Repair of complete syndactyly by tissue expansion and composite grafts

Transcription

1 British Journal of Plastic Surgery (1995), The British Association of Plastic Surgeons BRITISH JOURNAL OF / PLASTIC SURGERY I Repair of complete syndactyly by tissue expansion and composite grafts N. Ishikura, T. Heshiki, T. Kimura and S. Tsukada Department o[" Plastic and Reconstructive Surgery, Kanazawa Medical University, UchhTada, Ishikawa, Japan SUMMAR Y. Repair of complete syndactyly by a combination of tissue expansion and composite grafts from the glabrous non-weight bearing areas of the foot has been performed on three syndactylies in two patients. The commissure and the lateral areas of the proximal and middle phalanges were covered with expanded skin and the separated fingertips were covered with composite grafts. Without using an ordinary skin graft, this method can provide aesthetically excellent results with good skin colour and texture. The advantages of tissue expansion in the treatment of syndactyly are that it allows local skin to be used more and reduces, if not eliminates, the need for skin grafts which can have problems such as pigmentation and unsightly scarring. The technique can give excellent cosmetic results and we have used it in various cases, including those previously treated with skin grafts? However, the skin that can be expanded is limited to the level of the middle phalanx. Therefore, it is difficult to reconstruct a complete syndactyly with only expanded skin. To cover the separated distal phalanges one must use a method of skin cover which gives good functional and aesthetic results. Pulp plasty using a composite graft from glabrous, non-weight bearing areas of the foot is one option, 2 and so we have used it in combination with tissue expansion in two cases of complete syndactyly. Case reports Case 1 The first case was a 10-month-old female with simple complete syndactyly of the right third and fourth digits. Under general anaesthesia, a 2 ml expander was inserted into the dorsal subcutaneous area between the middle and ring fingers through a 2 cm incision along the dorsal wrist crease (Fig. IA). A reservoir dome was inserted into the subcutaneous area of the distal forearm through the same incision. Beginning l week after operation, ml of saline was injected through a 27G needle once a week under topical anaesthesia with 7% lidocaine cream. A total of about 8 ml of saline was injected until the circumference of the fused digits was twice as great as that of the left middle finger (Fig. IB). The fused digits were separated 161 days after the first operation. A commissure was formed by a rectangular flap and the lateral areas extending to the middle phalanges were covered with expanded skin (Fig. IC). Z- plasties were done at two levels to prevent postoperative contractures. The area of each distal phalanx deficient in skin was covered with a composite graft from the medial side of the sole of the right foot. The postoperative course was uneventful. The scars in the expanded skin were inconspicuous, no contracture occurred, and the interdigital regions and finger pulps were good I year and 6 months after the separation operation. The result was excellent from a cosmetic point of view (Fig. 1D). Case 2 The second case was a 14-month-old female with a complex complete syndactyly of the middle and ring fingers of both hands (Fig. 2A, B). Both hands were treated at the same time. The expanders were inserted as in the first case (Fig. 2B). The bony bridges of the distal phalanges were removed at the same operation as the expander insertion. The distal phalanges were covered with adjacent soft tissue as much as possible (Fig. 2C). The skin was expanded by the expanders (Fig. 2D) and the syndactylies were separated 110 days after the first operation as in the first case (Fig. 2E, F). Commissures were formed by rectangular flaps and the lateral areas extending to the middle phalanges were covered with expanded skin. Two Z-plasties were performed at the lateral areas of the proximal and middle phalanges as in case 1. The stumps of the bony bridges had been adequately covered with soft tissues and the areas were covered with composite grafts from the medial side of the great toe and the medial side of the sole of the right foot (Fig. 2G). The interdigital appearance and the form of the distal phalanges were fine and the scars were inconspicuous I year after the syndactyly release (Fig. 2H, I). Sufficient soft tissue was present above the stumps of the synostosis of the distal phalanges, as shown on the X-ray (Fig. 2J, K). Discussion The number of reports :~-~ concerning tissue expansion in the hand and finger is small compared to similar reports for head or trunk surgery and few describe its use for complete syndactyly).~ The advantage of tissue expansion in repair of incomplete syndactyly is that the reconstruction uses only local skin. Therefore, the method is free from the aesthetic problems of skin grafts, such as pigmentation of the grafts and substantial scarring at the graft margins. Another advantage is that the postoperative scars are inconspicuous because the suture lines on the digits are in the midlateral region. Midlateral scars also reduce the risk of postoperative contracture. Aesthetically good 396

