Comparative study of functional and aesthetically outcomes of reverse digital artery and reverse dorsal homodigital island flaps for fingertip repair.

579300 research-article2015

JHS0010.1177/1753193415579300Journal of Hand Surgery (European Volume)Chen et al.

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Comparative study of functional and aesthetical outcomes of reverse digital artery and reverse dorsal homodigital island flaps for fingertip repair

The Journal of Hand Surgery (European Volume) XXE(X) 1–9 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193415579300 jhs.sagepub.com

Q. Z. Chen, Y. C. Sun, J. Chen, J. Kong, Y. P. Gong and T. Mao Abstract This retrospective study was designed to compare functional and cosmetic outcomes of the reverse digital artery island flap and reverse dorsal homodigital island flap in fingertip repair. A total of 23 patients were followed for 24 to 30 months. The reverse digital artery island flap was used in 12 patients, and reverse dorsal homodigital island flap in another 11 patients. Flap sensibility was assessed using the Semmes–Weinstein monofilament test and static 2-point discrimination test. Patient satisfaction, active motion of the finger joints, complications and cold intolerance were evaluated. The static 2-point discrimination and Michigan Hand Outcomes Questionnaire (appearance) of the fingers treated with a reverse digital artery flap were significantly better than those with a reverse dorsal homodigital flap. The static 2-point discrimination of the skin-grafted donor sides after dorsal homodigital flap were poorer than that in the contralateral finger. No significant differences were found between the two flaps for pressure or touch sensibility, active ranges of digital motion, complications and cold intolerance. Level of evidence: III. Keywords Comparative study, finger defect reconstruction, sensation, reverse dorsal homodigital island flap, reverse digital artery island flap Date received: 6th October 2014; revised: 15th January 2015; accepted: 18th January 2015

Introduction The reverse digital artery island flap was first described by Weeks and Wray (1973). Since then, modifications and new techniques for finger soft tissue defects have been designed. The innervated reverse digital artery flap was designed to improve the flap sensory recovery (Brunelli and Mathoulin, 1991; Lai et al., 1992, 1993; Varitimidis et al., 2005). Other modifications for reconstruction of larger pulp defects include flaps from the palm of the hand (Moiemen and Elliot, 1994) or dorsolateral proximal phalangeal (Onder, 2010). Other options include the oblique triangular flap (Venkataswami and Subramanian, 1980), the ‘cap’ technique (Rose et al., 1989), digital artery perforator flaps (Koshima et al., 2006) and free toe pulp transfers (Koshima et al., 2000; Lin et al., 2007). The reverse dorsal homodigital island flap reported by Oberlin et al. (1988) is becoming popular in our unit because it

is a simple operation procedure and avoids sacrificing an important artery. In this study, we performed a retrospective study to compare the reverse dorsal homodigital island flap and the reverse digital artery island flap (both without neurorrhaphy) to reconstruct fingertip defects in subzone levels I and II (Ishikawa et al., 1990).

Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China Corresponding author: T. Mao, Department of Hand Surgery, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China. Email: [email protected]

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The Journal of Hand Surgery (Eur)

Methods From September 2011 to July 2012, we performed 32 reconstructive procedures with the reverse digital artery island flap or reverse dorsal homodigital island flap, both without neurorrhaphy, for fingertip amputations or finger pulp defects. Patients were selected based on the following criteria: (1) loss of soft tissue at least 1.5 cm in length but no larger than 2/3 of finger pulp; (2) single-stage procedure; (3) finger injuries, excluding the thumb; (4) aged 18–65 years; and (5) fingertip amputation in Ishikawa (Ishikawa et al., 1990) subzones I or II together with a pulp defect. Patients were excluded when they had any of the following: (1) a finger pulp defect less than 1.5 cm in length or larger than 2/3 of finger pulp; (2) the donor site of the flap was injured; or (3) a digital artery is injured. Before operation we told the patients about the indications for these two techniques: (1) both surgical procedures are reliable and well mastered by us for finger pulp and tip reconstruction; (2) the donor site of the reverse digital artery island flap is concealed, but it sacrifices an important artery of a finger with few complications; (3) the surgical procedure of reverse dorsal homodigital island flap is simple without sacrificing an important artery, but the scar is typically more obvious. Then the patients chose the flap. In this period, 32 fingers (32 consecutive patients) were surgically treated with one of two flaps by five surgeons in this study. Nine patients could not be contacted more than a year after surgery because of changes in address or phone numbers, or they refused to accept follow-up. Therefore we reviewed 23 patients. Twelve patients (9 men and 3 women) were treated with reverse digital artery island flap (Group A) and 11 (7 men and 4 women) with reverse dorsal homodigital island flap (Group B). The mean age was 43 years in Group A and 44 years in Group B. The mean follow-up time was 28 months in both groups. The patient demographics are shown in Tables 1 and 2. We also used a recently proposed fingertip wound classification in our patients (Figure 1) (Tang et al., 2014): the types of fingertip defects were either B or E, and extended to Zone 1A or the distal part of Zone 1B, but none to Zone 1C. The distal phalanx was exposed in most patients. Three surgeons who did not participate in the operations completed the follow-up.

