Second toe microsurgical free-flap for aesthetic and sensory reconstruction of palmar soft tissue defects of fingers

The modified second toe flap technique based on the dorsal digital artery of the toe in finger pulp reconstruction

BACKGROUND

The second toe flap is a widely used innervated neurovascular flap for repairing finger pulp defects. It mainly carries the proper plantar digital artery and nerve. But the donor site morbidity and arterial injury are common. The report retrospectively evaluated the clinical outcomes of the second toe free medial flap based on dorsal digital artery of the toe to investigate the esthetics and function in the treatment of soft tissue defects of fingertip pulp.

METHODS

From March 2019 to December 2020, 12 patients with finger pulp defects (seven acute crush, three cut, and two burn) undergoing the modified second toe flap were chosen for retrospective review. The average patient age was 38.6 (range: 23-52) years. The mean defect size was 2.1 × 1.6 (range: 1.5 × 1.3-2.6 × 1.9) cm. The defects did not extend beyond the distal interphalangeal joint and the phalanges were not damaged in all cases. The average follow-up was 9.5 (range: 6-16) months. Demographic information, flap data, and perioperative characteristics were collected.

RESULTS

The mean size of the modified flap was 2.3 × 1.8 (range: 1.7 × 1.5-2.7 × 2.0) cm and mean diameter of artery was 0.61 (range: 0.45-0.85) mm. The mean flap harvested time and operation time were 22.6 (range: 16-27) minutes and 133.7 (range: 101-164) minutes. A flap was ischemic after first day postoperatively and later it improved by releasing the sutures. All flaps were survival without necrosis. One patient was not satisfied with the appearance of the finger pulp because of scar hyperplasia. The other 11 patients were satisfied with the appearance and function of the injured digit after 6 months postoperatively.

CONCLUSION

The modified second toe flap technique based on the dorsal digital artery of the toe is a feasible choice to reconstruct the sensation and appearance of the injured fingertip with current microsurgical techniques.

Flow-through arterialized venous free thenar flaps for palmar soft tissue defects in fingers

Objective

To evaluate the efficacy of venous free thenar flaps for reconstructing palmar soft tissue defects in fingers.

Methods

From December 2018 to October 2019, 11 patients with palmar soft tissue defects in fingers were treated using venous free thenar flaps. At the final follow-up, the range of thumb radial and palmar abduction on the injured side and opposite side was calculated. The total active movement (TAM) of the injured and opposite fingers and flap sensibility recovery were also recorded.

Results

The mean follow-up time was 13.4 months, all flaps survived, and all wounds at the donor sites healed with no skin necrosis. At the last follow-up, the average range of thumb radial abduction and thumb palmar abduction on the injured side was 96.6% and 95.9% of the value on the opposite side, respectively. The average TAM of the injured fingers was 98.2% of the value of the opposite fingers. Sensation in the flaps was restored to grade S2 to S3.

Conclusion

Venous free thenar flaps can be alternatives for reconstructing palmar soft tissue defects in fingers.

Modified Heterodigital Neurovascular Island Flap for Sensory Reconstruction of Pulp or Volar Soft Tissue Defect of Digits

PURPOSE

We report the efficacy of a modified heterodigital neurovascular island flap innervated by the dorsal branch of the proper digital nerve and the proper digital nerve, for repairing either pulp or volar defects in the fingers.

METHOD

We repaired 14 digits of 14 patients who had a complex defect involving soft tissue and digital nerve in the pulp or volar surface of the digit using the modified heterodigital neurovascular island flap. Cases were divided into 2 groups: a pulp defect group including 5 thumbs and 1 little finger; and a volar defect group with a digital nerve defect, involving one thumb, 3 index and 3 middle fingers, and one ring finger. At the recipient site, nerve stumps of the PDNs in the pulp defect group were coapted with the proximal ends of the dorsal branch of the PDN and the proper digital nerve in the flap. The distal and proximal ends of the PDN in the flap were intercalated into the defect of the PDN in volar defect group, and the proximal end of dorsal branch of PDN in the flap was also coapted to the proximal end of the proper digital nerve of the recipient finger. At the donor site, the defect of the proper digital nerve was repaired with nerve graft harvested from the proximal portion of the dorsal branch of the same proper digital nerve, and a full-thickness skin graft covered the donor site.

RESULTS

All flaps and the skin grafts of the donor site survived completely. At the final follow-up, 9 of 14 flaps had a static 2-point discrimination result below the normal threshold (< 6 mm).

CONCLUSIONS

The modified heterodigital neurovascular island flap is a useful and reliable treatment option for a digital pulp or volar defect, especially when the digital nerve defect requires repair.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Reconstruction of digit planer injuries using component transfer of double second toes: A case report

The purpose of this report is to show that customized component second-toe transfers may improve functional and aesthetic outcomes following bone, soft tissue, and joint destruction of traumatically injured digits. A 22-year-old male sustained a planer injury resulting in loss of the distal volar soft tissues of the middle, ring, and small fingers, along with variable destruction of middle phalanges and distal interphalangeal joints. Simultaneous vascularized second-toe transfers were performed with customized joint and pulp reconstruction of middle and small fingers. The ring finger was salvaged using non-vascularized autologous bone graft and acellular dermal matrix. The patient had an uncomplicated postoperative course. Five-year strength, sensory and patient reported outcomes represent overall satisfactory results. Strength testing revealed the injured hand to perform within 90% strength of the uninjured side. Sensory outcomes showed present but diminished sensory perception in each of the injured digits. The patient's upper extremity function, physical health, quality of life, and foot health were overall acceptable, and he returned to using his hand for typing, writing, weight-lifting, and woodworking.