Digital artery perforator flaps for fingertip reconstructions

Double-pivot proper digital artery perforator flap for fingertip reconstruction

BACKGROUND

Dorsal flap based on proper digital artery perforator has been commonly used in wound coverage of fingertip; yet a small diameter and short length poses a risk of pedicle kinking or occlusion. The present study aims to present our preliminary results of using a double-pivot perforator flap based on the end dorsal branch of proper digital artery to repair finger pulp defect.

METHODS

We designed a double-pivot flap based on the end-dorsal perforator branch of proper digital artery, raised from the dorsal aspect of the middle phalanx, with inclusion of both the perforator and a section of the trunk of the artery. This modified procedure forms a pedicle with a larger diameter and length than traditional designs. Twelve patients (12 fingers) each with a soft-tissue defect of the fingertip were successfully treated and followed up in this retrospective study.

RESULTS

All the flaps survived without showing any signs of necrosis; three cases presented with transient venous flow disorder, these self-resolving without requiring any additional treatment. At final follow-up (12-33 months, mean 20 months), mean static two-point discrimination on the flap was 7.0 mm (range, 6-9).

CONCLUSION

The double-pivot proper digital artery flap serves as a reliable option in fingertip reconstruction offering added benefits of having greater rotation flexibility, a lower risk of vessel kinking or occlusion, and good recovery of cutaneous sensation.

Fingertip coverage with uni-pedicled volar rotational advancement flap with large Z-plasty: a report on 112 cases

BACKGROUND

Simple and safe fingertip reconstruction methods involve the use of local neurovascular islands flaps that can preserve functional length and sensitivity, and reconstruction with skin of the same texture. However, techniques involving flaps have numerous drawbacks and do not satisfy all the requirements for fingertip reconstruction. A particular problem is the persistence of contracture deformity due to lack of full flap advancement. We present a new technique using uni-pedicled volar rotational advancement flap with large Z-plasty, and describe the results of long-term follow-up.

METHODS

From October 1993 to December 2009, 112 fingers of 98 patients were covered with uni-pedicled volar rotational advancement flap with large Z-plasty after sustaining various types of injuries or finger pulp avulsion. A longitudinal incision was made along the lateral border of the digit and a large neurovascular volar flap was elevated just above the pulleys and flexor tendon sheath. To release tension, a large Z-plasty was applied at the metacarpophalangeal joint or interphalangeal joint crease. The final patient outcomes were reviewed retrospectively.

RESULTS

All fingertip injuries were treated without flap necrosis. Partial wound dehiscence was observed in two patients and average static two-point discrimination was 5.2 mm. There were no postoperative contracture deformities, joint stiffness, paresthesia, or hypersensitivity. Most patients were left with acceptable scarring and were free of postoperative pain and cold intolerance during the long-term follow-up.

CONCLUSIONS

Our novel technique provides durable, completely sensate, and well-vascularized coverage of the fingertip with minimal discomfort to patients.

Comparison of reading man flap and skin grafting for closure of resultant donor defects in homodigital reverse flow flaps

BACKGROUND

The reading man procedure is a valuable treatment option for circular defects of different parts of the body. The aim of this study was to compare reading man procedure and skin grafting for coverage of resultant donor defects in homodigital reverse flow flaps.

METHODS

From January 2018 to October 2020, 38 patients underwent fingertip reconstruction using homodigital reverse flow flaps. The donor sites were resurfaced with full-thickness skin grafts in 20 patients and with reading man flaps in 18 patients. Flap survival, postoperative complications, operative time for closure of donor site, return work time, range of motion of the injured fingers, static two-point discrimination, and aesthetic results were evaluated.

RESULTS

All the outcomes, including flap survival, postoperative complications, operative time for closure of donor site, return work time, range of motion of the injured fingers, static two-point discrimination, and aesthetic results, were similar between the two groups. No patients complained of cold intolerance or hypersensitivity.

CONCLUSION

The reading man flap is useful and reliable for covering resultant donor defects in homodigital reverse flow flaps. The functional and aesthetic outcomes in both groups are similar.

The Efficacy of Antegrade Homodigital Neurovascular Island Flaps in Distal Fingertip Reconstruction: A Systematic Literature Review

BACKGROUND

Antegrade homodigital neurovascular island flaps (AHIFs) are a heterogeneous group of pedicled flaps used for reconstruction of traumatic digital detipping injuries. While numerous single-center studies have documented their use, there are no large or multicentre studies validating their efficacy, applicability, and functional outcomes. We performed a systematic review of the contemporary literature to establish the safety and functional outcomes of this technique.

