LETTERS TO THE EDITOR
Regarding “Fingertip Reconstruction With Simultaneous Flaps and Nail Bed Grafts Following Amputation” To the Editor: An option for fingertip reconstruction is a flap with perionychial full-thickness graft.1 Mantero described this technique in 1973, although his article was not widely recognized because it was not indexed in Index Medicus.2 We then described the technique in 1999,3 and Sabapathy did so in 2002.4 I use this technique when the patient brings the amputated tip. Composite fingertip grafts and fingertip replantation have high failure rates. Crush injury (often accompanying fingertip amputations) may preclude replantation, but perionychial tissues can be used as full-thickness grafts. Replantation cost is also high. Perionychial tissues—hyponychium, paronychium,
sterile matrix—cannot be reconstructed and these tissues may be further lost if replantation or wholetip composite graft were to fail. Germinal matrix and eponychial composite grafts, by contrast, have poor success rates. I agree this is a useful technique for distal fingertip amputations where germinal matrix remains. Late hook nail is minimized by soft tissue bulk provided by generous flaps. Large homodigital (retrograde or anterograde) flaps avoid distal donor sites, provide fingertip sensation, and avoid striking color mismatch, even for volar oblique amputations.5 The authors imply that soft tissue flap bulk alone prevents long-term hook nail, even with bone loss.
FIGURE 1: A Bone deficiency and hook nail deformity after initial secondary healing. B Scar release, nailbed elevation (antenna procedure), and large neurovascular flap advancement. C Improved nail appearance with additional volar pulp soft tissue but still with some residual deformity.
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
171
172
LETTERS TO THE EDITOR
Nail curvature cannot be totally avoided if there is substantial bone loss. I replace and fix bone from the amputated part if it is large. Treatment of late hooknail deformity is not fully reversed by thorough scar release and provision of soft tissue bulk alone (Fig. 1).6 Some have added bone by distraction7 or delayed bone grafting, but resorption is a problem. Even the more severe Allen classification injuries illustrated by Hwang et al1 have bone support. Their Figure 4 represents a dorsal oblique injury, and their Figure 6 shows a degloving injury. I write for 3 reasons—first, for historical perspective; second, to emphasize that large neurovascular advancement or retrograde island flaps avoid problems of color mismatch, distant donor sites, and inadequate tip sensation even for volar oblique amputations; finally, to stress the importance of nailbed support provided by the distal phalanx.
6. Dumontier C, Gilbert A, Tuviana R. Hook-nail deformity. Surgical treatment with a homodigital advancement flap. J Hand Surg Br. 1996;20(6):830e835. 7. Lee Y, Kwon S, Ko K. Correction of crooked nail deformity by modified osteoplastic reconstruction. Ann Plast Surg. 2000;45(3): 264e268.
In Reply: Thank you for your interest in our article. We appreciate learning that the concept of fingertip reconstruction using a flap and perionychial tissue was proposed by Mantero in 1973. We agree that large neurovascular advancement or retrograde island flaps can avoid color mismatch and can add comfort by not using a distant flap. However, a neurovascular advancement flap can tether the perionychial tissue, which increases the possibility of the hook-nail deformity. A retrograde island flap usually cannot provide enough bulk for the reconstruction of volar side of an amputated fingertip despite sufficient pedicle length. Furthermore, both flaps can produce the unwanted scarring on the entire remnant finger. Phalangeal support is the best option to prevent the hook deformity, but unlike others, we did not replace and fix any fractured bony fragment to the remnant phalanx. Instead, we debrided tiny floating bone chips and tried to elevate as large a flap as possible and perform tight fixation of the flap to lateral edge of the remnant finger part to avoid tension on the nailbed graft. In addition, we made an effort to mold a reconstructed finger to prevent the hook-nail deformity after surgery. We believe that the hook-nail deformity can be minimized by tension-free fixation of the flap and the postoperative molding, even in situations in which there is no phalangeal support of the reconstructed part of the fingertip.