2 Tissue expansion and composite grafts for complete syndactyly 397 Fig. 1 Figure l--case I. (A) Preoperative complete syndactyly. The expander and reservoir dome were inserted through a small incision along the dorsal wrist crease. (B) Expansion completed. (C) Before composite grafting. Syndactyly separated, with two Z-plasties on each finger, and the commissure formed with a rectangular flap. (D) Appearance I year and 6 months after separation of syndactyly. results obtained by tissue expansion can relieve the anxiety of the patients and their families who may fear that scars and skin grafts indicate congenital abnormalities. In addition to tissue expansion, skin stretching using a local epidermoplasty7or a pincer 8have been reported as skin expansion methods for syndactyly. Epidermoplasty involves the distraction of interdigital tissue by devices fixed to the syndactyly fingers with pins penetrating the metacarpal and phalangeal bones. The apparatus is strong enough to allow the skin to be widely expanded. The risk of pin tract infection, however, restricts the use of the hand while the apparatus is in place. The pincer technique uses a Ushaped metal apparatus which, when applied to the fused interdigital region, gradually expands the skin of the interdigital space by compressing the skin from both the dorsal and volar aspect. Although this method is non-invasive and easy to control, the disadvantage is that it cannot be used in cases of synostosis syndactyly. Another disadvantage is that it cannot sufficiently expand the skin around the commissure. Therefore, the reconstructed commissure may be tight from lack of skin. The disadvantages of tissue expansion for syndactyly release include the need for two operations, the risk of expander exposure or rupture, repeated injections and the length of time to complete treatment. Although Van Beek and Adson had no problems with reconstruction, they acknowledged that there was expander leakage. 4 We have recently compared tissue expansion of the finger and hand with that of the arm

3 398 British Journal of Plastic Surgery Fig. 2 Figure 2--For legend see facing page. and f o r e a r m ) In that series, 16 tissue expansions were done in conjunction with excision of naevi or scars on the dorsal aspect of the hands or fingers in 15 patients, 6 expansions were done to correct syndactyly in 6 patients, and 68 expansions were done in conjunction with excision of naevi or scars on the arms or forearms in 47 patients. Major complications which inhibited expansion were observed in 5 (22.7 %) expansions in the hand or finger group, including one syndactyly repair. These complications were observed in 9 (13.2%) expansions in the arm or forearm group. There were more severe complications in the finger

4 Tissue expansion and composite grafts for complete syndactyly 399 Fig. 2 (cont.) Figure 2--Case 2. (A, B) Preoperative left and right complex complete syndactyly. Expander site marked on right. (C) The bony bridges of the distal phalanges were removed at the same time as expander insertion. Bony stumps covered with adjacent soft tissue. Separated pulps not grafted and allowed to fuse. (D) Expansion completed. (E) Design of incisions. (F) Be[ore composite grafting. Syndactyly separated. (G) Donor sites of the composite grafts. (H, I) Results 1 year and 8 months after separation of syndactyly of both hands. (J) Preoperative X-ray of left hand. (K) Postoperative X-ray of left hand.

