HAND/PERIPHERAL NERVE Innervated Reverse Digital Artery Island Flap through Bilateral Neurorrhaphy using Direct Small Branches of the Proper Digital Nerve Jihyeung Kim, Young Ho Lee, Min Bom Kim, Seung Hoo Lee, Goo Hyun Baek,
M.D. M.D. M.D. M.D. M.D.
Seoul, South Korea
cpt
Background: The reverse digital artery flap uses the radial or ulnar surface of the proximal phalanx of the involved digit and has been applied to sensate flaps using the superficial sensory nerve branch and the dorsal branch of the proper digital nerve. As these nerve branches innervate the dorsal surface of the finger, however, hypesthesia of the dorsal side of the middle phalanx is inevitable. Methods: Thirty fingers of 25 patients who had the innervated reverse digital artery flap using direct small branches of the proper digital nerve were included in this study. The minimum follow-up duration was 24 months, and the average defect size was 2.8 cm2. Results: In all cases, the pulp defects were successfully reconstructed with this flap. The average size of the donor flap was 3.9 cm2. At 6 months after surgery, the average static two-point discrimination value was 5.9 mm, the average moving two-point discrimination value was 5.0 mm, and the average SemmesWeinstein monofilament score was 3.79. At 1 year postoperatively, the average Cold Intolerance Severity Score was 20. The percentage total active motion was measured at 99 percent 2 years after surgery. Conclusions: Because this flap does not sacrifice the proper digital nerve or dorsal branch of the nerve, the sensibility of the dorsal aspect of the proximal and middle phalanx can be preserved. This flap is cosmetically excellent, as it uses a donor flap similar to the injured fingertip and the donor scar can be hidden by adjacent fingers. (Plast. Reconstr. Surg. 135: 1643, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
F
ingertip or pulp defects are among the most common types of hand injury. Many traditional surgical techniques, such as the volar V-Y advancement flap, lateral V-Y advancement flap, thenar flap, and cross-finger flap, have been used in the treatment of fingertip injuries with exposed bone, tendons, or joints.1–4 A triangular volar flap is very useful for the reconstruction of amputated fingertips,1 and the lateral V-Y advancement flap is another useful method for treatment of traumatic fingertip amputations with palmar and transverse oblique deformities.2 Nevertheless, overextended indications with excessive traction for distal advancement may result in poor sensitivity or a dysesthetic flap.5 Local regional flaps, such From the Department of Orthopedic Surgery, Seoul National University College of Medicine. Received for publication September 22, 2014; accepted December 11, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001290
as the thenar flap4 and cross-finger flap,3 can be applied when local advancement flaps are inadequate. These flaps, however, require two-stage operations, and prolonged immobilization can lead to stiffness of the involved fingers. The reverse digital artery island flap can provide adequate and durable tissue without invading the palm or other digits and is a single-stage procedure. In 1973, Weeks and Wray first applied the distally based arterial island flap for fingertip reconstruction.6 Lai et al.7 and Kojima et al.8 used a similar flap for fingertip reconstruction, but the sensation of the digit was not restored. The innervated reverse digital artery flap through bilateral neurorrhaphy, which was suggested by Lai et al.9 in 1993, yielded more satisfactory reconstruction of Disclosure: The authors have no financial interest in any of the products, devices, or drugs mentioned in this article. The authors have no conflicts of interest to declare in relation to the content of this article.
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Plastic and Reconstructive Surgery • June 2015 sensate pulp. In the present study, we successfully used the innervated reverse digital artery island flap through bilateral neurorrhaphy by using the direct small branches of the proper digital nerve. In a previous cadaveric study, the anatomical constancy of the direct small branches of the proper digital nerve was verified,10 and these branches have been used in the innervated lateral middle phalangeal finger flap.11
PATIENTS AND METHODS We retrospectively reviewed all patients with fingertip injuries who underwent the innervated reverse digital artery island flap procedure using direct small branches at our hospital between March of 2006 and February of 2012. The Institutional Review Board of our hospital reviewed and approved this study. The inclusion criteria were (1) a diagnosis of traumatic fingertip injury of fingers other than the thumb, (2) innervated reverse digital artery island flap using direct small branches, and (3) follow-up of more than 2 years. Thirty digits of 25 patients (22 men and three women) were included in the present study
(Table 1). Twenty-one patients had fingertip injury of a single digit, three patients had fingertip injuries of two adjacent digits, and one patient had fingertip injuries of three adjacent digits. The mechanisms of injury included crushing type injury in six patients and avulsion type injury in 19. Of the 30 digits included in this study, the index finger was involved in seven cases, the middle finger in nine cases, ring finger in 10 cases, and little finger in four cases. The involved finger was on the right hand in 19 cases and left hand in 11 cases. The average size of the defects was 2.8 cm2, with the smallest defect measuring 1.3 × 1.2 cm and the largest measuring 3.2 × 1.7 cm. The average age at the time of surgery was 33 years (range, 15 to 63 years). The average duration of follow-up was 27 months (range, 24 to 37 months). All operations were performed by one orthopedic surgeon. Our patients were followed up at 2 weeks, 4 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. At 6 months postoperatively, sensation of the flap was assessed by static and moving two-point discrimination using the Mackinnon-Dellon Disk-Criminator (AliMed, Dedham, Mass.) and Semmes-Weinstein monofilament tests. During the static two-point
Table 1. Demographic Data of 25 Patients Case
Age/Sex
1 2 3 4 5 6
63/M 57/M 40/M 48/M 30/F 46/M
7 8 9 10 11 12
22/M 23/M 31/M 58/M 35/M 22/M
13 14
20/M 21/M
15 16 17 18 19 20 21 22 23
22/M 22/M 21/M 20/M 20/M 45/M 52/F 48/M 32/M
24 25
22/M 15/F
Injury Side Left Right Left Right Right Right Right Right Left Left Left Right Right Right Right Left Right Right Right Left Right Left Right Left Right Left Right Right Right Left
Injured Finger Middle Ring Index Little Middle Index Middle Ring Ring Index Index Middle Index Middle Ring Little Middle Ring Middle Ring Little Index Middle Ring Ring Index Middle Ring Little Ring
Injury Type
Defect Size, cm × cm
Donor Site
Flap Size, cm × cm
Transverse Transverse Volar oblique Transverse Volar oblique Volar oblique Volar oblique Volar oblique Volar oblique Transverse Transverse Volar oblique Transverse Volar oblique Volar oblique Volar oblique Transverse Transverse Transverse Volar oblique Transverse Volar oblique Volar oblique Transverse Volar oblique Transverse Transverse Volar oblique Volar oblique Volar oblique