METHODS

Electronic searches were performed using PubMED, Embase, and MEDLINE from inception date to October 2020, with further studies identified from study reference lists and independent searches. Relevant studies reported on complications and functional outcomes of the AHIFs, as used for digital detipping injuries. Data were then extracted and analyzed.

RESULTS

Twenty-seven studies published between 1974 and 2019 yielded 744 patients. Four studies provided incomplete epidemiologic data, resulting in a total of 559 patients with 584 digital injuries. Index and middle fingers were most frequently involved. Mean final 2-point discrimination (2-PD) was 4.9 mm static and 5.1 mm dynamic, with dynamic 2-PD reported in 2 studies. Mean total active motion of the digit was 200.3°. Mean time to return to work was 6.7 weeks in 10 studies. Flap survivorship was found to be 99.6% in 23 studies. Cold intolerance was the most common complication at 18%, followed by pain and hypersensitivity.

CONCLUSIONS

Antegrade homodigital neurovascular island flaps provide a safe and effective method of treating distal finger amputations, yielding satisfactory functional outcomes across all ages. Further studies comparing outcomes between the AHIFs and other reconstructive modalities would be useful.

Use of digital artery perforator flaps for repairing soft tissue defects after fasciectomy for Dupuytren's contractures in the ring and little fingers: A case report

Fasciectomy is the standard treatment for Dupuytren's contracture, but, in many cases, skin defects may occur after fasciectomy. If the preoperative contracture is severe, the skin defect is large, which makes covering the defect difficult. We describe a case of severe skin defects after fasciectomy of Dupuytren's contractures in the ring and little fingers covered with multiple digital artery perforator (DAP) flaps . A 58-year-old man with extension restrictions of the ring and little fingers on his left hand was diagnosed with Dupuytren's contracture. The angles of insufficient extension were 70° and 40° for the metacarpophalangeal and proximal interphalangeal joints, respectively, of the little finger and 42° for the metacarpophalangeal joint of the ring finger. DAP flaps were used to cover the defect on the ring finger's metacarpophalangeal joint and little finger's proximal interphalangeal joint, whereas an ulnar palmar DAP flap was used on the defect on the little finger's metacarpophalangeal joint. The flaps survived without any complications, and, at 6 months postoperatively, satisfactory results were obtained. The extension angles were 0° for the metacarpophalangeal and proximal interphalangeal joints of the little finger and −5° for the ring finger's metacarpophalangeal joint. Such flaps can be designed to fit the width of the skin defect and can be applied to a large skin defect by combining the perforator flaps. Thus, the use of DAP flaps after fasciectomy to cover defects is considered helpful, even in cases of Dupuytren's contracture with severe extension restriction.

The Bridged Digital Artery Perforator Flap as an Alternative Reconstructive Option for Dorsal Digital or Toe Soft Tissue Defects

BACKGROUND

Dorsal digital soft tissue defects are considered among the most challenging to reconstruct. Numerous treatment options are proposed, including advancement flaps, antegrade, retrograde flow flaps, adipofascial flaps, and digital artery perforator flaps. However, the optimal treatment remains controversial. The concept of the "bridge principle," consisting of the indirect transfer of the flap to the defect area through a muscular bridge, has recently introduced by authors for medial canthal reconstruction. The aim of the study was to examine the feasibility of its application in digital reconstruction for dorsal defects and the development of a new flap. The utilization of the dorsal subcutaneous adipofascial digital or toe tissue as a "bridge" led to description and development of bridged digital artery perforator flaps as an alternative treatment of such defects.

METHODS

From November 2017 to September 2019, a series of 14 patients (mean age of 57.1 years) suffered from dorsal digital or toe soft tissue defects of different dimensions and sustained reconstruction with this new technique.

RESULTS

Twelve digits and 2 toes have been concerned. The mean size of the defects was 1.3 × 1.1 cm. All flaps survived without a sign of venous congestion. No functional digital or toe problems were observed during the follow-up period (mean of 11.6 months). Minor wound dehiscence presented in 2 cases (2 of 14 [14.3%]) and a transient skin swelling around the flap in 1.

CONCLUSIONS

A new concept was introduced to resolve a challenging problem. Initial outcomes are very encouraging. These flaps could be a valuable and reliable reconstructive option.

