> ## Content Index > Fetch the complete content index at: https://www.theplasticsfella.com/llms.txt > Use this file to discover other available public pages before exploring further. # Volar Incisions – Bruner, Mid-lateral & others - URL: https://www.theplasticsfella.com/volar-incisions-bruner-mid-lateral-others/ - Published: 2021-03-13T16:15:48.000Z - Updated: 2025-02-07T14:22:32.000Z - Description: There are different techniques described for volar hand surgery. This article describes, illustrates, and compares Bruner, Mild-lateral, and other incisions. - Author: PlasticsFella - Tags: Upper Limb, #kurt > **In this Article** > > - [Key Points](https://www.theplasticsfella.com/volar-incisions-bruner-mid-lateral-others/#key-points) > - [Principles of a Hand Incision](https://www.theplasticsfella.com/volar-incisions-bruner-mid-lateral-others/#principles-of-a-hand-incision) > - [Bruner's Incision](https://www.theplasticsfella.com/volar-incisions-bruner-mid-lateral-others/#bruner-incision) > - [Midlateral Incision](https://www.theplasticsfella.com/volar-incisions-bruner-mid-lateral-others/#midlateral-incision) > - [Antero-lateral Longitudinal Incision](https://www.theplasticsfella.com/volar-incisions-bruner-mid-lateral-others/#anterolateral-longitudinal-incision) > - [References](https://www.theplasticsfella.com/volar-incisions-bruner-mid-lateral-others/#references) ## Key Points There are several described techniques for volar finger, hand and wrist incisions for different [zones of the hand](https://www.theplasticsfella.com/zones-of-the-hand/). The table below compares the two most commonly used in practice, Bruner and Mid-lateral. | | Bruner | Mid-Lateral | | ---------------------------------------------------------------------------------------------- | -------------------------------------------- | ----------------------------------------- | | Design | “Zig-Zag” | Straight-line | | Location | Volar flexion crease | Dorsal to flexion crease | | [Flexor](https://www.theplasticsfella.com///////verified/flexor-tendons-and-muscles/) Exposure | Good | Good | | Neurovascular Structures | Preserved | Division of dorsal branches | | [Scar](https://www.theplasticsfella.com///////verified/hypertrophic-vs-keloid-scar/) | Volar surface with potential for sensitivity | Neutral position during flexion/extension | --- ## Principles of a Hand Incision > The modern-day principles of hand incisions are largely founded on JM Bruner’s publications in 1951, 1966, 1967\. Modifications do exist , as discussed below. --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Screenshot-2020-05-13-at-10.56.06.png) ### The “Perfect” Incision The ideal hand incision should have the following​1​: 1. Maximal exposure of the structures 2. Minimal scarring and contracture (incisions cannot cross flexion creases) 3. Minimal neurovascular and lymphatic disturbance 4. Minimal impact on tendon gliding and joint motion ### Types of Incisions Several hand incisions have been described and the commonly used include: 1. Zig-Zag Incision (Bruner) 2. Mid-lateral incision (Bunnell) 3. Antero-lateral Incision (Koch and Mason) 4. Median Longitudinal Incision (McIndoe) ### Anatomy of a Hand Incision According to Bruner, the palmar creases of each finger joint have slight variation - DIPJ: single crease - PIPJ: double crease - MCPJ: ring and middle finger has double crease, index and little has single crease. According to Wood-Jones, between the flexion creases longitudinal lines are more prominent and represent the tension lines of Langer. These lines can be usual guide for limited incisions. --- ## Bruner Incision ### Design A Bruner’s incision is a volar zig-zag incision between flexion creases designed with 3 key principles in mind: 1. Reduce flexor contracture – straight-line incisions do not cross flexion creases. 