Foucher Flap to reconstruct volar thumb soft tissue defect
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Thumb contributes to almost half of the hand function. Reconstruction of thumb defects are therefore of a high priority and complex reconstructions are often undertaken to maintain the length and sensations. Pulp of the thumb is a specialised area where the texture of skin and sensations are important. Where possible, local flaps from the thumb tissue is used to reconstruct pulp defects. However when the defects are more substantial, reconstructions become more challenging.
Pulp loss can results from trauma, infection or resection of tumours. Traumatic loss can involve the skin alone, skin and deeper soft tissues or a composite loss involving soft tissues and bone.
There are several reconstructive options for a thumb pulp loss involving the whole of the thumb distal phalanx. These range from skin grafting, cross finger flap from the index finger dorsum, Foucher flap(flap taken from the dorsum of the index finger metacarpal based on the first dorsal metacarpal artery or a free tissue transfer from the great toe pulp based on the dorsalis pedis artery. The reconstructive method is often chosen based on the patient’s functional demands and co-morbidities.
This case illustrates reconstruction of the thumb defect using a Foucher flap. Foucher flap is an eponymous flap based on the first dorsal metacarpal artery and was first described by the French Hand surgeon Guy Foucher.
The radial artery enters the palm between the two heads of the first dorsal interosseus muscle. At this point it gives off a branch called the first dorsal metacarpal artery which divides into smaller branches and supplies a fascia over the first dorsal interosseus muscle and the skin over the dorsum of the index finger. The skin overlying the index finger proximal phalanx can therefore be harvested based on this arterial plexus if the fascia, the overlying superficial radial nerve branches and the superficial veins are harvested. This provides a good quality skin over the thumb which is sensate, though the sensations are referred to the index finger till the brain re-learns it. The donor defect over the index finger will need reconstruction and this is done using a full thickness skin graft taken from a suitable donor site.
Author:Mr Rajive Jose FRCS
Institution: The Queen Elizabeth Hospital, Birmingham, UK.
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