Nail Lengthening and Fingertip Amputations

Fingertip amputations in children: Atasoy flap's indications and limitations

INTRODUCTION

The Atasoy flap is considered simple and reliable for covering distal digital defects in adults. Various studies in children have shown more contrasting results, particularly in terms of aesthetics and function. The aim of this study is to evaluate the long-term results of this flap specifically in children, in order to determine its limitations and indications.

HYPOTHESIS

The Atasoy flap is reliable and reproducible for coverage of distal digital substance loss up to zone 2 in children.

MATERIALS AND METHODS

Fifty-six children who benefited from an Atasoy flap operated on between January 2017 and January 2020 were included. Lesion area, operative technique, postoperative complications (infection, healing difficulties, necrosis), and ultimately nail appearance, cold intolerance or finger pain, finger eviction, extension defect, and final parental satisfaction were analyzed.

RESULTS

Forty-nine children were evaluated with a mean follow-up of 18 months (min = 3 months, max = 38 months, SD = 11.3 months). Eighteen children had a hook nail, resulting in 6 of them having their finger excluded. The majority of hook nails were found in zone III and in proximal zone II lesions (12 cases). Eighty-nine percent of children with distal suture fixation to the nail bed (8 children) had this complication. Cold intolerance was present in 9 children. There were no cases of extension failure or early post-operative complications. Final parent satisfaction was 9.1/10 (min = 5, max = 10, SD = 1.3).

CONCLUSION

The Atasoy flap in children appears reliable for covering loss of distal digital substance. The main complication is the occurrence of hook nails. Compliance with its indications (transverse substance loss not exceeding the proximal third of zone II) and a precise surgical technique (distal needle fixation without suturing to the nail bed, deep flap lift, non-closure of the donor site) help limit this risk.

LEVEL OF EVIDENCE

IV; retrospective study.

Distal fingertip replantation: indications, strategy and postoperative management

Distal fingertip replantation is associated with being a technically demanding procedure and dubious outcomes, although it is now performed more frequently across the world. However, the technique and outcomes remain controversial with disagreement among replantation surgeons due to lack of consensus about the indications, intraoperative strategy and postoperative regimes. In this article, we asked six experienced hand surgeons several pertinent questions that every replantation surgeon performing distal fingertip replantation would face in their clinical practice. The article summarizes their responses, which might provide valuable insight to every replantation surgeon in different parts of their career while managing these injuries.

The Aesthetic Outcomes of Fingertip Amputation Are Better with Proximal Nail Fold Recession

Background: There are numerous flaps described for the treatment of fingertip amputation. Most flaps do not address the shortened nail resulting from amputation. Proximal nail fold (PNF) recession is a simple procedure that exposes the hidden portion of the nail and improves the aesthetic appearance of an amputated fingertip. The aim of this study is to measure the size and aesthetic outcomes of the nail following fingertip amputation in patients treated with PNF recession compared to those treated without PNF recession. Methods: This study was conducted between April 2016 and June 2020 and included patients with a digital-tip amputation who underwent a local flap or shortening closure for reconstruction. All suitable patients were counselled for PNF recession. In addition to demographic, injury and treatment data, the length and area of the nail were measured. The outcomes were assessed at a minimum of 1 year after surgery and included measurement of the size of the nail, patient satisfaction and aesthetic outcomes. A comparison of the outcomes was done between patients who underwent PNF recession versus those who did not. Results: Out of 165 patients treated for fingertip injury, 78 underwent PNF recession (Group A) and 87 did not undergo PNF recession (Group B). In Group A, the nail length was 72.54% (SD: 14.4) and the nail plate area was 74.35% (SD: 13.96) compared to the contralateral uninjured nail. These results were significantly better (p = 0.000) compared to Group B where the values were 36.49% (SD: 8.45) and 35.8% (SD: 8.4), respectively. The patient satisfaction and aesthetic outcome scores were also significantly higher in Group A patients (p = 0.002). Conclusions: The size and aesthetic outcomes of the nail following fingertip amputation in patients treated with PNF recession are better compared to those treated without PNF recession. Level of Evidence: Level III (Therapeutic).

