cross-finger, homodigital island, and heterodigital island flap could all be considered. Although obviously not the focus of this talk, free tissue transfer, such as toe pulp transfer, is also theoretically an option. So what is a cross-finger flap? It was first described in 1951 by Cronin. It is ideal for reconstruction of extensive fingertip pulp loss, but can also cover more proximal volar wounds over the middle or distal phalanx. It is also generally quite reliable if the neighboring finger is uninjured. The technique is as followed. The flap is outlined and elevated in open-book fashion as a three-sided rectangle, and is outlined on the dorsum of the middle phalanx of the healthy digit, usually. The fourth side of the rectangle acts as the hinge, and is located at the mid-axial line of the finger nearest to the injured digit. A pattern can be used and transposed, and ideally your flap should be designed slightly larger than the defect to avoid excessive tension with closure. A full-thickness skin flap is then raised, leaving the peritoneum on the underlying extensor tendon. This is critical, as you will later close the donor defect with a full-thickness skin graft. After flap elevation, the flap is rotated 180 degrees on its hinge, and secured over the palmar defect of the adjacent injured finger. And then your full-thickness skin graft is harvested to close the secondary defect. Usually the fingers are divided at about two to three weeks at a second procedure. Important considerations when choosing a cross-finger flap include that it is a two-stage procedure, requiring two to three weeks in between stages. It utilizes a theoretically uninjured digit, making it susceptible to stiffness. Hair from the dorsum of the finger can be transferred to the volar surface as well, and although it is not innervated, cross-finger flaps can achieve good sensory recovery. Relative contraindications for a cross-finger flap include active smoking, peripheral vascular disease, dorsal skin loss from adjacent digits, or injury to surrounding digits. Additionally, as with all reconstructive hand cases, even the very simple, you must consider various social aspects, including the patient's support system, ability to comply with extensive hand therapy, and their ability to understand potential donor site morbidity. This paper from the University of Louisville back in 1974, one of the earliest outcome studies for the cross-finger flap, their patients had good return of both motion and sensation with absence of pain, but poor appearance and cold intolerance for both post-op issues, especially in younger patients. So back to our patient. As a reminder, here is his initial injury photos. Here's the design of our cross-finger flap based on the dorsal uninjured finger. Uninjured ring finger, sorry. And here's our flap elevated and sutured into place with a full thickness skin graft on the dorsum of the ring finger at the donor site. Here's the appearance just before division at two weeks. Note the well-perfused appearance of our flap on the volar small finger. Here he is immediately post-division with a well-perfused flap over the volar small finger and the ring finger full thickness skin graft healing well. As mentioned before, the morbidity of cross-finger flaps can include donor finger IP joint stiffness, decreased sensation in the donor finger, cold intolerance in the donor finger, and aesthetic concerns of both the donor and recipient fingers. A variation of the cross-finger flap is the reverse cross-finger flap. The reverse cross-finger involves transferring subcutaneous tissues from the donor digit to the dorsal aspect of the recipient digit, followed by a full thickness skin graft. The reverse cross-finger flap was first described by Pakian in 1982. It allows for coverage of dorsal finger defects, including exposed extensor tendon without peritonin. It also allows reconstruction of full thickness sterile matrix nail bed defects with exposed bone, coverage of complete nail bed and germinal matrix evulsions, and boutonniere deformities with poor skin quality over the PIP joint. The reverse cross-finger is good for defects over the dorsal aspect of the proximal middle phalanges, but the dorsal aspects of the VIP and PIP joints should be avoided as donor sites. The technique is similar to the traditional cross-finger flap. The design is also similar, except the skin is elevated in the opposite direction. Under loop magnification, a thin, full thickness skin graft with intact subdermal vascular plexus is elevated based on the opposite side of the uninjured finger. The subcutaneous tissues are then elevated at the level of the peritonin in the opposite direction. Dorsal veins and blood supply are preserved in the flap. The elevated subcutaneous flap is now sutured to the defect. The originally elevated thin, full thickness skin flap is then sutured back to cover the donor defect. The reverse surface of the thin subcutaneous flap on the injured finger is covered with a thin, full thickness skin graft without a tie-over dressing. The reverse cross-finger can be used to reconstruct complex defects involving the aponechial fold shown in the diagram and clinical example from this paper in the Journal of Hansardry by Dr. Adesoy in 2016. He also describes the use of the reverse cross-finger for sterile nail bed matrix defects with exposed bone shown here in the diagram and clinical example with excellent results. Here's an example of a creative use of the reverse cross-finger. So this patient had complex open fractions of the right index and middle distal phalanges with exposed bone on both the index and middle fingers, or if it was completed on the right as shown in the plain films there. The skin flap on both the middle finger and ring fingers were then deepithelized and sutured into place over the exposed bony fractures as perfused subcutaneous flaps. These were then covered with full thickness skin grafts which were divided at three weeks. Post-division is shown here. Although cross-finger and reverse cross-finger flaps can be great solutions for certain defects, having other options in your armamentarium are necessary, especially for complex multi-digit injuries where cross-finger flaps may not be available. Here is a patient who also presented with a left-hand table saw injury. His injury involved partial amputations of the left index, middle, and ring fingers, requiring revascularization and repair of flexor tendons and digital nerves. Although he recovered initially well, he returns with lack of full flexion and a non-healing wound over the volar PIP joint. He has no significant past medical history and once again is a non-smoker. Here you can see his initial post-op result with obvious threatened skin on the volar aspect of the middle finger. Although this did eventually heal, he was brought back to the OR for tenolysis and excision of the non-healing sinus. Once excised and tenolysis performed, the result was a small volar wound overlying the middle phalanx with exposed flexor tendon. Similar to our first patient, a number of options exist. However, things like wound care, skin graft, and Integra all put our tenolysis at risk for readhesion and failure. Additionally, a crossed finger was not reasonable given the injury to the neighboring digits. Therefore, we chose a