Regarding “Fingertip Reconstruction With Simultaneous Flaps and Nail Bed Grafts Following Amputation”

Abstract

An option for fingertip reconstruction is a flap with perionychial full-thickness graft.1Hwang E. Park B.H. Song S.Y. Jung H.S. Kim C.H. Fingertip reconstruction with simultaneous flaps and nail bed grafts following amputation.J Hand Surg Am. 2013; 38: 1307-1314Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Mantero described this technique in 1973, although his article was not widely recognized because it was not indexed in Index Medicus.2Netscher D.T. Repair of fingertip amputations with local digital flaps and perionychial composite grafts from the amputated part [letter].Plast Reconstr Surg. 2005; 115: 1217-1218Crossref PubMed Scopus (2) Google Scholar We then described the technique in 1999,3Netscher D.T. Meade R.A. Reconstruction of fingertip amputations with full-thickness perionychial grafts from the retained part and local flaps.Plast Reconstr Surg. 1999; 104: 1705-1712Crossref PubMed Scopus (36) Google Scholar and Sabapathy did so in 2002.4Sabapathy R.S. Venkatramani H. Bharathi R. Jayachandran S. Reconstruction of finger tip amputations with advancement flap and free nail bed graft.J Hand Surg Br. 2002; 27: 134-138Crossref PubMed Scopus (28) Google Scholar I use this technique when the patient brings the amputated tip. Composite fingertip grafts and fingertip replantation have high failure rates. Crush injury (often accompanying fingertip amputations) may preclude replantation, but perionychial tissues can be used as full-thickness grafts. Replantation cost is also high. Perionychial tissues—hyponychium, paronychium, sterile matrix—cannot be reconstructed and these tissues may be further lost if replantation or whole-tip composite graft were to fail. Germinal matrix and eponychial composite grafts, by contrast, have poor success rates. I agree this is a useful technique for distal fingertip amputations where germinal matrix remains. Late hook nail is minimized by soft tissue bulk provided by generous flaps. Large homodigital (retrograde or anterograde) flaps avoid distal donor sites, provide fingertip sensation, and avoid striking color mismatch, even for volar oblique amputations.5Foucher G. Khouri R.K. Digital reconstruction with island flaps.Clin Plast Surg. 1997; 24: 1-32PubMed Google Scholar The authors imply that soft tissue flap bulk alone prevents long-term hook nail, even with bone loss. Nail curvature cannot be totally avoided if there is substantial bone loss. I replace and fix bone from the amputated part if it is large. Treatment of late hook-nail deformity is not fully reversed by thorough scar release and provision of soft tissue bulk alone (Fig. 1).6Dumontier C. Gilbert A. Tuviana R. Hook-nail deformity. Surgical treatment with a homodigital advancement flap.J Hand Surg Br. 1996; 20: 830-835Crossref Scopus (19) Google Scholar Some have added bone by distraction7Lee Y. Kwon S. Ko K. Correction of crooked nail deformity by modified osteoplastic reconstruction.Ann Plast Surg. 2000; 45: 264-268Crossref PubMed Scopus (5) Google Scholar or delayed bone grafting, but resorption is a problem. Even the more severe Allen classification injuries illustrated by Hwang et al1Hwang E. Park B.H. Song S.Y. Jung H.S. Kim C.H. Fingertip reconstruction with simultaneous flaps and nail bed grafts following amputation.J Hand Surg Am. 2013; 38: 1307-1314Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar have bone support. Their Figure 4 represents a dorsal oblique injury, and their Figure 6 shows a degloving injury. I write for 3 reasons—first, for historical perspective; second, to emphasize that large neurovascular advancement or retrograde island flaps avoid problems of color mismatch, distant donor sites, and inadequate tip sensation even for volar oblique amputations; finally, to stress the importance of nailbed support provided by the distal phalanx. Fingertip Reconstruction With Simultaneous Flaps and Nail Bed Grafts Following AmputationJournal of Hand SurgeryVol. 38Issue 7PreviewTo report our technique and results with treating fingertip amputations with flaps and simultaneous nailbed grafts. Full-Text PDF In Reply:Journal of Hand SurgeryVol. 39Issue 1PreviewThank you for your interest in our article. We appreciate learning that the concept of fingertip reconstruction using a flap and perionychial tissue was proposed by Mantero in 1973. Full-Text PDF