Original Article

Hand/Peripheral Nerve
Pedicled Abdominal Flaps for Hand Reconstruction
in Adults: Physiotherapy of the Attached Hand
Mohammad M. Al-Qattan, MBBS*
Alwaleed K. Alammar, MBBS† Background: Hand reconstruction using pedicled abdominal flaps has several dis-
Faisal A. Alfaqeeh, MBBS‡ advantages, including delayed hand therapy leading to stiffness.
Lamees A. Altamimi, MBBS§ Methods: This is a retrospective study of 70 cases of pedicled abdominal flaps used
Norah S. Alfehaid, MBBS§ for hand reconstruction in adults in whom physiotherapy of the attached hand was
Nehal A. Mahabbat, MBBS¶ implemented. The review aims to investigate the rate of flap dehiscence, infection,
Rajeev Pant, MBBS, FRCS(Ed)║ hematoma, and flap edge necrosis in our cases, and to establish that physiotherapy
of the attached hand is not associated with an increased risk of complications.
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The review also aims to establish the effectiveness of physiotherapy of the attached
hand in reducing the risk of stiffness by documenting the range of motion of the
uninjured digits immediately after flap division and at final follow-up.
Results: There were no cases of flap dehiscence, infection, or hematoma. Six cases
had minor partial flap edge necrosis that was treated conservatively and allowed to
heal by secondary intention. In 62 patients, the range of motion of the uninjured
digits was 90%–100% of the normal range of motion at day 1 post-flap division,
and all of these patients recovered a full range of motion (in the uninjured digits)
within 2 weeks of follow-up. Eight patients were reluctant to do the exercises as
instructed because of low pain threshold; 4 of these 8 patients had residual stiffness
at the final follow-up.
Conclusion: The implementation of active exercises of the attached hand is fea-
sible in selected cases and it helps minimize the risk of stiffness of the hand.
(Plast Reconstr Surg Glob Open 2021;9:e3474; doi: 10.1097/GOX.0000000000003474;
Published online 24 March 2021.)

INTRODUCTION abdominal flaps for hand coverage are still being used in the
Hand reconstruction using pedicled abdominal flaps current era of microsurgery. The indications for their use
has been a well-established procedure for many years.1–4 have been recently reviewed by Al-Qattan and Al-Qattan.5
However, this method of reconstruction has several disadvan- One of the major disadvantages of pedicled abdomi-
tages, including the cumbersome positioning, the need for nal flap reconstruction is stiffness of the uninjured digits.
flap division, and delayed hand therapy leading to stiffness. Literature is lacking regarding the feasibility, safety, and
Hence, free flaps have become the method of choice in the benefit of implementing immediate postoperative physio-
coverage of large complex hand defects. However, pedicled therapy of the attached hand (before flap division).
For over 15 years, the senior author (MMA) has been
From the *Department of Surgery, King Saud University, Riyadh, designing and in-setting pedicled abdominal flaps used
Saudi Arabia; †Department of Plastic Surgery, Prince Sultan for hand reconstruction in adults so that physiotherapy
Military Medical City, Riyadh, Saudi Arabia; ‡King Khalid of the attached hand before flap division is feasible. This
University Hospital, Riyadh, Saudi Arabia; §College of Medicine, method was applied in cases of coverage of a single ana-
King Saud University, Riyadh, Saudi Arabia; ¶Department of tomical area such as the coverage of a distal digital defect,
Surgery, Division of Plastic Surgery, King Faisal Specialist Hospital a proximal digital defect, a dorsal hand defect, or a pal-
and Research Centre, Riyadh, Saudi Arabia; ║Department of mar hand defect.
Orthopaedic Surgery, King Faisal Specialist Hospital and Research The aim of this article is to retrospectively review 70
Centre, Riyadh, Saudi Arabia. cases of pedicled abdominal flaps used for hand recon-
Received for publication December 2, 2020; accepted January 8, struction in adults in whom physiotherapy of the attached
2021. hand was implemented. The review aims to investigate the
Copyright © 2021 The Authors. Published by Wolters Kluwer Health, rate of flap dehiscence, infection, hematoma, and flap
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative Disclosure: The authors have no financial interest to
Commons Attribution-Non Commercial-No Derivatives License 4.0 declare in relation to the content of this article. The work was
(CCBY-NC-ND), where it is permissible to download and share the funded by the College of Medicine Research Centre, Deanship
work provided it is properly cited. The work cannot be changed in of Scientific Research, King Saud University, Riyadh, Saudi
any way or used commercially without permission from the journal. Arabia.
DOI: 10.1097/GOX.0000000000003474

www.PRSGlobalOpen.com 1
 PRS Global Open • 2021

edge necrosis in our cases to establish that physiotherapy reconstruction using pedicled abdominal flaps with imple-
of the attached hand is not associated with increased risk mentation of immediate postoperative physiotherapy of
of complications. The review also aims to establish the the attached hand.
effectiveness of physiotherapy of the attached hand in
Designing and In-setting of the Flap to Allow Physiotherapy
reducing the risk of stiffness by documenting the range
of the Attached Hand
of motion of the uninjured digits immediately after flap
For distal digital (tip) defects (usually done for thumb
division and at final follow-up.
avulsion amputations), a tubed flap is used and the pedi-
cle is made long enough to allow active flexion and exten-
METHODS sion exercises of the fingers, as shown in Figure 1.
This is a retrospective review of 70 adult patients with For proximal finger defects, the flap pedicle is also
complex skin defects of the hand treated by the senior made long enough to allow physiotherapy of the remain-
author over the last 15 years. All patients underwent ing fingers, as shown in Figure 2.