1.8 × 1.2 1.3 × 1.2 2.1 × 1.6 1.6 × 1.3 1.6 × 1.3 3 × 1.6 3.2 × 1.7 2 × 1.4 2.2 × 1.3 1.9 × 1.6 2.6 × 1.8 2 × 1.3 2.6 × 1.6 2.1 × 1.6 2.2 × 1.5 2 × 1.3 1.5 × 1.2 1.6 × 1.2 1.5 × 1.5 1.7 × 1.4 1.4 × 1.2 2×2 2 × 1.8 1.8 × 1.6 1.8 × 1.2 1.5 × 1.5 1.5 × 1.3 1.5 × 1.5 1.7 × 1.2 1.8 × 1.3
Radial side Ulnar side Ulnar side Radial side Ulnar side Radial side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Radial side Radial side Radial side Radial side Radial side Radial side Ulnar side Ulnar side Radial side Radial side Ulnar side Radial side Radial side Radial side Ulnar side
2.1 × 1.5 1.6 × 1.4 2.5 × 1.9 1.9 × 1.6 2 × 1.6 3.5 × 1.9 3.5 × 2 2.4 × 1.7 2.5 × 1.6 2.3 × 1.9 3×2 2.4 × 1.6 3×2 2.5 × 1.9 2.5 × 1.8 2.3 × 1.6 1.8 × 1.4 1.8 × 1.4 1.8 × 1.6 2 × 1.7 1.8 × 1.5 2.3 × 2.2 2.3 × 2 2.2 × 1.8 2.1 × 1.4 1.9 × 1.7 1.7 × 1.6 1.8 × 1.7 2 × 1.5 2.1 × 1.6
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Volume 135, Number 6 • Reverse Digital Artery Island Flap discrimination test, we applied sufficient pressure to blanch the skin,12 and depressed the skin by no more than 1 mm.13 We also ensured that the stimuli were applied simultaneously and were of equal pressure.13 When performing the moving two-point discrimination test, we moved the testing device from a proximal to distal direction, parallel to the long axis of the finger.14 During the Semmes-Weinstein monofilament test, the monofilament was pressed perpendicular to the fingertip with sufficient pressure to bend it for 1.5 seconds. At 1 year postoperatively, the cold intolerance of the injured finger was measured via the self-administered Cold Intolerance Severity Score questionnaire.15 The maximum score was 100 and was grouped into four ranges, 0 to 25, 26 to 50, 51 to 75, and 76 to 100, which corresponded to mild, moderate, severe, and extreme severity, respectively. At 2 years postoperatively, the active range of motion of the proximal interphalangeal joint and the distal interphalangeal joint of the injured finger was measured with a goniometer.
OPERATIVE PROCEDURE The innervated reverse digital artery island flap using direct small branches of the proper
digital nerve was harvested from the lateral or ventrolateral skin of the homodigital proximal phalanx. A digital Allen test was performed on the injured digit to ascertain the roles of both proper digital arteries. For reconstruction of fingertip defects, the flap was harvested on the more injured side. In cases in which the defect was located in the center of the pulp, however, the donor flap was elevated on the ulnar side of the index, middle, and ring fingers, and on the radial side of the little finger. The skin incision of the flap was designed on the lateral or ventrolateral side of the proximal phalanx involved, according to the size and shape of the pulp defect. The skin incision was extended from the distal end of the donor flap to the injured fingertip. First, the proper digital nerve and its direct small branches were dissected and preserved (Fig. 1). Two or three branches that projected toward the donor flap were cut at the branching points from the proper digital nerve, preserving the proper digital nerve and dorsal branch of the nerve (Fig. 2). During dissection of the palmar proper digital artery, periarterial soft tissues were included in the vascular pedicle. The flap was then elevated and placed on top of the injured finger. Bilateral neurorrhaphy was performed, under a microscope
Fig. 1. The anatomy of the proper digital nerve (black arrow), its dorsal branch (green arrow), and superficial sensory nerve branch (red arrow). The green dotted line represents the skin incision of the flap.
Fig. 2. The direct small branches (white arrows) were included in the donor flap. We preserved the proper digital nerve (black arrow), its dorsal branch (green arrow), and superficial sensory nerve branch (red arrow). The yellow dotted lines represent the previous locations of the direct small branches.
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Plastic and Reconstructive Surgery • June 2015 Table 2. Postoperative Assessments of the Reconstructed Fingers Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Injured Finger Middle Ring Index Little Middle Index Middle Ring Ring Index Index Middle Index Middle Ring Little Middle Ring Middle Ring Little Index Middle Ring Ring Index Middle Ring Little Ring
Static 2PD, mm
Moving 2PD, mm
SWM
CISS
6 8 6 7 5 6 6 7 5 6 5 7 5 7 5 5 6 5 6 5 6 6 5 6 7 7 5 6 6 5
5 7 6 6 4 6 5 6 5 5 4 5 4 6 5 4 5 4 5 5 5 5 4 5 6 6 5 5 4 4
3.84 4.08 3.61 4.08 3.84 3.84 3.84 4.08 3.61 3.61 3.22 4.17 3.61 4.17 3.84 3.84 4.17 3.61 3.84 3.61 3.61 3.84 3.61 3.84 4.08 3.84 3.84 3.61 3.84 3.22
36 44 22 20 18 20 18 16 24 22 24 18 16 16 8 24 20 18 18 20 24 18 18 14 8
ROM PIP Joint
ROM DIP Joint
105 100 105 105 115 110 105 100 110 100 110 100 110 105 110 110 105 110 105 110 95 110 110 105 100 110 115 110 105 110
65 55 70 65 70 65 70 70 75 60 70 60 70 65 70 70 65 60 65 65 65 70 60 65 55 70 70 65 65 65
2PD, two-point discrimination; SWM, Semmes-Weinstein monofilament test; CISS, Cold Intolerance Severity Score; ROM, range of motion; PIP, proximal interphalangeal joint; DIP, distal interphalangeal joint.
using 10-0 nylon microsutures, between one or two direct small branches and the ulnar digital nerve stump, and between the branches and the radial digital nerve stump. If the injured finger had unilateral digital nerve injury, the digital nerve on the injured side was coapted with one or two direct small branches of the proper digital nerve. The flap was then snugly sutured with 5-0 nylon. The donor defect was covered with a full-thickness skin graft. The turnover vascular base was also covered with a piece of skin graft to avoid vascular compromise.
RESULTS Thirty cases of pulp defects were successfully reconstructed with the reverse digital artery flap. In all of our cases, the flap was viable. With regard to complications, one case of venous congestion and one case of infection occurred. Venous congestion was improved by partial stitch removal, and infection was controlled after débridement. The average size of the donor flap was 3.9 cm2, with the smallest defect measuring 1.6 × 1.4 cm and the largest measuring 3.5 × 2 cm
(Table 1). At 6 months postoperatively, the average static two-point discrimination value was 5.9 mm (range, 5 to 8 mm), the average moving two-point discrimination value was 5.0 mm (range, 4 to 7 mm), and the average SemmesWeinstein monofilament score was 3.79 (range, 3.22 to 4.17) (Table 2). The average score on the Cold Intolerance Severity Score questionnaire15 was 20 (range, 8 to 44) 1 year postoperatively. The scores of 23 patients corresponded to mild cold intolerance, with two patients’ scores corresponding to moderate intolerance. At 2 years postoperatively, the average total active motion of the proximal interphalangeal joint was 107 degrees (range, 95 to 115 degrees) and that of the distal interphalangeal joint was 66 degrees (range, 55 to 75 degrees). All fingers in our series achieved excellent total active motion according to the criteria of Strickland and Glogovac16 for flexor tendon results.