Surgical technique The reverse digital artery island flap was designed at the lateral area on the proximal phalange of the injured finger (index, middle and ring on the ulnar aspect), such that the required flap size was slightly

bigger than the defect size. After the digital artery was ligated, this flap was raised with the artery, preserving the digital nerve with the finger. The flap was then turned 180° at the pivot point 5 mm proximal to the distal interphalangeal (DIP) joint to reach the fingertip defect (Figure 2). The donor site was resurfaced with a split-thickness skin graft harvested from the inner aspect of the arm. We marked the reverse dorsal homodigital island flap on the dorsum of the middle phalanx of the injured finger, between the mid-lateral lines. The shape of the flap depended on the defect pattern. The pedicle was designed along the dorsal branch of the proper digital artery, located at the level of the DIP joint where the pivot point was marked. Initial incisions were made along the free edges of the flap. Afterward, the flap was raised entirely, preserving the paratenon. A strip of skin of approximately 3 mm in width was harvested with the pedicle to avoid compression and ensure venous return after flap transfer. We turned the flap 180° to cover the defect site (Figure 2). The flap donor site was grafted as described above.

Level of expertise of surgeons All 12 cases in Group A were operated by surgeons of expertise level 3, and those in Group B were performed by surgeons with expertise Level 2 (1 case) or 3 (10 cases) (Tang, 2009, 2013). No surgeon levels were 1, 4 or 5.

Postoperative treatment After operation, the hand was placed above the heart level to reduce venous congestion of the flap for 1 or 2 days. The colour and capillary refilling were checked carefully until the flap reached a steady state. Active and passive range-of-motion exercises were encouraged thereafter. Usually patients stayed in hospital for about 7 days.

Outcome evaluation All patients were followed for a minimum of 2 years, maximum 30 months (Tables 1 and 2). At final followup, the senior surgeons assessed the patients as follows. The patients were asked to report their satisfaction based on the appearance and function of the injured hand (a 5-point response scale) according to the Michigan Hand Outcomes Questionnaire (MHQ) (Chung et al., 1998, 1999). We also recorded whether the patients complained of pain in either the flap donor or recipient sites. The sensibility of the flaps were measured with the Semmes–Weinstein (SW) monofilaments


29 27 27 26 27 26 26 30 30 30 28 29 28.0 1.6

4 5 4 5 5 5 5 5 5 5 4 5 4.8 0.4

3.61 3.61 3.61 3.61 3.61 3.61 3.61 3.61 3.61 6.31 3.61 3.61 3.85 0.77

SWF

7 5 9 10 11 5 9 5 5 11 7 6 7.5 2.3

Flap 12 13 14 20 8 13 16 9 11 16 11 12 12.8 3.1

Donor

S-2PD (mm)

12 9 11 20 12 11 9 11 8 14 10 10 11.4 3.0

CD 67.1 83.3 91.7 87.3 100 94.3 85.7 83.3 100 40 100 100 85.7 17.2

DIP

% ROM

100 100 100 88.2 95.2 93.3 87.6 95.1 100 95.2 100 100 96.3 4.4

PIP 0 0 0 0 0 17 17 0 0 18 0 0 4.3 7.5

CISS (scores)


26 26 30 30 29 29 25 24 30 29 28 28.0 2.0

5 4 5 5 5 4 5 4 5 4 5 4.6 0.5

4.31 3.61 4.31 4.31 4.31 3.61 3.61 3.61 3.61 4.56 3.61 3.96 0.38

SWF

15 9 11 8 11 16 8 10 6 10 11 10.4 2.8

Flap

15 9 11 16 11 12 10 12 13 8 14 11.9 2.4

Donor

S-2PD(mm)

