Hi, good evening everybody. Thanks for joining us tonight for the webinar on non-microsurgical reconstruction in the hand and upper extremity. My name is Harvey Chin from University of Florida and I'll be moderating this webinar. So I'd like to start with some housekeeping issues. Please mute your audio during the presentations. The webinar will be recorded and emailed to all registrants. Please ask questions. If you have questions, please enter in the Q&A section in the chat and the faculty will try our best to answer your questions. In case of technical difficulties, please contact the ASSH and please remember to claim your CME and this can be available through the ASSH website. So I hope and all of us hope that after attending tonight's webinar, you have all the tools you need to really cover any hole in the hand and upper extremity without the use of the microscope. We have an all-star faculty lineup tonight. Everybody is an expert in flaps and reconstructive microsurgery. We changed the order a little bit because Dr. Helen has to go and do a case. She's on call. So Dr. Huizhou will start with talking about radial forearm flap and flaps for elbow coverage. Next, we have Suheil Mittani from Duke who will be talking about how to reconstruct thumb wounds. After that, we have Dr. Ryan Katz who will be talking about how to cover finger wounds. I will talk a little bit about the posterior interosseous artery flap, propeller flaps and functional reconstruction applications in the hand and Dr. Sabapathy will talk about groin and abdominal flaps. And finally, we'll end with a little Q&A in case there are any questions from any of the audience. So without further ado, I'd like to invite Dr. Huizhou to start us off with her talk. Thank you so much for having me here. And we will be discussing here elbow coverage and upper extremity coverage using a pedicle flap such as a radial forearm and latissimus flap. I have no relevant disclosures. I find that I always just start with a case, you know, what we get faced with. So I have a woman with a GSW AK47 to the left forearm. This is her x-rays on initial presentation with the both bones forearm fracture segmental and then this is her soft tissue defect. It was just on the dorsal aspect. The bones were then plated and fixated in such a manner and we required multiple debridements to sort of debride the bits of bone and as well as bullet fragments. So after several debridements and ensuring that cultures are negative, we temporized, you can see here, the tubing with a vac dressing. But ultimately, she basically had exposed hardware along with tendons that needed reconstructing. And so this is certainly not something that can be skin grafted and there was a large defect. So I'd like to show this photo because oftentimes, even though I pose for microsurgical cases, I get this as a microscope with no eyepieces. So what do we do for this wound when there's no microscope? The pedicle radial forearm flap, I find to be a very reliable flap. It's very reliable in that its anatomic location is ideally found. And so you can take most commonly skin and fascia, although you could take tendon and even a bit of radius bone. The innervation, if you want it to be sensate, you can include the dorsal radiosensory nerve. The artery is obviously the radial artery and its perforators and then the vena comitantes. You can also include cephalic vein if you'd like further outflow drainage and any subcutaneous vein that run under the flap. The pedicle length basically is as long as the forearm. You would just have to further dissect to free up the artery so that you can make your arc of rotation. There we go. The preoperative considerations for this flap for me, I tend to still test for an Allen's test because that way I know if I need to plan for a vein reconstruction of the artery after I harvest the flap, such as a reverse saphenous vein graft. Any prior arterial lines if someone's very sick and they've been in the ICU for a bit prior to their wound. Even some IVs in case it's the cephalic vein that's injured and that's your dominant draining vein. And then lastly, you've got to consider the pedicle design. If you're trying to cover a proximal wound of the forearm and or elbow, you want to design the flap traditionally or distal flap. And for a hand or wrist wound, which is also very useful, you would design a more proximal flap or the reverse radial forearm flap. And I keep hitting the wrong area on the button. Here is the harvest for a distally base or traditional radial forearm flap. The radial artery is identified between the BR and FCR. And I do tell my residents to always try to harvest just like this distally, make the incision like they would approaching the distal radius for an ORIF, but then just go transversely identifying FCR, BR first. Then you find the artery and mena comatantes, ligate that distally and then raise the artery in the flap so that you don't end up sort of, if you go from lateral or radial or ulnar, you tend to have a risk of raising your skin without the perforators and the radial artery. And then here's further dissection approximately again to get your arterial rotation for whatever defect you're trying to cover. And you just clip any branches and perforators that you don't need, but you keep them, maintain the ones that are on the distal part of the flap on the skin. And so for this patient that I showed, I used a template to basically also check my axis of rotation on turning. So distal, I say distal and then proximal part of this little design. And then I take that into the distal forearm based and try to center it over the radial artery. And then you can see my transverse incision at the distal palmar crease. So I don't want to cross that. And here's a radial view. And this is the flap already tunneled through from the ulnar side to the dorsal side. And for this patient, I actually went ahead and did an Integra initially. You can certainly skin graft it, especially if you leave healthy peritonin and FCR, but I chose to place an Integra to get a little bit better tendon glide and then inset the flap dorsally. So here's a radial view with both the flap and then the donor side covered. And here's one more view of how the flap lays on a defect with the pedicle, and it reaches quite well. And so this is a patient about 10 months post-op. And again, I do skin graft that Integra after it's healed about three weeks, but you can see a very good contour, not bulky. And obviously her hardware is covered and protected. And here is at about a year. Next case is a right elbow open olecranon wound. And so we'll go a little bit more proximal. This young patient had a severe, mostly, most of his body burned, but his right upper extremity was very severely burned. It was managed by a burn team with tangential excision for several passes. And ultimately they attempted some skin grafting, but ended up with this pretty bad elbow wound. And you can see exposed, nearly sort of dried olecranon bone. And so I had someone else at the institution try a abdominally based flap. And I think this is also a good option. However, I think in this patient's case, it was underestimated the amount of injury to his abdominal skin from his initial burn wounds, even though they were skin grafted. I think it's a little bit trickier to rely on these perforators based on burned skin. So ultimately, unfortunately, this went on to necrosis, pretty much full thickness. There was a little bit of fat that remained adherent to the olecranon at least. So that was burned down and now there's some fat on it, but ultimately this is still a wound that needs some good soft tissue covering, especially when we further dissected and identified that the burns team had actually excised part of the ulnar nerve, which is unfortunate. So we transposed it anteriorly to some healthy soft tissue and excised the neuroma or the injured portion and performed an allograft since it's a high ulnar nerve injury, and it was a bit delayed in being identified. So here's the allograft. I wrapped it because it's a bit of a hostile environment at the coaptation sites and then transposed it with his own soft tissue here and it's protected. And so for me, I like to ensure, and you can see this young man, I got him back to full extension and full flexion. So good range of motion and the nerve is not in any sort of tension or kinking. And I actually performed a ulnar motor transfer, which is for another talk, but still with this ulnar, this elbow wound, now with less exposed olecranon. So I