SCIENTIFIC ARTICLE
Innervated Digital Artery Perforator Propeller Flap for Reconstruction of Lateral Oblique Fingertip Defects Xiao Fang Shen, MD, Ming Yu Xue, MD, Jing Yi Mi, MD, Li Qiang , MD, Yong Jun Rui, MD, Harvey Chim, MD Purpose To report our experience with the use of a digital artery perforator propeller flap based on a constant distal perforator in the middle phalanx for resurfacing of lateral oblique fingertip amputations. Methods Twelve fingertips in 10 patients underwent reconstruction, with a mean follow-up of 8 months (range, 8e12 mo). The size of the flaps ranged from 2.5 1.5 cm to 3.0 2.0 cm. Results All flaps survived entirely and restored a rounded fingertip contour. Mean static 2-point discrimination was 5 mm (range, 4e6 mm). With the exception of 1 patient with an amputation at the distal interphalangeal joint, the distal interphalangeal joint was preserved in all patients and had 30 to 60 of motion at final follow-up. No patients complained of cold intolerance or residual joint contracture. No hooked nail deformity occurred in patients who had remaining nailbed. Conclusions The digital artery perforator propeller flap is particularly suited to coverage of a lateral oblique fingertip defect, because only a 90 rotation is required when inset, and the bulk of the flap serves to restore the rounded contour of the fingertip. The skin over the entire dorsal surface of the middle phalanx can be elevated as a flap, providing adequate tissue to resurface the defect and restore a rounded contour to the fingertip. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Fingertip injuries, dorsal digital artery flap, oblique fingertip injury, finger amputation, perforator flap.
DIVIDES fingertip injuries by zone and pattern. The pattern can be divided into transverse or oblique amputations; oblique amputations are further subdivided
T
HE ALLEN CLASSIFICATION
1
From the Department of Hand Surgery, Wuxi Ninth People’s Hospital, Wuxi, Jiangsu, China; and the Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL. Received for publication February 3, 2015; accepted in revised form March 25, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Harvey Chim, MD, Division of Plastic Surgery, University of Miami Miller School of Medicine, Clinical Research Building, 1120 N.W. 14th St., 4th Floor, Miami, FL 33136; e-mail: [email protected]; or Yong Jun Rui, MD, Department of Hand Surgery, Wuxi 9th People’s Hospital Wuxi, Jiangsu, 214062, China; e-mail: ruiyj@ hotmail.com. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.03.024
into dorsal, volar, or lateral oblique injuries. Although some have advocated conservative treatment and healing by secondary intention,2 this can sometimes result in a hypersensitive fingertip, cold intolerance, and joint stiffness.3 The lack of soft tissue coverage over bone can result in pain. In addition, patients from Asian cultures often request immediate coverage and restoration of the normal contour of the fingertip and preservation of the length of the finger. For coverage of lateral oblique defects, the options are limited. The oblique triangular flap, described by Venkataswami and Subramanian in 1980,4,5 is probably the best known technique specific to reconstruction of a lateral oblique defect. This relies on V-Y advancement of an island flap extending
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DIGITAL ARTERY PERFORATOR FLAP FOR FINGERTIP
FIGURE 1: A Perforators arise from the proper digital arteries at constant locations and supply the dorsal skin over the proximal and middle phalanges. These can be used as the basis for flaps using dorsal finger skin. (1) Basal metacarpal arch. (2) Dorsal metacarpal artery. (3) Perforating branches from dorsal metacarpal artery. (4) Dorsal perforating branches from proper digital artery. (5) Deep palmar arch. (6) Superficial palmar arch. (7) Palmar metacarpal artery. (8) Common digital artery. (9) Proximal dorsopalmar anastomosis. (10) Distal dorsopalmar anastomosis. (11) Proper digital artery. (12) Distal dorsal perforating branch of the middle phalanx (in orange). B The distal dorsal perforating branch of the middle phalanx (highlighted in orange) can be used to supply a flap that can be rotated to cover lateral oblique defects following fingertip amputations.
TABLE 1. Case 1
Patient Demographics and Outcomes (n[12) Sex Male
Age (y)
Finger Involved
Size of Flaps (cm)
Static 2PD at Follow-Up (mm)
DIP Joint ROM ( )
42
Right index
3.0 2.0
4
NA
2
Female
42
Left middle
3.0 2.5
4
0e50
3
Female
48
Right index
3.0 1.5
4
0e45
4
Male
24
Left ring
3.0 1.5
5
0e60
5
Male
46
Left middle
2.0 2.5
6
0e30
5
Male
46
Left ring
2.0 2.5
6
0e30
6
Female
35
Right middle
2.5 1.5
5
0e45
7
Female
27
Left ring
2.5 1.5
6
0e60
7
Female
27
Left middle
2.5 2.0
5
0e50
8
Male
34
Left index
2.5 2.0
4
0e50
9
Male
19
Left middle
3.0 2.0
6
0e30
10
Male
29
Right ring
3.0 1.5
5
0e45
2PD, 2-point discrimination; ROM, range of motion.
