Finger Defects Research Articles

Free Medial Plantar Artery Perforator (MPAP) Flap for the Resurfacing of Finger Defect-Report of Two Cases

Background: Finger destruction secondary to trauma represents a much more significant influence on the activity of daily living. Various surgical techniques contribute to cover the distal defect of the finger. Aim and Objectives: We would like to introduce a find-designed perforator skin flap to reconstruct the finger defects. Material and Method: Two patients received free medial plantar artery perforator (MPAP) flaps to resurface the palmar defects of fingers. The flaps were harvested without interrupting the circulation of the medial plantar artery. The flap perforator was anastomosed to proper digital artery and the superficial vein of the MPAP flap was anastomosed to dermal vein of the injured finger which had no severe length discrepancy or metacarpophalangeal joint injury. Results: One male and one female patient were arranged for free MPAP flap reconstruction in March and August 2007. The mobility of the fingers was not restricted after surgery. One flap survived completely with no vascular compromise. Another flap encountered venous congestion and only partially failed (30% loss) after salvage. Conclusion: The MPAP flap is a suitable choice to reconstruct defect of the finger with less donor site morbidity. The cushiony characteristic of the MPAP flap is anatomically similar to the pulp tissue of fingers. Technical difficulty is focused on anastomosis of perforators (diameter≦ 0.8mm) and limited access of concomitant vein. With the many advantages of the MPAP flap, it is worthy of application to more reconstruction needs, particularly for finger defects.

Free Flap From the Superficial Palmar Branch of the Radial Artery (SPBRA Flap) for Finger Reconstruction

Functional reconstruction after a severe hand injury is best achieved by obtaining primary, stable soft tissue coverage to avoid delayed wound healing, prolonged immobilization, and joint stiffness. A wide range of procedures from spontaneous healing to local flaps has been proposed to treat soft tissue defects in appropriate circumstances. However, these pedicled flaps are insufficient in covering larger finger defects, so we used flaps from the free superficial palmar branch of the radial artery (SPBRA) for such cases. Between June 2003 and May 2007, 11 people with traumatic finger injury were treated with SPBRA flaps. The blood supply of the flap is derived from the SPBRA, which can be palpated and confirmed by Doppler flowmetry 18 mm proximal to the palmar wrist crease. Anastomoses of vessels were performed under a microscope, linking the SPBRA to the digital artery and the concomitant vein to the digital dorsal vein. The defects were located at the fingertip in seven patients, in the dorsum of the proximal phalanx in two, and at the interphalangeal joint in two. The average flap size was 8.4 cm with the largest flap being 12.5 cm2 (50 mm x 25 mm). All the flaps survived completely and the wound healed satisfactorily, except for one partial necrosis. All the donor sites were closed primarily without complications or obvious scarring. Most of the fingers involved achieved a full range of motion and showed a good contour. Two-point spatial sensory discrimination was recorded for six patients and adequate protective sensation was attained. The SPBRA flap provides a thin, pliable, reliable, and good glabrous skin flap for covering medium to large finger defects. Only one operative field is required and the major vessels are preserved. This approach can add to the armamentarium of the plastic surgeon for covering large defects of the finger.

Free serratus anterior fascia flap for reconstruction of hand and finger defects

Reconstruction of the dorsal surface of hand defects requires thin, pliable, well vascularized tissue with a gliding surface for the extensor tendon course. Also defects of the palmar hand and degloved fingers need non-bulky soft tissue for reconstruction. We present a retrospective analysis of nine patients with free serratus anterior fascia flaps used to cover defects of the palmar and dorsal hand and of degloved fingers. Three of the patients presented limited range of hand motion due to full-thickness burns; one patient had defects of the dorsum of one hand after acute burn injury. Two patients had an acute trauma of the dorsum of the hand with extensor tendon injury, another patient a soft-tissue defect of his thumb and dorsal hand due to an avulsion injury. One patient presented dorsal defect of three fingers after degloving injury. One patient had a palmar defect after industrial crush injury with exposed tendons, vessels, and nerves. The flaps were applied as pure fascial flaps with an immediate partial-thickness skin graft. One patient presented a partial necrosis of <10% flap size. All other flaps survived completely. Two of the patients presented wound healing problems of the skin graft that healed secondarily. All patients recovered useful hand function without a bulky contour of their hand or fingers. Except for the scar, no donor-site morbidity was reported. The free serratus anterior fascia flap has good functional and cosmetic properties and there is low donor-site morbidity. It is an excellent flap for soft-tissue reconstruction combined with extensor tendon reconstruction on the dorsum of the hand. The flap is also very useful for palmar and finger defects.

