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Tos P, Fin A, Crosio A, Chen C. Microsurgical reconstruction of the nail. HAND SURGERY & REHABILITATION 2024; 43S:101676. [PMID: 38447746 DOI: 10.1016/j.hansur.2024.101676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 03/08/2024]
Abstract
Very often, post-traumatic defects involve multiple tissues. Microsurgical techniques can reconstruct them with tissues taken from a toe: from the nail complex alone to compound osteo-onychocutaneous flaps. Several techniques have been reported since the 1980s. This paper describes techniques and indications for microsurgical nail reconstruction. Technique differs according to the deficit, and first and foremost whether only the nail complex is involved or whether other components of the fingertip important for the normal growth of the nail, such as the phalanx bone or the finger pad, are also missing (toenail flaps and the custom-made osteo-onychocutaneous flaps). For most patients the absence of a fingernail is an esthetic rather than functional concern, and the outcomes of microsurgical reconstruction are far from ideal in this regard. We prefer to reserve reconstruction for symptomatic patients with functional impairment.
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Affiliation(s)
- Pierluigi Tos
- Department of Hand Surgery and Reconstructive Microsurgery, ASST Gaetano Pini-CTO, Via Gaetano Pini 9, 20122 Milano, Italy.
| | - Alessandra Fin
- Department of Hand Surgery and Reconstructive Microsurgery, ASST Gaetano Pini-CTO, Via Gaetano Pini 9, 20122 Milano, Italy
| | - Alessandro Crosio
- Department of Hand Surgery and Reconstructive Microsurgery, ASST Gaetano Pini-CTO, Via Gaetano Pini 9, 20122 Milano, Italy
| | - Chao Chen
- Department of Hand & Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, China
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Cai L, Zhang X, Zhang Y, Xiang G, Luo P, Li Z, Zhou F. Reconstruction of Composite Soft Tissue Defect in the Distal Finger Using Partial Toenail Flap Transfer. Orthop Surg 2023; 15:2716-2723. [PMID: 37644638 PMCID: PMC10549822 DOI: 10.1111/os.13829] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/13/2023] [Accepted: 06/19/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Composite tissue loss involving the distal finger pulp and the nail is a common but challenging finger injury to restore. This study introduces a reconstruction procedure for a distal finger pulp and nail defect using a partial toenail flap transfer. METHODS Twenty digits, including 16 thumbs, two index fingers, and two middle fingers, with composite soft tissue defects were treated with a partial toenail flap transfer from October 2015 to January 2020. Shortening revision of the great toe phalanx, a V-Y advancement flap of the toe pulp, and a local pedicle flap from a second toe transfer were used to cover the donor sites, and no skin grafts were required. Functionality was evaluated using the validated Spanish version of the Quick-DASH scale. The aesthetics of both the reconstructed and donor sites were evaluated using the Vancouver Scar Scale (VSS). The static two-point discrimination (2-PD) of the finger pulp was used as a measure of tactile agnosia. RESULTS All donor site wounds healed well. The average follow-up time was 23.6 months (6-39 months). The mean Quick-DASH functional score was 7.1. The VSS scores were 4.02 ± 0.29 and 4.00 ± 0.38 for the reconstructed and donor sites, respectively. The static 2-PD of finger pulp was 4.5 ± 0.76 mm. The patients were satisfied with finger motion, sensory function, and aesthetic contour. CONCLUSIONS Partial toenail flap transfer is the recommended treatment to regain motion, sensation, function, and a satisfactory aesthetic appearance when considering repairing a composite soft tissue distal finger defect with accompanying loss of the perionychium, particularly in the thumb, index finger, or middle finger.
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Affiliation(s)
- Leyi Cai
- Department of Orthopaedic SurgeryThe Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Xian Zhang
- Department of Operation Care UnitThe Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Yingying Zhang
- Department of Operation Care UnitThe Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Guangheng Xiang
- Department of Orthopaedic SurgeryThe Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Peng Luo
- Department of Orthopaedic SurgeryThe Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Zhijie Li
- Department of Orthopaedic SurgeryThe Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Feiya Zhou
- Department of Orthopaedic SurgeryThe Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical UniversityWenzhouChina
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Zhou X, Sun D, Liu F, Li WJ, Gu C, Zhang LL. A mini hallux neurovascular osteo-onychocutaneous free flap for refined reconstruction of distal defects in thumbs and fingers. J Plast Surg Hand Surg 2023; 57:415-421. [PMID: 36495035 DOI: 10.1080/2000656x.2022.2147695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Distal injury in thumbs and fingers is common in emergency. Although multiple surgical techniques have been introduced for repair purpose, it is still challenging for restoring both good function and cosmetic appearance. The present study reports our experiences on how to reconstruct amputated fingertips in thumbs and fingers using a mini hallux neurovascular osteo-onychocutaneous free flap with favorable outcomes in 15 patients (average age, 27.27 ± 5.43 years old). Follow-up period was 19.47 ± 10.18 months (range, 6-48 months). Digital function was improved indicated by the static two-point discrimination (2-PD) and key-pinch, which were 8.40 ± 1.64 mm (range, 6-12 mm) and 85.37 ± 3.03% (range, 80.2-90.6%) of that of the intact contralateral thumbs and fingers, respectively, after surgery. As to aesthetic outcomes, all reconstructed digits were self-graded as good by patients. 73.3% of the donor halluces were self-graded as good and four halluces (26.7%) were graded as fair. In conclusion, the mini hallux neurovascular osteo-onychocutaneous flap may be used for refined reconstruction of type I amputated injury in thumbs and fingers achieving both satisfactory functional and aesthetic outcomes.
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Affiliation(s)
- Xianyu Zhou
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Di Sun
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Fei Liu
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Wen Jun Li
- Department of Hand Surgery, Shanghai Zhongye Hospital, Shanghai, People's Republic of China
| | - Chuan Gu
- Department of Hand Surgery, Shanghai Zhongye Hospital, Shanghai, People's Republic of China
| | - Ling Ling Zhang
- Department of Hand Surgery, Shanghai Zhongye Hospital, Shanghai, People's Republic of China
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End-to-side Anastomosis on Digital Arteries: Just a Technical Choice or a Real Benefit? PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e4535. [PMID: 36203740 PMCID: PMC9529035 DOI: 10.1097/gox.0000000000004535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/27/2022] [Indexed: 11/26/2022]
Abstract
High-quality evidence is currently poor regarding the benefits of end-to-end (ETE) or end-to-side (ETS) anastomosis in arterial and venous anastomoses, despite being postulated as a potential influence on outcomes. A sufficient microvascular anastomosis is indispensable for the success of any free tissue transfer. ETS microvascular anastomoses have been becoming increasingly important as they allow reconstruction even in patients with impaired vascular status. To the authors’ knowledge, no studies have examined the choice of ETE or ETS anastomoses specifically for digital arteries.