Fig. 1. An example of a Tubed Flap for thumb tip coverage. A, The flap pedicle is long enough to allow
exercises of the attached hand. B, Active finger flexion with the hand still attached. C–D, Full range of
motion 2 days post-flap division.

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Al-Qattan et al. • Pedicled Abdominal Flaps for Hand Reconstruction

For dorsal hand defects, flap in-setting is done so that There were no cases of flap dehiscence, infection, or
the ulnar border of the hand is lying on the abdomen, as hematoma. Six cases had minor partial flap edge necrosis
shown in Figure 3. that was treated conservatively and allowed to heal by sec-
For volar (palm) defects, the flap is designed and inset ondary intention.
so that the hand is resting on the abdomen, with gauze at In 62 patients, the range of motion of the uninjured
the metacarpophalangeal joints of the fingers to maintain digits was 90%–100% of the normal range of motion at
the hand in the safe/functional position between exer- day 1 post-flap division; all these patients recovered a
cises, as shown in Figure 4. For physiotherapy, the gauze is full range of motion (in the uninjured digits) within 2
removed, and active exercises of the digits are done. weeks of follow-up (Figs. 1–3). Eight patients were reluc-
tant to do the exercises as instructed because of low pain
Parameters Studied threshold. In these 8 cases, the range of motion of the
Demographic data were documented regarding gen- uninjured digits at day 1 after flap division was below 60%
der, age, the etiology of the hand defect, the site of hand of the normal range of motion, mainly because of stiff-
defect (a digital tip defect, a proximal digital defect, a dor- ness of the metacarpophalangeal joints (MPJ) in exten-
sal hand defect, or a palm defect), and follow-up time. sion. The differences in range of motion at day 1 post-flap
Complications (flap dehiscence, infection, hematoma, division in patients who underwent physiotherapy of
and flap edge necrosis) were documented. the attached hand versus patients who did not undergo
Finally, a range of motion of the uninjured digits was physiotherapy were highly significant (Table 1). These
documented as percentage of normal range of motion patients were referred to the physiotherapy department
(compared with the digits of the contralateral unin- for postoperative exercises. At final follow-up, 4 of the 8
jured hand) both at day 1 post-flap division and at final patients recovered a full range of motion of the uninjured
follow-up. digits (Fig. 4), and the remaining 4 patients had residual
stiffness at the final follow-up. This stiffness was noted at
RESULTS the MPJ in all 4 patients (mean range of motion at the
Of the 70 patients, there were 63 men and 7 women. MPJ was 0–70 degrees in 2 patients and 0–60 degrees in 2
The mean age was 36 years (range, 20–56 years). There patients). The fact that all cases of residual stiffness were
were 60 patients with traumatic hand defects and 10 seen in patients who did not undergo physiotherapy of the
patients with oncologic hand defects. The sites of hand attached hand was also highly significant (Table 2).
defects were 20 digital tip defects, 16 proximal digital Note should be given that we did not provide a range
defects, 30 dorsal hand defects, and 4 palm defects. The of motion data for the injured digits because motion in
mean follow-up of the patients was 8 months (range, 6–10 these digits is greatly affected by the degree of injury. For
months). example, the patient shown in Figure 4 had soft tissue

Fig. 2. An example of a proximal finger defect. A, A patient with deep electrical burn of the index finger. B, Debridement of the burn. C, The
abdominal flap pedicle is long enough to allow active extension of the uninjured fingers but not too long to avoid kinking of the pedicle.
D, Active flexion of the uninjured fingers with the hand still attached to the abdomen. E, Full extension of the uninjured fingers 2 weeks
after flap division. F, Full flexion of the uninjured fingers 2 weeks after flap division.