Reversed Dermis Cross finger flap for dorsal finger defects: A Case Report

Digital trauma associated with exposure of deep structures can lead to significant functional loss unless prompt soft tissue coverage is provided. The dorsal digital defect always poses a challenge for the reconstructive surgeon as not many options are available loco-regionally. The Reversed deepithelialized cross finger flap, which is a modification of the traditional cross-finger flap, provides a good cover and has been found to be a reliable option for reconstructing dorsal defects of the digit.

Repairing finger defects with free vascularized flaps based on the descending branch of the upper-wrist cutaneous branch of ulnar artery.

Objective To study a new surgical method to repair finger defects with free vascularized flaps based on the descending branch of the upper-wrist cutaneous branch of ulnar artery, and evaluate the clinical effects.Methods From March 2001 to December 2006, 75 patients (79 fingers) suffered soft were treated using free flaps pedicled with the descending branch of the upper-wrist cutaneous branch of ulnar artery.There were 41 males (45 fingers) and 34 females (34 fingers), with the mean age of 31 years (ranged from 20 to 45 years).Among them, 59 cases of 62 fingers adopted emergency surgery or delay surgery to repair, 16 cases of the 17 fingers adopted selective operation to repair.Vascular variations were studied in the process.Results The grafted flaps in all 79 fingers of 75 patients successfully survived except for one necrosis case in the distal part of the flap, which was then healed with skin grafting.Three different types of variation of the upper-wrist cutaneous branch of ulnar artery were identified in the operation, including the origin and the number of cutaneous branches, and corresponding surgical approaches had contributed to successful survival of the flaps pedicled with vascular variations.Follow-up studies that lasted 6-24 months after the procedure revealed adequate texture and shape of the flaps with the two-point discrimination of 6-11 mm, did not match nerves, skin protection 6 months after the restoration of feeling, the functional recovery of the fingers being satisfying.Conclusion It can provide the relatively constant vascular anatomy and easy operation to repair finger defects with free vascularized flaps based on the descending branch of the upper-wrist cutaneous branch of ulnar artery, and get satisfied skin flap appearance, texture and feeling function. Key words: Surgical flaps; Ulnar artery; Finger injuries; Treatment outcome

Malformations of the index nails

We report a 52-year-old woman with micronychia of the index fingers. Radiographic examination revealed a Y-shaped bifurcation of the distal phalanx of both index fingers. She was diagnosed with congenital onychodysplasia of the index fingers (COIF) or Iso-Kikuchi syndrome. COIF is a rare condition characterized by a variety of nail dysplasia of the index fingers. Five criteria characterize COIF: congenital occurrence, unilateral or bilateral index finger involvement, variability in nail appearance, hereditary involvement and frequently associated bone abnormalities. Micronychia, polyonychia, anonychia, hemionychrogryphosis and malalignment are the observed index finger defects. Most cases have been described in Japan, and to our knowledge, this is the first case of COIF reported in South America.

End-of-skin grafts in syndactyly release: description of a new flap for web space resurfacing and primary closure of finger defects.

