Finger reconstruction with dorsal metacarpal artery perforator flaps and dorsal finger perforator flaps based on the dorsal branches of the palmar digital arteries - 40 consecutive cases

[Long-Term Outcome of Digital Defect Reconstruction using Cross-Finger Flaps]

INTRODUCTION

Although multiple advances have been made in finger defect reconstruction, cross-finger flaps remain an important reconstructive tool. However, data on long-term results are scarce in the literature. This study aimed to assess the clinical and subjective long-term outcomes of patients who underwent cross-finger flap reconstruction for palmar digital and fingertip defects.

PATIENTS AND METHODS

Between January 2003 and July 2022, 35 patients (31 male, 4 female, mean age: 59.0 years±20.1) were screened and included in the study. The data were obtained through a clinical examination, a Quick-DASH score and a self-designed questionnaire. Clinical outcomes were assessed by evaluating the range of motion (ROM) of the reconstructed finger and the donor finger compared with the contralateral uninjured hand. In addition to ROM, a static two-point separation test was performed to assess the sensory function of the reconstructed finger. The follow-up period was between 1 year and 19 years (mean: 12.6 years±6.1).

RESULTS

There was no significant difference in terms of ROM between the reconstructed finger and the donor finger compared with the contralateral uninjured hand. All patients reported normal discrimination between sharp and blunt objects. However, there was a significant difference in two-point discrimination between the reconstructed finger and the healthy contralateral finger (p<0.05). The average Quick-DASH score was 5.1 points. Satisfaction with the functional outcome in terms of mobility and load-bearing capacity of the cross-finger flap averaged 8.1 out of 10 points. Satisfaction with the aesthetic outcome of the reconstructed finger averaged 7.7 out of 10 points. In 4 cases, persistent pain was reported when the reconstructed finger was under stress. No cases of pain at rest were reported.

CONCLUSION

In the long run, cross-finger flaps are a safe and effective reconstructive procedure for covering defects in palmar injuries of the finger and fingertip amputation. They represent a simple, reliable, long-lasting reconstructive technique. The necessary temporary iatrogenic syndactyly does not lead to long-term limitations in the range of motion.

One-stage secondary debulking procedure: A unique technique to restore the differential contour of digit after groin flap reconstruction

BACKGROUND

Pedicled groin flap is a reliable reconstructive method for digits. However, problems with the contour, mobility, and sensation, especially while providing strict thin skin coverage still exist.

PATIENTS AND METHODS

A total of 17 cases with 36 digits injured by trauma were identified. One-stage secondary debulking procedure was adopted for flap revision. The skin over the flap was harvested as a full-thickness graft. At the dorsal side of the reconstructed digit, the subcutaneous tissue and fat were debulked till the deep fascial layer. At the volar side, the flap was debulked till the superficial fascial layer. The skin was then re-grafted. The outcomes were reviewed after 12 months follow-up.

RESULTS

The average timing for debulking procedure after flap reconstruction was 116 days. After removal of bolster dressing 7 days after debulking, all the grafted skin took well. A mean length of 2.5 cm of digit was preserved for the non-replantable digits. The reconstructed digits achieved comparable diameter and contour with that of the contralateral side. The two-point discrimination of the injured digits of adults was 10.4 ± 1.6 mm. Using a 5-point Likert scale, post-debulking digits showed statistically significant improvement compared to pre-debulking digits. The evaluation of the patients' satisfactory outcomes of the reconstructed digits was judged as "very satisfying" in 12 patients (75 %) and "good" in 4 patients (25 %).

CONCLUSIONS

One-stage secondary debulking procedure resulted in excellent functional and esthetic outcomes for digits according to different structures of the dorsal and volar sides.

LEVEL OF EVIDENCE

IV, Retrospective.

Propeller Perforator Flaps Used for Hand and Digit Reconstruction: A Systematic Review

Background

Propeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction.

Methods

A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected.

Results

Out of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm2. Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%.

Conclusion

PPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival.

Double-pivot proper digital artery perforator flap for fingertip reconstruction

BACKGROUND

Dorsal flap based on proper digital artery perforator has been commonly used in wound coverage of fingertip; yet a small diameter and short length poses a risk of pedicle kinking or occlusion. The present study aims to present our preliminary results of using a double-pivot perforator flap based on the end dorsal branch of proper digital artery to repair finger pulp defect.

METHODS

We designed a double-pivot flap based on the end-dorsal perforator branch of proper digital artery, raised from the dorsal aspect of the middle phalanx, with inclusion of both the perforator and a section of the trunk of the artery. This modified procedure forms a pedicle with a larger diameter and length than traditional designs. Twelve patients (12 fingers) each with a soft-tissue defect of the fingertip were successfully treated and followed up in this retrospective study.

RESULTS

All the flaps survived without showing any signs of necrosis; three cases presented with transient venous flow disorder, these self-resolving without requiring any additional treatment. At final follow-up (12-33 months, mean 20 months), mean static two-point discrimination on the flap was 7.0 mm (range, 6-9).

CONCLUSION

The double-pivot proper digital artery flap serves as a reliable option in fingertip reconstruction offering added benefits of having greater rotation flexibility, a lower risk of vessel kinking or occlusion, and good recovery of cutaneous sensation.

