Donor-Site Morbidity after Partial Second Toe Pulp Free Flap for Fingertip Reconstruction

From Simple to Complex: Preserving and Reconstructing the Traumatized Thumb

Traumatic thumb injuries significantly affect overall hand function and may result in considerable disability. Reconstructing the traumatized thumb requires a detailed preoperative assessment of the defect and evaluation of the patient's social history and medical comorbidities. Reconstructive techniques can be stratified by the level of thumb injury. The goals of thumb reconstruction are to restore length, stability, mobility, and sensibility. This article reviews reconstructive principles and operative techniques for reconstructing the traumatized thumb.

Reconstruction of Plantar Forefoot Area with Lateral Toe Pulp Flap: Case Report and Literature Review

Reconstruction of the plantar forefoot area is challenging because it performs important functions, including carrying the body weight and balancing the ambulation gait, and lacks similar skin and soft tissues to manage the adjacent region. Herein, we shared our experience of using a lateral toe pulp flap and reviewed the relevant literature on this topic. A 33-year-old man presented with a large granuloma in the left plantar forefoot area after undergoing multiple operations owing to the diagnosis of callus. After tumor excision, the wound exhibited tendon exposure and a large infected dead space in the myofascial layer. After serial debridement with negative pressure wound therapy, the wound, which measured ~3.5 × 2.5 cm2, was reconstructed using a lateral toe pulp flap. The flap was transposed to obliterate the dead space; the remaining skin defect (size: ~2 × 2 cm2) was resurfaced with a full-thickness skin graft, harvested from the left inguinal region, followed by primary closure of the flap donor site. The flap completely survived. The lateral toe pulp flap is an easy, effective, and reliable option for reconstruction of the defects in the plantar forefoot area.

Reconstruction of circumferential fingertip defect using free superficial palmar branch of the radial artery flap: Report of two cases

Wide local excision of noninvasive malignant melanomas has been increasingly performed instead of digit amputation, which often results in extensive fingertip defects. Owing to the unique anatomical characteristics of the fingertips, achieving favorable outcomes in both function and cosmesis is challenging during reconstruction. The free superficial palmar branch of the radial artery (SPBRA) flap is advantageous for finger reconstruction. However, its application in circumferential fingertip defects has rarely been reported. In this report, we describe two cases of circumferential fingertip defect reconstruction using a free SPBRA flap after wide local excision of subungual melanoma. The patients were women aged 74 and 63 years at the time of surgery. They presented with subungual melanoma on the right fourth finger and left thumb, in which both biopsies confirmed malignant melanoma in situ (Tis N0 M0), Breslow thickness of 0 mm (noninvasive). After wide local excision, circumferential defects, sized 2.5 × 6 and 2.7 × 7 cm, were formed on their fingertips. A vertically designed free SPBRA flap measuring 2.7 × 6 and 3 × 6 cm was elevated from the unaffected palm in each patient. After performing microvascular anastomosis, the flap was inserted transversely, wrapping the exposed phalangeal bone in a conical shape. The donor site was primarily closed. All flaps survived, and postoperative complications did not develop. Neither local recurrence nor distant metastasis was detected at the latest follow-up in either patient at 24 or 28 months postoperatively. The patients were satisfied with the natural contour of the reconstructed fingertip and recovered functions. In the evaluation of subjective sensory recovery using four scales (excellent, good, fair, and poor), they responded "fair" and "good," respectively. We suggest that the free SPBRA flap could be a reliable reconstructive method for circumferential fingertip defects.

The modified second toe flap technique based on the dorsal digital artery of the toe in finger pulp reconstruction

BACKGROUND

The second toe flap is a widely used innervated neurovascular flap for repairing finger pulp defects. It mainly carries the proper plantar digital artery and nerve. But the donor site morbidity and arterial injury are common. The report retrospectively evaluated the clinical outcomes of the second toe free medial flap based on dorsal digital artery of the toe to investigate the esthetics and function in the treatment of soft tissue defects of fingertip pulp.

METHODS

From March 2019 to December 2020, 12 patients with finger pulp defects (seven acute crush, three cut, and two burn) undergoing the modified second toe flap were chosen for retrospective review. The average patient age was 38.6 (range: 23-52) years. The mean defect size was 2.1 × 1.6 (range: 1.5 × 1.3-2.6 × 1.9) cm. The defects did not extend beyond the distal interphalangeal joint and the phalanges were not damaged in all cases. The average follow-up was 9.5 (range: 6-16) months. Demographic information, flap data, and perioperative characteristics were collected.