2. Ensure flap vascularity – flap angles are 90 degrees or greater 3. Adequate access to structures – oblique incisions between flexion creases ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Bruners-Incisi-1.png) Bruner’s Incision: Positive and Negatives of this technique / Bruner’s Incision: Positive and Negatives of this technique In the 1950’s, “zig-zag” incisions became popularised for the surgical treatment of Dupuyteren’s disease. This was evolved into a volar approach to elective and non-elective hand conditions by Bruner in the 1950/1960s​1,2​. --- ### Positive and Negatives There is widespread acceptance for the utility of Bruner’s incisions. The following is a table discussing the pro’s and con’s of this surgical technique. | Positives | Negatives | | -------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------ | | Good exposure to [flexor tendons](https://www.theplasticsfella.com///////verified/flexor-tendons-and-muscles/) | [Scar](https://www.theplasticsfella.com///////verified/hypertrophic-vs-keloid-scar/) sensitivity | | Direct access | Volar skin sensory disturbance | | Preservation of neurovascular bundles | Contractures & adhesions still possible | | Possible to extend into palm/wrist | | | | | ### Modifications - [2008 Modification by Dancey et al](https://www.jprasurg.com/article/S1748-6815%2808%2900344-6/abstract?ref=theplasticsfella.com)​3​ - [1986 Modification by Hall et al](https://www.ncbi.nlm.nih.gov/pubmed/3734556?ref=theplasticsfella.com)​4​ --- ## Midlateral Incision ### Design The “Bunnell” incision (1949) is mid-lateral incision dorsal to the flexion crease designed with 3 key principles: 1. Preservation of neurovascular bundles in the volar flap 2. Neutral scar position in respect to finger flexion and extension 3. Good access to all structures ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Bruners-Incisi-1-1.png) Bruner’s Incision: Positive and Negatives of this technique ### Positives and Negatives The following is a table discussing the pro’s and con’s of this surgical technique. | Positives | Negatives | | -------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------- | | Good exposure to [flexor tendons](https://www.theplasticsfella.com///////verified/flexor-tendons-and-muscles/) | Indirect access to [flexor tendons](https://www.theplasticsfella.com///////verified/flexor-tendons-and-muscles/) | | Preservation of neurovascular bundles | Divides dorsal branches of Digital artery and nerve | | | Requires extension dissection, possible injury lateral structures (lateral bands, collateral and reticular ligaments) | | | Can inhibit post-operative function if lateral structures damaged | | | | Interestingly, the midlateral incision is preferred technique in [*Green’s Operative Hand Surgery*](https://www.elsevier.com/books/greens-operative-hand-surgery-2-volume-set/wolfe/978-1-4557-7427-2?ref=theplasticsfella.com) for [zone 1 and zone 2 flexor tendon repairs](https://www.theplasticsfella.com///////verified/flexor-tendons-and-muscles/) because it gives wide exposure and places intact skin and subcutaneous fat directly over the flexor tendon sheath. --- ## Anterolateral Longitudinal Incision *This is a less commonly used technique*. The antero-lateral longitudinal incision as used by Koch and Mason is designed on the principles of: 1. Incision volar to the neurovascular bundle 2. Dorsal retraction of neurovascular bundles after the skin is divide ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Bruners-Incisi-2.png) Antero-Lateral Incision of Hand ## References 1. 1\. Bruner JM. Incisions for plastic and reconstructive (non-septic) surgery of the hand. *British Journal of Plastic Surgery*. Published online 1951:48-55\. doi:[10.1016/s0007-1226(51)80006-7](https://doi.org/10.1016/s0007-1226%2851%2980006-7?ref=theplasticsfella.com) 2. 2\. BRUNER JM. The Zig-Zag Volar-Digital Incision for Flexor-Tendon Surgery. *Plastic and Reconstructive Surgery*. Published online December 1967:571-574\. doi:[10.1097/00006534-196740060-00010](https://doi.org/10.1097/00006534-196740060-00010?ref=theplasticsfella.com) 3. 3\. Dancey A, Titley OG. A modification of the Bruner incision for the hand and review of the literature. *Journal of Plastic, Reconstructive & Aesthetic Surgery*. Published online September 2008:1130-1131\. doi:[10.1016/j.bjps.2008.05.004](https://doi.org/10.1016/j.bjps.2008.05.004?ref=theplasticsfella.com) 4. 4\. Hall R, Vliegenthart D. A modified midlateral incision for volar approach to the digit. *J Hand Surg Br*. 1986;11(2):195-197\. doi:[10.1016/0266-7681(86)90258-5](https://doi.org/10.1016/0266-7681%2886%2990258-5?ref=theplasticsfella.com)