A Systematic Review of Outcomes and Complications of Primary Fingertip Reconstruction Using Reverse-Flow Homodigital Island Flaps

Evaluation of electrophotobiomodulation as a recent tool in the armamentarium of treatment of fingertip injuries

BACKGROUND

Traditional reconstructive options of fingertip injuries are technically difficult, usually need donor site skin grafting, leave visible scars, and need a protracted period of finger immobilization resulting in joint stiffness. Electro-photobiomodulation (EPBM), is the process of combining intense pulsed light and radiofrequency to modify tissues to help the body heal itself, lower inflammation, and promote wound healing.

PATIENTS AND METHODS

This study included 60 patients presented with fingertip injuries. Patients were randomly divided into two groups. Group 1 includes patients who were treated by EPBM. Group 2 includes patients who were treated by cross finger flap (CFF). Six months after complete healing, evaluation was performed for aesthetic and functional outcome and patient satisfaction.

RESULTS

Compared to group 2 patients, group 1 patients had statistically significant better sensory outcome, better total active motion of affected digits, grip strength, patient satisfaction, healing time, and plastic surgeon general aesthetic evaluation and also, they had statistically significant less adverse events and cold intolerance with absent donor site pain and deformity.

CONCLUSION

EPBM is safe and effective treatment of fingertip injuries which shortens the healing time, produces the best aesthetic and functional result while avoiding donor site morbidity of the traditional reconstructive options.

Reconstruction of Soft-Tissue Defects of the Thumb Using Reverse-Flow Homodigital Flaps: A Systematic Review

Introduction

Soft-tissue thumb defects are common reconstructive challenges, the main goals being restoration of tactile sensibility, range of movement, pulp padding, length, and cosmesis. The reverse-flow dorsoulnar and dorsoradial collateral artery flaps are homodigital flaps used to cover both distal dorsal and volar thumb defects. These flaps can be used as compound flaps including skin, fat, and/or nerves. As there is no critical analysis of these studies, this study aims to create a synthesized comprehensive systematic review.

Methods

Systematic review was performed using the databases PubMed, Embase, and Medline. Eligible studies followed the inclusion criteria: English language and all studies published to date. The primary outcome was flap survival. Other data collected included anatomical area of the defect, flap constituents and dimensions, donor-site closure and complications, transfer method, reoperation, revision, and functional outcomes.

Results

A total of 19 articles incorporating 189 flaps met the inclusion criteria. These flaps were categorized and analyzed as dorsoradial (50%), dorsoulnar (39%), and turnover flaps (11%). Dorsoradial flaps were used in fasciocutaneous fashion alone. Partial flap failures occurred in five cases. Dorsoulnar flaps were used as fasciocutaneous or as osteocutaneous flaps. Complete flap failure was reported in one patient alone, whereas partial necrosis was reported in four patients. Adipofascial turnover flaps had two partial flap failures reported but no complete failures. The overall complete and partial flap failure rates were 0.5 and 6.5%, respectively.

Conclusion

Reverse-flow homodigital random or axial-based flaps provide a reliable means of reconstruction for soft-tissue defects with reasonable success rate and good functional outcomes. They have a consistent anatomy with a good potential for personalization and therefore increased versatility.

Reconstructive Timing of Nail Preserved Fingertip Injury With Reverse Digital Artery Island Flap

BACKGROUND

This study aimed to compare the outcomes of reverse digital artery island flap (RDAIF) in primary and secondary reconstruction after failed replantation or composite graft method.

METHODS

This study retrospectively analyzed 42 patients that underwent RDAIF (18 primary and 24 secondary). Preoperative details (demographics, injury details, and waiting days) and postoperative outcomes (active arc of proximal interphalangeal [PIP] and distal interphalangeal (DIP) joints, extension loss of PIP, flexion arc of metacarpophalangeal joint, total active motion, flap sensation, the presence of numbness, Tinel's sign and cold intolerance) were evaluated. Quick Disabilities of the Arm, Shoulder, and Hand score (Quick-DASH) and patient satisfaction were also statistically compared between the 2 groups.