RESULTS

The mean size of the modified flap was 2.3 × 1.8 (range: 1.7 × 1.5-2.7 × 2.0) cm and mean diameter of artery was 0.61 (range: 0.45-0.85) mm. The mean flap harvested time and operation time were 22.6 (range: 16-27) minutes and 133.7 (range: 101-164) minutes. A flap was ischemic after first day postoperatively and later it improved by releasing the sutures. All flaps were survival without necrosis. One patient was not satisfied with the appearance of the finger pulp because of scar hyperplasia. The other 11 patients were satisfied with the appearance and function of the injured digit after 6 months postoperatively.

CONCLUSION

The modified second toe flap technique based on the dorsal digital artery of the toe is a feasible choice to reconstruct the sensation and appearance of the injured fingertip with current microsurgical techniques.

Composite classification and algorithmic reconstruction of fingertip defects with free lateral great toe flaps

BACKGROUND

This study aimed to classify fingertip defects according to dimensions and composite content, and present algorithmic reconstruction results with free lateral great-toe flaps.

METHODS

A total of 33 patients who underwent reconstruction for full-thickness defects of fingertips with free lateral great-toe flaps were retrospectively reviewed. Patients were divided into four groups by the algorithm according to the dimension and content of defects. Functional disabilities of the upper extremities, limitations of donor feet, finger cosmetics, sensory recovery, and pinch power were evaluated using the disabilities of the arm, shoulder and hand, foot function index, 5-point Likert satisfaction scales, Semmes-Weinstein monofilament and static 2-point discrimination tests, and pulp pinch-strength test, respectively.

RESULTS

The standardized distribution of patients according to dimensions and content of defects was achieved. When the composite content of defects increase such as group 4, complex surgical skills are required, duration of surgery is extended, return to work is delayed, and donor-site complications are increased. Functional limitations of the hands improved normally after reconstruction (p < 0.00). Sensory recovery of flaps was normal and test scores were strongly correlated (p = 0.78). All patients and observers were satisfied with finger's cosmetics.

CONCLUSION

Our classification and reconstruction algorithm is simple and easy to apply for all fingertip defects without complicated reference points, and it provides information about the surgical and post-surgical periods. When the dimension and composite deformities of the defect increase through groups 1-4, more complex reconstruction, increased donor-site complications, prolonged duration of surgery, and delayed return to work are observed.

The Clinical Effect of Digital Dorsal Fascial Island Flap Combined With Crossfinger Flap for Repairing Distal Degloving Injury and Sensory Reconstruction

Background

To explore the clinical effect of digital dorsal fascial island flap combined with crossfinger flap to repair distal degloving injury and sensory reconstruction.

Methods

A total of 19 patients with distal fingertip degloving injuries treated with digital dorsal fascial island flap combined with crossfinger flap in our hospital from April 2018 to August 2020 were retrospectively included. Semmes–Weinstein (SW) monofilament and static two-point discrimination (S-2PD) tests, active range-of-motion (ROM) of the fingers, cold intolerance, visual analog scale (VAS) score patient complications, and patient satisfaction were evaluated.

Results

Five cases with post-operative flap blisters were treated at the time of dressing changes until successful scab formation. Three cases with post-operative arterial crisis of finger arterial dorsal branch vessel were relieved after suture removal and tension reduction. All other skin flaps and skin grafts survived. Nineteen patients received follow-up between 3 and 26 months (average 14.6 months). The active ROM of metacarpophalangeal (MCP) and interphalangeal (IP) joints of the injured fingers were satisfactory.

Conclusion

The digital dorsal fascial island flap combined with the crossfinger flap for repairing the distal degloving injury of the distal segment of the finger is a good surgical method, which is simple and easy to operate, can repair a large area of soft tissue defect, and obtain a satisfactory effect.

Secondary Management of Nonnail Perionychial Deformities: Restoring Aesthetic and Functional Subunits

Delayed finger and thumb tip reconstruction should try to optimally reconstruct perioncyhial aesthetic and functional units by replacing tissue as closely resembling the original loss as possible. Avoid thinking in terms of a "reconstructive ladder" but rather going directly to the reconstructive choice that seems most suited to the task. Some reconstructive choices may seem more attractive because of their simplicity, but may not necessarily give the best functional and aesthetic result. Free flaps and the newer advancements with vascular island flaps give many more and versatile reconstructive options.

Partial second toe pulp free flaps in early childhood

Background

The introduction of the partial second toe pulp free flap has enabled superior aesthetic and functional results for fingertip reconstruction in adults. Children undergoing fingertip amputation for various reasons have limited options for reconstruction. Conventional treatment could shorten the finger, leading to poor cosmesis and function. We report 18 years of our experiences with fingertip reconstruction using partial second toe pulp free flaps in patients in early childhood.

