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Hand Surgery, Vol. 20, No. 1 (2015) 133–136 © World Scientific Publishing Company DOI: 10.1142/S0218810415500197

POSTOPERATIVE VOLUMINAL FLAP REDUCTION AFTER FINGERTIP RECONSTRUCTION USING THE REVERSE DIGITAL ARTERY ISLAND FLAP Satoshi Usami,* Satoshi Kodaira,† Tsutomu Homma* and Mutsumi Okazaki* *Department

of Plastic and Reconstructive Surgery Graduate School of Science, Tokyo Medical and Dental University 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan †

Department of Plastic and Reconstructive Surgery Saitama Hand Surgery Institute, Saitama Seikeikai Hospital 1721, Ishibashi Higashimatsuyama Saitama 355-0072, Japan Received 19 May 2014; Revised 8 September 2014; Accepted 8 September 2014; Published 20 January 2015 ABSTRACT A total of 16 fingers of 16 patients were subjected to fingertip reconstruction using the reverse digital artery island flap (RDAIF). We evaluated the influences of postoperative flap congestion, initial harvested flap size, patient’s age and smoking habit on postoperative final flap size and postoperative range of total active motion (TAM) in affected fingers at a mean interval of 11.4 months. In the results, final flap size and TAM showed a tendency to decrease with increase in the initial harvested flap size and age. Eventually, the final flap size moved towards the size of the fingertip defect. Factors of flap congestion and smoking habit had little influence on the change in flap size and TAM. In conclusion, wide harvested flaps showed significant postoperative reduction in size compared with the small flaps, and extensive skin defect after flap harvest caused a decrease in postoperative TAM. Thus, the size of the harvested RDAIF should be comparable to that of the fingertip defect to prevent postoperative decrease in range of motion in affected fingers, and indication of this flap to the elderly needs to be considered. Keywords: Flap Reduction; Flap Atrophy; Reverse Flap; Fingertip Reconstruction.

INTRODUCTION

Replanted fingers with severe congestion tend to be atrophic compared with other replanted fingers that have uneventful postoperative courses.6 We think that the same phenomenon might occur in a reverse flow flap such as a RDAIF with postoperative long-term congestion. The volume of the fingertip volar soft tissue affects the pressure applied to the pinch grip and tactile sensitivity7; thus, postoperative soft tissue volume is quite important in fingertip reconstruction. To our knowledge, there is

Reverse digital artery island flap (RDAIF) is a very useful procedure for fingertip reconstruction,1–3 but postoperative complications such as flap congestion, joint and scar contracture, sensory disturbance and cold intolerance have been reported.3–5 In particular, early flap congestion after flap fixation, which is a characteristic of reverse blood flow flap often bothers surgeons.

Correspondence to: Dr. Satoshi Usami, Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. Tel: (þ81) 3-5803-5923, Fax: (þ81) 3-5803-0218, E-mail: [email protected] 133

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no report of any study on reverse island flap voluminal reduction after fingertip reconstruction. In this paper, we compared the intra and postoperative flap volumes of RDAIF, and studied the influences of postoperative flap congestion, initial harvested flap size, age and smoking habit on the final flap size and postoperative range of active motion of affected fingers.

PATIENTS AND METHODS A total of 16 fingers of 16 patients were subjected to fingertip reconstructive surgeries with RDAIF from September 2008 to August 2013 (Table 1) in a single institution where the corresponding author belongs. This study was approved by the Ethical Review Board of the author’s institution and the patients gave their consent. Affected fingers included six index, seven middle, and three ring fingers. Patients were followed-up over 6 months. We measured the size of the fingertip defect, the size of the harvested flap, and the size of the final flap over 6 months postoperatively. We defined \flap reduction rate" as the size of the final flap/initial harvested flap. As this flap was very thin with slight fat, we used the flap area to estimate flap volume. In measurement of flap area, we assumed that the shape of the RDAIF was a symmetrical ellipse to conveniently Table 1

Fig. 1

Design of the RDAIF and approximation of the flap size.

measure only the major and minor axes (Fig. 1), because we designed most RDAIFs as a circle or ellipse. The procedure of flap elevation followed those described by Kojima et al.1 and Lai et al.2 Briefly, the flap was designed at the lateral aspect of the damaged finger, and the required flap size was slightly larger than the defect size in most cases. The neurovascular bundle was found at the proximal phalangeal level, and the flap was raised with the digital artery but preserving the digital nerve with the finger. Harvested flap was turned 180  at the pivot point, which was located at the

Summary of Cases of the RDAIF.

