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L o c a l Fl a p s o f t h e H a n d Shady A. Rehim, MB ChB, MSc, MRCSa, Kevin C. Chung, MD, MSb,* KEYWORDS 000f Hand flaps 000f Soft tissue coverage 000f Reconstruction
KEY POINTS 000f When indicated, local hand flaps offer excellent coverage of soft tissue defects that replaces like with like. 000f A variety of traditional and nontraditional local hand flaps can be used to cover most of small to moderate-sized defects of the hand. 000f Although routinely used, the application of local hand flaps is an evolving field with multiple new flap designs and modifications being described based on the intricate vascular anatomy of the hand. 000f Local hand flaps frequently result in optimum functional and aesthetic outcomes and may spare patients and surgeons from more complicated methods of soft tissue repair.
The hand is an intricate part of the body that plays an essential role in social functioning, expression, productivity, and interactions with the environment.1 The skin/soft tissue envelope of the hand is a complex structure that not only covers the underlying structures but also has specialized functional and sensory components. The thick glabrous skin of the palm withstands shearing forces encountered during daily activities and provides discriminatory sensory function that transfers touch, pain, and temperature, whereas the dorsal skin is pliable and mobile, and permits a wide range of motion of the hand such as finger pinch and grip.1,2 Soft tissue defects of the hand following trauma or tumor resection are frequently encountered in hand surgery and may result in a temporary or permanent disability if not managed appropriately.
Over the past decades, several reconstructive procedures and their modifications have evolved to provide the ideal soft tissue coverage of the hand.3 Conventionally, these included a range of options of primary wounds closure, skin grafts, local flaps, distant flaps, and micro-vascular free tissue transfer.3–6 However, selecting the most suitable type of soft tissue cover for a particular defect can be a challenging process. Furthermore, the abundance of currently available reconstructive techniques makes this task difficult, especially for the inexperienced surgeon. When choosing one reconstructive method over another, it is prudent for the surgeon to have a sound knowledge of all available options, their limitations, complications, and expected outcomes. Reconstruction algorithms such as the reconstructive ladder, reconstructive elevator, and reconstructive matrix have been devised to assist surgeons in
Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. This work was supported in part by grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute on Aging (R01 AR062066), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (2R01 AR047328-06), and a Midcareer Investigator Award in patientoriented research (K24 AR053120) (K.C. Chung). a Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA; b Section of Plastic Surgery, University of Michigan Medical School, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA * Corresponding author. E-mail address: [email protected] Hand Clin 30 (2014) 137–151 0749-0712/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
Rehim & Chung determining the most appropriate type of soft tissue reconstruction.7,8 Although sometimes useful, there is no simple schema for reconstruction because every injury is different and every patient has a unique set of medical conditions. This article is a practical guide that offers an overview of several types of local hand flaps. With these flaps, most small-to-medium sized defects of the fingers, thumb, and dorsum of the hand can be reconstructed with minimal donor site morbidity and excellent functional and aesthetic results because a tissue defect is replaced with similar tissue type from its immediate anatomic vicinity.
GENERAL CONSIDERATIONS A careful patient history and mechanism of the injury are indispensible in assessing the potential structural involvement and previous interventions. This provide a framework in which to begin treatment. One of the most influential factors in consideration of any treatment is tissue loss, including defect size, site, depth, orientation, and composition. However, other factors, such as those related to patients and surgeons’ technical ability as well as the availability of resources, are of equal importance (Table 1). A systematic evaluation of all these factors is essential to individualize the reconstruction plan to each patient. When closure of skin defects of the hand cannot be achieved by simple methods such as Table 1 Perioperative considerations Wound
Donor site
Size Site Side (eg, volar or dorsal) Amount and type of tissue loss (eg, isolated soft tissue injury or compound) Functional loss Scar location Morbidity Texture Color Volume Hairiness Sensibility Hand dominance Age Sex Occupation Medical comorbidities Preferences Knowledge Technical skill Preference
healing by secondary intention or primary closure, other methods should be used. Skin grafts require a vascularized wound bed for the graft to take and are not suitable to cover defects over exposed tendons or bones without paratenon or periosteum. Furthermore, the high contracture potential, limited scar pliability, and poor sensibility limit their successful use as a primary method of reconstruction in the hand.5 Locoregional or free tissue transfers bring their own blood supply, and thus have been frequently used to cover complex injuries with exposed tendons and bones. However, choosing between local flaps (harvested from adjacent tissue) or flaps (harvested from distant anatomic sites), several factors need to be considered. First, the simplest procedure that provides an adequate amount of tissue coverage and results in maximal gain of function together with the least amount of donor site deformity should be selected. Second, whenever possible, tissue replacement should follow the principle of replacing like with like to provide good color, texture, hairiness, and volume match.8,9 Different regions of the hand have different functional and aesthetic requirements. For example, reconstructing highly sensate areas such as the fingertips with nonsensate skin may cripple the function of a patient’s hand. In contrast, transposing skin containing hair follicles to a hairless surface such as the palm results in poor aesthetic appearance and patient dissatisfaction with surgery. Because of the special relationship between function and aesthetics of the hand, we have coined the term ‘functional aesthetic units and subunits’ of the hand by dividing the hand into distinct regions after taking into consideration the unique functional and aesthetic properties of each specific region that should be considered when planning for soft tissue reconstruction of the hand. If there are no specific contraindications for local skin flaps such as crush injuries or the presence of local infection, they should be considered as the first line of treatment.9 In addition to replacing like with like, the use of local skin flaps avoids the need for skin grafts or more extensive procedures such as free flaps. In all the following flap descriptions, we assume that other reconstructive options apart from local flaps have been weighed and rejected.
