PMC8497149_01
Intraoperative images showing the first stage of the Brunelli flap. Intraoperative image showing (a) marking of the Brunelli flap and the dorsoulnar artery perioperatively, as well as the palmar connection between the dorsoulnar artery and the palmar ulnar digital artery at the level of the interphalangeal joint of the thumb. (b) The skin paddle is incised deep till the paratenon of the extensor pollicis longus on its radial edge is reached and deep to the fascia covering the first dorsal interosseous muscle on its ulnar edge. (c) Rotation of the flap just proximal to the interphalangeal joint, followed by insertion and suturing in place.
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fig1
The flap's axis was between the ulnar midlateral line and the dorsal middle line of the thumb's dorsum aspect, where the dorsoulnar artery was identified roughly one centimeter ulnar to the thumb's dorsal middle line (Figure 1(a)). The flap was outlined just proximal to the metacarpophalangeal joint of the thumb; the dissection started from proximal to distal; on the radial edge, the skin paddle was incised till the paratenon of the extensor pollicis longus was encountered, in which it was kept intact along with the tendon; and on the ulnar edge, it was incised deep to the fascia covering the first dorsal interosseous muscle (Figure 1(b)). The flap was rotated, inserted, and sutured into place while keeping the pivot point at least 5 mm proximal to the interphalangeal joint crease (Figure 1(c)).
Intraoperative image showing the second and final stage of the Brunelli flap. An intraoperative image showing (a) donor defect with the marking of the Hatchet flap. (b) Rotation of the (Hatchet) flap. (c) Closing the donor site through the flap in the first webspace.
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fig2
Finally, to close the donor site, a rotational advancement (Hatchet) flap was designed in the first webspace to avoid the need for skin grafts (Figures 2(a)-2(c)).
Follow-up images 2.5 years from operation. Follow-up image after 2.5 years showing the dorsal thumb webspace with complete healing of the defect and an acceptable flap appearance.
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fig3
We observed no evidence of local or distant recurrences with a good functional outcome after 2.5 years of follow-up (Figure 3).
PMC8497149_02
Intraoperative image showing V-Y plasty coverage of the defect. Intraoperative image showing (a) excision of the nail bed including both the periosteum and the eponychium up to the base of the nail fold. (b, c) A surprising degree of V-Y flap advancement resulting in coverage of the defect.
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fig4
Under awake local anesthesia, after planning our flap, radical excision was done of the nail bed including both the periosteum and the eponychium as it was detached along its entire width up to the base of the nail fold (Figure 4(a)), proximal nail fold was elevated and advanced as a flap to be combined with V-Y plasty to aid in coverage, and a high-speed burr was utilized to shave the dorsal bone as well as to ablate the germinal matrix to prevent any future growth of his nail with caution not to injure the insertion of the extensor tendon. Interestingly, there was a lot of flap advancement, which was sutured to the advanced proximal skin fold flap (Figures 4(b) and 4(c)).
Follow-up images 2 years from operation. Follow-up image 2 years postoperative showing a dorsal and lateral view of the ring finger with an acceptable flap appearance.
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fig5
He is kept on regular follow-up for 2 years, and his latest imaging showed no disease recurrence or metastasis with intact functionality (Figure 5).