find the pedicle latissimus dorsi flap an excellent workhorse flap to reach things to the elbow, maybe just a bit beyond, but not further. So you can include muscle and skin if you'd like. It is an innervated flap, so it's sensate, so they shouldn't have pressure sores, thoracodorsal nerve. The thoracodorsal artery is its main supply along with its vena comitantes and pedicle length up to 15 centimeters. That's more relevant if you're taking it as a free flap. What's important to consider preoperatively is that it's the largest muscle in the body up to 20 by 40 centimeters, which is great for very large defects. There's really no functional donor defect, deficit functional defect. And the other component that makes it a little bit tricky is that it requires the patient to be in lateral decubitus position for the surgery, which either I usually just operate in that position, even with the upper extremity, or other people may want to close the back and reposition. Either way, it will reach the elbow defects, but not distal to the elbow. So keep that in mind, it gets a little too tight. The harvest, again, lateral decubitus position, I tend to put the defect, the arm with the defect on a sterile mayo stand. And then I begin the harvest by simply raising skin flaps anteriorly and medially off of the muscle fascia in this illustration. And then I tend to go superiorly and finding, basically using my fingers to hook around the latissimus muscle, right at the base of the scap, tip of the scapula. I release it off its para spinous attachments medially, and then distally. And then usually the anterior attachments off the serratus, a little bit of bovie comes right off. So here's the design on this gentleman, you can see again, multiple skin graft harvest sites, but still the skin is very good. And here's the muscle harvested out on a blue towel. And here is it compared to the defect on the mayo stand. And then once I tunnel it under the axilla, that's what it looks like on the right. You can certainly open the incision between the arm and the axilla, and then just close, but most times a deaver, you can access the wound. And so what I did is inset the muscle flap around the nerve, around the olecranon wound, and then skin grafted it with quite a bit of meshing, because we're this actually want a little bit of contraction, kind of closed on the wound. He had a little bit of a wound breakdown because he was still in bed recovering, but again, nothing exposed, no more nerve problems. And here's three months post-op, full extension, full flexion. And here is at five months. In summary, I think that the pedicle flap reconstruction for upper extremities does include radioforum flaps as well as reverse radioforum flaps and latissimus dorsi flaps. What you must consider is your wound bed, missing elements, and the wound size. And you want to always plan for the proper pedicle length to rotate into your wound. Thank you very much. Great. Thank you so much, Helen. That was a really, really great cases. And thank you so much for sharing your experience with us and all the best for your case. Hopefully it goes well. Thank you, Harvey. And next, I'd like to invite Dr. Suheil Mittani, who will be talking to us about thumb reconstruction. Suheil, please. Thank you, Harvey. Really an honor to be on this panel and talking about management of thumb wounds. So this is my disclaimer. There are many fancier options in what I'm going to talk about in terms of how to manage thumb wounds. And we are kind of charged by talking with non-microsurgical reconstructions. And there are many elegant options that don't involve microsurgery as well as some flaps that are applicable to other digits that I've left out to be covered by my esteemed colleagues. But what I am going to share with you is, in my practice, what I've found to have some practical reproducible solutions for management of these types of wounds and defects. So I'm going to talk a little bit about kind of my approach to management of thumb wounds, the defect types, and then kind of go through a case-based walkthrough of some clinical scenarios and the flaps that I chose and kind of hopefully give you a sense of at least how I tackle these kinds of problems. So from the standpoint of the principles and approach, particularly I think with any wound of the hand and fingers, but particularly with the thumb, the goals are to restore mobility, stability, sensibility, length, and ultimately appearance. The kind of one thing that I'll say is I think in as much as managing the wounds is the topic of this this discussion, I will try my hardest to try to put anything that's cut off back on on the thumb. And some of my most, I think, grateful replantations have been at the IP level or distal on the thumb and it's not, given the size of the vessels, it's more reasonable than you think on the initial inspection. And I'll always try to revask it if you can. Better to avoid the wound if you can possibly do that. So then when you're faced with the wound, really the next thing you kind of think about is the level of injury and the nature of the tissue loss that you're dealing with. By and large, you can kind of divide the thumb into its thirds. It's the distal third injuries tend to be the ones where soft tissue reconstruction is indicated. Middle third types of injuries when you're talking about lengthening to kind of maintain the functions of the thumb. And then when proximal third metacarpal level types of injuries, you're kind of looking at things like microvascular reconstructions or polysizations. When we think about the defects that were faced in the distal third, this is where the flaps and local regional flaps kind of come into play. Really for me in the acute setting, exposure of tendon or bone for sure necessitates consideration of flap coverage. And then a secondary consideration which will come into play in at least one of my cases is the need for sensation given that the function and importance of the thumb in gripping and grasping and the overall function of the hand. Sometimes the sensibility is necessary to be able to kind of optimize functionality. So really the indications kind of boil down to either straight up soft tissue coverage for large defects, preservation of bone and length, and the restoration of sensibility. And these are three various defects that I was been faced with in the last several years in my practice. There are a variety of options and I know Harvey at this point is like, oh my god, this guy's going to talk about stuff for another hour and a half. But you can see all the choices that are there. We're really going to focus on these three things. The Moberg flap, the first dorsal metacarpal artery flap, and the groin flap. And I'll be relatively succinct on the groin flap as Dr. Sabapathy is going to address it in more detail and kind of get into its versatility. But really these are the three major things in my armamentarium when I'm faced with local and regional options for flap coverage. So the Moberg flap unsurprisingly was described by Dr. Moberg in 1964. It's an advancement flap that's based upon both neurovascular bundles of the thumb and it returns sensation as well as glabrous skin to the defect site. So ultimately they're replacing like with like. You typically will need to flex the IP joint and not necessarily get a contractor, but you need to flex it and work yourself usually out of a little bit of stiffness in order to achieve suture of the flap distally. There are many different ways or variations that this has been described including a back cut transversely to be able to kind of back graft at the thenar eminence border with the thumb itself. I have found that this the way that I'm going to describe is the way that's worked the best for me in my practice. So typically as you can kind of see here I'll incise laterally along the mid-lateral lines on each side of the thumb and care is taken to kind of maintain the neurovascular bundles along the in the volar skin that you elevate it and really kind of just staying directly above the level of the tendon sheath of the FPL that's there. And I think one of the mistakes that people make is they don't get enough excursion so you really end up bending the IP joint. You can see this defect in the schematic is kind of that ideal injury that one to two centimeter type of defect at the distal third of the thumb with preserved nail. What you really need to do is make that incision all the way down into the thenar eminence really basically intersecting a line drawn