homodigital ontop for reconstruction of this volar wound. First prescribed by Weeks and Ray in 1973, it is based on the volar blood supply of the digit, either the radial ulnar digital artery and their vena comatose. It can be harvested antegrade or retrograde. It is a single-stage operation and combines injury to the injured digit. However, it can be technically challenging and can result in decreased sensation at the donor site. It also may not be suitable for patients with peripheral vascular disease. A retrograde or reverse flap is demonstrated here on the right. This is good for volar wounds and can even be extended to the fingertip. An integrated example is shown here and can be used for both dorsal or volar injuries. The flap requires intact radial and digital arteries, and the reverse flap relies on anastomosis between these two. So back to our patient. Here is the design of a reverse homodigital island flap. Here is the flap elevated on the left and then being moved into place on the right. And our final inset here. Again, this flap relies on both an intact radial and ulnar digital artery and intact connections between them. The digital nerve is not included in the flap, and the donor site is closed primarily in this case. Here he is at about two weeks post-op with a profuse flap. And here he is at about six weeks post-op. To touch very briefly on heterodigital island flaps, these flaps are similar to homodigital island flaps in that they involve a skin paddle raised on a digital artery, the main difference being that it is transferred to another digit. Usually you are barring from a less critical area on the uninjured finger to repair a critical defect on another. Although these flaps are well described in literature, such as the Littler flap, they have largely been replaced by other methods, including skin substitutes or free tissue transfer, given the potential for a large donor defect. A good example is shown here on the bottom right with a large dorsal small finger injury with exposed tendon, and they borrowed a heterodigital island flap from the adjacent ulnar aspect of the ring finger. So in conclusion, there are numerous options for fingertip, volar, and dorsal digital wounds. When considering a cross-finger, reverse cross-finger, homodigital, or heterodigital flaps, you must consider whether you prefer a one- or two-stage procedure, various patient factors, presence of risk of vascular disease, age, occupation, smoking, etc., as well as your preference and experience with these various options. Thank you for your time. Hello, I'm Bob Aksafa with the Bunke Clinic, and I want to thank the organizing committee for including me in the program this year. I'll be discussing venous flaps, an ideal flap for small hand defects. I have no disclosures for this talk. The venous flap is a nonconventional perfusion flap. It's usually based on the volar veins of the distal forearm, and it does provide a tremendous amount of variability in design and application. One of the great things about this flap is that it's very thin, it's very pliable, and with a good design consideration, it is very reliable as well. And the donor site is very minimal, since it is basically just a segment of skin and subcutaneous fat. The physiology is not entirely known. However, there are a number of theories. And as opposed to a regular skin flap where you have inflow in an artery and outflow of a vein, in a venous flap, you basically have a venous plexus only. If you do not design this flap properly, you may get some shunting across the edge of the flap through the path of least resistance. But if it's designed properly, you actually will be able to force the blood across the different venous channels and out the efferent vein. In general, the distal forearm is the most common area for us to harvest these flaps from. You can usually visualize the veins directly quite easily. You can be fairly creative in designing the inflow and outflow. This is both a good thing and a bad thing, because it's basically very design-dependent, and there's a steep learning curve involved with this. The general classification of the venous flap depends on how the vein is arterialized. There's an AVA construct, where you're effectively reconstructing an artery. These are usually reversed AVA flaps. There's an AVV flap, where you're essentially creating an AV fistula with an outflow vein. This can be either reversed or non-reversed. Additional design considerations are the directionality, and I'll show examples of both reversed and non-reversed flaps. The reasons we choose either AVA or AVV, as well as the directionality, depends entirely on the location of the defect and the recipient vessels that are available. Let's look at a case example here. This is a middle finger defect. We did not have the part to replant in this case. This was about two days after the injury. Instead of doing a thenar flap or a cross-finger flap, we chose to do an outpatient single-stage reconstruction in an effort to maintain the FTP insertion for grip strength purposes. This is now a non-reversed AVV venous flap. This is brought into the fingertip. The inflow is from the ulnar digital artery, and the outflow here with the arrow is a volar vein. So, again, this is a non-reversed AVV flap, and you can hear the pulsations of the arterialized vein here. So, we've basically gone, in one stage, from this defect to this reconstruction, and we've been able to maintain the entire length of the finger. Again, AVV non-reversed flap, outpatient procedure, patient's on aspirin, and she can go home. Let's look at another example. This is an ATV rollover accident. The index and middle fingers were not replantable, but the reason he was sent to us was because the ring finger was also devascularized. There's a long segment of distally-based skin, and you can see there's a significant evulsive component here. We see that the ulnar and radial digital arteries are both evulsed, and there's a very large distally-based flap of skin. These long skin flaps that are fed in a retrograde fashion typically don't do well, so in general, I just excise these, and when I revascularize it, I do it with a venous flap, and so this is now going to be an AVA reversed venous flap. So, we're essentially reconstructing, in this case, two arteries, and here's our design. Here's a flap harvested with, again, one inflow vein and then two outflow veins into both digital arteries, and here's a video just kind of showing the bleeding off the edge of the flap. The flap is an inset. The PIP joint is temporarily pinned in order to minimize flexion and kinking of the distal veins, and the defect is closed primarily, and so this entire surface is basically, this entire area is resurfaced on the volar aspect of the ring finger, and both digital arteries are reconstituted. So again, an example of an AVA reversed flap. Now what's interesting about these cases is that only three weeks post-op, the best part of this guy's hand is actually the venous flap. So if we need to go back to do a tenolysis or a neuroplasty or even a nerve repair, his nerves were not cut, they were just crushed, we will be going through healthy skin as opposed to a very dense, tight scar. Here's another example. This is going to be a different design. This is an avulsion injury from the PIP joint