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VY Advancement, Thenar Flap, and Cross-finger Flaps

  • Jin Xi Lim
    Correspondence
    Corresponding author. Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University health System, Singapore, Singapore.
    Affiliations
    Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore

    Department of Hand and Reconstructive Microsurgery, National University Health System, 1E Kent Ridge Road, Level 11, Singapore 119228, Singapore
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  • Kevin C. Chung
    Affiliations
    Section of Plastic Surgery, The University of Michigan Medical School, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI, USA
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      Keywords

      Key points

      • Fingertip amputations are common injuries with a myriad of management options.
      • The VY advancement flap is classically used to cover distal transverse or volar favorable fingertip amputations.
      • Volar unfavorable amputations can be reliably resurfaced by thenar or cross-finger flaps.
      • 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
      • Tranquilli-Leali E.
      Ricostruzione dell’apice delle falangi ungueali mediante autoplastica volare peduncolata per scorrimento.
      in 1935. A variation of this flap was popularized by Atasoy and colleagues
      • Atasoy E.
      • Ioakimidis E.
      • Kasdan M.L.
      • et al.
      Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure.
      in 1970 that differs in its vascular supply. Other variations include the neurovascular Tranquilli-Leali flap,
      • Elliot D.
      • Moiemen N.S.
      • Jigjinni V.S.
      The neurovascular Tranquilli-Leali flap.
      • O'connor D.
      • Samuel A.W.
      Finger flaps: using the modified neurovascular Tranquilli-Leali flap.
      • Loréa P.
      • Chahidi N.
      • Marchesi S.
      • et al.
      Reconstruction of fingertip defects with the neurovascular tranquilli-leali flap.
      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.
      • Elliot D.
      • Moiemen N.S.
      • Jigjinni V.S.
      The neurovascular Tranquilli-Leali flap.
      DeJongh
      • DeJongh E.
      A simple plastic procedure of the fingers for conserving bony tissue and forming a soft tissue pad.
      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.
      • Chung S.R.
      • Foo T.L.
      Crescent flap for fingertip reconstruction.
      Figure thumbnail gr1
      Fig. 1Alternative flap designs for VY advancement flap. (A) Crescent flap. (B) VY cup flap.
      An alternative method for advancement was described by Snow,
      • Snow J.W.
      The use of a volar flap for repair of fingertip amputations: a preliminary report. Comment.
      Furlow,
      • Furlow L.T.
      V-Y "Cup" flap for volar oblique amputation of fingers.
      and Tezel,
      • Tezel E.
      • Numanoğlu A.
      A new swing of the atasoy volar V-Y flap.
      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
      • Atasoy E.
      • Ioakimidis E.
      • Kasdan M.L.
      • et al.
      Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure.
      (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.
      Figure thumbnail gr2
      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. (IK) After flap inset is complete.

      Surgical Anatomy

      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.
      • Gharb B.B.
      • Rampazzo A.
      • Armijo B.S.
      • et al.
      Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study.
      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.
      • Elliot D.
      • Moiemen N.S.
      • Jigjinni V.S.
      The neurovascular Tranquilli-Leali flap.
      • Gharb B.B.
      • Rampazzo A.
      • Armijo B.S.
      • et al.
      Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study.

      Operative Technique

      Our preference is to raise the flap in the manner described by Atasoy and colleagues
      • Atasoy E.
      • Ioakimidis E.
      • Kasdan M.L.
      • et al.
      Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure.
      (Figs. 2 and 3):
      • 1.
        The procedure is done under digital block.
      • 2.
        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).
      Figure thumbnail gr3
      Fig. 3Fingertip contour after flap healing. (A) Volar aspect. (B) Lateral aspect. (C) Dorsal aspect.

      Aesthetic Refinements

      Pulp contour

      • 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.
        • Thoma A.
        • Vartija L.K.
        Making the V-Y advancement flap safer in fingertip amputations.
      • 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.
        Figure thumbnail gr4
        Fig. 4Complications. (A) Result of VY advancement with flap of smaller base. (B) Hook nail deformity.

      Tip contour and hook nail deformity

      The nail bed in a normal digit was shown to be entirely supported by the distal phalanx and none of it rests on soft tissue.
      • Kumar V.P.
      • Satku K.
      Treatment and prevention of "hook nail" deformity with anatomic correlation.
      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.
      • Foo T.L.
      • Wan K.H.
      • Chew W.Y.
      Safe and easy method to preserve fingertip contour in VY-plasty.

      Nail

      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.
      • Xing S.
      • Shen Z.
      • Jia W.
      • et al.
      Aesthetic and functional results from nailfold recession following fingertip amputations.
      • Adani R.
      • Marcoccio I.
      • Tarallo L.
      Nail lengthening and fingertip amputations.
      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).
      Figure thumbnail gr5
      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.