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FIGURE 2: A 42-year-old man sustained a radial oblique amputation of his index fingertip after it was crushed by a steel beam. A The level of the amputation was at the DIP joint. A digital artery perforator propeller flap was designed and elevated B, preserving and dividing the dorsal digital nerve on the contralateral side proximally C. DeF The perforator (arrowhead) from the proper digital artery was identified and freed of its attachments. G The flap was then rotated into place to cover the defect. H A full-thickness skin graft was used to resurface the donor site. The flap was reinnervated by coapting the contralateral dorsal digital nerve to the proper digital nerve on the side of the injury.
proximally to the proximal interphalangeal (PIP) joint crease based on a neurovascular bundle. Although an excellent option, dissection is extensive and the advancing edge of the flap opposite the pedicle is denervated. Other options include the hatchet flap6 or a local rotation flap.7 J Hand Surg Am.
Different authors have described the constant presence of perforators from the proper digital arteries (Fig. 1), supplying the vascular system of the dorsal skin over the proximal and middle phalanges, which forms the basis for flaps involving the dorsal skin.8e10 Strauch and Moura11 found 2 constant r
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FIGURE 3: At 8 months’ follow-up, the flap was well healed with a sensate and rounded fingertip with good bulk and contour. A Lateral view. B Dorsal view.
(n ¼ 3), avulsion (n ¼ 4), and crush (n ¼ 3). The size of the raised flaps ranged from 2.5 1.5 cm to 3.0 2.0 cm. The flap is designed on the dorsum of the middle phalanx of the injured finger in a teardrop shape between the midlateral lines. The flap on the side of the defect is designed to extend more distally and also extends just beyond the midlateral line to capture the perforator from the proper digital artery. The contralateral side of the flap extends proximally to the PIP joint crease. The flap is elevated superficial to the paratenon on the side opposite the defect. The contralateral dorsal digital nerve is identified and divided proximally. Flap elevation continues until the dorsal digital artery perforator on the side of the defect is identified. The perforator is then dissected free from surrounding structures and left attached to its origin from the proper digital artery. A cuff of tissue should be preserved around the pedicle where possible to minimize venous congestion. When dissecting the perforator in a retrograde fashion to its origin from the proper digital artery, an attempt is made to dissect as far away from the pedicle as possible, maintaining a 2to 3-mm cuff of tissue on each side of the pedicle. In addition, an attempt is made to keep the attachments of the overlying skin to the perforator intact to reduce venous congestion. The flap is then rotated 90 to resurface the lateral oblique fingertip defect. Fingertip sensation is reestablished through coaptation of the proximal end of the contralateral dorsal digital nerve to the proper digital nerve on the side of the injury, which is the proximal margin of the oblique fingertip amputation. The donor site is covered with a fullthickness skin graft.
cutaneous dorsal branches emanating from the proper digital arteries at the level of the metaphyses and epiphyses of the proximal and middle phalanges. Endo et al12 showed that 3 branches of the proper digital arteries constituted the vascular system of the dorsal skin over the proximal phalanx, whereas 2 branches supplied the vascular system over the middle phalanx. The location of these perforators was measured by Braga-Silva et al13 in 144 cadaver fingers. Two constant perforators were found supplying the middle phalanx, with the proximal perforator originating at a distance of between 5 and 8 mm distal to the PIP joint line and the distal perforator originating at a distance of between 9 and 13 mm distal to the PIP joint line. In addition, they found that the perforators were symmetrical on the radial and ulnar aspects of the digits in respect to the distance from the PIP joint. On the basis of these studies, a digital artery perforator flap can be designed based on the constant distal perforator over the middle phalanx from the proper digital artery (Fig. 1) and rotated to cover fingertip defects. The flap is innervated by coapting the proximal end of the dorsal digital nerve from the contralateral side to the distal cut end of the proper digital nerve in the area of the defect. MATERIALS AND METHODS Between 2009 and 2014, 12 fingers in 10 patients had reconstruction of a lateral oblique defect using a digital artery perforator rotation flap (Table 1). A retrospective review of patient data was conducted following approval by our institutional review board. Informed consent was obtained from patients. Patient age ranged from 19 to 48 years (mean, 35 y). Four patients were women. Three index, 5 middle, and 4 ring fingertips were reconstructed. The mechanism of injury included sharp injuries J Hand Surg Am.
