September 23, 2014
4:27:55pm
WSPC/135-HS
FA1
1472037
Hand Surgery, Vol. 19, No. 3 (2014) 459–461 © World Scientific Publishing Company DOI: 10.1142/S021881041472037X
CRESCENT FLAP FOR FINGERTIP RECONSTRUCTION
Hand Surg. 2014.19:459-461. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 02/09/15. For personal use only.
Sze-Ryn Chung and Tun-Lin Foo Department of Hand and Reconstructive Microsurgery National University Hospital, Singapore Received 23 March 2014; Revised 9 May 2014; Accepted 9 May 2014; Published 26 August 2014 ABSTRACT A volar advancement flap based on V-Y concept for fingertip reconstruction is described. The crescent flap utilises curved incision to preserve fingertip contour and distal digital crease. Satisfactory outcome was achieved in two patients who underwent fingertip reconstruction using this technique. Its advantages are technical simplicity, minimal donor morbidity, and may be used in situation where conventional V-Y incision is unsuitable. Keywords: Fingertip Amputation; Fingertip Flap; VY Plasty; Fingertip Reconstruction.
INTRODUCTION
TECHNIQUE
V-Y advancement flap is one of the most commonly used flaps for fingertip reconstruction owing to its relative simplicity. First described by Tranquilli-Leali in 1935,1 and a later variant by Atasoy in 1970,2 this flap is classically designed as a triangle with its apex based proximally to allow primary closure of the donor site, and its base advanced distally to cover the fingertip defect. Ideal indications for this flap are transversely oriented volar neutral or favourable amputations as sufficient length is needed to facilitate closure of donor site. To obtain greater flap size and reach, the apex of the flap can be based more proximally3 or a neurovascular island type flap can be designed.4 The former may result in skin contracture of the distal digital crease, while the latter is technically demanding. When neither of the aforementioned technique is not feasible, the proposed crescent flap technique described in this article may be an appropriate option that retains the technical simplicity of a V-Y flap and minimal donor morbidity.
Case 1 A 28-year-old carpenter sustained a left thumb volar favourable amputation from a wood-cutting machine (Fig. 1). Under tourniquet control and local anaesthesia, the wound was first debrided with attention to preserve distal phalanx. Then, a Cshaped incision was made and the flap was raised subperiosteally in the manner described by Atasoy2. After advancement to cover the exposed bone, a fine K-wire was used to hold the flap to the distal phalanx and its sides were tagged with 6/0 sutures. To restore distal sterile matrix, split thickness nail matrix graft was harvested from the amputate and laid onto the flap. Donor site was left to heal by secondary intention, and dressing changes were performed twice a week for two weeks post-operatively. Digital mobilisation was initiated within a week after surgery, and K-wire was removed two weeks postoperatively. Satisfactory healing of the donor site and nailbed
Correspondence to: Dr. Tun-Lin Foo, Department of Hand and Reconstructive Microsurgery, Tower Block Level 11, National University Hospital Singapore, 5 Lower Kent Ridge Road, Singapore 119074. Tel: (þ65) 6772-5599, Fax: (þ65) 6779-5190, E-mail: Anthony _ [email protected] 459
September 23, 2014
Hand Surg. 2014.19:459-461. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 02/09/15. For personal use only.
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4:27:55pm
WSPC/135-HS
FA1
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S.-R. Chung & T.-L. Foo
Fig. 1 Volar favourable thumb amputation with distal nail matrix loss. After advancing the flap to cover exposed bone, split thickness nail matrix graft (white arrow, from amputate, inset) was laid onto the distal phalanx.
was observed. He was able to resume work four weeks after surgery. At six months, the regrown nail was adherent to the grafted area and stable for fine object manipulation. Two point discrimination (2PD) was 7 mm (Fig. 2).
Case 2 A 36-year-old mechanic sustained an index finger crushing injury resulting in tranverse volar unfavourable amputation
Fig. 2 Flap healed with preservation of pulp contour (compared to contralateral thumb). Scarred but adherent nail regrown over grafted area.
