- •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.
VY advancement flaps
Historical Review and Variations
- 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.
- 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.12
- •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.
Tip contour and hook nail deformity
Historical Review and Variations
- 1.The procedure can be done under a wrist block.
- 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).
|Author, Year||N||Age (y)||Division (d)||Follow-up (y)||Sensation (mm)||ROM||Complications at Donor Site||Design|
|32||3–67||14 (10–21)||4||1% of patients with DIPJ stiffness. No PIPJ stiffness noted||NR||Proximally based|
|Melone et al,|
|150||35 (2–73)||10–14||>1||Static 2 PD: 7||4% of patients with stiffness (none was a direct result of the procedure)||1% of patients with sensitive scar||Proximally based|
|5||22 (18–31)||21||3||Static 2 PD: 6 (4–10)|
Moving 2 PD: 3 (3–4)
|No residual finger stiffness||Nil complications||Distally based|
|Fitoussi et al,|
|12||4 (2–11)||22 (18–25)||2 (1–3)||Static 2 PD|
|No joint contractures||No flap necrosis, no donor site morbidity||Distally based|
|Okazaki et al,|
|8||40 (11–57)||14 (12–17)||1||Moving 2 PD: <6||No PIPJ contracture||No scar contracture||Distally based|
|17||21 (3–48)||13 (10–15)||NR||Static 2 PD|
|Not significantly reduced compared with contralateral side||17% cold intolerance||Radially based|
|Barr et al,|
|16||11 (1–18)||16 (12–24)||6.8 mo (4.1–9.6 mo)||Static 2 PD|
|Average total active motion 248° (235°–260°)||No flap necrosis, no donor site morbidity||Proximally based|
- 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.
- 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.
|Author, Year||N||Age (y)||Division (d)||Follow-up (y)||Sensation||Range of Motion in Donor Finger||Complication||Design|
|Bralliar & Horner,|
|14||17–59||21||2 (0.2–5)||86% 2 PD 9 mm (2–19)|
14% 2 PD not measurable
|NR||15% had hypersensitivity of pulp preventing use of digit||Single-innervated cross-finger flap|
|Kleinert et al,|
|56||1–67||12–14||NR||59% had 2 PD of <6 mm||12.5% with limitation in motion||NR||Standard cross-finger flap|
|Nicolai & Hentenaar,||51||30 (1–63)||21.6 (15–28)||NR||35 patients: ≤6 mm difference compared with uninjured finger||NR||59% with cold sensitivity||Standard cross-finger flap|
|Nishikawa & Smith,|
|28||NR||NR||2 (1–4)||Average of 70% subjective recovery||60% had subjective stiffness but no measurable loss||53% with cold sensitivity||Standard cross-finger flap|
|Paterson et al,|
|16||41 (6–59)||12–17||4 (1–9)||NR||50% with limitation in motion||62.5% cold sensitivity (at donor site)||Standard cross-finger flap|
|Koch et al,|
|23||30 (2–59)||NR||7 (2–18)||NR||Total ROM|
Donor: 156° (20°–235°)
Control: 174° (95°–270°)
|30.4% cold sensitivity (at donor site)||Standard cross-finger flap|
|Rabarin et al,|
|22||59 (27–82)||15||20 (17—23)||No interphalangeal joint flexion stiffness||No flap necrosis, infection or wound dehiscence|
31.8% with cold sensitivity
|Standard cross-finger flap|
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Disclosure: The authors have no commercial or financial conflicts of interest.
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