RESULTS

There was no significant difference in patient demographics between the 2 groups in sex, age, smoking and diabetic history, affected hand and finger, injury type and level, and flap area. The only difference was in waiting days. Similar sensory recovery and patient satisfaction were found in both groups. Range of motion in the DIP and PIP joints, extension loss of PIP, total active motion, and Quick-DASH were superior in the primary coverage group. Increasing age, subzone III injury, and secondary reconstruction were found to be the factors that adversely affected the postoperative range of motion.

CONCLUSIONS

Secondary reconstruction was more likely to result in joint contracture. In the event of a damaged fingertip amputation in older patients, primary flap reconstruction should be considered as the initial treatment of choice, with regard to the ultimate range of motion.

Clinical Outcomes and Complications of Primary Fingertip Reconstruction Using a Reverse Homodigital Island Flap: A Systematic Review

BACKGROUND

Reverse homodigital island flaps (RHIFs) are increasingly used to reconstruct traumatic fingertip injuries, but there is limited evidence on the efficacy of this technique. We performed a systematic review of the literature to establish the safety and functional outcomes of RHIF for traumatic fingertip injuries.

METHODS

Electronic searches were performed using 3 databases (PubMed, Ovid Medline, Cochrane CENTRAL) from their date of inception to April 2020. Relevant studies were required to report on complications and functional outcomes for patients undergoing RHIF for primary fingertip reconstruction. Data were extracted from included studies and analyzed.

RESULTS

Sixteen studies were included, which produced a total cohort of 459 patients with 495 fingertip injuries. The index and middle fingers were involved most frequently (34.6% and 34.1%, respectively), followed by the ring finger (22%), the little finger (6.7%), and the thumb (2.6%). The mean postoperative static and moving 2-point discrimination was 7.2 and 6.7 mm, respectively. The mean time to return to work was 8.4 weeks. The mean survivorship was 98.4%, with the pooled complication rate being 28%. The pooled complication rate of complete flap necrosis was 3.6%, of partial flap necrosis was 10.3%, of venous congestion was 14.6%, of pain or hypersensitivity was 11.5%, of wound infection was 7.2%, of flexion contractures was 6.3%, and of cold intolerance was 17.7%.

CONCLUSIONS

Reverse homodigital island flaps can be performed safely with excellent outcomes. To minimize complications, care is taken during dissection and insetting, with extensive rehabilitation adhered to postoperatively. Prospective studies assessing outcomes of RHIF compared with other reconstruction techniques would be beneficial.

Application of B-flow imaging and its enhanced mode in perforator mapping

AIM

To explore the value of B-flow (B-mode blood flow) imaging and its enhanced mode in perforator mapping.

MATERIALS AND METHODS

Before surgery, B-flow imaging, enhanced B-flow imaging, colour Doppler flow imaging (CDFI), and contrast-enhanced ultrasound (CEUS) were used to detect the skin-perforating vessels and small vessels in the fat layer of the donor site. Taking the intra-operative results as the reference standard, the diagnostic consistency and efficiency of the four modes were compared. Statistical analysis was performed using the Friedman M-test, Cochran's Q-test, and the Z-test.

RESULTS

Thirty flaps were excised, with 34 skin-perforating vessels and 25 non-skin-perforating vessels, as confirmed during surgery. In order of the number of skin-perforating vessels detected, the results showed that enhanced B-flow imaging detected more vessels than B-flow imaging and CDFI (all p<0.05), CEUS detected more vessels than B-flow imaging and CDFI (all p<0.05), B-flow imaging detected more vessels than CDFI (p<0.05). All four modes had remarkable and satisfactory diagnostic consistency and effectiveness, but B-flow imaging was the best (sensitivity 100%, specificity 92%, Youden index 0.92). In order of the number of small vessels in the fat layer detected, the results showed that enhanced B-flow imaging detected more vessels than CEUS, B-flow imaging, and CDFI (all p<0.05). CEUS detected more vessels than B-flow imaging and CDFI (all p<0.05).

