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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 27  |  Issue : 1  |  Page : 14-18

Complicated fingertip defects: Clinical approach to their reconstruction and the flaps that can be used in emergency settings


1 Department of Plastic Reconstruction and Aesthetic Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
2 Department of Plastic Reconstruction and Aesthetic Surgery, Medical Park Hospital Bursa, Turkey
3 Department of Plastic Reconstruction and Aesthetic Surgery, Liv Hospital Istanbul, Istanbul, Turkey

Date of Web Publication4-Jan-2019

Correspondence Address:
Dr. Ozlem Colak
Okmeydani Research and Training Hospital, Department of Aesthetic, Plastic and Reconstructive Surgery, Darulaceze Cad No: 25, Sisli, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_43_18

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  Abstract 


Aim: Numerous flaps have been described for the reconstruction of complicated defects of the fingertip. The aim of this study was to evaluate our experience on flaps that can be used in emergency settings, and analyze the outcomes of these procedures. Materials and Methods: A retrospective analysis of 81 patients, who presented to the emergency unit with complicated fingertip defects between 2009 and 2014 and in whom replantation was deemed unsuitable due to various reasons including crush or avulsion type of injury mechanism, absence of the amputated part, or unrepairable vascular injury in the amputate, was carried out. Results: Eighty-nine flaps were performed in 81 patients. The defects were repaired with V-Y advancement flaps in 57% (45 patients – 51 fingers) of the defects, kite flap in 15% (13 patients – 13 fingers), cross-finger flap in 12% (11 patients – 11 fingers), Kutler flap in 6% (4 patients – 5 fingers), digital artery perforator flap in 6% (4 patients – 5 fingers), and thenar flap in 4% (4 patients – 4 fingers) of the injuries. One patient operated with the digital artery perforator flap, and one other operated with the kite flap, developed partial flap necroses. There were no other complications. Conclusion: Functional and esthetic restoration of soft tissues in the fingers is possible with the use of appropriate flaps and meticulous surgical technique.

Keywords: Complicated defect, fingertip, flap, partial necrosis


How to cite this article:
Mutlu OO, Colak O, Dilber A, Bingol D, Egemen O. Complicated fingertip defects: Clinical approach to their reconstruction and the flaps that can be used in emergency settings. Turk J Plast Surg 2019;27:14-8

How to cite this URL:
Mutlu OO, Colak O, Dilber A, Bingol D, Egemen O. Complicated fingertip defects: Clinical approach to their reconstruction and the flaps that can be used in emergency settings. Turk J Plast Surg [serial online] 2019 [cited 2019 Nov 14];27:14-8. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/1/14/249398




  Introduction Top


Fingertip defects are among the most common hand injuries, and their reconstruction is challenging due to functional and esthetic concerns. The goals in fingertip defect reconstruction are to provide a painless tip with good quality skin and adequate protective sensation, preserve the length, and prevent nail deformities. Restoration of fingernail and pulp integrity is important in handling of small objects and performing fine movements. In most fingertip amputations, replantation is the preferred option to protect finger function and achieve better cosmesis.[1] However, replantation may not be feasible when the amputate is missing, the vessels are not amenable to repair, or in the presence of crush or avulsion injury. Finger defects with exposed joint, bone, and tendons are named as complicated finger defects.[2] When replantation cannot be performed, or it fails, such defects require flap reconstruction during the early period to preserve function. Numerous flaps have been described for the reconstruction of finger defects. These include the cross-finger flap or the thenar flap which necessitate two stages with temporary attachment and immobilization of the finger, or other flaps that allow single-stage repair and early mobilization, such as the V-Y advancement flap and digital artery perforator flap.[3],[4],[5],[6],[7] The aim of this study was to present our surgical experience and results in flaps used for the reconstruction of complicated fingertip defects.


  Materials and Methods Top


Between 2009 and 2014, 81 patients who presented with complicated fingertip defects with bone exposure, and who underwent flap reconstruction, were included in the study. There were 66 men (81%), and 15 women (19%). Mean age was 27 (7–58) [Table 1]. The most common cause of injury was occupational injury (58 patients, 72%), followed by crushing in a door (21%, 17 patients) [Figure 1]. The injury was in the right hand in 47 patients (58%) and left hand in 34 (42%) of the patients. The third and second fingers were the most commonly injured fingers (30 fingers [34%], and 22 fingers [25%], respectively). The small finger was the least injured finger (11 fingers, 12%) [Figure 2]. All patients had exposed bone, joint, and tendon, either isolated or in combination. Patients considered unsuitable for replantation for reasons including crush or avulsion type of injury, absence of the amputate, and vascular repair not amenable for repair, were included in the study. All patients were operated under local anesthesia. Minimum postoperative follow-up was 6 months. Patient evaluations were carried out on the postoperative 6th month and included assessment of sensation, adequacy of soft-tissue cover, and esthetic appearance-based patient satisfaction. Sensory evaluations were carried out with Semmes-Weinstein monofilament and two-point discrimination tests. Esthetic appearance and patient satisfaction were scored by the patients themselves, as either excellent, good, moderate, or poor.
Table 1: Distribution of patients with fingertip defects according to age and sex