approximately from the ulnar border of the middle finger. That will allow you basically you're just kind of unraveling the soft tissues of the volar thumb and allowing it to kind of have some distal excursion and all that release is really necessary to accommodate the tightness at the base of the thumb and usually obviates the need to have to actually do a back cut or a significant amount of IP flexion. And you can see this clinical case that one of my colleagues Dr. Detlev Erdman provided me and kind of elegantly he shows the way that this is kind of achieved and the nature and depth of the cuts that have to be made in order to facilitate that closure. And this one you can see there's very limited IP flexion that happens in order to be able to achieve that primary closure. So another clinical case that kind of goes into the next flap we're talking about is a 32 year old gentleman who had a table saw injury and really had a significant glove into the radial side of his thumb with a non-reconstructible radial digital neurovascular bundle that eventually went on to heal was skin grafted but he really had no sensation. It was greater than 15 millimeters at the central radial tip of the thumb despite kind of being out five or six months. So this isn't a wound per se but this is the sequelae of the wound and potentially could have been addressed in the primary setting. The biggest issue he kind of complained was that he just he couldn't hold on to things he couldn't feel where his thumb was and he was a laborer so he was holding nails and doing things that he needed to stabilize with and it was interfering with his job. So when you kind of look at the things that he needs he needs sensation at the tip of his thumb. Ideally glabrous skin but that's not always a possibility and really needs some better resurfacing of the tissue of the radial aspect of the thumb and optimizing his return to work. So really that kind of took out considerations for microsurgical types of interventions. So this was the situation in which we we thought to use an FDMA flap. The first dorsal metacarpal artery travels in the fascia overlying the index metacarpal. It is a branch of the radial artery and it supplies the skin overlying the dorsum of the proximal phalanx and here you can see where it sits in the screen on the image on the upper right portion of the screen. It sits right on top of the fascia of the first dorsal interosseous and in the subcutaneous tissue above it are some subcutaneous veins as well as the radial nerve branch. So how this flap is elevated typically I'll elevate it from distal to proximal the skin and subcutaneous elevated over the proximal phalanx with care taken to preserve the index finger extensor periton and typically if you take a wide enough swath of subcutaneous tissue the skin flap can be designed to include a terminal branch of the superficial radial nerve rendering it sensate. What I clinically will do and you can see it in the lower right picture is I will take the entire fascia of the first dorsal interosseous. So I make an incision over the index finger metacarpal and cut down to the periton, get sorry to the periosteum, get underneath the fascia of the first dorsal interosseous and then make a a more radial cut along that fascia and basically elevate that entire fascia in continuity with the subcutaneous overlying tissues. The FDMA sits in those soft tissue sleeves so the exposure of the vessel is not necessary during the dissection. In this particular case we happen to be able to visualize it. I typically do this under tourniquet control so you really you know don't have to be sitting there kind of looking at the vessel or even dopplering it. Then the flap is transposed to the first web space. Sometimes people will tunnel it. I tend to unroof the tunnel to kind of optimize my inset and avoid any kinking. I don't really like passing this flap or really any flap through a tunnel. So in this case I kind of made that incision and you can see where he looked like before and this is where we resurfaced that radial aspect of the thumb and it went on to heal and he returned to work relatively quickly. I will say that the donor site not entirely awesome. There's always a little bit of a divot. I've tried to do full thickness skin grafting to kind of try to minimize that divot as well as trying other adjunctive kinds of things but it tends to be a not ideal donor site. Thankfully I've not had any issues with contractures in the index finger. I think just trying to be really meticulous about sparing that periton provides a good bed and I'll not use a mesh graph in these locations as well. The thing that's been my experience with this flap is kind of borne out by the literature in that people get pretty good two-point discrimination from this and while they initially kind of feel like they're touching the back of their index finger within four to six months they kind of cortically re-educate and it becomes more natural and while it's not a glabrous skin like your your volar skin is on the thumb, it's relatively hardy and I haven't had any wound complications or anything like that downstream in terms of people's use. And this is just another study talking about the two-point discrimination. So the final case I'll show in the final kind of, I think, workhorse flap for me will be elucidated by this one. This is a gentleman who was fishing off the coast of North Carolina. The line got wrapped around his thumb and the skin and soft tissue is gone and it's in the ocean somewhere. So he came in looking like this with exposed proximal phalanx, basically lost everything distal to the IP joint. And so for me, this is a situation where I think a groin flap is a great option. And I won't really get too much into the technical details so as not to bring up Dr. Sabapathy, but basically it's a pedicle flap, one of the oldest flaps and relatively easy to elevate and really something that I think is critically important to have in almost everybody's armamentarium that's managing any type of soft tissue defect because it's really an outstanding last resort. And sometimes it can be a very good first resort in terms of your options here. I found it particularly useful as a tubed flap for cylindrical kind of defects of the thumb. And this one, the pedicle is the superficial circumflex artery. And you just have to be careful about the lateral femoral cutaneous nerve, which is adjacent to it as you're elevating it. And you can see, you don't typically actually have to see the pedicle when you're doing it in a pedicle fashion. But you can see it here in our elevation from a different case, but this is what the gentleman's thumb looks like kind of intubated. And then typically what we'll do is take him at three weeks and wrap a pen rose around the tube itself. And then usually I'll use either laser angiography, or I don't think it's unreasonable to do clinical examination, but laser angiography feels like you get a little bit more quantitative assessment of what things look like in terms of the perfusion with the pedicle clamped off. And then I'll divide at that point inset. Typically have to do a couple of rounds of at least one round of thinning to kind of get the contour the way that you want it, even when you have a relatively thin person. But this was the final result. And it was, in my opinion, a reasonable result for what we were kind of dealing with. So in summary, there are many considerations in soft tissue reconstruction of the thumb. I think sensate reconstruction is a premium. Unfortunately, that groin flap does not provide that for you. Then for those types of degloving injuries, you will have to kind of resort to more microsurgical types of things if you're looking for optimizing sensation. But for me, when I'm looking at kind of pulp avulsion, those distal, very tip injuries that are relatively small in size, I'm looking at a Moberg flap, if that's precluded, or if it's a larger defect, the FDMA has been my go-to, and these larger degloving types of circumferential injuries is when I turn to a groin flap. So thank you all very much for your time and attention, and I will turn it back over to Harvey. Great. Thank you so much. That was a really great talk and beautiful cases. Next, I'd like to invite Dr. Ryan Katz to talk to us about finger wounds. Ryan, please. So when Harvey asked me to participate in this talk, I thought, yes, you know, I can finally talk about microvascular reconstruction of fingers. And then he said, wait, wait, wait, wait, no micro, it's whatever you can do without micro. So I felt like my hands were tied a little bit, but I still love this topic. So I thought I would take on the challenge. 