CASE REPORT A 63-year-old man presented with amputation of the left middle fingertip (Fig. 3). To reconstruct the stump, an innervated reverse digital artery island flap was raised on the radial side. We
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Volume 135, Number 6 • Reverse Digital Artery Island Flap DISCUSSION
Fig. 3. To cover the pulp defect, an innervated reverse digital artery island flap was designed on the radial side of the proximal phalanx. included the proper digital artery and the direct small branches of the proper digital nerve on the donor flap, preserving the proper digital nerve and dorsal branch of the nerve (Fig. 4). Two direct branches of the proper digital nerve were coapted with the distal ends of both radial and ulnar digital nerves, respectively (Fig. 5). The flap was then snugly sutured with 5-0 nylon (Fig. 6). The donor defect was covered with a full-thickness skin graft. No complications occurred during the early postoperative period. Six months postoperatively, static and moving two-point discriminations were 6 and 5 mm, respectively. Two years postoperatively, the finger showed an excellent range of active motion (Fig. 7).
Lai et al.9 suggested innervated reverse digital artery flap through bilateral neurorrhaphy for the reconstruction of fingertip injuries. This flap uses the dorsal branch of the proper digital nerve and the superficial sensory branch from the radial or ulnar nerve. Through neurorrhaphy, it can prevent neuroma formation from the injured digital nerve stumps. Although this is a good sensate flap for one-stage reconstruction of major pulp defects, it has several limitations, such as noticeable donor-site scarring and sensory loss on the dorsal side of the proximal and middle phalanges. The superficial sensory nerve branch innervates mainly the dorsal side of the proximal phalanx, and sensory restoration of the volar side of the donor flap cannot be expected when using this nerve.17 We devised this innervated reverse digital artery island flap to complement these drawbacks. As the donor flap is elevated on the lateral or ventrolateral side of the proximal phalanx, the scar is unnoticeable. As the small branches of the proper digital nerve directly innervate the donor flap, good sensory recovery can be expected. In a study in which authors used the innervated lateral middle phalangeal finger flap using those small branches of the proper digital nerve, static two-point discrimination values of approximately 6 mm were achieved.11 The anatomical constancy of the direct small branches of the proper digital nerve was also verified in
Fig. 4. (Left) We dissected the proper digital nerve and found direct small branches of the nerve. (Right) We preserved the proper digital nerve and the dorsal branch of the nerve.
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Plastic and Reconstructive Surgery • June 2015
Fig. 5. Epineural neurorrhaphy using two or three 10-0 nylon microsutures was performed between the direct small branches and both cut ends of the digital nerves.
Fig. 6. The donor flap was sutured to the defect and drains were inserted under the flap.
a previous anatomical study.10 In this cadaveric study, the thickness of the sensory branches of the proximal phalanx was similar to the diameter of the digital nerve at the distal interphalangeal joint. Furthermore, as we preserved the dorsal branch of the proper digital nerve, the sensitivity of the dorsal side of the middle phalanx could be maintained. In healthy young adults, the static two-point discrimination values of the fingertip were 2.6 and 2.5 mm in the long and little fingers,
respectively.13 In another study, the values were 2.5 mm in the index finger, and approximately 2 mm in the long, ring, and little fingers during the second decade of life.18 Those values increased, however, to approximately 5 mm in the index finger, and more than3 mm in the long, ring, and little fingers, during the eighth decade of life. Moving two-point discrimination values were less than the static two-point values,12 and the normal values of the moving two-point discrimination among individuals aged between 4 and 18 years were reported as between 2 and 4 mm.19 In a reverse digital artery flap without neurorrhaphy, the mean static and moving twopoint discrimination values in the flap were 6.5 and 3.5 mm, respectively7; however, the twopoint discrimination test was not performed in all patients in that study. In another study of the insensate reverse digital artery flap, the static two-point discrimination test values were between 6 and 10 mm in 10 of 13 fingers.20 In a study of the innervated reverse digital artery flap in which authors used the dorsal branch of the proper digital nerve and the superficial sensory nerve branch, the static two-point discrimination was 5 mm, and the moving two-point discrimination ranged from 2 to 3 mm.9 In a study by Takeishi et al.,21 the static two-point discrimination ranged from 3 to 5 mm and the Semmes-Weinstein test results ranged from 0.036 to 0.754 g after use of the innervated reverse dorsal digital island flap technique using the dorsal branch of the proper digital nerve or superficial sensory nerve branch. Han et al.22 reported that the mean values of the static twopoint discrimination test in sensate and insensate flaps were 6.2 and 10.2 mm, respectively. In the present study, the two-point discrimination and Semmes-Weinstein monofilament tests were not administered by an independent examiner. Therefore, there was a possibility of examiner bias. However, the two-point discrimination test has demonstrable reliability and reproducibility,23 and we made every effort to perform the tests objectively and consistently. Static two-point discrimination values ranged from 5 to 8 mm and moving two-point discrimination ranged from 4 to 7 mm, which were comparable to the results of previous studies. Lai et al.7 and Kojima et al.8 described a reverse pedicle homodigital flap for fingertip reconstruction. The arterial anatomical study of the distal phalanx revealed that three arcades (superficial arcade, proximal subungual arcade, and distal subungual arcade) were
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Volume 135, Number 6 • Reverse Digital Artery Island Flap
Fig. 7. (Left) The pulp of the long finger was well contoured postoperatively. (Center) There was no extension lag in the proximal or distal interphalangeal joint. (Right) Full flexion was possible in the interphalangeal joints of the long finger at 2 years after surgery.
interconnected and formed a particularly rich vascular bed in the nail bed and the terminal segment of the finger.24 These abundant anastomoses enabled the reverse digital artery flap to obtain sufficient blood supply in a retrograde direction. As the reverse digital artery flap sacrifices one of the digital arteries in a traumatized finger, cold intolerance can occur as a complication. Cold intolerance occurred in 41.6 percent of the patients in a previous study performed by Yildirim et al.25 Niranjan and Armstrong26 reported that nine patients (36 percent) complained of cold intolerance among 25 patients with homodigital reverse pedicle island flaps. In the present study, most patients had no or mild cold intolerance, and only two patients had a moderate degree of cold intolerance. Because the veins of the finger do not run along with the digital artery as venae comitantes, the tiny venules and capillaries embedded in the perivascular fat provide sufficient channels for venous drainage of the flap.27,28 Therefore, as much perivascular tissue as possible should be included to preserve these venules. The reverse digital artery flap is a single-stage reconstructive procedure, requires brief immobilization, and does not use other fingers as donor sites. Therefore, we can expect good functional results using this flap. In the present study, the percentage of total active motion was 99 percent at 2 years postoperatively. We began active finger motion exercises 2 weeks after the procedure, and patients were educated about the active and passive range-of-motion exercises of the interphalangeal
joints and the importance of the exercises at each follow-up visit.