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Figure 1: Injury etiology

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Figure 2: Distribution of the affected fingers

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  Results Top


Eighty-nine complicated fingertip defects in 81 patients were reconstructed with flaps. The defects were repaired with V-Y advancement flaps in 57% (45 patients – 51 fingers), kite flap in 15% (13 patients – 13 fingers), cross-finger flap in 12% (11 patients – 11 fingers), Kutler flap in 6% (4 patients – 5 fingers), digital artery perforator flap in 6% (4 patients – 5 fingers), and thenar flap in 4% (4 patients – 4 fingers) of the injuries [Figure 3]. One patient operated with the digital artery perforator flap, and one other with the kite flap developed partial flap necrosis; there were no other complications [Table 2]. The necrotic areas were debrided in these two patients, and the defects healed completely by secondary intention. Cross finger and thenar flaps were separated on the 10th day to prevent joint stiffness. These patients were suggested to undergo physical therapy immediately after separation. Two-point discrimination tests on the postoperative 6th month showed the following mean values: 7 mm in V-Y advancement flaps, 6.8 mm in cross-finger flaps, 7.4 mm in Kutler flaps, 7.2 mm in kite flaps, 7.6 mm in thenar flaps, and 7.8 mm in digital artery perforator flaps [Table 2]. Static two-point discrimination assessment showed decreased-moderate sensation in all patients. Semmes-Weinstein monofilament test showed normal sensation in 44 patients (54%), diminished light sensation in 27 (33%), and diminished protective sensation in 10 (13%). Esthetic appearance and satisfaction were subjectively evaluated by the patients. Six patients (7%) reported the outcomes as excellent, 26 (32%) good, 35 (44%) moderate, and 14 (17%) as poor [Figure 4]. The esthetic appearances and the satisfaction rates were worse in the kite and cross-finger flaps because their donor sites could not be closed primarily. The esthetic appearances in the pediatric age group were also worse compared to the adults. None of the patients reported any pain or hypersensitivity.
Figure 3: Distribution of the flaps used to repair finger defects

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Table 2: Flaps used in the reconstruction of fingertip defects, mean twopoint discrimination and complications

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Figure 4: The esthetic appearances and the patient satisfaction rates

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  Discussion Top


The fingers are very crucial organs, and numerous techniques have been described for the reconstruction of their defects. The goals of any fingertip reconstruction are maintaining the length and volume of the finger, minimizing the esthetic losses, and preserving the functions.[1],[3],[7],[8],[9],[10],[11] Fingertip injuries are among the most common hand injuries presenting to the emergency units. In adults, the most common cause is occupational injury, which was also the case in our series. There are numerous classification systems for the classification of fingertip injuries.[12],[13],[14] Treatment options depend on the mechanism of injury, size and plane of the defect, the surgeon's algorithm, patient's demands, the condition of the stump and the amputated part. There is an agreement that if the amputated part is present and replantable, replantation is the best option to preserve finger length and normal anatomy of the nail complex.[15],[16] Atasoy flap (transverse and dorsal oblique tip amputations),[17] Kutler flap (V-Y advancement flaps from both sides of the finger is midlateral distal amputations),[18] first dorsal metacarpal artery flap (kite flap),[19] cross-finger flap (in volar soft-tissue defects),[20] thenar and hypothenar flaps (pulp and fingertip defects in young patients),[18] digital artery perforator flap (transverse or side oblique fingertip defects with exposed bone),[7] are among the most commonly used options which can be performed in emergency settings.[21]

Local flaps are good alternatives in the closure of vital tissues, without further bone shortening and harvesting tissues from other fingers [Figure 5]. Furthermore, their outcomes are better compared to grafts because they restore the contour and fullness of the pulp. The inclusion of the artery to the flap is necessary because these are random flaps.[22] The major disadvantages of local flaps are a limited amount of advancement (5–10 mm distal tissue advancement is possible),[23] limited size of the flaps, deficiency of pulp sensitivity due to the scar line (V-Y flap), and failure to include the nerve into the flap (thenar flap).
Figure 5: Fingertip reconstruction with volar V-Y advancement flap. (a) Volar oblique fingertip injury of the index finger - volar view, (b) lateral view, (c) flap inset on the injured fingertip