10 minutes is not enough to talk about all the methods of coverage of the fingers, fingertips, different location of the fingers. So I'm going to try and highlight my experience with the Homo digital island flap. And anytime we have left, we'll move on to things like cross finger flap, etc. You will have access to these slides. So anything that we don't get to cover, you get to look at after the fact and feel free to reach out via email or chat at the end. You always have to consider what are we covering? Where are we going to go to get it? The ideal, of course, is to try and restore like with like, you're looking for sensei glabra skin on the palmar aspect of the finger, kind of soft pliable skin on the palmar and dorsal aspect of the finger. So how do we do it before we get into it? I think it's really important to consider two things. Number one, non-operative treatment of fingertip wounds. Even if there's exposed bone, if it's covered by periosteum, it oftentimes can and will heal without the need for surgical intervention. So you need to determine, does this person need an operation? If so, fine, you can do it. But if it's a small wound, even if there's some exposed distal phalanx, you could consider non-operative treatment and oftentimes see a reasonable result. And we've known that for a very long time, especially in kids. If kids have fingertip injuries, you could consider non-operative treatment. Even if they've lost the tip of their finger in a door or a drawer, either non-operative treatment or composite grafting in kids less than two years of age usually ends up with a pretty good result. And here's an example of a lady on whom I was going to operate and then she fell off the map and then came back about four weeks later. She's almost healed the wound. It's not an ideal result. It's not what I want for her. I want supple sensei glabra skin, but she's well on her way to healing this with non-operative treatment, just dressing changes alone. The other thing to consider is skin graft for the tip of the finger. And I find that the more advanced I get, the more this has become an option, even though it seems like probably the bottom rung of the reconstructive ladder. Sometimes you cannot do a flap to the fingertip, local or regional, or you feel like the patient is a bad candidate for whatever reason. This is a guy on whom I was going to do a homo digital island flap. It was not an option because he had a very puny vessel in the finger and he ends up with a skin graft. And you can see on the right his result. It looks amazing. And then this is him playing the guitar using his skin grafted fingers. So pretty, pretty amazing stuff. Um, when we're talking about fingertip injuries and how we're going to reconstruct, so we're, we're moving on to flap reconstruction and away from non-operative treatment. If you're good, if I'm going to do a flap on a finger, usually I'm determining, is it worthwhile saving it? And for me, that determination is based on whether or not there's preservation of distal phalanx length and dorsal nail elements. So if there's distal phalanx length and dorsal nail elements, then I will go on to reconstruct the fingertip. If there's absence of distal phalanx or dorsal nail elements, I would consider an amputation. These are a couple of in-service classics. I put them on here because it's often asked on exams, self-assessment board exams, et cetera. So here's an example. It's a distal phalanx level injury. There's preservation of distal phalanx length, preservation of dorsal nail elements. How do we cover this wound? You can see there's a cut right there in the volar aspect of the finger. What do you do with this? The classic in-service exam answer is Cutler flaps. These are bilateral VY advancement flaps. I would say beware of cartoon drawings. They always kind of exaggerate what you can get. This is what the Cutler flap can give you. Again, it's a classic in-service question. Take a look at this defect though here in the top right. That's something that probably would heal with dressing changes or non-operative treatment alone like we talked about. And look at this advancement. So this is an illustration. You tend to put your best results in your illustrations. So this is from the 60s. You can see very limited advancement here. And that's been my experience with this flap. So I don't really use it even though it is an in-service classic. Here's another in-service classic. Very similar injury, only no volar defects. So what do you do here? The classic answer is a VY advancement. So this is called an adesoy flap or a VY advancement. It's a VY from the pulp. And you make incisions through skin and dermis only to make your V. And then you release the sharpies fibers along the periosteum to mobilize the flap. Then you can grab it with a little hook and advance it distally. Again, it's a cartoon. I think it exaggerates the results here. It exaggerates the amount of coverage that you can get. Here are some photographs from the 1970s showing the amount of advancement you can get. It looks pretty reasonable. I mean, it absolutely can cover distal phalanx, but it puts incisions in the volar pulp outside of the inter-nervous plane. When you're working on the finger, if you can work within the inter-nervous plane, so that's between the nerves, it's always better. So this puts cuts right over the nerves. It's not my favorite. This is a photo from the ASSH showing someone who's early during their recovery after a VY advancement adesoy flap for distal tip coverage. And again, it's an okay result. It's a fair amount of scarring in the pulp. I've done these. I don't love them. The patients are often hypersensitive at the fingertip. So what to do for fingertip level injuries. When you pull up the papers in the journals, you'll find this ABCD, different orientation, algorithm. But I would argue that if it's A, that's to the far left, it's non-operative treatment. They're going to heal up fine. And then everything else for me, everything else is a homodigital island flap. And because it's so important to my practice, I want to give it to you because I think it'll be very important for your practice. I mean, it literally was a game changer for me. This is an example of a case. This looks just like those classic in-service questions, exposed bone, but mind you, preservation of distal phalanx and preservation of nail elements. This should not be a revision amputation in the ER. That would be too aggressive. You can absolutely resurface this. Here's the homodigital island flap. I raised it through a mid-lateral incision. And all you have to do is identify the digital nerve and the digital artery, and you're going to harvest them together. It's surrounded by a little bit of fat. Do not over dissect. You don't want to separate the artery from the nerve. And if the, if you can bring this up with a little bit of fat, it can carry all the skin distally. And then you gently flex the digit and gently advance the flap and you can inset it and you can get a result like this very reasonable result. This flap has a lot of benefits. It's single stage it's sensei glabrous tissue, and it can cover just about anywhere in the finger, not a new concept. There's a lot of papers to guide you. If you want to do some reading on it, and if you want to try the flap, this is one from 1990, basically using the technique that, that I use as well. So this is a good reference here from JHS. Here's a couple other papers. You can see here, the flap is elevated on a neurovascular Island surrounded by just a little bit of fat. Don't over dissect the pedicle. And there's a lot of references here. There'll be included in the talk for you to look up. My thoughts about the homodigital island flap, single stage sensei glabrous skin. You don't sacrifice a nerve. It's extremely versatile. I do not use anything else for fingertips anymore. I don't use the Adesoy. I don't use Cutler flaps. This is my go-to. There are some potential drawbacks, which are often cited. There's the potential for PIP joint contracture, but I would posit that the potential for PIP contracture is no worse than the potential for contracture with other methods of reconstructing the fingertip, like the thenar flap or a cross finger flap. Those have potential for PIP contractions as well. And I like to put a full thickness skin graft at the donor defect. So you do have to use a full