Treatment of syndactyly necessitates creation of neo-web space and separation of fingers. Traditionally, this has been done by use of flaps taken from the dorsum; the resultant raw areas thus created have been managed by use of skin grafts. The classical teaching has been that the separated fingers will need skin graft as primary closure is not possible. The skin grafts have a tendency to contract and lead to finger flexion contractures and "creep" of the web space. We describe a flap based upon subcutaneous tissue in the web that is moved in a V-Y fashion to resurface the neo-web. The flap donor site can easily be closed primarily. The fingers are then separated; the subcutaneous fat is carefully removed from the finger flaps under magnification to allow primary closure of the finger defects. It has been possible to primarily close the donor site and fingers in all the patients. The procedure has been used in seven patients with 14 web releases. The age varied between 10 months to 3 years. The V-Y advancement flap based upon the subcutaneous pedicle in the region of the web allows adequate creation of a new web space. The careful de-fattening of skin flaps allows the separated fingers to be closed primarily.

Re: Use of a dorsal adipofascial flap for reconstruction of large volar finger defects

Re: Use of a dorsal adipofascial flap for reconstruction of large volar finger defects

Reverse thenar perforator flap for volar hand reconstruction

The glabrous skin of the palm provides the best colour and texture match for reconstructing volar hand defects, but only a limited number of local axial pattern flaps of the palm have been described in the literature. This report describes a new reverse thenar perforator flap harvested from the midpalm and the thenar region. A total of 12 patients with volar hand defects of the index finger, palm, or first web space were reconstructed with this flap between August 2005 and August 2007. The causes of the defects were trauma (one patient), burn contracture release of the first web and index finger (four patients), and Dupuytren contracture release (seven patients). The flap was supplied from one or two of the perforating branches of the terminal branch of the superficial palmar arch or the superficial palmar branch of the radial artery. Flap sizes ranged from 1.5 x 3.0 cm to 2.5 x 6.5 cm. The donor sites were repaired primarily in all patients. There were no major postoperative problems: 11 flaps out of 12 survived completely with just one partial loss. Excellent functional and cosmetic results were observed during a mean follow up of 12.6 months. The reverse thenar perforator flap offers glabrous skin for defects of the palm, first web and index finger. Donor scarring of the flap is minimal and it is suitable for the 'replacement with similar tissue' concept.

Reverse dorsolateral proximal phalangeal island flap: a new versatile technique for coverage of finger defects

All flaps described for the reconstruction of finger defects have limited indications and many disadvantages. In this study, I successfully developed a reverse digital artery flap raised from the overall side and dorsal aspects of the proximal phalanx, excluding the digital nerve, for closure of fingertip and middle phalangeal defects, and called this the 'reverse dorsolateral proximal phalangeal island flap'. The donor site defect was covered by another flap called the 'dorsal metacarpal V-Y island flap'. The method was used for 12 complicated phalangeal defects in 11 patients. Flap sizes ranged from 2 x 1.5 cm to 3 x 2.5cm. The flap was applied with versatile designs including distal interphalangeal (DIP) (9) or proximal interphalangeal (PIP) anastomoses-based flaps (3); homodigital (10) or heterodigital flaps (2) from the injuries or adjacent finger, respectively; multiple flaps from the two distinct fingers in the same hand (1); and a sensate flap (1). The average follow-up time was 11.5 months. All reverse flaps and V-Y donor site flaps survived completely. Finger lengths and motions were satisfactory with favourable aesthetic results in all cases. The mean value of static two-point discrimination was 9.3mm. I strongly advocate this new flap, as a single versatile flap, for repair of different-sized or complex phalangeal defects. By means of this 'dual-flap manoeuvre', any defect distal to the PIP joint in various dimensions can safely be covered without using a skin graft in the donor area. I also suggest the dorsal metacarpal V-Y island flap alone for dorsal phalangeal defects proximal to this point.

Emergent reconstruction and repair of thumb and finger defect by toes and combined toes transplantation

Objective To explore the method and effect of thumb and finger reconstruction and repair by emergent primary toes transplantation. Methods Three hundred and fourteen fingers of 282 cases including finger thumb defect and complex injury with hyperthena palm radid soft tissue of forearm were reconstructed and repaired by the second toes, wrap-around flap and the second third toes wrap-around flap combined with distal flap of leg or other complex tissue flap transplantation. Results Three hundred and eight reconstructed fingers survived, the survival rate was 98%. After a follow up to 6 months to 6 years, the reconstructed thumbs and fingers have accepted nip, grasp, opponent function. The result was graded as excellent in 214 fingers, good in 63, fair in 26, poor in 5. The excellent and good rate was 88%according to the upper limb functional evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association. Conclusion Different type of toes and combined toes transplantation can obtain preferable clinical effect on emergent primary thumb and finger defect. Key words: Thumb; Finger; Microsurgical operation; Emergency; Reconstruction