Harvested Final Flap Flap Flap Size Size Defect Size Reduction TAM Follow-Up Age Case (Years Old) Gender #1 Finger #2 Smoking DM (Months) Congestion (cm  cm) #3 (cm  cm) #3 (cm  cm) #3 Rate (%) (  ) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

29 29 70 27 44 53 56 60 62 31 38 47 80 51 25 18

M F M M F F M F M F M M M M M M

R middle L index L index R ring L index L index R ring L middle L middle R middle R index L middle R index R ring R middle L middle

  þ þ   þ þ   þ þ þ þ  

      þ         

6 6 13 16 23 13 15 12 8 6 24 11 12 6 6 6

None Mild Severe Mild Mild Mild Mild Mild None Severe None None Severe Severe None Mild

3:0  2:5 2 82 0 2:5  2:5 1:2  1:2 1:3  1:1 2:0  1:5 2:2  1:8 2:5  2:2 2:0  2:0 1:5  1:0 2:0  1:7 2:1  1:7 2:6  2:5 2:5  2:0 2:0  1:6 2:4  2:0

3:3  2:5 3:0  2:5 3:0  2:5 1:4  1:4 1:6  1:4 2:0  1:5 2:2  2:2 2:8  2:3 2:5  2:0 1:5  1:0 2:2  1:7 2:3  1:7 3:0  2:6 2:8  2:0 2:5  1:6 2:6  2:2

2:9  23 2 8  2:1 2:6  2:1 1:3  1:1 1:6  1:2 1:9  1:3 2:1  1:7 2:3  2:1 2:3  2:0 1:5  1:0 2:2  1:7 2:1  1:7 2:5  2:2 2:4  2:0 2:0  1:6 2:5  2:2

80.8 78.4 72.8 73 85.7 82.3 73.8 75 92 100 100 91.3 70.5 85.7 80 96.2

205 200 185 235 200 185 160 150 225 230 190 260 175 175 245 205

Note: TAM: Total active motion (MP þ PIP þ DIP joints); DM: Diabetes mellitus; #1: M ¼ male, F ¼ female; #2: R ¼ right, L ¼ left; #3: Product of the major and minor axes of the flaps.

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Flap Reduction of Reverse Digital Artery Island Flap

mid-middle phalangeal level, so that the flap will reach the fingertip defect. To prevent flap congestion, six flaps were harvested together with a thin skin pedicle (case 11–16), and the other flaps had no skin pedicle. In many cases, skin grafts were applied to cover the tissue defect after harvesting the flap from the hypothenar (cases 2, 3), arch of a foot (5, 7), cubital fossa (8, 9, 11) and forearm (10, 12–16). The defect of case 1 was covered with a dorsal metacarpal artery flap, and relatively small defects (cases 4, 6) were sutured. When the flap became congested, we took measures to decrease flap congestion. If the flap congestion was \severe", we performed bloodletting like phlebotomy via a small incision or used the medicinal leeches method. If the flap congestion was \none or mild", a wait-and-see approach was adopted. Eventually, we defined the cases that were treated with invasive bloodletting as \severe" and the other cases that did not require an invasive procedure as \none or mild". We assessed the influences of some factors (harvested flap size, congestion, age, finger, smoking and diabetes mellitus) on flap reduction rate and total active motion (TAM: the total arc of active motion of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints of the affected fingers). First, we evaluated the influence of the type of finger using the Steel–Dwass method for multiple comparisons. Then, we conducted multivariate analysis. Specifically, we used multiple regression analysis with stepwise method, that is, flap reduction rate and TAM were set as objective variables, and harvested flap size, congestion, age and smoking were set as explanatory variables. There was only one patient with diabetes mellitus, and was excluded from the factors of the explanatory variables. Statistical analyses and modellings were performed using JMP r 10 (SAS Institute Inc., Cary, NC, USA).