to the fingertip, exposed FTP, exposed distal phalanx. And in this case, we have nothing distal to plug into, so we can't really do an AVA flow through. So in this case, we're doing a non-reversed AVV flap. And so we have an inflow on the ulnar aspect of the flap, an outflow on the radial aspect of the flap, and we're going to clip this vein, and this vein was actually clipped further within the flap itself to force the blood to go through to the radial aspect and out this vein. We also found an MABC branch in this case for sensation, flap was brought in, and donor size closed primarily, the inflow again is off the ulnar aspect, ulnar digital artery, and the vein is flipped dorsally for drainage. These venous flaps typically go through an evolution of kind of a period of congestion. On the table, we can see it's fairly pale, but even in the PACU just a couple hours later, the flap pinks up quite a bit and begins to get a little bit full. On day two, if this was any regular skin flap, like a radial forearm flap or any other skin flap, you would be concerned that the vein is down. But with a venous flap, you would expect this, and in fact, you can Doppler the veins throughout this flap. So you just leave it. Here it is at three weeks with some desquamation of the very top layer of the skin. And here it is at three months with, again, full survival of the flap, you can see the hairs growing back, and he's forming flexion creases where he's flexing his finger. But again, very difficult reconstruction to do, in my opinion, without a very thin flap like a venous flap with excellent function, as you can see here. And the donor site is, again, fairly minimal, and you end up getting nice light touch sensation. So again, an example of an AVV non-reversed flap. These flaps are very useful in injuries that are toward the fingertip, where you have nothing distal to flow through to. And so here's another example. This is a gentleman who did not want a toe pulp used, but he had exposed distal phalanx. And so what we did in this case is fairly similar to the previous case, but just a smaller flap. This is a non-reversed AVV flap. So the flap is harvested, as you can see here. There's a venous arch within the flap. And we do these typically as an outpatient procedure and place them on aspirin. The criticism of these flaps is folks who don't believe in them say, oh, it's just a skin graft. Well, not only do the edges bleed, this gentleman came back post-op day one to clinic because his flap edge was bleeding, and we had to pop a stitch and cauterize the edge of that flap. So clearly, this is a vascularized flap. It's non-conventional perfusion, but there is blood flow in this flap. And so this is now about two weeks out. And just to again show the geometry of this, the flap is like here. We have the inflow out on the ulnar digital aspect. And then in this case, we actually flipped the vein dorsally and went to a dorsal vein that was a very high quality. And so this is now the patient roughly about maybe three or four months out, again, AVV non-reversed. And what I want to show here is the quality of the skin, as opposed to a skin graft that heals with a very kind of dense scar tissue. You can see this is very supple. All the fat is still in there. Now compare this to this case. This is a skin graft. And you can see a skin graft heals with a very dense scar. So if you're going to reaccess this finger, very difficult to do this through a skin graft. Here's another example, dorsal thumb defect, composite defect, including the EPL tendon, intraarticular fracture of the IP joint with a comminuted base of distal phalanx fracture. In this case, we harvested, we did a venous flap along with the palmaris longus as a composite flap. Now, in this case, we chose to do a reversed AVV flap, so an artery plugged into the distal vein going across the venous plexus, out a vein on the dorsum of the thumb. This again, harvested with the palmaris, so reversed AVV, and this is how it's inset. The tendon's inserted distally with a suture anchor and woven proximally into the EPL. The ulnar dorsal artery is then flipped dorsally to plug into the vein, and then the venous afloat is plugged into a distal branch of the cephalic vein. So this is all closed now. You can see the thinness of this flap. This is one of the advantages of the venous flap. It's very difficult to get a flap this thin from any other part of the body. So this is him at three weeks. You can see full survival of the flap. The donor side is just a segment of skin. Here he is at four months. He has a significant scar form, as you can see here. He had some tethering of his tendon, so we did an extensor tenolysis on him, and it was a very good opportunity for us to be able to see what's happening with the flap. All this is the full thickness, all the fat that's in the subcutaneous tissue of the flap, so it's all survived. And here is the tendon that we've now separated, and we do a tenolysis on him to essentially try to improve his flexion. There's some intrinsic reduction in his IP joint flexion from his intraarticular fracture, as you can see here. Then here he is at one year. Looks great. He reversed, again, as a classification for this one. Thumb function is excellent, and on this video, you can see that he actually does have pull through of that tendon. Some of the limitation in motion is because of his intraarticular fracture. Here's a case that demonstrates a combination of a replant and a venous flap. So we have the thumb that we actually were able to find structures to replant, and he's got this dorsal shave of full thickness skin, soft tissue, and some of the nail of the middle and index fingers. So for the thumb, we actually were able to, like I said, find digital artery and a couple of nerve branches to be able to replant this. And then for the index and middle finger defect, instead of just shortening the tips, we decided to do a syndactylized venous flap. And this, again, is a non-reversed AVV flap. Flap's harvested, and this is the inset, again, AVV, and the way this is hooked up is you have an inflow from the middle finger into the flap, and then outflow is on the dorsum of the index finger. We then do a syndactyly release a couple of months later, and after defatting and thinning, this is what we have now. You can see excellent contour and good arcade of the fingertips. Again, this is an AVV non-reversed flap, and the replant of the thumb also aesthetically looks phenomenal. And so this is a combination, again, of a replant and a venous flap. This is a flexion contracture, so they're not all for acute traumas, and this is clearly a case where we need some soft tissue. The idea here is you release the contracture, and you divide one of the digital arteries, and you bring in a venous flap and reconstitute that artery in an AVA fashion. In this case, we were able to get the PIP joint to roughly 30 degrees short of full extension because the nerves were too tight, so we decided to do the rest with dynamic splinting postoperatively. This is a venous flap harvested in an AVA fashion. We then did postoperative dynamic splinting, and we were able to get him out the rest of the way to full extension. So again, this is an AVA reverse flap reconstituting the digital artery, and we've gone from this to basically a finger