the hands in apert syndrome often demonstrate so - called spoon hand or mitten hand deformity , including syndactyly , symphalangism and soft - tissue anomalies . consideration of blood flow to the digits of each patient , not only arterial supply but also venous drainage , is very important in the division surgery . an apert syndrome infant with upton 's type ii hands underwent a series of surgeries . at the age of 14 months , separation between the middle and ring fingers was done . under general anaesthesia , just prior to the operation , infrared venography was done with genial - viewer ( genial light co. ltd . , hamamatsu , japan ) [ figure 1 ] and recorded in a laptop computer . full thickness skin graft was taken from the lower abdomen and replanted to cover the defect . separation of index - middle and ring - little fingers was performed 5 months after [ figure 2 ] . genial - viewer is consisted of measuring module ( front ) , power supply unit ( back right ) and a laptop computer for data processing and storage infrared venography through finger splitting surgeries for an apert patient . volar venous arch placed distally to the metacarpophalangeal joint , where incision had to be performed to divide fingers sufficiently . ( a , b ) snap shots of palmar side venogram , immediately before the separation surgery . ( c , d ) designs for the first separation surgery , ( e and f ) immediately after the first separation surgery . ( g , h ) snap shots of venogram , immediately before the second separation surgery . ( i , j ) fifteen months after the second separation surgery infrared venography was able to visualise superficial veins , which could not be seen with bare eyes . real - time venogram was able to be seen through display of a laptop computer . the images were captured and recorded . furthermore , video could be recorded . at the time before the separation procedures , vein of digits the arch placed distally to the metacarpophalangeal joint , where incision has to be done to divide fingers sufficiently . longitudinal vein of palm was observed very thin . on the dorsal aspect , for his left hand , veins could be observed on the radial margin of index , radial side of middle and ulnar margin of little finger . no proper dorsal vein of the ring finger could be identified at that moment . on the dorsum of his right hand , a vein runs on the index finger supplying branches to the middle finger . the other runs slightly radial side of ring - little inter - digital space , which seemed likely to be damaged by separation procedure [ figure 3 ] . at the time of immediately before secondary splitting surgery , palmar venous arch revealed to be severed by the first surgery [ figure 2 ] . venogram of the apert patient 's hands , based on infrared video and snap shots . there were palmar venous arches on both hands , which placed distally to the metacarpophalangeal joint infrared venography was able to visualise superficial veins , which could not be seen with bare eyes . real - time venogram was able to be seen through display of a laptop computer . the images were captured and recorded . furthermore , video could be recorded . at the time before the separation procedures , vein of digits the arch placed distally to the metacarpophalangeal joint , where incision has to be done to divide fingers sufficiently . longitudinal vein of palm was observed very thin . on the dorsal aspect , for his left hand , veins could be observed on the radial margin of index , radial side of middle and ulnar margin of little finger . no proper dorsal vein of the ring finger could be identified at that moment . on the dorsum of his right hand , a vein runs on the index finger supplying branches to the middle finger . the other runs slightly radial side of ring - little inter - digital space , which seemed likely to be damaged by separation procedure [ figure 3 ] . at the time of immediately before secondary splitting surgery , palmar venous arch revealed to be severed by the first surgery [ figure 2 ] . venogram of the apert patient 's hands , based on infrared video and snap shots . there were palmar venous arches on both hands , which placed distally to the metacarpophalangeal joint upton reported , based on his operative records , that a dominant deep palmar arch was present usually abnormally far into webspaces before digital bifurcation was demonstrated . with three - dimensional computed tomography ( ct ) and magnetic resonance imaging , holten et al . reported that common digital arteries tended to bifurcate after the metacarpophalyngeal joint . only writing could be found was a report with digital video angiography , stating  normal venous return  . this is the first report of venous abnormality in hands of an apert syndrome patient . light transmission through tissues is greatest within the red and near infrared wavelength . at near infra - red band , haemoglobin has lower absorbance than at visible band , though it is relatively high in comparison with other protein in the tissue . therefore , absorbance contrast between vessels and surrounding tissue can be used to visualise vascular pattern . infrared venogram of an author 's hand nowadays , infrared venography of finger or palm has been widely used for personal identification in automated teller machines . based on the same theory , genial - viewer was designed to visualise vasculature beneath skin . it is consisted of measuring module , power supply unit and lap - top computer for data processing and storage . measuring module is composed of infrared submission table and camera , connected with an arm . it is light and handy . it can be used in the operative field only have to be wrapped with an ordinal sterile plastic bag . as infrared ray has strong diffusional scattering character through tissue , it can not penetrate thick part of the body . it is suitable to observe superficial veins . in finger replantation surgery , it is useful to find vessels to anastomose . x - ray angiography , including three - dimensional ct , offers extensive information , but requires complicated sequence and time . there are a few infra - red imaging systems , utilising reflected infrared light while genial - viewer employs transmitted light . for visualising blood vessels of hand , early surgical intervention is recommended for hand in apert syndrome , to minimise progressive growth deformity and influence on patients psychological development . though , splitting all fingers by one stage , performing surgery on both sides of the same digit should be avoided . by means of ultra - red venography , abnormal venous distribution was detected . though , it was confirmed that it is safer to perform staged separation for apert hand , not only because of the arterial abnormality , but also the abnormal venous distribution .
as well as craniofacial synostosis , complex syndactyly of hands is a distinctive feature of apert syndrome . 
 consideration of blood flow to the digits is very important in separation surgery . 
 several reports offer information about arterial distribution in apert 's hands . 
 though , venous pattern has not been well discussed . 
 infrared venography offers a real - time image with minimal invasion . 
 an apert syndrome patient underwent a series of finger splitting surgeries . 
 infrared venography was carried out to assess veins . 
 there was a palmar venous arch , placing distally to the metacarpophalangeal joint . 
 the arch had to be cut to divide fused fingers sufficiently . as well as arterial abnormality , venous uniqueness 
 should be noted in apert syndactyly surgeries . 
 infrared venography , which can be carried out easily , offers good information that surgeon require .