thickness skin graft. There are, I want to highlight the versatility of this flap. So in addition to covering the fingertip, it can also be used to reconstruct the total pulp of a digit. So like in this example here, this gentleman is missing his entire pulp. And here we can come up with single stage sensei glabrous skin. You can see the skin graft on the radial side of the digit there. It's a mid lateral incision for me. So it's pretty much invisible once it's all healed. This is his final result, total pulp coverage. Here's another example, two homodigital island flaps for two total pulp reconstructions. There on the right, you can see the skin graft right below the flap, very well incorporated. This is an example of a PIP contracture. So it does happen, but you know, for somebody with a huge pulp defect, no micro, it's a fairly good result. Here is a homodigital flap, again, two flaps for a guy who put a saw across his hand. His middle finger is a no brainer. That's going to get a flap for preservation of length. The index finger, if I were to do an amputation to get soft tissue coverage, it would have to be at or through the PIP. So to preserve his PIP motion, I do another homodigital flap and you can see we are able to preserve his PIP and whatever remnant P2 he has and get excellent coverage. He's got a homodigital flap on the middle finger, which allows for an excellent contour, reasonable nail growth. And you can see this flap here has reached the dorsal aspect of the index finger for a reasonable result. Two other cases, then I'll turn it over. This is the gentleman you saw in the very beginning, put a saw across all three fingers. You wouldn't believe it, but he does have preservation of some distal phalanx length in the ring and the index. And this guy was amputated. He did not have the part. So he does not have his distal phalanx here. He gets shortened and closed here. And then we disassemble or he did bring the part and I'm sorry, we disassemble the amputated part and use it for spare parts. So he gets a homodigital flap on the ring finger and a spare part nail bed graft placed on the flap to get a result like this. That's his ring finger by the arrow pre-op and that's his ring finger post-op. So it's a homodigital flap to resurface the digit with a spare part skin graft or nail bed graft on top. And then the last case, this is a gentleman who lost half his digit. This is otherwise relatively unreconstructable. I don't know of any other good method to reconstruct this outside of microvascular surgery. You could consider a pedicle flap from the trunk, but here to highlight the power of the homodigital island flap, this gets elevated in a mid-lateral fashion, neurovascular island, sensory glabrous tissue, and it gets advanced distally and it can give you a result like this. Very reasonable. I am going to turn it over just for the sake of time, but I have uploaded the slides and I'd be happy to talk to you guys offline. My email is at the end of the slide, Dak. So if there's any questions from this talk, please send an email and I'd be happy to answer them for you. Great. Thank you so much, Ryan. That was really fantastic. I think the message from the talk is I have to start doing more homodigital island flaps as well. It really is. It's a great flap. So, you know, like Ryan, I really love microsurgery as well, but I think that there's really a place for pedicle flap reconstruction and a well-done pedicle flap can sometimes be more difficult than a free flap. So tonight I'm going to focus specifically on talking about the posterior interosseous artery flap, profiler flaps, and I'll just talk about two cases of functional reconstruction. So the PIA flap was first described in the mid-1980s and it really has advantages for reconstruction of defects in the hand and the wrist because it does not sacrifice any major arteries. However, the PIA flap is a bad reputation for tedious dissection and sometimes getting problems like venous congestion, hence it's not favored by some surgeons. But I really think it's all about how you dissect the flap and there are certain technical points and tricks and tips that I'll talk about tonight. They'll make it a reliable flap for you with low morbidity. So the PIA flap is most often used as a reverse flap for hand and wrist coverage. However, it can be used as an anti-grade flap as well for elbow coverage and as a free flap. The axis of the flap extends from the lateral epicondyle to the DRUJ or ulnar head. I personally like to bias a little bit ulnar, so align from lateral epicondyle to the ulnar head because the vascular pedicle is always a little bit more ulnar than you think it is. So in a retrograde flap, the perfusion to the flap comes from a perforator from the anterior interosseous to posterior interosseous artery just proximal to the DRUJ. So I think there's several technical tips and tricks that it's important to highlight. I think it's really important to maintain a wide adipofascial pedicle and skin bridge distally and this helps with the venous outflow. So we'll look at some cases in just a bit. And I think it's important to avoid dissection of the pedicle proximal to the PIA perforator because the posterior interosseous nerve is closer to the PIA proximally, so it becomes a bit more risky if you dissect proximal to the perforator. And again, I'll show this in the case subsequently. So the septum between the EDQ and the ECU, which is where the pedicle, the vascular axis runs, is actually better seen from the ulnar side, but the vascular axis is better seen on the radial side. And for me, the pedicle is easier to locate and initiate distally. And in my practice, I found the use of ultrasound useful to localize the PIA perforator preoperatively so you know exactly where to design your flap. So this is an example of an ultrasound. And here you can see that by using the ultrasound preoperatively, you can very precisely map the perforator and you can even see it branching closer to the skin so that you know exactly where to design your flap. So if you want to read more, there are these two excellent papers by Pedro Carvadas as well as Acharya in the Journal of Hand Surgery. They really describe pretty much what I've talked about in terms of the technical tricks for elevating a reliable PIA flap. So this is a case of a 27-year-old female, burns to the dorsal hand. Her skin grafted by the burn service and referred for tendon and bone exposure because part of the skin graft did not make it. So here you can see that the PIA flap has been elevated in the usual fashion and is able to be turned distally to cover the defect in the dorsal hand. And this is the medium-term post-operative result. Another case here is a patient who suffered a pretty severe dorsal hand injury with loss of tendon as well as injury to the superficial branch of the radial nerve. So I did an EIP to EPL tendon transfer for restoration of thumb extension as well as grafted the superficial branch of the radial nerve with allograft and then we used a PIA flap to cover the skin defect as you see over here. So it really reaches very well defects in the wrist as well as the dorsal hand. So this is another case which shows the anatomy of the PIA flap a little bit better. So this is a defect involving the radial hand. This gentleman had an amputation of the thumb and the index due to a sarcoma and I was asked to cover it. So you can see the axis along which the flap is designed and here is the perforator coming to the skin. If you look at the picture in the lower part of the screen you can see that the nerve is very close to the pedicle. So this brings me again to one of the technical points that it's really important to not dissect too proximally to avoid injuring the posterior interosseous nerve and you can really ligate the pedicle just proximal to the PIA perforator. And you can see it's able to reach the defect quite nicely and this is a range of motion post-operatively. So sometimes the PIA flap can be used as an anti-grade flap as well. The skin petal tends to be designed more distally and the point of rotation is at the origin of the PIA from the common interosseous artery. Again you have to be careful in the proximal dissection because it's close to the PIN. But really here you can see that it reaches the elbow quite nicely. So I'd like to talk a little bit about alternatives to a PIA flap and this is a case that I was actually asked to cover a defect on the dorsal ulnar wrist in a lady who had a Merkel cell carcinoma of the right wrist that was