Commentary Journal of Hand Surgery (European Volume) 2020, Vol. 45(8) 849–851 journals.sagepub.com/home/jhs
Commentary on: An ulnar parametacarpal perforator flap for volar digital soft tissue reconstruction. The parametacarpal perforator flap described by the authors represents an interesting alternative to the existing flaps. Through anatomical investigations, their study demonstrates the reliability of the flap in terms of number and location of nourishing perforator arteries. The versatility of the flap is confirmed by a copious number of schematic and case series figures that allow one to understand the indications and easily replicate the harvesting. The donor site morbidity is minimal, and the skin texture is perfect for fingertip reconstructions. The reported sensory recovery and time for return to work are impressive, making this flap a promising new method. This flap shows its greatest potential when pedicled. For instance, the volar surface of the small finger is usually difficult to reconstruct with a sensate flap, particularly in face of an extensive defect. In Europe, these tissue defects are mainly treated with pedicle flaps (Figures 1 and 2). The reliability, ease of harvesting and minimal resource requirement for local pedicle flaps are factors that make pedicle flaps the first choice. Free flap procedures are not commonly used for resurfacing digital pulp loss outside of Asia, especially when the thumb is not involved and the skin defect does not exceed 3 3 cm in size, although pedicle flaps are also the workhorse flaps in some Asian countries (Lim et al., 2019). Toepulp flaps, or other similar free flaps employed for fingertip reconstruction, are more popular in Asia, principally in China, Korea and Japan (Chen et al., 2019; Omokawa, 2019) than in Europe where patients are reluctant to donate tissue from the foot to reconstruct fingertip injuries. The treatment of skin and subcutaneous tissue loss of the fingertips continues to be a matter of discussion among hand surgeons. The challenge is represented by the search for a reliable flap that holds similar features of the defect area in terms of skin texture, sensibility and thickness. In volar fingertip defects, restoring
sensation and pinch function are mandatory. Several techniques have been described in recent years, which can be divided into three groups: local flaps, free flaps, and artificial skin and dermal templates. Many local flaps have been reported using different types of homodigital pedicle flaps (Tang et al., 2014), in most cases with direct flow vascularization. This approach can cover skin defects up to 3 2.5 cm, obtaining good recovery of the sensibility and following the concept of ‘like with like reconstruction’. If the defect is larger, it is necessary to employ other methods, such as heterodigital island flap or free flaps. Moist antiseptic dressings, to allow healing through self-regeneration, or dermal regeneration template, to allow growth of granulation tissues covering exposed bone with or without skin graft, represent another option. These methods are useful when patients refuse the option of coverage with a flap and when the patient requests a prompt return to work (Elliot et al., 2018; Tang, 2019). Fingertip injuries are increasingly being treated with transparent, semi occlusive and other dressings. This method has been evolving and is becoming more specific for different types of exposure (Lam and Jordan, 2019; Tos and Adani, 2019). It reduces donor site morbidity, surgery time and costs. However, we believe it cannot replace reconstructive surgery with flaps entirely. Questions remain: dermal regeneration template or flaps? When should flaps be employed? Is it really necessary to use microsurgical flaps for fingertip injuries? I would like to congratulate the authors and confirm the high level of microsurgical reconstruction skills achieved in Asia. However, fingertip or thumb tip repair are not areas with simpler, reliable and effective treatment. Though I cannot represent all hand surgeons in Europe, I believe most of them would choose a local pedicle flap as their first reconstructive choice. A microsurgical free flap transfer adds technical difficulties without a commensurate gain in outcome. The current trend in digital tip repair is to minimize donor site morbidity if there is a donor at all, and this is trending opposite from using a more technically demanding procedure.
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Journal of Hand Surgery (Eur) 45(8)
Figure 1. (a) A large pulp defect of the little finger is commonly treated with a pedicle flap. (b) Homodigital neurovascular pedicle flap with direct flow vascularization. (c) The result 2 months after surgery.
Figure 2. (a) Pulp loss of the thumb treated with a pedicle flap. (b) Palmar neurovascular pedicle flap. (c) The result 5 months after surgery.
Adani References Chen C, Wang ZT, Hao LW, Liu Y, Liu HL. Vascularized flap transfer to fingers with volar digital veins as recipient vessels. J Hand Surg Eur. 2019, 44: 1019–25. Elliot D, Adani R, Woo SH, Tang JB. Repair of soft tissue defects in finger, thumb and forearm. Less invasive methods with similar outcomes. J Hand Surg Eur. 2018, 43: 1019–29. Lam WL, Jordan D. Management of fingertip injuries in Scotland and United Kingdom. J Hand Surg Eur. 2019, 44: 1102–4. Lim JX, Chong AKS, Sebastin SJ. Maximal advancement of homodigital neurovascular island flaps. J Hand Surg Eur. 2019, 44: 1008–12. Omokawa S. Favoured treatments for fingertip defects and finger amputation distal to the distal interphalangeal joint in my unit and in Japan. J Hand Surg Eur. 2019, 44: 1101–2. Tang JB, Elliot D, Adani R, Saint-Cyr M, Stang F. Repair and reconstruction of thumb and fingertip injuries: a global view. Clin Plast Surg. 2014, 41: 325–59.
851 Tang JB. Fingertip repair methods. Choices for different fingers and sides emphasizing sensation. J Hand Surg Eur. 2019, 44: 1109–11. Tos P, Adani R. Finger amputations and pulp defects distal to the distal interphalangeal joint. J Hand Surg Eur. 2019, 44: 1105–6.