Methods

Medical charts of children who had undergone fingertip reconstruction using partial second toe pulp free flaps from 2001 to 2018 were retrospectively reviewed. The surgical procedures were identical to those for adults, except for the usage of 11-0 nylon sutures. Patients’ demographic data, vessel size, flap dimensions, length of the distal phalanx, and functional outcomes over the course of long-term follow-up were documented. The statistical analysis was performed with the Student t-test, the Mann-Whitney U test, and Pearson correlation analysis.

Results

Eighteen toe pulp flaps in 17 patients (mean age, 3.0 years) were identified. All the flaps survived without any major complications. In long-term follow-up, the flap-covered distal phalanges showed growth in line with regular development. There was no donor-site morbidity, and all children adapted to daily life without any problems. In two-point discrimination tests, the fingertip sensation recovered to almost the same level as that in the contralateral finger.

Conclusions

Partial second toe pulp free flaps are an excellent option for fingertip reconstruction in young children, as well as in adults.

Lateral Toe Pulp Flap Used in Reconstruction of Distal Dorsal Toe Defect: Case Report and Review of the Literature

BACKGROUND

When the distal dorsal part of the great toe is injured, especially with exposure of a tendon, bone, or joint, applying a free or local flap is difficult because of the lack of locally available tissue for reconstruction. Management of the distal dorsal part of a great toe soft tissue defect can be challenging for plastic surgeons.

PATIENT AND METHOD

An 18-year-old woman presented with an injury to the dorsal aspect of her right great toe caused by a cobra bite. After fasciotomy, the wound showed exposure of the extensor hallucis longus tendon. After demarcation and infection control, the wound was reconstructed using a lateral toe pulp flap of approximately 3.5 × 1.0 cm. The flap was transposed to the defect, and the donor site was closed primarily. Toe pulp flaps are mainly used to reconstruct finger pulp defects and are useful because they provide a glabrous skin flap suitable for resurfacing fingertip injuries. A lateral toe pulp flap uses a homodigital adjacent skin flap, which is transposed to cover the soft tissue defect. Using a quick and straightforward procedure, we designed this flap to reconstruct a distal dorsal defect of the great toe, with minimal morbidity at the donor site.

RESULTS

The flap initially showed mild congestion but survived completely.

CONCLUSIONS

Applying a lateral toe pulp flap is a quick, simple, and reliable 1-stage procedure. It may be an effective option in reconstructing distal dorsal defects of the great toe.

Free Flaps for Soft Tissue Reconstruction of Digits

Soft tissue reconstruction of the digit is challenging for hand surgeons because it must satisfy both functional and aesthetic requirements. A wide variety of treatment options exist. A free flap can be an alternative solution in some clinical situations. This article has 2 purposes. First, it discusses various considerations for free-flap usage for reconstruction of soft tissue defects of the digits and the available options. Second, it provides more detailed information regarding the 3 commonly used free flaps, namely, the partial toe pulp flap, radial artery superficial palmar branch flap, and arterialized venous flap.

Reconstruction of complex nail matrix defect using the homodigital reverse fasciocutaneous flap

Reconstruction of complex and severe nail matrix defects with the exposure of bone, tendon or joint continues to be challenging for the surgeon. We present our experience using the homodigital reverse laterodorsal fasciocutaneous flap in the reconstruction of complex nail matrix defects.Six patients (7 fingers) of complex nail matrix defects with the exposure of bone, tendon or joint were treated with the homodigital reverse laterodorsal fasciocutaneous flap based on the dorsal branches of the proper digital artery. In this study, the composite tissue defect size ranged from 1.0 × 1.5 cm to 1.3 × 2.5 cm. All 6 patients participated in follow-up.All flaps survived well, and no complications were found postoperatively. The mean size of the flaps was 1.4 × 2.4 cm (range, 1.2 × 2.0-1.5 × 3.0 cm); the mean follow-up period was 8 months (range, 4-15 months); patients' average time to get back to their former jobs was 4.3 weeks (range, 3-6 weeks) postoperatively. All patients were satisfied with the appearance and functional outcomes of the fingers.The homodigital reverse laterodorsal fasciocutaneous flap based on the dorsal branches of the proper digital artery is an ideal surgical method to reconstruct the complex and severe nail matrix defect.

Skin Coverage Considerations in a Mutilating Hand Injury

The foremost goal of managing a mutilated hand is provision of adequate skin coverage. The most suitable method is free tissue transfer. The specific role of volar surface requires replacement tissue to have similar texture for aesthetically satisfactory and functionally acceptable outcomes. Hand surgeons must approach mutilating hand injuries with the recognition that no 2 injuries are ever the same. The injured hand must be evaluated on the individual demand and characteristics of hand use. Optimal function and aesthetic outcomes require appropriate selection of skin coverage. Lost tissues must be replaced like with like tissue.