Fig. 3 Volar neutral amputation with exposed bone. Conventional V-Y (white dashed line) provides inadequate sized flap while extended V-Y (black dashed line) design crosses the distal digital crease. A ‘C’ incision provides adequate flap with minimal donor morbidity. Distal fibrofatty tissue (thick arrow) pinned to the phalanx and skin flap (thin arrow) advanced with sutures.
(Fig. 3). After debridement, a small crescent flap was raised and advanced distally cover the exposed distal phalanx. The distal portion of the flap consisted of fibrofatty tissue which was advanced over the phalanx while the skin was advanced to reconstitute distal lateral nail fold. The patient returned to work after four weeks. Fingertip sensation was normal with 2PD of 7 mm (Fig. 4). At the final follow-up, there was mild
Fig. 4
Contour preservation and donor healing at four weeks.
September 23, 2014
4:28:33pm
WSPC/135-HS
FA1
1472037
Hand Surg. 2014.19:459-461. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 02/09/15. For personal use only.
Crescent Flap for Fingertip Reconstruction
Fig. 5 Healed flap at 12 months. Mild nail beaking and shortening compared to contralateral index finger.
beaking of the nail that did not impair the ability for fine object manipulation (Fig. 5).
DISCUSSION This method is indicated in situations where V-Y plasty may be unsuitable due to inadequate donor tissue or fingertip contour distortion with donor site closure. In the former situation, the common alternatives are cross finger flap,5 neurovascular or vascular island flaps.3,4,6,7 However, these options incur donor digit morbidity, technically demanding dissection, and potential for digital skin crease contracture, respectively. A small advancement flap based on a ‘C’ incision that is raised in the manner described by Atasoy2 provides the coverage over the critical zone while the small donor site heals by secondary intention. The first case illustrates this concept where a critical defect over the thumb was covered by the flap that also provided fibrofatty tissue to support a nailbed graft. Raising the flap in this manner allowed preservation of the girth and rounded contour of the thumb. Furthermore, curvilinear incision is more in line with the epidermal ridges of the pulp and the healed scar is more subtle.
461
Another application of the crescent flap is in volar neutral amputation, that is a relative contraindication for conventional V-Y flap. The second case depicts this scenario where a crescent flap was used in place of aforementioned options to resurface the fingertip. To adequately cover the exposed phalanx, a flap with distal fibrofatty component was advanced to reconstruct the sterile matrix to pulp tissue interface; while the proximally based skin component is advanced to the distal pulp. Granulation tissue forms over the distal fibrofatty and proximal donor area to regenerate pulp contour with satisfactory results. In short, this method increases the armamentarium of simple flaps for fingertip reconstruction that incur minimal technical complexity and donor morbidity, bridging the indication gap between simple V-Y flaps and more complex options.
References 1. Tranquilli-Leali E, Ricostruzione dell’apice delle falangi ungueali mediante autoplastica volare peduncolata per scorrimento, Infort Traumatol Lav 1:186–193, 1935. 2. 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, 52:921–926, 1970. 3. Elliot D, Wilson Y, V-Y advancement of the entire volar soft tissue of the thumb in distal reconstruction, J Hand Surg Br 18:399–402, 1993. 4. Venkataswami R, Subramaniam N, Oblique triangular flap: a new method of repair for oblique amputation of the fingertip and thumb, Plast Reconstr Surg 66:296–300, 1980. 5. Gurdin M, Pangman WJ, The repair of surface defects of fingers by transdigital flaps, Plast Reconstr Surg (1946) 5:368–371, 1950. 6. Foucher G, Delaere O, Citron N, Molderez A, Long-term outcome of neurovascular palmar advancement flaps for distal thumb injuries, Br J Plast Surg 52:64–68, 1999. 7. Kojima T, Tsuchida Y, Hirase Y, Endo T, Reverse vascular pedicle digital island flap, Br J Plast Surg 43(3):290–295, 1990.