CONCLUSION

B-flow imaging is an alternative method for perforator mapping. Enhanced B-flow imaging can reveal the microcirculation of flaps.

The Homodigital Propeller Flap: A New Tool for Fingertip Reconstruction. Surgical Technique, Anatomical Study, and Clinical Relevance

BACKGROUND

An ideal flap for fingertip injuries should cover a significant loss of substance and avoid joint flexion to prevent later contracture and joint stiffness. In this study, the authors describe a modified homodigital island flap-the homodigital propeller flap-to better meet these requirements.

METHODS

An anatomical model of fingertip loss is used to analyze the advancement achieved without flexion of the finger. Twenty-four fresh-frozen fingers were dissected. Wires were inserted to maintain joints in extension. The skin paddle was similar in location to a homodigital island flap. The neurovascular bundle was dissected without exceeding the proximal interphalangeal joint and was released from the proximal half of the paddle. Then, the homodigital propeller flap was rotated 180 degrees to cover the defect. A mixture of India ink and barium sulfate was injected into the pedicle artery after the release of the proximal half of the flap from the neurovascular pedicle to assess residual flap vascularization. India ink highlights the residual subcutaneous vascularization network of the cutaneous paddle. A radiographic study of the flap was then performed to visualize the subcutaneous vascular network of the cutaneous paddle.

RESULTS

The homodigital propeller flap achieved an average cutaneous advancement of 18 mm (range, 15 to 22 mm) and allowed full coverage of cutaneous defects for all fingers while maintaining the proximal interphalangeal joint in strict extension.

CONCLUSIONS

The homodigital propeller flap is a refinement of the classic homodigital island flap. It allows efficient coverage of fingertip defects because of a large advancement without flexion of the finger reducing the risk of stiffness.

Long-term outcome of a "short" anterograde homodigital neurovascular island flap with a simple or double V-Y plasty

INTRODUCTION

Anterograde homodigital neurovascular island flaps are very useful for reconstructing proximal fingertip amputations with exposed bone but have the disadvantage of bringing about proximal interphalangeal joint (PIPJ) stiffness. The addition of a single or double V-Y plasty increases mobility without having to extend the dissection beyond the PIPJ. The purpose of this study was to examine the long-term functional outcome of patients who received a "short" anterograde homodigital neurovascular island flap with a single or double V-Y plasty. Our primary hypothesis was that this flap did not induce PIPJ stiffness and our secondary hypothesis was that it preserved good fingertip sensation.

MATERIALS AND METHODS

This was a retrospective study of patients operated between August 2017 and February 2019. The inclusion criteria were the following: a fingertip amputation caused by either a crush or laceration injury with exposed bone, treated during the acute phase of the injury or for secondary necrosis (attempted replantation or subtotal amputation) and classified as type II oblique palmar, type III or type IV amputations according to the Allen classification system. The assessment criteria were: joint mobility, sensory evaluation with the two-point discrimination and Semmes-Weinstein monofilament tests, time to healing, postoperative complications, postoperative splinting, duration of work stoppage, perioperative smoking, cold intolerance, touch hypersensitivity, nail deformity and excluded finger.

RESULTS

Nine patients (mean age 53.9 years [32-67]) were operated, of which eight long fingers and one thumb. One procedure was complicated by skin flap necrosis. At the mean follow-up of 22.4 months [16-31], the mean mobility for the metacarpophalangeal joint (MCPJ), proximal interphalangeal joint and distal interphalangeal joint (DIPJ) were 92-0-0°, 97.8-1.5-0° and 60.3-6.8-0°, respectively. In comparison to the contralateral side, a significant difference was only detected in the DIPJs. The mean two-point discrimination in the proximal portion of the flaps were 7.1mm on the ulnar side (p<0.05) and 7.6mm on the radial side (p<0.01), while in the distal portion they were 7.3mm (p<0.01) and 7.8mm (p<0.01). The Semmes-Weinstein monofilament test also detected significantly reduced sensation.

