Repair of soft tissue defects in finger, thumb and forearm: less invasive methods with similar outcomes

Free peroneal artery perforator flap for reconstruction of traumatic limb soft tissue defects: A retrospective case series study

BACKGROUND

The free peroneal artery perforator (FPAP) flap is used for soft tissue defects after burns and trauma. However, the use of FPAP flaps to repair limb soft tissue defects for immediate reconstruction was rarely reported previously. Therefore, the purpose of this report is to evaluate free peroneal artery perforator flap to reconstruct traumatic limb soft tissue defects for immediate reconstruction.

PATIENTS AND METHODS

A total of 25 cases of limb soft tissue defects undergoing immediate reconstruction of FPAP flap transfer were retrospectively evaluated from January 2019 to June 2019 in our institute. The locations of defects included the palm (10 cases), finger (5 cases), foot (7 cases), ankle (2 cases) and wrist (1 case). The sizes of defect varied from 3 × 2 cm to 15 × 7 cm (54.1 cm2 in average). Flaps were harvested based on the peroneal perforator vessels, initially marked using hand-held Doppler.

RESULTS

Average size of harvested flap was 9.7 × 6.2 cm (ranging from 3.5 × 2 cm to 16 × 8 cm). All perforators were harvested from the peroneal artery and the arterial diameter ranged from 0.8 to 1.7 mm. The average pedicle length was 3.04 cm (range, 1.85-4.75 cm). Five vascular thrombosis were found including three cases of arterial thrombosis and two cases of venous thrombosis which were successfully salvaged by re-operation and vein graft. Satisfying functional outcome and acceptable appearance were achieved at 6 months or longer after surgery (range, 6-15 months, 12 months in average). All flaps survived at the end-point.

CONCLUSIONS

The FPAP flap is a reliable and thin fasciocutaneous flap, which can be used for repairing limb soft tissue defects. The FPAP flap can be used for covering defects with various appearances, locations, and sizes.

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.

Study on the prevention and nursing intervention of infection after flap transfer for hand trauma

To analyze the factors associated with infection after flap transfer for hand trauma and use them to develop nursing strategies and observe the effects of their application. Eighty-two patients admitted to our hospital for flap transfer for hand trauma from January 2020 to May 2020 were selected for the retrospective analysis. Logistic regression analysis was performed to analyze the factors associated with postoperative infections to develop care strategies. Another 88 patients admitted for flap transfer for hand trauma from September 2020 to June 2021 were retrospectively analyzed and divided into the observation (n = 44) and control groups (n = 44) according nursing strategies that they received. The operative time, intraoperative bleeding, incision healing time, first postoperative time to get out of bed on their own and hospital stay were compared between the 2 groups. The patients postoperative adverse effects and flap survival rates were also counted. visual analogue score, total active motion, manual muscle test, Barthel index, self-rating anxiety scale, self-rating depression scale scores were used to assess patients pain, hand function recovery and psychology before and after treatment. Logistic regression analysis manifested that postoperative bed rest time, affected limb immobilization, and pain were independent factors affecting postoperative infection after flap transfer (P < .05). After using targeted care strategies, the observation group had dramatically shorter operative time, intraoperative bleeding, incision healing time, time to first postoperative bed release on their own, and hospital stay, less postoperative pain and adverse effects, and higher flap survival rate than the control group (P < .05). Total active motion, manual muscle test, and Barthel index were higher in the observation group than in the control group after treatment, while self-rating anxiety scale and self-rating depression scale scores were lower than in the control group (P < .05). Finally, total satisfaction was higher in the observation group than in the control group (P < .05). Postoperative bedtime, fixation of the affected limb, and pain are independent factors affecting postoperative infection after flap transfer for hand trauma. Implementing infection prevention care strategies based on these factors can effectively improve the safety of flap transfer, reduce the possibility of infection, and shorten the recovery period of patients, which has high clinical application value.

