V Advancement Flap for Fingertip Injury Preventing Necrosis and Hook Nail Deformity

Abstract

Objectives: V-Y advancement flap has been a reliable method to reconstruct fingertip defect, since described by Tranquilli-Leali originally in 1935 and popularized by Atasoy later in 1970. But flap necrosis and hook nail deformity due to suture line tension have been pointed out as relatively common complications in V-Y advancement flap for fingertip reconstruction. Concern about this problems, several authors have been described a modification of this technique. The aim of this study was to describe our modification of V advancement flap based on V-Y concept and to review the outcome of this procedure for fingertip amputation in 28 patients. Materials and Methods: This study was conducted from January 2006 to February 2014 and involved 28 consecutive patients (20 men and 8 women; 30 fingertip amputations) with fingertip injury that were treated operatively with the same procedure. All patients with a fingertip defect of more than 1.0 cm2 in area from the tip to lunula were included in this study. The causes of injuries were crushing with or without avulsion in 21, amputation with sharp laceration in 8, and human bite in 1. Twenty-seven injuries were transverse or dorsal oblique type and 3 were mild volar oblique type. According to Allen’s classification, 18 cases were type 2, 11 were type 3, and 1 was type 1. To allow for a tension-free closure, the proximal incision was left unclosed to heal by secondary intension. In addition, the distal nail bed was supported and maintained eversion against base of the flap with a minimal number of horizontal mattress sutures, and there was no suture crossing over the top to prevent hook nail deformity. Postoperatively, dressing changes were performed once daily for 3 or 4 weeks until reepithelialization was observed. Results: The mean age of the patients was 43.6 years (range, 24-65 years). The average follow-up periods was 15 months (range, 12-37 months). All patients underwent objective and subjective assessment at 6 and 12 months routinely and at final follow-up. At final follow-up, all flap healed uneventfully. In objective evaluation with Semmes-Weinstein monofilaments test, 24 cases recognized the 2.83 monofilament (0.07 g), 6 cases recognized the 3.61 monofilament (0.4 g). In static 2-point discrimination test, the mean values were 4.61 mm in injured finger and 4.00 mm in contralateral finger. None of the patients developed a noticeable hook nail deformity. None of the patients complained of hypersensitive digit. However, 3 patients had some residual short nails and 2 patients had mild nail ridges. Patients’ subject rating of the outcome was recorded: “excellent,” “good,” “fair,” and “poor.” Excellent or good results were achieved in 28 cases. Two cases had fair results and none of the patients had a poor result. Conclusions: This modified V advancement flap technique, when properly designed and executed, can minimize morbidity and successfully results in good wound healing without necrosis and hook nail deformity for fingertip injury.