SRPS PS - Plastic Surgery Internal

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and cosmetic outcomes. The advantage of this treatment is that as the wound contracts, it pulls proximal innervated pulp skin over the exposed bone, resulting in a very small area of residual scar located off the pressure area of the finger. However, if the same technique is used to treat more dorsal fingertip defects with involvement of the distal nail bed, the subsequent wound contraction can lead to “parrot beaking” of the nail, which can be difficult to correct secondarily. Skin Grafts Skin grafts commonly are used to repair fingertip defects. They can be used as a temporizing measure with a view to subsequent flap revision, or they can serve as the definitive wound closure. In the former situation, split-thickness skin is more appropriate because it has a more predictable “take.” Similarly, large soft-tissue defects are resurfaced with split skin because it tends to contract more than full-thickness skin, thus keeping the resultant insensitive area as small as possible. 353 Split-thickness skin from the hypothenar eminence or instep of the foot has a papillary pattern that most closely resembles native fingertip skin. 361 Beasley 353 has suggested full-thickness donor sites from the groin to minimize the cosmetic deformity of the donor site. Hypothenar full-thickness skin grafts have an excellent texture match and do not hyperpigment as groin skin tends to. Their size is limited by the necessity to obtain primary closure of the donor site. Although some spontaneous reinnervation of fullthickness skin grafts has been observed, 362 any insensitive or hyposensitive areas that remain limit the application of skin grafts in the hand. 363 Braun et al. 364 found no difference in 2-point discrimination between wounds covered by split-thickness grafts and those covered by local flaps. Flap Reconstruction Loss of fingertip pulp greater than one-third the length of the phalanx requires replacement of soft tissue to support the distal nail. Beasley 365 has offered the following guidelines for reconstruction in such cases: replacement soft tissue must have good ultimate sensibility and be capable of tolerating SRPS Volume 10, Issue 25, 2009 normal usage secondary disfigurement must be insignificant, with no functional loss at donor site method must be safe, practical, reliable, economical, and predictable in results Beasley further lists three indications for local flaps in the repair of fingertip amputations: 1) wound bed unsuitable for revascularization of skin graft; 2) need for subcutaneous tissue replacement in addition to skin; 3) protection of vital structure, such as nerve. Flaps for reconstruction of soft tissue of the fingertip can be from the same finger (homodigital) or another finger (heterodigital) or from local, regional, or distant sources. 366–369 An enormous number of flaps have been described, and countless more descriptions will be published in the years ahead. For a flap to be useful clinically, it must fulfill the guidelines listed above, but at the same time, it must be reliable and simple to create. Only select flaps are discussed in the sections that follow. Homodigital Flaps The most immediate source of tissue for fingertip replacement is the same finger. The obvious advantages are that it does not violate another normal finger or part of the body nor does it immobilize uninvolved joints. The tissue used must be outside the zone of injury. The neurovascular integrity of the finger should be maintained. The tissue directly adjacent to the wound is the closest source of flap tissue and forms the basis for many traditionally popular flaps. The Atasoy volar V-Y advancement 369-371 is useful for dorsal oblique to transverse amputations in cases in which the defect does not exceed 1 cm (Fig. 11). The usefulness of the flap is vastly improved by extending the proximal part of the “V” past the distal interphalangeal joint crease and into the middle phalangeal segment and by elevating the flap as a true bilateral neurovascular island flap on both pedicles. 372 In 1964, Moberg 373 described a rectangular volar advancement flap from the base of the thumb that can be used in thumb tip reconstruction. The volar advancement flap is a true axial flap in that the incisions are placed dorsal to the neurovascular bundles so as to include them with the flap and restore 21
SRPS Volume 10, Issue 25, 2009 Figure 11. V-Y advancement flap. A, Skin incision and mobilization of triangular flap. B, Advancement of flap. C, Closure with V-Y technique. (Reprinted with permission from Chao et al. 369 ) normal sensation to the tip. The tissue movement achieved in proportion to the extent of the dissection is disappointing, and if too large a defect is closed (>1 cm), flexion contracture of the interphalangeal joint will occur. Several authors 374–376 subsequently modified the method of mobilization, incorporating a V-Y closure in the advancement to make the flap more reliable. Alternatively, the flap can be converted into a true island and the proximal defect can be skin grafted. 377 Snow 378,379 applied the Moberg flap to the repair of fingertip amputations, but dorsal tip necrosis and an unstable pulp scar plagued the series. Macht and Watson 380 preserved the dorsal perforating vessels by using a “spreading-dissecting” technique with which the volar flap is not cut free except at its most distal 22 area. They reported no skin loss or joint stiffness occurring in 69 transfers and 2-point discrimination values within 2 mm of the contralateral normal finger. Lateral advancement flaps have the potential to offer the ideal fingertip reconstruction, replacing “like with like” from the same digit. Ipsilateral advancement flaps 369,381–386 move tissue from directly adjacent to the defect and maintain sensibility (Fig. 12). Bilateral advancement flaps can also be used, as described by Kutler 387 in 1944. As with all homodigital flaps, the potential exists for flap embarrassment if damaged tissues or pedicles are used. Figure 12. Oblique triangular flap. A, Volar oblique amputation. B, Design and raising of flap on digital neurovascular bundle. C, Closure of flap with V-Y technique. (Reprinted with permission from Chao et al. 369 ) Reversed digital artery island flaps from the proximal finger necessitate sacrifice of one digital artery and rely on retrograde flow through an intact anastomosis with the contralateral normal artery. 388–391 They require neurorrhaphy of a dorsal branch to the contralateral digital nerve for optimal recovery of sensibility. 392 A preoperative digital Allen’s test is essential to assess the patency of both arteries. Venous drainage of the flaps is via the soft tissue around the arterial pedicle, so the pedicle should not be skeletonized.
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