Dorsal Hand Coverage with Free Serratus Fascia Flap

Degloving injuries of the dorsal hand present unique challenges in reconstruction, primarily due to the delicate extensor tendons and the need for thin, pliable, adhesion-free replacement tissue.  Function and cosmetics are both important in the dorsal hand.  Fascial flaps have proven to be useful in meeting the challenges of providing thin, well-vascularized, supple tissue without excessive bulk.  These authors report on the use of serratus anterior fascial free flaps in reconstructing three dorsal hand defects with extensor tendon exposure or destruction requiring graft reconstruction.  The flap and technique for elevation are concisely described, emphasizing the reliability of the thoracodorsal blood supply and the importance of preserving the long thoracic nerve to prevent scapular winging.  The thin fascial flaps were skin grafted primarily with split-thickness grafts.  No formal anticoagulation was used, the patients receiving only low-dose aspirin for two weeks.  Complications included hematomas in two patients, requiring operative drainage.  Two-stage tendon reconstruction was undertaken in all of the patients for at least some of the extensor tendons.  No flap losses were reported after the primary or secondary procedures.  All patients were reported to have regained acceptable extensor function, with varying degrees of MCP joint stiffness and stricture, and good cosmetic results.  No donor site complications or morbidity were reported.

This paper illustrates the effective use of the serratus anterior fascial free flap in dorsal hand coverage.  The flap is effective for providing reliable, thin, pliable tissue of very large dimensions (up to 20 x 30 cm).  Harvest can be done with the patient supine, and morbidity is limited to a well-concealed cutaneous scar at the axillary donor site.  This is preferable to the unsightly and often unacceptable donor scars with use of the temporoparietal and dorsalis pedis fascial flaps.  The use of the thoracodorsal arterial source vessels ensures reliability of the vascular supply. 
 

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