Roberto Adani Department of Hand and Microsurgery University Hospital Modena, Modena, Italy Email: [email protected]
ß The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions doi: 10.1177/1753193420952027 available online at http://jhs.sagepub.com
Commentary on: An ulnar parametacarpal perforator flap for volar digital soft tissue reconstruction. The parametacarpal perforator flap described by the authors represents an interesting alternative to the existing flaps. Through anatomical investigations, their study demonstrates the reliability of the flap in terms of number and location of nourishing perforator arteries. The versatility of the flap is confirmed by a copious number of schematic and case series figures that allow one to understand the indications and easily replicate the harvesting. The donor site morbidity is minimal, and the skin texture is perfect for fingertip reconstructions. The reported sensory recovery and time for return to work are impressive, making this flap a promising new method. This flap shows its greatest potential when pedicled. For instance, the volar surface of the small finger is usually difficult to reconstruct with a sensate flap, particularly in face of an extensive defect. In Europe, these tissue defects are mainly treated with pedicle flaps (Figures 1 and 2). The reliability, ease of harvesting and minimal resource requirement for local pedicle flaps are factors that make pedicle flaps the first choice. Free flap procedures are not commonly used for resurfacing digital pulp loss outside of Asia, especially when the thumb is not involved and the skin defect does not exceed 3 3 cm in size, although pedicle flaps are also the workhorse flaps in some Asian countries (Lim et al., 2019). Toepulp flaps, or other similar free flaps employed for fingertip reconstruction, are more popular in Asia, principally in China, Korea and Japan (Chen et al., 2019; Omokawa, 2019) than in Europe where patients are reluctant to donate tissue from the foot to reconstruct fingertip injuries. The treatment of skin and subcutaneous tissue loss of the fingertips continues to be a matter of discussion among hand surgeons. The challenge is represented by the search for a reliable flap that holds similar features of the defect area in terms of skin texture, sensibility and thickness. In volar fingertip defects, restoring
sensation and pinch function are mandatory. Several techniques have been described in recent years, which can be divided into three groups: local flaps, free flaps, and artificial skin and dermal templates. Many local flaps have been reported using different types of homodigital pedicle flaps (Tang et al., 2014), in most cases with direct flow vascularization. This approach can cover skin defects up to 3 2.5 cm, obtaining good recovery of the sensibility and following the concept of ‘like with like reconstruction’. If the defect is larger, it is necessary to employ other methods, such as heterodigital island flap or free flaps. Moist antiseptic dressings, to allow healing through self-regeneration, or dermal regeneration template, to allow growth of granulation tissues covering exposed bone with or without skin graft, represent another option. These methods are useful when patients refuse the option of coverage with a flap and when the patient requests a prompt return to work (Elliot et al., 2018; Tang, 2019). Fingertip injuries are increasingly being treated with transparent, semi occlusive and other dressings. This method has been evolving and is becoming more specific for different types of exposure (Lam and Jordan, 2019; Tos and Adani, 2019). It reduces donor site morbidity, surgery time and costs. However, we believe it cannot replace reconstructive surgery with flaps entirely. Questions remain: dermal regeneration template or flaps? When should flaps be employed? Is it really necessary to use microsurgical flaps for fingertip injuries? I would like to congratulate the authors and confirm the high level of microsurgical reconstruction skills achieved in Asia. However, fingertip or thumb tip repair are not areas with simpler, reliable and effective treatment. Though I cannot represent all hand surgeons in Europe, I believe most of them would choose a local pedicle flap as their first reconstructive choice. A microsurgical free flap transfer adds technical difficulties without a commensurate gain in outcome. The current trend in digital tip repair is to minimize donor site morbidity if there is a donor at all, and this is trending opposite from using a more technically demanding procedure.
850
Journal of Hand Surgery (Eur) 45(8)
Figure 1. (a) A large pulp defect of the little finger is commonly treated with a pedicle flap. (b) Homodigital neurovascular pedicle flap with direct flow vascularization. (c) The result 2 months after surgery.
Figure 2. (a) Pulp loss of the thumb treated with a pedicle flap. (b) Palmar neurovascular pedicle flap. (c) The result 5 months after surgery.
Adani References Chen C, Wang ZT, Hao LW, Liu Y, Liu HL. Vascularized flap transfer to fingers with volar digital veins as recipient vessels. J Hand Surg Eur. 2019, 44: 1019–25. Elliot D, Adani R, Woo SH, Tang JB. Repair of soft tissue defects in finger, thumb and forearm. Less invasive methods with similar outcomes. J Hand Surg Eur. 2018, 43: 1019–29. Lam WL, Jordan D. Management of fingertip injuries in Scotland and United Kingdom. J Hand Surg Eur. 2019, 44: 1102–4. Lim JX, Chong AKS, Sebastin SJ. Maximal advancement of homodigital neurovascular island flaps. J Hand Surg Eur. 2019, 44: 1008–12. Omokawa S. Favoured treatments for fingertip defects and finger amputation distal to the distal interphalangeal joint in my unit and in Japan. J Hand Surg Eur. 2019, 44: 1101–2. Tang JB, Elliot D, Adani R, Saint-Cyr M, Stang F. Repair and reconstruction of thumb and fingertip injuries: a global view. Clin Plast Surg. 2014, 41: 325–59.
851 Tang JB. Fingertip repair methods. Choices for different fingers and sides emphasizing sensation. J Hand Surg Eur. 2019, 44: 1109–11. Tos P, Adani R. Finger amputations and pulp defects distal to the distal interphalangeal joint. J Hand Surg Eur. 2019, 44: 1105–6.
Roberto Adani Department of Hand and Microsurgery University Hospital Modena, Modena, Italy Email: [email protected]
ß The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions doi: 10.1177/1753193420952027 available online at http://jhs.sagepub.com
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