CLASSIFICATION OF SKIN FLAPS A flap is skin with a varying amount of underlying tissue that is used to cover a defect and receives its blood supply from a source other than the tissue to which it is transferred to.10,11 Skin flaps
Local Hand Flaps can be classified according to their method of transfer (eg, advancement, rotation, and transposition),11 composition (eg, cutaneous, fasciocutaneous, fascial, adipofascial, or compound flaps including bone and/or tendon),12 and geometric design (eg, rhomboid, bilobed). If classified according to their location in relation to the defect alone, they can be grouped into 3 types of flaps9: 000f Local flaps: harvested from the injured digit or tissue surrounding the injured zone of the hand 000f Regional flaps: harvested from adjacent noninjured digit or zone of the hand 000f Distant flaps: harvested away from the injured hand If local skin flaps are further divided according to their blood supply, they can be grouped into random or axial pattern flaps as shown by McGregor in 1972.13,14
Random Pattern Flaps Random pattern flaps have no known feeding blood vessel. Instead they are supplied by a random pattern of subdermal plexus and hence the name random pattern flaps. Because they lack a known vascular pedicle, the flap size is usually limited to a length/width ratio of 1:1 because of the limits of the perfusion pressure. However, this general rule does not strictly apply in highly vascularized areas such as the face or hands, in which a flap can be carefully extended to increase the flap length with respect to width in these areas. Examples of random pattern skin flaps include rotation, rhomboid, and transposition flaps.
Axial Pattern Flaps Axial pattern flaps are based on a known artery that directly supplies a specific skin territory. Interconnections between branches of adjacent axial vessels exist that connect neighboring skin territories. Behan and Wilson were first to describe a system of linked axial pattern flaps via vascular communications based on a known arterial supply that was termed an angiotome.15 Taylor and Palmer16 later emphasized the role of these interconnections (choke vessels) and stated that when a flap is based on vessels of one angiosome, the corresponding tissue of adjacent angiosome can be safely captured based on the blood supply of the first angiosome.17 Thus, in contrast with random pattern flaps, axial flaps may be extended beyond the 1:1 ratio to cover larger defects owing to their more robust blood supply because the axial vessel provides a larger perfusion territory.
An axial pattern flap can also be traced along its vascular pedicle thus converted to an island pedicled flap, which permits a greater freedom of mobility and increases the span of the flap to reach more distant defects. Although this can sometimes be advantageous, kinking or avulsion of the vascular pedicle jeopardizes the viability of the flap. Examples of axial pattern flaps include thumb neurovascular advancement flap (Moberg), first dorsal metacarpal artery flap, and second dorsal metacarpal artery flaps.
DORSUM OF THE HAND Random pattern flaps such as rotation or transposition flaps are useful local skin flaps for coverage of a variety of soft tissue defects over the dorsal surface of the hand. By taking advantage of the skin laxity together with carefully measured geometric flap designs, clinicians can successfully move tissue around to close several skin defects. Furthermore, if used correctly, random pattern flaps can be applied throughout the hand and fingers. As a rule, clinicians should always perform a finger pinch test to decide which adjacent area provides most soft tissue for closure with respect to relaxed skin tension lines when executing these flaps so the donor site can be closed directly.
THE ROTATION FLAP The name rotation flap refers to the vector of movement of the flap, which is usually curved or rotational. This flap can be thought of as the closure of a triangular defect by rotating adjacent skin around a rotation point (or fulcrum) into the defect (Fig. 1).18 After outlining the defect, the arc of the flap rotation should be designed at least 3 to 4 times larger than the diameter of the defect to allow sufficient rotation of the flap and closure without excessive tension. A common mistake is to design a flap that is too small and cannot be sufficiently rotated into the defect. In these instances a small back cut or creation of a Burow triangle can help gain extra rotation. However, despite these maneuvers, the flap frequently cannot be sufficiently mobilized and creates a secondary defect from the donor site. Extending the back cut in order to gain further length may jeopardize the viability of the flap as it cuts through the blood supply at the base of the flap. It is therefore advisable to design a large flap from the outset to avoid this situation.
THE RHOMBOID/LIMBERG FLAP First described by Limberg in 1928, the rhomboid flap is a transposition flap that consists of an equilateral parallelogram with 2 angles of 120000e and 2 of
Rehim & Chung
Fig. 1. Wrong design of rotation flap (A). Note that the length of the arc of the flap should be at least 3 to 4 times the diameter of the defect (B) to sufficiently rotate the skin flap into the defect (C).
