Fingertip Replantation: Technique Details and Review of the Evidence

P3 Flap: Technique for Fingertip Reconstruction

Fingertip amputations represent an important spectrum of injuries, and most are avulsions or crush trauma. There is no consensus about one single standard treatment, and a wide number of techniques are available. The authors present the P3 flap as an option for covering fingertip defects with bone exposure, avoiding painful scars in the pulp area, without a donor site. This study included 12 fingertips with amputated segment not available for replantation. Volar oblique fingertip defects and transverse amputations with bone exposure, not more proximal than Hirase Zone IIB, were included. Defects were less than 2 cm. The patients were followed up for an average of 6 months. The aesthetic and functional outcomes and fingertip discrimination recovery were evaluated at 6 months by the static two-point discrimination (2-PD) test and DASH score (quick version). The average postoperative 2-PD test at 6 months was 5.9 mm (range from 5 to 8 mm). The mean healing time of the fingertip was 4 weeks. Nail deformity was reported in three cases with level IIB of amputation. None of the P3 flaps failed, and local infection was not reported. The average DASH score at 6 months was 1.1. The mean time to return to work was 38 days (range from 30 to 53). The P3 flap proposed in this study demonstrates a reliable single-stage technique, performed under local anesthesia, for fingertip defect reconstruction, avoiding skin incision and scars in the pulp region and preserving digital length and nail bed.

Soft and tissue repair of the hand and digital reconstruction

This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.

Spare Parts Surgery with a Free Posterior Interosseous Artery Perforator Flap for Thumb Tip

Replantation is an ideal method for treating fingertip amputation. However, in some cases, replantation is known to be a challenging issue. This report described a successful thumb tip reconstruction performed with bone and nail bed salvaged as spare parts, and a free posterior interosseous artery perforator (PIAP) flap. A 75-year-old man accidentally amputated his left thumb with an electric saw, and emergency replantation was started under brachial plexus block. However, the distal stump of digital artery was unable to be identified, forcing the initial plan to change to flap reconstruction. After vascular anastomosis, complex tissue containing nail bed and side nail fold was grafted on the adipofascial tissue of PIAP flap. Both PIAP flap and the complex tissue survived completely. At 12 months after surgery, only a slight deformity in the nail plate was observed. Spare parts surgery is a surgical procedure effectively salvaging and utilizing tissue that is going to be discarded in severe limb trauma. This idea can be applied to treatment for the finger amputation. In this case, replantation would be difficult in the thumb tip amputation, so spare parts surgery was performed with a PIAP flap. The innervated PIAP flap is reported, including the posterior antebrachial cutaneous nerve. In this case, the cutaneous nerve was able to be identified, neurorrhaphy was performed, and sufficient sensory recovery was obtained. Surgical procedure with PIAP flaps was found to be a useful method for immediate reconstruction with salvaged spare parts after fingertip replantation was considered to be difficult intraoperatively.