Reverse homodigital dorsoradial flaps for thumb coverage obtained good sensory recovery after a long time follow up

Reverse homodigital dorsoradial flap (RHDF) of the thumb has become a qualified option for the reconstruction of thumb tissue defects. However, the sensory recovery of the flap in long term is still unknown. Therefore, this study focused on the sensory recovery of RHDFs for the coverage of thumb in hand after a long-term follow-up. From January 2010 to March 2011, 18 patients (14 men and four women) were treated consecutively with an RHDF. All the patients were followed up two times. The pain and cold intolerance of the flap were self-reported by the patients. The sensory recovery of the flap was evaluated using Semmes-Weinstein (SW) monofilament, moving two-point discrimination (M-2PD) and static two-point discrimination (S-2PD) tests. The average times of the first and second follow-up were 39 ± 4 and 88 ± 6 months, respectively. The mean value of SW monofilament sensitivity score and M-2PD at first follow-up was significantly higher than that of the second follow-up and contralateral thumb. The mean value of S-2PD at the second follow-up was significantly lower than that of the first follow-up and higher than that of the contralateral thumb. The cold intolerance severity score (CISS) at the first follow-up was higher than that at the second follow-up. No significant difference was found in terms of the pain between the two follow-ups. RHDFs without nerve coaptation for thumb coverage could obtain good sensory recovery after a long-term follow-up. Abbreviations: RHDF: reverse homodigital dorsoradial flap; CISS: cold intolerance severity score; SW: Semmes-Weinstein monofilament sensitivity score; M-2PD: moving two-point discrimination; S-2PD: static two-point discrimination; VAS: visual analog scale.

The efficacy and safety of platelet-rich plasma in the tendon-exposed wounds: a preliminary study

Objective

Currently, among wounds with large skin tissue defects caused by various reasons, the treatment of refractory wounds is still a major clinical problem. This study is aimed to preliminarily assess the therapeutic potentials of platelet-rich plasma (PRP) in refractory wounds with exposed tendons, as well as corresponding efficacy and safety.

Methods

A total of 12 patients (5 males and 7 females) with refractory wounds and exposed tendons who were admitted to our hospital from June 2018 to December 2020 were included in this study. After the preparation of PRP, the included patients underwent the PRP injection after the debridement of wounds, and the efficacy and prognosis were assessed by the same group of senior surgeons.

Results

The average age of included patients was 42.7 ± 12.9 years, and the causes of injury included traffic accidents (3 cases), contusion (2 cases), burns (2 cases), diabetes complications (4 cases), and melanoma complications (1 cases). The average healing time was 23.0 ± 5.0 days, and the mean size of the wound was 3.1 × 5.1 cm². During the whole treatment process, Vancouver Scar Scale (VSS) decreased from 7.4 ± 1.6 before PRP treatment to 3.6 ± 0.9 after treatment (P < 0.001), Manchester Scar Scale (MSS) decreased from 12.3 ± 4.5 before PRP treatment to 5.4 ± 1.2 after treatment (P < 0.001), and no redness and swelling were observed around wounds, the size and degree of wounds gradually reduced, the coverage rate of granulation tissue was acceptable, overall quality of scar was relatively good, skin sensitivity around wounds was normal, there was no local wounds secretion, and postoperative patient's satisfaction was relatively good during follow-up.

Conclusions

Our study has preliminarily indicated that PRP can promote the wounds healing, reduce the inflammation around wounds, and improve the granulation tissue and angiogenesis, thereby effectively polishing up the safety and efficacy.

Medial plantar artery perforator (MPAP) flap is an ideal option for reconstruction of complex soft tissue defect in the finger: Clinical experience from 11 cases

Introduction

Soft tissue defects of fingers are common in reconstructive plastic surgery, and reconstruction of the defects remains challenging for plastic surgeons. In our study, we reported our experience in finger reconstruction with a medial plantar artery perforator (MPAP) flap, especially using a lobulated MPAP flap for the complex multifinger soft defect.

Patients and methods

From the period April 2012 to October 2018, 11 patients (9 males and 2 females) with an average age of 44 years old (ranging from 11 to 58) received finger reconstruction with a free MPAP flap. In total, 11 flaps (8 single-lobulated flaps and 3 two-lobulated flaps) were raised from the ipsilateral or contralateral instep area. Trauma and scar contracture caused hand soft tissue loss in all cases.

Results

The sizes of the flaps ranged from 2×3 to 5×7.5 cm2. All flaps survived intact with no complications. One donor site was closed primarily, and other donor sites were covered with a full-thickness skin graft. The mean follow-up time was 6 months (ranging from 3 to 8 months). During the follow-up period, the patients were satisfied with their appearance without any traces of flap plastic surgery.

Conclusion

The MPAP flap is a reliable and acceptable option for the reconstruction of complex soft tissue defects in the finger. Depending on the two branches of the medial plantar artery, the use of the lobulated MPAP flap holds promise in the treatment of multifinger soft tissue defects.