14 8 11 12 10 7 6 7 7 6 7 8.7 2.6

CD

94.4 44.4 91.7 72.2 75 76.5 53.8 100 100 53.8 100 78.5 19.4

DIP

% ROM

100 100 100 100 100 100 100 100 100 83.3 100 98.4 4.9

PIP

10 0 0 0 0 20 0 0 0 10 0 3.7 6.5

CISS (scores)

CD: the site in the contralateral hand corresponding to the flap donor; CISS: Cold Intolerance Severity Score; DIP; distal interphalangeal: MHQ: Michigan Hand Outcomes Questionnaire; S-2PD: static 2-point discrimination; SWF: Semmes–Weinstein monofilament test of flap, the data shown are marking numbers; ROM: range of motion; PIP: proximal interphalangeal.

48 47 41 62 48 49 36 30 28 53 44 44.5 9.6

Function

MHQ (scores)

4 4 5 4 5 4 4 4 5 4 4 4.3 0.5

L index (2.5*1.8) R index (2.5*1.8) R index (3.0*1.7) L index (2.5*1.5) L ring (2.6*2) R middle (2.5*2) R index (2.2*1.5) R index (2*1.5) L middle (3*1.5) L index (2.2*1.4) R index (2*1.8)

Follow-up (months)

1. Female 2. Female 3. Male 4. Female 5. Male 6. Male 7. Male 8. Male 9. Male 10. Female 11. Male Mean SD

Age (years) Cosmetic

Finger (defects in cm*cm)

Cases, sex

Table 2. Demographics and information of final follow-up of the patients with reverse dorsal homodigital island flap.

CD: the site in the contralateral hand corresponding to the flap donor; CISS: Cold Intolerance Severity Score; DIP; distal interphalangeal: MHQ: Michigan Hand Outcomes Questionnaire; S-2PD: static 2-point discrimination; SWF: Semmes–Weinstein monofilament test of flap, the data shown are marking numbers; ROM: range of motion; PIP: proximal interphalangeal.

49 46 39 39 44 48 48 41 44 41 43 45 43.9 3.3

Function

MHQ (scores)

4 5 4 5 5 5 5 5 5 5 5 5 4.8 0.4

R ring (2.8*2.5) R ring (2.9*2.6) L index (2.4*2) L middle (2.3*2.1) L middle (2.4*2.4) L index (1.5*1.5) L middle (2.4*2) L ring (1.7*1.6) L ring (2.3*2) L middle (3*2.5) L index (2.2*2.1) R middle (2.4*2)

Follow-up (months)

1. Male 2. Male 3. Male 4. Female 5. Male 6. Male 7. Male 8. Male 9. Male 10. Female 11. Male 12. Female Mean SD

Age (years) Cosmetic

Finger (defect sizes in cm*cm)

Cases, sex

Table 1. Demographics and information of final follow-up of the patients with the reverse digital artery island flap.

Chen et al. 3

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Figure 1. The drawing showing a more comprehensive classification of the digital tip injury (Tang et al., 2014). Zones 1A, B and C are based on existing flexor tendon zoning. The tip distal to the digital flexor tendon insertion is termed Zone 0, which is further divided into Zone 0A (nail root intact), and 0B (nail root absent). Wounds are classified as: (A) oblique: no bone or nail involvement; (B) oblique: involving nail and bone, or tendon; (C) transverse: involving nail, or bone or tendon; (D) oblique (dorsal): nail involvement; (E) oblique: bone and tendon involvement.

Figure 2. Surgical procedures of two flaps used in this study. (A) Reverse digital artery island flap. The flap designed at the lateral area on the proximal phalange is supplied by the proper digital artery. (B) Reverse dorsal homodigital island flap. The flap is taken from the dorsum of the middle phalanx and the supplying artery is the distal dorsal branch of digital artery.