Arterial anatomical basis of the dorsal digito-metacarpal flap for long fingers

Several flaps have been described to treat severe soft tissue defects of the finger dorsal side. Many authors studied vascular organization of the hand on its dorsal side; most of them insisted on deep vascularization into the intermetacarpal spaces, which is formed by the dorsal metacarpal arteries. Those dorsal metacarpal arteries are the anatomical support of many flaps, which do not preserve the dorsal interosseous muscles fascias. Only few authors described dorsal vascular organization at the level of the proximal phalanx; however, using a rotation point of a flap distally to the metacarpal head with a donor site on the dorsal aspect of the hand could cover all distal soft tissue defect of long finger. In order to determine the technical limitations of dorsal digito-metacarpal flap procedures, we studied number and location of arterial anastomoses between the reticular subcutaneous dorsal network and the rest of the vascularization at this level, which was formed by the deeper dorsal metacarpal arteries, common palmar digital arteries and proper palmar digital arteries, and between the dorsal digital arteries. Twenty-four long fingers from embalmed cadavers were studied after a reverse flow injection of colored latex and dissected layer-by-layer preserving the digital-metacarpal arterial network. At the level of the hand, the dorsal metacarpal arteries of the third and fourth intermetacarpal spaces were inconstant. When present, two or three arteries anastomosed in star shape with the reticular network. No such arterial anastomosis was observed proximally to the level of the intertendinous connections (junctura tendinorum) that bridge the extensor digitorum communis tendons. When no dorsal metacarpal artery was present, some communicant arteries arose from the common palmar digital arteries. Moreover, all the nutrient branches were more numerous distally to the intertendinous connections (junctura tendinorum). At the level of the metacarpophalangeal joints, the hand cutaneous network was always anastomosed with the dorsal cutaneous network. At the level of fingers, the dorsal cutaneous network was always supplied by four branches arising from the proper digital artery. Our study supported the reliability of dorsal digitometacarpal flaps, supplied by numerous palmodorsal digital anastomoses and by a rich plexiforme network joining the hand skin supply and that of the dorsal finger skin. During the procedure, we recommend limiting the surgical dissection of the flap at the level of the middle phalanx.

Perforator-Based Reverse Radial Forearm Flap to Reconstruct Multiple Third-Degree Burn Defects of the Fingers

Adequate soft-tissue coverage is a cornerstone for successful hand reconstruction in burn patients allowing for hand mobilization and rehabilitation. Multiple finger injuries that involve separate soft-tissue defects with complex wounds challenge the reconstruction dilemma. In this case report, a modified application of reverse radial forearm flap for the simultaneous reconstruction of multiple separate finger defects for burn cases is presented. A 23-year-old heavy industry worker is presented with a history of third-degree electrical burn of left index and middle fingers. The proximal interphalangeal (PIP) joint of the both fingers were exposed. A distally based radial forearm flap with a dimension 7.5 x 6 cm was planned. The flap was transposed to the distal defect and splitted. The bilobed flap was inset. A tendon graft is used to span the gap of extensor apparatus before insetting the flaps in both fingers. The donor defect was closed primarily. A satisfactory coverage is observed in the recipient areas. Finger functions including full range of motion of the metacarpophalangeal and PIP joints of the index and PIP and distal interphalangeal joints of long fingers were observed. The technique presented here is advantageous as it is easy to perform, covers multiple finger defects simultaneously, avoids long-term immobilization, saves the operative time, avoids microsurgery. Donor site is closed primarily and finally this approach ensures a simultaneous repair of complex wounds with multiple vital anatomical structures i.e. bone, tendon, joint, and soft tissue.