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.

Partial second-toe pulp free flap for fingertip reconstruction: Experience and surgical tips to minimize complications

BACKGROUND

Traumatic fingertip injury is a common hand injury and various methods are available to address them. The partial second-toe pulp (PSTP) free flap is useful because of the similarity in shape, texture, and sensation to the fingertips. However, there may be many difficulties during surgery. The purpose of this report is to make the surgery easier and minimize complications by sharing the surgical tips of the authors obtained through many experiences.

PATIENTS AND METHODS

Thirty patients who underwent PSTP free flap due to trauma were reviewed retrospectively from February 2015 to June 2018. The average age of the patients was 49.4 years. Seventeen were injured on the right side and 13 were on the left side. After removal of the injured tissue, a teardrop-shaped flap was harvested from the medial side of the second toe. When inset, skin graft or vein graft was performed if necessary. When primary closure of the donor site was difficult, skin graft was performed (n = 21). The factors noted during surgery were analyzed.

RESULTS

The flap size was 2.39 (range: 1.5-5) x 1.29 (range: 1-1.8) cm² . All flaps survived. Venous congestion was found in two patients, neuroma was found in one patient, and partial necrosis was found in two patients; all recovered with conservative care. The mean follow up periods was 5.79 (range: 2-18) months. None of the patients had functional impairment.

CONCLUSION

Successful reconstruction and enhanced functional and cosmetic effects can be achieved using surgical tips.

Bilateral flaps based on the dorsal branches of the proper digital artery: A reliable reconstruction in one-stage for the multiple defects in one finger

PURPOSE

To repair multiple skin soft tissue defects of one finger is a challenge to hand surgeons. We introduce a method which can be used to repair multiple skin soft tissue defects of one finger with bilateral flaps in parallel pattern flap based on the dorsal branches of the proper digital artery.

METHOD

A patient suffered electric injury in her left index finger with two soft tissue defects, and the areas were 1.6 cm × 1.0 cm and 2.2 cm × 1.2 cm, respectively. And who underwent a homodigital parallel flaps based on the dorsal branches of the proper digital artery to repair in January 2018. The donor sites were covered by full-thickness skin grafting.

RESULTS

The flaps and the skin grafting survived uneventfully. All incisions achieved primary healing. The follow-up was 19 months, and the shape of the flaps was satisfactory with soft texture and suitable appearance. TAM of the injured finger was 210°, the level was excellent. The score of VAS was 9.

CONCLUSION

The homodigital bilateral flaps in parallel pattern based on the dorsal branches of the proper digital artery are a potential treatment in one-stage for multiple skin soft tissue defects of one finger with reliable blood supply, satisfactory results and simple surgical procedure.

Treatment of fingertip defect with reversed digital artery island flap through superficial vein anastomosis

BACKGROUND

This study prospectively explored the clinical effect of a reversed digital artery island flap (RDAIF) in repairing fingertip defects and the impact of the anastomosis of superficial veins in the recipient area on the incidence of venous crisis.

METHODS

A total of 92 patients with fingertip defects who underwent RDAIF from February 2016 to February 2018 were enrolled in this prospective, randomized, controlled trial. Of these, 44 patients underwent superficial vein anastomosis. The perioperative data, clinical efficacy and complications of the two groups were compared by the chi-squared test and binary logistic regression analysis.

RESULTS

The average follow-up time was 7.0 ± 2.9 months. The incidence of venous congestion was significantly correlated with flap size, surgical time and anastomosis of superficial veins (Wald = 6.512, 9.353 and 11.662; P = 0.011, 0.002 and 0.001, respectively). The fingertips of the two groups of patients were well repaired, wear resistant and stable in holding, and the two-point discrimination was 5-8 mm.

CONCLUSION

RDAIF is a safe and effective method for the treatment of fingertip defects, especially in patients who require maintenance of function or contour of the fingertip. Anastomosis of the superficial veins and reduction of the flap area and surgical time can significantly reduce the incidence of venous congestion.

The Burden of Fingertip Trauma on the US Military

Fingertip injuries in the military are common and often hinder the fighting force and support personnel. Injuries range from small subungual hematomas to proximal finger amputations. Treatment modalities are dictated by injury patterns, anatomic considerations, and the need to return to duty. Nail bed injuries should be repaired when possible and exposed bone or tendon is treated with appropriate soft tissue coverage. If soft tissue coverage is unobtainable, revision amputation should be performed with attention given to maintaining as much finger length as possible. Antibiotics may not be required, however they are often utilized in the deployed setting.

