Island dorsalis pedis skin flap in combination with toe or toe segment transfer based on the same vascular pedicle

Superficial Peroneal Neurocutaneous Flap for Coverage of Donor Site Defect After the Combined Transfer of Toe and Dorsal Foot Flap

BACKGROUND

Reconstruction of digital loss with soft tissue defects remains a tough challenge. Although a combined flap of toe and dorsal foot skin provides a good option for "like-for-like" hand reconstruction, the disappointed donor site morbidity prevents it from popularity. In this study, we presented experiences of the superficial peroneal neurocutaneous (SPNC) flap for donor site closure after the combined toe and dorsal foot flap transfer.

METHODS

Superficial peroneal neurocutaneous flaps were used to cover foot donor site defects in 9 patients. The flaps harvested from feet including 3 cases of wrap-around flap with dorsal foot flap, 4 cases of 2nd toe flap with dorsal foot flap, 2 cases of 2nd and 3rd toe flap with dorsal foot flap. The flap size, operation time, and complications were documented, and the donor sites were evaluated by the subjective outcome measure, the foot evaluation questionnaire, and the Vancouver Scar Scale.

RESULTS

All flaps but one survived completely without complications. Marginal necrosis occurred in the distal part of the flap in one case, which was treated by daily dressings. The skin grafts on the lower leg healed uneventfully. The average operation time of flap transfer was 40 minutes. Follow-up ranged from 9 to 16 months, and patients were content with the results of the foot donor site according to the outcome measures. All the patients were able to wear normal shoes walking and running with a normal gait, and none sustained complications of skin erosion or ulceration. Protective sensibility was obtained in all the flaps. Two patients complained of cold intolerance and 2 could not wear a thong sandal. The donor site scars on the lower leg were measured 3.2 on average on the Vancouver Scar Scale.

CONCLUSIONS

The SPNC flap is a practical procedure for donor site closure on the foot, especially when extra dorsal foot skin is elevated with a toe flap for hand reconstruction.

The Indications for Toe Transfer after “Minor” Finger Injuries

Toe-to-hand transfer is widely considered to be unjustified for “minor” finger injuries. In this invited personal view article the indications for toe-to-hand transfer for finger amputation and neurocutaneous and major pulp defects are discussed, and a classification of multidigital injury that has both prognostic and decision-making value is presented. In the author's opinion a toe transfer should always be considered as an option when reconstructing “minor” finger injuries, as it can reproduce significant long-term benefit to the hand and the patient's sense of well being. The procedure should be carried out in the acute period, not only because it is technically easier and better for hand function, but above all because the surgeon can save structures that will be lost if the transfer is delayed.

Severe mutilating injuries to the hand: guidelines for organizing the chaos

Major hand injuries have become a rarity in Western countries. The fact that there are well trained teams devoted to their management, should not obscure the fact that the first emergency surgeon has the major role of setting the foundations for a reconstruction. Understanding the goal to be sought: the 'acceptable hand' (one with three fingers, with near normal length, near normal sensation and a functioning thumb), is hoped to be of great help in primary care. Preservation of vital structures such as joints, flexor tendons, and vessels, in the initial debridement, which will help to build this 'acceptable hand' are discussed. The general guidelines for management of finger amputation and soft tissue problems are also given.

The tibial second toe vascularized neurocutaneous free flap for major digital nerve defects

PURPOSE

Most digital nerve defects can be reconstructed by means of nonvascularized nerve grafts or artificial tubes, for example. When the bed is poor, the defect is long, or there is a concomitant soft-tissue loss; however, a vascularized nerve graft may be a better option. Our purpose is to introduce a method of 1-stage reconstruction of complex neurocutaneous defects in the fingers and to report the results and clinical effectiveness at a minimum 1-year follow-up period.

METHODS

From 1997 to 2005 there were 6 consecutive patients who had a combined soft-tissue and digital nerve defect reconstructed by a vascularized neurocutaneous flap from the tibial (medial) side of the second toe. Three were acute and 3 were chronic cases. One flap was used for the ulnar side of the thumb, 2 for the radial aspect of the index finger, 1 for the radial of the small finger, and 2 for the ulnar side of the small finger. The nerve gap averaged 4.2 cm, and the flap size averaged 3.2 x 2.1 cm. The flaps were revascularized with standard microsurgical techniques to local vessels in the fingers. The nerves were sutured with epineural stitches. A split-thickness skin graft was used to close the donor site of the toe.

RESULTS

All flaps survived without complications. At the latest follow-up evaluation static two-point discrimination (s2PD) averaged 8 mm on the pulp. Three patients had normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of that of the normal side. Five patients rated their feeling as excellent on a subjective scale. The Disabilities of the Arm, Shoulder, and Hand questionnaire score averaged 5.

CONCLUSIONS

The tibial neurocutaneous second toe free flap is suitable for reconstructing a missing nerve and soft-tissue defect in the finger. We found good functional recovery and high satisfaction in this group of patients. The donor site morbidity has been minimal, although delayed healing is common.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The use of the reverse radial fasciosubcutaneous flap to provide soft tissue coverage and a distal recipient artery in a difficult case of toe-to-thumb transfer

Traumatic amputation of the thumb is a devastating injury. Toe-to-hand [Wei FC, Chen HC, Chuang CC, Chen HT. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1992;93:345; Wei FC, Tarek AE. Toe-to-hand transfer: current concepts, techniques and research. Clin Plast Surg 1996;23:103] transfer is a sophisticated option for replacing this vital structure, but this challenging procedure, is even more demanding if recipient vessels are difficult to locate, inadequate or even absent. Another frequently encountered difficulty in cases of traumatic thumb amputation is inadequate soft tissue cover in the region of the amputation stump or the first web space. Often this defect or potential defect requires a preliminary tissue transfer procedure, before toe-to-hand transfer can be considered.

Management of soft tissue deficiency of the hallux: salvage in trauma, diabetes, and following surgical complications

Loss of the hallux can lead to significant gait problems and cause difficult biomechanical problems with weight bearing. Amputation of the first ray should be avoided when possible. Soft tissue defect of the hallux can be particularly difficult to manage because of the absence of local muscle tissue for coverage. In younger patients, soft tissue loss usually is related to trauma; an understanding of the techniques that are available for coverage are important to maintain length and function of the first ray. Diabetic neuropathy and resultant ulceration of the hallux or metatarsophalangeal joint is another common cause of soft tissue deficiency that may lead to deep infection and potentially result in amputation. Certain systemic problems, such as inflammatory diseases or gout, can cause significant degeneration of the local tissues which also can be problematic. Wound dehiscence or loss of skin flaps that are created during surgery represent further difficulties that may be encountered. This article reviews the common causes of amputation of the hallux and the principles that are necessary for salvage of the digit.

Overcoming soft-tissue deficiency in toe-to-hand transfer using a dorsalis pedis fasciosubcutaneous toe free flap: Surgical technique

Reconstruction of combined finger and soft-tissue defects poses a technical surgical challenge. We present our experience with a hybrid flap: the dorsalis pedis fasciosubcutaneous-toe free flap. In a single stage, this flap solves the problem of medium-sized defects associated with digit losses in the hand. Donor-site morbidity has been minimal.