Reconstruction of Finger Pulp Defects With an Innervated Distally-Based Neurovascular Flap

The role of great toe terminal branch artery split-thickness nail bed flaps in fingertip reconstruction surgery

BACKGROUND

The common treatments used to repair fingertip defects remain controversial. We have previously conducted research on split-thickness nail bed flaps, but this method still damages the proper plantar digital arteries and nerves. The great toe terminal branch arteries (TBAs) have not been described in detail.

METHODS

Twenty cadaveric feet were used to dissect the terminal branches of the plantar arteries. The locations and diameters of the terminal branches were analyzed. Five patients underwent operations with a TBA split-thickness nail bed flap. We recorded the recovery of both the donor and recipient sites and evaluated the results.

RESULTS

The diameter of the TBAs was between 0.4 and 0.8 mm. The TBA split-thickness nail bed flaps of five patients survived. No complications were found in any of the patients. The nail outcomes were excellent (A) in four patients and very good (B) in one patient. All patients were satisfied with the appearance of the recipient and donor sites. The mean static two-point discrimination was 6.0 mm (range, 4-9). The mean Semmes-Weinstein monofilament test score was 3.03 g (range, 1.65-3.84). Patients neither experienced severe pain in the reconstructed finger or at the donor site, nor did they experience severe cold intolerance. This microsurgical technique avoids the destruction of the proper plantar digital arteries and nerves.

CONCLUSIONS

A TBA split-thickness nail bed flap from the great toe is clinically feasible and can achieve satisfactory results in fingertip repair.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Repair of Finger Pulp Defect and Sensory Reconstruction Using Reverse Homodigital Artery Island Flap With Palmar Cutaneous Branches of the Proper Digital Nerve

OBJECTIVE

To illustrate the clinical outcomes of the reverse digital proper artery island flap with anastomosing the palmar cutaneous branches of the proper digital nerve for the reconstruction of finger pulp defects.

METHODS

From December 2007 to December 2017, a total of 20 patients with finger pulp defects were treated with reverse digital proper artery island flap for innervated construction. Functional outcomes, aesthetic appearance, and complications were evaluated. Functional outcomes were assessed according to range of motion, sensory grade (S0-S4), static 2-point discrimination, Semmes-Weinstein monofilament test, and Cold Intolerance Severity Score. Aesthetic appearance was evaluated according to the Michigan Hand Outcomes Questionnaire.

RESULTS

All flaps survived completely without any complications, and all patients were followed up for at least 12 months. The average static 2-point discrimination, Semmes-Weinstein monofilament, and Cold Intolerance Severity Score results of the injured fingers were 6.35 mm (range, 5-8 mm), 3.64 (range, 2.83-4.17), and 19 (range, 8-24), respectively. All patients achieved recovery in sensation from S3+ to S4. The active ranges of motion of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints of the affected fingers were satisfactory. Based on the Michigan Hand Outcomes Questionnaire, 11 patients were strongly satisfied, and 9 were satisfied with the appearance of the injured finger.

CONCLUSIONS

The reverse digital proper artery island flap with anastomosing the palmar cutaneous branches of the proper digital nerve is an effective and reliable alternative for the reconstruction of finger pulp defect. In the recovery of sensation, this flap leads to satisfactory effects.

Reverse digital artery island flap with versus without sensory nerve coaptation for finger pulp reconstruction

PURPOSE

Whether an innervated reverse digital artery island flap is superior to a non-innervated reverse digital artery island flap still remains controversial. We aimed to compare the clinical outcomes of the two flaps in repairing finger pulp soft tissue defects.

METHODS

Medical records of patients who underwent finger pulp reconstruction between January 2007 and December 2017 were evaluated retrospectively. A total of 45 patients were included. Twenty underwent sensory nerve reconstruction with cutaneous branches of the proper digital nerve, and 25 underwent the surgery without sensory nerve reconstruction. Surgical results, complications and sensory function were collected for analysis. Sensory function was assessed by static two-point discrimination and the modified sensory evaluation standard of British Medical Research Council.

RESULTS

The average operation time of innervated flaps was 23 min longer than non-innervated flaps. All 45 flaps survived completely. There was no significant difference in complications between groups. The average follow-up was 22 months. At the final follow-up, five non-innervated flaps had no recovery of static two-point discrimination. The average static two-point discrimination of the remaining 20 non-innervated flaps was larger than that of innervated flaps. Innervated flaps consistently achieved higher sensory function grades according to the modified sensory evaluation standard of British Medical Research Council.

CONCLUSION

An innervated reverse digital artery island flap can achieve better sensory function recovery in a shorter time. This procedure did not increase the incidence of complications, although it extended the operation time. It has proven to be a good technique for finger pulp reconstruction.

Another new attempt to repair finger pulp defects: retrograde island flap bridge transfer of the adjacent phalangeal artery combined with vascular pedicle tubular skin grafting

This study investigated the surgical method and therapeutic effect of retrograde island flap bridge transfer of the adjacent phalangeal artery combined with vascular pedicle tubular skin grafting to repair finger pulp defects. From June 2008 to May 2020, 21 fingers (19 patients) were repaired using this method. The postoperative flap survival rate and complications, and the clinical effect, were evaluated. All flaps survived, and all patients were followed-up for 12 to 46 months. The static two-point discrimination (2PD) was 7 to 11 mm, no apparent complications were observed in the donor area and the McIndoe cold intolerance symptom severity (CISS) scores indicated mild severity. The Michigan hand outcome questionnaire (MHQ) indicated that all patients were satisfied with their overall hand appearance and function. Results were excellent in 15 cases and good in 4 cases, according to the Dargan function evaluation (DFE). It is safe and effective to repair finger pulp defects with a retrograde island flap bridge transfer of the adjacent phalangeal artery combined with vascular pedicle tubular skin grafting. This skin flap has the advantages of simple severing, good texture and concealed donor area, which is convenient for early postoperative functional exercise of the finger.