60000e .19 To execute this flap, first the defect is converted into a rhomboid. A line is extended that equals the height of the rhomboid. This line is then extended parallel to one side of the rhomboid (Fig. 2A). The flap is elevated and transposed into defect, whereas the secondary defect is closed directly. In practice, defects have different sizes, shapes, and orientation. Strictly adhering to the measurements/angles described earlier may not provide the best aesthetic appearance. As the surgeon gains cumulative experience with performing these flaps, the flap design can be modified to better fit the defect. For example, the margins of the defect as well as the transposed skin of the rhomboid flap can be rounded/curved in a similar fashion to the bilobed flap. This maneuver eliminates the pointed triangular edges of the flap that
can be strangulated by tight skin closure during flap inset (see Fig. 2B). Furthermore, when designing the rhomboid flap on the dorsum of the hand, clinicians must be mindful that the line of closure of the secondary defect lies parallel to relaxed skin tension lines to avoid puckering of the skin and achieve skin closure without excessive tension.
FINGERS It is easier to consider reconstruction of finger injuries if the fingers are divided into 3 parts: distal to the proximal interphalangeal (PIP) joint, at the level of PIP joint, and proximal phalanx. In addition to the level of injury, the side of injury should also be considered. Defects over palmar and dorsal Fig. 2. A skin lesion (basal cell carcinoma) on the dorsum of the hand (A) and an outline of rhomboid flap planned for coverage of postexcision skin defect. Note that the line of flap closure should lie within the relaxed skin tension lines to facilitate skin closure taking advantage of the skin laxity (B). Also note that the margins of the transposed flap have been curved or rounded off to avoid strangulation and necrosis of pointed triangular edges of the skin flap.
Local Hand Flaps surfaces of the fingers require different reconstruction options, as follows.
THE V-Y ADVANCEMENT FLAP The V-Y advancement flap was first described by Tranquilli-Laeli in 1935 but was popularized by Atasoy and colleagues20 in the United States in 1970.21 Fingertip amputation is a common injury that frequently results in soft tissue defects with an exposed underlying bone of the distal phalanx that cannot be left to heal with secondary intention or covered by skin grafts. The availability of remaining adjacent soft tissue and the pattern of injury usually dictate the method of treatment. The V-Y advancement flap is most suitable for coverage of transverse or dorsal oblique fingertip amputations with exposed bone and sufficient nail bed support and length.22 In addition, the V-Y advancement flap can be used to resurface adherent sensitive scars over fingertips resulting from previous amputation injuries. This flap provides excellent soft tissue replacement in terms of skin color, texture, sensation, and padding. However, in volar oblique fingertip amputations other options should be considered. The V-Y advancement flap incorporates the volar digital neurovascular bundles that provide vascular and sensory supply to the flap. The first step of executing this flap includes marking the boundaries of the V-Y flap by drawing an inverted V on the volar side of the distal phalanx (Fig. 3A). The apex of the flap extends proximal toward the level of the distal interphalangeal (DIP) joint crease and the base extends distally to the radial and ulnar borders of the amputated nail bed. Extension of the skin incision beyond the DIP joint flexural
crease should be avoided because this may result in the development of skin contracture and flexion deformity of the distal phalanx. In contrast, extending skin incisions laterally beyond the borders of the nail bed may result in a flattened appearance of the nail bed. A combination of sharp and microscissors dissection is used to raise the flap. On either ends of the base of the flap, fullthickness skin incisions are performed that extend down to the periosteum to free periosteal attachments of the flap while preserving nourishing digital vessels. Toward the center, the flap is dissected off the flexor tendon sheath by carefully passing the tip and body of the scalpel from distal to proximal to the deep margin of the flap to cut through fibrofatty subcutaneous tissue to aid mobilization of the flap (see Fig. 3A). Once the flap is freed from its attachments, a skin hook is used to gently pull the distal end and advance the flap into the defect (see Fig. 3B, C). At this point, it should be emphasized that most of published textbook illustrations of the V-Y flap give the impression that the flap can easily be advanced forward. However, V-Y advancement flap has a limited mobility and only about 0.5 to 1 cm of advancement can be obtained, which limits the use of this flap to small fingertip defects. After flap advancement, the proximal wound is closed as a Y, hence the name V-Y advancement flap. The tourniquet is released to check perfusion of the flap and the distal end is sutured without excessive tension (Fig. 4).
THE THENAR FLAP Gatewood23 first described the technique of a thenar flap for coverage of fingertip injuries in
Fig. 3. Design of V-Y advancement flap to cover fingertip amputation (A). Note that the flap is outlined and dissected off flexor tendon sheath incorporating digital vessels and then advanced to cover the defect (B, C).
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Fig. 4. A V-Y advancement flap was performed to resurface skin of a painful adherent scar resulting from a previous fingertip amputation of the index finger (top). Excellent soft tissue padding, contour, color, texture match, and mobility 9 months after surgery (below).
1926. This description was expanded on by Flatt24,25 in 1957. The thenar flap is indicated for volar skin avulsions over the pulp of the finger (eg, volar oblique amputations); however, its use can also be extended to cover dorsal defects over the nail bed. Advantages of the thenar flap include inconspicuous donor site defect and good soft tissue padding, color, and texture match from the glabrous skin over the thenar area to the pulp of the finger. The major disadvantage of this flap is the propensity of PIP joint contracture and finger stiffness. Young women and children tend to have more supple joints and are therefore good candidates for the thenar flap. The location of the donor site is identified by gently flexing the fingers toward the thenar eminence. The area of contact between the finger pulp and thenar eminence is the correct location of the donor site, which because of individual variation usually lies at or just proximal to the level of thumb metacarpophalangeal (MCP) joint. Excessive flexion of the finger results in marking a donor site too proximal on the palm, which eventually results in excessive tension on the flap and may jeopardize the success of the procedure. Once the correct donor site is identified, a rhomboidshaped flap is designed; alternatively a circular or an H-shaped flap can be designed based on the shape and size of the finger defect (Figs. 5 and 6). The flap should be made slightly larger than the size of the defect. A full-thickness skin flap is then raised at the level of thenar muscle