Vacuum-Assisted Therapy for Combined Volar-Dorsal Soft-Tissue Defects of the Hand: A Case Report

ABSTRACT

Application of negative-pressure wound therapy dressings to the web spaces and small, often moist, areas of the hand can be technically demanding and time consuming. The researchers present a case report and technique for managing a devastating hand infection and soft-tissue defects by creating a self-fabricated sponge glove that is easily reproducible. Vacuum-assisted therapy for combined volar dorsal soft-tissue defects of the hand, or "Hand Vac," is a novel approach for treating extensive hand wounds. This technique was used in a patient with diabetes with a deep space infection of the hand following serial debridements and antibiotic bead therapy. A single, medium-size sponge was cut using a knife and scissors to create an easily applied glove that was then sealed with adhesive dressing and a single suction port. The patient avoided complete amputation of the hand and deep infection was eradicated. The wounds had progressive granulation and healing and were eventually covered with split-thickness skin grafts. The authors conclude that severe soft-tissue defects involving both the volar and dorsal aspects of the hand can be effectively managed with a single glove-like sponge and suction port.

Soft and tissue repair of the hand and digital reconstruction

This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.

Clinical Application of Artificial Dermis and Autologous Skin in Repairing Skin and Soft Tissue Defects of Hands and Feet with Bone Exposure Injuries

Patients with skin and soft tissue defects are very common. Mild trauma often causes mild skin damage, while severe injuries are often accompanied by bone and tendon exposure, which brings great pain to patients. For the defect of skin and soft tissue, the traditional treatment methods are mostly medium or full-thickness skin or skin flap transplantation. These methods are effective in wound repair, but there are still many problems. In recent years, with the improvement of tissue engineering technology, the use of artificial skin to repair various skin wounds is gradually becoming clinical, and the key technology of skin tissue engineering lies in the development of dermal substitutes. The appearance of artificial dermis not only solves the shortage of autologous skin source but also makes the operation simple and easy. The purpose of this study was to investigate the clinical effect of artificial dermis combined with autologous skin grafts in repairing hand and foot skin and soft tissue defects with bone exposure. The results show that the use of artificial dermis combined with autogenous blade thick skin to treat patients with hand and foot soft tissue injury with bone exposure has a good clinical effect, and the skin is alive and has fewer complications, which is worthy of promotion.

Matriderm dermal substitute in the treatment of post traumatic hand's fingertip tissue loss

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.

[Repair of distal phalanx finger wound with modified great toe fibular flap with distal artery pedicle as reflux vein]

Objective

To investigate the effectiveness of the modified great toe fibular flap using the distal artery pedicle as reflux vein for repairing distal phalanx finger wound.

Methods

Between June 2018 and January 2020, 15 patients who suffered tissue defect of the distal phalanx finger were treated, including 12 males and 3 females, the average age was 40.2 years (range, 24-56 years). All of them were caused by machine crush injury. There were 2 cases of thumb, 6 cases of index finger, 3 cases of middle finger, 3 cases of ring finger, and 1 case of little finger. The defects ranged from 1.7 cm×1.3 cm to 3.0 cm×2.0 cm. The time from injury to admission was 0.6-4 hours, with an average of 2.3 hours. The medial fibular proper digital artery was further dissociated to the distal end and anastomosed with the recipient vein as the reflux vein. The area of flaps ranged from 2.0 cm×1.5 cm to 3.2 cm×2.2 cm.

Results

All the flaps survived without vascular crisis, and the wounds healed by first intention. Except for 1 case that the suture was too tight, the incision was partially split after the stitches were removed, and it healed spontaneously after dressing change, the other patients had good healing of the donor site incision and normal foot function. All 15 patients were followed up 3-18 months, with an average of 9.3 months. The appearance of finger pulps were satisfactory with full and threaded. The color, texture, and elasticity of the flaps were good, and the two-point discrimination was 6-8 mm at last follow-up. The flexion and extension of fingers were normal. At last follow-up, hand function was evaluated according to the upper limb function evaluation trial standard of the Chinese Medical Association Hand Surgery Society, and the results were 13 cases of excellent and 2 cases of good.

Conclusion

Modified great toe fibular flap using the distal arterial pedicle as a reflux vein can improve the venous drainage of the flap and contribute to increase the success rate of the flap without additional injury.

Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery

Several methods can be used for identifying tissues for transfer in donor-site-depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Indications and functional outcome of the use of integra® dermal regeneration template for the management of traumatic soft tissue defects on dorsal hand, fingers and thumb

INTRODUCTION

Few studies have been conducted to explore the utility of the Integra^® dermal regeneration template (IDRT) combined with a delayed split-thickness skin graft (STSG) for reconstructing complex dorsal hand, digit, and thumb injuries. This study reports the indications and outcomes for 14 patients treated with this technique via a two-stage process.

MATERIALS AND METHODS

We retrospectively reviewed all patients treated by IDRT combined with STSG from May 2015 to October 2018. The inclusion criterion was traumatic or post-infectious soft tissue defects (STDs) of the dorsal hand, fingers, and thumb, not suitable for direct wound closure and requiring local, pedicle, or free flap reconstruction. After debridement, a two-stage procedure was applied, namely IDRT followed by STSG. Indications, functional outcomes, aesthetic results, complications, patient satisfaction, and the STSG take rate were evaluated over a 36-month follow-up using standardised instruments.

RESULTS

A total of 14 patients with 15 reconstructions (average age = 48 years) were included. The dominant hand was involved in 50% of cases. Dorsal STDs involved the hand, fingers, thumb, and hand and thumb in 7, 3, 2 and 2 cases, respectively. The mean STD size was 35 cm² (range: 3-150 cm²). The wound was associated with exposed tendons (without peritenon), bone (without periosteum), and joints (without a capsule) in eight cases (57%). The IDRT/STSG take rate was 97%. The average Vancouver Scar Scale score was 2 (1-4).

CONCLUSION

The 36-month follow-up demonstrated that IDRT is a safe and reliable technique that can be considered a viable alternative to flap reconstruction for the management of traumatic STDs in selected patients. The aesthetic outcomes are acceptable, functional recovery of the fingers is excellent, patient satisfaction is very high and the rate of complications is very low.

An ulnar parametacarpal perforator flap for volar digital soft tissue reconstruction

We present outcomes of using a perforator-based ulnar parametacarpal flap in 25 patients for digital pulp defects. These included 17 free transfers to the thumb, index, middle and ring fingers and eight reverse pedicled transfers to the little fingers. This flap includes a dorsal sensory branch of the ulnar nerve, which was sutured to the digital nerve in all transfers. Each flap had one to three reliable perforators (mean 0.44 mm diameter) to the ulnar parametacarpal region and contained at least one perforator within 2 cm proximal to the palmar digital crease. All the 25 flaps survived completely. Twenty-two patients were followed for 15 months (range 12 to 24), and three were lost to follow-up. The mean static and moving two-point discrimination of the flap was 7 mm and 5 mm, respectively. At the donor site, sensory reinnervation was acceptable. We conclude that ulnar parametacarpal perforator flaps offer sensate, thick and glabrous skin for finger pulp repair, all in a single operative field.Level of evidence: IV.

Potential of Tissue-Engineered and Artificial Dermis Grafts for Fingertip Reconstruction

BACKGROUND

Management of skin and soft-tissue defects of the fingertips is functionally and aesthetically important, but controversial, especially when bones are exposed. Recent advances in wound healing technology allow the use of cells or biological dermis. The authors studied the clinical efficacy of tissue-engineered dermis grafts and artificial dermis grafts versus immediate reconstructive procedures, such as the reverse digital artery island flap, in treating bone-exposed fingertip defects.

METHODS

One hundred eighty-two patients with bone-exposed fingertip defects treated with tissue-engineered dermis grafts (n = 71), artificial dermis grafts (n = 23), or reverse digital artery island flaps (n = 88) were included in this retrospective cohort study. Surgical time, duration of hospitalization, total cost, success rate, healing time, sensory recovery, range of motion, scar quality, and patient satisfaction were compared.

RESULTS

No tissue-engineered or artificial dermis graft exhibited graft rejection or failure, whereas there was one partial loss and one total loss after reverse digital artery island flap surgery. Tissue-engineered dermis grafts were superior in scar quality, and artificial dermis grafts had shorter surgical times and lower surgical costs; both groups demonstrated superior results in postoperative range of motion and sensory recovery in two-point discrimination tests and shorter hospitalization, compared with the reverse digital artery island flap group. The reverse digital artery island flap had shorter complete closure time and less postoperative tingling sensation. There were no differences in overall patient satisfaction among the groups.