Digital artery perforator flap transfer for volar soft tissue defect due to dissociation from joint contracture in camptodactyly

Camptodactyly is a condition defined by persistent flexion contracture of the proximal interphalangeal joints of the hand. Surgical treatment requires flaps for the dissection of the skin and the resulting soft tissue defect, soft tissue release, and sometimes reconstruction of the extension mechanism. Z-plasty and transposition flap have been reported as methods used in soft tissue defects. In this case, covering the defects of the digits was necessary for keeping the wound clean; thus, we should select a surgical method that facilitates stable and reliable blood flow of the flap. The digital artery perforator flap is pedicled and its transfer does not require the dissection of neurovascular bundles; therefore, it can be used safety and relatively easily. We considered the digital artery perforator flap to be a useful technique in terms of securing stable and reliable blood flow and not twisting the skin. Thus, we performed a digital artery perforator flap transfer for a volar soft tissue defect due to dissociation from proximal interphalangeal joint contracture in camptodactyly.

Propeller Flaps for Hand and Digit Reconstruction

The reconstruction of soft tissue defects of the hand, as seen often after trauma or tumor excision, is a challenge due to the great differentiation of tissues depending on the hand area involved. The classical intrinsic "workhorse flaps" of the hand are associated with a significant donor-site morbidity. Capturing perforator vessels in discrete donor areas can reduce the amount of soft tissue that has to be dissected and included in what now would be a perforator flap, while also insuring robust vascularization of those transferred tissues. Moreover, the presence of perforator vessels both on the dorsal and volar sides of the hand allows harvest of perforator flaps that will respect the like-with-like principle by maintaining the main characteristics of volar and dorsal skin as desired. However, the dissection of these flaps, especially those based on volar palmar and digital perforators, still requires microsurgical skills to preserve the fine vascularization of these flaps. These small flaps are also amenable for application of the propeller flap concept. This is an especially valuable means for preserving the length of an amputated finger where bone is exposed by using more proximal uninjured tissues. Although in general only a short dissection is required to raise a propeller flap in this region, most often the donor site will have to be closed by a skin graft.

Patient satisfaction after innervated digital artery perforator flap for fingertip injuries

OBJECTIVE

The aim of this study was to evaluate the results of the innervated digital artery perforator (IDAP) flap and to analyze the relationship between patient satisfaction and outcome measures.

METHODS

A total of 17 fingertips of 15 patients (14 men and one woman; mean age: 47.2 (26-62) years) were included in this retrospective study. Patients' injured finger and defect type were recorded. At the last follow-up, the static two-point discrimination (s2PD) test, Semmes Weinstein monofilament (SWM) test, and range of motion of the affected finger were analyzed. We interviewed patients to determine hand dominance, cold intolerance, and their satisfaction with the result. We performed correlation and logistic regression analyses between patient satisfaction and outcome measures.

RESULTS

The mean follow-up period was 13.8 (7-18) months. The mean range of motion was 77.3±3.5 (70-80) degrees for the distal interphalangeal joints of affected fingers. The mean s2PD was 6.4 (3-10) mm, and the SWM records ranged from 2.83 to 4.93 monofilament markings. Cold intolerance was noted in seven fingers (41%). Patient satisfaction was negatively correlated with cold intolerance, and cold intolerance decreased as the follow-up period extended.

CONCLUSION

IDAP flap satisfies both patient and surgeon, with the only significant problem being cold intolerance, regarding which patients must be informed. Although cold intolerance is hard to treat, fortunately, it generally improves with time.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

The unilateral perforator V-Y flap for fingertip reconstruction-a versatile technique

Fingertip amputations are a very common form of injury seen in the emergency departments. Various techniques have been described for the management of these injuries including simple dressings, skin grafts, homodigital, heterodigital and regional flaps and also free flaps. We present our experience with 10 cases of unilateral V-Y flaps raised on a perforator vessel and advanced in a modified fashion to cover the entire tip with a single flap. The technique is quick and easy to perform under loupe magnification, has minimal donor site morbidity and achieves good results in terms of healing, hand function, sensory recovery, appearance and patient satisfaction.