fascia. Care must be taken not to injure the radial digital nerve of the thumb, which usually lies anterior to the midaxial lines of the thumb. Once the flap is elevated, the injured finger is advanced into the raw area to encompass the distal pulp space. The end of the flap is sutured to the defect and the donor site is closed primarily. The tourniquet is released to check the flap viability. The finger is left attached and after 2 to 3 weeks the flap is divided, thus replacing the original soft tissue defect with glabrous matching skin.
THE CROSS-FINGER FLAP The cross-finger flap is a 2-staged flap reconstruction that was first described by Cronin26 in 1951. Volar soft tissue defects located on the middle or distal phalanx can be covered with this flap. Another indication of the cross-finger flap is for more distal defects in which more tissue is required for coverage than can be obtained from a local advancement flap such as V-Y flap. Akin to thenar flap, PIP joint stiffness caused by joint flexion and immobilization is a concern when using the cross-finger flap. The middle finger can be used to repair defects on either adjacent index or ring fingers, otherwise the donor finger is the one radial to the injured finger. The flap is outlined and elevated in an open book fashion in which a 3-sided rectangular or a rhomboidal flap is outlined on the dorsum of the middle phalanx of the healthy digit. The fourth
Local Hand Flaps
Fig. 5. A 20-year-old female patient who sustained a crush injury to the left index finger with soft tissue loss and necrosis. The necrotic skin was debrided, and a thenar flap was then designed to cover the open area.
side of the rectangular flap acts as the hinge of the flap located at the midaxial line of the finger nearest to the injured digit. A pattern can be used and transposed onto the donor site to estimate the size of the flap required. The flap should be designed slightly larger than the defect to avoid closure with excessive tension. A full-thickness skin flap is then raised over the paratenon of the underlying extensor tendon (Figs. 7 and 8). Care must be taken not to strip off the paratenon so that the secondary defect can be closed with a skin graft. After flap elevation, the flap is rotated 180000e around its hinge and secured over the palmar defect of the adjacent injured finger. A full-thickness skin graft is then harvested to close the secondary defect. A Kirschner wire can be used to stabilize the fingers together to avoid pulling or detachment of
the flap, but this is not necessary in the authors’ experience. The fingers are immobilized for approximately 2 to 3 weeks, after which a secondary procedure is performed to divide the skin bridge. Pakian27 first used a modification of the crossfinger flap known as the reverse cross-finger flap for defects located on the dorsal side of the fingers. In principle, the reverse cross-finger flap is similar to the classic cross-finger flap; however, the technique is slightly different. The flap is designed within the functional limits of the phalanx on the dorsal aspect of the adjacent noninjured finger. A cross-finger flap should not be harvested from the volar side of the finger because this leads to volar scar contracture and leaves a major donor site problem. The same open-book technique of raising a 3-sided rectangle with the fourth side
Fig. 6. Results of the soft tissue replacement of the same patient as in Fig. 4 2 months after surgery.
Rehim & Chung
Fig. 7. A 49-year-old who had an electric burn injury with entrance wound over the index and middle fingers. Following wound debridement the patient had an exposed flexor tendon that was covered with a cross-finger flap obtained from the dorsum of the middle phalanx of the adjacent long finger.
acting as a hinge adjacent to the injured finger is used. The skin is raised at the level of the deep dermis leaving behind the rest of the deep layer of dermis and subcutaneous tissue, which in turn is raised in the same manner over the paratenon
and reflected 180000e to cover the primary defect. By doing so, the superficial surface of the subcutaneous flap lies directly on the wound bed of the primary defect, and its deep surface becomes superficial and is subsequently covered with a
Fig. 8. Results of soft tissue replacement with cross-finger flap of the same patient as in Fig. 6 5 months after surgery.
Local Hand Flaps full-thickness skin graft (Fig. 9). The skin flap that was initially raised from the donor site is then reflected back to cover the secondary defect. After a period of 2 to 3 weeks the bridge of the subcutaneous flap can be safely divided.
THE HOMODIGITAL ISLAND FLAP Weeks and Wray28 in 1973 described the homodigital island flap that is based on the volar blood supply of the fingers, either the radial or ulnar digital artery and its venae comitantes. The flap can be harvested on a proximal (antegrade) or a distal (retrograde) pedicle.29 Proximally based flaps are used to cover more proximal defects, whereas reverse pedicle digital island flaps, described by Lai and colleagues,30 are used to cover more distal defects over PIP and DIP joints (Fig. 10). In contrast with the cross-finger flap, the advantages of this flap include that it is a single-stage
procedure confined to the injured digit. However, hand surgeons are currently less enthusiastic to perform this flap because of fine dissections and increased risk of damage of the vascular pedicle as well as decrease of sensation over the donor site, especially in dominant fingers. Furthermore, this flap is not suitable for patients with peripheral vascular disease or in digits nourished by a single vessel. A positive digital Allen test showing incomplete collateral perfusion is therefore a contraindication to the use of this flap.21 For the reverse pedicle digital island flap, the flap is outlined on the lateral border of the base of the affected digit. A pattern is used and transferred onto the donor area to estimate the size of the flap required. In general, the flap should be designed slightly larger than the defect to allow for primary skin contraction. Dissection is performed from proximal to distal until enough length of the pedicle is obtained, which usually corresponds