RESULTS All flaps survived completely. One patient (case 3) had venous congestion, which resolved spontaneously r
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FIGURE 4: A A 48-year-old woman sustained an ulnar oblique defect of her right index finger following a machine crush injury. A digital artery perforator propeller flap was designed B, preserving the contralateral dorsal digital nerve C (arrowhead). The perforator was then freed of its attachments D, E, and the flap was rotated into place F. G A full-thickness skin graft was placed over the donor site. H After surgery, the flap exhibited venous congestion, which resolved with moist dressing changes.
with dressing changes. There were no other complications. The minimum follow-up period was 8 months (range, 8e12 mo). Static 2-point discrimination averaged 5 mm (range, 4e6 mm). With the exception of one patient with an amputation at the J Hand Surg Am.
distal interphalangeal (DIP) joint, the DIP joint was preserved in all patients and had 30 to 60 of motion at final follow-up. None of our patients complained of cold intolerance or residual joint contracture. No hooked nail deformity occurred in r
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FIGURE 5: One month after surgery, the venous congestion was totally resolved, and the flap was entirely viable with good bulk and round contour of the reconstructed fingertip. A Lateral view. B Dorsal view.
patients who had remaining nailbed. Representative cases are presented.
centered over the proximal part of the middle phalanxand retrograde arterial flow through an adipofascial pedicle. A digital artery perforator flap elevated in the form of a free-style flap was also described for fingertip coverage,17 designed over the radial or ulnar aspects of a digit.18,19 Owing to unstable blood flow to the flap, some flaps in this series had to be supercharged or were elevated as fat flaps.19 A major complication of flaps elevated based on the dorsal arterial system is venous congestion. This is particularly evident with a flap designed in the form of a reverse flow flap,14e16 which reduces venous drainage. By basing the flap directly on a perforator, the incidence of venous drainage can be reduced. In addition, preserving a strip of skin over the perforator pedicle, through extending the skin paddle beyond the midlateral line, appears to reduce the incidence of venous congestion by protecting tiny venules and preventing compression after rotation of the flap.20 However, the flap remains an island pedicle flap. Unlike other authors describing a 180 rotation of a digital artery perforator flap designed over the radial or ulnar aspect of a digit,18,19 we designed the flap to rotate only 90 . This may reduce the torsion on the pedicle and possibly the incidence of venous congestion. Digital artery perforator flaps over the dorsal digit may also be used to resurface defects on the middle phalanx, based on more proximal perforators originating from the proper digital arteries.20 Investigators have shown that digital artery perforators arise at constant locations in the proximal and middle phalanges at a fixed distance from known landmarks, such as the PIP joint.8e13 Digital artery perforator flaps should, therefore, not be considered as free-style flaps, but rather axial flaps originating from perforators at constant anatomical locations.
Case 1 A 42-year-old man sustained a radial oblique amputation of his index fingertip after it was crushed by a steel beam. The level of the amputation was at the DIP joint (Fig. 2). A digital artery perforator propeller flap was designed and elevated, preserving and dividing the dorsal digital nerve on the contralateral side proximally. The perforator from the proper digital artery was identified and freed of its attachments. The flap was then rotated into place to cover the defect. A full-thickness skin graft was used to resurface the donor site. The flap was reinnervated by coapting the contralateral dorsal digital nerve to the proper digital nerve on the side of the injury. At 8 months’ follow-up, the flap was well healed with a sensate and rounded fingertip with good bulk and contour (Fig. 3). Case 3 A 48-year-old woman sustained an ulnar oblique defect of her right index finger following a machine crush injury (Fig. 4). A digital artery perforator propeller flap was used. After surgery, the flap exhibited venous congestion, which resolved with moist dressing changes. On follow-up 1 month after surgery, the venous congestion totally resolved and the flap was entirely viable (Fig. 5). DISCUSSION Flaps based on the dorsal arterial system have been described for fingertip coverage.14e16 An innervated reverse flow island flap based on the end dorsal branch of the digital artery was described by Li et al14 and also by Takeishi et al,15 with the skin island J Hand Surg Am.
