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Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore, SingaporeDepartment of Hand and Reconstructive Microsurgery, National University Health System, 1E Kent Ridge Road, Level 11, Singapore 119228, Singapore
Section of Plastic Surgery, The University of Michigan Medical School, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI, USA
Fingertip amputations are common injuries with a myriad of management options.
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The VY advancement flap is classically used to cover distal transverse or volar favorable fingertip amputations.
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Volar unfavorable amputations can be reliably resurfaced by thenar or cross-finger flaps.
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Although these flaps are not innervated, patients can have good sensory recovery, especially younger patients.
Introduction
Fingertip amputations are one of the most common problems presenting for acute care. VY advancement, thenar flaps, and cross-finger flaps are work-horse flaps that are frequently used to resurface fingertip amputations, although they differ in their indications. These flaps are reliable and simple to perform without the need for neurovascular dissection.
VY advancement flaps
Historical Review and Variations
The earliest description of the VY advancement flap was by Dr Ettore Tranquilli-Leali
in which the flap design extends proximal to the distal interphalangeal crease and the flap is vascularized by the digital artery proper. The flap design was described for fingertip amputations that were proximal to the midnail level and that required a greater flap advancement for coverage.
described a variation of advancement flap for fingertip defects in which the flap is designed as a rectangle and a transverse incision is made on the pulp about 6 mm parallel and proximal to the amputation. A crescent flap (Fig. 1A) was also described for defects for use in situations in which the conventional VY flap would not be adequate for coverage and to preserve fingertip contour.
in which the distal ends of the triangular flap are brought together to form a cup at the end of the flap (Fig. 1B). This flap provides better coverage with less advancement of the flap and, when the 2 ends of the triangle fold together, the dog ear that results adds bulk and gives better contour to the reconstructed fingertip.
Indications
The volar VY advancement flap can advance about 5 to 7 mm in our experience, and is best used for resurfacing of a fingertip amputation that is either transverse or volar favorable
(Fig. 2A, B ). It is useful in distal fingertip amputations when at least 15 mm of the distal segment of the finger (measured from the distal interphalangeal joint crease) is available for flap advancement. It can also be used to resurface adherent or sensitive scars of the fingertip and hook nail deformity.
Fig. 2Steps of raising a VY advancement flap. (A, B) Volar neutral fingertip amputation. (C) VY flap design. (D) Yellow lines represent the lateral limits of the flap, which should be same as the width of the nail bed. (E) Division of fibrous tissue at the apex of the flap. (F) Separation of the deep margin of the flap from the periosteum and the flexor tendon sheath. (G) Using a skin hook for traction at the flap base, fibrous tissue that is limiting advancement is identified and divided. (H) The flap is then advanced and sutured to the nail bed. (I–K) After flap inset is complete.
The VY advancement flap is supplied by the terminal branches of the digital artery. In the Tranquilli-Leali flap, a full-thickness incision is made down to the periosteum of the distal phalanx. Therefore, the flap is supplied via the anastomotic connections between the terminal branches of the volar digital arteries and the dorsal arches through the fibro-osseous hiatus branch.
The Atasoy variation of this flap is raised by only incising the skin and other fibrous structures, as detailed later, while preserving the terminal branches of the digital artery and nerve.
Debridement is done. If there is a portion of the distal phalanx protruding beyond the nail bed, the bone is shortened to the level of the nail bed.
3.
A triangular flap is designed with the base at the edge of the amputation and its apex at the distal interphalangeal crease (see Fig. 2C). The base should be of the same width as the nail bed (see Fig. 2D).
4.
The skin incision is made first.
5.
To get good advancement, the following structures must be divided:
a.
Fibrous tissue at the apex of the flap (see Fig. 2E)
b.
Fibrous tissue at both sides of the base of the flap
6.
The deep margin of the flap is then separated from the periosteum and the flexor tendon sheath (see Fig. 2F).
7.
Using a skin hook for traction at the flap base, identify fibrous tissue that is limiting advancement and divide them (see Fig. 2G).
8.
The flap is then advanced and sutured to the nail bed (see Fig. 2H).
9.
The proximal portion of the V incision is closed linearly, forming a Y-shaped wound (see Fig. 2I–K).
Linear closure of the donor defect may reduce the circumference of the pulp. To prevent this, the authors recommend either of 2 methods: (1) flap design with a tapered apex (see Fig. 2C); (2) allowing the secondary defect to heal by secondary intention.
The base of the triangular flap should be the width of the nail bed. Raising a flap with narrower base results in problems with the pulp contour, as shown in Fig. 4A.