Fig. 9. The reverse cross-finger flap. The skin over the donor finger is reflected leaving part of the deep dermis and subcutaneous tissue (A, B) that is in turn swung over the primary defect and covered with a full-thickness skin graft. Reflecting back the skin that was initially elevated closes the secondary defect created over the donor finger (C, D).
Fig. 10. A reverse homodigital island flap.
with the level of the DIP joint. During dissection the digital nerve is gently separated from the vascular pedicle and the digital vessel is ligated proximally. The pedicle should be raised with a cuff of fat; attempts to skeletonize the pedicle may result in damage of the venous drainage or vascular supply of the flap. Once the island flap is elevated, it is rotated into the defect and sutured loosely to avoid compression of the pedicle. A full-thickness skin graft is then harvested to close the secondary defect.
In 1987, Earley and Milner31 first described the proximally based dorsal metacarpal artery flap based on the first and second dorsal metacarpal artery. In 1990, Quaba and Davison32 introduced another subset of flaps called the distally based dorsal metacarpal artery (DMCA) flap, which is not based on the dorsal metacarpal arteries but on a constant palmar-dorsal perforator present in the digital web space (Fig. 11). The DMCA flap became a popular flap for coverage of dorsal finger defects up to the level of the PIP joint. Several flap modifications have since been devised based on the vascular anatomy of the DMCA and the more distal dorsopalmar digital cutaneous perforators in order to increase the span of the flap to reach more distal defects.33–37 The DMCA flap is indicated for large dorsal finger defects or when a 1-stage procedure is preferred to allow finger mobilization. The flap can also be used to reconstruct volar defects over the proximal; however, this should be discouraged because the transposition of hairy pigmented skin from the dorsal surface of the hand is not an ideal match to the glabrous, lighter-colored skin of the palmar surface of the fingers, especially in darkskinned individuals. The flap is usually centered on the location of the palmar-dorsal perforator of the deep palmar arch. The boundaries of the flap extend between the distal edge of the extensor retinaculum proximally, the MCP joint distally, and the outer borders of the adjoining metacarpals on either side.38 The flap is harvested from proximal to distal, raising the skin flap above the paratenon of the underlying extensor tendon. The pedicle is traced along the course of the perforator that usually arises
Fig. 11. The vascular supply of the distally based DMCA perforator flap as described by Quaba and Davidson. (Data from Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg 1990;43(1):28–39.)
Local Hand Flaps immediately distal to the juncturae tendinum at the interdigital space. There should be no attempt to isolate the perforator because this may lead to its damage and affect flap viability. At this point the tourniquet is released to check flap perfusion. The flap is then rotated and passed through a subcutaneous tunnel to reach the defect (Figs. 12 and 13). The primary defect is closed by primary closure and the fingers and wrist are immobilized in extension. The DMCA flap can be modified to reach more distant defects over the dorsum of the middle/ distal phalanx. This modification may involve designing the flap as a curved ellipse instead of a straight ellipse. After raising the flap, straightening the curved skin ellipse during flap inset offers an additional 8 to 10 mm of length (Fig. 14). Another maneuver involves dividing and ligating the DMCA proximal to the perforator. Because a perforator arising from the deep palmar arch directly nourishes this flap, its attachment with the DMCA can be carefully divided to allow a greater advancement of the flap.38
THUMB The thumb represents 40% to 50% of hand function.39 Restoring thumb defects is essential for pulp-to-pulp and key pinch grip. The arterial supply of the thumb differs from that of other fingers. The volar side of the thumb is supplied by 2 palmar collateral arteries arising from the princeps pollicis artery, which in turn is derived from the radial artery at the first intermetacarpal web space.40 The dorsal blood supply of the thumb is
Fig. 12. Elevation and inset of DMCA flap as described by Quaba and Davidson32 (A) to cover a defect over the dorsum of the finger (B).
independent from its volar circulation. The skin over the dorsum of the thumb is predominantly supplied by ulnar dorsocollateral and radial dorsocollateral arteries, which are branches of the radial artery. Based on knowledge of the anatomic blood supply of the thumb, several local flaps can be elevated to reconstruct volar and dorsal defects, as follows.
THE MOBERG FLAP The advancement neurovascular flap of the thumb was originally described by the Erik Moberg41 in 1964 hence it is best known today as the Moberg flap. The Moberg flap is indicated for coverage of small-to-medium sized defects over the volar aspect of the distal phalanx of the thumb without the need to shorten the length. This flap provides excellent soft tissue coverage with highly sensate, well-padded skin of similar color and texture. The main disadvantage of the Moberg flap is the tendency for interphalangeal (IP) joint flexion deformity if the flap is insufficiently mobilized to cover the volar distal defect. The flap is outlined along midaxial lines on either sides of the thumb. The proximal border of the flap should correspond with the level of flexural crease of the MCP joint. At the distal end of the flap, a fullthickness skin incision is made along the midaxial lines. Care must be taken not to sever the neurovascular bundles nourishing the flap that lie just anterior to the midaxial crease (Fig. 15). The flap is gently dissected off the flexor pollicis longus tendon incorporating digital vessels and nerves. Once the flap is freed from all but its proximal attachment, the flap can be advanced 1 to 1.5 cm toward the distal end and sutured to the tip of the thumb to cover the defect without excessive tension. Often the flap cannot be advanced enough to cover the defect. In these instances minimal trimming of the distal phalanx can be performed. As an alternative, the IP joint can be slightly flexed. However, in order to preserve the length of the thumb and prevent flexion deformity of the IP joint, the proximal end of the flap can be modified to extend across the MCP flexural crease as a V-shaped incision, converting the flap into an island flap to gain further length. After advancing the flap the proximal wound is closed in a V-Y fashion. Another type of flap modification involves making a proximal transverse incision along the MCP joint crease; again, this converts the flap into an island flap. However, the resultant skin defect is not directly closed, and alternatively can be covered with a full-thickness skin graft to avoid the development of vertical skin contractures across the MCP joint. When executing these modifications, care is needed to preserve the