(Aesthesio Precision Sensory Evaluators, DanMic Global, Campbell, CA, USA). Static 2-point discrimination (S-2PD) was measured in the centre of the flap, donor site of the flap and the area in the contralateral

normal hand corresponding to the flap and donor site using a Disk-Criminator (North Coast Medical, Inc., Gilroy, CA, USA). We measured the ranges of active motion (ROM) of the interphalangeal joints of the


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Chen et al. Table 3. Comparisons of demographics and follow-up results between two groups. Variables

Reverse digital artery island flap

Mean age (years) Gender Levels of expertise of surgeons Level 2 Level 3 Follow-up (months) Mean ROM (%) PIP joint DIP joint SW (filament No.) S-2PD (mm) MHQ Appearance Score 5 Score 4 Function Score 5 Score 4 CISS No Mild

43 9 M, 3 F

44 7 M, 4 F

0 12 28

1 10 28

96 (4.6) 86 (17.5) 3.8 (0.7) 7.5 (2.3)

Reverse dorsal homodigital island flap

98 (5.1) 78 (20.6) 4.0 (0.4) 10.4 (2.8)

10 2

3 8

9 3

7 4

9 3

8 3

P values 0.935a 0.554b 0.740c 0.903a 0.097a 0.472a 0.279a 0.663a 0.015a 0.023c 0.651c 0.928c

CISS: Cold Intolerance Severity Score; DIP: distal interphalangeal; MHQ: Michigan Hand Outcomes Questionnaire; PIP: proximal interphalangeal; ROM: range of motion; S-2PD: static 2-point discrimination; SW: Semmes-Weinstein monofilament. at-test. bPearson’s χ2 test. cWilcoxon rank sum test.

injured finger. Percentage ROM was defined as the ratio of the sum of ROM of these two joints in the injured digits over that of the contralateral hand. Cold intolerance of the repair site of the fingertip was measured by the self-administered Cold Intolerance Severity Score questionnaire (CISS) (Irwin et al., 1997); the maximum score is 100. The score is grouped into four grades (0–25 mild, 26–50 moderate, 51–75 severe and 76–100 extremely severe).

Statistical analysis In our study, the levels of expertise of surgeons performing surgeries in two groups of patients were analysed using Wilcoxon rank sum test. A paired t-test was applied to compare the S-2PD of the donor sites versus the opposite side in each group. The independent sample t-test was applied to compare the age, size, follow-up time, percentage ROM and S-2PD of the fingers treated with the two methods. Pearson’s χ2 test was applied to compare gender of the two groups, while the MHQ (appearance and function) and CISS were assessed with the Wilcoxon rank sum test. The level of significance was set at 5% in all the tests.

The institutional review board approved this study and informed consent was obtained from all volunteers.

Results All flaps survived without secondary intervention. No patient reported rest pain in the flap or at the donor site. The objective outcomes of the SW test, S-2PD and percentage ROM of DIP and proximal interphalangeal (PIP) joints of the operated fingers, and the subjective outcomes of MHQ and CISS are detailed in Tables 1and 2. Comparisons are given in Table 3. There were no significant differences in age, sex, flap size and follow-up time between two groups. The levels of expertise of the surgeons performing operations in the two groups were not statistically different (Table 3). The S-2PD and appearance of the flap scored with MHQ scores in the fingers repaired with a reserve digital artery flap were significantly better than those with a reverse dorsal homodigital island flap (p = 0.015, p = 0.023, respectively) (Table 3). In the patients with the reverse dorsal homodigital island


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Table 4. Cold intolerance and relation with the loss of dominate proper digital artery in the fingertip repaired with a reverse digital artery flap. Fingers

Location of flap donor

Location of the dominate proper digital of the finger

Number of repaired fingertips

Cold intolerance (number of fingertips)

Cold intolerance (%)

Index Middle Ring

Ulnar Ulnar Ulnar

Ulnar Ulnar Radial

3 5 4

1 2 0

33.3 40 0

Figure 3. A patient repaired with a reverse digital artery flap. (A) Loss of soft tissue from the digital pulp of the left index finger. (B) Reverse digital artery island flap was designed on the ulnar side of the left index finger. (C) Reverse digital artery island flap covered the soft tissue defect of the index finger. (D) Appearance of the donor site covered with skin grafting. (E) Appearance of the flap 3 months postsurgery. (F) Appearance of dorsum of left index finger 3 months postsurgery.

flap, the S-2PD in the donor site was significantly worse than that in the corresponding area in the contralateral normal hand (p = 0.001). No significant differences were found in the percentage ROM, MHQ (function) and CISS between the two groups (Table 3). In the fingers repaired with a reverse digital artery island flap, we found cold intolerance of the flap occurred in the index and middle fingers (1/3 and 2/5, respectively), but not the ring fingers (Table 4). Figure 3 presents a case in which a reverse digital artery island flap was used; and Figure 4 presents a case with a reverse dorsal homodigital island flap. No complications other than some loss of range of motion and cold intolerance were noted.