      Outcomes

      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
      • Atasoy E.
      • Ioakimidis E.
      • Kasdan M.L.
      • et al.
      Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure.
      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.
      • Atasoy E.
      • Ioakimidis E.
      • Kasdan M.L.
      • et al.
      Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure.
      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.
      • Tupper J.
      • Miller G.
      Sensitivity following volar V-Y plasty for fingertip amputations.
      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
      • Gatewood A.
      Plastic repair of finger defects without hospitalisation.
      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,
      • Dellon A.L.
      The proximal inset thenar flap for fingertip reconstruction.
      proximally based,
      • Flatt A.E.
      The thenar flap.
      and H shaped
      • Smith R.J.
      • Albin R.
      Thenar "H-flap" for fingertip injuries.
      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.
      • Kwon Y.J.
      • Ahn B.M.
      • Lee J.S.
      • et al.
      Reconstruction of two fingertip amputations using a double thenar flap and comparison of outcomes of surgery using a single thenar flap.
      Thenar perforator flaps have also been described. Akita and colleagues
      • Akita S.
      • Kuroki T.
      • Yoshimoto S.
      • et al.
      Reconstruction of a fingertip with a thenar perforator island 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
      • Omokawa S.
      • Ryu J.
      • Tang J.B.
      • et al.
      Vascular and neural anatomy of the thenar area of the hand: its surgical applications.
      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 ).
        Figure thumbnail gr6
        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.
        Figure thumbnail gr7
        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.
      • 3.
        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).
      Table 1Results of thenar flaps
      Data from Refs.
      • Adani R.
      • Marcoccio I.
      • Tarallo L.
      Nail lengthening and fingertip amputations.
      • Miller A.J.
      Single finger tip injuries treated by thenar flap.
      • Melone C.P.
      • Beasley R.W.
      • Carstens J.H.
      The thenar flap--An analysis of its use in 150 cases.
      • Fitoussi F.
      • Ghorbani A.
      • Jehanno P.
      • et al.
      Thenar flap for severe finger tip injuries in children.
      • Okazaki M.
      • Hasegawa H.
      • Kano M.
      • et al.
      A different method of fingertip reconstruction with the thenar flap.
      • Rinker B.
      Fingertip reconstruction with the laterally based thenar flap: indications and long-term functional results.
      • Barr J.S.
      • Chu M.W.
      • Thanik V.
      • et al.
      Pediatric thenar flaps: a modified design, case series and review of the literature.
      Author, YearNAge (y)Division (d)Follow-up (y)Sensation (mm)ROMComplications at Donor SiteDesign
      Miller,
      • Miller A.J.
      Single finger tip injuries treated by thenar flap.
      1974
      323–6714 (10–21)4
      • Static 2 PD
        • 3 patients: 4
        • 5 patients: 4–5
        • 2 patients: 5–6
        • 8 patients: nil (only done in 18 patients)
      1% of patients with DIPJ stiffness. No PIPJ stiffness notedNRProximally based
      Melone et al,
      • Melone C.P.
      • Beasley R.W.
      • Carstens J.H.
      The thenar flap--An analysis of its use in 150 cases.
      1982
      15035 (2–73)10–14>1Static 2 PD: 74% of patients with stiffness (none was a direct result of the procedure)1% of patients with sensitive scarProximally based
      Dellon,
      • Dellon A.L.
      The proximal inset thenar flap for fingertip reconstruction.
      1983
      522 (18–31)213Static 2 PD: 6 (4–10)

      Moving 2 PD: 3 (3–4)
      No residual finger stiffnessNil complicationsDistally based
      Fitoussi et al,
      • Fitoussi F.
      • Ghorbani A.
      • Jehanno P.
      • et al.
      Thenar flap for severe finger tip injuries in children.
      2004
      124 (2–11)22 (18–25)2 (1–3)Static 2 PD

      5 (4–9)
      No joint contracturesNo flap necrosis, no donor site morbidityDistally based
      Okazaki et al,
      • Okazaki M.
      • Hasegawa H.
      • Kano M.
      • et al.
      A different method of fingertip reconstruction with the thenar flap.
      2005
      840 (11–57)14 (12–17)1Moving 2 PD: <6No PIPJ contractureNo scar contractureDistally based
      Rinker,
      • Rinker B.
      Fingertip reconstruction with the laterally based thenar flap: indications and long-term functional results.
      2006
      1721 (3–48)13 (10–15)NRStatic 2 PD

      6 (3–10)
      Not significantly reduced compared with contralateral side17% cold intoleranceRadially based
      Barr et al,
      • Barr J.S.
      • Chu M.W.
      • Thanik V.
      • et al.
      Pediatric thenar flaps: a modified design, case series and review of the literature.
      2014
      1611 (1–18)16 (12–24)6.8 mo (4.1–9.6 mo)Static 2 PD

      7 (6–10)
      For patients who were cooperative with sensory testing.
      Average total active motion 248° (235°–260°)No flap necrosis, no donor site morbidityProximally based
      Abbreviations: NR, not reported; PD, point discrimination; PIPJ, proximal interphalangeal joint; ROM, range of motion.
      a For patients who were cooperative with sensory testing.

