O0798 Oct.3: 1:10pm - A Novel ‘Starfish’ Flap for Syndactyly Release: Technique and Early Results

Background/Purpose:
Multiple incisions and flaps have been designed for congenital syndactyly release. Despite advances in synthetic dermal substitutes, graftless surgery has been advocated to decrease scarring, surgical time, and perhaps improve cosmesis. Dorsal skin rearrangement is the most common technique to add vascularized flaps to the release. We describe a novel technique, using a ‘starfish’ dorsal commissure flap, which incorporates a z-plasty advancement of the lateral commissure leaving transverse scars over the metacarpophalangeal (MCP) joints along Langer’s lines.

Methods:
The ‘starfish’ flap presented here is designed with a dorsal star pattern for the commissure instead of a traditional rectangular flap. Its proximal points are placed centrally over each of the 2 involved MCP joints and a standard rectangular commissure is sized to fit ⅔–¾ of the length of the proximal phalanx. Lateral wings are drawn proximally on the commissure flap with medial and lateral points in line with the medial and lateral borders of the affected digits. The distal aspect of the commissure flap is broken with a proximal inset to limit transverse scarring in the created web. Zig-zag incisions are extended from either distal point of the star to the fingertip dorsally, with mirror-image zig-zag incisions volarly. After separation, the lateral wings are advanced in a z-plasty fashion into the lateral commissure, leaving a transverse scar line dorsally, and the distal flap is inset volarly to create the web. Skin grafts are utilized as needed, typically in the middle-to-distal third of the digits, especially with complex syndactyly. Patients are casted for 3 weeks postoperatively. A retrospective review was performed to examine early outcomes after utilization of this novel flap design.

Results:
We identified 14 webspaces separated in 9 patients using the Starfish flap design from January 2018-2020. Eight were performed without skin grafts, and 6 required 1-3 skin grafts each, all at the middle or distal phalanx level. Mean follow-up time was 178 days (range 3 weeks – 10 months). Early web creep was only seen in 1 patient, after a graftless ring-small partial simple release. Four patients had mild loss of motion: 1 with complex symbrachydactyly, 1 with amniotic band syndrome and missing phalanges, 1 who underwent revision surgery for scarring after a failed release, and 1 patient with ring/small syndactyly and likely DIP joint dysplasia. One patient, age 10, was noted to have mild sensory loss postoperatively which resolved over time.

Conclusion:
We present here a novel ‘starfish’ flap for syndactyly release in children, designed to avoid skin grafting proximally in the lateral commissure and for use in graftless technique when appropriate. We report good early outcomes without any flap necrosis and only 1 patient with early web creep, with ongoing monitoring for long-term follow-up in progress.