Free Digital Artery Flap

The heterodigital arterialized flap is increasingly accepted as a flap of choice for reconstruction of large finger wounds. However, in situations where the adjacent fingers sustained concomitant injuries, the use of this flap as a local flap is precluded. This paper describes our experience with the free digital artery flap as an evolution of the heterodigital arterialized flap. Four patients with large finger wounds were reconstructed with free digital artery flap. Our indications for digital artery free flap were concomitant injuries to adjacent fingers that precluded their use as donor sites. The arterial supply of the flap was from the digital artery and the venous drainage was from the dominant dorsal vein of the finger. The flap was harvested from the ulnar side of the finger. The digital nerve was left in situ to minimize donor morbidity. The donor site was covered with a full-thickness skin graft and secured with bolster dressings. Early intensive mobilization was implemented for all patients. All flaps survived. No venous congestion was noted and primary healing was achieved in all flaps. In addition to providing well-vascularized tissue for coverage of vital structures, the digital artery was also used as a flow-through flap for finger revascularization in one patient. Donor-site morbidity was minimal, with all fingers retaining protective pulp sensation and the distal and proximal interphalangeal joints retaining full ranges of motion. In conclusion, the free digital artery flap is a versatile flap that is ideal for coverage of large-sized finger defects in situations where local flaps are unavailable. Donor-site morbidity can be minimized by preservation of the digital nerve, firmly securing the skin graft with bolster dressings, and early mobilization of the donor finger.

Reversed cross finger subcutaneous flap: A rapid way to cover finger defects

Adequate coverage of dorsal finger wounds is often a challenge. The reversed cross finger subcutaneous flap to cover defects on the dorsum of phalanx constitutes an excellent option for coverage of wounds over the middle and distal phalanges of the index, middle, ring, and small fingers. It's an easy flap and represents our first choice to cover those defects.

Reversed cross finger subcutaneous flap: A rapid way to cover finger defects

ABSTRACTAdequate coverage of dorsal finger wounds is often a challenge. The reversed cross finger subcutaneous flap to cover defects on the dorsum of phalanx constitutes an excellent option for coverage of wounds over the middle and distal phalanges of the index, middle, ring, and small fingers. It′s an easy flap and represents our first choice to cover those defects.

Decoration reconstruction for finger defect in emergency

目的 探讨拇手指缺损急诊修饰性再造的方法,观察其临床疗效.方法 对41例拇手指不同程度的缺损,分别应用部分(足母)趾甲皮瓣或第二趾甲皮瓣修复15例,应用(足母)趾甲皮瓣修复8例,应用第二趾趾尖再造7例,(足母)趾腹皮瓣或第二趾侧方瓣修复11例.结果 本组41例全部成活,1例(足母)趾甲皮瓣稍显臃肿,予二期手术修整.余病例经4～18个月随访,功能外形良好,指甲生长优良.供足行走功能无明显影响.结论 对于拇手指不同程度的缺损可以采用不同的方法予以急诊修饰性再造,可以最大程度的恢复手部功能外形。

145: Midtrimester sonographic findings for the prediction of Down syndrome in a population at risk

SYNDROME IN A POPULATION AT RISK ELISA POZZI, ANNA LOCATELLI, STEVEN WEINER, ANNA BIFFI, ALESSANDRO GHIDINI, PATRIZIA VERGANI, University of Milano-Bicocca, Obstetrics and Gynecology, Monza, Italy, George Washington University, Rockville, Maryland OBJECTIVE: The accuracy of genetic sonogram in algorithms of risk assessment for trisomy 21 (T21) is not established in prospective series. We calculated the adjusted effect sizes of midtrimester sonographic findings of T21 in a population at risk because of age and we then applied the prediction formula to a prospective series. STUDY DESIGN: Single-center cohort study conducted between 2001 and 2006 in women at risk for T21 undergoing genetic sonogram between 15 and 22 weeks= gestation. Univariate and logistic regression analysis were used to relate sonographic findings performed during the period 2001-2005 to occurrence of T21. Using the eventual model, predicted probabilities of Down syndrome were calculated for the cohort 2006. Subjects were classified as test positive or negative using a cut-off of 1/ 270 and sensitivity and false positive rates were calculated. RESULTS: Prevalence of Down syndrome was 27/1487 (1.8%). In the most parsimonious multivariable model adjusted for gestational age and maternal age, nuchal fold thickness (NFT) *5 mm, presence of renal pelvic dilation, absent midphalanx of the 5th finger, malformations, and heart defects were independently associated with T21, as were the following interactions: gestational age * NFT *5 mm and maternal age * aneuploid-associated anomalies or heart defects. The formula inclusive of these parameter estimates was prospectively used to calculate a woman=s adjusted risk of carrying a T21 fetus . Utilizing risk cut-off point of 1/270, the sensitivity of a genetic sonogram was 100% with a false positive rate of 22%. CONCLUSION: Genetic sonogram has adequate accuracy to be incorporated into current management algorithms for risk assessment of T21 in women at increased risk because of age.