CONCLUSIONS We experienced good surgical results after the innervated reverse digital artery island flap using direct small branches of the proper digital nerve. This is a single-stage procedure and does not sacrifice the proper digital nerve or dorsal branch of the nerve. This flap was cosmetically excellent because it used a donor flap most similar to the injured fingertip and the donor scar could be hidden by the adjacent fingers; however, several limitations remain. As the donor flap is elevated in the injured finger, there is a risk of flap failure if the whole proper digital artery is injured. Therefore, we should perform a digital Allen test before surgery. There is also a risk of cold intolerance because of the sacrifice of one digital artery. In addition, this flap requires delicate dissection and a great deal of microsurgical skill. Despite these disadvantages, the innervated reverse digital artery island flap using direct small branches of the proper digital nerve is a good surgical option for reconstruction of major pulp defects when sensory recovery is critical and other flaps are inappropriate. Young Ho Lee, M.D. Department of Orthopedic Surgery Seoul National University College of Medicine Seoul National University Hospital 101 Daehak-ro, Jongno-gu Seoul, 110–744, Korea [email protected]
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Plastic and Reconstructive Surgery • June 2015
CODING PERSPECTIVE
cpt
This information provided by Dr. Raymond Janevicius is intended to provide coding guidance.
15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel 15240-51 Full-thickness skin graft 64831-51 Digital nerve repair 64832 Digital nerve repair, additional nerve 69990 Operating microscope • The reverse digital artery flap is an island flap and is reported with code 15740. • The first digital neurorrhaphy is reported with code 64831. • Additional digital neurorrhaphy is reported with code 64832. • The digital neurorrhaphy codes do not include use of the operating microscope. Report 69990 once per operative session for use of the operating microscope, even though it is used for each nerve. • 64832 and 69990 are add-on codes and do not take the multiple procedure modifier, 51. • The donor-site repair with full-thickness skin graft is described with code 15240. references 1. 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;52:921–926. 2. Shepard GH. The use of lateral V-Y advancement flaps for fingertip reconstruction. J Hand Surg Am. 1983;8:254–259. 3. Tempest MN. Cross-finger flaps in the treatment of injuries to the finger tip. Plast Reconstr Surg. (1946) 1952;9:205–222. 4. Dellon AL. The proximal inset thenar flap for fingertip reconstruction. Plast Reconstr Surg. 1983;72:698–704. 5. Grad JB, Beasley RW. Fingertip reconstruction. Hand Clin. 1985;1:667–676. 6. Weeks PM, Wray RC. Management of Acute Hand Injuries: A Biological Approach. 2nd ed. St Louis: Mosby Co.; 1973:140–143. 7. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg. 1989;22:495–500. 8. Kojima T, Tsuchida Y, Hirasé Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg. 1990;43:290–295.
9. Lai CS, Lin SD, Chou CK, Tsai CW. Innervated reverse digital artery flap through bilateral neurorrhaphy for pulp defects. Br J Plast Surg. 1993;46:483–488. 10. Kim J, Lee YH, Kim MB, Rhee SH, Baek GH. Anatomy of the direct small branches of the proper digital nerve of the fingers: A cadaveric study. J Plast Reconstr Aesthet Surg. 2014;67:1129–1135. 11. Lee YH, Baek GH, Gong HS, Lee SM, Chung MS. Innervated lateral middle phalangeal finger flap for a large pulp defect by bilateral neurorrhaphy. Plast Reconstr Surg. 2006;118:1185– 1193; discussion 1194. 12. Louis DS, Greene TL, Jacobson KE, Rasmussen C, Kolowich P, Goldstein SA. Evaluation of normal values for stationary and moving two-point discrimination in the hand. J Hand Surg Am. 1984;9:552–555. 13. Nolan MF. Two-point discrimination assessment in the upper limb in young adult men and women. Phys Ther. 1982;62:965–969. 14. Dellon AL. The moving two-point discrimination test: Clinical evaluation of the quickly adapting fiber/receptor system. J Hand Surg Am. 1978;3:474–481. 15. Irwin MS, Gilbert SE, Terenghi G, Smith RW, Green CJ. Cold intolerance following peripheral nerve injury: Natural history and factors predicting severity of symptoms. J Hand Surg Br. 1997;22:308–316. 16. Strickland JW, Glogovac SV. Digital function following flexor tendon repair in zone II: A comparison of immobilization and controlled passive motion techniques. J Hand Surg Am. 1980;5:537–543. 17. Bas H, Kleinert JM. Anatomic variations in sensory innervation of the hand and digits. J Hand Surg Am. 1999;24:1171–1184. 18. Gellis M, Pool R. Two-point discrimination distances in the normal hand and forearm: Application to various methods of fingertip reconstruction. Plast Reconstr Surg. 1977;59:57–63. 19. Hermann RP, Novak CB, Mackinnon SE. Establishing normal values of moving two-point discrimination in children and adolescents. Dev Med Child Neurol. 1996;38:255–261. 20. Sapp JW, Allen RJ, Dupin C. A reversed digital artery island flap for the treatment of fingertip injuries. J Hand Surg Am. 1993;18:528–534. 21. Takeishi M, Shinoda A, Sugiyama A, Ui K. Innervated reverse dorsal digital island flap for fingertip reconstruction. J Hand Surg Am. 2006;31:1094–1099. 22. Han SK, Lee BI, Kim WK. The reverse digital artery island flap: Clinical experience in 120 fingers. Plast Reconstr Surg. 1998;101:1006–1011; discussion 1012. 23. Dellon AL, Mackinnon SE, Crosby PM. Reliability of twopoint discrimination measurements. J Hand Surg Am. 1987;12(5 Pt 1):693–696. 24. Flint MH. Some observations on the vascular supply of the nail bed and terminal segments of the finger. Br J Plast Surg. 1955;8:186–195. 25. Yildirim S, Avci G, Akan M, Aköz T. Complications of the reverse homodigital island flap in fingertip reconstruction. Ann Plast Surg. 2002;48:586–592. 26. Niranjan NS, Armstrong JR. A homodigital reverse pedicle island flap in soft tissue reconstruction of the finger and the thumb. J Hand Surg Br. 1994;19:135–141. 27. Eaton RG. The digital neurovascular bundle: A microanatomic study of its contents. Clin Orthop Relat Res. 1968;61:176–185. 28. Lucas GL. The pattern of venous drainage of the digits. J Hand Surg Am. 1984;9:448–450.