that's able to essentially be fully extended with full flexion. Very difficult, in my opinion, to get this kind of result without bringing in durable, full-thickness tissue over the PIP joint crease. Let's look at another acute trauma. This is a ring of ulcer. Similar concept here of an AVA reversed flap, essentially reconstituting the artery. So we're going to, in this case, reduce the PIP joint, but your tendons are intact, and so if the joints and the tendons are okay, it's certainly worth trying these if you have a distal target. Venous flap harvested, and the entire area of the crush injury is resected and resurfaced with a venous flap at the first stage. Couple of neurobiographs replaced, and so now we basically have a fully healed venous flap. Again, AVA reversed pattern for this flap. You can see excellent range of motion of his PIP and MP joint. The DIP is a bit stiff, but from a functional standpoint, it's not as significant. Even in a neurobandic type 2B, where the finger is still attached but devascularized, a ring of ulcer can cause a significant amount of injury. You can see the indent caused by the ring in the ring finger here. When you open this, you'd see this very evulsive mechanism. Both nerves and both arteries are transected, and that skin at the crush site here is not going to survive. There's going to be a lot of eschar forming, and you're probably going to get a contracture of the skin over time. So what we do in this case is we actually excise all that skin. We harvest the venous flap, and this is the excision that's marked. So the skin that I think is not going to do well, I'm just going to simply excise. I'm going to bring up this venous flap. In this case, we actually were able to plug in both proximal arteries into one distal one just the way the venous flap was arranged. A couple of nerve grafts replaced, and this is just a video showing the pulsations through the flap into the radial dysartery of the ring finger. This is at inset. In about two and a half months, you can see that you have nice, supple, soft tissue there so that if you need to go back to do a tenolysis, you're going through good tissue. Again, this is an AVA reversed flap, which we use for revascularization type scenarios. This is another revascularization, two fingers now, common root fractures, loss of skin. You can see they're both devascularized and very common root fractures that are dislocation of the PIP joint in the middle finger. So in this case, we're going to basically debride the skin. We did a little A4 reconstruction with a distally based FDS slip, and now we have to revascularize these fingers and bring in new soft tissue. So this is now a combination of two venous flaps side by side, both AVA reversed, much like a vein graft would be. So this is now, you can see both fingers are pink, venous flaps are in place, donor sites are closed primarily, and over time, you have full takeover of the venous flaps with no soft tissue defect and no flexion contractures. Again, AVA reversed flap. The same pattern is used for pretty much all revascularizations. This is a seven-year-old girl with a crush injury, prolonged ischemia time, and the only way you're going to be able to save this is if you can resurface all this area here with an acute flap. So this is now a venous flap harvested and brought into the field as an AVA pattern. The proximal side is on the left, distal is on the right here, and so what we have is basically now a salvaged finger with a venous flap to resurface that area. So you're going from pretty much an unsalvageable digit to one that actually looks pretty decent. This is just about a six-week follow-up or so. And here she is now. So the next case that I'm going to show is a slightly more complicated case, and this is an ATV rollover where there was a significant wound defect over the middle finger after a tenolysis was attempted with a tendon rupture at an outside institution, and the patient was referred to me for basically management of this wound. The tendon is excised. The wound is freshened up. We have a significant area that needs to be covered before we can do a tendon reconstruction. Tendon excision is done. The proximal artery is identified. The dorsal vein is identified in the web space. And then we create a template with our Esmark with the inflow and outflow marked. We then go to the contralateral forearm because there were a lot of scars on the ipsilateral side. And we're going to design a flap in a non-reversed AVV fashion. And this is then brought into the contralateral hand, inset. The proximal anastomosis and distal anastomosis are done, or the vein rather. And you can see full pulsations of the entire venous system of this flap. And even the outflow vein is pulsatile. When you see this, you feel fairly confident that this vein is not going to go down because it's pulsatile. So this is now the inset of the flap. And what you see, again, the classification here is an AVV non-reversed flap. Now here she is about six months later. And what you see is this very supple skin. This is not a skin graft. This is full thickness flap here. And you can see the pulsation of the artery, of the arterialized vein within the flap itself. The flap is elevated. A hunter rod is placed. We do pulmonary reconstructions with a palmaris for the A2 and the distally based FDS for the A4. And then three months later, we come back. Good passive flexion. We're going to re-elevate this flap. Again, nice and supple. We're going to attach a tendon graft to this. We're going to pull this through. We're going to attach the distal end of the tendon with a pull-out button. And we're going to weave the proximal end. And we're going to check this with a tenodesis effect, as you can see here. And this is impossible without adequate soft tissue coverage. And the last case that I'm going to show is a two-finger amputation in a 17-year-old girl who was walking her horse. And the reins caught on her fingertips and evolved to both fingertips. We did attempt a replantation, in this case, of the middle finger. But unfortunately, it did not survive. You can see the nail bed is also torn off. Again, this is the attempted replant. Unfortunately, it didn't survive from the crush component. So now we have to cover this area and try to maintain as much length as possible. We basically designed a venous flap. And the idea here, I saved the nail beds and the distal phalanx tuft fractures and did a syndactylized AVV reverse flap, in this case. The geometry of this inflows, as you can see here, with a red arrow. And then crossing back over is the outflow into a bowler vein. And here's a video just showing the pulsations of this. And even the outflow vein is arterialized. This is her just a few weeks out. And then after a couple of months, divide the syndactyly. And you can see we've maintained the full length of these fingers. And also, the nail bed graft did survive. And she now basically, especially for the left hand for a girl, being able to have the full length of the ring finger obviously is very, very important. And from a functional standpoint, as you can see here, excellent function for her. So in summary, the venous flap does provide a tremendous amount of variability. And it's one of the reasons why it's one of our workhorse flaps in treating very difficult