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Fig. 3. An example of a dorsal hand defect covered with an abdominal flap. A, Flap in-setting is done so
that the ulnar border of the hand is lying on the abdomen, allowing active digital extension. B, Active
digital flexion is also feasible. C, Digital extension at day 1 post-flap division. D, Digital flexion at day 1
post-flap division.

sarcoma of the thenar area, which required resection of DISCUSSION

the thenar muscles, the flexor pollicis longus tendon, both Our article mainly aims to introduce the concept of
volar neurovascular bundles of the thumb, and the radial implementation of physiotherapy of the attached hand in
side of the palmar arch (the thumb was viable through pedicled abdominal flap reconstruction. It is important to
the princeps pollicis artery). Reconstruction was done note that this is not feasible in all cases. The method is
by opponensplasty, flexor digitorum superficialis tendon difficult to apply in cases with multiple digital defects and
transfer to the distal end of the flexor pollicis longus, and those with large combined defects involving more than 1
nerve grafts (Figs. 5–6). The patient also had postopera- anatomical area. It is also difficult to apply if the abdomi-
tive radiotherapy. In this case, a poor range of motion of nal flap is based on the paraumbilical perforators because
the thumb (the injured digit) is expected regardless of the of limitations of the pedicle length. Our series included
rehabilitation program. only patients with complex skin defects in 1 anatomical

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Al-Qattan et al. • Pedicled Abdominal Flaps for Hand Reconstruction

Fig. 4. An example of a defect of the palm. This patient was reluctant to do physiotherapy while the
hand was attached to the abdomen. She required prolonged physiotherapy following flap division, but
she eventually recovered a full range of motion of the uninjured fingers at 4 months after flap division.
A, Demonstration of flap in-setting. B, The hand is resting on the abdomen, with gauze at the meta-
carpophalangeal joints of the fingers to maintain the hand in the safe/functional position (between
physiotherapy sessions). C, Full finger extension at 4 months. D, Full finger flexion at 4 months.

area, and did not include cases covered with flaps based exercises of the uninjured digits and to maintain the fin-
on the paraumbilical perforators. gers in the safe position (MPJ flexion and interphalangeal
We have given an overall outline of the site of hand joint extension).
defect and flap design. However, flap design may be modi- Several authors have stressed technical tips to ensure
fied according to the size of the defect, the vascular ped- a successful reconstruction of hand defects with pedicled
icle of the flap, and patient comfort.6,7 Physiotherapy was abdominal flaps.4,8 These tips include adequate debride-
done daily and is supervised by the physiotherapist. The ment, respect of the vascular territory of the flap, minor
first therapy session (at the first postoperative day) was thinning of the flap at the margins, tubing of the flap if
attended by the surgeon to give instructions to obtain safe possible, and the use of mattress sutures or simple sutures

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Table 1. Comparison of Range of Motion at Day 1 Post-flap

Division in Patients Who Underwent Physiotherapy of the
Attached Hand before Flap Division and in Patients Who
Were Reluctant to Do the Exercises
Patients who Patients who
Underwent Were Reluctant
Physiotherapy of to Do the
the Attached Hand Exercises
Excellent range of motion at day 62 0
1 post-flap division (90%–
100% of the normal range of
motion)
Poor range of motion at day 1 0 8
post-flap division (<60% of
the normal range of motion)
P is highly significant (<0.00001) by the Fisher Exact test.

Table 2. Comparison of Residual Stiffness at Final Follow-

up in Patients Who Underwent Physiotherapy of the
Attached Hand before Flap Division and in Patients Who
Were Reluctant to Do the Exercises
Patients Who Patients Who
Underwent Were Reluctant
Physiotherapy of the to Do the
Attached Hand Exercises
No residual stiffness at 62 4
the final follow-up
No residual stiffness at 0 4
the final follow-up
P is highly significant (P = 0.0001) by the Fisher Exact test.
Fig. 6. Intraoperative view showing the extensive resection and
reconstruction of sarcoma of the thenar area (see text for details).

1 cm apart. We applied these principles in our cases and

prefer to use 3/0 polypropylene interrupted mattress
sutures. Another important principle is the method of
limb immobilization and maintenance of hand position
after surgery to avoid kinking of the pedicle.8–10 In our
cases, we made the flap pedicle long enough to allow phys-
iotherapy, but not too long to reduce the risk of kinking
of the pedicle. Previously reported methods of immobili-
zation usually include a combination of Velcro straps and
adhesive tape. We prefer a combination of an arm sling
and adhesive tape, as shown in Figure 5. We divide our
flaps at 18–20 days. However, techniques allowing early
flap division have been described using gradual or inter-
mittent clamping of the pedicle.11,12
Complications of abdominal flaps in hand reconstruc-
tion are well described in the literature and range from
5% to 40%.8,13 Complications are known to be more
frequently observed in elderly patients, patients with
diabetics, smokers, and in the presence of infection.8
Furthermore, in severe hand trauma, there is a more
pronounced hand edema and a higher risk of stiffness.
The low rate of complications in our series is probably
partly related to several favorable conditions. Most of our
patients were relatively young industrial workers with no
major comorbidities. Hand infection at the time of recon-
struction was not present in any of our cases. Our series
included only traumatic or oncologic hand defects in our
Fig. 5. A demonstration of our method of immobilization. anatomical area, and hence, generalized hand edema was

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Al-Qattan et al. • Pedicled Abdominal Flaps for Hand Reconstruction

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