The two presented cases are difficult cases, and do not thors that primary first web and pulp flaps of the toes frequently occur, not even in a large hand trauma unit. are not possible directly, because the defect is too large The authors have chosen in these cases for debride- and the risk of losing the flap is too high. ment, followed by coverage with a pedicled distant flap The authors have established that innervated (partial) (from the abdomen). Later on two separate free vascular- toe flaps can demonstrate a good sensibility with 2 point ised first web and toe pulp flaps were used to reconstruct discrimination up to 6 mm, although I would urge to use the pulp of the remaining fingers' ends. Both patients the filament test in these cases, as this test is more objec- have good end results for which the authors should be tive. Sensibility in toe transfers has been reported to be gratulated. One case was presented three days after injury even better than on the donor site. The donor site of the with compartment injury. The other could be immediately dorsum of the foot and of the first web and pulp can re- treated in their own hospital. So, the latter case is the one main a problem for which I do not have an answer as yet. which can be discussed better. In conclusion debridement, even in these cases, can be First of all it is stated that debridement can not be per- completed in one stage. A temporal fascia free flap with formed enough initially. Although it can be very difficult, skin grafts in a very early stage can be an alternative to I still think it is possible. Debridement can also be per- a pedicled groin (or abdomen) flap. The authors have formed in the first three days in two sessions, after which demonstrated good results, with toe pulp and 1st web a more definite cover can be planned. We have also used flaps, which to my mind is the best method of reconstruc- the groin flap (or abdomen) for coverage in such difficult tion in these particular cases. cases, but nearly always directly after initial debridement. S.E.R. Hovius However, I do feel coverage, for instance with a temporal Department of Plastic and Reconstructive Surgery fascia flap, is possible in the first days, and should over- University Hospital Rotterdam, come the often seen stiffer joints following distant pedi- Dr. Molewaterplein 40, NL-3015 GD Rotterdam, cled flaps. In these particular cases I agree with the au- The Netherlands
European Journal of Plastic Surgery – Springer Journals
Published: May 17, 1999
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