A Review and Meta-analysis of Adverse Events Related to Local Flap Reconstruction for Digital Soft Tissue Defects

We reviewed the current literature to estimate incidence rates for adverse events with pedicled flaps in the hand. We identified 241 different studies reporting adverse events for 6693 flaps. The average incidence rate was 5.4% and total or partial loss of flap constituted 65% of all reported complications. Flaps with reverse or perforator-based flow may be more prone to vascular complications compared with flaps with antegrade flow or skin pedicle. The incidence rates were acceptable in all flaps (1%-10%) and thus the flap can be chosen primarily based on considerations other than risk of adverse events.

Flaps Based on Perforators of the Digital Artery

This review article summarizes the various types of digital artery perforator flaps used in digit reconstruction. The indications for use of digital artery perforator flaps and the preferred approach for reconstructing fingertip defects are explained in this article. Recent updates in digital artery perforator anatomy in the finger, techniques for flap harvest, and inset as well as a delayed approach to using digital perforator flaps in finger reconstruction are discussed.

Soft Tissue Coverage of the Digits and Hand

There are multiple options available for reconstruction of soft tissue defects of the digits. The main goal of reconstruction is to achieve normal or near-normal mobility. Soft tissue defects can be considered in the following groups: fingertip, nonfingertip, and multiple digits. The choice of reconstruction for fingertip defects depends primarily on the amount of volar skin available. The patient's functional demands and expectations, and the expertise of the surgeon, also determine the reconstructive strategy.

Proximal Interphalangeal Joint Adipofascial Flap Resurfacing Improves the Active Motion of the Proximal Interphalangeal Joint after Contracture Release

BACKGROUND

Posttraumatic proximal interphalangeal (PIP) joint contractures of the digits are common and are associated with impaired hand function. However, relapse is common after surgical release of PIP joint contractures. This article presents a novel treatment strategy with a PIP joint adipofascial flap to resurface the joint after release, and compares patients with similar joint contracture release who did and did not undergo resurfacing with a PIP joint adipofascial flap.

METHODS

From January of 2010 to January of 2018, 10 patients received single-digit PIP joint flexion contracture release and PIP joint adipofascial flap resurfacing; 20 patients received a stepwise release as a control group. Thirty joints were compared, and the degree of extension lag improvement over time was measured during an average follow-up period of 292.4 days.

RESULTS

Greater extension lag improvement was observed in the PIP joint adipofascial flap group compared with the control group (37.0 ± 19.2 degrees versus 21.0 ± 19.5 degrees; p =0.055). The ratio of improvement was also significantly higher in the flap group (0.79 ± 0.26 versus 0.49 ± 0.46; p =0.049). Flap resurfacing appeared to have a beneficial effect on improvements in extension lag (p =0.042), whereas a higher number of secondary operations, associated fractures, and maximum visual analogue scale score 1 week postoperatively were negatively associated with extension lag in univariate analysis (p < 0.05). Generalized estimating modeling showed that flap resurfacing had a significantly positive effect on extensor lag improvement with time (β = 2.235; p =0.04).

CONCLUSIONS

PIP joint adipofascial flap resurfacing following PIP joint contracture release may improve and maintain extensor lag. Recovery of joint motion may also be quicker compared with conventional release alone.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Finger defect coverage with digital artery perforator flaps

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.

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.

Free toe pulp flap for finger pulp and volar defect reconstruction

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.

Reconstruction of the plantar toe with a distal reverse instep sensory island flap

BACKGROUND

Plantar toe ulcers are a challenging surgical problem. There are several methods for reconstruction, but no attention has been given to the preservation of sensation. This report proposes a method to provide protective sensation for the reconstructed area.

PATIENTS AND METHODS

The ulcers of seven patients ranged from 2 × 3 to 7 × 3 cm with defects of the plantar first toe and distal metatarsus, including four burns, a trauma, a diabetic ulcer, and a neuropathy injury reconstructed with a distal reverse instep sensory island (DRISI) flap. The patients were 21-38 years old. The second metatarsus medial nerve was co-opted using the end-to-side method to the adjacent lateral nerve, then its proximal stump provided the donor nerve for the sensation of the flap. Patients were assessed in terms of protective sensory functions, including touch, pain, dermatomeric somatosensory-evoked potentials (SEP), thermal sensation and Semmes-Weinstein monofilament (SWM) light touch.

RESULTS

The flaps ranged from 2 × 3 to 7 × 3 cm. All transferred flaps to the plantar first toe survived. No complications were observed at the donor and flap sites. Patients were followed-up 8-24 months. Except for two cases, all nerves of the donor and flap sites exhibited protective sensation, including positive SEP responses between 44 and 50 ms and positive SWM responses ≤ 3.84.