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The cross-finger flap is a good option when other local flaps cannot be used [Figure 6]. Elevation of a flap from a healthy finger results in new morbidities including joint stiffness, undesirable scar, and contour deformity. This technique requires grafting of the donor site and a second operation for flap separation. This method is not suitable for those patients who do not wish to have their fingers remain attached for 2–3 weeks. Physical therapy is necessary to attain normal movements, and this delays the return of the patient to work.
Figure 6: Fingertip reconstruction with cross-finger flap. (a) Preoperative view: Volar oblique injury of the small finger. (b) The flap was transferred to the recipient site. (c) Dorsal postoperative view: Donor site was repaired with full thickness skin graft taken from the wrist

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Thenar flaps can be preferred in cases where local flaps are not sufficient to close the defects[24] [Figure 7]. For amputations involving oblique volar tissue loss when length preservation is important this flap is indicated. The flap should be approximately 20% to 30% larger in both length and width. These flaps require staged operations, and prolonged immobilization between the stages results in joint stiffness.
Figure 7: Thenar flap. (a) Volar oblique injury of the middle finger and design of the flap, (b) flap harvest, (c) transfer of the flap, (d) view of the reconstructed pulp one month after injury

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The first dorsal metacarpal artery flap is useful in especially soft reconstruction of the thumb[25] [Figure 8]. A small branch of the radial nerve can be elevated with the flap and sutured to the proximal digital nerve stump in the injured finger. Closure of the defect with vascularized and sensate skin is the main advantage of the flap.[24],[26]
Figure 8: Kite flap. (a) A thumb pulp defect, the first dorsal metacarpal artery flap was designed on the dorsum of the index finger, (b) the incision of the flap, (c) flap harvest, (d) transfer of the flap to the thumb defect, (e) after suturing the flap to the pulp defect and closure of the donor site with skin graft

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The digital artery perforator flap can be used in all transverse or side oblique amputations with exposed bone.[1] The flap can be elevated from the area close to the fingertip defect and has a reliable circulation.[7] It can be performed under emergency settings with loupe magnification and finger tourniquet. The operative time is shorter compared to other repair methods that require microsurgery.

Among various surgical techniques that were described to treat complicated fingertip defects, a detailed analysis of location (thumb or other fingers), exposed critical structures, and the extent of the area that requires coverage may give clues to assess and satisfy each scenario. Beside surgical skills, experience, and technical ability; patient's expectancy, demand, and compliance to treatment (single or two stage) are essential factors in decision-making to select the best technique since there is no universal approach. The flap types described here for digital reconstruction require a good knowledge of hand microsurgical anatomy, functional requirements of each finger, and experience on microsurgical dissection. A careful flap selection and preoperative planning are crucial in the coverage of a pulp defect, preservation of finger length, prevention of adjacent joint contracture, and minimizing donor site morbidity. Parallel to the current knowledge, the most common technique used in the patients included into the study was the V-Y advancement flap for defects up to 10 mm, because it was a single stage operation and could be easily applied in emergency settings. In patients with greater tissue loss in the palmar aspect, the V-Y advancement flap would be insufficient; therefore, patients with such defects other than thumb were preferentially reconstructed either with the cross-finger flap or thenar flap. Kite flap was the treatment of choice in large defects of thumb. Patients who refuse immobilization and/or do not wish to have their fingers remain attached for 2–3 weeks were alternatively treated with digital artery perforator flap.


  Conclusion Top


Restoration of the function and appearance in finger soft-tissue defects, without the development of postoperative complications, is possible with the use of appropriate flaps for each digital segment and a meticulous surgical technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mitsunaga N, Mihara M, Koshima I, Gonda K, Takuya I, Kato H, et al. Digital artery perforator (DAP) flaps: Modifications for fingertip and finger stump reconstruction. J Plast Reconstr Aesthet Surg 2010;63:1312-7.  Back to cited text no. 1
    
2.
Lai CS, Lin SD, Yang CC, Chou CK. The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger. Br J Plast Surg 1991;44:165-9.  Back to cited text no. 2
    
3.
Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am 1970;52:921-6.  Back to cited text no. 3
    