      Cross-finger flaps

      Historical Review

      The cross-finger flap is a 2-staged procedure first published by Gurdin and Pangman
      • Gurdin M.
      • Pangman W.J.
      The repair of surface defects of fingers by transdigital flaps.
      in 1950 but was used by Cronin
      • Cronin T.D.
      The cross finger flap, a new method of repair.
      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
      • Adamson J.E.
      • Horton C.E.
      • Crawford H.H.
      Sensory rehabilitation of the injured thumb.
      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.
      • Hastings H.
      Dual innervated index to thumb cross finger or island flap reconstruction.
      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.
      Figure thumbnail gr8
      Fig. 8Cross-finger flap. (AC) 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.

      Surgical Anatomy

      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.
      • Strauch B.
      • Moura W.
      Arterial system of the fingers.
      The anatomy of the dorsal branches of the digital artery was further detailed by Braga-silva and colleagues,
      • Braga-silva J.
      • Kuyven C.R.
      • Fallopa F.
      • et al.
      An anatomical study of the dorsal cutaneous branches of the digital arteries.
      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.
      Figure thumbnail gr9
      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.
      • Nicolai J.P.
      • Hentenaar G.
      Sensation in cross-finger flaps.
      • Kleinert H.E.
      • McAlister C.G.
      • MacDonald C.J.
      • et al.
      A critical evaluation of crossfinger flaps.
      In addition, a handful of studies reported having no reduced range of motion of the donor digit (Table 2).
      Table 2Results of cross-finger flaps
      Data from Refs.
      • O'connor D.
      • Samuel A.W.
      Finger flaps: using the modified neurovascular Tranquilli-Leali flap.
      • Nicolai J.P.
      • Hentenaar G.
      Sensation in cross-finger flaps.
      • Kleinert H.E.
      • McAlister C.G.
      • MacDonald C.J.
      • et al.
      A critical evaluation of crossfinger flaps.
      • Bralliar F.
      • Horner R.L.
      Sensory cross-finger pedicle graft.
      • Paterson P.
      • Titley O.G.
      • Nancarrow J.D.
      Donor finger morbidity in cross-finger flaps.
      • Koch H.
      • Kielnhofer A.
      • Hubmer M.
      • et al.
      Donor site morbidity in cross-finger flaps.
      • Rabarin F.
      • Saint cast Y.
      • Jeudy J.
      • et al.
      Cross-finger flap for reconstruction of fingertip amputations: long-term results.
      Author, YearNAge (y)Division (d)Follow-up (y)SensationRange of Motion in Donor FingerComplicationDesign
      Bralliar & Horner,
      • Bralliar F.
      • Horner R.L.
      Sensory cross-finger pedicle graft.
      1969
      1417–59212 (0.2–5)86% 2 PD 9 mm (2–19)

      14% 2 PD not measurable
      NR15% had hypersensitivity of pulp preventing use of digitSingle-innervated cross-finger flap
      Kleinert et al,
      • Kleinert H.E.
      • McAlister C.G.
      • MacDonald C.J.
      • et al.
      A critical evaluation of crossfinger flaps.
      1974
      561–6712–14NR59% had 2 PD of <6 mm12.5% with limitation in motionNRStandard cross-finger flap
      Nicolai & Hentenaar,
      • Nicolai J.P.
      • Hentenaar G.
      Sensation in cross-finger flaps.
      1981
      5130 (1–63)21.6 (15–28)NR35 patients: ≤6 mm difference compared with uninjured fingerNR59% with cold sensitivityStandard cross-finger flap
      Nishikawa & Smith,
      • Nishikawa H.
      • Smith P.J.
      The recovery of sensation and function after cross-finger flaps for fingertip injury.
      1992
      28NRNR2 (1–4)Average of 70% subjective recovery60% had subjective stiffness but no measurable loss53% with cold sensitivityStandard cross-finger flap
      Paterson et al,
      • Paterson P.
      • Titley O.G.
      • Nancarrow J.D.
      Donor finger morbidity in cross-finger flaps.
      2000
      1641 (6–59)12–174 (1–9)NR50% with limitation in motion62.5% cold sensitivity (at donor site)Standard cross-finger flap
      Koch et al,
      • Koch H.
      • Kielnhofer A.
      • Hubmer M.
      • et al.
      Donor site morbidity in cross-finger flaps.
      2005
      2330 (2–59)NR7 (2–18)NRTotal ROM

      Donor: 156° (20°–235°)

      Control: 174° (95°–270°)
      30.4% cold sensitivity (at donor site)Standard cross-finger flap
      Rabarin et al,
      • Rabarin F.
      • Saint cast Y.
      • Jeudy J.
      • et al.
      Cross-finger flap for reconstruction of fingertip amputations: long-term results.
      2016
      2259 (27–82)1520 (17—23)
      • No subjective difference in sensation
      • 2 PD:
        • 9 patients, no difference
        • 5 patients, 2-mm difference
        • 2 patients, 4-mm difference
      No interphalangeal joint flexion stiffnessNo flap necrosis, infection or wound dehiscence

      31.8% with cold sensitivity
      Standard cross-finger flap
      In the 2 cases reported by Hastings
      • Hastings H.
      Dual innervated index to thumb cross finger or island flap reconstruction.
      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.

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