Rehim & Chung
Fig. 13. A 34-year-old male patient who sustained a full-thickness electric burn injury over the dorsum of his left index finger. Following wound debridement a wound defect measuring 6 0002 3 cm with an underlying exposed MCP joint was created (A). A DMCA flap was raised (B) then mobilized (C) to cover the wound (D).
neurovascular bundles, and these modifications should only be performed when necessary.
Fig. 14. An ellipse design of the skin paddle of the DMCA flap that can be stretched owing to skin elasticity to reach more distant defects on dorsum of the finger. PMCA, palmar metacarpal artery.
Foucher and Braun42 in 1979 described the first DMCA flap, also known as the kite flap because the flap is raised with the pedicle, which resembles a kite. The kite flap is a skin island flap harvested from the dorsal surface of the adjacent index finger. The constant first DMCA, a branch of the radial artery, nourishes the flap. The flap may also incorporate a branch of the superficial radial nerve. These characteristics make the kite flap a good choice for reconstructing all dorsal defects of the thumb and can be used to restore sensibility over thumb pulp defects in a single-stage procedure. The disadvantages of this flap may include creating a conspicuous donor site defect that is closed with a skin graft. Furthermore, when reconstructing the pulp of the thumb, the darker dorsal skin containing hair follicles may produce a less aesthetically pleasing result. Execution of the kite flap involves outlining the boundaries on the dorsal surface of the proximal phalanx of the index finger. A full-thickness skin incision is then performed and the flap is dissected from distal to proximal. The flap is elevated together with the underlying fascia of the first interosseus muscle incorporating the vascular pedicle that runs deep in the overlying fascial pocket.
Local Hand Flaps
Fig. 15. A 22-year-old male patient who had a crush injury to the left thumb with loss of tissue at the nail bed that was treated initially with primary closure and left him with thin sensitive skin over the tip of the thumb. Following scar excision, a Moberg flap was performed to reconstruct the resultant defect. Note the digital nerves incorporated within the flap (left bottom).
The pedicle is harvested with a cuff of subcutaneous tissue and no effort should be made to identify or isolate the pedicle because this may damage its blood supply. The pedicle is then traced back to a point near its base at the anatomic snuff-box that contains the radial artery to allow rotation of the
flap. Once the flap and the pedicle are dissected, the perfusion of the flap is checked by temporarily deflating the tourniquet. A subcutaneous tunnel is then created in order to place the flap through the tunnel and into the thumb defect. The subcutaneous tunnel must be spacious enough not to exert
Fig. 16. Harvesting (A) and transfer (B) of the first dorsal metacarpal artery flap to cover dorsal thumb defect. FTSG, full-thickness skin graft.
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Fig. 17. A dorsoradial thumb defect (A) covered by reverse dorsoradial flap (Moschella flap) of the thumb (B). The dorsoulnar flap (Brunelli flap) is performed in a similar fashion but elevated from the dorsoulnar side of the thumb. (From Germann G, Bidermann N, Levin SL. Intrinsic flaps in the hand. Clin Plast Surg 2011;38(4):729–38; with permission.)
any pressure on the pedicle. As an alternative, a skin paddle is harvested over the pedicle that can be transposed along the path of the flap to the defect. We prefer this flap design to avoid passing the flap through the tunnel, which can kink the pedicle (Fig. 16). The donor defect is usually closed by a full-thickness graft.
THE DORSOULNAR AND DORSORADIAL COLLATERAL ARTERY FLAPS The reverse flow homodigital dorsoulnar and dorsoradial collateral artery flaps (Fig. 17) were described by Brunelli (1993)43–45 and Moschella and Cordova (2006),46,47 respectively. These flaps are supplied by the ulnar dorsocollateral and radial dorsocollateral arteries, which arise from the radial artery at the level of the head of the first metacarpal bone and run on their respective sides to supply the skin over the dorsum of the thumb. Studies have shown the constancy of these vessels, but a Doppler examination helps to identify the course of the vessel and to mark the pivot point of the flap.29 The advantage of using these flaps is 2-fold. First, the donor site is confined to the thumb and in most cases can be closed primarily, thus leaving inconspicuous scars. Second, the dorsocollateral branch of the superficial radial nerve can be harvested with the flap and reconnected to one of the volar collateral nerves of the thumb to create a sensate flap to reconstruct defects over the pulp of the thumb. The disadvantage associated with these flaps is the need for delicate microdissection, a process that has been described as microsurgery without anastomosis. The dorsoulnar and dorsoradial reverse flow collateral artery flaps are elevated in a similar fashion. First, the skin flap is centered on the feeding blood vessel either on the dorsoulnar or dorsoradial sides of the dorsum of the thumb, based on the type of flap to be executed. Flap dissection is performed from proximal to distal to
avoid damaging the pedicle. Clinicians should always avoid isolating the pedicle. Dissection of the flap is continued to a level at the middle of the proximal phalanx to preserve the anastomosis between palmar and dorsal vessels. At this point the tourniquet is deflated to check perfusion of the flap. The flap is then reflected and secured to the defect taking care not to compress the pedicle. A cutaneous tail should be harvested to avoid tunneling of the flap and to allow for primary skin closure after rotation of the flap into the defect.47
