The effect of intraoperative nerve identification technique on distally-based dorsal fasciocutaneous flap for thumb and fingertip reconstruction

Abstract

IntroductionThumb and fingertip resurfacing continues to be a challenge for hand surgeons, as the treatment varies widely. Being donor nerves in the flap for sensory restoration, the dorsal cutaneous nerves in hand have been widely described in the literature. However, their applications in providing anatomical information to sufficiently harvest the longitudinal axis of a robust flap are usually underestimated. This study reports reconstruction of thumb and fingertip defects with the distally based dorsal fasciocutaneous (DDF) flap and explores the effect of intraoperative nerve identification technique on clinical outcomes. HypothesisThe nerve identification technique can contribute considerably to the improvement of flap circulation, with less risk of poor venous return. Materials and methodsA retrospective study was conducted in 89 patients who had thumb or fingertip defects treated with the DDF flap from February 2014 to June 2020. Patients were divided into two groups based on whether intraoperative nerve identification technique was used. Flap survival was evaluated. The follow-up was conducted by using smartphone or by face-to-face visit. Time for complete wound healing, time to return to work, hand performance, the total active motion of the joints and static two-point discrimination of flaps were analyzed. ResultsThe 46 flaps (group A) that underwent intraoperative nerve identification technique had an 8.7% venous congestion rate versus a 27.9% venous congestion rate in the 43 flaps (group B) without using nerve identification technique (p=0.018). The mean follow-up was 11.08 (range 6–26) months. Time for complete wound healing and time to return to work were significantly shorter in group A (p=0.026 and p=0.012). Michigan Hand Outcomes Questionnaire (MHQ) scores were similar between groups. In the face-to-face follow-up, there was no significant difference in the total active motion of the injured fingers and static two-point discrimination between the two groups (p=0.657 and p=0.182). DiscussionThe use of nerve identification technique could decrease the odds of postoperative venous congestion in DDF flap for thumb and fingertip reconstruction, and result in improved outcomes in terms of time for complete wound healing and time to return to work. Level of evidenceIII; retrospective comparative study.