crush and avulsion injuries of the digits. The donor size is fairly minimal. And I hope this talk convinces you all that the venous flap is a flap that should be attempted. Thank you. Hello, and thank you for joining us. Today, we're going to be discussing our favorite flaps in the hand. We're joined by Dr. Daugherty, Dr. Helliwell, and Dr. Safa. And they've just given us fantastic presentations on their patients. So again, I thank you very much for the time in terms of putting those together for us. I think that they were fantastic. But I think now is a good time for a little bit of discussion. So we're going to kind of open it up. I'll start with you, Dr. Helliwell. So I think it's the use of the cross finger and the reverse cross finger probably don't get as much publicity or as much praise, you know, they're great flaps. But I think one of the most difficult things that I've struggled with as well is the timing for the division. So do you have any tips and tricks or is it different for the reverse cross finger or the standard cross finger for you in terms of when you would divide these? Yeah, no, thanks. That's a great question. It's definitely not the most sexy of flaps, but I think it definitely has its use. I'm usually somewhere in the two to three week range, which I think is pretty average for people. It depends on the patient, depends on some of it's just logistical in terms of getting them in the OR and whether you're trying to do it in the main OR or you can just do it under local in your office. I usually err on the side of a little bit longer just because I'm more conservative. So I'll aim for more three weeks if I can. But I think a lot of people get away with two, no problem. And do you use any sort of adjunctive kind of measures such as like banding or putting a rubber band around it or anything like that, or even endocyanin angiography or any sort of those things? No, I usually just splint them really, really well and make sure I put the splints on myself. I don't pin or band or anything like that. And I usually just leave them in that splint until I'm thinking about dividing them. Maybe I'll take it down and clinic just look at things and then put it back on myself. And no, I don't do any of the SPI or anything like that to check it out before I divide it. But if it doesn't work, I'll do something more interesting. Fair enough. An opportunity for another flap. Yeah, exactly. Perfect. All right. And Dr. Doherty, so your presentation was fantastic as well. I think one of the big questions that we would have would be, how do you determine kind of the extent of the flap or where you think the angiosome is? You know, I think my concern when designing these is always how big can I make it or what's really going to stay perfused? Yeah, I usually am not making it wider, usually than like one and a half to two centimeters, because that's pretty much the limit of what I've seen, you know, achieve primary closure in the back of the hand. And I usually, I don't want to take it and have to do a skin graft on the back of the hand. But as far as length, I usually don't go much more proximal than the, you know, extensor retinaculum, simply because I don't want to have any tip necrosis of the flap. And generally back in that level, you know, it's, it's usually going to be death related to venous outflow than even, even more so than arterial, but, um, so usually that's my stopping point. There are no real good studies that kind of show the, the proximal extent to which you can take it, but that's, that's kind of my landmark that I usually like to go to. Perfect. And you haven't seen much in the way of necrosis of distal parts or segmental loss or anything like that? I really haven't. The only time that you might see that is if you're, if you're going outside of that longitudinal angiosome, you know, some people will try to curve the flap, um, you know, either one radially or ulnarly in order to get more length. In my experience, I don't generally do that because I don't want to have any issues at that point. It's random blood supply. And again, more of an issue with venous outflow. So I usually don't, I usually just try to stay straight longitudinal with the extremity. Sure. Perfect. You know, I had a patient recently that, um, had grabbed, you know, a high tension or, um, electrical wire and had similar injury, but the issue was that there were burns and flexor tendon injuries almost across the whole palm. Do you think for something like that, you would design kind of a large one to push across multiple digits and divide it, you know, in a similar way to a cross finger, or do you think you would do multiple of those flaps at the same time? I think you could consider, I would consider maybe doing two, uh, but, but I, you know, it depends on, you know, which levels were involved, but I think it would be reasonable to probably do two, uh, flaps together, you know, simultaneously, and then always, you know, divide them later. It does actually work really, I didn't include that in my talk, but it does actually work really well for volar resurfacing after burn injuries from a bad contracture. Um, and I was just talking another, you know, one of my colleagues through that the other day. Um, but it is a very nice option for, for burn injury as well. Yeah. No, I think it's nice, especially because you know, that, that vascular network is theoretically out of that zone of injury by being through the dorsal arch. And so maybe it's served in those types, right. And, and like I said, in the presentation, there's almost nothing lost in just, you know, approaching it almost like a freestyle flap, just, you know, making an incision on either the radial or ulnar aspect, and just looking for a perforator. And if you don't see one, then the only thing you've cost them as an incision on the back of the hand, and you can always go to another option, but, um, usually I've never not seen one there. Um, but certainly as you do go to the ulnar side, the incidence of those perforators theoretically does decrease according to the papers. Sure. Interesting. Very interesting. All right. And Dr. Safa. So again, a technical masterpiece, uh, maestro for sure. Um, I think watching those videos though, it's interesting, uh, in terms of revascularizations that that flap seems very powerful. I think one of the big questions I have is in your practice or has it changed your practice in terms of utilizing vein graphs, meaning do you use this flap instead of, uh, multiple vein graphs? If you have, you know, replants or segmental loss? Yeah, I think, um, well first of all, thanks so much for having me on this and it's, it's a, it's a pleasure to be here. Um, so I think the, um, it definitely has made me much more aggressive bringing in new soft tissue to, um, a finger that's been, you know, traumatized in a way where there's some of the skin may not be adequate. Um, one thing that we see a lot of is we have these digits that are crushed or evulsed. Um, and even in the setting of a revast, sometimes you'll look at the skin and, you know, it's kind of beat up, it's kind of ratty and you stitch it back together again. And then a few months later or six months later, all that has kind of healed secondarily and contracted down a bit. So you have this kind of, um, you know, stable soft tissue, but