4:27:55pm
WSPC/135-HS
FA1
1472037
Hand Surgery, Vol. 19, No. 3 (2014) 459–461 © World Scientific Publishing Company DOI: 10.1142/S021881041472037X
CRESCENT FLAP FOR FINGERTIP RECONSTRUCTION
Hand Surg. 2014.19:459-461. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 02/09/15. For personal use only.
Sze-Ryn Chung and Tun-Lin Foo Department of Hand and Reconstructive Microsurgery National University Hospital, Singapore Received 23 March 2014; Revised 9 May 2014; Accepted 9 May 2014; Published 26 August 2014 ABSTRACT A volar advancement flap based on V-Y concept for fingertip reconstruction is described. The crescent flap utilises curved incision to preserve fingertip contour and distal digital crease. Satisfactory outcome was achieved in two patients who underwent fingertip reconstruction using this technique. Its advantages are technical simplicity, minimal donor morbidity, and may be used in situation where conventional V-Y incision is unsuitable. Keywords: Fingertip Amputation; Fingertip Flap; VY Plasty; Fingertip Reconstruction.
INTRODUCTION
TECHNIQUE
V-Y advancement flap is one of the most commonly used flaps for fingertip reconstruction owing to its relative simplicity. First described by Tranquilli-Leali in 1935,1 and a later variant by Atasoy in 1970,2 this flap is classically designed as a triangle with its apex based proximally to allow primary closure of the donor site, and its base advanced distally to cover the fingertip defect. Ideal indications for this flap are transversely oriented volar neutral or favourable amputations as sufficient length is needed to facilitate closure of donor site. To obtain greater flap size and reach, the apex of the flap can be based more proximally3 or a neurovascular island type flap can be designed.4 The former may result in skin contracture of the distal digital crease, while the latter is technically demanding. When neither of the aforementioned technique is not feasible, the proposed crescent flap technique described in this article may be an appropriate option that retains the technical simplicity of a V-Y flap and minimal donor morbidity.
Case 1 A 28-year-old carpenter sustained a left thumb volar favourable amputation from a wood-cutting machine (Fig. 1). Under tourniquet control and local anaesthesia, the wound was first debrided with attention to preserve distal phalanx. Then, a Cshaped incision was made and the flap was raised subperiosteally in the manner described by Atasoy2. After advancement to cover the exposed bone, a fine K-wire was used to hold the flap to the distal phalanx and its sides were tagged with 6/0 sutures. To restore distal sterile matrix, split thickness nail matrix graft was harvested from the amputate and laid onto the flap. Donor site was left to heal by secondary intention, and dressing changes were performed twice a week for two weeks post-operatively. Digital mobilisation was initiated within a week after surgery, and K-wire was removed two weeks postoperatively. Satisfactory healing of the donor site and nailbed
Correspondence to: Dr. Tun-Lin Foo, Department of Hand and Reconstructive Microsurgery, Tower Block Level 11, National University Hospital Singapore, 5 Lower Kent Ridge Road, Singapore 119074. Tel: (þ65) 6772-5599, Fax: (þ65) 6779-5190, E-mail: Anthony _ [email protected] 459
September 23, 2014
Hand Surg. 2014.19:459-461. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 02/09/15. For personal use only.
460
4:27:55pm
WSPC/135-HS
FA1
1472037
S.-R. Chung & T.-L. Foo
Fig. 1 Volar favourable thumb amputation with distal nail matrix loss. After advancing the flap to cover exposed bone, split thickness nail matrix graft (white arrow, from amputate, inset) was laid onto the distal phalanx.
was observed. He was able to resume work four weeks after surgery. At six months, the regrown nail was adherent to the grafted area and stable for fine object manipulation. Two point discrimination (2PD) was 7 mm (Fig. 2).
Case 2 A 36-year-old mechanic sustained an index finger crushing injury resulting in tranverse volar unfavourable amputation
Fig. 2 Flap healed with preservation of pulp contour (compared to contralateral thumb). Scarred but adherent nail regrown over grafted area.