Eponychial Flap: A Simpler Way to Achieve Better Aesthetic Outcome in a Fingertip Amputation

Background  There are numerous flaps described for the treatment of fingertip amputation. Shortened nail length resulting from amputation is an ignored area. Eponychial flap is a simple procedure that helps to lengthen the nail plate and correct this deformity. Methods  This case-control study was conducted between April 2016 and June 2020 aimed at comparing the outcome of nail defects in a fingertip amputation treated with eponychial flap and those treated without an eponychial flap. Results  Among 165 patients treated for fingertip injury, 78 were treated with eponychial flap (group A) and 87 without eponychial flap (group B). In group A, the nail length was 72.54% (standard deviation [SD]: 14.4) and the nail plate area was 74.35% (SD: 13.96) compared with the contralateral uninjured nail. These results were significantly better ( p  = 0.000) compared with group B where the values were 36.49 (SD: 8.45) and 35.8% (SD: 8.4), respectively. The aesthetic outcome score was also significantly higher in group A patients ( p  = 0.002). The patient satisfaction was superior in group A compared with group B. Conclusion  The eponychial flap is a simple and reliable technique that can be used to restore the visible nail length in traumatic fingertip defects. Compared with fingers treated without nail lengthening with eponychial flap gives excellent aesthetic results.

Aesthetic correction of short nail deformity in congenital brachydactyly Type D by distraction lengthening

Brachydactyly Type D is a congenital condition of the thumb in which there is a short and broad thumbnail. Although the thumb function is often unaffected, some patients seek surgery for cosmetic improvement. This study aimed to describe our method of distraction lengthening to correct nail deformity in brachydactyly Type D. A total of 163 thumbs in 95 patients underwent this surgery between 2018 and 2021.The mean thumbnail length improved from 9 mm to 15 mm, with a mean percentage increase of 62%. The ratio of nail length to width changed from 0.6 to 1.1, which was equal to normal. The mean increased fingernail length/width ratio was 0.5, with a percentage change of 78%. No obvious surgical scar was observed. The thumb function was not significantly affected. We conclude that aesthetic correction of short nail deformity in brachydactyly Type D can be achieved by distraction lengthening with high satisfaction and without functional impairment.Level of evidence: IV.

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.

Soft Tissue Coverage of the Digits and Hand

There are multiple options available for reconstruction of soft tissue defects of the digits. The main goal of reconstruction is to achieve normal or near-normal mobility. Soft tissue defects can be considered in the following groups: fingertip, nonfingertip, and multiple digits. The choice of reconstruction for fingertip defects depends primarily on the amount of volar skin available. The patient's functional demands and expectations, and the expertise of the surgeon, also determine the reconstructive strategy.

VY Advancement, Thenar Flap, and Cross-finger Flaps

The VY advancement, thenar flaps, and cross-finger flaps are workhorse flaps used in reconstruction of fingertip defects. They are reliable and simple to raise without need for microvascular dissection. In addition, they usually provide good results in terms of sensibility and range of motion. This article reviews the history, anatomy, and surgical technique of these flaps with a focus on aesthetic refinements with illustrative cases.

Is the adipofascial flap the key to regenerative surgery?

Objectives

"Form and function restoration" is the ultimate goal of reconstructive surgery, which is oriented toward regeneration rather than reparation. Recently, research in reconstructive surgery has focused on the regenerative potential of the adipose tissue. The aim of the study is to illustrate the surgical methods and show the functional and aesthetic results achieved by the reconstruction of finger soft-tissue defects using homodigital dorsal adipofascial reverse flap (HDARF).

Materials and methods

A total of 63 cases (45 acute and 18 elective) were included between September 2010 and August 2016. In each case, we preliminarily performed surgical debridement and then harvested an adipofascial flap from the back of the finger. Nine injured thumbs that were repaired with the flap as emergency cases were also included. The average age of the patients was 46 (range: 4-69) years.

Results

All flaps survived without any complications during the 24-month follow-up. Good nail regrowth through the flap and full regeneration were observed in approximately all cases. Sensitivity tests and histological analysis of biopsy samples of the regenerated fingers confirmed full regeneration of the epidermis, dermis, cutaneous adnexa, and nerves. All the patients were satisfied with the hand functionality and aesthetic appearance.