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Other options for fingertip reconstruction, such as thenar flaps and cross-finger flaps require a period of immobilization, whereas reverse-flow homodigital island flaps based on a proper digital artery can lead to cold intolerance because the sacrifice of a proper digital artery is required. The digital artery perforator flap is particularly suited to coverage of a lateral oblique fingertip defect, because only a 90 rotation is required when inset as a propeller flap, whereas the bulk of the flap serves to restore the rounded contour of the fingertip. The skin over the entire dorsal surface of the middle phalanx can be elevated as a flap, providing adequate tissue to resurface the defect and restore a rounded contour to the fingertip. Reinnervating the flap through the proximal end of the contralateral dorsal digital nerve serves to both restore sensation and also prevent formation of a painful neuroma. Disadvantages of the flap include the possibility of venous congestion.
5. Scerri GV, Park AJ, Hurren JS. A flap for segmental loss of a digital nerve. The Venkataswami flap revisited. J Hand Surg Br. 1995;20(4): 532e534. 6. Tuncali D, Barutcu AY, Gokrem S, Terzioglu A, Aslan G. The hatchet flap for reconstruction of fingertip amputations. Plast Reconstr Surg. 2006;117(6):1933e1939. 7. Foucher G, Dallaserra M, Tilquin B, Lenoble E, Sammut D. The Hueston flap in reconstruction of fingertip loss. Results in a series of 41 patients. J Hand Surg Am. 1994;19(3):508e515. 8. Levame JH, Otero C, Berdugo G. Arterial vascularization of teguments of the dorsal surface of the hand and fingers [in French]. Ann Chir Plast. 1967;12(4):316e324. 9. Oberlin C, Le Quang G. Anatomical study of the vascularization of the flag flap. Apropos of its use in loss of substance from the palmar face of the proximal phalanx [in French]. Ann Chir Main. 1985;4(2): 169e174. 10. Yousif NJ, Cunningham MW, Sanger JR, Gingrass RP, Matloub HS. The vascular supply to the proximal interphalangeal joint. J Hand Surg Am. 1985;10(6 Pt 1):852e861. 11. Strauch B, Moura W. Arterial system of the fingers. J Hand Surg Am. 1990;15(1):148e154. 12. Endo T, Kojima T, Hirase Y. Vascular anatomy of the finger dorsum and a new idea for coverage of the finger pulp defect that restores sensation. J Hand Surg Am. 1992;17(5):927e932. 13. Braga-Silva J, Kuyven CR, Fallopa F, Albertoni W. An anatomical study of the dorsal cutaneous branches of the digital arteries. J Hand Surg Br. 2002;27(6):577e579. 14. Li YF, Cui SS. Innervated reverse island flap based on the end dorsal branch of the digital artery: surgical technique. J Hand Surg Am. 2005;30(6):1305e1309. 15. Takeishi M, Shinoda A, Sugiyama A, Ui K. Innervated reverse dorsal digital island flap for fingertip reconstruction. J Hand Surg Am. 2006;31(7):1094e1099. 16. Pelissier P, Casoli V, Bakhach J, Martin D, Baudet J. Reverse dorsal digital and metacarpal flaps: a review of 27 cases. Plast Reconstr Surg. 1999;103(1):159e165. 17. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg. 2004;114(4):910e916. 18. Koshima I, Urushibara K, Fukuda N, et al. Digital artery perforator flaps for fingertip reconstructions. Plast Reconstr Surg. 2006;118: 1579e1584. 19. Mitsunaga N, Mihara M, Koshima I, et al. Digital artery perforator (DAP) flaps: modifications for fingertip and finger stump reconstruction. J Plast Reconstr Aesthet Surg. 2010;63(8):1312e1317. 20. Chen C, Tang P, Zhang X. The dorsal homodigital island flap based on the dorsal branch of the digital artery: a review of 166 cases. Plast Reconstr Surg. 2014;133(4):519ee529e.
ACKNOWLEDGMENT The authors would like to thank Priscila Sanchez, MD, for help with illustrations. REFERENCES 1. Allen MJ. Conservative management of finger tip injuries. Hand. 1980;12(3):257e265. 2. Weichman KE, Wilson SC, Samra F, Reavey P, Sharma S, Haddock NT. Treatment and outcomes of fingertip injuries at a large metropolitan public hospital. Plast Reconstr Surg. 2013;131(1): 107e112. 3. Tsai TM, Yuen JC. A neurovascular island flap for volar-oblique fingertip amputations. Analysis of long-term results. J Hand Surg Br. 1996;21(1):94e98. 4. 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(2):296e300.