Discussion Various reconstruction techniques have been reported in the literature for fingertip repair; local

advancement flaps (Peacock, 1960; Tranquilli-Leali, 1935) can only cover small-size defects. Cross-finger and thenar flaps provide stable pulp padding, but require a two-stage procedure (Cohen and Cronin, 1983). Free flaps can restore both contour and sensation of the pulp. However, the technique requires vascular anastomosis, prolongs operating times and carries a risk of anastomotic failure (Deglise and Botta, 1991). The homodigital reverse-flow island flap is widely used for soft tissue defects of the fingers. This technique is suitable for obtaining durable tissue without invading the palm and limiting the mobility to adjacent fingers and even can be applicable in multiple adjacent injured fingers. The reverse digital artery island flap is a reverseflow flap that depends on the communicating branch between the digital arteries at the level of the distal middle phalanx (Kojima et al., 1990). Given the rich blood supply and considerable size of the donor site, coverage of a large finger defect is feasible. Several


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Chen et al.

Figure 4. Reverse dorsal homodigital island flap. (A) Loss of soft tissue from the digital pulp of the left ring finger. (B) Reverse dorsal homodigital island flap was designed on the dorsum of the ring finger. (C) The flap was transferred into the defect site. (D) Reverse dorsal homodigital island flap covered the soft tissue defect of the ring finger. (E) Appearance of the flap 3 months postsurgery. (F) Appearance of the dorsum of the left ring 3 months postsurgery.

articles have reported the disadvantage of sacrificing an important artery of a finger and the long scar along the lateral aspect of finger through joint (Alagoz et al, 2006; Yildirim et al., 2002). In our follow-up, no patient complained about cold intolerance of the injured finger and obvious loss of motion. We observed that some sensory recovery in the flap can be achieved. Some authors (Han et al., 2004) have reported no difference between sensate and insensate flaps regarding objective and subjective sensory recovery view over a long period. In our series, the mean S-2PD was 7.5 mm at over 2-year follow-up. In the fingers repaired with a reverse digital artery island flap, we always harvested this flap from the ulnar aspect of the digit and found cold intolerance of the flap did not occur in the ring fingers. This may relate to fact that the dominant proper digital artery (i.e. the artery of a larger diameter in a digit) is the radial side of the ring finger. In contrast, in the index and middle fingers, the dominant proper digital artery is damaged, which led to cold intolerance of the flap in about one-third of the digits. In our operation, the donor site is always located in the concealed area – i.e. the ulnar aspect of the index, middle and ring fingers – for aesthetic reasons. Given our small sample size this observation is not as yet proven. The reverse dorsal homodigital island flap is also a reverse-flow flap. This flap is based on the terminal dorsal branch of the digital artery at the level of the

DIP joint to the dorsum of the middle phalanx. To avoid affecting joint mobility, the flap cannot be harvested over the PIP joint. Previous studies have reported that the flap can cover two-thirds of the entire finger pulp at most (Chen et al., 2012); hence, it is only suitable for small and moderate soft tissue defects of the finger (Chen et al., 2013). Modifications were reported, including enlarging the donor side of the reverse dorsal homodigital island flap used for digital reconstruction (Keramidas et al., 2004), and performing neurorrhaphy to improve flap sensation (Chen et al., 2012, 2014; Pan et al., 2004). Flap sensation may be improved by neurorrhaphy, but the reported S-2PD varies considerably (Keramidas et al., 2004; Pan et al., 2004) from 6 to 9 mm. More recently, the innervated reverse dorsal homodigital island flap has been reported to have better sensation than the non-innervated flap (Chen et al., 2014). Our result of S-2PD without neurorrhaphy is 10.4 mm. We recorded a significant difference in S-2PD between the two flaps. The reverse digital artery flap was found give better sensory recovery. It is possible that adequate blood supply may provide better nutrition for reinnervation of the peripheral nerves in this flap (Usami et al., 2013). We speculate that stable blood supply is an important factor for good self-sensory recovery. The skin is, however, taken from different areas of the finger with different innervation, so that may be the key factor if this effect is established in larger studies.