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Fuse Y, Yamamoto T, Kageyama T, Sakai H, Tsukuura R, Yoshimatsu H, Yamamoto N. Domino Free Flap Transfer Using a Superficial Circumflex Iliac Artery Perforator Flap for the Toe Flap Donor Site. Ann Plast Surg 2022; 88:293-297. [PMID: 34225310 DOI: 10.1097/sap.0000000000002948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Toe-to-hand transfer is a favorable option for finger reconstruction, but donor site healing can be challenging. The superficial circumflex iliac artery perforator (SCIP) flap has yet to be used widely for toe reconstruction. The purpose of this report was to validate the efficacy of the sequential simultaneous free SCIP flap transfer for the toe flap donor site in a consecutive case series. METHODS The medical records of 18 consecutive patients who underwent a simultaneous SCIP flap transfer and a toe-to-hand transplant were reviewed. Free SCIP flap reconstruction was performed in a simultaneous 2-team approach. The SCIP flaps were transferred to various toe flap donor sites: a great toe wraparound flap in 9 cases, a second toe distal phalangeal flap in 4 cases, a great toe osteo-onycho-cutaneous flap in 3 cases, a twisted wraparound flap in 1 case, and a great toe hemipulp flap in 1 case. RESULTS The size of the SCIP flap ranged from 5 × 3 to 16 × 8 cm. A mean of the total operative time was 229.2 minutes (range, 118-441 minutes; SD, 75.8 minutes). All the SCIP and toe flaps survived completely. Minor wound dehiscence was seen in 2 cases, and the wound healed by conservative treatment. The mean follow-up period was 23.7 months (range, 7-44 months; SD, 9.7 months). No patient had gait dysfunction postoperatively. CONCLUSIONS A sequential SCIP flap transfer was performed simultaneously without additional time, allowing secure soft tissue coverage of the toe flap donor even with avascular tissue such as bone or tendon exposed. The sequential SCIP flap transfer can be a useful option for reconstruction of toe flap donor site, when multiple microsurgeons and microscopes are available.
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Affiliation(s)
| | | | - Takashi Kageyama
- From the Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine
| | - Hayahito Sakai
- From the Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine
| | - Reiko Tsukuura
- From the Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research
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Partial Second Toe Pulp Flap Transfer for the Coverage of Great Toe Hemipulp Flap Donor Site. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4152. [PMID: 35242492 PMCID: PMC8884535 DOI: 10.1097/gox.0000000000004152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/04/2022] [Indexed: 11/25/2022]
Abstract
The great toe hemipulp flap transfer is a viable reconstructive method for finger pulp defect. However, early functional recovery of the donor foot is essential for returning to daily life activities, and functional and aesthetic restoration of the donor site remains challenging. We present a case in which the great toe hemipulp flap donor site was reconstructed with pedicled partial second toe pulp flap transfer, aiming for early recovery of the donor foot and aesthetically and functionally satisfactory donor-site reconstruction. A 62-year-old man underwent left little finger-pulp crush amputation in Tamai zone 2 and received free great toe hemipulp flap transfer. For the defect following flap harvest, the partial second toe pulp flap was elevated and transferred. The donor site of the partial second toe pulp flap was primarily closed. The postoperative course was uneventful, and the patient started walking on postoperative day 2. Postoperatively, the sensory recovery of the transferred flap was excellent, and the reconstructed great toe was functionally and aesthetically satisfactory. The pedicled partial second toe pulp flap transfer may be a viable alternative for the coverage of great toe hemipulp flap donor site.
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Fulchignoni C, Rocchi L, Cauteruccio M, Merendi G. Matriderm dermal substitute in the treatment of post traumatic hand's fingertip tissue loss. J Cosmet Dermatol 2021; 21:750-757. [PMID: 33786967 DOI: 10.1111/jocd.14115] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/13/2021] [Accepted: 03/24/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Treatment of fingers tissue loss is particularly challenging as it often necessitates advanced reconstructive techniques such as flaps or grafts, with esthetic and functional results that are not always as good as hoped for, with long healing times. Recently, along with tissue engineering development, numerous types of dermal substitute have been commercialized, with promising possibilities of treatment in finger tissue loss. In the author's unit, Matriderm® is the most commonly used dermal substitute. As described by the manufacturer, this scaffold is designed to be covered with a split-thickness skin graft. In using a two-step procedure, the authors realized that in most cases of fingertips injuries, at three weeks follow-up, the wound appeared in an advanced state of healing, which permitted to avoid grafting. MATERIAL AND METHODS Between October 2017 and October 2018, 27 fingers have been included in this study. Patients have been divided in two groups: those treated with Matriderm® alone (15 fingers) and those who had a skin graft three weeks after the first surgery (12 fingers). At the 6-month follow-up, authors evaluated the esthetic results with the Vancouver Scar Scale (VSS), the functional results with Quick Disability of the Arm, Shoulder and Hand (qDASH) score, and sensibility by the mean of two-point discrimination test (2-PD). RESULTS All outcomes were overlapping in patients treated with or without skin graft: mean VSS was 2.3, mean qDASH was 13.3, and mean 2-PD was 7.7 mm. CONCLUSIONS The results obtained allow to consider Matriderm® , used also without skin graft coverage, as a valid solution for treatment of fingertip tissue loss.
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Affiliation(s)
- Camillo Fulchignoni
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Roma, Italia
| | - Lorenzo Rocchi
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Roma, Italia
| | - Michele Cauteruccio
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Roma, Italia
| | - Gianfranco Merendi
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Roma, Italia
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Li M, Chen Z, Yang Y, Ma L, Zhang Z. Split-Thickness Nail Bed Flap Graft in the Management of Distal Partial Defect of the Nail Bed Combined With Soft Tissue. J Hand Surg Am 2020; 45:879.e1-879.e10. [PMID: 32299689 DOI: 10.1016/j.jhsa.2020.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/12/2020] [Accepted: 02/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE We report a surgical procedure for the management of nail bed injuries combined with soft tissue defects. METHODS We reviewed the records of patients with a nail bed injury combined with a soft tissue defect, who were surgically treated at our hospital from 2015 through 2018. According to the Allen classification, 5 patients were characterized as type 2 and 3 were characterized as type 3. Two also had partial defects of the distal phalanx. In all cases, we created a split-thickness nail bed flap of the great toe to reconstruct the nail bed injury. All patients underwent supervised postoperative rehabilitation. We reviewed patients' medical records for the Michigan Hand Outcomes Questionnaire, 2-point discrimination, and postoperative healing in the donor area. RESULTS Both the nails and flaps of all patients survived. No complications were observed after surgery. The nail was completely attached to the nail bed. In addition, there were no deformities, and the nail plate appearance was close to normal. A nail with an unsatisfactory appearance was noted in one patient. The shape, texture, and elasticity of the flaps of all patients were acceptable. All patients were capable of normal pinching, gripping, and grasping. Twelve months after the operation, 3 of 8 patients had 2-point discrimination of 6 mm or less. All patients were satisfied with the hand function according to the Michigan Hand Outcomes Questionnaire. The toenail of the donor site grew well, and no deformity or pain with walking was noted. CONCLUSIONS We demonstrate that this approach is a safe means of repairing a nail bed injury combined with a soft tissue defect. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Muwei Li
- Department of Microsurgery and Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen Guangdong Province, People's Republic of China
| | - Zhiying Chen
- Department of Microsurgery and Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen Guangdong Province, People's Republic of China
| | - Yanjun Yang
- Department of Microsurgery and Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen Guangdong Province, People's Republic of China
| | - Lifeng Ma
- Department of Microsurgery and Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen Guangdong Province, People's Republic of China
| | - Ziqing Zhang
- Department of Microsurgery and Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen Guangdong Province, People's Republic of China.