Repair of a finger pulp or fingertip defect using a palmar rotatory flap pedicled with the perforating branch of the proper palmar digital artery: a retrospective study

BACKGROUND

Soft tissue defects in the hand may result from trauma, oncological procedures, or severe infections. This study aimed to introduce an innovative method for repairing soft tissue defects on the palmar side of the distal segment of the affected finger or fingertip. We explored this surgical method and its curative effect on the volar rotation pedicled flap base on a perforator of the palmar digital artery (VRPF-PPDA) for repairing ventral or fingertip soft tissue defects of the distal segment of the affected finger without impairing its main blood vessels.

METHODS

Between June 2019 and January 2021, 13 patients with finger pulp or fingertip soft tissue defects were treated with VRPF-PPDA. Flap survival rate, complication rate, two-point discrimination (2PD), and patient satisfaction were used to evaluate the efficacy of this method. The function of the affected finger was evaluated using the upper limb function evaluation method issued by the Trial Standards for Evaluation of Partial Function of the Upper Extremity of the Chinese Society for Surgery of the Hand of the Chinese Medical Association (CMA) and the Disabilities of the Arm, Shoulder, and Head (DASH) score, 6-12 months after the flap-based operation.

RESULTS

Thirteen patients (18 fingers) achieved complete flap survival. The finger pulp flap was full, and no complications occurred. 2PD checks of the flaps revealed that all of them were 4-10 mm in length. According to the Trial Standards for Evaluation of Partial Function of the Upper Extremity of the Chinese Society for Surgery of the Hand of the CMA, hand function was excellent in 12 patients (17 fingers) and good in one patient, with a mean DASH score of 26.05 ± 0.45. Eleven patients selected "excellent" on the subjective satisfaction survey, while the other two selected "good."

CONCLUSION

VRPF-PPDA surgery is a simple, effective, minimally invasive, and reliable method for repairing soft tissue defects in the distal finger pulp or fingertips. Optimal esthetic reconstruction and anatomical and functional repair can be achieved in fingers repaired using the VRPF-PPDA surgical approach.

Fingertip degloving injury coverage with homodactyle bipedicled dorsal island flap

OBJECTIVES

To investigate the curative effect of repairing digital degloving with flaps from the bilateral dorsal branch of the proper digital artery of the same finger.

MATERIAL AND METHODS

Twenty-three patients with fingertip degloving injury treated with flaps from the bilateral dorsal branch of the proper digital artery of the same finger in our hospital from February 2020 to March 2022 were retrospectively included. Active finger range of motion, cold intolerance, pain on visual analogue scale and patient satisfaction were evaluated.

RESULTS

There were 3 cases of flap blister and 2 of vascular crisis after the operation, all of which healed after symptomatic treatment. All the other flaps and skin grafts survived. Follow-up ranged between 6 and 25 months (mean, 13.8 months). The skin flap was full in shape and soft in texture. Incidence of cold intolerance was low in the palmar flaps and dorsal flaps, and finger range of motion recovered well. The technique relieved pain, and patients were satisfied with the results.

CONCLUSION

Flaps from the bilateral dorsal branch of the proper digital artery of the same finger were effective for repair of fingertip degloving. The technique easy to implement, and can repair large defects; the repaired finger shows good function and appearance.

Finger Reconstruction With Distally Based Dorsal Metacarpal Flaps: A Systematic Review

BACKGROUND

Distally based dorsal metacarpal flaps for the reconstruction of finger soft-tissue defects are classified into 3 categories: dorsal metacarpal artery perforator flap, reverse dorsal metacarpal artery (RDMA) flap, and extended reverse dorsal metacarpal artery (ERDMA) flap. The present systematic review aimed to evaluate differences in the outcomes of commonly encountered defects and postoperative complications among these three flaps.

METHODS

PubMed, Scopus, and Web of Science were systematically searched from when the flats were first reported to May 2021. Random-effects meta-analysis for each outcome was performed, and 24 studies were included in the analysis.

RESULTS

Dorsal metacarpal artery perforator flaps were mainly used for defects extending to the proximal interphalangeal joint (n = 62 [29.1%]) and proximal phalanx (n = 85 [39.9%]). Conversely, defects extending to the distal phalanx (n = 24 [43.6%]) were mostly reconstructed using the ERDMA flap. The rate of venous congestion was highest for the ERDMA flap (29.3%; 95% confidence interval [CI], -17.2% to 65.1%; I2 = 0%) and lowest for RDMA flap (8.1%; 95% CI, -5.9% to 21.7%; I2 = 0%). The RDMA flap showed the lowest rate of any short-term complications, including partial and total necrosis (6.6%; 95% CI, -6.8% to 19.8%; I2 = 0%).

CONCLUSIONS

This systematic review demonstrated that the dorsal metacarpal artery perforator flap was suitable for reconstruction proximal to the middle phalanx, and the ERDMA flap was suitable for reconstruction distal to the distal interphalangeal joint. Although the RDMA flap showed the lowest rate of short-term complications and limited analysis was secondary to limited data available, these occurred in 6.6% to 10.9% of distally based dorsal metacarpal flaps.

Functional and aesthetic reconstruction of a dorsal digital skin defect with a sensory neurotized DMCA III flap

The dorsal metacarpal artery (DMCA) flap is an elegant way to reconstruct tissue defects. We present a 25-year-old female patient with a dorsal injury on the fourth digit, which was reconstructed with a third webspace DMCA flap which was neurorrhaphied with a branch of the ulnar nerve, to regain sensation.