RESULTS All the flaps survived. Among these flaps, three flaps (cases 6, 13, 14) showed partial necrosis at the distal portion, but was cured with conservative therapy. The mean follow-up period was 11.4 months (range 6–24 months). Disappearance of postoperative flap congestion occurred in a mean period of 3.1 days (range 0– 7 days). Four flaps had severe congestion (cases 3, 10, 13, 14), which resolved in a mean period of 5.3 days (range, 4–7 days), while it resolved in a mean period of 4 days (range 2–6 days) for flaps with mild congestion. The mean ratio of harvested flap size/fingertip skin defect size was 119.8% (100–156.6%). Mean flap reduction rate was 82.8% (70.5–100%) (Table 1).

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Table 2 Comparison of Flap Reduction Rate and TAM Among the Finger Groups. Finger Index N =6 Mean  SD Age (Years Old) Harvested Flap Size (cm 2 ) #1 Flap Reduction Rate (%) TAM (  )

Middle N =7 Mean  SD

Ring N =3 Mean  SD

52:3  19:5 38:9  17:5 44:7  15:5 5:30  2:57 4:97  2:14 4:13  1:92

N.S. #2 N.S. #2

81:6  10:6 189:2  9:7

87:9  9:3

77:5  7:1

N.S. #2

2171  35:7

190  39:7

N.S. #2

Note: SD: Standard deviation; #1: Product of the major and minor axes of the flaps; #2: There were no significant differences among the three finger groups.

Table 3 Influences of Initial Harvested Flap Size and Patient’s Age on Postoperative Flap Reduction Rate and TAM. Objective Variable

Explanatory Variable

p-Value

R2

Flap reduction rate

Harvested flap size Age Harvested flap size Age

0.02 0.15 0.17 0.006

0.327 0.429 0.511 0.432

TAM

Note: Statistical analysis was performed using multiple regression analysis with the stepwise method.

There was no significant difference in flap reduction rate and TAM among the finger groups (Table 2). With regards to flap reduction rate, harvested flap size and age were influential factors (harvested flap size; p < 0:05, age; p ¼ 0:15). With regards to TAM, harvested flap size and age were also influential (harvested flap size; p ¼ 0:17, age; p < 0:05) (Table 3). Factors of flap congestion and smoking had little influence on flap reduction rate and TAM. In conclusion, flap reduction rate and TAM showed a tendency to decrease with increase in the initial harvested flap size and age. In other words, wide harvested flaps had significant postoperative reduction in size compared with small flaps, and wide skin defects after flap harvest may cause a decrease in postoperative TAM.

DISCUSSION It is important to elevate the flap with an appropriate volume to match the defect size. There is, however, a broad consensus that the size of the transferred flap will be reduced in many

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cases.8–11 We suggest that accurate estimation of the appropriate volume for the flap is important for preventing donor site complications. Donor site complications such as skin scar formation, joint contracture, numbness or hypersensitivity of the elevated side of the flap in RDAIF have been reported.3–5 In our study, TAM showed a tendency to decrease with increase in the size of the skin defect and age. In particular, cases where the boundaries of the skin graft exceeded the proximal interphalangeal joint were susceptible to joint or skin contracture. Thus, elevation of the RDAIF with an appropriate size is important for postoperative range of motion by preventing postoperative joint contracture or scar formation. The rate of flap volume reduction after surgery differs according to the kind of flap tissue.10 Flaps consisting of muscle tissue tend to undergo the greatest reduction in size compared with other tissue flaps,11 because the transferred muscle tissue rarely contracts as muscle innervation is interrupted.8,9,12 In addition, fasciocutaneous and fat flaps were reported to be reduced in the same way.9,10 According to the flap volume study between intra and postoperative fat volume after free flap transfer using magnetic resonance imaging, postoperative fat flap decreased to 80.1% in flap thickness,10 and 85.5% in flap volume.11 With respect to vascularized fat flaps in rat model, they reduced in weight by about 44% due to apoptosis, necrosis, denervation or direct damage during surgery.13 The present study shows that elevated flaps that are slightly larger than the size of the fingertip defect (119.8%) tended to decrease in volume and approach the size of the fingertip defect (98.4%). This tendency may be attributed to the rigid anchoring of the fingertip skin to the periosteum of the distal phalanx through the ligament and tendon or thick skin.14,15 That is, we expect that the fixed power of fingertip skin around the defect exceeded the tension of flap contraction after the operation. So the flap transfer to the fingertip would be almost the same size as the tissue defect in the long-term. Moreover, the present study showed that there was no significant difference in the rate of flap reduction between none/mild and severe congestive flaps. As reasons of this result, we think that RDAIF is insulated from the influence of congestion because it is very small and a thin flap with slight fat tissue. In summary, the size of RDAIF tended to reach the fingertip defect size regardless of the size of the harvested flap. Therefore, we believe that the size of the RDAIF should be comparable to the size of the fingertip defect to prevent postoperative decrease in range of active motion of affected fingers, and we need to consider