Conclusion

The HDARF represents a very useful alternative for the reconstruction of nailbed crushes, achieving regeneration of injured segments in deformities caused by trauma or infection.

Management of complications relating to finger amputation and replantation

There are many options in the management of fingertip or finger amputations. Injudicious revision amputation may cause complications. These complications can be prevented by tension-free closure of the amputation stump or primary coverage with appropriate flap. Replantation is the best way to keep the original length and maintain digital function. Patent vein repair or venous drainage with bleeding until neovascularization to the replanted part is the key to successful replantation. Prevention and management of complications in replantation and revision amputation increase patients' satisfaction and decrease costs. Research is needed to define new indications of replantation for digital amputation.

Aesthetic and functional results from nailfold recession following fingertip amputations

PURPOSE

To analyze the aesthetic and functional results of a technique for nail salvage by recessing the nailfold to increase the exposed nail matrix after fingertip amputation.

METHODS

Thirty cases of fingertip amputation with distal partial nail bed defects underwent nailfold recession and pulp reconstruction. We increased nail bed exposure by recessing a rectangle flap of eponychium and reconstructed the pulp with different local flaps depending on the injury geometry. A 0.3- to 0.4-cm-wide rectangular strip of eponychium was de-epithelialized. The eponychial flap was separated from the nail matrix and slid proximally to expose more nail matrix, thereby effectively lengthening the exposed nail bed.

RESULTS

The flaps survived in all patients. The exposed nail beds were lengthened 0.3 to 0.4 cm and enlarged 38% to 100%. The fingertips had smooth and natural nail plates with inconspicuous scars on both the eponychium and pulp and no deformities. The sensation and mobility of injured and uninjured contralateral fingers did not differ statistically. All patients were satisfied with the appearance and function of the reconstructed fingertips.

CONCLUSIONS

Nailfold recession combined with different local flaps provided for the aesthetic and functional restoration of the fingertip after amputation with partial nail bed defect.

Management of fingertip amputations

Injuries to the fingertips are among the most common injuries to the hand and result in approximately 4.8 million emergency department visits per year. Most injuries are lacerations or crushes; amputations represent a small but complex spectrum of injury. Treatments available cover a broad range of techniques with no single recommended reference standard for treatment. Although there is no consensus on how these injuries should be treated, the goals of treatment should include minimization of pain, optimization of healing time, preservation of sensibility and length, prevention of painful neuromas, avoidance or limiting of nail deformity, minimization of time lost from work, and provision of an acceptable cosmetic appearance. In this review we present a variety of options in caring for these injuries to help achieve these goals, and the available data that support the various treatment plans.

Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap

Fingertip injuries often result in fingernail defects. Reconstruction of this structure is important for adequate functional and aesthetic results. This study evaluates the eponychial flap reconstruction technique in 45 fingertip amputations with loss of more than half the fingernail. In 33 cases the procedure was performed in combination with a palmar island flap for pulp reconstruction. Average follow up was 5 months. All eponychial flaps healed uneventfully. In 44 cases, the pulp volume was restored without nail growth disturbance. Five complications (9%) were observed (pain, soft nail, and nail deformity). Only one hook nail deformity required reoperation. All patients were satisfied with the aesthetic and functional outcome. We found eponychial flap fingernail reconstruction effective even for injuries proximal to the lunula and have extended the indication for this technique to very proximal fingernail defects. Eponychial flap reconstruction is a simple, safe, and time-effective technique without donor site morbidity. Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip.

Onycho-osteo-cutaneous defects of the thumb reconstructed by partial hallux transfer

PURPOSE

To present our experience in distal thumb amputations reconstructed by partial toe to hand transfers with special emphasis on manual workers.

METHODS

Twenty-five patients who experienced amputation of the thumb distal to the interphalangeal joint, excluding pure soft tissue losses, were included in the study. All but 2 were manual workers. Twenty were reconstructed within 2 weeks after injury. The other 5 were referred late. In all patients, the ipsilateral hallux was used as donor, based on the proper digital artery (18 cases), the intermetatarsal artery (6 cases), and the dorsalis pedis artery (1 case).