it's difficult to reaccess to do anything else like a tinolysis or other stuff that you may have to do. And oftentimes we need a vein graft anyway for these digits. Um, now harvesting a vein graft versus harvesting a venous flap, it's, it's, um, it's about the same amount of time. It's actually not that much more. And the learning curve really is more the, um, the design of the flap, um, and deciding, you know, obviously if you have a revast, you know, it's going to be an ADA flap. So it's going to be a flow through flap to an artery. Um, but how do you design it? The, the axis of the vein within the ellipse of the, of the skin flap. Um, and those things are, are, are something that I think is, um, more important than the technical part itself, because anybody can still want a vein graft. Um, but it's really the design of the flap itself that, that has to do with that. And it becomes more complicated when it's more of a coverage issue where you have more options. Do you do a flow through? Do you do an AVV as a flow through where you create a fistula? Do you do an AVV where it's non-reversed? So you have the inflow and outflow on the proximal side of the flap. So I think the, the, the challenge is, is designing it. And that's kind of why I was trying to include as many different examples of, of ways of designing these, these flaps to really show how powerful they can be. Oh yeah. Very much so. I, and I guess for somebody who's looking at these flaps and, and, you know, wants to try them, um, it, it seems like a AVA flap might be the easiest to sort of start with what would be your recommendations for somebody that wants to try these flaps, um, in terms of kind of looking for that optimum scenario? Yeah. So an AVA flap, um, it, you're using it basically not only to bring in soft tissue, but primarily to revascularize the tissue typically, not, not always, but typically. And so your, your primary goal is to make sure you have blood flow into the finger. And in doing so you have what, what we consider to be a true flow through where you essentially have, um, a fairly low resistance system through the flap to revascularize the, the, the digit. And so in my experience, AVA true flow through AVA flaps, um, there's definitely a size limitation to them, um, because you're not pumping as much blood through, um, these kinds of additional venous channels to try to perfuse that. I've had much, much larger, um, venous flaps that are non-reversed AVV flaps where you're literally are pumping this arterialized flow through all these little venous channels. Um, and those flaps I could design a little bit larger. Um, so in some ways it is an easier flap in that it's, um, you're just revascularizing your fingers. So the indication is easy if you've taken a small ellipse. One thing that I would tell, um, you know, fellows or folks who haven't done these before is, um, if you're going to design an ellipse, um, and if the vein graft is, I guess I'll try to do it on my finger here. Let's say this is your ellipse, the vein, the vein is literally within it, within it going straight through. Um, it's, it potentially not going to perfuse the periphery of the flap as much. And so what I try to do is I try to lay, I try to align the ellipse in such a way where the, where the graft is kind of going almost obliquely through it. Interesting. So it's going, it's going through more of the substance of the flap before it exits to kind of perfuse the distal artery. Um, and so I think, um, trying to design the vein so they're more central within the flap, I think is key. Okay. No, I think that's, and certainly it sounds like then probably having a little bit more tolerance, especially if you're trying this flap as an AVA, uh, a little bit more tolerance for maybe some marginal, uh, necrosis or kind of ischemia that, that we might otherwise see, but, you know, more, uh, important, maybe that design to have that obliquely through there to, to get a larger zone of perfusion. Yeah. And then what, what typically happens as we, as always happens with vein grafts is they lengthen quite a bit. And so with the venous flap, you know, there's a fair bit of, um, kind of predicting or trying to predict like where the, where it's going to lie and to make sure it doesn't kink too much and that's not too redundant. Um, and the, and the key is, as I showed in some of the cases is just to create a little template with an S mark, um, and just place that over the defect and then put an arrow where the, you know, ideally where you want the vein to enter and then arrow where you want it to exit and then move that to the forearm and just try to kind of align it somewhere on the forearm where, where it kind of fits, um, fits best. And the other thing is that with the tourniquet up, um, it's hard to know which of the forearm veins are kind of the bigger ones, which ones are, which ones are the smaller ones. Um, and so what I do is just when I put dots on the, on the veins before I put the tourniquet up, I'll put larger dots on the larger veins and smaller ones on the smaller veins. So that once I've opened everything up and I see how big the vessels are, that I have a roadmap even to the size of the veins. So I can like design it and place it exactly where I want the, there to be hopefully less of a mismatch. Perfect. No, I think that's, I think that's a great tip. Very interesting. And then a question for, for all of you. So when evaluating these patients and thinking about, you know, a local flap, um, are there any sort of, um, vascular or angiographic studies that, that you get or anything like that, that you, you like before these types of flaps? Um, I guess I can comment on my, the, I guess my talk, which was on venous flaps. We don't really get any studies on those. Um, the only thing that we sometimes do is we sometimes use a vein finder. Um, if the patient, um, has a fair amount of sub Q fat where it may be difficult to see where the veins are. That blue window flashlight thing. Yeah. It's kind of like, it kind of shines at one of the cases, I think I showed the vein finder. We, we put that on that because we couldn't see the veins. We just kind of wanted to show what it looks like. So that's as much of a, you know, um, mapping the vessels that we would do for a venous flap really. Um, and the rest of it is just kind of freestyling it basically. Sure. No, I think that's great. Uh, Dr. Doherty for, for your flaps, do you feel like you need any imaging or any diagnostics prior to proceeding? I typically don't, uh, to be honest. Um, sometimes if the resident wants to, um, you know, play around and try to find it with a Doppler, then, then, you know, obviously I'll allow that. But, um, typically I just kind of find that there's a lot going on with the hand. There's a lot to hear. So, uh, I can't guarantee that that's the exact perforator. So I typically don't, I just go based off of anatomy. And like Dr. Safa said, just kind of freestyle investigate for the perforator and go from there. I, I first for like the quaba flap, um, I usually, um, I usually do that with the tourniquet up and that perforator, you can actually see pretty darn well, um, even more so than sometimes the FDMA, um, which I did one of those today. And, and, um, that, that flap can sometimes be really hard to see a perforator and you're