Reconstruction of fingertip amputations with full-thickness perionychial grafts from the retained part and local flaps.

The treatment of fingertip amputations distal to the distal interphalangeal joint when the amputated part is saved is difficult and controversial. Both reattachment of the amputated portion as a composite graft and microvascular anastomosis are prone to failure in this distal location. The authors have evolved a reconstructive plan that uses the nail matrix, perionychium, and hyponychium of the amputated fingertip as a full-thickness graft when the amputation is between the midportion of the nail bed andjust proximal to the eponychial fold. Various flaps are used to lengthen and augment the finger pulp, and skeletal pinning is carried out as necessary. The charts of 15 patients who underwent this procedure over a 38 month period were evaluated retrospectively. Seven returned to the office for examination at least 1 year after the fingertip reconstruction described above; four others were interviewed by telephone. Nail deformity, fingertip sensation, and joint range of motion were evaluated, and the reconstructed fingertips were photographed in standardized views. In six of the seven patients seen in the office, aesthetic and functional results were judged as good by both patient and physician; one of the six had minimal nail curvature. The seventh patient had no nail growth, although finger length was retained and there was no functional disability. The four patients interviewed by phone reported normal fingertip use with no dysesthesias or cold intolerance; all had nail growth, although three patients described slight nail curvature that required care in trimming. The authors favor salvage of all perionychial parts when a distal fingertip amputation occurs. Reconstruction of the fingertip with grafting of the hyponychium, perionychium, and nail matrix from the amputated part combined with local flaps can provide a very satisfactory functional and aesthetic result.     

Delayed primary reconstruction of subtotal nail bed loss using a split-thickness nail bed graft on decorticated bone

Split-thickness nail bed grafting is the accepted method of treatment for injuries involving loss of nail bed tissue. The nail bed of the great toe may be used without donor-site morbidity, and nail bed grafting may be combined with other procedures for fingertip reconstruction. A case of fingertip avulsion injury with loss of the nail plate, nail bed, and periosteum over the exposed distal phalanx of the thumb was reconstructed by a split-thickness nail bed graft placed directly on granulating decorticated bone. The length, appearance, and function of the injured dominant thumb were preserved.     

The extended Segmüller flap

A modification of the homodigital lateral V-Y advancement flaps described by Segmüller in 1976 for the treatment of fingertip injuries is described. The extended flap used in this series makes this flap more versatile in the treatment of injuries with considerable soft-tissue loss from the volar aspect of the fingertip. The Segmüller flap technique, its applications, and the results of 100 flaps are reported and discussed.     

The dorsal reverse adipofascial flap for fingertip reconstruction

Nine patients who presented with fingertip amputations were treated with the dorsal reverse adipofascial flap. The mean age of the patients was 41.3 years and the mean follow-up was 18 months. The flap described here was used only for amputations at the level of the nail fold, from approximately the lunula to the proximal nail matrix. This flap is based on the dorsal arterial branches that originate from the volar digital arteries just distal to the distal interphalangeal joint. The flap uses only the adipofascial tissue over the middle phalanx of the injured finger; it is turned over to cover the fingertip defect and then covered with a split-thickness skin graft. All flaps survived completely, and the patients continue to use their fingertips as before the amputation injury. This one-step operation is easily performed (even in the emergency department), makes no use of the adjacent digits, and provides a pleasing and stable cover for the fingertips.     

REPAIR OF INJURIES TO SOFT TISSUES OF FINGERS—Primary and Secondary Reconstruction

Preservation of maximum function and appearance of the finger can best be attained by wide excision of crushed or traumatized tissue and closure of defects by primary split thickness skin grafts. Primary pedicle flaps are rarely indicated and should be reserved for cover of denuded cortical bone or joint surfaces. In only 1 per cent of fresh injuries were primary pedicle flaps used. Finger length, nail bed and root, bone and tendon can be adequately preserved with minimal morbidity by split thickness skin grafts. Restoration of contour if necessary is best done secondarily, utilizing thenar or hypothenar flaps. These flaps are particularly indicated in the reconstruction of finger tips.     

One-stage reconstruction of the postburn nailfold contracture

Dorsal digital burn contractures cause unsightly eponychial retraction and proximal nail exposure. These areas are subject to breakdown with minor trauma. These deformities are often ignored as trivial. Many surgeons are unaware that simple reconstruction is possible. Correction is a worthwhile undertaking. This report illustrates a new modification: one-stage reconstruction with bilateral proximally based flaps, dorsally transposed and interdigitated. Donor sites are closed primarily. This technique has been successfully applied to 14 affected fingertips in 4 patients with no complications and no revisions. Patients have been gratified by the resultant restoration of the nailfold. Contractures have not recurred.     