resected. So you can see the defect is actually over the ulnar head and at the time I thought that the PIA pedicle had probably been resected as well because this is the vicinity of that. So we did a dorsal ulnar artery or Becker flap. This was first described in 1988 by Becker and Gilbert and relies on a very constant perforator from the ulnar artery that goes to the side and has an ascending and descending branch. So in this case a very reliable flap can be designed along the ulnar border of the forearm and this is really a very simple flap. We essentially just draw a skin petal along the ulnar side of the forearm and you elevate it and it's super reliable and you just in this case we just turn it distally to cover the ulnar head and this is about one or two weeks out and this is probably about a month out and she did undergo radiation therapy for her Merkel cell carcinoma and she did fine which would not have been possible if we did not have robust flap coverage. So it is another simple flap that you can add to your armamentarium. So I'd like to talk a little bit about propeller flaps as well. So these really can be used for different defects in the upper extremity and the idea of a propeller flap is that it's based on a single perforator and it can be rotated in the fashion of a propeller or advanced however you like to do it and the idea is just that the flap is actually islanded on a single perforator. So this is an example of that case. This is actually a freestyle lateral arm perforator flap. This is a 60 year old female who had a melanoma in the arm underwent white local excision and had a lateral elbow defect. So we did a freestyle perforator flap. Essentially I just dissected under the skin approximately and I found this nice perforator that was probably coming from the posterior radial collateral artery and we just designed a freestyle flap in a hatchet shape fashion and we're able to advance it in a V-Y fashion and close the defect. So you can design freestyle perforator flaps however you like in the upper extremity to close small defects. And I have about two or three minutes left. I'd like to go through two cases where to kind of bring more complicated cases of non-microsurgical reconstruction. So this is actually a case of thumb reconstruction and I'm glad that Suheel didn't talk about this. So it gives me something new to talk about. This is a guy who had a failed replantation and was referred to see me with a shorter thumb. And obviously there are a whole lot of options you can use for non-microsurgical reconstruction. But what we did in this case was to do a reverse radiiform osteocutaneous flap to restore the length. So this has been described before in a number of papers. In this case we designed a skin petal approximately together with a segment of bone. And you can see that it can be tubularized distally to reconstruct the length in the thumb. And here's the osteosynthesis to restore the length in the thumb. So it's not exactly the same obviously but the length is relatively similar. And here's a video showing his function. I just want to show one more case to kind of bring things together. So this is another complicated case, but again, that can be taken care of using non-microsurgical reconstruction. So this guy was a 30-year-old male who was involved in a bad accident, had his left arm pinned under a vehicle for about an hour or so, and came in with a really crushed arm. So initially, I did do some microsurgery. I repaired his brachial artery, fixed his radius fracture, X-fixed his radiocarpal joint. And then I thought I did a pretty good job. Everything came together pretty nicely. But unfortunately, his brachial artery repair blew out due to infection about two days later. And after multiple debridements, he still had a really bad infection. So we ended up deciding to do an amputation. But in the case of an amputation, all is not lost because you still have to use all available sources of soft tissue. So we actually did a fillet flap of the palm of the hand. As you can see over here, that didn't look as bad. And we're able to cover the stump of the transradial amputation. And then we did a bipolar latissimus flap to reconstruct elbow flexion. And here he is eight months post-op. So these are more complicated cases of non-microsurgical reconstruction. And this is another case. So in conclusion, pedicle flaps have many applications. For coverage, functional reconstruction, or in combination, freestyle perforator flaps are an option. And really, I think even for really more complicated cases of reconstruction of the thumb of elbow flexion, the microscope is not needed. Thank you very much for your attention. I'm going to turn the podium over to Dr. Sabapathy, who needs no introduction. Dr. Sabapathy, please. He's going to be talking about groin and abdominal flaps. Yeah, thank you so much, Harvey. Now I'll share my screen. So my edit is to talk on groin and abdominal flaps. And the most important thing is to tell the audience is almost any defect in the upper limb below the elbow can reliably be covered with groin and abdominal flaps. There are a lot of things to be told against pedicle flaps, but all the disadvantages that could be told can be circumvented by refining the indications and refining the techniques so that you should be able to do that. And for example, you have a patient who has got a defect to be covered on the dorsum as well as on the other side on the other side is in the fingers and on the dorsum is on the dorsum of the hand. And if you have to design a microsurgical flap, I think it's quite a complicated design that we had to do and it become bulky when you turn it over. So what we do is after debridement and we are designed a hypogastric flap that is based on the Sushnivyapigastric artery and the groin flap. That's the other one. Use the groin for the dorsum of the hand and a hypogastric flap for the olar side. And then you will find that you could cover both and you got a syndactylized hand on the other side. One great advantage of a pedicle flap is when you come back for thinning, you could really be radical in making this thinning the pedicle flaps. For example, when you separate the syndacty, I almost not taken the whole of the fat that is there. These flaps survive with the skin edges and not through the fat. So that's the results that you could get. You could get a good flexion, good extension and almost not good looking hand. And the most important is that now the MCP joint function is also now fully preserved. The point number two is always said that you could do primary reconstructions with only with free flaps because all edges are closed. But that again is not an important thing. But what is really important is if you have to do a primary reconstruction like a nerve graft or a bone graft, what is really important is the debridement that goes before the this thing is very important. You must debride the wound as if you are putting a free flap. So here we syndactylize the hand and then put in iliac crest bone grafts and syndactylize and then we have covered it up. But the most important thing is you need to design the flap in such a way that the curve around and the total part of it is inset. And once it is inset, after that you could divide and you see that all the bone grafts have gone in for union and is using his hand. The most important point, technical aspect is there. And we have written out all our concepts of what we learned in the last 30 years in the two ASSH books, the groin flap and abdominal flap. And then there we make a good reading. This is the anterior superior iliac spine. I think that needs to be marked properly. That is, you go your finger along the inguinal ligament and the first bony prominence that you touch is the anterior superior iliac spine. This is important. Suppose if you mark it a little bit on the iliac crest, what happens is you will miss the point. It comes from a two-finger breast below the anterior superior iliac spine. And along the level of the femoral artery, you get the superior inferior epigastric artery and there's the sepa. And you get a lot of parambilical perforators in this region. These are the things for the DF flap. The important thing that we have found is that however bulky an individual is, the distance of emergence of these two arteries is only about six to seven centimeters, even the bulky person. So by keeping a base that is narrow, you could now raise almost the whole of the lower part of the abdomen, they could raise. So that's the important part that