Fig. 4Complications. (A) Result of VY advancement with flap of smaller base. (B) Hook nail deformity.
Hook nail deformity (Fig. 4B) or a beaked nail occurs when there is loss of bony support for the distal nail bed and the excess nail bed curves palmarly at its most distal portion. This deformity is unsightly and may result in difficulties with picking up small objects and nail trimming. To prevent hook nail deformity, nail beds that extend distal to the tip of the distal phalanx should be excised.
In addition, the authors have advocated the use of Kirschner wires to pin the flap to the distal phalanx instead of direct suture. The flap is advanced to cover the critical area and secured with a pin. The rest of the wound is not closed but left to heal by secondary intention. This technique improves the reach of the flap without excessive risk for flap ischemia. Pulp contour is improved because of the healing by secondary intention.
In a volar favorable fingertip amputation, clinicians might encounter patients with very short remnant nails. To improve the appearance of the fingertip, an eponychial recession can be performed. This technique exposes the portion of the germinal matrix normally hidden by the eponychium, thus making the nail look longer by 2 to 4 mm.
A crescent-shaped area of skin is excised about 4 to 5 mm proximal to the eponychium. The maximum width of the excised skin is approximately 3 to 4 mm. The wound is then closed linearly, effectively bringing the eponychium to a more proximal position relative to the nail bed (Fig. 5).
Fig. 5Eponychial recession. (A) Volar favorable fingertip amputation with 3 mm of exposed nail bed. A crescent-shaped area of skin is excised 5 mm proximal to the eponychium with width of 3 mm. (B) The resultant wound is then closed directly, effectively recessing the eponychium and exposing 3 mm more of the nail bed. (C) Clinical view showing results at 3 months after the procedure.
This flap is simple to perform, reliable, and the donor site can be closed linearly. It also preserves good fingertip sensation with glabrous skin. Atasoy and colleagues
reported excellent aesthetic outcomes with normal finger range of motion and normal fingertip sensation in 97% of their patients. In their series of 61 patients, 2 had superficial skin necrosis.
In another study of 20 patients with 5.9 years of follow-up, there was an average of 3-mm difference in 2-point discrimination (2 PD) between the injured finger and the contralateral normal fingertip. However, 25% of the fingertips had persistent tenderness and 15% had nail beaking.
It would be logical to assume that the Tranquilli-Leali technique would give a worse outcome in terms of sensibility because the branches of the digital nerves would be transected during the procedure. However, this has not been proved in the literature.
Thenar flaps
Historical Review and Variations
The earliest description of the thenar flap was by Gatewood
in 1926. He described an ulnarly based pedicled flap over the thenar eminence that was used to cover a 2 × 2.5-cm defect over the index fingertip. The donor defect was closed linearly and the flap was divided at 12 days after the initial surgery. Since then, flaps that are distally based,
have been described. Investigators have also used double thenar flaps for coverage of multiple fingertip defects and have shown that the results are comparable with those of doing only a single thenar flap.
stated that the inclusion of a perforator allowed a longer and larger flap to be raised, which, in turn, allowed the finger joints to be in lesser degrees of flexion and potentially less stiffness in the injured digit.
Indications
The thenar flap can be used to cover volar unfavorable fingertip amputations and more extensive pulp losses of the involving the index, middle, and ring finger. It can also be used to cover defects of the nail bed.
Surgical Anatomy
The thenar flap is a random pattern flap and does not need any specific vascular dissection. However, knowledge of detailed vascular anatomy and sensory innervation allows surgeons to raise perforator and free flaps from this area.
The vascular anatomy of the thenar eminence was shown by Omokawa and colleagues
in a cadaveric study. The skin over the thenar eminence was supplied by the superficial palmar branch of the radial artery. The skin territory supplied by this vessel was 5.1 × 3.4 cm on average. The average diameter of the artery at its origin was about 1.4 mm with a pedicle length of 2 cm. The superficial palmar branch also had connections to other arteries in the palm in 63% of the specimens. The thenar eminence is drained via one of 3 routes: venae comitantes of the superficial palmar branch of the radial artery, superficial veins from the dorsal border of the thenar eminence, and superficial palmar veins that drain into the superficial forearm median vein. Sensory innervation of the thenar eminence is mainly supplied by the palmar cutaneous branch of the median nerve. There are also contributions from the lateral antebrachial cutaneous nerve and superficial radial nerve in varying degrees.
Operative Technique
1.
The procedure can be done under a wrist block.
2.
After thorough debridement of the injured fingertip, the digit is flexed so that the defect leaves an imprint on the thenar eminence (Figs. 6 and 7A ).
