The Anatomy Basic And Clinical Applications On The Dorsal Perforator Flap Of The Volar Artery In The First Web

Objective:1.To investigate the morphological characteristics of the volar artery dorsal perforating vessel in the first web and provide anatomical basis for the design of the dorsal perforation flap of volar artery in the first web.2.To investigate the clinical features of the volar artery dorsal perforating flap of the first web and provide the clinical evidence for the promotion of this flap.Method:1.Microscopic anatomy: Twenty-one specimens of adult cadaveric upper limbs were injected with red latex via arterial cannula,and the origin,course,branch and anastomosis of the dorsal perforating vessel of the first web were observed by vascular perfusion,macro-micro-anatomy and mimic surgery and the anatomical images were taken by a digital camera.The data were collected and analyzed.2.Clinical application: Seven patients who received surgical restoration of skin and soft-tissue defects on the thumb,the index finger and the thenar eminence by the volar artery dorsal perforating flap of the first web between January 2015 and January 2017 were included.The clinical images were taken by a digital camera and the patients were followed up and assessed after theoperation.Results:1.The blood supply of the first web: The blood supply of the dorsal first web arises from multiple sources,which is provided by the branches of the radial palmar proper artery of the index finger,the ulnar palmar proper artery of the thumb and the first dorsal metacarpal artery.(1)The radial palmar proper artery of the index finger: After arising from different origins,this artery proceeds through the space between the first dorsal interosseous muscle and the transverse head of the adductor pollicis,distributes in the radial margin,and then sends off 2~3 perforators to the dorsum at the unlar margin of the first web.The perforators are(0.6±0.4)mm in outer diameter and(1.2±0.2)cm in length,and they anastomosed with the intermediate branch of the first dorsal metacarpal artery constantly to supply the dorsal skin of the first web.(2)The ulnar palmar proper artery of the thumb: After arising from different origins,this artery runs along the ulnar side of the tendinous sheath of flexor pollicis longus,crosses over the end of the adductor pollicis and the sesamoid on the ulnar side to the finger tip,and finally distributes at the thumb palmar ulnar margin and sends off 1~2 perforators to the dorsum at the radial margin of the first web.The perforators are(0.7±0.3)mm in outer diameter,and(1.1±0.4)cm in length,and they anastomosed with the intermediate branch of the first dorsal metacarpal artery constantly to supply the dorsal skin of the first web.(3)The First Dorsal Metacarpal Artery: The first dorsal metacarpal artery originates from radial artery constantly,travels along the first interosseous spatium and gives out three terminal branches as follows: the radial branch,the ulnar branch,and the intermediate branch.The radial branch passes along the dorsum of the first metacarpal bone and continues as the ulnar dorsal digital artery.The ulnar branch passes along the dorsal radial side of the second metacarpal bone and continues as the radial dorsal digital artery.The intermediate branch runs along the surface of the first dorsal interosseous muscle to the interval of the first finger web,and then anastomosed with the two dorsal perforators mentioned above.2.Clinical applications: Seven cases with skin and soft-tissue defects on the thumb,the index finger and the thenar eminence were treated with the volar artery dorsal perforating flap of the first web.All the flaps survived after operation,however the flap appeared blackening and clumsy on a small part of the edge in one case of dorsal thumb defect.After the timely drainage,detumescence,anti-inflammation,the swelling subsided and the wound healing gradually.After a follow-up of 12 months,the flap survived uneventfully with a fine appearance and two-point discrimination and without dysfunction or contracture of the thumb web and so on.Conclusion:1.Although the perforating branches of the radial palmar proper artery of the index finger,the ulnar palmar proper artery of the thumb aretiny,they had such advantages as high occurrence rate,constant perforating position and abundant anastomosis with the first dorsal metacarpal artery branches.The flap could be designed with the radial palmar proper artery perforator of the index finger or the ulnar palmar proper artery perforator of the thumb as its pedicleto form a dorsal cross-region flap of the first web which could be transferred to repair the soft tissue defects in the thumb,and the index finger and the thenar.2.This flap is adjacent in position and similar in texture to the recipient site,therefore,the appearance,function and sense would recover well after the restoration.It would not injury the main vessel of the donor site to ensure the blood supply of the hand,and the learning and performance of this surgical technique are simple to carry out in primary hospitals.