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M.D. M.D. M.D. M.D. M.D.
Seoul, South Korea
cpt
Background: The reverse digital artery flap uses the radial or ulnar surface of the proximal phalanx of the involved digit and has been applied to sensate flaps using the superficial sensory nerve branch and the dorsal branch of the proper digital nerve. As these nerve branches innervate the dorsal surface of the finger, however, hypesthesia of the dorsal side of the middle phalanx is inevitable. Methods: Thirty fingers of 25 patients who had the innervated reverse digital artery flap using direct small branches of the proper digital nerve were included in this study. The minimum follow-up duration was 24 months, and the average defect size was 2.8 cm2. Results: In all cases, the pulp defects were successfully reconstructed with this flap. The average size of the donor flap was 3.9 cm2. At 6 months after surgery, the average static two-point discrimination value was 5.9 mm, the average moving two-point discrimination value was 5.0 mm, and the average SemmesWeinstein monofilament score was 3.79. At 1 year postoperatively, the average Cold Intolerance Severity Score was 20. The percentage total active motion was measured at 99 percent 2 years after surgery. Conclusions: Because this flap does not sacrifice the proper digital nerve or dorsal branch of the nerve, the sensibility of the dorsal aspect of the proximal and middle phalanx can be preserved. This flap is cosmetically excellent, as it uses a donor flap similar to the injured fingertip and the donor scar can be hidden by adjacent fingers. (Plast. Reconstr. Surg. 135: 1643, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
F
ingertip or pulp defects are among the most common types of hand injury. Many traditional surgical techniques, such as the volar V-Y advancement flap, lateral V-Y advancement flap, thenar flap, and cross-finger flap, have been used in the treatment of fingertip injuries with exposed bone, tendons, or joints.1–4 A triangular volar flap is very useful for the reconstruction of amputated fingertips,1 and the lateral V-Y advancement flap is another useful method for treatment of traumatic fingertip amputations with palmar and transverse oblique deformities.2 Nevertheless, overextended indications with excessive traction for distal advancement may result in poor sensitivity or a dysesthetic flap.5 Local regional flaps, such From the Department of Orthopedic Surgery, Seoul National University College of Medicine. Received for publication September 22, 2014; accepted December 11, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001290
as the thenar flap4 and cross-finger flap,3 can be applied when local advancement flaps are inadequate. These flaps, however, require two-stage operations, and prolonged immobilization can lead to stiffness of the involved fingers. The reverse digital artery island flap can provide adequate and durable tissue without invading the palm or other digits and is a single-stage procedure. In 1973, Weeks and Wray first applied the distally based arterial island flap for fingertip reconstruction.6 Lai et al.7 and Kojima et al.8 used a similar flap for fingertip reconstruction, but the sensation of the digit was not restored. The innervated reverse digital artery flap through bilateral neurorrhaphy, which was suggested by Lai et al.9 in 1993, yielded more satisfactory reconstruction of Disclosure: The authors have no financial interest in any of the products, devices, or drugs mentioned in this article. The authors have no conflicts of interest to declare in relation to the content of this article.
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Plastic and Reconstructive Surgery • June 2015 sensate pulp. In the present study, we successfully used the innervated reverse digital artery island flap through bilateral neurorrhaphy by using the direct small branches of the proper digital nerve. In a previous cadaveric study, the anatomical constancy of the direct small branches of the proper digital nerve was verified,10 and these branches have been used in the innervated lateral middle phalangeal finger flap.11
PATIENTS AND METHODS We retrospectively reviewed all patients with fingertip injuries who underwent the innervated reverse digital artery island flap procedure using direct small branches at our hospital between March of 2006 and February of 2012. The Institutional Review Board of our hospital reviewed and approved this study. The inclusion criteria were (1) a diagnosis of traumatic fingertip injury of fingers other than the thumb, (2) innervated reverse digital artery island flap using direct small branches, and (3) follow-up of more than 2 years. Thirty digits of 25 patients (22 men and three women) were included in the present study
(Table 1). Twenty-one patients had fingertip injury of a single digit, three patients had fingertip injuries of two adjacent digits, and one patient had fingertip injuries of three adjacent digits. The mechanisms of injury included crushing type injury in six patients and avulsion type injury in 19. Of the 30 digits included in this study, the index finger was involved in seven cases, the middle finger in nine cases, ring finger in 10 cases, and little finger in four cases. The involved finger was on the right hand in 19 cases and left hand in 11 cases. The average size of the defects was 2.8 cm2, with the smallest defect measuring 1.3 × 1.2 cm and the largest measuring 3.2 × 1.7 cm. The average age at the time of surgery was 33 years (range, 15 to 63 years). The average duration of follow-up was 27 months (range, 24 to 37 months). All operations were performed by one orthopedic surgeon. Our patients were followed up at 2 weeks, 4 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. At 6 months postoperatively, sensation of the flap was assessed by static and moving two-point discrimination using the Mackinnon-Dellon Disk-Criminator (AliMed, Dedham, Mass.) and Semmes-Weinstein monofilament tests. During the static two-point
Table 1. Demographic Data of 25 Patients Case
Age/Sex
1 2 3 4 5 6
63/M 57/M 40/M 48/M 30/F 46/M
7 8 9 10 11 12
22/M 23/M 31/M 58/M 35/M 22/M
13 14
20/M 21/M
15 16 17 18 19 20 21 22 23
22/M 22/M 21/M 20/M 20/M 45/M 52/F 48/M 32/M
24 25
22/M 15/F
Injury Side Left Right Left Right Right Right Right Right Left Left Left Right Right Right Right Left Right Right Right Left Right Left Right Left Right Left Right Right Right Left
Injured Finger Middle Ring Index Little Middle Index Middle Ring Ring Index Index Middle Index Middle Ring Little Middle Ring Middle Ring Little Index Middle Ring Ring Index Middle Ring Little Ring
Injury Type
Defect Size, cm × cm
Donor Site
Flap Size, cm × cm
Transverse Transverse Volar oblique Transverse Volar oblique Volar oblique Volar oblique Volar oblique Volar oblique Transverse Transverse Volar oblique Transverse Volar oblique Volar oblique Volar oblique Transverse Transverse Transverse Volar oblique Transverse Volar oblique Volar oblique Transverse Volar oblique Transverse Transverse Volar oblique Volar oblique Volar oblique