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Hattori Y, Imai S, Nakamura R, Niu A. Use of a near-infrared vein visualization device in partial second toe pulp flap transfer for fingertip reconstruction. Microsurgery 2020; 40:719-720. [PMID: 32584465 DOI: 10.1002/micr.30619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/29/2020] [Indexed: 11/07/2022]
Affiliation(s)
| | - Shoichi Imai
- Department of Plastic Surgery, Kanto Central Hospital, Tokyo, Japan.,Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Runa Nakamura
- Department of Plastic Surgery, Kanto Central Hospital, Tokyo, Japan.,Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Atsushi Niu
- Department of Plastic Surgery, Kanto Central Hospital, Tokyo, Japan
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Abstract
AIM The aim of this paper is to demonstrate the advantages of using local resources in the coverage of such defects. Our approach in fingers' defects is the use of local perforator flaps, both as propeller flaps or bi-lobed pedicled flaps. PATIENTS AND METHODS After performing an anatomical study on cadaver segments injected with latex followed by transparentation, 81 local perforator flaps in 80 patients during a period of 10 years (2007-2016), i.e. 47 digital artery propeller perforator flaps (DAPP), 10 island transposition perforator flaps (DATP), and 24 bi-lobed pedicled perforator flaps (BLP) were performed in our department. The patients were evaluated regarding finger mobility (ROM), two-points discrimination (TPD), and degree of satisfaction (DS) from cosmetic point of view. RESULTS The mean interval for social and professional reintegration was 12 days. As complications, we registered only venous congestion in 7 cases followed by epidermolysis in 4 cases and superficial necrosis in 3 cases, which healed by reepithelialization. The range of motion (ROM) of the reconstructed fingers was normal in all the patients. All the flaps regain a satisfactory degree of sensibility (TPD between 4 mm and 14 mm). The DS was relatively high, with 67 patients very satisfied, 11 satisfied, and 2 unsatisfied. CONCLUSIONS This fast and less invasive method, which replaces like-with-like, allows an early and good reinervation and a rapid social and professional reintegration, proves to be a very reliable alternative in digital defects coverage.
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Affiliation(s)
- Ileana Rodica Matei
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu, Cluj Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Str. Viilor 46-50, 400347 Cluj Napoca, Romania
| | - Marko Bumbasirevic
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; School of Medicine, University of Belgrade, Serbia
| | - Alexandru Valentin Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu, Cluj Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Str. Viilor 46-50, 400347 Cluj Napoca, Romania.
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Nail bed defect reconstruction using a thenar fascial flap and subsequent nail bed grafting. Arch Plast Surg 2019; 46:57-62. [PMID: 30685942 PMCID: PMC6369052 DOI: 10.5999/aps.2018.00227] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/30/2018] [Indexed: 11/18/2022] Open
Abstract
Background Full-thickness nail bed defects with significant exposure of the distal phalanx are typically challenging to reconstruct. We describe a novel method of nail bed defect reconstruction using a thenar fascial flap combined with nail bed grafting. Methods Full-thickness nail bed defects were reconstructed in a 2-stage operation involving the placement of a thenar fascial flap and subsequent nail bed grafting. A proximally-based skin flap was designed on the thenar eminence. The flap was elevated distally to proximally, and the fascial layer covering the thenar muscle was dissected proximally to distally. The skin flap was then closed and the dissected fascial flap was turned over (proximal to distal) and inset onto the defect. The finger was immobilized for 2 weeks, and the flap was dressed with wet and ointment dressings. After 2 weeks, the flap was divided and covered with a split-thickness nail bed graft from the great toe. Subsequent nail growth was evaluated on follow-up. Results Nine patients (9 fingers) treated with the novel procedure were evaluated at follow-up examinations. Complete flap survival was noted in all cases, and all nail bed grafts took successfully. Five outcomes (55.6%) were graded as excellent, three (33.3%) as very good, and one (11.1%) as fair. No donor site morbidities of the thenar area or great toe were observed. Conclusions When used in combination with a nail bed graft, the thenar fascial flap provides an excellent means of nail bed reconstruction.
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Hong JP(J, Song S, Suh HSP. Supermicrosurgery: Principles and applications. J Surg Oncol 2018; 118:832-839. [DOI: 10.1002/jso.25243] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/23/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Joon Pio (Jp) Hong
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
| | - Sinyoung Song
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
| | - Hyun Suk Peter Suh
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
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Palmar Ulnar Artery Perforator Free Flap for Fingertip Reconstruction: Anatomical and Clinical Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2862879. [PMID: 29854740 PMCID: PMC5966683 DOI: 10.1155/2018/2862879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/13/2018] [Accepted: 04/01/2018] [Indexed: 11/17/2022]
Abstract
Background Fingertips are a common site for hand injuries. The ideal substitute for fingertip pulp is tissue that matches texturally with minimal donor site morbidity. We described anatomical findings from cadaveric studies and the reliability of the palmar ulnar artery perforator (PUAP) free flap techniques for the reconstruction of fingertips injuries. Methods The cadaveric study involving 8 hands was conducted to illuminate the anatomy of the hypothenar region. We investigated the emerging point of perforators, diameter of the artery at the origin, and the length of the pedicle. Forty-four patients with fingertip injuries underwent fingertip reconstruction using PUAP free flaps. Data on the baseline patient demographics, hospital courses, and flap sizes were obtained retrospectively. The 6-month postoperative sensory capacity was determined using a 2-point discrimination test. Results The cadaveric study found that the PUAP pedicles arose from the superficial palmar arch, the mean length of pedicles, and the diameter and location of perforators were also analyzed. The PUAP flap sizes varied from 2.0 × 2.3 cm to 2.5 × 3.5 cm, and the mean operative time was 124 min. In all cases, we performed neurorrhaphy for fingertip sensory restoration. All donor sites were closed primarily, and the 2-point discrimination test result was 5.7 ± 0.87 mm 6 months after surgery. Conclusions We confirmed the anatomical consistency of the PUAP. Among the numerous reconstruction options available for fingertip injuries, the PUAP free flap is a useful fingertip reconstruction option.
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Neuwirth M, Müller-Eggenberger M, Bürger H, Rab M. Two large fingertip defects in a child successfully reconstructed with two osteo-onycho-tendo-cutaneous lateral great toe flaps. JPRAS Open 2017. [DOI: 10.1016/j.jpra.2017.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Abstract
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.