CONCLUSION

The DRISI flap can be used for the reconstruction of various plantar first toe defects with acceptable protective sensation. End-to-side neurorrhaphy provides a sensory nerve end to subsequent end to end co-optation to the flap nerve for protective sensation.

The reconstruction for proximal nail fold mucous cyst using reverse and island flap

We performed nail fold reconstruction after digital mucous cyst (DMC) excision using an island-type lateral finger flap on seven patients (four males and three females). Our procedure is a simple and useful method to repair minor nail fold lesion defects after DMC excision.

Fingertip and Thumb Tip Wounds: Changing Algorithms for Sensation, Aesthetics, and Function

Management of fingertip and thumb tip injuries has recently undergone substantial changes. The time-proven traditional armamentarium of local flaps has been expanded and replaced by a wide variety of flaps. Simultaneous with the development of new flaps, the conservative treatment of fingertip and thumb tip injuries with semiocclusive dressings has also become a more acceptable treatment for these injuries. The excellent results with respect to restoring contour, sensibility of the pulp, and aesthetics of the finger justify this more tedious and time-consuming treatment of fingertip and thumb tip injuries. This article gives an update of the most commonly used flaps and the semiocclusive dressing treatments of fingertip and thumb tip injuries.

IFSSH scientific committee on skin coverage: 2015 report

Skin coverage in hand reconstruction is a challenging and vast chapter in hand surgery; covering every aspect of it in a report is simply not feasible. Therefore, this report focuses on a few specific topics. The coverage of anatomical regions like the fingertips is common ground for hand surgeons worldwide, but in the last 10 years, various refinements have been published in order to optimize the reconstruction of this organ. Nevertheless, in many emergency departments, the amputation of badly injured fingertips, including the thumb, remains the preferred treatment. The main focus of this report is to counter this tendency by providing alternatives to surgeons. Large defects in the fingers involving more than one segment, defects in the palm and in the dorsum of the hand are currently debated in international meetings. The use of skin substitutes vs. the use of extremely refined microsurgical procedures vs. classic island flaps has generated animated discussions, which are also influenced by cultural and socioeconomic factors around the world. This report offers the views of six surgeons from four different countries, in the hope of animating discussions and suggesting new approaches.

Repair of Fingertip Defect Using an Anterograde Pedicle Flap Based on the Dorsal Perforator

Background:

The purposes of this article are to introduce and assess the results of a long-term follow-up of using anterograde pedicle flap based on the dorsal branches of proper digital neurovascular bundles from the dorsum of the middle phalanx for the fingertip defect.

Methods:

Between February 2011 and December 2012, 31 patients underwent reconstruction of fingertip defects using a homodigital flap based on the dorsal perforator in the middle phalanx. The defect size ranged from 1.3 cm × 1.5 cm to 2.4 cm × 3.0 cm. During surgery, the flap was designed on the dorsal middle phalangeal region. The pedicle was a neurovascular bundle consisting of an artery, vein, and sensory nerve; the rotation of pedicle was <90 degrees.

Results:

The clinical results were satisfactory after 3 to 9 months of follow-up. The flaps were considered cosmetically acceptable by both patients and doctors. The sensory recovery was excellent, 2-point discrimination was 4.96 ± 1.47 mm, and the recovery of range of motion of the interphalangeal joints was very good.

Conclusions:

The anterograde island flap based on the dorsal branches of proper digital neurovascular bundles is an ideal aesthetic reconstruction method for fingertip defect. A 90-degree rotated island pedicle flap was very versatile, easy to design, and had good survival. This technique is simple with less damage to the donor site, without sacrificing the branch of the digital artery and nerve. The reliable source of blood supply and satisfactory recovery of sensation can be achieved without affecting the interphalangeal joint activity.

Simple and easy reconstruction of nail matrix lesion using lateral finger flap after excision of digital mucous cyst

We treated nine patients with skin defect produced by digital mucous cyst (DMC) excision on the finger and toe using lateral finger flap (LFF). The postoperative scars were esthetically acceptable and no recurrence of mucous cysts was observed. Our LFF is a simple method to repair minor distal dorsal finger defects.