1.8 × 1.2 1.3 × 1.2 2.1 × 1.6 1.6 × 1.3 1.6 × 1.3 3 × 1.6 3.2 × 1.7 2 × 1.4 2.2 × 1.3 1.9 × 1.6 2.6 × 1.8 2 × 1.3 2.6 × 1.6 2.1 × 1.6 2.2 × 1.5 2 × 1.3 1.5 × 1.2 1.6 × 1.2 1.5 × 1.5 1.7 × 1.4 1.4 × 1.2 2×2 2 × 1.8 1.8 × 1.6 1.8 × 1.2 1.5 × 1.5 1.5 × 1.3 1.5 × 1.5 1.7 × 1.2 1.8 × 1.3
Radial side Ulnar side Ulnar side Radial side Ulnar side Radial side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Ulnar side Radial side Radial side Radial side Radial side Radial side Radial side Ulnar side Ulnar side Radial side Radial side Ulnar side Radial side Radial side Radial side Ulnar side
2.1 × 1.5 1.6 × 1.4 2.5 × 1.9 1.9 × 1.6 2 × 1.6 3.5 × 1.9 3.5 × 2 2.4 × 1.7 2.5 × 1.6 2.3 × 1.9 3×2 2.4 × 1.6 3×2 2.5 × 1.9 2.5 × 1.8 2.3 × 1.6 1.8 × 1.4 1.8 × 1.4 1.8 × 1.6 2 × 1.7 1.8 × 1.5 2.3 × 2.2 2.3 × 2 2.2 × 1.8 2.1 × 1.4 1.9 × 1.7 1.7 × 1.6 1.8 × 1.7 2 × 1.5 2.1 × 1.6
1644 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Reverse Digital Artery Island Flap discrimination test, we applied sufficient pressure to blanch the skin,12 and depressed the skin by no more than 1 mm.13 We also ensured that the stimuli were applied simultaneously and were of equal pressure.13 When performing the moving two-point discrimination test, we moved the testing device from a proximal to distal direction, parallel to the long axis of the finger.14 During the Semmes-Weinstein monofilament test, the monofilament was pressed perpendicular to the fingertip with sufficient pressure to bend it for 1.5 seconds. At 1 year postoperatively, the cold intolerance of the injured finger was measured via the self-administered Cold Intolerance Severity Score questionnaire.15 The maximum score was 100 and was grouped into four ranges, 0 to 25, 26 to 50, 51 to 75, and 76 to 100, which corresponded to mild, moderate, severe, and extreme severity, respectively. At 2 years postoperatively, the active range of motion of the proximal interphalangeal joint and the distal interphalangeal joint of the injured finger was measured with a goniometer.
OPERATIVE PROCEDURE The innervated reverse digital artery island flap using direct small branches of the proper
digital nerve was harvested from the lateral or ventrolateral skin of the homodigital proximal phalanx. A digital Allen test was performed on the injured digit to ascertain the roles of both proper digital arteries. For reconstruction of fingertip defects, the flap was harvested on the more injured side. In cases in which the defect was located in the center of the pulp, however, the donor flap was elevated on the ulnar side of the index, middle, and ring fingers, and on the radial side of the little finger. The skin incision of the flap was designed on the lateral or ventrolateral side of the proximal phalanx involved, according to the size and shape of the pulp defect. The skin incision was extended from the distal end of the donor flap to the injured fingertip. First, the proper digital nerve and its direct small branches were dissected and preserved (Fig. 1). Two or three branches that projected toward the donor flap were cut at the branching points from the proper digital nerve, preserving the proper digital nerve and dorsal branch of the nerve (Fig. 2). During dissection of the palmar proper digital artery, periarterial soft tissues were included in the vascular pedicle. The flap was then elevated and placed on top of the injured finger. Bilateral neurorrhaphy was performed, under a microscope
Fig. 1. The anatomy of the proper digital nerve (black arrow), its dorsal branch (green arrow), and superficial sensory nerve branch (red arrow). The green dotted line represents the skin incision of the flap.
Fig. 2. The direct small branches (white arrows) were included in the donor flap. We preserved the proper digital nerve (black arrow), its dorsal branch (green arrow), and superficial sensory nerve branch (red arrow). The yellow dotted lines represent the previous locations of the direct small branches.
1645 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2015 Table 2. Postoperative Assessments of the Reconstructed Fingers Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Injured Finger Middle Ring Index Little Middle Index Middle Ring Ring Index Index Middle Index Middle Ring Little Middle Ring Middle Ring Little Index Middle Ring Ring Index Middle Ring Little Ring
Static 2PD, mm
Moving 2PD, mm
SWM
CISS
6 8 6 7 5 6 6 7 5 6 5 7 5 7 5 5 6 5 6 5 6 6 5 6 7 7 5 6 6 5
5 7 6 6 4 6 5 6 5 5 4 5 4 6 5 4 5 4 5 5 5 5 4 5 6 6 5 5 4 4
3.84 4.08 3.61 4.08 3.84 3.84 3.84 4.08 3.61 3.61 3.22 4.17 3.61 4.17 3.84 3.84 4.17 3.61 3.84 3.61 3.61 3.84 3.61 3.84 4.08 3.84 3.84 3.61 3.84 3.22
36 44 22 20 18 20 18 16 24 22 24 18 16 16 8 24 20 18 18 20 24 18 18 14 8
ROM PIP Joint
ROM DIP Joint
105 100 105 105 115 110 105 100 110 100 110 100 110 105 110 110 105 110 105 110 95 110 110 105 100 110 115 110 105 110
65 55 70 65 70 65 70 70 75 60 70 60 70 65 70 70 65 60 65 65 65 70 60 65 55 70 70 65 65 65
2PD, two-point discrimination; SWM, Semmes-Weinstein monofilament test; CISS, Cold Intolerance Severity Score; ROM, range of motion; PIP, proximal interphalangeal joint; DIP, distal interphalangeal joint.
using 10-0 nylon microsutures, between one or two direct small branches and the ulnar digital nerve stump, and between the branches and the radial digital nerve stump. If the injured finger had unilateral digital nerve injury, the digital nerve on the injured side was coapted with one or two direct small branches of the proper digital nerve. The flap was then snugly sutured with 5-0 nylon. The donor defect was covered with a full-thickness skin graft. The turnover vascular base was also covered with a piece of skin graft to avoid vascular compromise.
RESULTS Thirty cases of pulp defects were successfully reconstructed with the reverse digital artery flap. In all of our cases, the flap was viable. With regard to complications, one case of venous congestion and one case of infection occurred. Venous congestion was improved by partial stitch removal, and infection was controlled after débridement. The average size of the donor flap was 3.9 cm2, with the smallest defect measuring 1.6 × 1.4 cm and the largest measuring 3.5 × 2 cm
(Table 1). At 6 months postoperatively, the average static two-point discrimination value was 5.9 mm (range, 5 to 8 mm), the average moving two-point discrimination value was 5.0 mm (range, 4 to 7 mm), and the average SemmesWeinstein monofilament score was 3.79 (range, 3.22 to 4.17) (Table 2). The average score on the Cold Intolerance Severity Score questionnaire15 was 20 (range, 8 to 44) 1 year postoperatively. The scores of 23 patients corresponded to mild cold intolerance, with two patients’ scores corresponding to moderate intolerance. At 2 years postoperatively, the average total active motion of the proximal interphalangeal joint was 107 degrees (range, 95 to 115 degrees) and that of the distal interphalangeal joint was 66 degrees (range, 55 to 75 degrees). All fingers in our series achieved excellent total active motion according to the criteria of Strickland and Glogovac16 for flexor tendon results.