Fig. 6Siting of donor site. (A) Incorrect location of thenar flap. This is too near to the first web space and the thumb base and poses danger to the neurovascular bundle of the thumb. (B) The correct location of the flap should be more proximal, over the thenar area. This location prevents scar contractures of the thumb and first web space.
Fig. 7Thenar flap. (A) Flap design: rhomboid-shaped flap is outlined at the proximal thenar eminence. (B) Flap is raised with linear closure of donor site. (C) Flap inset. (D) Flap division. (E) Results at 4 months after surgery.
The authors typically raise this flap as a distally based flap. The distal end of a proximally based flap is inset into the nail bed, whereas the distal end of a distally based flap is inset into the pulp. We prefer a distally based flap because we think that the distally based flap allows inset over a larger surface area. Care must be taken to avoid injuring the radial digital nerve of the thumb. Avoid raising a flap close to first web to prevent web space contractures. The secondary defect is closed linearly (Fig. 7B).
4.
Flap inset (Fig. 7C) is done over the proximal and lateral aspects of the finger defect and dressings applied. It is important to ensure that the flap does not get kinked while in the dressings.
5.
Flap division is performed 2 to 3 weeks later (Fig. 7D, E).
Aesthetic Refinements
Primary closure of the secondary defect can be made easier by designing either a rhomboid or H-shaped flap, instead of a rectangular flap design. As far as possible, the flap donor site should be more proximal on the thenar eminence to prevent scar contractures of the thumb or the first web space (see Fig. 6).
Outcomes
A major advantage of this flap is the presence of good tissue matching with glabrous skin and easy flap dissection. The secondary defect has a healthy muscle bed and is easily closed linearly or using a skin graft. The scarring at the donor site is usually inconspicuous. Disadvantages includes stiffness of the digit, injury to digital nerve to the thumb, and donor site scar contracture and sensitivity. In general, all reported series of the thenar flap have good aesthetic outcomes, good sensory recovery, with absent to minimal finger stiffness and donor site problems. Raising the flap distally, proximally, or laterally did not seem to affect outcomes (Table 1).
as an original procedure since 1945. The flap is taken from the dorsum of an adjacent digit, usually at the level of the middle phalanx, and is used to resurface a volar unfavorable pulp amputation. This flap does not require the patient to place the arm in an awkward position, and is also easier to perform and less time consuming than raising an island flap.
The innervated cross-finger flap was first published by Adamson and colleagues
in 1967. The flap was harvested from the index finger along with branches of the superficial radial nerve to cover the thumb pulp. This technique was described with the aim of providing sensation to the thumb. A dual-innervated flap was also described.
The dual innervation originates from branches of the superficial radial nerve as well as the dorsal branch of the digital nerve proper. The dorsal branch of the proper radial digital nerve is cut and then neurotized to the thumb ulnar digital nerve to provide a dual source of innervation.
Indications
The cross-finger flap is reliable and has the ability to cover extensive loss of the pulp of the fingers and the thumb (Fig. 8A–C ). It can also cover defects at any level of the digit, unlike the thenar flap, which can only resurface defects at the fingertip. It is limited only by the amount of available skin from the donor digit; the width is limited by the midlateral line of the digit, and the maximum length extends from the level of the distal interphalangeal joint to the level of the palmodigital crease.
Fig. 8Cross-finger flap. (A–C) Volar unfavorable fingertip defect. (D) Excess skin is needed to recreate the pulp contour. (E) The proximal and distal extent of the flap is incised first and dissection is carried down to the paratenon of the extensor tendon. (F) The flap is then separated from the paratenon with blunt dissection. (G) To get good fingertip contour, anchor the sides of the flap at the lateral aspect of the distal-most region of the defect first and leave about 5 mm of excess flap hanging out distally. After the proximal part of the flap inset is done, the tip is turned down and then sutured to the sterile matrix. (H) A full-thickness skin graft is then harvested and used to cover the flap donor defect and the exposed skin bridge. (I, J) Flap inset is complete.
The cross-finger flap was initially raised as a random pattern flap. Investigators advised respecting the flap length/width ratio during flap harvest to ensure flap viability. However, consistent dorsal branches of the digital artery were described in 1990 by Strauch and Moura.
who described 4 constant dorsal branches arising at predictable distances from the proximal interphalangeal joint. The skin from the dorsum of the finger can be harvested as an island flap because of the presence of these branches.
Sensory innervation of the dorsum of a finger has 2 main contributions: 1 from the dorsal branches of the digital nerve proper, the second from branches of either the superficial radial nerve or dorsal branch of ulnar nerve.
