The versatile reverse-flow digital artery cross-finger flap

Dorso Proximal Interphalangeal Island Flap

Background

This study aimed to demonstrate the clinical application of the dorsoproximal interphalangeal island flap as an alternative approach to skin graft or cross-finger flap to repair lesions at the ventral site at the proximal interphalangeal (PIP) finger joint.

Methods

Fifteen patients received flaps (11 men and four women, n = 25 flaps). The repair of volar contracture in finger sequelae after burn injuries was the main indication. Five patients underwent two or more flaps during the same surgical session. The mean patient age was 18 years (range, 7-56 years). Most patients presented with palmar finger contractures of the PIP joint. In three patients, six flaps were rotated to the lateral radial and ulnar proximal surfaces of the finger to treat syndactyly.

Results

Most flaps survived and provided satisfactory functional and aesthetic improvement of palmar scar contracture in the PIP region. Postoperative donor site follow-up was normal. The color and pliability of the skin are similar to those of the surrounding area. The follow-up period ranged from 6 months to 12 years.

Conclusions

Dorsoproximal interphalangeal island flaps are an option for repairing lesions that lack soft tissue and range in size from 10 × 15 to 12 × 18 mm at the volar site and around the PIP joint. The arch of rotation of this flap allows for lateral, ulnar, and radial rotations around the joint. The indication of six flaps in three patients to repair a proximal lack of tissue caused by syndactyly demonstrated its potential use in this anomaly.

Flap decisions and options in soft tissue coverage of the upper limb

Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.

Reverse digital artery flap from radial and ulnar borders of palm

Reconstructing skin defects of the volar aspect of fingers can be a challenging task due to a lack of local expendable tissue. The reverse digital artery flap is a versatile and reliable technique that can be used to manage such disabling injuries. Various authors have used this flap effectively, but most have used the digit itself as the donor site. This limits the size of the flap and also necessitates skin grafting to cover the donor site. Large reverse digital artery flaps can be raised from the radial and ulnar borders of the palm facilitating coverage of significant digital defects and primary closure of the donor site, resulting in minimal donor-site morbidity. We describe 3 illustrative cases to highlight the flaps versatility.

Repair of dorsal defects over the middle phalanx and proximal interphalangeal joint with a transposition flap from the dorsum of the proximal phalanx

PURPOSE

We report the use of a transposition flap raised from the dorsum of the proximal phalanx for coverage of soft tissue defects on the dorsum of the middle phalanx and proximal interphalangeal joint involvement.

METHODS

From October 2005 to November 2008, we treated 16 digits in 16 patients in our unit. There were avulsion (n = 3), third-degree burn (n = 7), and crush (n = 6) injuries. The mean flap size was 2.3 × 1.8 cm (range, 1.8 × 1.7 cm to 2.6 × 2.3 cm). The mean pedicle length was 1.7 cm (range, 1.0-2.3 cm). At follow-up, we measured active joint motion. The scar pain at the donor site was determined by the patient's self-reported assessment. We measured cold intolerance using the self-administered Cold Intolerance Severity Score questionnaire.

RESULTS

All flaps survived completely. At the final follow-up after 2 years, the mean active motion of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints were 90°, 105°, and 57°, respectively. All scars on the donor sites were painless. All patients were mildly cold intolerant.

CONCLUSIONS

This transposition flap raised from the dorsum of proximal phalanx is useful and reliable for coverage of a dorsal defect over the middle phalanx and proximal interphalangeal joint with minimal donor site morbidity.

Coverage of fingertip defect using a dorsal island pedicle flap including both dorsal digital nerves

PURPOSE

Fingertip or pulp resurfacing is a challenging reconstructive problem, as the treatment varies widely. In this study, we report the results of a dorsal island pedicle flap raised from an adjacent finger, including the bilateral dorsal digital nerves, for coverage of extensive soft tissue defect in the fingertip or pulp.

METHODS

The mean defect and the flap were 3.7 x 2.2 cm and 3.9 x 2.4 cm in size, respectively. In all cases, bilateral coaptation between the dorsal digital nerves and the proper digital nerves were performed. Patient follow-up lasted 25 to 34 months (mean, 27 months). The range of motion of the injured digits was measured. Sensibility of both radial and ulnar sides of the flap in the finger pulp was evaluated by the Semmes-Weinstein monofilament test and 2-point discrimination. Satisfaction with the appearance, pain, and cold intolerance were also assessed.

RESULTS

All flaps survived completely with maintenance of the normal-length digit. Full motion was maintained at the distal and proximal interphalangeal joints of both the injured and donor fingers. The mean values of Semmes-Weinstein sensitivity were 4.22 g and 4.31 g on the radial and ulnar sides of the flap in the pulp, respectively. The mean values of static 2-point discrimination were 4.4 mm and 4.5 mm on the radial and ulnar sides, respectively. All patients were satisfied with appearance of the fingertips.

CONCLUSIONS

The dorsal island pedicle flap from an adjacent finger can be used for coverage of extensive fingertip or pulp defects, with maintenance of a normal-length digit and restoration of sensation on both the radial and ulnar sides of the finger pulp. The sensation recovery of this series is superior to those dorsal island pedicle flaps previously described in the literature, which did not include incorporation of both dorsal digital nerves.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.