should make you make the patient comfort comfortable. Comfort comes with increasing the inset. The comfort does not come with increasing the length of the pedicle. That's what we have learned. So keeping the base narrow is the first step towards the large flaps. If you keep the base wide, then mobility is restricted, inset is not possible. So we don't, we can raise in a mushroom-shaped flap. So like this, you raise and you attach it before you go for a toe transfer. The second is don't keep the pedicle too long. I think probably most of the time we're taught to keep the pedicle too long. If we keep the pedicle too long, what happens is in the pedicle, the flap which has got a good blood supply gets wasted in the pedicle. And then what you really put on the hand has got poor blood supply. And that's another cost of the flap. And you could do the flaps primarily. That's very important. And that's very useful. If you're confident of debridement, if you have a hand like this, you debride very nicely. And then you put it on primarily. And that's the result. So you've got to put in a flap for this area and grafted the other area. So you can get a good result from this. The most important thing that we do is we plan exactly to the defect. Always know plan in reverse. But we say that you repeatedly keep planning and so that you design the flap nicely. For example, if you've got a raw area like this, we should not get a flap which goes like this and comes out here. You should try to increase the inset. So for we had drawn this thing, that's the sartorius. So two centimeters below this comes and there's a flap that's in the marking. So again, we plan and you see the plan has been drawn so that the base is kept narrow. And after that, now you thin the flap. I think if in bulky individuals, all the fat deeper to the scarpus fascia can just be taken off. I think in the place where you're going to insert is going to be taken off. And there's the flap that's raised. The flap is made really thin. So that's the trick when you do it for bulky people. Take off all the fat below the scarpus fascia in the area which you're going to insert into the hand. And you see, that means now you're able to use it. So if the thumb is mobile, the index finger is stable and is able to use the hand. So now we come to large flaps. Now, how do you make large flaps? Abdominal flaps and groin flaps are very important because if you have the need for a broad area of flap distally, whereas if you take, you know, entry ALT, when you do it, I think as you go distally, you don't make it broader, you know, you make it smaller. So if you require a wide base distally, I think this is a flap. So that's the way he was referred. So now you see that we have put the thumb position in the far away abducted position. So you really require a large, broad flap and you can read it up to the elbow. So you recruit all the areas, you know, you could recruit one area. So that's the groin and there's the hypogastric, there's the prudential area, and you just recruit the last one area. And it goes on to the posterior axillary line. I think how far can you take this anticephalic spine is a posterior, posterior axillary line is the distal limit. So whole of it is taken and you see custom design flaps, it's fitted well and he has no extensors. And later on, we do a tendon transfer for a finger, finger extension. So he gets flexion and good extension he gets. So that's what the dorsal defects, whenever you have a dorsal defect, you know, you've been inferiorly based flaps, but then if you have to get no olar defects, you just place the hand wherever it's sitting comfortably and you need to raise no superiorly based flaps for the olar defects. So you base it on the parambulic perforators and it sits in very well. So that's the way. So olar defects go for, you know, superiorly based flaps. So that's the result, but you got no circumferential defects. That means, you know, you cannot insert in all sides, you know, so you need to do it in stages. Vishnu was referred to as for whom an approximate lot of injuries he had, so he cannot have a vessels. So we had to go for a pedicle flap. So here, what we did was we planned for a big flap, but then you can't insert the whole thing. So this part of it gets inserted in the beginning. And after three weeks, what we do, we recruit a little bit of more flap you can recruit. So you delay the flap here. So you delay the flap and then you transfer it back. So you got a flap cover, both on the dorsum and on the olar side. And thereafter, now you go for a microsurgery or, you know, a nerve grafting, tendon grafting, all the facial tendon grafts we have done, and nerve grafts, tendon grafts. And there's the child, you know, where she's able to use the hand after she has done all the recursion. Good amount of flexion, good extension she has got. So now you get a circumferential defect. I think this shows the versatility of the pedicle flaps. If you have to choose a free flap, I think we can do it. I can show examples for similar thing, free flap also. But I think this is much more simpler, straightforward. Now it just takes a couple of hours to finish it off. So we have taken off the index, which is not there. So fix it in position as if you've done a re-amputation. So you need to cover both on the dorsum. So we have taken, we have raised up a groin flap and made a small hole in it and brought the thumb out. So you just, it has got almost, it has got a real good insert, it has got. And now you see in one stage, now you've got a good web, you've got a good oral surrogate. So how do you get now refinements? Now bulky edges of the flap are difficult to suture. So at the edges, now you make it really thin. So you find that the vessels are deeper at the place where they start, at the base. But then as they go up, I think the vessels are all here and it's the subdermal plexus, which is important. So you could now thin the area now where you're going to attach. The second point is, if you have, you don't have enough flaps like this, if you do this, you can't, you know, attach it. So it's the tightness of the things, which is important. So you bevel the edges of the thing whenever you suture. That means if you are going to attach it to the digit, that means you can't put in a thick flap, you can't put, this can apply to any flap that you raise. And for example, if you have bilateral deflection, both sides, bilateral, both on the dorsum and the olar side, see what you've done is now we have done a bone graft, we have got a tendon graft, we put a nerve graft, all of them we have put on all sides we have put. And for one side, now you're taking two flaps, one for the dorsum and the olar side. And then in a primary reconstruction has been possible. So the closing thoughts is the only one point which I noted, do we delay the delay before division? I think now if the insert of the flap is less than about 75% of the deflection, then we delay. If the insert is more than 80%, most of the times we don't delay because we are making a custom flare. One other area where you must delay is that if you make a two pedicle flap, now for the thumb or circumcision, two pedicle, because the insert is very small, then almost always we delay. So the closing thoughts are pedicle flaps are generally considered to be uncomfortable to the patient, bulky, they require more stages and no possibility of primary reconstruction, but all these things can be circumvented by refining the techniques so that the presumed disadvantages can be overcome. So even if you're a good micro surgeon, even if you're doing a fingertip replacement, you will still need to do a good pedicle flap since you need them when free flap options are not available or failed. So thank you so much for the opportunity, Harvey. Thanks so much. Bye-bye. Great. Thank you so much. That was fantastic as usual. We do have a question from the chat. Somebody wanted to know how do you divide your fingers when you syndicalize them in the context of a groin or abdominal flap? Do you do a straight line incision to divide the fingers? Yes, I do a straight line incision to divide the fingers. Usually you'll find when we put in a flap on the syndicalized hand, you put in a little bit extra skin. So you need to put a loose skin, you need to put, you thin the flap, but you put in a lot of skin and you divide it straight, you divide. So usually you're not able to close the sides because there's a lot of fat in between. So I started working on how does this flap survive, whether they survive