4.
Melone CP Jr., Beasley RW, Carstens JH Jr. The thenar flap – An analysis of its use in 150 cases. J Hand Surg Am 1982;7:291-7.  Back to cited text no. 4
    
5.
Foucher G, Dallaserra M, Tilquin B, Lenoble E, Sammut D. The hueston flap in reconstruction of fingertip skin loss: Results in a series of 41 patients. J Hand Surg Am 1994;19:508-15.  Back to cited text no. 5
    
6.
Foucher G, Braga Da Silva J, Boulas J. “Reposition-flap” technique in amputation of the finger tip. Apropos of a series of 21 cases. Ann Chir Plast Esthet 1992;37:438-42.  Back to cited text no. 6
    
7.
Koshima I, Urushibara K, Fukuda N, Ohkochi M, Nagase T, Gonda K, et al. Digital artery perforator flaps for fingertip reconstructions. Plast Reconstr Surg 2006;118:1579-84.  Back to cited text no. 7
    
8.
Dellon AL. The proximal inset thenar flap for fingertip reconstruction. Plast Reconstr Surg 1983;72:698-704.  Back to cited text no. 8
    
9.
Cohen BE, Cronin ED. An innervated cross-finger flap for fingertip reconstruction. Plast Reconstr Surg 1983;72:688-97.  Back to cited text no. 9
    
10.
Kojima T, Tsuchida Y, Hirasé Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg 1990;43:290-5.  Back to cited text no. 10
    
11.
Kim KS, Yoo SI, Kim DY, Lee SY, Cho BH. Fingertip reconstruction using a volar flap based on the transverse palmar branch of the digital artery. Ann Plast Surg 2001;47:263-8.  Back to cited text no. 11
    
12.
Allen MJ. Conservative management of finger tip injuries in adults. Hand 1980;12:257-65.  Back to cited text no. 12
    
13.
Hirase Y. Salvage of fingertip amputated at nail level: New surgical principles and treatments. Ann Plast Surg 1997;38:151-7.  Back to cited text no. 13
    
14.
Xu JH, Xu JH, Chen H, Tan WQ, Yao JM. Linguiform rotation flap for amputations of the fingertip. Scand J Plast Reconstr Surg Hand Surg 2007;41:320-5.  Back to cited text no. 14
    
15.
Sungur N, Kankaya Y, Yıldız K, Dölen UC, Koçer U. Bilateral V-Y rotation advancement flap for fingertip amputations. Hand (N Y) 2012;7:79-85.  Back to cited text no. 15
    
16.
Pederson WC. Replantation. Plast Reconstr Surg 2001;107:823-41.  Back to cited text no. 16
    
17.
Lister G. The theory of the transposition flap and its practical application in the hand. Clin Plast Surg 1981;8:115-27.  Back to cited text no. 17
    
18.
Russell RC, Van Beek AL, Wavak P, Zook EG. Alternative hand flaps for amputations and digital defects. J Hand Surg Am 1981;6:399-405.  Back to cited text no. 18
    
19.
Tränkle M, Sauerbier M, Heitmann C, Germann G. Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap. J Hand Surg Am 2003;28:758-66.  Back to cited text no. 19
    
20.
Kappel DA, Burech JG. The cross-finger flap. An established reconstructive procedure. Hand Clin 1985;1:677-83.  Back to cited text no. 20
    
21.
Matsui J, Piper S, Boyer MI. Nonmicrosurgical options for soft tissue reconstruction of the hand. Curr Rev Musculoskelet Med 2014;7:68-75.  Back to cited text no. 21
    
22.
Alagoz MS, Uysal CA, Kerem M, Sensoz O. Reverse homodigital artery flap coverage for bone and nailbed grafts in fingertip amputations. Ann Plast Surg 2006;56:279-83.  Back to cited text no. 22
    
23.
Ramirez MA, Means KR Jr. Digital soft tissue trauma: A concise primer of soft tissue reconstruction of traumatic hand injuries. Iowa Orthop J 2011;31:110-20.  Back to cited text no. 23
    
24.
Hong JP, Lee SJ, Lee HB, Chung YK. Reconstruction of fingertip and stump using a composite graft from the hypothenar region. Ann Plast Surg 2003;51:57-62.  Back to cited text no. 24
    
25.
Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr Surg 1979;63:344-9.  Back to cited text no. 25
    
26.
Chen C, Zhang X, Shao X, Gao S, Wang B, Liu D, et al. Treatment of thumb tip degloving injury using the modified first dorsal metacarpal artery flap. J Hand Surg Am 2010;35:1663-70.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2]



 

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