Indian Journal of Plastic Surgery
An open access publication of Association of Plastic Surgeons of India
Users Online: 629  
Home | Subscribe | Feedback | Login 
  Navigate here 
  Search
 
   Next article
   Previous article 
   Table of Contents
  
 Resource links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (412 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  
  In this article
   References

 Article Access Statistics
    Viewed1852    
    Printed111    
    Emailed0    
    PDF Downloaded82    
    Comments [Add]    

Recommend this journal

 


 
LETTER TO EDITOR
Year : 2009  |  Volume : 42  |  Issue : 2  |  Page : 270-271
 

Comments on foucher's flap


Department of Orthopaedics, Kasturba Medical College, Mangalore, Karnataka, India

Date of Web Publication29-Jan-2010

Correspondence Address:
B Jagannath Kamath
Department of Orthopaedics, Kasturba Medical College, Mangalore, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-0358.59300

Rights and Permissions



How to cite this article:
Kamath B J. Comments on foucher's flap. Indian J Plast Surg 2009;42:270-1

How to cite this URL:
Kamath B J. Comments on foucher's flap. Indian J Plast Surg [serial online] 2009 [cited 2019 May 22];42:270-1. Available from: http://www.ijps.org/text.asp?2009/42/2/270/59300


Foucher's flap is one of the ideal flaps to cover traumatic defect of the pulp and dorsum of the thumb. Though ideally described for thumb defects with some shortening, it has been proved beyond doubt that it can also be requisitioned to resurface thumb defects without shortening. In the latter indication, it is necessary to harvest the flap up to the dorsum of the PIP joint. However, the distal 1/3 of such a first dorsal metacarpal artery (FDMA) flap becomes a random part of the axial artery flap and hence carries some risk of marginal necrosis. It is surmised that the survival of such a flap is ultimately determined by the relative length of index and thumb.

Normally, the tip of the adducted thumb roughly reaches upto 70% of the length of the proximal phalanx of the index finger (32% of the index finger length beyond MP joint); [1],[2] such thumbs being ideally suited for conventional FDMA flaps. Individuals with thumb length more than 70% of the proximal phalanx of index finger are the ones likely to need an extended FDMA flap i.e. wherein flap is harvested beyond the PIP joint. One more ambiguous parameter of this flap is the amount of blood supply which comes alongwith the superficial branch of radial nerve. We know that every superficial nerve is accompanied by an artery and vein of its own supplying the skin and integument. Being a neuro-sensory flap, it is an ideal flap for pulp of thumb which restores an acceptable level of sensation, however, it may not match Littler's neuro-vascular island flap because of poorer cortical reorientation.

Kulkarni et al.[3] need to be congratulated for describing one more indication for FDMA flap. Though small traumatic defects on the radial side of the palm are rare, when encountered, this flap is really handy when compared to the alternatives. These flaps are also used in reconstructive surgeries following post burn scar contracture release, [4] syndactyly release, and partial loss of reimplanted thumb. [5] Donor-defect following this flap usually needs split skin graft or full-thickness skin graft. These usually do not give rise to functional deficit. Cosmesis, however, will be a consideration. This can be avoided if one harvests only adipofascial flap to cover the thumb defect as described by Vishwa Prakash. [6] One more modification suggested is the usage of this flap as distally-based flap for coverage of web and ulnar aspect of the dorsum of the hand and distal dorsum of the index. The size of the FDMA flap at widest portion could be 1.2 to 1.5mm which for some super micro surgeons may be an option for a small free neuro-vascular flap for other digits.

The article gives a lucid description and illustration of the use of the FDMA flap for thumb defects. However, I feel it may be risky to perform this flap without loop magnification, under local anaesthesia and without proper tourniquet. The chances of survival can be further enhanced by including more than one dorsal vein as described by El Khatib, [7] who has harvested the flap from not only the dorsum of proximal but also from the middle phalanx of the index finger extending into what he calls the "dynamic territory" or the random part of the flap. He argues in favour of including the dorsal veins to prevent venous congestion in the flap. His modification enables the surgeon to cover any defect on the thumb of normal length. The same philosophy has been further propagated by Gebhard et al. [8] in his case report wherein he has harvested the flap up to the DIP joint so as to wrap around the proximal phalanx of a traumatized but shortened thumb which was found unsuitable for reimplantation. If one wants to play safe and use this extended FDMA flap, it may not be a bad idea to delay this distal dynamic territory/random part of the flap in the first stage and raise the whole of the extended FDMA flap in the second stage.

The arterial pedicle of the flap, which is the ulnar-most of the three branches, coming from radial artery just before dipping in between the two heads of first dorsal interossei is almost constant and is amenable to be pivoted as proximally as the medial border of the EPL in line with the radial border of the second metacarpal. This unique arterial supply gives the surgeon a wide arc of rotation with the pedicle length of 6-7 cm in adults; as in the present report.

 
  References Top

1.Goldfarb C, Gee AO, Heinze LK, Manske PR. Normative values for thumb length, girth and width in paediatric population. J Hand Surg Am 2005;30:1004-8.  Back to cited text no. 1      
2.Sunil T. Clinical indicators of normal thumb length in adults. J Hand Surg 2004;29:489-93.  Back to cited text no. 2      
3.Kulkarni AA, Abhyankar SV, Singh RR, Chaudhari GS. Another use of Foucher's flap. Indian J Plast Surg 2009;42:276-78.  Back to cited text no. 3      
4.Eski M, Nisanci M, Sengezer M. Correction of thumb deformities after burn: Versatility of first dorsal metacarpal artery flap. Burns 2007;33:65-71.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Saba SC, Lee J, Pathy VV, Weber RV. Salvage of thumb reimplant using bilobed dorsal metacarpal artery flap: Case report and literature review. Hand 2008;3:366-71.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Prakash V, Chawla S. First dorsal metacarpal artery Adipofascial flap for a dorsal defect of the thumb. Plast Reconstr Surg 2004;114:1353-5.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.El-Khatib HA. Clinical experience with the extended first dorsal metacarpal artery islanded flap for thumb reconstruction. J Hand Surg Am 1998;23:647-52.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Gebhard B, Meissl G. An extended first dorsal metacarpal artery neurovascular island flap. J Hand Surg Br 1995;20:529-31.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  




 

Top
Print this article  Email this article
Previous article Next article

    

Site Map  |  Home  |  Contact Us  |  Feedback  |  Copyright and Disclaimer
Online since 11th March '04
Published by Wolters Kluwer - Medknow