Reconstruction of the Severely Deformed Hand Using a Thinned Anterolateral Thigh Flap

Severely deformed hands secondary to trauma represent a formidable challenge to the reconstructive surgeon. The pathology in these cases extends not only to all anatomic features but also impacts on the intricacies of hand function as well. This necessitates both replacement of severely damaged tissue and restructuring of all other tissue of reasonable quality. The aims of such reconstruction is not to achieve a normal functioning hand, but rather to maximize the potential of remaining tissues in the hand and thereby improve hand function.

The authors reported three patients who sustained severe trauma to the hand following burns (2) or snake bite (1). All had completely deformed, non-functional hands. The skin quality precluded operative management of deeper structures without providing adequate soft-tissue cover. The thinned anterolateral thigh perforator flap was used to provide large, thin, pliable skin to cover bone and tendon reconstruction. All patients required a virtual “dismantle” of the hand structures. Bones were osteotomized and K-wired into functional positions, while joints underwent capsulotomies before being fixed in functional positions. All fibrous tissue was excised. Tendons were freed and lengthening procedures were performed, if required.

Flap survival was 100%, with tip necrosis in a single case that required debridement and skin grafting. All patients experienced an improvement in functional position and therefore use of the hand. Compliance with physiotherapy and rehabilitation proved to be difficult, particularly for the child.

The thinned anterolateral thigh perforator flap provides reliable, thin, pliable, good cosmetic quality skin cover for extensive operations to the hands. Functional improvement in severely deformed hand is possible to achieve. A restructuring of all the affected components of the hand is required, together with a motivated patient willing to comply with postoperative rehabilitation.

Stiff, virtually nonfunctional deformed hands require an extensive release of all the structural scarring. Reliable soft tissue provides cover for deep structure reconstruction. The cases reported failed to live up to the functional expectations. Patient, surgeon, surgical methods, and causative factors may be to blame for the outcomes.