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We detected a statistically significant difference between the two groups in MHQ (appearance). Some patients with a reverse dorsal homodigital island flap had very obvious donor site scaring and skin sinking. No patient with a reverse digital artery flap complained about problems of long scar along the lateral side of the finger. Reduced sensibility of the grafted skin over the donor site was observed in the fingers with a reverse dorsal homodigital island flap compared with the corresponding site in the contralateral normal hand, but no difference in S-2PD was found between the grafted skin at the donor site after harvesting of a reverse digital artery flap and the corresponding area in the contralateral normal hand. This should be interpreted with care, because the donor site at the proximal lateral aspect of the finger naturally is less sensate than the dorsal fingertip. Sensory recovery of free skin graft depends on the reinnervation of the peripheral nerves around and under the skin (Waris et al., 1983), which may cause different recovery of sensation of the two donor sites. We note that some differences between two flaps could not be included into evaluation of this study. For example, the surgical procedure of a reverse dorsal homodigital island flap is simpler. In performing the flap, we used digital nerve block with lidocaine 1% and the tourniquet was used at the base of the finger, which can be performed by the hand surgeon. In the finger with a reverse digital artery flap, surgery was performed under brachial plexus block with a pneumatic tourniquet on the arm and surgical dissection was extended over the entire lateral side of the finger. Surgeons in our unit have used both flaps in the past 15 years, but some of us, including the senior authors of this article, have tended to use a reversed dorsal homodigital flap more frequently in recent years. The reason for this shift is mainly because it is easier and there is a smaller surgical field. Our results slightly favour the reverse digital artery flap over a reversed dorsal homodigital flap with regards to appearance of fingertip, S-2PD in the flap and sensibility of the donor site. However, we must note that evaluation of many other aspects indicated no significant differences between the two procedures and differences in sensibility in either the flap or donor site were actually quite small despite being statistically significant. Based on the current findings, we will keep both treatment options in active use, but we will inform future patients with the findings from this study when they decide on an option to proceed with. There are limitations in this study, particularly the small sample size. The subjective outcomes of MHQ and CISS are evaluated by patients. These may have been biased as the patients chose their particular operation.

In conclusion, when reconstructing soft tissue defects of the fingertip, the reverse digital artery island flap appears to give better S-2PD, appearance and sensibility of the grafted skin over the donor site compared with reverse dorsal homodigital island flaps. Acknowledgements The 32 patients reported in this study were operated by a team of five surgeons. As well as the three surgeons (Q. Z. Chen, Y. P. Gong and T. Mao) listed as authors, two surgeons (J. Tan and A. D. Deng) contributed their cases. We express gratitude to their contribution.

Conflict of interests None declared.

Funding Supported by grants from Jiangsu Medical Research Center, Jiangsu Provincial Special Program of Medical Science [BL2013020].

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Chen et al. Ishikawa K, Ogawa Y, Soeda H et al. A new classification of the amputation level for the distal part of the fingers. J Jpn Soc Microsurg. 1990, 3: 54–62. Keramidas E, Rodopoulou S, Metaxotos N et al. Reverse dorsal digital and inter commissural flaps used for digital reconstruction. Br J Plast Surg. 2004, 57: 61–5. Kojima T, Tsuchida Y, Hirase Y et al. Reverse vascular pedicle digital island flap. Br J Plast Surg. 1990, 43: 290–5. Koshima I, Inagawa K, Urushibara K et al. Fingertip reconstructions using partial-toe transfers. Plast Reconstr Surg. 2000, 105: 1666–74. Koshima I, Urushibara K, Fukuda N et al. Digital artery perforator flaps for fingertip reconstructions. Plast Reconstr Surg. 2006, 118: 1579–84. Lai CS, Lin SD, Chou CK et al. A versatile method for reconstruction of finger defects: reverse digital artery flap. Br J Plast Surg. 1992, 45: 443–53. Lai CS, Lin SD, Chou CK et al. Innervated reverse digital artery flap through bilateral neurorrhaphy for pulp defects. Br J Plast Surg. 1993, 46: 483–8. Lin CH, Lin YT, Sassu P et al. Functional assessment of the reconstructed fingertips after free toe pulp transfer. Plast Reconstr Surg. 2007, 120: 1315–21. Moiemen NS, Elliot D. A modification of the Zancolli reverse digital artery flap. J Hand Surg Br. 1994, 19: 142–6. Oberlin C, Sarcy JJ, Alnot JY. Cutaneous arterial supply of the hand: Application in the creation of island flaps (in French). Ann Chir Main. 1988, 7: 122–5. Onder T. Reverse dorsolateral proximal phalangeal island flap: a new versatile technique for coverage of finger defects. Br J Plast Surg. 2010, 63: 146–52. Pan XG, Tian WC, Guan TX. A clinical study on the extended reverse digital artery island flap (in Chinese). Zhong Hua Zheng Xing Wai Ke Za Zhi. 2004, 20: 33–4.