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del Piñal F. The Indications for Toe Transfer after “Minor” Finger Injuries. ACTA ACUST UNITED AC 2016; 29:120-9. [PMID: 15010156 DOI: 10.1016/j.jhsb.2003.12.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2003] [Accepted: 12/18/2003] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- F del Piñal
- Institute for Hand and Plastic Surgery, Private Practice, and Mutua Montañesa, Santander, Spain.
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Abstract
BACKGROUND This study was designed to introduce free toe soft tissue transfer using local infiltration anesthesia in patients not suitable for general anesthesia and local tissue coverage. METHODS From January 2006 to August 2012, a total of 11 traumatic fingertip defects were reconstructed by toe soft tissue transfer. All procedures except 1 were done as primary reconstructions, with either the lateral side of the great toe (5 cases) or the medial side of the second toe (6 cases) used as a donor. Postoperative follow-up periods were between 8 months to 2 years and 6 months. RESULTS Flap sizes varied from 1.0 × 2.0 to 2.0 × 3.5 cm. The mean operative times were 4 hours 29 minutes for cases done by a single team and 3 hours 21 minutes for cases done by a 2-team approach. Approximately 5.8 mL of local anesthetic agent was used in each finger and 5.9 mL was used in the toes for a total of 11.7 mL. All flaps survived and were fully taken without complications, except 1 case that presented partial necrosis. CONCLUSIONS Fingertip soft tissue reconstruction by free toe tissue transfer under local anesthesia uses a more limited operative field, with a shorter operative time, enabling reconstruction in patients not suitable for general anesthesia. This is even more so with a microsurgical 2-team approach, which reduces the volume of anesthetic agent needed, making this method a sufficiently realistic option for fingertip soft tissue reconstruction.
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Diaz-Abele J, Hayakawa T, Buchel E, Brooks D, Buntic R, Safa B, Islur A. Anastomosis to the common and proper digital vessels in free flap soft tissue reconstruction of the hand. Microsurgery 2016; 38:21-25. [PMID: 27392815 DOI: 10.1002/micr.30066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/04/2016] [Accepted: 04/22/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This study seeks to demonstrate the safety of anastomosing free flaps to the common or proper digital artery, and to the volar or dorsal digital vein in soft tissue reconstruction of the hand; as well, as to discuss the advantages of this technique. METHODS Retrospective review of all patients who underwent free flap reconstruction of the hand in two institutions over a period of 5 years. RESULTS A total of 29 free flaps (9 great toe pulp, 7 anterolateral thigh, 6 second toe pulp, 4 radial artery perforator, 2 partial medial rectus, 1 lateral arm) in 28 patients met our inclusion criteria. All recipient vessels were the proper or common digital artery and the volar or dorsal digital vein. There was one case of venous congestion that resolved with leeching. There was no partial or total loss of any of the flaps. CONCLUSION Anastomosing soft tissue free flaps to the common or proper digital artery, and the volar or dorsal digital vein is a safe and effective approach with numerous advantages that should be considered in the reconstruction of soft tissue defects of the hand. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:21-25, 2018.
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Affiliation(s)
| | - T Hayakawa
- University of Manitoba, Winnipeg, MB, Canada
| | - E Buchel
- University of Manitoba, Winnipeg, MB, Canada
| | - D Brooks
- The Buncke Clinic, San Francisco, CA
| | - R Buntic
- The Buncke Clinic, San Francisco, CA
| | - B Safa
- The Buncke Clinic, San Francisco, CA
| | - A Islur
- University of Manitoba, Winnipeg, MB, Canada
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Abstract
BACKGROUND Fingertip injury requiring flap cover is very common in the modern era. The ideal cover should fulfill both functional and aesthetic improvement. MATERIALS AND METHODS From June 2015 to April 2016, we performed seven free toe pulp flaps for finger defect reconstruction. All patients were males. Five flaps were done in emergency post-traumatic cases, and two were done in elective set up. The cases included reconstruction of three thumbs, one index and one ring finger in an emergency set up and two ring fingers in the elective. Thumb reconstruction was done with great toe lateral pulp and the other digits reconstructed with second toe pulp flap. Follow-up evaluation included both functional and aesthetic assessment. RESULTS Five flaps survived completely, one suffered partial loss, and one flap failed completely. The median follow-up period was 9 months. The median duration of surgery was 255 min (range 210 to 300 min). The median two-point discrimination was 6.5 mm (range 4-8 mm). There was the return of temperature sensation in all patients; two had cold intolerance. The Semmes-Weinstein monofilament score varied from 3.61 to 5.07 (median filament index value 4.31/pressure value of 2 g/mm2). Three patients had delayed donor site wound healing. CONCLUSIONS The free toe pulp flap is an efficient choice for fingertip and volar finger defects reconstruction with an excellent tissue match.
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Affiliation(s)
- Jyoshid R. Balan
- Department of Plastic Surgery, Sushrutha Institute of Plastic Reconstructive and Aesthetic Surgery, Elite Mission Hospital, Thrissur, Kerala, India
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Innervated Digital Artery Perforator Flap: A Versatile Technique for Fingertip Reconstruction. J Hand Surg Am 2015; 40:2352-7. [PMID: 26527595 DOI: 10.1016/j.jhsa.2015.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 09/21/2015] [Accepted: 09/21/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To demonstrate the advanced use of innervated digital artery perforator (IDAP) flaps for fingertip reconstruction. METHODS From August 2011 to May 2014, 65 fingers (59 patients) underwent fingertip or finger stump reconstruction using IDAP flaps. Sixty-one fingers from 55 patients who were followed up for more than 6 months were included in this study. The objective outcomes of patient evaluations consisted of the results of static 2-point discrimination tests, Semmes Weinstein monofilament tests, and extension loss tests. The subjective patient outcome evaluations consisted of the results of hypersensitivity and cold intolerance tests and patient satisfaction. RESULTS All flaps survived completely, and no patients required early secondary interventions. The mean follow-up period was 18 months (range, 6-36 months). The static 2-point discrimination in the flaps ranged from 2 to 6 mm (mean, 3.5 mm) compared with a range of 2 to 3 mm (mean, 2.5 mm) in the contralateral hands. The Semmes Weinstein monofilament test results ranged from 0.07 to 1.4 g compared with 0.04 to 0.4 g for the contralateral hand. One patient exhibited mild extension loss in the reconstructed finger, 4 patients experienced mild cold intolerance, and 2 patients exhibited mild hypersensitivity. CONCLUSIONS The IDAP flaps are sensitive, reliable, and versatile and should be considered for reconstructing acute fingertip defects. The use of IDAP flaps for revisions of previously reconstructed defects is also possible. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Song D, Li J, Li K, Liu J, Xu J. Modified Innervated Radial Collateral Artery Perforator Flap for Repairing Digital Defects. Indian J Surg 2015; 77:1032-7. [DOI: 10.1007/s12262-014-1117-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/26/2014] [Indexed: 11/24/2022] Open
