Innervated Digital Artery Perforator Flap: A Versatile Technique for Fingertip Reconstruction

Outcomes of antegrade homodigital neurovascular island flap in fingertip amputations

BACKGROUND

Antegrade homodigital neurovascular island flap (AHIF) is one of the methods used in fingertip amputations to cover the defect area, preserve finger length and obtain a painless and sensitive fingertip. The aim of this study was to evaluate the functional and sensory outcomes in patients who underwent AHIF for fingertip amputation and to analyze the relationship between patient satisfaction and outcome measures.

METHODS

Twenty patients with a mean age of 37 (18-63) years were analyzed retrospectively. The patients were evaluated in terms of hook nail development, active interphalangeal joint movements, cold intolerance, and sensory function of the flap covered area. Static two-point discrimination test and Semmes Weinstein monofilament test were performed for sensory evaluation.

RESULTS

All flaps survived completely at the end of follow-up (mean, 36 months; range 11-64 months). Five patients had cold intolerance and two had hook nails. In total, proximal interphalangeal or distal interphalangeal joint flexion contracture developed in 25 % of the patients. The mean static two-point discrimination score was 4.6 ± 1.6 (2-8) and Semmes-Weinstein monofilament test score was 3.48 ± 0.6 (2.44-4.17). Subjective satisfaction levels of the patients were found to be high and did not show a statistical relationship with the measured clinical outcome parameters (p > 0.05).

CONCLUSIONS

Since AHIF contains a solid and continuous neurovascular pedicle, the probability of necrosis and loss of sensation is low in AHIF. In addition, the graft need of the donor area is not high. Its disadvantage is the rate of restriction of joint movements.

LEVEL OF EVIDENCE

IV.

Partial second-toe pulp free flap for fingertip reconstruction: Experience and surgical tips to minimize complications

BACKGROUND

Traumatic fingertip injury is a common hand injury and various methods are available to address them. The partial second-toe pulp (PSTP) free flap is useful because of the similarity in shape, texture, and sensation to the fingertips. However, there may be many difficulties during surgery. The purpose of this report is to make the surgery easier and minimize complications by sharing the surgical tips of the authors obtained through many experiences.

PATIENTS AND METHODS

Thirty patients who underwent PSTP free flap due to trauma were reviewed retrospectively from February 2015 to June 2018. The average age of the patients was 49.4 years. Seventeen were injured on the right side and 13 were on the left side. After removal of the injured tissue, a teardrop-shaped flap was harvested from the medial side of the second toe. When inset, skin graft or vein graft was performed if necessary. When primary closure of the donor site was difficult, skin graft was performed (n = 21). The factors noted during surgery were analyzed.

RESULTS

The flap size was 2.39 (range: 1.5-5) x 1.29 (range: 1-1.8) cm² . All flaps survived. Venous congestion was found in two patients, neuroma was found in one patient, and partial necrosis was found in two patients; all recovered with conservative care. The mean follow up periods was 5.79 (range: 2-18) months. None of the patients had functional impairment.

CONCLUSION

Successful reconstruction and enhanced functional and cosmetic effects can be achieved using surgical tips.

Bilateral flaps based on the dorsal branches of the proper digital artery: A reliable reconstruction in one-stage for the multiple defects in one finger

PURPOSE

To repair multiple skin soft tissue defects of one finger is a challenge to hand surgeons. We introduce a method which can be used to repair multiple skin soft tissue defects of one finger with bilateral flaps in parallel pattern flap based on the dorsal branches of the proper digital artery.

METHOD

A patient suffered electric injury in her left index finger with two soft tissue defects, and the areas were 1.6 cm × 1.0 cm and 2.2 cm × 1.2 cm, respectively. And who underwent a homodigital parallel flaps based on the dorsal branches of the proper digital artery to repair in January 2018. The donor sites were covered by full-thickness skin grafting.

RESULTS

The flaps and the skin grafting survived uneventfully. All incisions achieved primary healing. The follow-up was 19 months, and the shape of the flaps was satisfactory with soft texture and suitable appearance. TAM of the injured finger was 210°, the level was excellent. The score of VAS was 9.

