Comments on Foucher ’ s flap

Foucher’s flap is one of the ideal flaps to cover traumatic defect of the pulp and dorsum of the thumb. Though ideally described for thumb defects with some shortening, it has been proved beyond doubt that it can also be requisitioned to resurface thumb defects without shortening. In the latter indication, it is necessary to harvest the flap up to the dorsum of the PIP joint. However, the distal 1/3 of such a first dorsal metacarpal artery (FDMA) flap becomes a random part of the axial artery flap and hence carries some risk of marginal necrosis. It is surmised that the survival of such a flap is ultimately determined by the relative length of index and thumb.

Foucher's flap is one of the ideal flaps to cover traumatic defect of the pulp and dorsum of the thumb.Though ideally described for thumb defects with some shortening, it has been proved beyond doubt that it can also be requisitioned to resurface thumb defects without shortening.In the latter indication, it is necessary to harvest the flap up to the dorsum of the PIP joint.However, the distal 1/3 of such a first dorsal metacarpal artery (FDMA) flap becomes a random part of the axial artery flap and hence carries some risk of marginal necrosis.It is surmised that the survival of such a flap is ultimately determined by the relative length of index and thumb.
Normally, the tip of the adducted thumb roughly reaches upto 70% of the length of the proximal phalanx of the index finger (32% of the index finger length beyond MP joint); [1,2] such thumbs being ideally suited for conventional FDMA flaps.Individuals with thumb length more than 70% of the proximal phalanx of index finger are the ones likely to need an extended FDMA flap i.e. wherein flap is harvested beyond the PIP joint.One more ambiguous parameter of this flap is the amount of blood supply which comes alongwith the superficial branch of radial nerve.We know that every superficial nerve is accompanied by an artery and vein of its own supplying the skin and integument.Being a neuro-sensory flap, it is an ideal flap for pulp of thumb which restores an acceptable level of sensation, however, it may not match Littler's neuro-vascular island flap because of poorer cortical reorientation.
Kulkarni et al. [3] need to be congratulated for describing one more indication for FDMA flap.Though small traumatic defects on the radial side of the palm are rare, when encountered, this flap is really handy when compared to the alternatives.These flaps are also used in reconstructive surgeries following post burn scar contracture release, [4] syndactyly release, and partial loss of reimplanted thumb. [5]Donor-defect following this flap usually needs split skin graft or full-thickness skin graft.These usually do not give rise to functional deficit.Cosmesis, however, will be a consideration.This can be avoided if one harvests only adipofascial flap to cover the thumb defect as described by Vishwa Prakash. [6]One more modification suggested is the usage of this flap as distally-based flap for coverage of web and ulnar aspect of the dorsum of the hand and distal dorsum of the index.The size of the FDMA flap at widest portion could be 1.2 to 1.5mm which for some super micro surgeons may be an option for a small free neuro-vascular flap for other digits.
The article gives a lucid description and illustration of the use of the FDMA flap for thumb defects.However, I feel it may be risky to perform this flap without loop magnification, under local anaesthesia and without proper tourniquet.The chances of survival can be further enhanced by including more than one dorsal vein as described by El Khatib, [7] who has harvested the flap from not only the dorsum of proximal but also from the middle phalanx of the index finger extending into what he calls the "dynamic territory" or the random part of the flap.He argues in favour of including the dorsal veins to prevent venous congestion in the flap.His modification enables the surgeon to cover any defect on the thumb of normal length.The same philosophy has been further propagated by Gebhard et al. [8] in his case report wherein he has harvested the flap up to the DIP joint so as to wrap around the proximal phalanx of a traumatized but shortened thumb which was found unsuitable for reimplantation.If one wants to play safe and use this extended FDMA flap, it may not be a bad idea to delay this distal dynamic territory/random part of the flap in the first stage and raise the whole of the extended FDMA flap in the second stage.
The arterial pedicle of the flap, which is the ulnar-most of the three branches, coming from radial artery just before dipping in between the two heads of first dorsal interossei is almost constant and is amenable to be pivoted as proximally as the medial border of the EPL in line with the radial border of the second metacarpal.This unique arterial supply gives the surgeon a wide arc of rotation with the pedicle length of 6-7 cm in adults; as in the present report.

Use of Thomas splint in salvaging free flaps of the lower limb in violent postoperative patients
Sir, Postoperative care like immobilization, monitoring, local warmth, and limb elevation of patients is very important for the first few days after free flaps until the anastomoses becomes stable. [1] found that most of our chronic alcoholic patients, who underwent free flap surgery for posttraumatic soft tissue loss, became very irritable, violent, and uncontrollable.They lost their orientation and did not obey any verbal instructions.This could be most commonly attributed to alcohol withdrawl syndrome [2] or could be the effect of head injury or general anesthesia.
Postoperatively, these violent patients are restless and move their limbs in bed which can lead to microvascular flap failure. [3]Their limbs can not be tied because of the operative site and fear of compression of vascular supply.We have found that the innovative use of the Thomas splint to immobilize the limbs of such patients, gives good stability even when these patients continued to be violent and restless.
We use the Thomas splint on the operated limb to immobilize the knee joint [4] and secure the Thomas splint tight enough to the thigh and the knee as shown in Figure 1, so that patient can not move his leg.We keep the Thomas splint until the patient is co-operative and well oriented.
Figure 2 shows a below-knee posterior POP slab given for flap and fracture immobilization and to secure the skin graft in position with de-rotation and the use of a small metal plate.We can tie this plate tightly with the Thomas splint to immobilize leg.The below-knee slab is not enough to immobilize violent patient as they start to lift their leg, bend the knee, and flex their thigh.With the Thomas splint firmly in place, we were able to immobilize the entire lower limb without any direct tight pressure over the flap; and secure the slab with the splint.Thus, we have salvaged our free flaps in more than ten violent patients with the Thomas splint.It is very difficult to control violent patients with sedatives or immobilizing them with above-knee POP slabs, since they usually break free.To restrict and decrease the patients' direct forces over the leg or the operated area we have used the Thomas splint firmly in place to immobilize the proximal two joints, the hip and the knee.We can strap or tie as many places to the Thomas splint frame on the side and

Figure 2 :
Figure 2: Patient's limb with free L.D. Muscle flap immobilized with Thomas splint with below knee de-rotation posterior POP slab

Figure 1 :
Figure 1: Thomas splint frame with bandage strapping