CONCLUSION

The combination of a "short" anterograde homodigital neurovascular island flap with a single or double V-Y plasty seems to avoid PIPJ stiffening while preserving good fingertip sensation.

LEVEL OF EVIDENCE

IV; retrospective study.

Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments

There are many outcome measures to choose from when caring for or studying fingertip and nail bed trauma and treatments. This article outlines general outcome measures principles as well as guidelines on choosing, implementing, and interpreting specific tools for these injuries. It also presents recent results from the literature for many of these measures, which can help learners, educators, and researchers by providing a clinical knowledge base and aiding study design.

Locoregional Options for Acute Volar Pulp Fingertip Defects

The volar fingertip is a unique anatomic structure, delicate yet durable, that allows us to navigate the world, acquire information from our surroundings, and express ourselves. Injuries to the volar finger can cause permanent dysfunction and should be taken seriously. In treating injuries of the volar fingertip, the surgeon has an opportunity to choose from a host of reconstructive options and provide the patient with an outcome suitable to their needs. In doing so, the hand surgeon is well-positioned to aim for the reconstructive ideal of restoring both structure and function.

Secondary Management of Nonnail Perionychial Deformities: Restoring Aesthetic and Functional Subunits

Delayed finger and thumb tip reconstruction should try to optimally reconstruct perioncyhial aesthetic and functional units by replacing tissue as closely resembling the original loss as possible. Avoid thinking in terms of a "reconstructive ladder" but rather going directly to the reconstructive choice that seems most suited to the task. Some reconstructive choices may seem more attractive because of their simplicity, but may not necessarily give the best functional and aesthetic result. Free flaps and the newer advancements with vascular island flaps give many more and versatile reconstructive options.

Treatment of Fingertip Injuries

The goal of care when treating fingertip injuries is to minimize the risk of infection while maximizing function, tactile sensation, digit length, pulp padding, and appearance. This outcome can be achieved with careful soft-tissue coverage and, if possible, nail-bed preservation. When replantation for a fingertip amputation is not possible for anatomic or logistical reasons, local or regional flap reconstruction can be a useful alternative to gain early soft-tissue coverage and allow more functional rehabilitation. Reviewing current fingertip soft-tissue coverage procedures and demonstrating key anatomic and technical points with cadaveric dissections provides a foundation for the incorporation of these techniques into practice.

Propeller perforator flaps from the dorsal digital artery perforator chain for repairing soft tissue defects of the finger

Background

When restoring the appearance and function of the fingers, hand surgeons face a challenge in choosing a suitable surgical method to repair finger skin defects.

Methods

In this study, we designed a long elliptical flap based on a propeller perforator flap and located slightly toward the dorsal lateral aspect of the finger. The flap with a pedicle consisting of the dorsal perforator of the distal digital artery and dorsal digital artery perforator chain is rotated to cover a large wound on the distal end. From December 2014 to December 2017, 10 patients with finger soft tissue defects were treated with the propeller perforator flap described in this study.

Results

All flaps survived after surgery, and 2 had a transient venous congestion. After a follow-up period of 3 to 12 months, the static two-point discrimination of the flap was 8.06 ± 1.75 mm, and the range of motion was 149.4 ± 12.9°. This designed flap can span several angiosomes supplied by the perforators. Due to the inclusion of a vessel chain between the dorsal digital artery perforators, the length-to-width ratio of the flap can be up to 3:1.

Conclusions

This technique increases the size of flap that can be harvested safely while retaining a reliable blood supply. The present study describes a new method for repairing soft tissue defects of the finger by using the technique of propeller perforator flaps based on dorsal digital artery perforator chains.

Trial registration

The registration number of this study is ChiCTR1800014588; it has been retrospectively registered with Chinese Clinical Trial Registry (chictr.org.cn), 18/11/2019.