Heterodigital arterialized flaps for large finger wounds: results and indications

Deep defects of the hand and fingers with an unhealthy bed exposing denuded tendon, bone, joint, or neurovascular structures require flap coverage. However, the location and size of the defects often preclude the use of local flap coverage. Free-flap coverage is often not desirable either, because the recipient vessels may be unhealthy from surrounding infection or trauma. In such situations, a regional pedicled flap is preferable. A solution to this is the heterodigital arterialized flap. This flap is supplied by the digital artery and a dorsal vein of the finger for venous drainage. Unlike the neurovascular island flap, the digital nerve is left in situ in the donor finger, thus avoiding many of the neurologic complications associated with the Littler flap. The digital artery island flap is centered on the midlateral line of the donor finger. It extends from the middorsal line to the midpalmar line. The maximal length of the flap is from the base of the finger to the distal interphalangeal joint. By preserving the pulp and the digital nerve, a sensate pulp on the donor finger remains that reduces donor-finger morbidity and also preserves fingertip cosmesis. Twenty-nine flaps were performed in 29 patients and the outcomes in the donor finger and the reconstructed finger were reviewed. The flap survival was 100 percent. There were no cases of flap ischemia or flap congestion. Good venous drainage of the flap through the additional dorsal vein was helpful in preventing the occurrence of early postoperative venous congestion, which is common in island flaps of the fingers, which depend on only the venae comitantes for drainage. Donor-finger morbidity, measured in terms of range of motion and two-point discrimination in the pulp, was minimal. Ninety-seven percent of the donor fingers achieved excellent or good total active motion according to the criteria of Strickland and Glogovac. Pulp sensation in the donor fingers was normal in 28 of the 29 donor fingers. No cold intolerance of the donor finger or the adjacent finger is reported in this series.     

Reconstruction of heel and sole defects by free flaps

One latissimus dorsi musculocutaneous flap and five radial forearm flaps were used in reconstruction of weight-bearing parts of the heel and sole, the follow-up period being 7 to 38 months. Additional injuries such as forefoot amputations or amputations of the other leg were present in four patients. There was no flap loss. The latissimus dorsi flap proved to be too bulky and showed recurrent ulcerations, several reoperations were necessary, and definite healing has not occurred. The five forearm flaps gave good results, with a walking range from 2 hours to unimpeded walking. Complications included fissuring at the edges of one large flap and a local infection which was successfully treated. Cutaneous sensation returned in all but one flap, where it was reduced preoperatively due to a meningomyelocele. The results indicate that the fasciocutaneous radial forearm flap should be taken into consideration for reconstruction of weight-bearing areas of the heel and sole. Shortcomings of this flap include an unsightly donor defect and possible hair growth on the flap.     

The use of subcutaneous pedicle flaps in the treatment of postburn scar contractures

Subcutaneous pedicle flaps, which were usually applied to repair small skin defects in the face or the fingertip, have been used with success in the treatment of 17 postburn scar contractures, with the exception of one partial flap necrosis. The results indicate the reliability and usefulness of this technique in the treatment of scar contractures, even in the extremities or the trunk. Subcutaneous pedicle flaps are effective for relatively wide contractures or quadratic contractures. When the skin tension across the contracture line is too great to use any local flap, such as a Z-plasty or V-Y plasty, the subcutaneous pedicle flap is particularly useful, because it can be freely designed in an area where the tension is small. When the flap contains some superficial scarring, the subcutaneous pedicle flap is preferred over other local flaps because of the superior vascularity and mobility.     

Reconstruction of proximal nasal defects with island composite nasal flaps

There are few local nasal flap options for repair of proximal nasal defects. Absence of suitable donor sites and the large dimensions of the defects limit the use of local nasal flaps in this region. Regional paranasal flaps may not be suitable in these cases because of color, texture, and donor-site scars. The composite procerus muscle and nasal skin flap, which is vascularized by the dorsal nasal branch of the angular artery, can be a useful treatment modality for proximal nasal reconstruction. Seven patients were successfully treated using the composite nasal flaps. The maximal size of the defects was 2.4 cm. In one case, the composite nasal flap was readvanced to close a new defect resulting from reexcision. The composite nasal flap has several advantages in reconstruction of proximal nasal defects. Reconstruction is performed with the same tissue and the donor defect is closed primarily. The composite nasal flap can be moved in multiple directions and has great mobility to reach every point of the proximal part of the nose with axial blood supply. Furthermore, it can be easily readvanced without additional morbidity in case of reexcision.     