CONCLUSION

The homodigital bilateral flaps in parallel pattern based on the dorsal branches of the proper digital artery are a potential treatment in one-stage for multiple skin soft tissue defects of one finger with reliable blood supply, satisfactory results and simple surgical procedure.

Patient satisfaction after innervated digital artery perforator flap for fingertip injuries

OBJECTIVE

The aim of this study was to evaluate the results of the innervated digital artery perforator (IDAP) flap and to analyze the relationship between patient satisfaction and outcome measures.

METHODS

A total of 17 fingertips of 15 patients (14 men and one woman; mean age: 47.2 (26-62) years) were included in this retrospective study. Patients' injured finger and defect type were recorded. At the last follow-up, the static two-point discrimination (s2PD) test, Semmes Weinstein monofilament (SWM) test, and range of motion of the affected finger were analyzed. We interviewed patients to determine hand dominance, cold intolerance, and their satisfaction with the result. We performed correlation and logistic regression analyses between patient satisfaction and outcome measures.

RESULTS

The mean follow-up period was 13.8 (7-18) months. The mean range of motion was 77.3±3.5 (70-80) degrees for the distal interphalangeal joints of affected fingers. The mean s2PD was 6.4 (3-10) mm, and the SWM records ranged from 2.83 to 4.93 monofilament markings. Cold intolerance was noted in seven fingers (41%). Patient satisfaction was negatively correlated with cold intolerance, and cold intolerance decreased as the follow-up period extended.

CONCLUSION

IDAP flap satisfies both patient and surgeon, with the only significant problem being cold intolerance, regarding which patients must be informed. Although cold intolerance is hard to treat, fortunately, it generally improves with time.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

A Review and Meta-analysis of Adverse Events Related to Local Flap Reconstruction for Digital Soft Tissue Defects

We reviewed the current literature to estimate incidence rates for adverse events with pedicled flaps in the hand. We identified 241 different studies reporting adverse events for 6693 flaps. The average incidence rate was 5.4% and total or partial loss of flap constituted 65% of all reported complications. Flaps with reverse or perforator-based flow may be more prone to vascular complications compared with flaps with antegrade flow or skin pedicle. The incidence rates were acceptable in all flaps (1%-10%) and thus the flap can be chosen primarily based on considerations other than risk of adverse events.

Flaps Based on Perforators of the Digital Artery

This review article summarizes the various types of digital artery perforator flaps used in digit reconstruction. The indications for use of digital artery perforator flaps and the preferred approach for reconstructing fingertip defects are explained in this article. Recent updates in digital artery perforator anatomy in the finger, techniques for flap harvest, and inset as well as a delayed approach to using digital perforator flaps in finger reconstruction are discussed.

Comparison of Innervated Digital Artery Perforator Flap Versus Homodigital Reverse Flow Flap Techniques for Fingertip Reconstruction

PURPOSE

The aim of this study was to investigate and compare outcomes of 2 different flap techniques for fingertip reconstruction: innervated digital artery perforator (IDAP) flap and homodigital reverse-flow flap.

METHODS

Medical records of 33 patients who underwent fingertip reconstruction either with an IDAP flap (15 patients) or with a homodigital reverse-flow flap (18 patients), between 2014 and 2016, were evaluated retrospectively. In both study groups, full-thickness skin grafts harvested from the proximal/volar side of the forearm were used to cover the flap donor site. Flap survival, venous congestion, cold intolerance, static 2-point discrimination, flap size, duration of surgery, time to return to work, proximal and distal interphalangeal joint range of motion, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time were evaluated.

RESULTS

All the major outcomes, including flap survival, cold intolerance, static 2-point discrimination, flap size, time to return to work, range of motion values for proximal and distal interphalangeal joints, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time, were similar between the 2 flap methods. Mean duration of surgery was shorter in the IDAP flap group. Marginal flap necrosis occurred in 1 IDAP flap, and there was complete survival of the remainder of the flap after debridement. Temporary venous congestion was seen in 3 IDAP flaps, all of which resolved with nonsurgical measures.

CONCLUSIONS

Similar success rates and satisfactory outcomes were achieved with IDAP flap and reverse-flow flap techniques used for fingertip reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.