SUMMARY If there are no clinical restrictions, local flaps represent an ideal soft tissue cover for small and moderate soft tissue defects. A surgeon who is well versed in the vascular anatomy of the hand and different types of local flap reconstruction is able to treat a variety of defects without requiring more complex methods of soft tissue repair. Nonetheless, clinicians must also recognize the limitations of local flaps and be prepared to change the treatment plan if the necessity arises.
REFERENCES 1. Hegge T, Henderson M, Amalfi A, et al. Scar contractures of the hand. Clin Plast Surg 2011;38(4): 591–606. 2. Upton J, Havlik RJ, Khouri RK. Refinements in hand coverage with microvascular free flaps. Clin Plast Surg 1992;19(4):841–57. 3. McGregor IA. Flap reconstruction in hand surgery: the evolution of presently used methods. J Hand Surg Am 1979;4(1):1–10. 4. Rockwell WB, Lister GD. Soft tissue reconstruction. Coverage of hand injuries. Orthop Clin North Am 1993;24(3):411–24. 5. Giessler GA, Germann G. Soft tissue coverage in devastating hand injuries. Hand Clin 2003;19(1): 63–71, vi.
Local Hand Flaps 6. Friedrich JB, Katolik LI, Vedder NB. Soft tissue reconstruction of the hand. J Hand Surg Am 2009; 34(6):1148–55. 7. Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994;93(7):1503–4. 8. Maciel-Miranda A, Morris SF, Hallock GG. Local flaps, including pedicled perforator flaps: anatomy, technique, and applications. Plast Reconstr Surg 2013;131(6):896e–911e. 9. Foucher G, Boulas HJ, Braga Da Silva J. The use of flaps in the treatment of fingertip injuries. World J Surg 1991;15(4):458–62. 10. Pederson WC, Lister G. Local and regional flap coverage of the hand. In: Wolfe SW, editor. Green’s operative hand surgery. 6th edition. Philadelphia: Elsevier Churchill Livingstone; 2011. p. 1662. 11. Lister G. Local flaps to the hand. Hand Clin 1985; 1(4):621–40. 12. Cormack GC, Lamberty BG. A classification of fasciocutaneous flaps according to their patterns of vascularisation. Br J Plast Surg 1984;37(1):80–7. 13. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast Surg 1973;26(3):202–13. 14. McGregor IA, Jackson IT. The extended role of the deltopectoral flap. Br J Plast Surg 1970;23:173. 15. Lamberty BG, Cormack GC. Progress in flap surgery: greater anatomical understanding and increased sophistication in application. World J Surg 1990; 14(6):776–85. 16. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40(2):113–41. 17. Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003; 30(3):331–42, v. 18. Birkbeck DP, Moy OJ. Anatomy of upper extremity skin flaps. Hand Clin 1997;13(2):175–87. 19. Chasmar LR. The versatile rhomboid (Limberg) flap. Can J Plast Surg 2007;15(2):67–71. 20. Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am 1970;52(5):921–6. 21. Chao JD, Huang JM, Wiedrich TA. Local hand flaps. J Hand Surg Am 2001;1(1):25–44. 22. Ramirez MA, Means KR Jr. Digital soft tissue trauma: a concise primer of soft tissue reconstruction of traumatic hand injuries. Iowa Orthop J 2011;31:110–20. 23. Gatewood A. A plastic repair of finger defects without hospitalization. JAMA 1926;87:1479. 24. Flatt AE. The thenar flap. J Bone Joint Surg Br 1957; 39(1):80–5. 25. Flatt AE. Minor hand injuries. J Bone Joint Surg 1955;37:117. 26. Cronin T. The cross finger flap: a new method of repair. Am Surg 1951;17:419–25.
27. Foucher G, Merle M, Debry R. The reversed deepithelialized flap. Ann Chir Main 1982;1(4):355–7. 28. Weeks PM, Wray RC. Management of acute hand injury. St Louis (MO): Mosby; 1973. 29. Germann G, Biedermann N, Levin SL. Intrinsic flaps in the hand. Clin Plast Surg 2011;38(4):729–38. 30. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg 1989;22:495–500. 31. Earley MJ, Milner RH. Dorsal metacarpal flaps. Br J Plast Surg 1987;40(4):333–41. 32. Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg 1990;43(1):28–39. 33. Maruyama Y. The reverse dorsal metacarpal flap. Br J Plast Surg 1990;43:24–7. 34. Pelissier P, Casoli V, Bakhach J, et al. Reverse dorsal digital and metacarpal flaps: a review of 27 cases. Plast Reconstr Surg 1999;103(1):159–65. 35. Bene MD, Petrolati M, Raimondi P, et al. Reverse dorsal digital island flap. Plast Reconstr Surg 1994;93:552. 36. Santa Comba A, Amarante J, Silva A, et al. Reverse dorsal metacarpal osteocutaneous flaps. Br J Plast Surg 1997;50(7):555–8. 37. Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg 2007;60(7):731–9. 38. Sebastin SJ, Mendoza RT, Chong AK, et al. Application of the dorsal metacarpal artery perforator flap for resurfacing soft-tissue defects proximal to the fingertip. Plast Reconstr Surg 2011;128(3):166e–78e. 39. Bunnell S. Reconstruction of the thumb. Am J Surg 1958;95(2):168–72. 40. Brunelli F, Vigasio A, Valenti P, et al. Arterial anatomy and clinical application of the dorsoulnar flap of the thumb. J Hand Surg Am 1999;24(4):803–11. 41. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg Am 1964;46:817–25. 42. Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr Surg 1979;63(3):344–9. 43. Brunelli F. Le lambeau dorso-cubital du pouce. Ann Chir Main 1993;12:105–14. 44. Tera´n P, Carnero S, Miranda R, et al. Refinements in dorsoulnar flap of the thumb: 15 cases. J Hand Surg Am 2010;35(8):1356–9. 45. Moschella F, Cordova A, Pirrello R, et al. Anatomic basis for the dorsal radial flap of the thumb: clinical applications. Surg Radiol Anat 1996;18:179. 46. Moschella F, Cordova A. Reverse homodigital dorsal radial flap of the thumb. Plast Reconstr Surg 2006; 117(3):920–6. 47. Hrabowski M, Kloeters O, Germann G. Reverse homodigital dorsoradial flap for thumb soft tissue reconstruction: surgical technique. J Hand Surg Am 2010;35(4):659–62.
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E R free F o c / o, for all data with F o 2 (F o) excluded from refinement. F Calculated by using PROCHECK. HPCNA bound to PIP-box peptides derived from the lar surface as the p21 PIP-box (see below). Like p21, p66 subunit of pol- (residues 452–466) and from FEN1 the conserved hydrophobic triumvirate of the PIP-box (residues 331–350). How to spread a wide page of PDF on two pages area in flipbook? How to read flip book on an Apple device? Why can't I share my published flip book via email in Flash directly? How to read your text to readers in flipping book? How to create audio story books for children? Please contact us at: [email protected]

