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My First FDMA Flap

By Michelle Zec, MD

“I thought it would be a good idea to try out a technique that I haven’t done before, Your Honor.”

During fellowship, one of my staff was fond of saying that you should always consider how your surgical plan sounds with the words “your Honor” added to the end. 

Exploring and trying new techniques is essential to one’s growth as a surgeon but with that important caveat, “First, do no harm.” So how to proceed?

I recently performed my first First Dorsal Metacarpal Artery (FDMA) flap on a twenty year-old gentleman with an avulsion injury to his thumb. His thumb was amputated through the IP joint with exposed proximal phalanx.  Shortening was an option, but I was keen to avoid this if possible. The patient is an aspiring photographer, so dexterity and sensibility were important to him. I ran through a short-list of other potential coverage options, but I kept coming back to the FDMA flap.

Reconnaissance. For elective cases, we often have the luxury of lead time to prepare for a case, but this is less true for trauma. I find that I am often “scouting” for techniques that I might need to employ in a trauma setting and gathering resources as they turn up at courses, conferences or on the ListServ. Having already gathered a handful of resources on this flap, it didn’t seem like a big stretch to try out for this patient.

Find a friend. “I thought it would be a good idea to have a colleague assist me with this new technique, Your Honor.” “Yes, that sounds credible.” Two heads are better than one. I popped my head into my colleague Dr. Steve McCabe’s office, “Can I run a case by you?” Steve agreed to see the patient and graciously agreed to join me for the case. We weighed the pros and cons of different coverage options, discussed those with the patient and his family, and based on his input and our combined impression, chose the FDMA flap.

Perform. We shared resources before the case and reviewed our game plan outside the OR. As we elevated the flap, we recited the key steps as we went. Once the flap was raised and inset, we relaxed, a little bit. The flap looked good post-op day 1, but truthfully, we didn’t completely relax until his first outpatient visit. It still looked good!

Debrief. The patient continues to improve post-operatively – his wounds are healing, his motion is improving, the flap is sensate and he’s becoming accustomed to his shorter thumb. After his OR, Steve and I debriefed the case – what went well and what we would do differently. We continue to revisit this as the patient progresses through his recovery.

Share. It’s definitely rewarding when a new technique goes well, but more importantly it’s important to share what works and what doesn’t.  Innovation should be driven by the patient’s needs and implemented with their full consent. The need to engage colleagues to reduce the risk of poor outcomes is a point worth considering. Thank you to all those who have shared their experiences by publishing techniques, producing videos, teaching courses and sharing tips on the ListServ. We all benefit, and our patient’s benefit, from these shared experiences. I rest my case, Your Honor.

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