Innervated Lateral Middle Phalangeal Finger Flap for a Large Pulp Defect by Bilateral Neurorrhaphy

The dorsal middle phalangeal finger flap is a reliable flap. However, it requires skin grafting on the whole surface of the dorsum of the middle phalanx of the donor finger for an exposed extensor tendon and leaves a conspicuous contour deformity at the donor site. In an effort to overcome this problem, the authors have been using a heterodigital innervated lateral middle phalangeal finger flap for resurfacing sizable defects of the pulp. Flaps were designed on the lateral ulnar side of the middle finger for five thumb defects and the ring finger for two little finger defects. To provide sensation to the flap, one nerve fascicle from the direct small branches of the proper digital nerve after interfascicular dissection (palmar aspect of the flap) and the dorsal branch of the proper digital nerve (dorsal aspect) were identified and sectioned proximally, leaving a 1-cm nerve tail attached to the flap. These flaps provided sensate coverage with static two-point discrimination values of approximately 6 mm. Donor finger morbidity was minimal, and pulp sensation in donor fingers was normal in all cases. No donor finger cold intolerance was reported in this series. This described flap supplies glabrous skin of nearly normal sensibility. One nerve fascicle from the direct small branches of the proper digital nerve and the dorsal branch of the proper digital nerve were used for maximal sensation. Donor fingers are cosmetically better than those of dorsal middle phalangeal finger flaps because the grafted skin is hidden by an adjacent finger.

Vascularized Bone Blocks From the Toe Phalanx to Solve Complex Intercalated Defects in the Fingers

Vascularized bone transplants resist infection and allow rapid healing but keeping small bony segments vascularized, as needed for a finger defect, is a challenge. The purpose of this article is to present a cohort of patients with traumatic intercalated compound bony defects in the fingers that were reconstructed by a vascularized toe phalanx (or part of a phalanx) in a single stage. Eight patients were treated with an intercalary vascularized bone graft that included a part of the proximal phalanx (3 patients), most of the middle phalanx (4 patients), or a portion of each phalanx (1 patient) of a second toe (totaling 9 bone blocks). There was an associated soft-tissue defect in each patient, an infection in 6 patients, and cartilage loss in 4 patients. The toes were pedicled on the proper digital artery (6 patients) or a segment of the first dorsal metatarsal artery (2 patients). A mean length of 12 mm of vascularized bone was transferred. The associated skin island varied from a minimum of 2 x 1 cm to a maximum of 5 x 3 cm. Bleeding from all of the bone surfaces was evidenced once the clamps were released. The homolateral digital nerve and the contralateral neurovascular pedicle of the toe were kept in place. The toe defect was treated by soft-tissue arthroplasty or arthrodesis. No toe was amputated. Radiologic bony union was evident at 4 to 6 weeks, except in 1 patient with an acute infection whose distal union failed to unite at 6 weeks because the infection recurred. Finger length loss averaged 3 mm. All patients returned to their preoperative occupation. In this group of patients the toe phalanx reliably maintained its vascularization, allowing us to solve compound osteocutaneous defects in the fingers in a single stage. Donor site morbidity was minimal.