Fig. 3 Volar neutral amputation with exposed bone. Conventional V-Y (white dashed line) provides inadequate sized flap while extended V-Y (black dashed line) design crosses the distal digital crease. A ‘C’ incision provides adequate flap with minimal donor morbidity. Distal fibrofatty tissue (thick arrow) pinned to the phalanx and skin flap (thin arrow) advanced with sutures.
(Fig. 3). After debridement, a small crescent flap was raised and advanced distally cover the exposed distal phalanx. The distal portion of the flap consisted of fibrofatty tissue which was advanced over the phalanx while the skin was advanced to reconstitute distal lateral nail fold. The patient returned to work after four weeks. Fingertip sensation was normal with 2PD of 7 mm (Fig. 4). At the final follow-up, there was mild
Fig. 4
Contour preservation and donor healing at four weeks.
September 23, 2014
4:28:33pm
WSPC/135-HS
FA1
1472037
Hand Surg. 2014.19:459-461. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 02/09/15. For personal use only.
Crescent Flap for Fingertip Reconstruction
Fig. 5 Healed flap at 12 months. Mild nail beaking and shortening compared to contralateral index finger.
beaking of the nail that did not impair the ability for fine object manipulation (Fig. 5).
DISCUSSION This method is indicated in situations where V-Y plasty may be unsuitable due to inadequate donor tissue or fingertip contour distortion with donor site closure. In the former situation, the common alternatives are cross finger flap,5 neurovascular or vascular island flaps.3,4,6,7 However, these options incur donor digit morbidity, technically demanding dissection, and potential for digital skin crease contracture, respectively. A small advancement flap based on a ‘C’ incision that is raised in the manner described by Atasoy2 provides the coverage over the critical zone while the small donor site heals by secondary intention. The first case illustrates this concept where a critical defect over the thumb was covered by the flap that also provided fibrofatty tissue to support a nailbed graft. Raising the flap in this manner allowed preservation of the girth and rounded contour of the thumb. Furthermore, curvilinear incision is more in line with the epidermal ridges of the pulp and the healed scar is more subtle.
461
Another application of the crescent flap is in volar neutral amputation, that is a relative contraindication for conventional V-Y flap. The second case depicts this scenario where a crescent flap was used in place of aforementioned options to resurface the fingertip. To adequately cover the exposed phalanx, a flap with distal fibrofatty component was advanced to reconstruct the sterile matrix to pulp tissue interface; while the proximally based skin component is advanced to the distal pulp. Granulation tissue forms over the distal fibrofatty and proximal donor area to regenerate pulp contour with satisfactory results. In short, this method increases the armamentarium of simple flaps for fingertip reconstruction that incur minimal technical complexity and donor morbidity, bridging the indication gap between simple V-Y flaps and more complex options.
References 1. Tranquilli-Leali E, Ricostruzione dell’apice delle falangi ungueali mediante autoplastica volare peduncolata per scorrimento, Infort Traumatol Lav 1:186–193, 1935. 2. 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, 52:921–926, 1970. 3. Elliot D, Wilson Y, V-Y advancement of the entire volar soft tissue of the thumb in distal reconstruction, J Hand Surg Br 18:399–402, 1993. 4. Venkataswami R, Subramaniam N, Oblique triangular flap: a new method of repair for oblique amputation of the fingertip and thumb, Plast Reconstr Surg 66:296–300, 1980. 5. Gurdin M, Pangman WJ, The repair of surface defects of fingers by transdigital flaps, Plast Reconstr Surg (1946) 5:368–371, 1950. 6. Foucher G, Delaere O, Citron N, Molderez A, Long-term outcome of neurovascular palmar advancement flaps for distal thumb injuries, Br J Plast Surg 52:64–68, 1999. 7. Kojima T, Tsuchida Y, Hirase Y, Endo T, Reverse vascular pedicle digital island flap, Br J Plast Surg 43(3):290–295, 1990.