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Innervated Digital Artery Perforator Propeller Flap for Reconstruction of Lateral Oblique Fingertip Defects Xiao Fang Shen, MD, Ming Yu Xue, MD, Jing Yi Mi, MD, Li Qiang , MD, Yong Jun Rui, MD, Harvey Chim, MD Purpose To report our experience with the use of a digital artery perforator propeller flap based on a constant distal perforator in the middle phalanx for resurfacing of lateral oblique fingertip amputations. Methods Twelve fingertips in 10 patients underwent reconstruction, with a mean follow-up of 8 months (range, 8e12 mo). The size of the flaps ranged from 2.5 1.5 cm to 3.0 2.0 cm. Results All flaps survived entirely and restored a rounded fingertip contour. Mean static 2-point discrimination was 5 mm (range, 4e6 mm). With the exception of 1 patient with an amputation at the distal interphalangeal joint, the distal interphalangeal joint was preserved in all patients and had 30 to 60 of motion at final follow-up. No patients complained of cold intolerance or residual joint contracture. No hooked nail deformity occurred in patients who had remaining nailbed. Conclusions The digital artery perforator propeller flap is particularly suited to coverage of a lateral oblique fingertip defect, because only a 90 rotation is required when inset, and the bulk of the flap serves to restore the rounded contour of the fingertip. The skin over the entire dorsal surface of the middle phalanx can be elevated as a flap, providing adequate tissue to resurface the defect and restore a rounded contour to the fingertip. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Fingertip injuries, dorsal digital artery flap, oblique fingertip injury, finger amputation, perforator flap.
DIVIDES fingertip injuries by zone and pattern. The pattern can be divided into transverse or oblique amputations; oblique amputations are further subdivided
T
HE ALLEN CLASSIFICATION
1
From the Department of Hand Surgery, Wuxi Ninth People’s Hospital, Wuxi, Jiangsu, China; and the Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL. Received for publication February 3, 2015; accepted in revised form March 25, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Harvey Chim, MD, Division of Plastic Surgery, University of Miami Miller School of Medicine, Clinical Research Building, 1120 N.W. 14th St., 4th Floor, Miami, FL 33136; e-mail: [email protected]; or Yong Jun Rui, MD, Department of Hand Surgery, Wuxi 9th People’s Hospital Wuxi, Jiangsu, 214062, China; e-mail: ruiyj@ hotmail.com. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.03.024
into dorsal, volar, or lateral oblique injuries. Although some have advocated conservative treatment and healing by secondary intention,2 this can sometimes result in a hypersensitive fingertip, cold intolerance, and joint stiffness.3 The lack of soft tissue coverage over bone can result in pain. In addition, patients from Asian cultures often request immediate coverage and restoration of the normal contour of the fingertip and preservation of the length of the finger. For coverage of lateral oblique defects, the options are limited. The oblique triangular flap, described by Venkataswami and Subramanian in 1980,4,5 is probably the best known technique specific to reconstruction of a lateral oblique defect. This relies on V-Y advancement of an island flap extending
Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
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DIGITAL ARTERY PERFORATOR FLAP FOR FINGERTIP
FIGURE 1: A Perforators arise from the proper digital arteries at constant locations and supply the dorsal skin over the proximal and middle phalanges. These can be used as the basis for flaps using dorsal finger skin. (1) Basal metacarpal arch. (2) Dorsal metacarpal artery. (3) Perforating branches from dorsal metacarpal artery. (4) Dorsal perforating branches from proper digital artery. (5) Deep palmar arch. (6) Superficial palmar arch. (7) Palmar metacarpal artery. (8) Common digital artery. (9) Proximal dorsopalmar anastomosis. (10) Distal dorsopalmar anastomosis. (11) Proper digital artery. (12) Distal dorsal perforating branch of the middle phalanx (in orange). B The distal dorsal perforating branch of the middle phalanx (highlighted in orange) can be used to supply a flap that can be rotated to cover lateral oblique defects following fingertip amputations.
TABLE 1. Case 1
Patient Demographics and Outcomes (n[12) Sex Male
Age (y)
Finger Involved
Size of Flaps (cm)
Static 2PD at Follow-Up (mm)
DIP Joint ROM ( )
42
Right index
3.0 2.0
4
NA
2
Female
42
Left middle
3.0 2.5
4
0e50
3
Female
48
Right index
3.0 1.5
4
0e45
4
Male
24
Left ring
3.0 1.5
5
0e60
5
Male
46
Left middle
2.0 2.5
6
0e30
5
Male
46
Left ring
2.0 2.5
6
0e30
6
Female
35
Right middle
2.5 1.5
5
0e45
7
Female
27
Left ring
2.5 1.5
6
0e60
7
Female
27
Left middle
2.5 2.0
5
0e50
8
Male
34
Left index
2.5 2.0
4
0e50
9
Male
19
Left middle
3.0 2.0
6
0e30
10
Male
29
Right ring
3.0 1.5
5
0e45
2PD, 2-point discrimination; ROM, range of motion.