5 400 British Journal of Plastic Surgery and hand group, although the difference was not statistically significant. (It should be noted that not all of our syndactyly cases are treated with tissue expansion; other cases have more conventional treatments). The skin of the fingers can only be expanded up to the level of the middle phalanx, and the distal phalanx cannot be covered with expanded skin. Therefore, careful pulp reconstruction is essential in the complete syndactyly when cosmetic improvement is of high priority, as in the cases reported in this paper. There are various reported methods of reconstructing complex complete syndactyly with synostosis. The pulp colour is poor in distant flap methods, such as those using abdominal flaps) Although the thenar flap usually has adequate volume and good colour, its disadvantages are the limitation of the flap volume and the scar on the palm. l" Furthermore, when tissue expansion is combined with a thenar flap, a three-stage procedure is necessary and this increases the time needed to complete separation of the syndactyly. Pulp plasty with composite grafting, 2 which we used, is superior to the methods described above because the surgical procedure is relatively easy to carry out, and the colour and form of the reconstructed pulp are quite satisfactory, as reported by Sommerkamp et al." An inconspicuous scar around graft edges is an additional advantage. The synostosis is excised and grafting is carried out in one stage in the method of Sommerkamp, on the assumption that revascularisation of the composite graft from the graft margins is more important than that from the graft bed. However, there still remains a possibility of bone exposure secondary to graft necrosis although Sommerkamp et al. did not experience such cases. Our method does not have this danger because the synostosis is separated during the first operation and the skin grafts are applied at the second operation. Tissue expansion in the fingers is not difficult for plastic surgeons accustomed to using tissue expanders and the perioperative care is essentially similar to that required in other tissue expansion cases. Composite grafting is also a standard technique in plastic surgery. Although tissue expansion is not without its compli- cations, the combination of tissue expansion and composite grafts can give good results in complete syndactyly. References I. lshikura N, Tsukada S. Reconstruction of syndactyly using tissue expander. J Jpn Soc Surg Hand 1992: 9: Sommerkamp TG. Ezaki M, Carter PR, Hentz VR. The pulp plasty: a composite graft for complete syndactyly fingertip separations. J Hand Surg 1992; 17A: Morgan RF, Edgerton MT. Tissue expansion in reconstructive hand surgery: case report. J Hand Surg 1985; 10A: Van Beek AL, Adson MH. Tissue expansion in the upper extremity. Clin Plast Surg 1987: 14: 535~ Aubert J-P, Paulhe P, Magalon G. Forum: I'expansion tissulaire. L'expansion cutan~e au membre sup6rieur. Ann Chit Plast Esther 1993: 38: Coombs C J, Mutimer KL. Tissue expansion for the treatment of complete syndactyly of the first web. J Hand Surg 1994: 19A : , 7. Gudushat, ri OH. Tvaliashvili LA. Local epidermoplasty for syndactyly, lnt Orthop 1991: 15: Ogawa Y, Kasai K, Doi H, Takeuchi E. The preoperative use of extra-tissue expander for syndactyly. Ann Plast Surg 1989: 23 : Ishikura N, Kawakami S. Sakurai T. Ueno T. Tsukada S. Tissue expansion in the dorsal aspect of the hands and fingers. J Jpn Soc Surg Hand 1994; 10: Thomson HG. Isolated acrosyndactyly: avoiding post-operative contracture. Br J Plast Surg 1971 : 24: I. Sugihara T, Ohura T, Umeda T. Surgical method for treatment of syndactyly with osseous fusion of the distal phalanges, Plast Reconstr Surg 1991 ; 87: van der Biezen J J, Bloem J JAM. The double opposing palmar flaps in complex syndactyly. J Hand Surg 1992: 17A; The Authors Naotaka ishikura, MD, Associate Professor Heshiki Takaya, MD, Associate Professor Tetsuji Kimura, MD, Associate Professor Sadao Tsukada, MD, Professor and Chief Department of Plastic and Reconstructive Surgery, Kanazawa Medical University, Uchinada, Ishikawa, , Japan. Correspondence to Naotaka lshikura, MD. Paper received 30 September 1994, Paper accepted 7 March after revision.