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Chen QZ, Sun YC, Chen J, Kong J, Gong YP, Mao T. Comparative study of functional and aesthetically outcomes of reverse digital artery and reverse dorsal homodigital island flaps for fingertip repair. J Hand Surg Eur Vol 2015; 40:935-43. [PMID: 25862526 DOI: 10.1177/1753193415579300] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/18/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED This retrospective study was designed to compare functional and cosmetic outcomes of the reverse digital artery island flap and reverse dorsal homodigital island flap in fingertip repair. A total of 23 patients were followed for 24 to 30 months. The reverse digital artery island flap was used in 12 patients, and reverse dorsal homodigital island flap in another 11 patients. Flap sensibility was assessed using the Semmes-Weinstein monofilament test and static 2-point discrimination test. Patient satisfaction, active motion of the finger joints, complications and cold intolerance were evaluated. The static 2-point discrimination and Michigan Hand Outcomes Questionnaire (appearance) of the fingers treated with a reverse digital artery flap were significantly better than those with a reverse dorsal homodigital flap. The static 2-point discrimination of the skin-grafted donor sides after dorsal homodigital flap were poorer than that in the contralateral finger. No significant differences were found between the two flaps for pressure or touch sensibility, active ranges of digital motion, complications and cold intolerance. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Q Z Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Y C Sun
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - J Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - J Kong
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Y P Gong
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - T Mao
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
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Song D, Deng X, Chen Y, Xie S, Zhou X. Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction. Arch Orthop Trauma Surg 2015; 135:1623-31. [PMID: 26377731 DOI: 10.1007/s00402-015-2324-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Tissue loss accompanied by bone defects in the thumb is a challenging reconstruction problem. Traditional repair methods are unsatisfactory. METHODS Microsurgical thumb reconstruction was performed using 13 thinned chimeric radial collateral artery (RCA) perforator flaps. The flap was created with a thinned skin paddle and humeral bone segments using independent perforators. Primary defatting was completed when the thickness of the perforator entry was approximately similar to that in the periphery. The posterior cutaneous nerve of the arm was carried to make a sensory flap. Defects were 8.5 × 4.5 cm(2) on average (ranging in size from 4.5 × 1.5 to 15.0 × 6.0 cm(2)), and flap size was 9.0 × 5.5 cm(2) on average (ranging in size from 5.0 × 2.0 to 16.0 × 7.0 cm(2)), whereas the humeral fragments were 2.0 × 1.0 cm(2) on average (ranging in size from 1.5 × 0.5 to 4.0 × 1.5 cm(2)). All data were expressed as mean ± SD. The cosmetic appearance of the donor and recipient sites, Kapandji opposition score and static two-point discrimination of the operated thumb were evaluated during a follow-up visit. RESULTS Follow-up time was 16.6 months (ranging from 14 to 28 months). Flap thickness before defatting, measured immediately after flap elevation was 14.5 mm (ranging from 10.0 to 25.0 mm). Average flap thickness after defatting was 3.5 mm (ranging from 3.0 to 6.0 mm). Venous congestion occurred in two cases. Successful microsurgical revision was achieved in both cases. All flaps survived. Bone components achieved union in all cases at an average period of 4.8 months (ranging from 3 to 6 months). Based on Kapandji opposition score, the mean thumb opposition score was 6. The mean sensation of flap was 7.5 mm (ranging from 6 to 11 mm). No further flap revision or defatting procedures were required in all cases. Cosmetically acceptable results were achieved for all patients. CONCLUSIONS Findings proved that thinned chimeric RCA perforator flap is a beneficial microsurgical alternative for reconstructing complex bone and soft tissue defects in thumb.
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Affiliation(s)
- Dajiang Song
- Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.,Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Xiangwu Deng
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China
| | - Yanmin Chen
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China
| | - Songlin Xie
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China. .,Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China.
| | - Xiao Zhou
- Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.
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TORRES FUENTES CARLOSEDUARDO, Hernández Beltrán JA, CASTAÑEDA HERNANDEZ DIEGOALEJANDRO. MANEJO INICIAL DE LAS LESIONES DE PUNTA DE DEDO: GUÍA DE TRATAMIENTO BASADO EN LA EXPERIENCIA EN EL HOSPITAL SAN JOSÉ (91 CASOS). REVISTA DE LA FACULTAD DE MEDICINA 2015. [DOI: 10.15446/revfacmed.v62n3.39603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Xing S, Shen Z, Jia W, Cai Y. Aesthetic and functional results from nailfold recession following fingertip amputations. J Hand Surg Am 2015; 40:1-7. [PMID: 25443165 DOI: 10.1016/j.jhsa.2014.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 08/30/2014] [Accepted: 09/02/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the aesthetic and functional results of a technique for nail salvage by recessing the nailfold to increase the exposed nail matrix after fingertip amputation. METHODS Thirty cases of fingertip amputation with distal partial nail bed defects underwent nailfold recession and pulp reconstruction. We increased nail bed exposure by recessing a rectangle flap of eponychium and reconstructed the pulp with different local flaps depending on the injury geometry. A 0.3- to 0.4-cm-wide rectangular strip of eponychium was de-epithelialized. The eponychial flap was separated from the nail matrix and slid proximally to expose more nail matrix, thereby effectively lengthening the exposed nail bed. RESULTS The flaps survived in all patients. The exposed nail beds were lengthened 0.3 to 0.4 cm and enlarged 38% to 100%. The fingertips had smooth and natural nail plates with inconspicuous scars on both the eponychium and pulp and no deformities. The sensation and mobility of injured and uninjured contralateral fingers did not differ statistically. All patients were satisfied with the appearance and function of the reconstructed fingertips. CONCLUSIONS Nailfold recession combined with different local flaps provided for the aesthetic and functional restoration of the fingertip after amputation with partial nail bed defect.
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Affiliation(s)
- Shuliang Xing
- Department of Plastic, Hand and Aesthetic Surgery, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zunli Shen
- Department of Plastic, Hand and Aesthetic Surgery, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China.
| | - Wanxin Jia
- Department of Plastic, Hand and Aesthetic Surgery, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yanxian Cai
- Department of Plastic, Hand and Aesthetic Surgery, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Yoshimatsu H, Yamamoto T, Iwamoto T, Hayashi A, Narushima M, Iida T, Koshima I. The role of non-enhanced angiography in toe tip transfer with small diameter pedicle. Microsurgery 2014; 35:364-9. [PMID: 25382745 DOI: 10.1002/micr.22353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 10/23/2014] [Accepted: 10/27/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Toe tip transfer allows functional and esthetic reconstruction of the lost fingertip, but it is still uncommon because identification and dissection of donor and recipient veins can be challenging. Nonenhanced angiography (NEA) is a device that emits infrared light at a wavelength of 850 nm, which is exclusively absorbed by hemoglobin. The light penetrates the bones and other soft tissues, effectively visualizing veins in real time. The aim of this report is to present the experience on the preoperative use of nonenhanced angiography for visualization of donor and recipient veins in toe tip transfers in a series of patients. PATIENTS AND METHODS Four cases of toe tip transfer and one case of free nail flap were performed for reconstruction of the tips of thumb and finger with preoperative examination using NEA. Patients' age ranged from 29 to 52 years old (average, 29.2 years old). Before the operation, the veins in the donor and recipient sites were marked using NEA, and the blood flow of the veins in the recipient site was confirmed. RESULTS Pedicles in all transferred toe tips were less than 2 cm in length, with diameters smaller than 0.8 mm. The postoperative courses were uneventful, and all transferred toe tips survived completely, with satisfying functional and aesthetic results. CONCLUSIONS NEA may facilitate venous dissection of the donor and the recipient sites, allowing safe and efficient toe tip transfer with a small pedicle.