indicating this flap for the elderly who tend to experience loss of the angle of active motion in postoperative affected fingers.

ACKNOWLEDGEMENTS We would like to thank Masako Akiyama for valuable comments and assistance in statistical calculations on this paper.

References 1. Kojima T, Tsuchida Y, Hirase Y, Endo T, Reverse vascular pedicle digital island flap, Br J Plast Surg 43:290–295, 1990. 2. Lai CS, Lin SD, Yang CC, The reverse digital artery flap for fingertip reconstruction, Ann Plast Surg 22:495–500, 1989. 3. Usami S, Kawahara S, Yamaguchi T, Hirase Y, Homodigital artery flap reconstruction for fingertip amputation: A comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap, J Hand Surg [Eur] 2013 [Epub ahead of print]. 4. Yildirim S, Avci G, Akan M, Ak€oz T, Complications of the reverse homodigital island flap in fingertip reconstruction, Ann Plast Surg 48:586–592, 2002. 5. Huang YC, Liu Y, Chen TH, Use of homodigital reverse island flaps for distal digital reconstruction, J Trauma 68:429–433, 2010. 6. Hahn HO, Jung SG, Results of replantation of amputated fingertips in 450 patients, J Reconstr Microsurg 22:407–413, 2006. 7. Murai M, Lau HK, Pereira BP, Pho RW, A cadaver study on volume and surface area of the fingertip, J Hand Surg [Am] 22:935–941, 1997. 8. Wolff KD, Stiller D, Functional aspects of free muscle transplantation: Atrophy, reinnervation, and metabolism, J Reconstr Microsurg 8:137– 142, 1992. 9. Baker SR, Microvascular free flaps in soft-tissue augmentation of the head and neck, Arch Otolaryngol Head Neck Surg 112:733–737, 1986. 10. Fujioka M, Masuda K, Imamura Y, Fatty tissue atrophy of free flap used for head and neck reconstruction, Microsurgery 31:32–35, 2011. 11. Sakamoto Y, Takahara T, Ota Y, Aoki T, Yamazaki H, Otsuru M, Takahashi M, Aoyama K, Kaneko A, Kawada S, Ichikawa T, Imagawa K, Miyasaka M, MRI analysis of chronological changes in free-flap volume in head and neck reconstruction by volumetry, Tokai J Exp Clin Med 39:44–50, 2014. 12. Zhang F, Lineaweaver WC, Ustüner T, Kao SD, Tonken HP, CampagnaPinto D, Buncke HJ, Comparison of muscle mass preservation in denervated muscle and transplanted muscle flaps after motor and sensory reinnervation and neurotization, Plast Reconstr Surg 99:803–814, 1997. 13. Oashi K, Furukawa H, Akita S, Nakashima M, Matsuda K, Oyama A, Funayama E, Hayashi T, Hirano A, Yamamoto Y, Vascularised fat flaps lose 44% of their weight 24 weeks after transplantation, J Plast Reconstr Aesthet Surg 65:1403–1409, 2012. 14. Shrewsbury M, Johnson RK, The fascia of the distal phalanx, J Bone Joint Surg [Am] 57:784–788, 1975. 15. de-Ary-Pires B, Valdez CF, Shecaira AP, de Ary-Pires R, Ary Pires-Neto M, Cleland’s and Grayson’s ligaments of the hand: A morphometrical investigation, Clin Anat 20:68–76, 2007.

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

A total of 16 fingers of 16 patients were subjected to fingertip reconstruction using the reverse digital artery island flap (RDAIF). We evaluated the...
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