or the fat survives the skin or the skin survives the fat, but actually it's the skin that is surviving this. So you really take off all the fat. Then, you know, you require more skin to drape on this. If you're not fully able to drape, put a small graft on this, don't stretch it out. It should be fine. Okay. Thank you very much. So I know we're kind of running over a little bit, but one of the aims of this webinar is to make it really easy for the attendees to cover defects in the hand and upper extremity. So I'd like to ask the panel, just a very simple question. What's your favorite pedicle flap for use to cover defects in the fingers and the thumb and the hand? And what are the reasons for that? So I guess I'll start first. I'll say that in the fingers, even though now I'm going to do more homo-digital island flaps because of Ryan's talk, I actually use a lot of cross finger flaps because I find them very reliable. A lot of my patients are actually smokers or unhealthy or drug abusers. So I've just found that a very reliable flap. And then at the thumb, I do tend to like the FDMA flap. And I found sometimes the Moberg flap is a little bit hard to reach distantly. And really for me in the hand or the wrist, my go-to flap is the PIA flap because I really don't want to sacrifice a major artery like the radial artery. So any of you guys want to start first and just talk about your favorite flaps? Yeah, I think because you told about cross-finger flaps and I'll tell. Cross-finger flaps is also one of our workhorse flaps in our area, where we find is extremely reliable if you really make them design it very well. And except for the color, all of them in a match is very good. And after some time, and one great advantage of crossing a flap is that you don't do anything. You don't disturb the proximal area of the finger at all. That's it. And you can raise big flaps also raise whole fingers can be covered. Tips can be covered. Everything can be covered. So you don't have to be against crossing a flap. But the only thing is it requires two stages. That's a definite, that's a definite advantage. Other than that's fine. Yeah, but it's really reliable. Yeah. Yes. You know, one of the things for me is the donor sites. I always, I'm always looking to try to get something for free, whether that's in life or in flaps of the hand. And that's why for me, a flap that we didn't talk about this evening, but has been helpful for me for fingers is the Quaba flap. So a propeller, a hand-based propeller flap, many times you can close the donor site primarily. And I've been able to get to just a little bit past the PIP joint with these flaps. And that's a nice dorsal finger cuff that has no downside from a donor site. No, you're absolutely right. That flap kind of slipped my mind, but you know, definitely it's a low cost flap as well for the proximal pair lengths. How about you, Ryan? If you couldn't do an anti-grade HomoDigital Island flap, what would you do? If I needed to cover the fingertip? Sure, fingertip is a finger. Yeah. Yeah. I like a retro, there's a retrograde HomoDigital, which might be cheating a little bit with that answer. That flap can be raised without the digital nerve and it can go up to the fingertip. And the benefit of that flap, even though it's a little bit more dicey because you're excluding the nerve, is that it doesn't come with a risk of a PIP contracture. Now, if you said no HomoDigital at all, I do like cross finger flap. I think that's reasonable. Thenar flap is reasonable for fingertip. Suhail, I like the Quava 2 for P1 level volar defects. There's very little else that reliably can cover that with full thickness supple skin. So that's a great flap. How about the thumb? What would you use to cover like a really big volar thumb defect? Yeah, I love the FDMA for thumb defects. And that is extremely versatile as you were talking about, Harvey. It can cover the volar thumb, it can cover the dorsal thumb. And I have, you can wrap probably 270 degrees around the thumb. I mean, you could do a subtotal thumb reconstruction with an FDMA flap. Yeah, for me, I've always found the Moberg a little hard to reach. And I know you talked about it, Suhail, but is that your go-to flap for the thumb or do you use the FDMA flap more if you had a large volar defect? The Moberg is really kind of that small tip defect where you're like, gosh, it would be a little bit too much. But if I just can inch a little bit more skin up there and I'm not going to get a hook nail, like it's that one where like, you know, two thirds of the nail is still intact. And it's kind of that a volar oblique that Ryan kind of showed. That's where the Moberg comes for me. Otherwise, I think you guys, I'm on the same page as you all that the FDMA is kind of the workhorse for thumb reconstruction for bigger defects and in general. Dr. Sababat, did you use the FDMA quite a bit as well? Yeah. Yeah. FDMA is a flap in our armamentarium. We use it quite a lot. And sometimes even for the thumb defects, you know, you use a cross-finger flap. Suppose if a person is on call, it's not very easy. You just take the same area where you use the FDMA, turn it over and put it on the thumb. That again can be done as a cross-finger. FDMA is a workhorse flap for us too. That's great. And I think you probably, I know you have a paper on the PIA flap, so I guess you use it quite a lot for hand defects as well, right? It's a very important flap. We don't know about 175 PIA flaps. We never had any arterial anomaly or something like that, but then we always go by the, maybe dissect from the digital side. As was originally described by Claude Ariani and Zancoli, that paper which you quoted is a fantastic paper. What you quoted is the first paper. That's a fantastic paper. So ever since I read that and doing exactly the same way we do, it's a very, very reliable flap and you don't sacrifice a major vessel. But the only thing is that the donor defect, if you put a skin graft, it comes on the dorsum. It's more visible than any graft that you put on the molar side. Okay. How about you Ryan and Suheil? What do you guys use for dorsal hand and wrist defects? It really depends on the size. I love the PIA. I think it's a great flap. It costs you almost nothing. Some questionable, occasionally variable anatomy, so a little bit of a challenging dissection at times, but the PIA is great. If the PIA is not going to work for me or I feel like I need a whole significant amount of skin for a very large wound, I would consider either a reverse radial forearm flap or a groin flap for a large dorsal hand. A pedicle groin flap gets the job done every time. That answer would be the same for the wrist as well. Okay. Yeah. I've struggled a little bit with the bulk. Besides the PIA, even a reverse radial forearm flap has had some bulk issues. It's probably taboo in this one, in this conversation, but I will say that I've started to go more towards free tissue transfer for larger dorsal hand defects, particularly with the thinner flaps like an MSAP. Then one of the other little tips that I've figured out, a reverse radial forearm flap without skin on it, so just the adipofascial flap, is oftentimes sufficiently thinner and you can skin graft it. The color match ends up being quite outstanding. It's a nice little option when you're a little bit less excited to have bulk. I've covered a couple of oncologic defects, dorsal thumb and dorsal wrist hand with that. I've been very pleased with it from that standpoint. Well, I'm actually guilty of that as well. For a dorsal hand defect, I'm actually more biased to do a free tissue transfer. For me, I just don't like doing a reverse radial forearm flap. I just feel bad about taking a major artery in the upper extremity. I know you like free flaps as well, Ryan and Dr. Sabapati. Tonight, we're talking about pedicle flaps, but I think we could just certainly do another session on free flaps as well. I think we've had a great session and if there are no other questions from the participants, I'd really like to thank our panelists and faculty tonight. Thank you so much for sharing your experience. Really fantastic talks. I learned so much tonight from the talks and the discussion and I hope our attendees did as well. Thank you so much again, everybody, and have a good night.

non-microsurgical techniques

reconstructing hand and upper extremity wounds

radial forearm flaps

thumb wounds

finger wounds

groin and abdominal flaps

Moberg flap

FDMA flap

Homo digital island flap

pedicle flaps

cross-finger flap