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Affiliation(s)
- Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Taku Iwamoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Akitatsu Hayashi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takuya Iida
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Yamamoto T, Hayashi A, Tsukuura R, Goto A, Yoshimatsu H, Koshima I. Transversely‐inset great toe hemi‐pulp flap transfer for the reconstruction of a thumb‐tip defect. Microsurgery 2014; 35:235-8. [DOI: 10.1002/micr.22347] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 10/10/2014] [Accepted: 10/16/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgerythe University of TokyoTokyo Japan
| | - Akitatsu Hayashi
- Department of Plastic and Reconstructive Surgerythe University of TokyoTokyo Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgerythe University of TokyoTokyo Japan
| | - Aya Goto
- Department of Plastic and Reconstructive Surgerythe University of TokyoTokyo Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgerythe University of TokyoTokyo Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgerythe University of TokyoTokyo Japan
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Yamamoto T, Yoshimatsu H, Kikuchi K, Taji M, Uchida G, Koshima I. Use of non-enhanced angiography to assist the second toetip flap transfer for reconstruction of the fingertip defect. Microsurgery 2014; 34:481-3. [DOI: 10.1002/micr.22239] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 02/12/2014] [Accepted: 02/14/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery; The University of Tokyo; Tokyo Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery; The University of Tokyo; Tokyo Japan
| | - Kazuki Kikuchi
- Department of Plastic and Reconstructive Surgery; The University of Tokyo; Tokyo Japan
| | - Megumi Taji
- Department of Plastic Surgery; Senpo Tokyo Takanawa Hospital; Tokyo Japan
| | - Gentaro Uchida
- Department of Plastic Surgery; Senpo Tokyo Takanawa Hospital; Tokyo Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery; The University of Tokyo; Tokyo Japan
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Innervated digital artery perforator flap. J Hand Surg Am 2013; 38:350-6. [PMID: 23218789 DOI: 10.1016/j.jhsa.2012.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 10/05/2012] [Accepted: 10/11/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe a technique for covering defects of the fingertips: the innervated digital artery perforator (IDAP) flap. METHODS A total of 17 patients were treated with an IDAP flap. The size of the flaps varied between 2 ×1 cm and 3.5 × 2 cm. Postoperative evaluation of the patients consisted of the Semmes-Weinstein Monofilament test, static 2-point discrimination, patient satisfaction, extension loss, and an investigation into complications. RESULTS All IDAP flaps survived completely, and no patients required secondary interventions. The mean follow-up period was 7 months (range, 6-10 mo). The Semmes-Weinstein monofilament test results ranged from 3.22 to 3.84. The static 2-point discrimination in the flaps ranged from 2 mm to 4 mm (mean, 3.4 mm) compared with a range of 2 mm to 3 mm (mean, 2.7 mm) on the contralateral hand. There were no joint contractures in the reconstructed fingertips, although 2 patients developed mild hook nail deformity. One patient experienced mild cold intolerance, and 1 patient exhibited mild postoperative hypersensitivity. CONCLUSIONS The advantages of the IDAP flap include minimally invasive surgery; a reliable, versatile flap; and the ease of the technique for different-sized fingertip defect reconstructions with few complications. The IDAP flap may be useful in fingertip amputations when the amputated part is not suitable for replantation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Abstract
BACKGROUND Fingertip amputation is the most common type of injury in the upper limb. Goals in fingertip amputation reconstruction are covering the defect, establishing maximum tactile gnosis, keeping the length of the finger, protecting the joint function, acquiring a well-padded pulp tissue, providing a bed for growing nail, obtaining a satisfactory cosmetic appearance and allowing the patient to return to work as soon as possible. Adjacent skin and soft tissue are the best covers for fingertip injuries. However, local homodigital flaps lack enough tissue to cover the defect. To solve this problem, we used V-Y rotation advancement flap bilaterally in fingertip amputations which meets all the reconstruction goals. Rotation besides advancement makes this flap more mobile and easier to cover larger defects in all amputation planes. METHODS Between 2007 and 2009, we performed bilateral V-Y rotation advancement flap on seven male patients' pulpa (average age, 37.6 years) whose fingertips were not replantable. RESULTS Fourteen flaps were made on 7 fingers. There was neither total nor partial flap loss. Patients had neither cold intolerance nor scar hypersensitivity. Stiffness of the PIP joint did not occur. No obvious hooked nail occurred in patients who have remaining nail matrix. Because flaps contain neurovascular bundle, there was no difference in sensation and perfusion between the finger's pre-operative and post-operative status. The result was satisfactory with painless pinching. CONCLUSION In addition to the various and versatile fingertip reconstruction methods, we want to present V-Y rotation advancement flap as a quick, reliable and aesthetic method.
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Reconstruction Scalp Defects After Malignant Tumor Resection With Anterolateral Thigh Flaps. J Craniofac Surg 2011; 22:2208-11. [DOI: 10.1097/scs.0b013e318231fdb2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
The introduction of supermicrosurgery, which allows the anastomosis of smaller caliber vessels and microvascular dissection of vessels ranging from 0.3 to 0.8mm in diameter, has led to the development of new reconstructive techniques. New applications of this technique are for crushed fingertip replantations with venule grafts, toe tip transfers for fingertip loss, partial auricular transfers for total tracheal and eyelid defects, and lymphaticovenular anastomoses under local anesthesia for lymphedema. Regarding free flaps, free perforator-to-perforator flaps, including deep inferior epigastric perforator or paraumbilical perforator flaps, gluteal artery perforator flaps, thoracodorsal artery perforator flaps, anterolateral thigh perforator flaps, superficial circumflex iliac artery perforator flaps, tensor fasciae lata perforator flaps, and medial plantar perforator flaps, with a short pedicle, have been used for extremity and facial defects. The success rate is almost the same as that of usual free flap transfers with large and long pedicles. The advantages of these flaps are the simple operation and the short time needed for flap elevation, plus the fact that the flaps can be obtained from anywhere in concealed areas. The disadvantages are the need for supermicrosurgical technique and the anatomic variation of these perforators.