David T. Netscher, MD Division of Plastic Surgery and Department of Orthopedic Surgery Baylor College of Medicine, Houston, TX and the Department of Surgery Weill Medical College Cornell University Ithaca, NY http://dx.doi.org/10.1016/j.jhsa.2013.10.032 REFERENCES 1. Hwang E, Park BH, Song SY, Jung HS, Kim CH. Fingertip reconstruction with simultaneous flaps and nail bed grafts following amputation. J Hand Surg Am. 2013;38(7):1307e1314. 2. Netscher DT. Repair of fingertip amputations with local digital flaps and perionychial composite grafts from the amputated part [letter]. Plast Reconstr Surg. 2005;115(4):1217e1218. 3. Netscher DT, Meade RA. Reconstruction of fingertip amputations with full-thickness perionychial grafts from the retained part and local flaps. Plast Reconstr Surg. 1999;104(6):1705e1712. 4. Sabapathy RS, Venkatramani H, Bharathi R, Jayachandran S. Reconstruction of finger tip amputations with advancement flap and free nail bed graft. J Hand Surg Br. 2002;27(2):134e138. 5. Foucher G, Khouri RK. Digital reconstruction with island flaps. Clin Plast Surg. 1997;24(1):1e32.
Euna Hwang, MD Department of Plastic and Reconstructive Surgery Bundang CHA Medical Center CHA University Seongnam, South Korea http://dx.doi.org/10.1016/j.jhsa.2013.11.027
Increased Prevalence of Ganglion Formation Among Patients With Wrist Hyperlaxity excellent paper demonstrating high prevalence of dorsal wrist ganglions among patients with ligamentous hyperlaxity. I could not agree more with their conclusions.
To the Editor: I read with great interest the article entitled “Ligamentous Hyperlaxity and Dorsal Wrist Ganglions” by K. E. McKeon et al.1 It is, indeed, an J Hand Surg Am.
r
Vol. 39, January 2014
Regarding “Fingertip Reconstruction With Simultaneous Flaps and Nail Bed Grafts Following Amputation” To the Editor: An option for fingertip reconstruction is a flap with perionychial full-thickness graft.1 Mantero described this technique in 1973, although his article was not widely recognized because it was not indexed in Index Medicus.2 We then described the technique in 1999,3 and Sabapathy did so in 2002.4 I use this technique when the patient brings the amputated tip. Composite fingertip grafts and fingertip replantation have high failure rates. Crush injury (often accompanying fingertip amputations) may preclude replantation, but perionychial tissues can be used as full-thickness grafts. Replantation cost is also high. Perionychial tissues—hyponychium, paronychium,
sterile matrix—cannot be reconstructed and these tissues may be further lost if replantation or wholetip composite graft were to fail. Germinal matrix and eponychial composite grafts, by contrast, have poor success rates. I agree this is a useful technique for distal fingertip amputations where germinal matrix remains. Late hook nail is minimized by soft tissue bulk provided by generous flaps. Large homodigital (retrograde or anterograde) flaps avoid distal donor sites, provide fingertip sensation, and avoid striking color mismatch, even for volar oblique amputations.5 The authors imply that soft tissue flap bulk alone prevents long-term hook nail, even with bone loss.
FIGURE 1: A Bone deficiency and hook nail deformity after initial secondary healing. B Scar release, nailbed elevation (antenna procedure), and large neurovascular flap advancement. C Improved nail appearance with additional volar pulp soft tissue but still with some residual deformity.