Planning digital artery perforators using color Doppler ultrasonography: A preliminary report

Digital artery perforator (DAP) flaps have been applied for the coverage of finger soft tissue defects. Although an advantage of this method is that there is no scarification of the digital arteries, it is difficult to identify the location of the perforators during intraoperative elevation of the DAP flap. In this study, anatomically reliable locations of DAPs were confirmed using color Doppler ultrasonography (US) in healthy volunteers. A successful case using an adiposal-only DAP flap for the coverage of a released digital nerve using preoperative DAP mapping with color Doppler US is also described. A total of 40 digital arteries in 20 fingers of the right hands of five healthy volunteers (mean age: 32.2 years old) were evaluated. The DAPs were identified using color flow imaging based on the beat of the digital artery in the short axial view. In total, 133 perforators were detected, 76 (an average of 3.8 per finger) arising from the radial digital artery and 57 (an average of 2.9 per finger) arising from ulnar digital artery. Sixty-three perforators (an average of 3.2 per finger) in the middle phalanges and 70 (an average of 3.5 per finger) in the proximal phalanges were found. Overall, an average of 1.7 perforators from each digital artery was detected in the proximal or middle phalanges. Moreover, at least one DAP per phalanx was reliably confirmed using color Doppler US. Preoperative knowledge of DAP mapping could make elevating the DAP flap easier and safer.

Predictable Pattern Digital Artery Perforator Flap: An Alternative Concept in Digital Reconstruction

BACKGROUND

The proper digital arteries as any other axial vessel give rise to multiple cutaneous perforators either volar or dorsal along their course. Their identification is performed with Doppler flowmetry. The vasculo-cutano-tendino-osseous complex (VCTOC), which was described by the senior authors, was responsible for the vascularization of all digital anatomic structures (extensor apparatus, skin, periosteum). Their consistent appearance to well measured distances from the digital joints led the way to the present clinical study for highlighting this described anatomy in-vivo and demonstrating the predictability in digital artery perforator (DAP) flap harvest.

METHODS

From November 2012 to March 2014, fifteen patients underwent reconstruction with a predictable pattern digital artery perforator flap (PPDAP), based on the previously described VCTOC mapping, for digital lesions secondary to tumor extirpation. Flaps were designed as V-Y advancement or propeller type. Postoperative control concerned flap viability and digital function.

RESULTS

Seven males and 8 females underwent elective surgery using PPDAP flaps for digital defects following tumor extirpation. The diameter of the defect ranged from 0.5 to 1.5 cm. The vast majority of the lesions were identified on the right hand, the index, the ring finger and the distal phalanx. All flaps survived without signs of venous congestion. No functional digital problems were observed during follow up (mean of 77 months). A minor wound dehiscence presented in one patient.

CONCLUSIONS

Authors introduced the concept of a "predictable pattern" in the surgery of perforator flaps in the digits. These flaps are reliable and could be a valuable reconstructive option.

Innervated Digital Artery Perforator Flap: A Versatile Technique for Fingertip Reconstruction

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.

Comparative study of functional and aesthetically outcomes of reverse digital artery and reverse dorsal homodigital island flaps for fingertip repair

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.

Innervated Digital Artery Perforator Propeller Flap for Reconstruction of Lateral Oblique Fingertip Defects

PURPOSE

To report our experience with the use of a digital artery perforator propeller flap based on a constant distal perforator in the middle phalanx for resurfacing of lateral oblique fingertip amputations.

METHODS

Twelve fingertips in 10 patients underwent reconstruction, with a mean follow-up of 8 months (range, 8-12 mo). The size of the flaps ranged from 2.5 × 1.5 cm to 3.0 × 2.0 cm.

RESULTS

All flaps survived entirely and restored a rounded fingertip contour. Mean static 2-point discrimination was 5 mm (range, 4-6 mm). With the exception of 1 patient with an amputation at the distal interphalangeal joint, the distal interphalangeal joint was preserved in all patients and had 30° to 60° of motion at final follow-up. No patients complained of cold intolerance or residual joint contracture. No hooked nail deformity occurred in patients who had remaining nailbed.