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Reconstruction de l’unité unguéale par transferts vascularisés à pédicule court. À propos de 13 transferts de l’appareil pulpo-unguéal. ANN CHIR PLAST ESTH 2010; 55:1-7. [DOI: 10.1016/j.anplas.2009.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 05/26/2009] [Indexed: 11/18/2022]
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Posterior interosseous free flap for finger re-surfacing. J Plast Reconstr Aesthet Surg 2009; 63:832-7. [PMID: 19369132 DOI: 10.1016/j.bjps.2009.01.071] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 01/29/2009] [Accepted: 01/31/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND The authors present their clinical experience and surgical methods of soft-tissue coverage for the finger using a posterior interosseous free flap. METHODS Twelve posterior interosseous free flaps, including two dual-paddle flaps, were performed in 12 patients. Indications included: 1) patients with soft-tissue coverage of the dorsum of the finger (n=4), pulp (n=1), fingertip and pulp (n=5), 2) patients subsequent to release of finger and palm contracture (n=1) and 3) patients subsequent to finger separation (n=1). The posterior interosseous vessels were ligated below the level at which the motor branch to the extensor carpi ulnaris crossed the vessel superficially. The recipient vessels were the proper digital artery and palmar subcutaneous vein (n=10), deep branch of the ulnar palm artery (n=1), superficial branch of the radial palm artery (n=1) and the vena comitante. The cosmetic appearance of the donor and recipient sites, static two-point discrimination and active total range of motion of the operated finger were evaluated in a follow-up visit. RESULTS All flaps survived completely and all donor sites were closed directly, leaving a linear scar. De-fatting of the flap was carried out in one case in the late postoperative period; all other patients achieved a cosmetically acceptable result. Static two-point discrimination scores averaged 11 mm (range: 8-15 mm). Postoperatively, seven patients maintained normal flexion and extension of the joint. Two patients who had experienced a fracture and flexor injury recovered near-normal flexion and extension after flexor release; the other patients only recovered partially due to severe preoperative joint stiffness. Preoperatively, the active total range of motion of the operated fingers averaged 187 (range: 20-260). The average active total range of motion of the operated fingers at the last follow-up was 210 (range: 60-260). There was a significant difference between the preoperative and follow-up values (p=0.042). CONCLUSIONS The posterior interosseous free flap may become one valuable option for finger re-surfacing. Avoiding the sacrifice of a main artery of the hand and shorter pedicle can reduce the morbidity and operative time associated with this procedure. In addition, separate regions can be reconstructed with a dual-paddle flap.
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Abstract
Loss of distal fingertip bone and soft tissue defect can be treated using different methods, but the involvement of the nail influences the choice of surgical approach and makes reconstruction more difficult. The eponychial flap is a backward cutaneous translation flap that lengthens the nail plate and restores a good appearance of the nail apparatus. Pulp reconstruction is usually performed using local flaps (Tranquilli-Leali or Venkataswami flaps). The eponychial flap technique is a safe and easy technique that is indicated in cases of transverse fingertip angulations for lengthening the short amputated nail. This procedure can be used in combination with different flaps for pulp reconstruction.
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Affiliation(s)
- Roberto Adani
- Department of Orthopaedic Surgery, University of Modena and Reggio Emilia, Modena, Italy. adani.roberto.it
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Koshima I, Urushibara K, Fukuda N, Ohkochi M, Nagase T, Gonda K, Asato H, Yoshimura K. Digital artery perforator flaps for fingertip reconstructions. Plast Reconstr Surg 2006; 118:1579-1584. [PMID: 17102731 DOI: 10.1097/01.prs.0000232987.54881.a7] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Isao Koshima
- Tokyo and Okayama, Japan From the Departments of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, and Kawasaki Medical School
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Woo SH, Lee GJ, Kim KC, Ha SH, Kim JS. Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb. Plast Reconstr Surg 2006; 117:1906-15. [PMID: 16651964 DOI: 10.1097/01.prs.0000210011.71759.65] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thumb defects distal to the interphalangeal joint do not cause any disability; therefore, any consideration to reconstruct the thumb is governed by the lifestyle and cultural background of the patient. This study presents the excellent results achieved by immediate partial great toe-to-hand transfer to reconstruct acute composite defects of the distal thumb. METHODS Fifty-three patients with amputation or crush injury of the distal thumb who underwent partial great toe-to-hand transfer at the authors' institute over an 11-year period were reviewed. Based on the amputation level of the distal thumb, the authors classified the injuries into three groups. Operative techniques used were osteo-onychocutaneous flap with partial or whole toenail from the great toe and partial great toe transfer with arthrodesis of the interphalangeal joint. Overall results were evaluated in terms of success rate, incidence of emergency reexploration, and number and type of secondary operation. Static two-point discrimination, range of motion, pinch strength, and subjective satisfaction were also evaluated. RESULTS The success rate of immediate partial great toe-to-hand transfer was 100 percent. The incidence of inflammation and the reexploration rate were not significantly different from those in previously reported articles. In 35 cases where postoperative follow-up was possible, static two-point discrimination, total active range of motion, and pinch strength were generally excellent and the majority of the patients were satisfied with the final outcome. CONCLUSION Immediate reconstruction with partial great toe transfer is an excellent option for reconstruction of composite defects of the distal thumb, not only for aesthetic reasons but also for functional purposes.
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Affiliation(s)
- Sang-Hyun Woo
- Kim & Woo's Institute for Hand and Reconstructive Microsurgery, Hyundae General Hospital, Daegu, Korea.
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Woo SH, Lee GJ, Kim KC, Ha SH, Kim JS. Cosmetic reconstruction of distal finger absence with partial second toe transfer. J Plast Reconstr Aesthet Surg 2006; 59:317-24. [PMID: 16756243 DOI: 10.1016/j.bjps.2005.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The authors successfully performed a series of 32 distal finger reconstructions using partial second toe-to-finger transfers solely for aesthetic indications. The resulting hand function shows an average static 2-point discrimination of 8 mm. Total active range of motion was 205 degrees. Key-pinch strength and grip strength averaged 65 and 90% of the normal contralateral side, respectively. Patient satisfaction, as reflected by the average subjective satisfaction scores for aesthetic appearance and function (SSSAF) of the reconstructed distal finger, was high at 82 and 78, respectively. The SSSAF for the donor site averaged 88 for function and 75-80 for aesthetic appearance, which is statistically significant (p<0.05). The authors modified the technique of distal finger reconstruction using second toe transfers in three ways. One is to skeletonize the neurovascular bundle of the harvested toe and pass it through a subcutaneous tunnel between the distal finger incision and the web space incision to avoid lengthy and unsightly scars on the reconstructed finger. Another is to defat the skin flaps developed at the amputated stump and to use a zigzag incision on the toe flap to create a smoother skin junction between the stump and the transferred toe. The third refinement is to perform the arterial microanastomosis at the level of the web space to take advantage of the larger diameter of the vessels in this area. Cosmetic reconstruction of the distal finger with a partial second toe-to-hand transfer provides a high degree of patient satisfaction, both aesthetically and functionally.
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Affiliation(s)
- Sang Hyun Woo
- Kim and Woo's Institute for Hand and Reconstructive Microsurgery, Hyundae General Hospital, 266-5 Choong Dong, Soosung Gu, Daegu 706-838, Korea.