CASE REPORT A 63-year-old man presented with amputation of the left middle fingertip (Fig. 3). To reconstruct the stump, an innervated reverse digital artery island flap was raised on the radial side. We
1646 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Reverse Digital Artery Island Flap DISCUSSION
Fig. 3. To cover the pulp defect, an innervated reverse digital artery island flap was designed on the radial side of the proximal phalanx. included the proper digital artery and the direct small branches of the proper digital nerve on the donor flap, preserving the proper digital nerve and dorsal branch of the nerve (Fig. 4). Two direct branches of the proper digital nerve were coapted with the distal ends of both radial and ulnar digital nerves, respectively (Fig. 5). The flap was then snugly sutured with 5-0 nylon (Fig. 6). The donor defect was covered with a full-thickness skin graft. No complications occurred during the early postoperative period. Six months postoperatively, static and moving two-point discriminations were 6 and 5 mm, respectively. Two years postoperatively, the finger showed an excellent range of active motion (Fig. 7).
Lai et al.9 suggested innervated reverse digital artery flap through bilateral neurorrhaphy for the reconstruction of fingertip injuries. This flap uses the dorsal branch of the proper digital nerve and the superficial sensory branch from the radial or ulnar nerve. Through neurorrhaphy, it can prevent neuroma formation from the injured digital nerve stumps. Although this is a good sensate flap for one-stage reconstruction of major pulp defects, it has several limitations, such as noticeable donor-site scarring and sensory loss on the dorsal side of the proximal and middle phalanges. The superficial sensory nerve branch innervates mainly the dorsal side of the proximal phalanx, and sensory restoration of the volar side of the donor flap cannot be expected when using this nerve.17 We devised this innervated reverse digital artery island flap to complement these drawbacks. As the donor flap is elevated on the lateral or ventrolateral side of the proximal phalanx, the scar is unnoticeable. As the small branches of the proper digital nerve directly innervate the donor flap, good sensory recovery can be expected. In a study in which authors used the innervated lateral middle phalangeal finger flap using those small branches of the proper digital nerve, static two-point discrimination values of approximately 6 mm were achieved.11 The anatomical constancy of the direct small branches of the proper digital nerve was also verified in
Fig. 4. (Left) We dissected the proper digital nerve and found direct small branches of the nerve. (Right) We preserved the proper digital nerve and the dorsal branch of the nerve.
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Plastic and Reconstructive Surgery • June 2015
Fig. 5. Epineural neurorrhaphy using two or three 10-0 nylon microsutures was performed between the direct small branches and both cut ends of the digital nerves.
Fig. 6. The donor flap was sutured to the defect and drains were inserted under the flap.
a previous anatomical study.10 In this cadaveric study, the thickness of the sensory branches of the proximal phalanx was similar to the diameter of the digital nerve at the distal interphalangeal joint. Furthermore, as we preserved the dorsal branch of the proper digital nerve, the sensitivity of the dorsal side of the middle phalanx could be maintained. In healthy young adults, the static two-point discrimination values of the fingertip were 2.6 and 2.5 mm in the long and little fingers,
respectively.13 In another study, the values were 2.5 mm in the index finger, and approximately 2 mm in the long, ring, and little fingers during the second decade of life.18 Those values increased, however, to approximately 5 mm in the index finger, and more than3 mm in the long, ring, and little fingers, during the eighth decade of life. Moving two-point discrimination values were less than the static two-point values,12 and the normal values of the moving two-point discrimination among individuals aged between 4 and 18 years were reported as between 2 and 4 mm.19 In a reverse digital artery flap without neurorrhaphy, the mean static and moving twopoint discrimination values in the flap were 6.5 and 3.5 mm, respectively7; however, the twopoint discrimination test was not performed in all patients in that study. In another study of the insensate reverse digital artery flap, the static two-point discrimination test values were between 6 and 10 mm in 10 of 13 fingers.20 In a study of the innervated reverse digital artery flap in which authors used the dorsal branch of the proper digital nerve and the superficial sensory nerve branch, the static two-point discrimination was 5 mm, and the moving two-point discrimination ranged from 2 to 3 mm.9 In a study by Takeishi et al.,21 the static two-point discrimination ranged from 3 to 5 mm and the Semmes-Weinstein test results ranged from 0.036 to 0.754 g after use of the innervated reverse dorsal digital island flap technique using the dorsal branch of the proper digital nerve or superficial sensory nerve branch. Han et al.22 reported that the mean values of the static twopoint discrimination test in sensate and insensate flaps were 6.2 and 10.2 mm, respectively. In the present study, the two-point discrimination and Semmes-Weinstein monofilament tests were not administered by an independent examiner. Therefore, there was a possibility of examiner bias. However, the two-point discrimination test has demonstrable reliability and reproducibility,23 and we made every effort to perform the tests objectively and consistently. Static two-point discrimination values ranged from 5 to 8 mm and moving two-point discrimination ranged from 4 to 7 mm, which were comparable to the results of previous studies. Lai et al.7 and Kojima et al.8 described a reverse pedicle homodigital flap for fingertip reconstruction. The arterial anatomical study of the distal phalanx revealed that three arcades (superficial arcade, proximal subungual arcade, and distal subungual arcade) were
1648 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 135, Number 6 • Reverse Digital Artery Island Flap
Fig. 7. (Left) The pulp of the long finger was well contoured postoperatively. (Center) There was no extension lag in the proximal or distal interphalangeal joint. (Right) Full flexion was possible in the interphalangeal joints of the long finger at 2 years after surgery.
interconnected and formed a particularly rich vascular bed in the nail bed and the terminal segment of the finger.24 These abundant anastomoses enabled the reverse digital artery flap to obtain sufficient blood supply in a retrograde direction. As the reverse digital artery flap sacrifices one of the digital arteries in a traumatized finger, cold intolerance can occur as a complication. Cold intolerance occurred in 41.6 percent of the patients in a previous study performed by Yildirim et al.25 Niranjan and Armstrong26 reported that nine patients (36 percent) complained of cold intolerance among 25 patients with homodigital reverse pedicle island flaps. In the present study, most patients had no or mild cold intolerance, and only two patients had a moderate degree of cold intolerance. Because the veins of the finger do not run along with the digital artery as venae comitantes, the tiny venules and capillaries embedded in the perivascular fat provide sufficient channels for venous drainage of the flap.27,28 Therefore, as much perivascular tissue as possible should be included to preserve these venules. The reverse digital artery flap is a single-stage reconstructive procedure, requires brief immobilization, and does not use other fingers as donor sites. Therefore, we can expect good functional results using this flap. In the present study, the percentage of total active motion was 99 percent at 2 years postoperatively. We began active finger motion exercises 2 weeks after the procedure, and patients were educated about the active and passive range-of-motion exercises of the interphalangeal
joints and the importance of the exercises at each follow-up visit.