Free Games

Project description

Free Python Games is an Apache2 licensed collection of free Python gamesintended for education and fun. The games are written in simple Python code anddesigned for experimentation and changes. Simplified versions of severalclassic arcade games are included.

  1. ⋙ Read Free See Pip Flap The Adventures of Otto David Milgrim Books. See Pip Flap The Adventures of Otto David Milgrim Books Download As PDF: See Pip Flap The.
  2. Pip can be downloaded and installed using command-line by going through the following steps: Download the file and store it in the same directory as python is installed. Change the current path of the directory in the command line to the path of the directory where the above file exists. Run the command given below: python
  3. Download KooBits. 4 A-PDF Page Turner. It is a software that can convert any PDF or document into PDF pages of which can be flipped. The trial version ads watermark which makes it a little annoying. However, its great for personal usage. Read more about it here. 5 Etext reader. It looks similar to PDF reading but is limited to just 2 pages.

Python is one of the top-five most popular programming languages in the worldand available for free from Pythonincludes an extensive Standard Library distributed with your installation. TheStandard Library has a module called Turtle which is a popular way to introduceprogramming to kids. Turtle was part of the original Logo programming languagedeveloped by Wally Feurzig and Seymour Papert in 1966. All of the games inFree Python Games are implemented using Python and its Turtle module.

Starting in 2012, Free Python Games began as an after school program toteach programming to inner-city youth. The goal was to have fun as much as itwas to learn. Since then the games have been improved and used in a variety ofsettings ranging from classrooms to summer day-camps.

The games run anywhere Python can be installed which includes desktop computersrunning Windows, Mac OS, or Linux and older or low-power hardware such as theRaspberry Pi. Kids across the United States in grades 6th-12th have enjoyedlearning about topics such as encryption and projectile motion through games.

Each game is entirely independent from the others and includes comments alongwith a list of exercises to work through with students. Creativity andflexibility is important. There is no right or wrong way to implement a newfeature or behavior! You never know which games students will engage with best.


“I love Free Python Games because the games are fun and they’re easy tounderstand and change. I like making my own games now.”

– Luke Martin, Student

“Free Python Games inspired and introduced a new hobby to our son. Thank you somuch for exposing him to coding. He is having so much fun!”

– Mary Lai, Parent

“Free Python Games are great because they really engage students and let themlearn at their own pace.”

– Rick Schertle, Teacher, Steindorf STEAM School

“Free Python Games combines play and learning in a flexible environment thatreduces the stress of a difficult topic like programming.”

– Brett Bymaster, Youth Pastor, The River Church Community

“Free Python Games is great for students, is highly organized and flexible,and seeks to unleash inquiry and understanding.”

– Terri Furton, Principal, Downtown College Prep


  • Fun to play!
  • Simple Python code
  • Easy to install
  • Designed for education
  • Depends only on the Python Standard Library
  • Used in hundreds of hours of classroom instruction
  • Fully Documented
  • 100% Test Coverage
  • Developed on Python 3.7
  • Tested on CPython 2.7, 3.4, 3.5, 3.6, and 3.7
  • Tested on Windows, Mac OS X, Raspbian (Raspberry Pi), and Linux
  • Tested using Travis CI and AppVeyor CI


Installing Free Python Games is simple with pip:

Free Python Games supports a command-line interface (CLI). Help for the CLI isavailable using:

The CLI supports three commands: list, copy, and show. For a list of all gamesrun:

Any of the listed games may be played by executing the Python module from thecommand-line. To reference the Python module, combine “freegames” with the nameof the game. For example, to play the “snake” game run:

Games can be modified by copying their source code. The copy command willcreate a Python file in your local directory which you can edit. For example,to copy and play the “snake” game run:

Python includes a built-in text editor named IDLE which can also execute Pythoncode. To launch the editor and make changes to the “snake” game run:

You can also access documentation in the interpreter with Python’s built-inhelp function:

Free Games


Paint – draw lines and shapes on the screen. Click to mark the start of ashape and click again to mark its end. Different shapes and colors can beselected using the keyboard.


Snake – classic arcade game. Use the arrow keys to navigate and eat thegreen food. Each time the food is consumed, the snake grows one segmentlonger. Avoid eating yourself or going out of bounds!


Pacman – classic arcade game. Use the arrow keys to navigate and eat allthe white food. Watch out for red ghosts that roam the maze.

Pdf Free Download For Windows 7


Cannon – projectile motion. Click the screen to fire your cannnonball. Thecannonball pops blue balloons in its path. Pop all the balloons before they cancross the screen.


Connect – Connect 4 game. Click a row to drop a disc. The first player toconnect four discs vertically, horizontally, or diagonally wins!


Flappy – Flappy-bird inspired game. Click the screen to flap yourwings. Watch out for black ravens as you fly across the screen.


See Pip Flap Pdf Free Download Windows 10

Memory – puzzle game of number pairs. Click a tile to reveal anumber. Match two numbers and the tiles will disappear to reveal an image.


Pong – classic arcade game. Use the keyboard to move your paddle up anddown. The first player to miss the ball loses.

Simon Says

Simon Says – classic memory puzzle game. Click the screen to start. Watchthe pattern and then click the tiles in the same order. Each time you get thesequence right the pattern gets one step longer.

Tic Tac Toe

Tic Tac Toe – classic game. Click the screen to place an X or O. Connectthree in a row and you win!


Tiles – puzzle game of sliding numbers into place. Click a tile adjacent tothe empty square to swap positions. Can you make the tiles count one to fifteenfrom left to right and bottom to top?


Tron – classic arcade game. Use the keyboard to change the direction ofyour Tron player. Avoid touching the line drawn by your opponent.


Life – Conway’s Game of Life. The classic, zero-player, cellular automationcreated in 1970 by John Conway.


Maze – move from one side to another. Inspired by A Universe in One Lineof Code with 10 PRINT. Tap the screen to trace a path from one side toanother.


Fidget – fidget spinner inspired animation. Click the screen to acceleratethe fidget spinner.

User Guide

See Pip Flap Pdf Free Download 64 Bit

For those wanting more details, this part of the documentation describescurriculum, API, and development.


Free Python Games License

Copyright 2017-2020 Grant Jenks

Licensed under the Apache License, Version 2.0 (the “License”); you may not usethis file except in compliance with the License. You may obtain a copy of theLicense at

Unless required by applicable law or agreed to in writing, software distributedunder the License is distributed on an “AS IS” BASIS, WITHOUT WARRANTIES ORCONDITIONS OF ANY KIND, either express or implied. See the License for thespecific language governing permissions and limitations under the License.

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