just going based off of your normal anatomic landmarks. And, and I, even for that one, don't typically Doppler is kind of fair. No, I think I do similar. Um, you know, I think I, the only times I really get an angiogram one, when there's a history of vascular trauma, but two probably more frequently with free flaps just to verify kind of inflow outflow. Um, but I think it's interesting to determine kind of what we might want in an optimal scenario before some of these cases. And certainly I think, you know, I think, uh, Bob X or Dr. Safa's, um, lecture touched on it a little bit. Um, but you know, I think one of my favorite flaps in the hand are certainly free flaps. Um, so, you know, putting a small skip or a small perforator flap like that, I think is a, is a lot of fun. Uh, but again, you know, we can put those flaps anywhere. Um, it's kind of a double-edged sword. Cause you know, um, you have more versatility, obviously when you do a free flap, because you know, it's usually when you do a pedicle flap, it can work very well, but then sometimes there's a lot of injury issues. Sometimes it's a reach issue. Um, but then the flip side of it is obviously technically it's more demanding and not every patient is right for it. So, um, so it's kind of like this double-edged sword where, you know, there's not a right answer for everyone. And, um, and, and some patients that they're just may not even be a candidate for even a local flap, just put some integral on it. Yeah. I think one of the biggest determinants that I've seen in terms of selecting flaps is like you said, previously, I think in your talk, you mentioned that, um, whether or not I plan to return, you know, if, if there's, uh, an injury that involves the joint and the finger is going to be stiff and there's, you know, the tendons otherwise intact, and there's not much for me to do. Otherwise, other than the soft tissue, you know, putting a skin substitute or a skin graft, um, you know, I'm totally fine with, I think, um, I'm, I'm a little trepidatious when it comes to Tina license, probably not my most favorite case. Uh, I I'm sure that's similar for most of us, but, um, making sure that I almost kind of build in a, an entryway or a doorway so that, you know, when I come back to do revision Tina license on, you know, replants or tendons and their nerves that I've got a supple soft tissue on. So I think, you know, these local flaps be a crossfinger quava, um, a Venus flaps provide that, that soft tissue stability. Yeah, for sure. I think that you're absolutely right. I think whenever I, I see an injury or an injured hand, I always think, okay, based on my experience of what I've seen, you know, what else does, is this patient going to need in the future? And if I see a mangled hand and my guy will, you know, beyond tonight, this patient's going to need this, this, this, this, this, then I'm much more likely to be aggressive and bring it in new soft tissue, um, be it a small one, if it's just a finger or if it's a bigger thing, being in a big, big free flap and reaccessing it later. Sure. Yeah, I completely agree. Um, I got a question for the group. Yeah, please. Oh, yeah, no, I was going to ask, um, how do you guys feel about your flaps in smokers? Yeah, that's a great question. Um, so it's funny because for elective flaps, we always tell patients, oh, you got to be off of, you know, any kind of smoking for at least two, three months, blah, blah, blah, all this kind of stuff for traumas. It's almost like, um, I don't know. It doesn't really matter as much because, you know, I'm not going to, I mean, I mean, it's, I'm not going to say I never say always or never on for anything, but, um, but if a patient comes in and they have a finger that's cut off or a thumb or whatever it is, but they want it on and they're a smoker, I'm still going to try it. I'll just tell them, look, there's a high likelihood that it's going to fail. Um, and in traumas, I have a much more threshold for doing that. But if somebody comes in and says, Hey, I want a phalloplasty tomorrow, right? I'm a smoker. I'll be like, yeah, no, we're not going to do that. So it's just one of those things where it's, I think with traumas, I have a much lower threshold for that, at least for me. Sure. Yeah, I agree. That's kind of the same way I approach it. And that's, that's honestly, I love flaps that are expendable, you know, the skip, the gracilis, things that you can just close them. Primarily, you haven't caused the patient much deficit. And that's how, that's why I really do love the, the, um, the DMAP flap or the co-op of flap simply because of that. You know, you can generally, you should achieve primary closure. And if you, if it, if it did die, say if it was a smoker, then you haven't really cost the patient a whole lot. Typically. I agree. I mean, I think one of the, the pros and cons with hand surgery certainly is that, you know, we deal with much more acute issues from time to time. Uh, not always, you know, elective, um, coverage or elective flaps and things like that. So you're right. So I think very frequently we have patients that, um, in our elective practices, we would probably say are not optimized or not a surgical candidate, but, you know, when they come in with multiple fingers in a bag or they're open tibia fracture or whatever it may be, um, you know, you kind of have to take some of that good with the bad and, you know, to the same point of Dr. Safai, you know, I still do them. Um, and, uh, you know, I think I'd have to look critically back to see if I actually see any differences or, you know, if just the vast majority of my practice is acute trauma smokers. Uh, but I haven't noticed that much of a difference. I mean, certainly I counsel patients and say, Hey, you know, you need to quit to allow this to heal. I think for me, I worry more about the ongoing secondary healing and revascularization of the flap as opposed to, um, kind of an acute microvascular thrombus. I haven't, I haven't really seen that as associated. So, you know, for like, uh, you know, for Dr. Hallowell for, you know, a cross finger flap, you know, if they smoked a pack a day, I'm probably pushing them out to, you know, three or four weeks, um, before I buy them. No, that's great. Yeah. That's useful. I mean, that's my practice too. So it's sort of like you learn to just deal with it, but I'm always curious how other people handle it. I agree. And we just have to keep the nicotine patches off of them in the, in the hospital. Exactly. Hey, Dr. Asapa, uh, are you ever having to get a venous flow through or a venous flap from elsewhere other than the forearm? So I, I've never done that. Um, I do have a couple of colleagues and one of my former fellows who have taken it from the foot as well. And we actually did, we wrote a paper on, well, actually I can't say I've never done that. I have done that. We, we did a paper on, um, uh, saphenous vein grafting for mangled, um, forearms and hands with a skin paddle on top, not as a coverage thing, but more as a temporary coverage to prevent desiccation of the, of the vein. So we did a series of, um, and, and the reason for that is the, the connections of the saphenous vein to the superficial skin is fairly kind of loose aerial, or it's not really integrated with it as, as much as these distal forearm