CONCLUSIONS

Tissue-engineered and artificial dermis grafts may be promising alternatives for fingertip reconstruction. In particular, tissue-engineered dermis grafts may deliver superior functional results, including recovery of sensory discomfort and aesthetic results in terms of scar quality over artificial dermis grafts.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Compound or Specially Designed Flaps in the Lower Extremities

Novel and combined tissue transfers from the lower extremity provide new tools to combat soft tissue defects of the hand, foot, and ankle, or fracture nonunion. Flaps can be designed for special purposes, such as providing a gliding bed for a grafted or repaired tendon or for thumb or finger reconstruction. Propeller flaps can cover soft tissue defects of the leg and foot. In repairing severe bone and soft tissue defects of the lower extremity, combined approaches, including external fixators, one-stage vascularized bone grafting, and skin or muscle flap coverage of the traumatized leg and foot, have become popular.

A Global View of Digital Replantation and Revascularization

Survival rates of digital replantation vary in different regions and countries, and Asian surgeons see more challenging cases and have developed some unique methods. Replantation of multiple digits in one or both hands can follow a structure-by-structure method or a digit-by-digit method. For replanting all 10 digits, 3 or 4 teams should be organized. Flow-through flaps, often venous flaps, can be taken from the distal forearm or lower extremity to repair defects of soft tissues and arteries. A pedicled digital artery flap from the adjacent digit can also repair tissue defects and supply blood to the replanted digit.

Microsurgical Tissue Transfer in Complex Upper Extremity Trauma

Microsurgical tissue transfer may provide reconstructive option for extensive loss of tissues due to upper extremity trauma or tumor resection. This article reviews the authors' experience in using microsurgical tissue transfers for reconstruction of upper extremity trauma.

Major Changes in Lymphatic Microsurgery and Microvascular Surgery in Past 20 Years

This article summarizes the major changes seen in lymphatic microsurgery and microvascular surgery in first 20 years of the 21st century. Lymphatic microsurgery is discussed first, as more advances have been seen in imaging of the lymphatic system, lymphatico-venous anastomosis, and vascularized lymph node transfers. During the past 2 decades, there have been more patient population changes than major technical evolutions in microvascular surgery, although new techniques and modifications emerged and became clinical routines, with the landscape of microvascular surgery evolving in this time period.

Vascularized flap transfer to fingers with volar digital veins as recipient vessels

Traditionally free vascularized flap transfers to the fingers connect to the proper digital artery and dorsal veins. We report our experience using the volar digital veins as recipient veins for free vascularized flap transfers in 14 fingers of 12 patients. One or two veins (three flaps with two veins, 11 flaps with one vein) of the flap were anastomosed to volar digital veins in the recipient site. The arteries of these flaps were connected to the proper digital arteries. All the transferred flaps survived. No vessel crisis occurred. Our patients demonstrated that volar veins can be the recipient veins for free flap transfers in the fingers without increased risk of venous crisis and flap loss. Level of evidence: IV.

Maximal advancement of homodigital neurovascular island flaps

We investigated the maximal advancement of the homodigital neurovascular island flap with the digit in full extension and its correlation to the digital length. In 32 adult cadaveric digits, flaps measuring 1 × 1 cm were sequentially elevated to different dissection points. Dissection of the flap to the proximal interphalangeal joint crease, palmo-digital crease, division of adjacent digital artery and the superficial arch resulted in flap advancement of 8, 12, 15 and 18 mm, respectively. The degree of advancement correlated to the length of the finger and was approximately 19% of the finger length. We conclude that dissection of a homodigital antegrade neurovascular island flap to the proximal interphalangeal joint, palmo-digital crease, after ligation of adjacent digital artery and the superficial arch allows progressively more advancement. The advancement obtained by flap dissection to the palmo-digital crease was about 19% of the finger length.

Extending Applications of Local Anesthesia Without Tourniquet to Flap Harvest and Transfer in the Hand

The authors' experience demonstrates that wide-awake flap surgery in the hand is safe. The authors used this approach in 4 commonly used flaps in the hand in 27 patients: the extended Segmuller flap, the homo-digital reverse digital artery flap, the dorsal metacarpal artery perforator flap, and the Atasoy advancement flap. Wide-awake flap surgery works very well and safely achieved excellent anesthetic and vasoconstrictive effects in the authors' cases. The authors found that vasoconstriction caused by epinephrine mainly affects the capillaries and does not affect digital arteries and their major branches in the hand.