CONCLUSIONS

The digital artery perforator propeller flap is particularly suited to coverage of a lateral oblique fingertip defect, because only a 90° rotation is required when inset, and the bulk of the flap serves to restore the rounded contour of the fingertip. The skin over the entire dorsal surface of the middle phalanx can be elevated as a flap, providing adequate tissue to resurface the defect and restore a rounded contour to the fingertip.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of thumb tip injuries

The management of thumb tip injuries has undergone great changes in recent years. The traditional armamentarium of flaps has been expanded and replaced by a wide variety of flaps with more versatility and less donor side morbidity. Parallel to the development of new flaps, the conservative treatment of thumb tip injuries with semi-occlusive dressing has gained ground in the treatment of these injuries. Although tedious and time-consuming, and requiring intensive communication with the patient to explain the look and occasionally fetid smell of the wound, this technique yields excellent results with respect to restoring contour and sensibility in pulp injuries. The article gives an update on the current options for treating thumb tip injuries including the most commonly applied flaps.

An evolutionary perspective on the history of flap reconstruction in the upper extremity

Examining the evolution of flap reconstruction of the upper extremity is similar to studying the evolution of biological species. This analogy provides a perspective to appreciate the contributing factors that led to the development of the current arsenal of techniques. It shows the trajectory for the future and provides a glimpse of the factors that that will be influential in the future.

Classification of distal fingertip amputation based on the arterial system for replantation

During replantation of distal fingertip amputation, identification of the artery is the most important but time consuming procedure. Depending on the damaged arterial structure, we classified distal fingertip amputations into 4 zones, on the basis of three dimensional concept. Zone 1 injury was defined as damage to the proximal central pulp artery; zone 2 injury, damage to the branch of the central pulp artery; zone 3 injury, damage to the distal central pulp artery; and zone 4 injury, no injury to the central pulp artery, injury only to the lateral pulp artery. From April 2010 to June 2011, 27 patients were evaluated. Successful replantation was observed in 21 patients. Skin necrosis occurred in six patients. For distal fingertip amputation classification based on the damaged arterial system is an easy method to find out the appropriate artery which should be anastomosed during replantation.

Outcome of free digital artery perforator flap transfer for reconstruction of fingertip defects

BACKGROUND

Fingertip defect can be treated with many flaps such as random pattern abdominal flap, retrograde digital artery island flap, V-Y advancement flap, etc. However, swelling in the fingertip, dysfunction of sensation, flexion and extension contracture or injury in the hemi-artery of the finger usually occurs during the recovery phase. Recently, digital artery perforator flaps have been used for fingertip reconstructions. With the development of super microsurgery techniques, free flaps can be more effective for sensory recovery and durability of the fingertip.

MATERIALS AND METHODS

Six cases (six fingers) of fingertip defects were treated with free digital artery perforator flaps of appropriate size and shape from the proximal phalanx. During surgery, the superficial veins at the edge of flap were used as reflux vessels and the branches of the intrinsic nerve and dorsal digital nerve toward the flap were used as sensory nerves. The proximal segment of the digital artery (cutaneous branches) towards the flap was cut off to form the pedicled free flap. The fingertips were reconstructed with the free flap by anastomosing the cutaneous branches of digital artery in the flap with the distal branch or trunk of the digital artery, the flap nerve with the nerve stump and the veins of the flap with the digital artery accompanying veins or the superficial veins in the recipient site.

RESULTS

Six flaps survived with successful skin grafting. Patients were followed up for 6-9 months. The appearance and texture of the flaps was satisfactory. The feeling within the six fingers recovered to S4 level (BMRC scale) and the two point discrimination was 3-8 mm.

CONCLUSION

Free digital artery perforator flap is suitable for repairing fingertip defect, with good texture, fine fingertip sensation and without sacrificing the branch of the digital artery or nerve.

Fingertip reconstruction using the hypothenar perforator free flap

BACKGROUND

The purpose of this study was to present the results of using the hypothenar perforator free flap for fingertip reconstruction.

METHODS

Between 2004 and 2012, 24 patients underwent reconstruction of fingertip defects using the hypothenar perforator free flap at our institute.

RESULTS

Flap survival was complete in 22 flaps. Flap size ranged from 1.5 to 2.5 cm in width and 2.7-4.5 cm in length. Donor sites were closed primarily in all patients. Healing of all donor sites was uncomplicated, and donor-site morbidity was minimal with acceptable scarring. Long-term follow-up for more than 12 months (range, 12-51 months) was possible in 14 patients and revealed excellent flap sensibility.

CONCLUSIONS

The hypothenar perforator free flap provides acceptable functional and cosmetic outcomes for the reconstruction of fingertip defects. The authors recommend that this flap should be considered as a useful option for fingertip reconstruction.

Innervated digital artery perforator flap

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.