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Zhang F, Hu EC, Chen W, Lineaweaver WC. Treatment of Painful Neuroma of Amputated Phalanx with Distal Toe Transfer: A Case Report. South Med J 2006; 99:85-9. [PMID: 16466129 DOI: 10.1097/01.smj.0000197513.71146.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A painful neuroma in the amputation stump of a finger can be psychologically and physically disabling. Numerous surgical procedures have been attempted to prevent and treat amputation neuromas of the finger, but the results are inconsistent. Microsurgical transfer of the distal second toe to the amputated stump of the finger can provide a pathway and target for the regenerating axons and avoid recurrence of neuromas. In this article, we present the experience of successful treatment of amputation neuromas of an index finger with microsurgical distal toe transfer.
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Affiliation(s)
- Feng Zhang
- Division of Plastic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MI 39216, USA.
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Sica A, Dubert T. Reconstruction d'une forme particulière d'arrachement digital par bague par greffe de peau totale et lambeau « cross finger ». ACTA ACUST UNITED AC 2005; 24:246-50. [PMID: 16277149 DOI: 10.1016/j.main.2005.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An exceptional case of complete cutaneous ring finger avulsion is reported. The distal fragment was not replantable because of lack of vessels. The reconstruction restored a functional finger.
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Affiliation(s)
- A Sica
- Département de chirurgie de la main, clinique la Francilienne, 16, avenue de l'Hôtel de Ville, 77340 Pontault Combault, France.
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Sawabe K, Suzuki S, Miyata A, Kitayama T, Ishikawa K. Application of the Palmar Pocket Method for Total Nail Reconstruction Without Vascular Anastomoses. Ann Plast Surg 2005; 54:673-5. [PMID: 15900160 DOI: 10.1097/01.sap.0000164731.99795.fe] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present a case of a nail defect, which was reconstructed by free composite nail combined with the palmar pocket method without vascular anastomoses. A 40-year-old man lost his nail of the right middle finger by trauma 1 year ago. A total nail composite graft, composed of germinal and sterile matrices, and proximal nail fold, from which the nail plate was removed, was harvested from the ipsilateral first toe and was grafted on the right middle fingertip. The grafted nail was inserted into the palmar subcutaneous pocket. Fourteen days after the first operation, the grafted part was removed from the pocket, and active bleeding was noted on the sterile matrix. Seven months after the second surgery, the nail had grown and had an almost normal appearance. There was no conspicuous scar at either the recipient or the donor site.
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Affiliation(s)
- Kazuma Sawabe
- Department of Plastic and Reconstructive Surgery, Kyoto University, Kyoto, Japan.
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Adani R, Marcoccio I, Tarallo L, Fregni U. The aesthetic mini wrap-around technique for thumb reconstruction. Tech Hand Up Extrem Surg 2005; 9:42-6. [PMID: 16092818 DOI: 10.1097/01.bth.0000151862.54660.96] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
In the past 12 years, 16 thumb defects at, or distal to, the interphalangeal joint were reconstructed using a great toe mini wrap-around flap. A flap including the entire nail and most of the distal phalanx of the great toe was used. Fifteen of the grafts survived. The sensory recovery of the reconstructed thumb was good as assessed by 2-point discrimination test with an average of 10 mm (range 5-15), and there were no complaints of cold intolerance. This technique results in good cosmetic appearance, and all patients were pleased with the cosmetic aspect of the thumb and there was no significant morbidity at the great toe donor site. The final decision to reconstruct a distal thumb amputation is influenced by gender, job, and age of the patients. The great toe mini wrap-around flap is an excellent reconstruction technique in selected patients.
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Affiliation(s)
- Roberto Adani
- Department of Orthopaedic Surgery, University of Modena and Reggio Emilia, Modena, Italy.
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Abstract
Fingertip injuries can be treated in different ways, including shortening with primary closure, skin grafts, and local or distant flaps. Nail bed involvement complicates fingertip reconstruction and may influence the choice of treatment. Local flaps can usually replace the pulp and provide a satisfactory functional and aesthetic result, whereas reconstruction of the fingernail apparatus is more difficult. In the period between 1998 and 2001, 12 fingertip injuries with nail bed involvement were treated with a combination of local flaps (Tranquilli-Leali and Venkataswami flaps) and the eponychial flap. The eponychial flap described by Bakhach is a backward cutaneous translation flap that lengthens the nail plate and restores a good appearance of the nail apparatus. This technique is simple to use and can be used with different flaps for pulp reconstruction.
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Affiliation(s)
- Roberto Adani
- Department of Orthopedic Surgery, University of Modena and Reggio Emilia, Italy.
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Abstract
Nails enhance pulp sensibility, increase pulp stability and are necessary for fine prehension. A finger without a nail will compromise a musician's career if the finger involved is necessary to play a note (strings, keyboards) or hold a position (winds). Salvage of the nail is then a very important part of any surgical procedure in musicians with distal finger trauma. Surgical techniques will depend on the level and type of nail injury. Replantation is by far the best technique in distal finger amputation but, when not feasible, reposition-flap repair may be used. In isolated nail lesions, sutures, split-thickness nail bed graft, or nail matrix flaps are used according to the level and severity of the lesion.
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Hofer SOP, Cronin KJ, Morrison WA. A long-term study of ring finger transfer in the reconstruction of transmetacarpal amputations. J Hand Surg Am 2002; 27:1087-94. [PMID: 12457362 DOI: 10.1053/jhsu.2002.35883] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Restoration of adequate function in patients with metacarpal hands is a major challenge. In 1984, we presented a technique in which the contralateral uninjured ring finger was transferred by microvascular techniques to restore the dual hand functions of pinch and palmar grips. This was performed in combination with thumb reconstruction when necessary. The original 5 patients described in 1984, as well as 2 later cases, were reviewed for a long-term follow-up study (average, 19 y; range, 8-25 y). The average age of the patients at follow-up evaluation was 44 years (range, 13-73 y). Range of motion, grip span, sensibility, and grip strengths were measured. The Disabilities of the Arm, Shoulder, and Hand outcome measure was used to evaluate disability. The data show persistent good function with improving sensibility over the years. The ring finger transfer in reconstruction of transmetacarpal amputation has proven to be a good technique with an overall satisfactory outcome, especially in its ability to restore some capacity for palmar grip, a function that has hitherto been unattainable by other means.
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Affiliation(s)
- Stefan O P Hofer
- Department of Plastic and Reconstructive Surgery, St.Vincent's Hospital, University of Melbourne, and Bernard O'Brien Institute of Microsurgery, Melbourne, Australia
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Double-Level Replantation of the Upper Extremity with Microvascular Pulp Transfer onto an Intermediate Macroreplant Segment. Plast Reconstr Surg 2002. [DOI: 10.1097/00006534-200210000-00013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Christian Dumontier
- Consultant, Institut de la Main, Paris France, Orthopedic department, Hôpital Saint Antoine, Paris, France.
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Affiliation(s)
- Kazuteru Doi
- Department of Orthopaedics, Ogori Daiichi General Hospital, 862-3 Shimogo, Ogori-cho, Yoshiki-gun, Yamaguchi prefecture 754 0002, Japan.
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