veins are. So maybe that's why, but, but they, we put them on and they just got kind of congested and then it didn't look that great. But then after about a week, the thing was ready for a flap. So we peeled it off and put a flap on top. So not truly a venous flap per se. Um, but I think that because the indication in my practice is primarily for digits and hand coverage, um, and the forearm is right there in the field. Um, that's really where I take them from. There've been a few cases where I've taken them from the contralateral forearm because of injuries to the form on the epsilon side. Um, but I think it's difficult to, you know, the dorsum of the foot is almost like a dorsum of the hand in that it's a similar problem. The veins aren't as, um, almost as attached, if you will, to those superficial skin. So you may, you may not be able to perfuse as much, but there are folks who have done it. I just don't have much experience with it myself. Yeah. Have you taken any of the, uh, forearm flaps, uh, with say the medial or the lateral antebrachial cutaneous for, for nerve reconstruction? Yes. So I've done, um, uh, certainly innervated, um, venous flaps. And actually one of the cases in the video is a, is a volar coverage of, uh, almost the entire middle finger on a guy who had bolstered off on a conveyor belt. Um, and on that one, we actually founded this and maybe C branch that we just kind of plugged with the visual nerve and he got some good light touch. Having said that there, there's a fair amount of literature out of the far East. Um, it was a Korean paper with about 30, some venous flaps. Um, and they compared the ones where they did innovate versus the ones where they didn't know. Most of them were fingertip type stuff. Um, but they were getting a fair amount of spontaneous renovation with light touch, which, so I'm like, do we really need it? I mean, if I find a nerve, I'll definitely do it, especially if it's a bowler finger, um, or closer to the pad, as opposed to just, um, you know, proximal digit. And, um, and then we, we've also done a lot with, um, with the palmaris, um, and, you know, is that vascularized tendon or is it just a graft? Who knows? But if you need a tendon and the venous flaps directly on the palmaris, just take it. And one of the cases that I think I did was that I showed on in the thing was, um, um, EPL reconstruction, um, with, um, along the dorsal skin on the proximal films of the thumb. So you can certainly do that. And technically it's super easy because it's right there. And that's the thing. These are, none of them are technical challenges per se. It's really just a, mostly a design challenge and trying to come up with a creative way of, of solving it. Sure. Do you have to come back and, and Tina lice the tendon away from the overlying flap or. So, um, in the, in the one case that I'm talking about with the, with, with the thumb, I did go back and Tina lice it. And it was interesting because I, um, you know, you, you see the venous flap on top and you see, um, uh, you know, the fat is all there and it's basically full thickness skin and fat is there. So it's certainly not as can graph to some folks would say. Um, and that was mainly because the tendon was stuck down to the proximal failings because he shaved off all the cardiovascular injury. Um, so yeah, sometimes you have to go back and do the Tino Isis on it. Yeah. So not necessarily adherence to the flat, but more so kind of to the underlying wound better exist. Yeah, exactly. And, and just like you, I mean, Tina lices are definitely not my favorite procedure. Having said that I'd much prefer to do an extensive Tino Isis than a flexor Tino Isis. That's very fair. Very fair. Yeah. All right. Any other questions, uh, for each other on any of the cases or, or the favorite flaps and hands as it were? Uh, I was just going to ask a follow-up question to the smoking question is, um, do you, do you guys have, um, a lower threshold for epinephrine as in some of these patients, if you see either that their vessels don't look great or they're, they're heavy smoker pack a day for 30 years or whatever. Um, I agree that I wouldn't necessarily do it something different per se, if they didn't need a revasc or replant or, or a small flap. Uh, but how, um, when do you think about potentially doing, um, kind of either therapeutic or self-therapeutic heparinization in some of these patients? So I, I like to use heparin, um, as you know, sub-q prophylaxis, uh, for me to, to jump up to a heparin drip, I don't necessarily use that kind of low dose, you know, 500 per hour, because ultimately if it calculates out to 5,000 TID anyways, to me, it seems kind of like a wash. And so I'll typically use, you know, a vascular protocol, intermediate dose. Um, but I think more frequently, if I find that I've gotten in there and they're a heavy smoker and there's calcification and plaque, and, you know, in some cases you've got to do like a little endarterectomy, I worry more about, um, the aggregation, the arterial side. So I'll actually put them on a platelet agent, such as like a Plavix, um, you know, on the first post-op day to really try to thin that out. Uh, but again, that's just like based on, um, kind of my experience, but, you know, if they just come in as trauma and they're a heavy smoker, but their vessels look okay, the micro goes okay. Um, I just kind of keep them status quo. Okay. Yeah. I usually save heparin drip for when, um, like I've done an anastomosis and it's gone down or something has happened and you might say like, probably maybe that's technical, maybe it's not, but that's when I usually get out the therapeutic heparin drip. Um, I'm sure I don't usually start it just because they're smokers if things otherwise look okay. Tim, how about you? I do the same essentially. And, um, like in a, in a rotation flap, you know, like the quaba, I don't worry about it so much, but, you know, I did a venous flow through flap the other day on a guy who was a heavy smoker. It was, uh, to revasca finger. And I just sent him home with Lovinox 40, um, daily for 30 days and an aspirin. Um, but, um, you know, perhaps, you know, in, in perforator flaps or rotational flaps like the quaba, maybe I've missed it, but, um, but I haven't run into that situation specifically for those, but. Yeah. I guess my question wasn't exactly about the micro. Cool. Thanks. Any other questions from the group? So perfect. Awesome. Yeah. Thank you again. So, I mean, I think this, um, it was a fantastic session. You know, I thank you again for taking the time out both to, to have this discussion as well as to put your, your talks together and show those clinical cases. I think they were fantastic. Um, but otherwise this concludes the educational programming session. Um, please drop a question for the faculty in the Q and a tab or comment in the chat window, uh, to the right of this window. And as we said previously, there is a forum in which you can address additional questions to us. Uh, and, and hopefully we can get you a good answer. Other than that, uh, thank you again for your attention and for joining us.

hand surgery

versatile flaps

dorsal metacarpal artery perforator flap

finger defects

cross finger flaps

reverse cross finger flaps

venous flaps

revascularization

trauma cases

reconstructive surgery