Supermicrosurgery in fingertip defects-split tibial flap of the second toe to reconstruct multiple fingertip defects: A case report

BACKGROUND

Injuries to multiple fingertips pose a significant treatment dilemma. Numerous reconstructive options exist, all with the ultimate goal of restoring function and sensibility to the injured fingertips.

CASE SUMMARY

A 24-year-old male suffered injury to multiple fingertips of the right hand, resulting in exposed distal phalanges of the middle, ring, and small fingers. The amputated distal stumps were not possible for replantation. Free flap coverage was selected in order to achieve better functional outcome. The fingertip defects were covered by performing a right second toe split tibial flap using local anesthesia at the harvest site and brachial plexus nerve block for the right upper extremity. At 6-month follow-up, all three of the reconstructed fingertips had some preserved nail growth, Semmes-Weinstein Monofilaments testing was equal to the contralateral side and the Static Two-Point Discrimination were comparable to the contralateral side.

CONCLUSION

This report provides a novel reconstructive option for the management of multiple fingertip injuries and demonstrates the utility of supermicrosurgery in management of these injuries.

Comparison of Innervated Digital Artery Perforator Flap Versus Homodigital Reverse Flow Flap Techniques for Fingertip Reconstruction

PURPOSE

The aim of this study was to investigate and compare outcomes of 2 different flap techniques for fingertip reconstruction: innervated digital artery perforator (IDAP) flap and homodigital reverse-flow flap.

METHODS

Medical records of 33 patients who underwent fingertip reconstruction either with an IDAP flap (15 patients) or with a homodigital reverse-flow flap (18 patients), between 2014 and 2016, were evaluated retrospectively. In both study groups, full-thickness skin grafts harvested from the proximal/volar side of the forearm were used to cover the flap donor site. Flap survival, venous congestion, cold intolerance, static 2-point discrimination, flap size, duration of surgery, time to return to work, proximal and distal interphalangeal joint range of motion, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time were evaluated.

RESULTS

All the major outcomes, including flap survival, cold intolerance, static 2-point discrimination, flap size, time to return to work, range of motion values for proximal and distal interphalangeal joints, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time, were similar between the 2 flap methods. Mean duration of surgery was shorter in the IDAP flap group. Marginal flap necrosis occurred in 1 IDAP flap, and there was complete survival of the remainder of the flap after debridement. Temporary venous congestion was seen in 3 IDAP flaps, all of which resolved with nonsurgical measures.

CONCLUSIONS

Similar success rates and satisfactory outcomes were achieved with IDAP flap and reverse-flow flap techniques used for fingertip reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Reverse vascular pedicle digital island flap with preservation of the dorsal branch of the digital nerve

A reverse vascular pedicle digital island flap is a useful treatment option for reconstruction in fingertip amputation. We describe a surgical procedure to preserve the dorsal branch of the digital nerve in the middle phalanx during elevation of this flap with favourable outcomes.

A Systematic Study of Vascular Distribution Characteristics and Axis Design of Various Flap Types

Background

The aim of this study was to define blood flow characteristics of multiple types of flaps and the theoretical basis of flap axis design.

Material/Methods

Sixty Sprague-Dawley (SD) rats were randomly divided into 6 groups: a normal skin group, and 5 groups with different types of flap: abdominal flap group, dorsal flap group, single-perforator flap group, double-perforators flap group, and delayed cutaneous nerve flap group. The vascular distribution characteristics of normal skin and various flap types were observed by gross morphology of specimens and X-ray after perfusion.

Results

There were distinct differences in vascular anastomosis and density in dorsal and ventral SD rats. The area of flap survival in the dorsal flap group was superior to that in the abdominal flap group, but the flap axis of the 2 groups passed straight through the middle of the pedicle. The flap surviving area in the double-perforators flap group was remarkably larger than in the single-perforator flap group, while the flap axis in the single-perforator flap group passed straight through the perforators, and in the double-perforators flap group there was a linking vessel between the 2 perforators. There were linking and reticulate vessels, in addition, linking vessels and cutaneous nerves were concomitant in the delayed cutaneous nerve flap group. The flap axis was the travel route of the cutaneous nerve.