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FIGURE 2: A 42-year-old man sustained a radial oblique amputation of his index fingertip after it was crushed by a steel beam. A The level of the amputation was at the DIP joint. A digital artery perforator propeller flap was designed and elevated B, preserving and dividing the dorsal digital nerve on the contralateral side proximally C. DeF The perforator (arrowhead) from the proper digital artery was identified and freed of its attachments. G The flap was then rotated into place to cover the defect. H A full-thickness skin graft was used to resurface the donor site. The flap was reinnervated by coapting the contralateral dorsal digital nerve to the proper digital nerve on the side of the injury.
proximally to the proximal interphalangeal (PIP) joint crease based on a neurovascular bundle. Although an excellent option, dissection is extensive and the advancing edge of the flap opposite the pedicle is denervated. Other options include the hatchet flap6 or a local rotation flap.7 J Hand Surg Am.
Different authors have described the constant presence of perforators from the proper digital arteries (Fig. 1), supplying the vascular system of the dorsal skin over the proximal and middle phalanges, which forms the basis for flaps involving the dorsal skin.8e10 Strauch and Moura11 found 2 constant r
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DIGITAL ARTERY PERFORATOR FLAP FOR FINGERTIP
FIGURE 3: At 8 months’ follow-up, the flap was well healed with a sensate and rounded fingertip with good bulk and contour. A Lateral view. B Dorsal view.
(n ¼ 3), avulsion (n ¼ 4), and crush (n ¼ 3). The size of the raised flaps ranged from 2.5 1.5 cm to 3.0 2.0 cm. The flap is designed on the dorsum of the middle phalanx of the injured finger in a teardrop shape between the midlateral lines. The flap on the side of the defect is designed to extend more distally and also extends just beyond the midlateral line to capture the perforator from the proper digital artery. The contralateral side of the flap extends proximally to the PIP joint crease. The flap is elevated superficial to the paratenon on the side opposite the defect. The contralateral dorsal digital nerve is identified and divided proximally. Flap elevation continues until the dorsal digital artery perforator on the side of the defect is identified. The perforator is then dissected free from surrounding structures and left attached to its origin from the proper digital artery. A cuff of tissue should be preserved around the pedicle where possible to minimize venous congestion. When dissecting the perforator in a retrograde fashion to its origin from the proper digital artery, an attempt is made to dissect as far away from the pedicle as possible, maintaining a 2to 3-mm cuff of tissue on each side of the pedicle. In addition, an attempt is made to keep the attachments of the overlying skin to the perforator intact to reduce venous congestion. The flap is then rotated 90 to resurface the lateral oblique fingertip defect. Fingertip sensation is reestablished through coaptation of the proximal end of the contralateral dorsal digital nerve to the proper digital nerve on the side of the injury, which is the proximal margin of the oblique fingertip amputation. The donor site is covered with a fullthickness skin graft.
cutaneous dorsal branches emanating from the proper digital arteries at the level of the metaphyses and epiphyses of the proximal and middle phalanges. Endo et al12 showed that 3 branches of the proper digital arteries constituted the vascular system of the dorsal skin over the proximal phalanx, whereas 2 branches supplied the vascular system over the middle phalanx. The location of these perforators was measured by Braga-Silva et al13 in 144 cadaver fingers. Two constant perforators were found supplying the middle phalanx, with the proximal perforator originating at a distance of between 5 and 8 mm distal to the PIP joint line and the distal perforator originating at a distance of between 9 and 13 mm distal to the PIP joint line. In addition, they found that the perforators were symmetrical on the radial and ulnar aspects of the digits in respect to the distance from the PIP joint. On the basis of these studies, a digital artery perforator flap can be designed based on the constant distal perforator over the middle phalanx from the proper digital artery (Fig. 1) and rotated to cover fingertip defects. The flap is innervated by coapting the proximal end of the dorsal digital nerve from the contralateral side to the distal cut end of the proper digital nerve in the area of the defect. MATERIALS AND METHODS Between 2009 and 2014, 12 fingers in 10 patients had reconstruction of a lateral oblique defect using a digital artery perforator rotation flap (Table 1). A retrospective review of patient data was conducted following approval by our institutional review board. Informed consent was obtained from patients. Patient age ranged from 19 to 48 years (mean, 35 y). Four patients were women. Three index, 5 middle, and 4 ring fingertips were reconstructed. The mechanism of injury included sharp injuries J Hand Surg Am.