Peacock EE. Reconstruction of the hand by the local transfer of composite tissue island flaps. Plast Reconstr Surg. 1960, 25: 298–311. Rose EH, Norris MS, Kowalski TA et al. The “cap” technique: nonmicrosurgical reattachment of fingertip amputations. J Hand Surg Am. 1989, 14: 513–8. Tang JB. Re: levels of experience of surgeons in clinical studies. J Hand Surg Eur. 2009, 34: 137–8. Tang JB. Outcomes and evaluation of flexor tendon repair. Hand Clin. 2013, 29: 251–9. Tang JB, Elliot D, Adani R et al. Repair and reconstruction of thumb and finger tip injuries: a global view. Clin Plastic Surg. 2014, 41: 325–59. Tranquilli-Leali E. Ricostruzione dell’apice delle falangi ungueali mediante autoplastica volare peduncolata per scorrimento. Infortunistica Traumatol Lavaro. 1935, 1: 186–93. Usami. S, Kawahara S, Yamaguchi T et al. Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap. J Hand Surg Eur. 2014, 40: 291–7. Varitimidis SE, Dailiana ZH, Zibis AH et al. Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip. J Hand Surg Br. 2005, 30: 338–42. Venkataswami R, Subramanian N. Oblique triangular flap: a new method of repair for oblique amputations of the fingertip and thumb. Plast Reconstr Surg. 1980, 66: 296–300. Waris T, Rechardt L, Kyosola K. Reinnervation of human skin grafts: a histochemical study. Plast Reconstr Surg. 1983, 72: 439. Weeks PM, Wray RC. Management of acute hand injury. St. Louis, Mosby. 1973: 140. Yildirim S, Avci G, Akan M et al. Complications of the reverse homodigital island flap in fingertip reconstruction. Ann Plast Surg. 2002, 48: 586–92.


Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap.

Coverage of the neurovascular unit of the fingertip using a reverse homodigital dorsal flap.

Postoperative voluminal flap reduction after fingertip reconstruction using the reverse digital artery island flap.

The Reverse Homodigital Flap Based on the Dorsal Branch of the Digital Artery for Reconstruction of Acquired Clinodactyly.

Direct and reverse dorsal metacarpal flaps.

The dorsal homodigital island flap based on the dorsal branch of the digital artery: a review of 166 cases.

Reverse vascular pedicle digital island flap.

Dorsal metacarpal reverse flaps. Anatomical basis and clinical application.

A comparison of the dorsal digital island flap with the dorsal branch of the digital nerve versus the dorsal digital nerve for fingertip and finger pulp reconstruction.

Bipedicled homodigital neurovascular island flap for resurfacing dorsal digital defects amputation.

Vascularized Heterodigital Island Flap for Fingertip and Dorsal Finger Reconstruction.

Innervated Reverse Digital Artery Island Flap through Bilateral Neurorrhaphy using Direct Small Branches of the Proper Digital Nerve.

Reconstruction of dorsal hand and finger defects with reverse radial fasciocutaneous forearm flaps.

Schwannoma of the digital nerve and reconstruction with reverse-flow dorsal metacarpal artery flap: A case report.

Hemiarthroplasty versus reverse shoulder arthroplasty: comparative study of functional and radiological outcomes in the treatment of acute proximal humerus fracture.

The reverse dorsal metacarpal flap.

The versatile metacarpal and reverse metacarpal artery flaps in hand surgery.

Reverse flow first dorsal metacarpal artery flap for covering the defect of distal thumb.

Vascularization of the dorsal base of the second metacarpal bone: implications for a reverse second dorsal metacarpal artery flap.

Cross-arm dermis flaps for repair of dorsal finger defects.

Reply: vascularization of the dorsal base of the second metacarpal bone: implications for a reverse second metacarpal dorsal artery flap.

A versatile method for reconstruction of finger defects: reverse digital artery flap.

PROSPECTIVE AND COMPARATIVE STUDY ON FUNCTIONAL OUTCOMES AFTER OPEN AND ARTHROSCOPIC REPAIR OF ROTATOR CUFF TEARS.

The ulnar digital artery perforator flaps.