An innervated cross-finger flap for fingertip reconstruction

An innervated cross-finger flap for treatment of severe fingertip injuries is described. With this method, the dorsal skin over the middle phalanx, together with its sensory nerve, is transferred as a compound skin-nerve flap. A neurorrhaphy is performed between this nerve and the cut end of the digital nerve at the injury site. Seven of eight patients (88 percent) treated with this method (mean follow-up time 14.4 months) achieved measurable two-point discrimination. The average for those who did was 4.8 mm. A group of patients with similar injuries treated with standard cross-finger flaps exhibited slower sensory return that progressed to a lower level. In this group (mean follow-up time 16.3 months), three of six (50 percent) achieved measurable two-point discrimination with a mean value of 9 mm.     

Does the nail bed really regenerate?

From observations of nail bed injuries, the regeneration of the nail bed seemed evident. The nail bed regenerated well in the presence of the nail matrix and poorly in its absence, suggesting that the nail bed regenerated from the nail matrix. Full-thickness skin graft or flap coverage of nail bed defects resulted in the good nail bed regeneration. The nail bed grew back, pushing the graft or the flap distally. The regenerated nail beds were about 70 percent of normal size in guillotine-type amputations and about 90 percent in the presence of an intact distal phalanx. The difference between full- and split-thickness skin grafts seemed to be adherence to the phalangeal bone, the former giving way to the advancing nail bed and the latter staying in the way. In addition, the destination of the moving nail bed cells was discussed.     

Bipedicle strap flaps in reconstruction of longitudinal dorsal skin defects of the digits

Dorsal skin defects in which the loss of integument is longitudinal in shape are not uncommon after injury by rotating machinery and by glass shearing along the length of the digit. This shape of defect is difficult to reconstruct with commonly used flaps but lends itself to reconstruction by the use of longitudinal bipedicle strap flaps moved across the dorsum of the finger from lateral to medial. A variant of this traditional technique was used in the reconstruction of 28 dorsal digital defects. The incidence of these defects and the need for this reconstructive technique were analyzed by a review of 1077 patients with dorsal digital injuries treated in a 6-year period between 1989 and 1995. Approximately 20 percent of all dorsal digital injuries requiring flap reconstruction were suitable for reconstruction with bipedicle strap flaps.     

Lip and vermilion reconstruction with the facial artery musculomucosal flap

The lips are a complex laminated structure. When lost through injury or disease, they present a complex reconstructive challenge. The facial artery musculomucosal (FAMM) flap is a composite flap with features similar to those of lip tissue. In this article, the anatomy, dissection, and clinical applications for the use of the FAMM flap in lip and vermilion reconstruction are discussed. A series of 16 FAMM flaps in 13 patients is presented. Seven patients had upper-lip reconstruction and six had lower-lip reconstruction. Superiorly based FAMM flaps were used in eight patients, and eight inferiorly based flaps were performed in five patients. Three patients had bilateral, inferiorly based flaps. In summary, the FAMM flap is a local flap that can be used for lip and vermilion reconstruction. Although not identical to the lip, it has many similar features, which make it an excellent option for lip reconstruction.     

The boomerang flap in managing injuries of the dorsum of the distal phalanx

Finding an appropriate soft-tissue grafting material to close a wound located over the dorsum of a finger, especially the distal phalanx, can be a difficult task. The boomerang flap mobilized from the dorsum of the proximal phalanx of an adjacent digit can be useful when applied as an island pedicle skin flap. The vascular supply to the skin flap is derived from the retrograde perfusion of the dorsal digital artery. Mobilization and lengthening of the vascular pedicle are achieved by dividing the distal end of the dorsal metacarpal artery at the bifurcation and incorporating two adjacent dorsal digital arteries into one. The boomerang flap was used in seven individuals with injuries involving the dorsal aspect of the distal phalanx over the past year. Skin defects in all patients were combined with bone,joint, or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one-step procedure preserves the proper palmar digital artery to the fingertip and has proven valuable for the coverage of wide and distal defects because it has the advantages of an extended skin paddle and a lengthened vascular pedicle. When conventional local flaps are inadequate, the boomerang flap should be considered for its reliability and low associated morbidity.     

Triple coverage of ischial ulcers with adipofascial turnover and fasciocutaneous flaps

Despite a wide variety of flap options, ischial ulcers remain the most difficult pressure ulcers to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using adipofascial turnover flaps combined with a local fasciocutaneous flap. After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the two flaps. A local fasciocutaneous flap (Limberg flap) is applied to the raw surface of the turnover flaps. Twenty-two patients with ischial ulcers were treated using this surgical procedure. Overall, 86.4 percent of the flaps (19 of 22) healed primarily. Triple coverage with the combination of double adipofascial turnover flaps and a local fasciocutaneous flap allows for an easily performed and minimally invasive procedure, preservation of future flap options, and a soft-tissue supply sufficient for covering the prominence and bony prominence and filling dead space. This technique provides successful soft-tissue reconstruction for minor to moderate-size ischial pressure ulcers.     

