Saturday, November 11, 2017

Syndactyly Revision Surgery

I enjoy performing surgery to correct syndactyly because it is a reliable procedure with high patient, family, and physician satisfaction.  But, as with any surgery, there are complications and adverse events that can happen in the short term or at longer follow- up.  The risk of complications related to syndactyly surgery is very low.  It includes risks of:

- nerve injury,
- loss of blood supply to the finger,
- infection

Each of these risks is very low especially if the surgery is performed by an experienced surgeon who can take steps to minimize each of these risks.  In our experience, even the risk of infection is lower than the risk in most surgeries.

More challenging in syndactyly reconstruction is the risk of adverse events or less the perfect outcomes.  I have previously posted on some of these in several posts including HERE.  These include:

- thickened scar
- discolored skin grafts
- web creep (the slow advancement of the skin between the fingers after the surgery)
- scar bands limiting finger extension
- fingernail abnormalities

Each of these is a risk no matter the experience of the surgeon.  The characteristics of the patient's syndactyly will affect the outcome of the surgery.  For example, a complex syndactyly (with bone connections) is known to be more difficult to correct and has a greater likelihood of fingernail abnormalities and web creep.  However, the experienced surgeon can take steps to limit each of these risks.  For example, it has been shown that avoiding a transverse incision for the commissural flap will limited skin tension and therefore limit web creep (Citation here). 

This child had complex syndactyly (bony connection and therefore more challenging to reconstruct) which was treated with reconstruction.  It affected the ring/ small finger of both hands.  There is a strong family history but each member of the family was affected differently.  He has had previous reconstruction with a graftless technique on the right and a 'standard' technique on the left with skin grafts (taken from the antecubital crease of the elbow).  While he is generally happy, the patient and his family do not like the creep on the right and the scar band which has developed- this band limits ring finger straightening.  Today, I rarely perform the graftless technique (dorsal commissural flap) utilized on his right hand, for two reasons.  First, I believe in the use of hyalomatrix as previously posted HERE.  And second, in some patients the flap migrates back dorsally and becomes noticeable as demonstrated in these pictures. 

Graftless syndactyly reconstruction.  Note the flap scar which has migrated.

Syndactyly reconstruction using skin grafts.

Palmar view showing a nice deep web on both sides after syndactyly reconstruction.

The right hand syndactyly, treated with a graftless technique, has developed a scar contracture with web creep.

This patient is scheduled for revision syndactyly surgery for the right hand.  We will deepen the web and use a z-plasty to 'break up" the scar band limiting the ring finger straightening.  We expect a very good long term outcome.


Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu

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