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
171
172
LETTERS TO THE EDITOR
Nail curvature cannot be totally avoided if there is substantial bone loss. I replace and fix bone from the amputated part if it is large. Treatment of late hooknail deformity is not fully reversed by thorough scar release and provision of soft tissue bulk alone (Fig. 1).6 Some have added bone by distraction7 or delayed bone grafting, but resorption is a problem. Even the more severe Allen classification injuries illustrated by Hwang et al1 have bone support. Their Figure 4 represents a dorsal oblique injury, and their Figure 6 shows a degloving injury. I write for 3 reasons—first, for historical perspective; second, to emphasize that large neurovascular advancement or retrograde island flaps avoid problems of color mismatch, distant donor sites, and inadequate tip sensation even for volar oblique amputations; finally, to stress the importance of nailbed support provided by the distal phalanx.
6. Dumontier C, Gilbert A, Tuviana R. Hook-nail deformity. Surgical treatment with a homodigital advancement flap. J Hand Surg Br. 1996;20(6):830e835. 7. Lee Y, Kwon S, Ko K. Correction of crooked nail deformity by modified osteoplastic reconstruction. Ann Plast Surg. 2000;45(3): 264e268.
In Reply: Thank you for your interest in our article. We appreciate learning that the concept of fingertip reconstruction using a flap and perionychial tissue was proposed by Mantero in 1973. We agree that large neurovascular advancement or retrograde island flaps can avoid color mismatch and can add comfort by not using a distant flap. However, a neurovascular advancement flap can tether the perionychial tissue, which increases the possibility of the hook-nail deformity. A retrograde island flap usually cannot provide enough bulk for the reconstruction of volar side of an amputated fingertip despite sufficient pedicle length. Furthermore, both flaps can produce the unwanted scarring on the entire remnant finger. Phalangeal support is the best option to prevent the hook deformity, but unlike others, we did not replace and fix any fractured bony fragment to the remnant phalanx. Instead, we debrided tiny floating bone chips and tried to elevate as large a flap as possible and perform tight fixation of the flap to lateral edge of the remnant finger part to avoid tension on the nailbed graft. In addition, we made an effort to mold a reconstructed finger to prevent the hook-nail deformity after surgery. We believe that the hook-nail deformity can be minimized by tension-free fixation of the flap and the postoperative molding, even in situations in which there is no phalangeal support of the reconstructed part of the fingertip.
David T. Netscher, MD Division of Plastic Surgery and Department of Orthopedic Surgery Baylor College of Medicine, Houston, TX and the Department of Surgery Weill Medical College Cornell University Ithaca, NY http://dx.doi.org/10.1016/j.jhsa.2013.10.032 REFERENCES 1. Hwang E, Park BH, Song SY, Jung HS, Kim CH. Fingertip reconstruction with simultaneous flaps and nail bed grafts following amputation. J Hand Surg Am. 2013;38(7):1307e1314. 2. Netscher DT. Repair of fingertip amputations with local digital flaps and perionychial composite grafts from the amputated part [letter]. Plast Reconstr Surg. 2005;115(4):1217e1218. 3. Netscher DT, Meade RA. Reconstruction of fingertip amputations with full-thickness perionychial grafts from the retained part and local flaps. Plast Reconstr Surg. 1999;104(6):1705e1712. 4. Sabapathy RS, Venkatramani H, Bharathi R, Jayachandran S. Reconstruction of finger tip amputations with advancement flap and free nail bed graft. J Hand Surg Br. 2002;27(2):134e138. 5. Foucher G, Khouri RK. Digital reconstruction with island flaps. Clin Plast Surg. 1997;24(1):1e32.
Euna Hwang, MD Department of Plastic and Reconstructive Surgery Bundang CHA Medical Center CHA University Seongnam, South Korea http://dx.doi.org/10.1016/j.jhsa.2013.11.027
Increased Prevalence of Ganglion Formation Among Patients With Wrist Hyperlaxity excellent paper demonstrating high prevalence of dorsal wrist ganglions among patients with ligamentous hyperlaxity. I could not agree more with their conclusions.
To the Editor: I read with great interest the article entitled “Ligamentous Hyperlaxity and Dorsal Wrist Ganglions” by K. E. McKeon et al.1 It is, indeed, an J Hand Surg Am.
r
Vol. 39, January 2014