The segmental rectus abdominis free flap for ankle and foot reconstruction.

The reconstruction of soft-tissue defects of the ankle and foot usually requires free-tissue transfer. Although certain local flaps have been described for the reconstruction of these injuries, their utility may be compromised by significant crush injury or the size and location of the defect. Part of the rectus abdominis muscle, the segmental rectus abdominis free flap, is ideally suited for this use because of the muscle's versatility, reliability, and negligible donor deformity when harvested through a low transverse abdominal incision. Seven patients reconstructed with this flap are presented, and the technique is discussed. All patients have been successfully reconstructed with preservation of the ankle and foot. At present, all patients are fully or partially weight-bearing. The segmental rectus abdominis free flap is recommended for the reconstruction of such wounds.     

Sensory reconstruction of the fingertip using the bilaterally innervated sensory cross-finger flap

The authors present a series of 15 patients with large soft-tissue defects of the fingertips as a prospective, nonrandomized study. In all cases, reconstruction was achieved using a bilaterally innervated sensory cross-finger flap. This sensory fasciocutaneous flap relies on the dorsal branch of the proper digital nerves, which branch off at the level of the head of the proximal phalanx; sensory supply to the dorsal skin of the middle phalanx is thus ensured. The reconstructive procedure consists of two steps. First, the contralateral dorsal branch of the proper digital nerve is elevated with the flap at proximal interphalangeal joint level. Microsurgical coaptation is performed to the proximal nerve stump of the injured fingertip. After 3 weeks, when the pedicle is dissected, the second nerve is dissected and coapted. Clinical results were evaluated after 12 months. Because the regenerative distance is only 1.5 to 2.5 cm, good sensory regeneration should be expected. In nine of 16 flaps, sensory quality of S2+ (Highet) was present in the flap after 3 weeks. After 12 months, two-point discrimination was present in all patients, the values ranging between 2 and 6 mm (for two-point discrimination), with an average of 3.6 mm. The rate of complications was low. With acceptable additional operative action, a good functional result can be achieved. The indications of this method are discussed in comparison with other methods of fingertip reconstruction.     

A new strategy of fingertip reattachment: sequential use of microsurgical technique and pocketing of composite graft

Many methods have been used to reattach amputated fingertips. Of these methods, microsurgery has been accepted as the procedure of choice because the defining characteristic of a microsurgically replanted finger is that its surival in the recipient bed is predicated on functioning intravascular circulation. Although considerable progress has been made in the techniques for microvascular replantation of amputated fingers, the replantation of an amputated fingertip is difficult because digital arteries branch into small arteries. This is in addition to digital veins that run from both sides of the nail bed to the median dorsal sides, which are difficult to separate from the immobile soft tissue. Furthermore, even with the most technically skilled microsurgeon, replantation failure often occurs, especially in severe injury cases. Therefore, the technique is not the only protection against failure, and a new strategy of fingertip reattachment is needed. From March of 1997 to December of 1999, 12 fingers of 11 patients with zone 1 or zone 2 fingertip amputations that were reattached microsurgically but were compromised were deepithelialized, reattached, and then inserted into the abdominal pocket. All had been complete amputations with crushing injuries. Approximately 3 weeks later, the fingers were depocketed and covered with a skin graft. Of the 12 fingers, 7 survived completely and 3 had partial necrosis on less than one-third the volume of the amputated part. The complete survival rate was approximately 58 percent. The results of the above 10 fingers were satisfactory from both functional and cosmetic aspects. The authors believe that this high success rate was achieved because the deepithelialized finger pulp was placed in direct contact with the deep abdominal fascia, which was equipped with plentiful vascularity, not subcutaneous fat. In addition, the pocketing was performed promptly before necrosis of the compromised fingertip occurred. From the results of this study, it is clear that this new method is useful and can raise the survival rate of an amputated fingertip.     

Finger Tip Amputations—Review of Procedures and Applications

Repair of finger tip amputations depends upon the slope of transsection and how much of the tip has been amputated. Type 1 and 2 injuries are easily handled in the emergency room by local flaps with results acceptable by functional and economic criteria. Type 3 amputations with losses of less than 25 percent can be repaired by primary closure. Losses of 50 percent or over are best treated by local or “distant” flaps from the involved or adjacent fingers or palm. Each style of flap and technique has advantages and disadvantages.