RESULTS All flaps survived completely. One patient (case 3) had venous congestion, which resolved spontaneously r
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FIGURE 4: A A 48-year-old woman sustained an ulnar oblique defect of her right index finger following a machine crush injury. A digital artery perforator propeller flap was designed B, preserving the contralateral dorsal digital nerve C (arrowhead). The perforator was then freed of its attachments D, E, and the flap was rotated into place F. G A full-thickness skin graft was placed over the donor site. H After surgery, the flap exhibited venous congestion, which resolved with moist dressing changes.
with dressing changes. There were no other complications. The minimum follow-up period was 8 months (range, 8e12 mo). Static 2-point discrimination averaged 5 mm (range, 4e6 mm). With the exception of one patient with an amputation at the J Hand Surg Am.
distal interphalangeal (DIP) joint, the DIP joint was preserved in all patients and had 30 to 60 of motion at final follow-up. None of our patients complained of cold intolerance or residual joint contracture. No hooked nail deformity occurred in r
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FIGURE 5: One month after surgery, the venous congestion was totally resolved, and the flap was entirely viable with good bulk and round contour of the reconstructed fingertip. A Lateral view. B Dorsal view.
patients who had remaining nailbed. Representative cases are presented.
centered over the proximal part of the middle phalanxand retrograde arterial flow through an adipofascial pedicle. A digital artery perforator flap elevated in the form of a free-style flap was also described for fingertip coverage,17 designed over the radial or ulnar aspects of a digit.18,19 Owing to unstable blood flow to the flap, some flaps in this series had to be supercharged or were elevated as fat flaps.19 A major complication of flaps elevated based on the dorsal arterial system is venous congestion. This is particularly evident with a flap designed in the form of a reverse flow flap,14e16 which reduces venous drainage. By basing the flap directly on a perforator, the incidence of venous drainage can be reduced. In addition, preserving a strip of skin over the perforator pedicle, through extending the skin paddle beyond the midlateral line, appears to reduce the incidence of venous congestion by protecting tiny venules and preventing compression after rotation of the flap.20 However, the flap remains an island pedicle flap. Unlike other authors describing a 180 rotation of a digital artery perforator flap designed over the radial or ulnar aspect of a digit,18,19 we designed the flap to rotate only 90 . This may reduce the torsion on the pedicle and possibly the incidence of venous congestion. Digital artery perforator flaps over the dorsal digit may also be used to resurface defects on the middle phalanx, based on more proximal perforators originating from the proper digital arteries.20 Investigators have shown that digital artery perforators arise at constant locations in the proximal and middle phalanges at a fixed distance from known landmarks, such as the PIP joint.8e13 Digital artery perforator flaps should, therefore, not be considered as free-style flaps, but rather axial flaps originating from perforators at constant anatomical locations.
Case 1 A 42-year-old man sustained a radial oblique amputation of his index fingertip after it was crushed by a steel beam. The level of the amputation was at the DIP joint (Fig. 2). A digital artery perforator propeller flap was designed and elevated, preserving and dividing the dorsal digital nerve on the contralateral side proximally. The perforator from the proper digital artery was identified and freed of its attachments. The flap was then rotated into place to cover the defect. A full-thickness skin graft was used to resurface the donor site. The flap was reinnervated by coapting the contralateral dorsal digital nerve to the proper digital nerve on the side of the injury. At 8 months’ follow-up, the flap was well healed with a sensate and rounded fingertip with good bulk and contour (Fig. 3). Case 3 A 48-year-old woman sustained an ulnar oblique defect of her right index finger following a machine crush injury (Fig. 4). A digital artery perforator propeller flap was used. After surgery, the flap exhibited venous congestion, which resolved with moist dressing changes. On follow-up 1 month after surgery, the venous congestion totally resolved and the flap was entirely viable (Fig. 5). DISCUSSION Flaps based on the dorsal arterial system have been described for fingertip coverage.14e16 An innervated reverse flow island flap based on the end dorsal branch of the digital artery was described by Li et al14 and also by Takeishi et al,15 with the skin island J Hand Surg Am.