Conclusions

Variations in flap blood supply patterns and axes with alterations based on flap types have implications for flap survival. Understanding blood flow characteristics within each flap type and accurately designing the flap axis is essential for flap survival.

Retrospective study to evaluate the treatment of digital pulp lesions using a homodigital flap

Objective

To assess the homodigital flap surgical procedure, as well as the function of the finger, pain, sensation, esthetics, and patient satisfaction.

Method

Retrospective analysis of records and questionnaires of patients who underwent this surgical technique between the months of May 2013 and October 2016. Eight were included in the study, with an average follow-up period of 23 months. Patients with digital pulp lesions of the thumbs and those who did not perform rehabilitation were excluded. All underwent the two-point discrimination test, the Semmes–Weinstein test, and range of motion evaluation. The age varied from 22 to 59 years (average of 32.9), six (75%) being male patients.

Results

Three patients (37.5%) had involvement of the right hand and five of the left (62.5%). Regarding the etiology, seven suffered injury and one a chemical burn. The average distance obtained from the two-point discrimination test was 7.3 mm. All patients who underwent the Semmes–Weinstein test obtained response to the purple filament. The average sum of the range of motion of the affected digit was 98.9%. The flap area was on average 294.4 mm². The return to work averaged seven weeks. A positive Tinel sign was found in the donating area and two reported intolerance to cold. Partial or total necrosis of the flap was not observed.

Conclusion

The homodigital flap technique presented satisfactory esthetics and functional results regarding feasibility, sensation, and digital mobility in pulp lesions.

Supermicrosurgery: History, Applications, Training and the Future

Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon's practice.

Why borrow from Peter when Paul can afford it? Reverse homodigital artery flap for fingertip reconstruction

Background:

Fingertip injuries that are complicated by pulp loss, bone or tendon exposure will need a flap cover. Cross finger flap is commonly used to cover such defects. However, patients are apprehensive about injuring the uninjured finger as a donor site. Reverse homodigital artery flap (RHAF) can provide reliable vascularised cover to such defects.

Aims:

This study aims to assess the functional and aesthetic outcomes along with the patient satisfaction of RHAFs done for fingertip defects.

Materials and Methods:

RHAFs done in 18 patients operated between August 2015 and October 2016 were retrospectively analysed on flap survival, sensory recovery, range of movements, hypersensitivity, cold intolerance, flexion contracture and donor site morbidity.

Results:

Seventeen of the 18 flaps done survived completely. One flap had partial necrosis of 3 mm that healed conservatively. Middle finger of the right hand was the most commonly injured finger. Touch, pain and pressure sensations recovered in 8–12 weeks. Two-point discrimination was 4.5 mm at 6 months. The deficit of 5° s was present at distal interphalangeal joint during active flexion at 6 months. Cold intolerance and flexion contracture were not seen and 2 instances of hypersensitivity at 2 months got cured conservatively after 4 months. Overall satisfaction of patients was 8/10.

Conclusion:

RHAF provides single staged well-vascularised cover for fingertip injuries with good sensory recovery without damaging the adjacent uninjured finger. Hence, it can be a reliable flap for fingertip reconstruction in selected cases.

Microsurgical Flaps in Repair and Reconstruction of the Hand

The authors' strategy for soft-tissue coverage of the hand is presented. The concept of replacing like with like and reconstruction with similar adjacent tissue enhances functional and aesthetic outcomes. In this viewpoint, the pedicle perforator flap is an ideal flap. A decision-making algorithm to select an ideal flap for a particular hand defect is challenging, requiring experiential consideration of functional outcome, appearance, donor-site morbidity, and patient satisfaction. To assist surgeons in determining the most appropriate flap with more evidence, studies are necessary to compare the outcomes of each flap by evaluating hand function, aesthetics, donor site morbidity, and patient satisfaction.

Innervated dorsoradial perforator free flap: A reliable supermicrosurgery fingertip reconstruction technique

INTRODUCTION

This study demonstrates the use of a modified free innervated DRAP flap utilizing the supermicrosurgery technique for fingertip reconstruction.