Operative Technique
1.
The procedure can be done under a digital block or wrist block (Fig. 8).
2.
After debridement of the injured fingertip, the defect size is measured.
3.
For a pulp defect, the flap is designed on the dorsum of the middle phalanx of an adjacent digit. Choice of donor digit usually respects the natural finger cascade after flap inset. Keep in mind that some excess tissue has to be taken to get good pulp contour (see Fig. 8D).
4.
The proximal and distal extent of the flap is incised first and dissection is carried down to the paratenon of the extensor tendon (see Fig. 8E). The flap is then separated from the paratenon with blunt dissection (see Fig. 8F). A rectangular flap is harvested, leaving the edge of the flap closest to the recipient finger intact. It is important to ensure the paratenon of the extensor tendon is left intact to have good take of the skin graft.
5.
Flap inset is then performed. To get good fingertip contour, one suggestion is to anchor the sides of the flap at the lateral aspect of the distal defect first and to leave about 5 mm of excess flap hanging out distally (see Fig. 8G). After the proximal part of the flap inset is done, the tip is turned down and then sutured to the sterile matrix.
6.
A full-thickness skin graft is then harvested and used to cover the secondary defect and the exposed skin bridge (see Fig. 8H). A tie-over dressing is then placed over the skin graft recipient site.
7.
Dressings are then applied and there is no need for any immobilization.
The second stage is usually done 2 to 3 weeks later. It is imperative to ensure good dermal healing at the recipient site before flap division.
1.
The procedure is done under a wrist block.
2.
After cleaning the operative site, the base of the flap is divided, ensuring adequate skin for coverage of the defect.
3.
The cut edge of the flap is shaped, defatted to ensure good contour, and closed primarily.
4.
The cut edge of the flap at the donor site is also trimmed and closed primarily.
5.
Dressings are placed and early range-of-motion exercises are started.
Aesthetic Refinements
Typically flaps are designed to match the defect. However, in the cross-finger flap, the defect must be matched to the flap. In a smaller or irregularly sized defect, the defect should be enlarged to match the rectangular shape of the cross-finger flap. This process often requires excision of some normal skin. In addition, covering a circular defect in the pulp with a cross-finger flap often results in an unsightly bulbous flap caused by circular scar contracture (Fig. 9). Enlarging the defect also allows a flap with a larger base to be raised. If the flap donor site is a dense hair-bearing area, a cross-finger flap might not be a suitable choice for the patient because hair will then grow on the pulp after transfer of the tissue.
Fig. 9If flap is too small, the circular scar will contract with time and result in a bulbous flap.
Note that hair will also continue to grow on full-thickness skin grafts and will be similar to the density at the donor site. Therefore, choice of skin graft donor site is important to ensure that the appearance of the donor site will be more aesthetically pleasing. Common areas for donor sites include the distal wrist crease, cubital fossa, and the proximal medial forearm. The authors do not harvest skin graft from the distal wrist crease because the scar resembles the scar of a self-inflicted wound and may be stigmatizing to some patients.
Outcomes
The main criticism of the cross-finger flap is that it is a 2-staged procedure, uses an uninjured digit, and may result in stiffness of the donor finger. In addition, it does not provide glabrous skin for coverage. Although the flap is not an innervated flap, it has been shown that this flap can achieve good sensory recovery and good results with younger patients.
on the use of a dual-innervated cross-finger flap to resurface the thumb pulp, 1 patient obtained a 2 PD of 5 mm at 1.5 years and the other achieved this at 7 months.
Summary
The VY advancement, thenar, and cross-finger flaps are all reliable and easy to raise. All 3 flaps gave consistently good results in terms of sensitivity. Comparing thenar and cross-finger flaps, the thenar flap gives better return of sensibility because of the higher density of nerve endings in the palmar skin, whereas the cross-finger flap is usually harvested from the dorsum of a digit. Flap division can be safely done at 2 to 3 weeks with very few reports of flap necrosis. It is postulated that earlier flap division may reduce the degree of stiffness in the donor and recipient digit. The VY advancement flap is only indicated in distal transverse or volar favorable fingertip amputations. The thenar and cross-finger flaps can cover a bigger defect, but both require a 2-stage procedure. Other alternatives that can be considered for similar-sized defects include neurovascular island flaps, reverse vascular island flaps, heterodigital neurovascular island flaps, and free flaps. However, these flaps require microvascular dissection and a higher level of expertise.
References
Tranquilli-Leali E.
Ricostruzione dell’apice delle falangi ungueali mediante autoplastica volare peduncolata per scorrimento.
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