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The dorsal middle phalangeal finger flap 393–395 can be raised on a short or long antegrade or retrograde pedicle and can be used as a free flap, an arterial and/or venous flow-through flap, or a neurovascular flap. Heterodigital Flaps In 1951, Cronin first described the cross-finger flap for fingertip reconstruction. 396 The cross-finger flap brings durable cover to exposed bone, joint, or flexor tendons when homodigital flaps do not suffice. 396–400 Blood supply of the cross-finger flap is random and based on the subdermal plexus of an adjacent digit. The flap can be based laterally, proximally, or distally, depending on the most comfortable approximation of donor digit to defect. The dorsum of the middle phalanges of the index, middle, and ring fingers is the most appropriate donor site in terms of joint immobilization. Use of a cross-finger flap from the volar aspect of the middle finger, rather than from the thinner dorsal finger skin, provides better tissue quality for resurfacing the pulp of the thumb. 365,401 Hoskins details the technical points of cross-finger flap elevation and transfer (Fig. 13). 91,402 The pedicle can be divided safely by the 8th or 9th day to lessen the risk of joint stiffness from joint immobilization. Many variations of the cross-finger flap have been described. The dorsal sensory branch can be included in the flap and sutured to the digital nerve of the injured fingertip, 403 although that technique has not been shown SRPS Volume 10, Issue 25, 2009 to improve the ultimate sensibility of the flap. The flap can be de-epithelialized and used to resurface dorsal defects of adjacent fingers, necessitating an additional skin graft on top of the flap. 404,405 Advantages of the cross-finger flap technique are that it is easy to elevate and can carry ample quantities of similar tissue. Disadvantages are that it is a two-stage procedure, a skin graft is required for the donor site (which is obvious on the exposed dorsum of the finger), stiffness of the involved digits is a possibility, and 2point discrimination values average only 9 mm. 406,407 In a study of 54 patients with cross-finger flaps, Nishikawa and Smith 407 found that despite recovery of protective sensation, no patient had recovered tactile gnosis. Maximal recovery of sensibility occurs in those younger than 20 years, and 2-point discrimination plateaus at 1 year. 406 Contraindications to the use of cross-finger flaps include arthritis, Dupuytren’s contracture, and generalized vasospastic syndromes. Littler 408 and Tubiana and Duparc 409 developed the technique of interdigital transfer of pedicled neurovascular island flaps. Pedicled neurovascular island flaps have found their greatest application in reconstruction of the ulnar thumb pulp, 410,411 with median nerve-innervated skin being transferred from the ulnar pulp of the middle finger (less desirably, the radial pulp of the ring finger). For the flap to reach the tip of the thumb, the digital nerve must be dissected well back into the median nerve and the proper digital Figure 13. Elevation and transfer of dorsal cross-finger flap. Full-thickness skin graft should be sutured to edge of defect adjacent to donor finger before flap is inset so that a “closed” system is created. (Reprinted with permission from Lister. 91 ) 23
SRPS Volume 10, Issue 25, 2009 artery to the adjacent finger must be sacrificed. Cortical misrepresentation remains a problem, and the sensibility of the transferred skin has been variable in several series. 412,413 Holevich 414 reported a pedicled island flap from the dorsum of the index finger that is based on the first dorsal metacarpal artery. It includes a terminal branch of the radial nerve and can be used to resurface a shortened thumb. A problem exists with cortical interpretation, and the skin is not pulp skin. Several authors 415–417 later expanded the applications of the first dorsal metacarpal artery flap in hand resurfacing. Regional Flaps In 1926, Gatewood 418 first proposed a thenar flap for resurfacing the tip of the index finger in one patient. Thirty years later, Flatt 419 presented his results with a similar “palmar flap” in a large series of fingertip reconstructions. The classic thenar flap is based proximally to ensure good venous return and to minimize proximal interphalangeal joint flexion. Contracture can be further controlled by placing the thumb in full palmar abduction and bringing the metacarpophalangeal joint of the involved digit into full flexion. 353,420 If designed properly, the donor site usually can be closed primarily. 420,421 Unlike the true palmar flap, the thenar flap is not likely to produce joint stiffness postoperatively, provided the pedicle is divided in approximately 10 days. Small Defects of the Hand or Digits Homodigital Flaps Lai et al. 422 described the adipofascial turn-over flap with which dorsal defects of the finger and hand can be resurfaced by a flap of subcutaneous tissue hinged on a pedicle that borders the defect. This flap is especially useful in cases of abrasion injuries of the distal interphalangeal joint with exposed terminal extensor tendon. The donor site is closed primarily, and the flap is grafted (Fig. 14). 423 Heterodigital Flaps Small defects of the hand can be resurfaced using socalled venous flaps. Venous flaps consist of skin islands raised on a single-vein pedicle from the dorsum of the 24 Figure 14. Surgical technique. A, Complex defect exposing dorsal aspect of distal interphalangeal joint. B, Design of adipofascial flap. Base of flap is adjacent to defect. C, Development of distally based adipofascial flap. D, Flap is turned over on itself to cover defect. E, Primary closure of donor site. Flap is covered with split-thickness skin graft. (Reprinted with permission from Al-Qattan. 423 ) hand over the proximal phalanx and are used to reconstruct either the dorsal or volar surfaces of adjacent digits. 424–427 Earley 428 detailed the anatomy of the second dorsal metacarpal artery and reported various uses for this neurovascular island flap hand reconstruction. He and others 428–431 broadened the applications of the second dorsal metacarpal artery flap. Regional Flaps Maruyama 432 and Quaba and Davison 433 elevated skin islands from the dorsum of the hand, based distally over the metacarpal head (Fig. 15). These reverse dorsal metacarpal artery flaps are sustained by
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