MATERIALS AND METHODS

From January 2010 to February 2014, 20 cases of fingertip reconstruction were performed using a short pedicle mini innervated transverse DRAP flap. The patients demographics, the mechanism of injury, the defect size and anatomical location, the source of pedicle vessels, the recipient vessels, the nerve branch used for innervation, the follow-up and sensation outcomes are reported. Three cases are presented demonstrating different anatomical fingertip injury reconstructions.

RESULTS

20 consecutive traumatic fingertip injuries (M:F-14:6) were reconstructed with a free DRAP flap from the same hand. 6 index, 6 middle, 5 ring and 3 little finger defects were included in this study. All procedures were performed under regional anaesthesia and sedation. There were no intra- or post-operative complications. The average operative time was 105 (85-120) minutes. Each flap size was matching the size of the defects. All donor sites achieved primary closure and good cosmesis. The average follow-up was 12.8 (6-28) months. Follow-up demonstrated a static two-point discrimination of the flaps with an average distance of 5.5 (4-7) mm.

CONCLUSION

The innervated DRAP flap has proven to be an easy, reliable and effective sensate fingertip reconstruction option, utilizing the supermicrosurgery technique.

LEVEL OF EVIDENCE

Level IV, retrospective series.

Reconstruction of two fingertip amputations using a double thenar flap and comparison of outcomes of surgery using a single thenar flap

BACKGROUND

Although thenar flap for single fingertip amputation is a common and popular surgical technique, double thenar flap technique for patients with two fingertip amputations has rarely been reported in the literature. The purpose of this case-control study was to introduce the double thenar technique and compare the clinical outcomes between single thenar flap and double thenar flap surgical treatments.

METHODS

From January 2005 to December 2014, 92 patients with single fingertip amputations were treated with thenar flap (Group I) and 28 patients with two fingertip amputations were treated with double thenar flap (Group II). These 120 patients were followed-up for a minimum of 12 months postoperatively. At the latest follow-up, the two groups were assessed for pain, cold intolerance in the reconstructed finger, functional outcomes by Chen's criteria, and subjective patient satisfaction.

RESULTS

At the final follow-up, all flaps in both groups had survived. No flap failure occurred. There was no significant difference in cold intolerance (p=0.783), donor site pain (p=0.728), fingertip pain (p=1.000), or paresthesia (p=0.514) between the two groups. A total of 100 (83.3%) patients were completely or fairly satisfied. There was no significant difference in satisfaction between the two groups (p=0.801). According to the Chen criteria, 102 (85%) patients had excellent or good results.

CONCLUSION

This study demonstrated that the double thenar flap technique used for patients with two fingertip amputations produced complete survival with functional outcomes comparable to those of the single thenar flap technique at the last follow-up.

Evaluation of sensory function and recovery after replantation of fingertips at Zone I in children

Sensory function is the most significant criterion when evaluating the prognosis of replanted fingers. Current clinical research has focused on surgical techniques and indications for finger replantation; however, few studies have focused on recovery of finger sensory function after replantation. This study retrospectively assessed data of eight patients who had undergone nine Zone I replantations of the fingertips in the First Affiliated Hospital of Sun Yat-sen University of China from July 2014 to January 2016. Variations in the extent of damage, with the residual vessels or nerves in some fingers being too short or even missing, prevented tension-free suture repair in some patients. Thus, repair of four of the nine fingertips included arteriovenous anastomosis, the remaining five undergoing arterial anastomosis during replantation of the amputated fingers. Three patients underwent nerve repair, whereas the remaining six cases did not. Fingertip replantations were successful in all eight patients. Compared with the patients without vascular anastomosis, no obvious atrophy was visible in the fingertips of patients who did undergo vascular anastomosis during replantation and their sensory function did recover. Fingertip replantation provides good sensory function and cosmetic outcomes when good artery and vein anastomoses have been created, even when digital nerves have not been repaired.