RESULTS

All transferred flaps survived. At a minimum follow-up of 1 year (range, 1-14 y), active range of motion at the interphalangeal joint was more than 55° in 23 patients. Two had an interphalangeal joint arthrodesis, 1 of them before referral. Pinch and grip were similar to the contralateral side. Two-point discrimination was normal in the dorsal oblique amputations and 7 to 11 mm in the rest. Patient satisfaction was high from a functional and aesthetic standpoint (9.5 out of 10 on a visual analog scale for both outcomes). All patients returned to work 2 to 4.5 months after the operation. Delayed donor site healing was noticed in 4 cases.

CONCLUSIONS

In contrast to classic teaching that recommends stump closure for cases of distal thumb amputation, we attained excellent results with partial toe transfer in manual workers. In our experience, the thumb can be restored to nearly normal with an acceptable donor site sequela. The best indication is for cases of dorsal oblique amputations, because thumb sensibility is unaffected, and for amputations where the germinal matrix is preserved, because nail regrowth occurs. Early transfer is strongly recommended.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Combination V-Y advancement flap and composite graft for reconstruction of an amputated fingertip

Fingertip amputations can lead to both functional and aesthetic problems. We present the results of our preferred technique to address fingertip amputations in zone 1 and zone 2 which have been deemed non-replantable by microsurgery. It is based on the "reposition technique" described by Dubert et al. in 1997(1) and the free perionychial graft technique suggested by Netscher and Meade in 1999.(2) The technique that we prefer is best described as a combination of an advancement flap and a composite graft. So far seven patients have been treated with this method and our results have been satisfactory in all of them. It is a simple and quick technique that does not require advanced skills and can be done by a well-trained resident or fellow. It allows preservation of finger length, retains the nail and is functionally and aesthetically pleasing.

Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the anatomy of the fingertip. 2. Describe the methods of evaluating fingertip injuries. 3. Discuss reconstructive options for various tip injuries.

SUMMARY

The fingertip is the most commonly injured part of the hand, and therefore fingertip injuries are among the most frequent injuries that plastic surgeons are asked to treat. Although microsurgical techniques have enabled replantation of even very distal tip amputations, it is relatively uncommon that a distal tip injury will be appropriate for replantation. In the event that replantation is not pursued, options for distal tip soft-tissue reconstruction must be considered. This review presents a straightforward method for evaluating fingertip injuries and provides an algorithm for fingertip reconstruction.

A technique to improve foot appearance after trimmed toe or hallux harvesting

We describe a technique to improve the appearance of the donor site after hallux harvesting. The surgery has been used in 6 consecutive patients having a trimmed-toe-type transfer. Instead of the classic stump closure advised by Wei, the following steps were performed on the donor site: (1) removal en bloc of the second metatarsal and transposition of the second toe on top of the proximal phalanx of the hallux, (2) interposition of a tibial (medial) glabrous flap from the tibial aspect of the hallux onto the tibial side of the second toe to increase its size, and (3) eponichial flap to increase the nail show on the second toe. Fixation of the toe was achieved with K-wires and cerclage wire. Crossed K-wires stabilized the first to the third metatarsals for 4 to 6 weeks. Ambulation with a stiff sole was allowed a few days after surgery. The main advantage of this technique is the improved donor site appearance. As a bonus, the amount of skin that can be harvested with the trimmed toe is slightly increased. The main drawback is that the number of toes is reduced to 4.

Nail salvage using the eponychial flap

Loss of distal fingertip bone and soft tissue defect can be treated using different methods, but the involvement of the nail influences the choice of surgical approach and makes reconstruction more difficult. The eponychial flap is a backward cutaneous translation flap that lengthens the nail plate and restores a good appearance of the nail apparatus. Pulp reconstruction is usually performed using local flaps (Tranquilli-Leali or Venkataswami flaps). The eponychial flap technique is a safe and easy technique that is indicated in cases of transverse fingertip angulations for lengthening the short amputated nail. This procedure can be used in combination with different flaps for pulp reconstruction.