CONCLUSIONS We experienced good surgical results after the innervated reverse digital artery island flap using direct small branches of the proper digital nerve. This is a single-stage procedure and does not sacrifice the proper digital nerve or dorsal branch of the nerve. This flap was cosmetically excellent because it used a donor flap most similar to the injured fingertip and the donor scar could be hidden by the adjacent fingers; however, several limitations remain. As the donor flap is elevated in the injured finger, there is a risk of flap failure if the whole proper digital artery is injured. Therefore, we should perform a digital Allen test before surgery. There is also a risk of cold intolerance because of the sacrifice of one digital artery. In addition, this flap requires delicate dissection and a great deal of microsurgical skill. Despite these disadvantages, the innervated reverse digital artery island flap using direct small branches of the proper digital nerve is a good surgical option for reconstruction of major pulp defects when sensory recovery is critical and other flaps are inappropriate. Young Ho Lee, M.D. Department of Orthopedic Surgery Seoul National University College of Medicine Seoul National University Hospital 101 Daehak-ro, Jongno-gu Seoul, 110–744, Korea [email protected]
1649 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2015
CODING PERSPECTIVE
cpt
This information provided by Dr. Raymond Janevicius is intended to provide coding guidance.
15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel 15240-51 Full-thickness skin graft 64831-51 Digital nerve repair 64832 Digital nerve repair, additional nerve 69990 Operating microscope • The reverse digital artery flap is an island flap and is reported with code 15740. • The first digital neurorrhaphy is reported with code 64831. • Additional digital neurorrhaphy is reported with code 64832. • The digital neurorrhaphy codes do not include use of the operating microscope. Report 69990 once per operative session for use of the operating microscope, even though it is used for each nerve. • 64832 and 69990 are add-on codes and do not take the multiple procedure modifier, 51. • The donor-site repair with full-thickness skin graft is described with code 15240. references 1. 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;52:921–926. 2. Shepard GH. The use of lateral V-Y advancement flaps for fingertip reconstruction. J Hand Surg Am. 1983;8:254–259. 3. Tempest MN. Cross-finger flaps in the treatment of injuries to the finger tip. Plast Reconstr Surg. (1946) 1952;9:205–222. 4. Dellon AL. The proximal inset thenar flap for fingertip reconstruction. Plast Reconstr Surg. 1983;72:698–704. 5. Grad JB, Beasley RW. Fingertip reconstruction. Hand Clin. 1985;1:667–676. 6. Weeks PM, Wray RC. Management of Acute Hand Injuries: A Biological Approach. 2nd ed. St Louis: Mosby Co.; 1973:140–143. 7. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg. 1989;22:495–500. 8. Kojima T, Tsuchida Y, Hirasé Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg. 1990;43:290–295.
9. Lai CS, Lin SD, Chou CK, Tsai CW. Innervated reverse digital artery flap through bilateral neurorrhaphy for pulp defects. Br J Plast Surg. 1993;46:483–488. 10. Kim J, Lee YH, Kim MB, Rhee SH, Baek GH. Anatomy of the direct small branches of the proper digital nerve of the fingers: A cadaveric study. J Plast Reconstr Aesthet Surg. 2014;67:1129–1135. 11. Lee YH, Baek GH, Gong HS, Lee SM, Chung MS. Innervated lateral middle phalangeal finger flap for a large pulp defect by bilateral neurorrhaphy. Plast Reconstr Surg. 2006;118:1185– 1193; discussion 1194. 12. Louis DS, Greene TL, Jacobson KE, Rasmussen C, Kolowich P, Goldstein SA. Evaluation of normal values for stationary and moving two-point discrimination in the hand. J Hand Surg Am. 1984;9:552–555. 13. Nolan MF. Two-point discrimination assessment in the upper limb in young adult men and women. Phys Ther. 1982;62:965–969. 14. Dellon AL. The moving two-point discrimination test: Clinical evaluation of the quickly adapting fiber/receptor system. J Hand Surg Am. 1978;3:474–481. 15. Irwin MS, Gilbert SE, Terenghi G, Smith RW, Green CJ. Cold intolerance following peripheral nerve injury: Natural history and factors predicting severity of symptoms. J Hand Surg Br. 1997;22:308–316. 16. Strickland JW, Glogovac SV. Digital function following flexor tendon repair in zone II: A comparison of immobilization and controlled passive motion techniques. J Hand Surg Am. 1980;5:537–543. 17. Bas H, Kleinert JM. Anatomic variations in sensory innervation of the hand and digits. J Hand Surg Am. 1999;24:1171–1184. 18. Gellis M, Pool R. Two-point discrimination distances in the normal hand and forearm: Application to various methods of fingertip reconstruction. Plast Reconstr Surg. 1977;59:57–63. 19. Hermann RP, Novak CB, Mackinnon SE. Establishing normal values of moving two-point discrimination in children and adolescents. Dev Med Child Neurol. 1996;38:255–261. 20. Sapp JW, Allen RJ, Dupin C. A reversed digital artery island flap for the treatment of fingertip injuries. J Hand Surg Am. 1993;18:528–534. 21. Takeishi M, Shinoda A, Sugiyama A, Ui K. Innervated reverse dorsal digital island flap for fingertip reconstruction. J Hand Surg Am. 2006;31:1094–1099. 22. Han SK, Lee BI, Kim WK. The reverse digital artery island flap: Clinical experience in 120 fingers. Plast Reconstr Surg. 1998;101:1006–1011; discussion 1012. 23. Dellon AL, Mackinnon SE, Crosby PM. Reliability of twopoint discrimination measurements. J Hand Surg Am. 1987;12(5 Pt 1):693–696. 24. Flint MH. Some observations on the vascular supply of the nail bed and terminal segments of the finger. Br J Plast Surg. 1955;8:186–195. 25. Yildirim S, Avci G, Akan M, Aköz T. Complications of the reverse homodigital island flap in fingertip reconstruction. Ann Plast Surg. 2002;48:586–592. 26. Niranjan NS, Armstrong JR. A homodigital reverse pedicle island flap in soft tissue reconstruction of the finger and the thumb. J Hand Surg Br. 1994;19:135–141. 27. Eaton RG. The digital neurovascular bundle: A microanatomic study of its contents. Clin Orthop Relat Res. 1968;61:176–185. 28. Lucas GL. The pattern of venous drainage of the digits. J Hand Surg Am. 1984;9:448–450.
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