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DIGITAL ARTERY PERFORATOR FLAP FOR FINGERTIP
Other options for fingertip reconstruction, such as thenar flaps and cross-finger flaps require a period of immobilization, whereas reverse-flow homodigital island flaps based on a proper digital artery can lead to cold intolerance because the sacrifice of a proper digital artery is required. The digital artery perforator flap is particularly suited to coverage of a lateral oblique fingertip defect, because only a 90 rotation is required when inset as a propeller flap, whereas the bulk of the flap serves to restore the rounded contour of the fingertip. The skin over the entire dorsal surface of the middle phalanx can be elevated as a flap, providing adequate tissue to resurface the defect and restore a rounded contour to the fingertip. Reinnervating the flap through the proximal end of the contralateral dorsal digital nerve serves to both restore sensation and also prevent formation of a painful neuroma. Disadvantages of the flap include the possibility of venous congestion.
5. Scerri GV, Park AJ, Hurren JS. A flap for segmental loss of a digital nerve. The Venkataswami flap revisited. J Hand Surg Br. 1995;20(4): 532e534. 6. Tuncali D, Barutcu AY, Gokrem S, Terzioglu A, Aslan G. The hatchet flap for reconstruction of fingertip amputations. Plast Reconstr Surg. 2006;117(6):1933e1939. 7. Foucher G, Dallaserra M, Tilquin B, Lenoble E, Sammut D. The Hueston flap in reconstruction of fingertip loss. Results in a series of 41 patients. J Hand Surg Am. 1994;19(3):508e515. 8. Levame JH, Otero C, Berdugo G. Arterial vascularization of teguments of the dorsal surface of the hand and fingers [in French]. Ann Chir Plast. 1967;12(4):316e324. 9. Oberlin C, Le Quang G. Anatomical study of the vascularization of the flag flap. Apropos of its use in loss of substance from the palmar face of the proximal phalanx [in French]. Ann Chir Main. 1985;4(2): 169e174. 10. Yousif NJ, Cunningham MW, Sanger JR, Gingrass RP, Matloub HS. The vascular supply to the proximal interphalangeal joint. J Hand Surg Am. 1985;10(6 Pt 1):852e861. 11. Strauch B, Moura W. Arterial system of the fingers. J Hand Surg Am. 1990;15(1):148e154. 12. Endo T, Kojima T, Hirase Y. Vascular anatomy of the finger dorsum and a new idea for coverage of the finger pulp defect that restores sensation. J Hand Surg Am. 1992;17(5):927e932. 13. Braga-Silva J, Kuyven CR, Fallopa F, Albertoni W. An anatomical study of the dorsal cutaneous branches of the digital arteries. J Hand Surg Br. 2002;27(6):577e579. 14. Li YF, Cui SS. Innervated reverse island flap based on the end dorsal branch of the digital artery: surgical technique. J Hand Surg Am. 2005;30(6):1305e1309. 15. Takeishi M, Shinoda A, Sugiyama A, Ui K. Innervated reverse dorsal digital island flap for fingertip reconstruction. J Hand Surg Am. 2006;31(7):1094e1099. 16. Pelissier P, Casoli V, Bakhach J, Martin D, Baudet J. Reverse dorsal digital and metacarpal flaps: a review of 27 cases. Plast Reconstr Surg. 1999;103(1):159e165. 17. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg. 2004;114(4):910e916. 18. Koshima I, Urushibara K, Fukuda N, et al. Digital artery perforator flaps for fingertip reconstructions. Plast Reconstr Surg. 2006;118: 1579e1584. 19. Mitsunaga N, Mihara M, Koshima I, et al. Digital artery perforator (DAP) flaps: modifications for fingertip and finger stump reconstruction. J Plast Reconstr Aesthet Surg. 2010;63(8):1312e1317. 20. Chen C, Tang P, Zhang X. The dorsal homodigital island flap based on the dorsal branch of the digital artery: a review of 166 cases. Plast Reconstr Surg. 2014;133(4):519ee529e.
ACKNOWLEDGMENT The authors would like to thank Priscila Sanchez, MD, for help with illustrations. REFERENCES 1. Allen MJ. Conservative management of finger tip injuries. Hand. 1980;12(3):257e265. 2. Weichman KE, Wilson SC, Samra F, Reavey P, Sharma S, Haddock NT. Treatment and outcomes of fingertip injuries at a large metropolitan public hospital. Plast Reconstr Surg. 2013;131(1): 107e112. 3. Tsai TM, Yuen JC. A neurovascular island flap for volar-oblique fingertip amputations. Analysis of long-term results. J Hand Surg Br. 1996;21(1):94e98. 4. 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(2):296e300.
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